Projecting prevalence, costs and evaluating simulated interventions for diabetic end stage renal disease in a Canadian population of aboriginal and non-aboriginal people: an agent based approach

BACKGROUND

Diabetes-related end stage renal disease (DM-ESRD) is a devastating consequence of the type 2 diabetes epidemic, both of which disproportionately affect Indigenous peoples. Projecting case numbers and costs into future decades would help to predict resource requirements, and simulating hypothetical interventions could guide the choice of best practices to mitigate current trends.

METHODS

An agent based model (ABM) was built to forecast First Nations and non-First Nations cases of DM-ESRD in Saskatchewan from 1980 to 2025 and to simulate two hypothetical interventions. The model was parameterized with data from the Canadian Institute for Health Information, Saskatchewan Health Administrative Databases, the Canadian Organ Replacement Register, published studies and expert judgement. Input parameters without data sources were estimated through model calibration. The model incorporated key patient characteristics, stages of diabetes and chronic kidney disease, renal replacement therapies, the kidney transplant assessment and waiting list processes, costs associated with treatment options, and death. We used this model to simulate two interventions: 1) No new cases of diabetes after 2005 and 2) Pre-emptive renal transplants carried out on all diabetic persons with new ESRD.

RESULTS

There was a close match between empirical data and model output. Going forward, both incidence and prevalence cases of DM-ESRD approximately doubled from 2010 to 2025, with 250-300 new cases per year and almost 1300 people requiring RRT by 2025. Prevalent cases of First Nations people with DM-ESRD increased from 19% to 27% of total DM-ESRD numbers from 1990 to 2025. The trend in yearly costs paralleled the prevalent DM-ESRD case count. For Scenario 1, despite eliminating diabetes incident cases after 2005, prevalent cases of DM-ESRD continued to rise until 2019 before slowly declining. When all DM-ESRD incident cases received a pre-emptive renal transplant (scenario 2), a substantial increase in DM-ESRD prevalence occurred reflecting higher survival, but total costs decreased reflecting the economic advantage of renal transplantation.

CONCLUSIONS

This ABM can forecast numbers and costs of DM-ESRD in Saskatchewan and be modified for application in other jurisdictions. This can aid in resource planning and be used by policy makers to evaluate different interventions in a safe and economical manner.

Vitamin D insufficiency and bone mineral status in a population of newcomer children in Canada

BACKGROUND

Low levels of circulating vitamin D are more likely to be found in those with darker skin pigmentation, who live in areas of high latitude, and who wear more clothing. We examined the prevalence of vitamin D deficiency and inadequacy in newcomer immigrant and refugee children.

METHODS

We evaluated circulating vitamin D status of immigrant children at the national level. Subsequently, we investigated vitamin D intake, circulating vitamin D status, and total body bone mineral content (TBBMC) in newcomer children living in Saskatchewan.

RESULTS

In the sample of newcomer children in Saskatchewan, the prevalence of inadequacy in calcium and vitamin D intakes was 76% and 89.4%, respectively. Vitamin D intake from food/supplement was significantly higher in immigrants compared to refugees, which accords with the significant difference in serum status. Circulating vitamin D status indicated that 29% of participants were deficient and another 44% had inadequate levels of serum 25(OH)D for bone health. Dietary vitamin D intake, sex, region of origin, and length of stay in Canada were significant predictors of serum vitamin D status. RESULTS for TBBMC revealed that 38.6% were found to have low TBBMC compared to estimated values for age, sex, and ethnicity. In the regression model, after controlling for possible confounders, children who were taller and had greater circulating vitamin D also had greater TBBMC. Nationally, immigrant children, particularly girls, have significantly lower plasma 25(OH)D than non-immigrant children.

INTERPRETATION

Newcomer immigrant and refugee children are at a high risk of vitamin D deficiency and inadequacy, which may have serious negative consequences for their health.

From closed ranks to open doors: Elaine and John Cummings' mental health education experiment in 1950s Saskatchewan

During late 1951 and early 1952, married couple, social biologist Elaine Cumming and psychiatrist John Cumming, led a mental health education experiment in Indian Head, Saskatchewan. The study, which was intended to inform strategies toward deinstitutionalization, sought to determine if attitudes regarding mental illness could be changed through commonly used educational practices. It was shaped by the shared interests of powerful philanthropic, charitable, psychiatric, academic and governmental bodies to create healthier citizens and a stronger democratic nation through expert knowledge. However, in addition to the disappointing findings indicating that attitudes remained unchanged, the town appeared to close ranks against the research team. Nonetheless, the Cummings' later association with sociologists at Harvard University enabled them to interpret the results in a way that lent the study credibility and themselves legitimacy, thus opening the door to their careers as very successful researchers and policy-makers.

Visiting the mentally ill: volunteer visitors at Saskatchewan hospital, Weyburn 1950-1965

This article offers a glimpse into the lives and activities of some of the patients, volunteers and staff in the Saskatchewan mental health system during the period of deinstitutionalization. Drawing on her own experience as a patient in psychiatric wards as well as ongoing research in the history of mental health, it features the role of Regina Volunteer Visitors in Saskatchewan Hospital, Weyburn and examines the importance of occupational and recreational therapies and activities in improving the lives of the patients in that institution. It emphasizes the perspectives of patients and volunteers who actively worked to develop recreational activities, with the intention of helping individuals connect with the surrounding communities. The views and perspectives presented here are drawn from a variety of historical and oral interview sources, including views from visitors to the asylum and patients who lived within its walls. The author has also been a consumer of mental health services, and spent time in the Provincial Mental Hospital in North Battleford. The article therefore makes an important contribution to enhancing our understanding of the social history of deinstitutionalization, not only for its unique source base, but also because those sources have been examined and explained to readers through the perspectives of a former patient herself. This article draws significant attention to the changing opportunities for patients as they interacted with the women's volunteer groups, as well as to how the changes brought about by the encroaching deinstitutionalization, care in the community, and decisions from "above" affected the individuals on the ground.

Shades of greener grass

Neither system or culture is perfect; a blend just might be. I can't say that one is definitely better, only different. Many Canadian doctors have emigrated only to return within a year or two, frustrated with a market-driven health care system and a much more eclectic and individualistic society. Yes, family physicians can earn more money here and have better access to diagnostics and treatment. But that has to be balanced with a larger bureaucracy and-at least on the surface-less freedom to access those resources. With time and the ubiquitous fiscal imperative, both countries could emerge from their respective crises at similar destinations, but by separate paths. Traveling and particularly working in another culture has been a positive experience for our family. It might not be for everyone. Each physician, with his or her family, must weigh the pros and cons of such a decision. To boldly go where you've never been before, to move or not to move: that is the question.

Sociodemographic variation in the prevalence of cardiovascular disease

OBJECTIVE

To estimate the prevalence and social correlates of cardiovascular disease.

DESIGN

Population-based cross-sectional survey. Survey data were obtained through a standardized home interview and a clinic visit by trained nurses. The question sequence of the London School of Hygiene (the Rose Questionnaire) was used to identify the presence of definite angina, possible infarction, definite infarction, intermittent claudication and stroke.

SETTING

Eight urban communities and rural areas in Saskatchewan in 1990.

PARTICIPANTS

A probability sample of 2167 noninstitutionalized men and women aged 18 to 74 years who participated in the Saskatchewan Heart Health Survey.

MAIN OUTCOME MEASURES

Prevalence of cardiovascular diseases.

RESULTS

Among men, the prevalence of definite angina increased gradually with age from 1.7% (95% CI 0.6% to 2.7%) in the 18 to 34 year group, 3.8% (1.3% to 6.0%) in the 35 to 54 year group to 4.8% (2.8% to 8.3%) in the 55 to 74 year group, while the prevalence among women ranged from 2.5% (1.2 to 3.7%), 4.0% (1.6% to 6.5%) to 7.1% (5.1% to 11.6%) in these same age groups. The prevalence of possible angina, definite infarction, possible infarction and intermittent claudication increased with age as well, being higher in men than in women. Generally, the conditions were more prevalent among those with less education, lower income and those who were unemployed.

CONCLUSIONS

These findings indicate that there is sociodemographic inequality in the prevalence of these manifestations of cardiovascular disease, and there is a need for in-depth qualitative research into causal factors in this relationship and for targeted programs of health promotion.