1. 1 Canadian Institute for Health Information

2. Hospital Care for Heart Attacks Among First Nations, Inuit and Métis Released January 31, 2013 2

3. Report Overview In Canada, little is known about the incidence of heart attacks among First Nations, Inuit and Métis or the care that they receive to treat a heart attack This report aims to fill this important gap by examining whether disparities exist between the rates of heart attacks and treatment- related factors and outcomes for First Nations and Inuit and for others in Canada Analyses related to heart health for Métis from two recent provincial studies are also included in the report The report also includes the results of a scan of Canadian interventions that identify promising approaches to health service delivery that support Aboriginal populations in dealing with chronic disease, including heart disease 3

4. Methods: Area-Based Approach Information about patients’ ethnicity is not recorded consistently across the country in hospital records Area-based (Geozones) methodology, developed by Statistics Canada, used in the absence of ethnic identifiers in hospital records Methodology identifies patients living in areas where a relatively high proportion of residents self-identified as First Nations and Inuit (known as high–First Nations and high-Inuit areas) –High–First Nations areas are compared with low-Aboriginal areas –High-Inuit areas are compared with low-Aboriginal areas that are also remote, given that all residents from high-Inuit areas are located in remote areas An area-based Geozones methodology cannot be used to identify areas where there is a relatively high proportion of Métis 4

5. Methods: Data Sources and Analysis Data sources –Discharge Abstract Database (CIHI) –National Ambulatory Care Reporting System (CIHI) –Alberta Ambulatory Care Database (Alberta Health and Wellness) Data was pooled for 2004–2005 to 2010–2011, due to the small number of heart attack events in high-Aboriginal areas Data is for patients age 20 and older Bivariate and multiple-variate analysis assessed whether disparities exist in –Admission and diagnosis: rates of hospitalized heart attack events and treatment-related factors—age, comorbidities, distance to treatment –In-hospital treatment for heart attacks: rates of cardiac procedures among heart attack patients, such as coronary angiography, percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) –Hospital discharge and outcomes of care: length of stay, discharge destination and 30-day in-hospital mortality 5

6. Key Findings From First Nations Chapter 6 Notes * Statistically significant. Figure does not include Quebec data. Sources Discharge Abstract Database, 2004–2005 to 2010–2011, Canadian Institute for Health Information; Census, 2006, Statistics Canada. High–First Nations Areas Low-Aboriginal Areas Residents of high–First Nations areas are more likely to experience a heart attack and to do so at a younger age, and they are admitted to hospital with more comorbid conditions, especially diabetes, compared with residents of low-Aboriginal areas

7. Key Findings From First Nations Chapter 7 More than one-third (38%) of patients from high–First Nations areas had to travel more than 250 km to access the nearest hospital with on-site cardiac revascularization capacity, compared with only 8% of patients from low-Aboriginal areas Note Figure does not include Quebec data. Sources Discharge Abstract Database, 2004–2005 to 2010–2011, Canadian Institute for Health Information; Census, 2006, Statistics Canada.

8. Key Findings From First Nations Chapter 8 Notes * Statistically significant. Figure does not include Quebec data. Sources Discharge Abstract Database and National Ambulatory Care Reporting System, 2004–2005 to 2010–2011, Canadian Institute for Health Information; Alberta Ambulatory Care Database, 2004–2005 to 2009–2010, Alberta Health and Wellness; Census, 2006, Statistics Canada. High–First Nations Areas Low-Aboriginal Areas Heart attack patients from high–First Nations areas are less likely to receive cardiac angiography and revascularization procedures (PCI in particular) than patients from low-Aboriginal areas; this pattern persists after controlling for patient and clinical factors

9. Key Findings From First Nations Chapter 9 Note Figure does not include Quebec data. Sources Discharge Abstract Database, 2004–2005 to 2010–2011, Canadian Institute for Health Information; Census, 2006, Statistics Canada. High–First Nations Areas Low-Aboriginal Areas Heart attack patients from high–First Nations areas have similar short-term outcomes for 30-day in-hospital mortality and length of stay as those from low-Aboriginal areas; overall, the majority of all heart attack patients head home after their hospital stay

10. Key Findings From Inuit Chapter 10 Notes * Statistically significant. Figure does not include Quebec data. Sources Discharge Abstract Database, 2004–2005 to 2010–2011, Canadian Institute for Health Information; Census, 2006, Statistics Canada. Residents of high-Inuit areas are less likely to be admitted to acute care hospitals for a heart attack than residents of remote low-Aboriginal areas High-Inuit Areas Remote Low-Aboriginal Areas

11. Key Findings From Inuit Chapter 11 All heart attack patients from high-Inuit areas travel more than 500 km to access hospitals with cardiac revascularization capacity; despite this distance, 42% of patients from those areas receive revascularization procedures, similar to the proportion of patients from remote low-Aboriginal areas (44%) Note Figure does not include Quebec data. Sources Discharge Abstract Database, 2004–2005 to 2010–2011, Canadian Institute for Health Information; Census, 2006, Statistics Canada.

12. Key Findings From Métis Chapter 12 An area-based Geozones methodology cannot be used to identify areas where there is a relatively high proportion of Métis, as less than 10% of Métis live in areas that meet the Geozones definition of a high-concentration area Findings are presented from studies in Manitoba and Ontario, where provincial Métis registries have been linked to hospital records to examine the health and health service use of Métis at the individual level in these provinces While these studies are not directly comparable, they show that Métis have a higher risk for and rate of heart attacks than their provincial counterparts, and that Métis in Manitoba are more likely to receive CABG than others in Manitoba

13. Key Findings From Chapter on Interventions to Support Aboriginal Peoples The pan-Canadian scan conducted to identify promising approaches to health service delivery that support Aboriginal peoples in dealing with chronic disease identified more than 70 examples of policies and programs for Aboriginal peoples –The synthesis focused on about 30 initiatives that have been evaluated, to profile some of what is known about programming for heart health, but non-evaluated programs were also included to provide useful information about current activity Relationships between patients and providers, and their communities, are the foundation for many of these interventions Care for chronic conditions also involves initiatives outside of hospital settings that can affect access to care, and building relationships that address geographic and cultural barriers were identified as important in the delivery of health care services 13

14. Conclusion This report highlights that disparities exist in rates of heart attacks and the hospital experiences of heart attack patients in high- Aboriginal and low-Aboriginal areas There continues to be a need to further explore disparities in treatment and care for heart attacks among Aboriginal peoples and non-Aboriginal peoples in Canada Future research could more fully explore treatment interventions beyond diagnostic and revascularization procedures in acute care settings as well as longer-term outcome indicators, which would provide a more comprehensive picture of the care pathways of, equity in access to and receipt of cardiac care for First Nations, Inuit and Métis with heart disease 14

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16. About the Canadian Institute for Health Information (CIHI) CIHI established in 1994 as independent, not-for-profit corporation CIHI’s vision: Better data. Better decisions. Healthier Canadians. CIHI’s mandate: To lead the development and maintenance of comprehensive and integrated health information that enables sound policy and effective health system management that improve health and health care CIHI’s data holdings: 27 databases of health information Range of stakeholders in health system and beyond –Government organizations (such as Health Canada and Statistics Canada), ministries of health, regional health authorities, non- government organizations, private-sector organizations, professional associations, health facilities 16

17. About the Canadian Population Health Initiative (CPHI) CPHI is a branch within CIHI CPHI’s mission: To support policy-makers and health system managers in Canada in their efforts to improve population health and reduce health inequalities through research and analysis, evidence synthesis and performance measurement 17

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