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Research

Hospital admission for stroke or transient ischemic attack among First Nations people with diabetes in Ontario: a population-based cohort study

Moira K. Kapral, Baiju R. Shah, Michael E. Green, Joan Porter, Rebecca Griffiths, Eliot Frymire, Morgan Slater, Kristen Jacklin, Roseanne Sutherland and Jennifer D. Walker
March 16, 2020 8 (1) E156-E162; DOI: https://doi.org/10.9778/cmajo.20190199
Moira K. Kapral
Department of Medicine (Kapral, Shah), University of Toronto; ICES (Kapral, Shah, Porter, Walker), Toronto, Ont.; Department of Family Medicine (Green, Frymire, Slater), Queen’s University; ICES Queen’s (Green, Griffiths, Frymire, Slater), Kingston, Ont.; Memory Keepers Medical Discovery Team (Jacklin), Department of Family Medicine and Biobehavioral Health, University of Minnesota Medical School Duluth, Duluth, Minn.; Chiefs of Ontario (Sutherland); School of Rural and Northern Health (Walker), Laurentian University, Sudbury, Ont.
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Baiju R. Shah
Department of Medicine (Kapral, Shah), University of Toronto; ICES (Kapral, Shah, Porter, Walker), Toronto, Ont.; Department of Family Medicine (Green, Frymire, Slater), Queen’s University; ICES Queen’s (Green, Griffiths, Frymire, Slater), Kingston, Ont.; Memory Keepers Medical Discovery Team (Jacklin), Department of Family Medicine and Biobehavioral Health, University of Minnesota Medical School Duluth, Duluth, Minn.; Chiefs of Ontario (Sutherland); School of Rural and Northern Health (Walker), Laurentian University, Sudbury, Ont.
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Michael E. Green
Department of Medicine (Kapral, Shah), University of Toronto; ICES (Kapral, Shah, Porter, Walker), Toronto, Ont.; Department of Family Medicine (Green, Frymire, Slater), Queen’s University; ICES Queen’s (Green, Griffiths, Frymire, Slater), Kingston, Ont.; Memory Keepers Medical Discovery Team (Jacklin), Department of Family Medicine and Biobehavioral Health, University of Minnesota Medical School Duluth, Duluth, Minn.; Chiefs of Ontario (Sutherland); School of Rural and Northern Health (Walker), Laurentian University, Sudbury, Ont.
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Joan Porter
Department of Medicine (Kapral, Shah), University of Toronto; ICES (Kapral, Shah, Porter, Walker), Toronto, Ont.; Department of Family Medicine (Green, Frymire, Slater), Queen’s University; ICES Queen’s (Green, Griffiths, Frymire, Slater), Kingston, Ont.; Memory Keepers Medical Discovery Team (Jacklin), Department of Family Medicine and Biobehavioral Health, University of Minnesota Medical School Duluth, Duluth, Minn.; Chiefs of Ontario (Sutherland); School of Rural and Northern Health (Walker), Laurentian University, Sudbury, Ont.
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Rebecca Griffiths
Department of Medicine (Kapral, Shah), University of Toronto; ICES (Kapral, Shah, Porter, Walker), Toronto, Ont.; Department of Family Medicine (Green, Frymire, Slater), Queen’s University; ICES Queen’s (Green, Griffiths, Frymire, Slater), Kingston, Ont.; Memory Keepers Medical Discovery Team (Jacklin), Department of Family Medicine and Biobehavioral Health, University of Minnesota Medical School Duluth, Duluth, Minn.; Chiefs of Ontario (Sutherland); School of Rural and Northern Health (Walker), Laurentian University, Sudbury, Ont.
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Eliot Frymire
Department of Medicine (Kapral, Shah), University of Toronto; ICES (Kapral, Shah, Porter, Walker), Toronto, Ont.; Department of Family Medicine (Green, Frymire, Slater), Queen’s University; ICES Queen’s (Green, Griffiths, Frymire, Slater), Kingston, Ont.; Memory Keepers Medical Discovery Team (Jacklin), Department of Family Medicine and Biobehavioral Health, University of Minnesota Medical School Duluth, Duluth, Minn.; Chiefs of Ontario (Sutherland); School of Rural and Northern Health (Walker), Laurentian University, Sudbury, Ont.
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Morgan Slater
Department of Medicine (Kapral, Shah), University of Toronto; ICES (Kapral, Shah, Porter, Walker), Toronto, Ont.; Department of Family Medicine (Green, Frymire, Slater), Queen’s University; ICES Queen’s (Green, Griffiths, Frymire, Slater), Kingston, Ont.; Memory Keepers Medical Discovery Team (Jacklin), Department of Family Medicine and Biobehavioral Health, University of Minnesota Medical School Duluth, Duluth, Minn.; Chiefs of Ontario (Sutherland); School of Rural and Northern Health (Walker), Laurentian University, Sudbury, Ont.
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Kristen Jacklin
Department of Medicine (Kapral, Shah), University of Toronto; ICES (Kapral, Shah, Porter, Walker), Toronto, Ont.; Department of Family Medicine (Green, Frymire, Slater), Queen’s University; ICES Queen’s (Green, Griffiths, Frymire, Slater), Kingston, Ont.; Memory Keepers Medical Discovery Team (Jacklin), Department of Family Medicine and Biobehavioral Health, University of Minnesota Medical School Duluth, Duluth, Minn.; Chiefs of Ontario (Sutherland); School of Rural and Northern Health (Walker), Laurentian University, Sudbury, Ont.
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Roseanne Sutherland
Department of Medicine (Kapral, Shah), University of Toronto; ICES (Kapral, Shah, Porter, Walker), Toronto, Ont.; Department of Family Medicine (Green, Frymire, Slater), Queen’s University; ICES Queen’s (Green, Griffiths, Frymire, Slater), Kingston, Ont.; Memory Keepers Medical Discovery Team (Jacklin), Department of Family Medicine and Biobehavioral Health, University of Minnesota Medical School Duluth, Duluth, Minn.; Chiefs of Ontario (Sutherland); School of Rural and Northern Health (Walker), Laurentian University, Sudbury, Ont.
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Jennifer D. Walker
Department of Medicine (Kapral, Shah), University of Toronto; ICES (Kapral, Shah, Porter, Walker), Toronto, Ont.; Department of Family Medicine (Green, Frymire, Slater), Queen’s University; ICES Queen’s (Green, Griffiths, Frymire, Slater), Kingston, Ont.; Memory Keepers Medical Discovery Team (Jacklin), Department of Family Medicine and Biobehavioral Health, University of Minnesota Medical School Duluth, Duluth, Minn.; Chiefs of Ontario (Sutherland); School of Rural and Northern Health (Walker), Laurentian University, Sudbury, Ont.
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    Figure 1:

    Age- and sex-standardized rate of hospital admission for acute stroke or transient ischemic attack among First Nations people and other people in Ontario per 100 000 people with diabetes, Apr. 1, 1996, to Mar. 31, 2016. Dotted lines represent 95% confidence intervals.

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    Table 1:

    Characteristics of First Nations people and other people in Ontario with diabetes admitted to hospital with stroke or transient ischemic attack in Ontario, Apr. 1, 2011, to Mar. 31, 2016

    CharacteristicNo. (%) of people*
    First Nations people with diabetes
    n = 536
    Other people in Ontario with diabetes
    n = 28 338
    Age, yr, median (IQR)63 (55–71)74 (65–81)
    Age group, yr
     20–4966 (12.3)1065 (3.8)
     50–64231 (43.1)5841 (20.6)
     65–79190 (35.4)12 564 (44.3)
     ≥ 8049 (9.1)8868 (31.3)
    Female sex287 (53.5)13 274 (46.8)
    Rurality†
     Urban151 (28.2)19 265 (68.4)
     Semiurban90 (16.8)6203 (22.0)
     Rural121 (22.6)2680 (9.5)
     Missing174 (32.5)190 (0.7)
    Comorbidity
     Low (≤ 4 ADGs)67 (12.5)3158 (11.1)
     Medium (5–9 ADGs)173 (32.3)9979 (35.2)
     High (≥ 10 ADGs)296 (55.2)15 201 (53.6)
    Stroke type
     Hemorrhagic55 (10.3)3203 (11.3)
     Ischemic372 (69.4)20 854 (73.6)
    Transient ischemic attack109 (20.3)4281 (15.1)
    • Note: ADGs = Aggregated Diagnosis Groups (used as a measure of comorbidity),

    • IQR = interquartile range.

    • ↵* Except where noted otherwise.

    • ↵† Defined according to the Rurality Index for Ontario.21

    • View popup
    Table 2:

    Rates per 100 000 of hospital admission for stroke or transient ischemic attack among First Nations people and other people in Ontario with diabetes, Apr. 1, 2015, to Mar. 31, 2016, by sex, age group and event type

    VariableRate per 100 000 (95% CI)
    First Nations peopleOther people in Ontario
    Overall641.2 (539.8–756.2)540.2 (527.7–552.9)
    Sex
     Men667.0 (518.0–845.6)555.4 (537.8–573.4)
     Women619.0 (485.2–778.3)523.8 (506.1–542.0)
    Age, yr
     20–29–*42.0 (18.2–82.8)
     30–49271.0 (154.9–440.1)99.0 (85.3–114.2)
     50–64776.4 (605.2–980.9)281.8 (266.5–297.8)
     65–79837.7 (611.0–1120.9)621.3 (598.8–644.4)
     ≥ 80990.1 (474.8–1820.8)1466.3 (1411.7–1522.4)
    Event type
     Stroke602.9 (490.2–733.6)448.3 (437.1–459.7)
     Transient ischemic attack151.5 (97.2–225.2)75.4 (70.9–80.2)
    • Note: CI = confidence interval.

    • ↵* Suppressed owing to small cell count.

    • View popup
    Table 3:

    Rates of processes of care and outcomes after acute stroke among First Nations people and other people in Ontario with diabetes, Apr. 1, 2011, to Mar. 31, 2017*

    Care/outcome†Point estimate, % (95% CI)
    First Nations peopleOther people in Ontario
    Neuroimaging‡94.6 (85.9–100.0)96.0 (94.2–97.9)
    Thrombolysis§6.3 (3.9–9.7)11.0 (10.3–11.7)
    Carotid revascularization§1.4 (0.5–3.0)2.7 (2.4–3.0)
    Discharge to inpatient rehabilitation¶31.8 (26.0–38.5)34.8 (33.6–36.1)
    7-d case fatality¶12.0 (8.9–15.9)8.5 (8.0–9.0)
    30-d case fatality¶19.2 (15.2–24.0)16.0 (15.3–16.6)
    1-yr case fatality¶
     Overall33.8 (28.2–40.2)28.1 (27.1–29.1)
     Sex
      Men34.3 (26.8–43.2)32.9 (31.9–33.9)
      Women31.9 (24.9–40.1)37.9 (36.8–39.1)
     Age, yr
      30–4928.6 (15.6–47.9)15.0 (12.7–17.7)
      50–6427.4 (20.4–35.9)21.3 (20.1–22.6)
      65–7937.2 (28.0–48.4)33.4 (32.3–34.5)
      ≥ 8051.1 (32.4–76.7)49.9 (48.3–51.5)
    • Note: CI = confidence interval.

    • ↵* All events (with the exception of age- and sex-specific case fatality) were age- and sex-standardized to the 2001 Ontario population aged 20 years or more with diabetes.

    • ↵† The denominator for brain imaging and thrombolysis included people admitted to hospital with events between Apr. 1, 2012, and Mar. 31, 2017. The denominator for carotid revascularization, discharge to inpatient rehabilitation and case fatality included those admitted to hospital between Apr. 1, 2011, and Mar. 31, 2016.

    • ↵‡ Computed tomography or magnetic resonance imaging of the brain; calculated in those with any stroke or transient ischemic attack (TIA).

    • ↵§ Calculated in those with ischemic stroke (TIA and hemorrhagic stroke excluded).

    • ↵¶ Calculated in those with any stroke (TIA excluded).

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Hospital admission for stroke or transient ischemic attack among First Nations people with diabetes in Ontario: a population-based cohort study
Moira K. Kapral, Baiju R. Shah, Michael E. Green, Joan Porter, Rebecca Griffiths, Eliot Frymire, Morgan Slater, Kristen Jacklin, Roseanne Sutherland, Jennifer D. Walker
Jan 2020, 8 (1) E156-E162; DOI: 10.9778/cmajo.20190199

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Hospital admission for stroke or transient ischemic attack among First Nations people with diabetes in Ontario: a population-based cohort study
Moira K. Kapral, Baiju R. Shah, Michael E. Green, Joan Porter, Rebecca Griffiths, Eliot Frymire, Morgan Slater, Kristen Jacklin, Roseanne Sutherland, Jennifer D. Walker
Jan 2020, 8 (1) E156-E162; DOI: 10.9778/cmajo.20190199
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