Abstract
Objective
End-stage kidney disease continues to disproportionally impact the lives of First Nations(FN) peoples. This paper examines the trajectory of chronic kidney disease (CKD) care in FN individuals who started dialysis.
Methods
We used health administrative data held at the Manitoba Centre for Health Policy (MCHP) for the period of 2000–2019, which was linked to the Manitoba First Nations Research File to identify Registered FN. Data we used included: Diagnostic Services Manitoba Laboratory Data, Medical Claims, Hospital Discharge Abstracts, Drug Program Information Network Data, Public Canadian Census Files, Manitoba Health Insurance Registry, and Physician Resource File. All records are de-identified. Our primary outcome was to assess the frequency of uninformed dialysis starts among FN.
Lessons Learned
We identified 1,686 FN people who started dialysis during the study period. Of those, 396 (23.5%) started dialysis within three months of their first nephrology visit. We compared those initiating dialysis within 3 month to other FN with longer nephrology follow-up: as a group, FN initiating dialysis within 3 month of their first nephrology visit were more unwell as evidenced by a significantly higher Elixhauser co-morbidity index (5 vs. 3 P < 0.001), hypertension (70.7% vs. 57.1% p < 0.001) and congestive heart failure (31.1 vs17.4% P < 0.001). Primary care visits in all FN groups with CKD occurred in over 95% and CKD screening was similar in all groups at over 40% a year prior to the first nephrology visit. Less than 70% of FN with CKD were on appropriate preventative medications (69 vs. 68% p = NS))
Implications
Improvements in primary prevention at the primary care level are needed to avoid late nephrology referrals and improve overall care of FN with CKD.
Keywords: Renal, Primary care, Indigenous, Aboriginal, Continuity of care
Background
Manitoba First Nations peoples (FNs) have the highest documented prevalence and the second highest incidence of end stage kidney disease (ESKD) in Canada [1]. Those living in rural and remote locations and requiring renal care experience systemic, geographical and economic barriers in accessing optimal care [2]. Although preventable, nephrologists working with FNs have encountered statements that chronic kidney disease (CKD) and ESKD are inevitable, especially from “renal families”, i.e. FN families where other members have already developed CKD and/or ESKD, likely reflecting a sense of powerlessness in the face of systemic barriers (poverty, lack of access to affordable food, limited local access to care, substandard access to primary car and specialists, non-responsive care ) [3–9] that perpetuate risk factors and undermine access to appropriate care until dialysis is required. Studies have documented that FNs diagnosed with ESKD were previously unaware of problems with their kidneys, suggesting a possible failure of primary healthcare [10].
Relocation, and the subsequent dislocation from family, community, support networks, and cultural roles have profound health, social and economic consequences [11]. The renal health trajectory of FNs remain poorly understood, factors include traditional medical risk factors such as HGA1C but may also include poverty, substandard infrastructure as well as failure of the primary healthcare system [8]. Further, the impact of relocating to urban centres on health, housing, education, social and other services, for patients and their families relocating to urban areas, is also insufficiently described [11].
Prevention or at least delay of ESKD and dialysis is possible. Screening for kidney disease in FN populations has been shown to be cost effective [12] and is a long established guideline in those with diabetes [13], which represents the majority of kidney disease in Indigenous populations. During the study period (2000–2019), many interventions were available to help reduce the progression including: use of Angiotensin Converting Enzyme Inhibitor or Angiotensin Receptor Blockers (ACEI or ARB) [13], hypertension (HTN) control and diabetes control [13]. Timely referral to kidney specialists (nephrologists) has been shown to improve outcomes when transitioned to dialysis [14–16] and slow CKD progression to dialysis [17]. Screening and timely referral are increasingly important as medications beyond ACEI and ARBs have now been shown to be effective to delay progression of CKD in the last several years such as sodium-glucose co-transporter 2 (SGLT2) inhibitors Mineralocorticoid receptor (MRA) antagonists and Glucagon-like peptide-1 (GLP-1) agonists [18–26].
This study examines where the health system failed a cohort of FN patients who were seen by nephrology specialists very late in the progression of their kidney disease. Our intent is to learn where in the disease progression opportunities for intervention were missed, in order to galvanize prevention efforts.
Methods
Study methods are detailed in our previous paper [27], but to briefly summarize: the IKHealth project is a partnership between the First Nation Health and Social Secretariat of Manitoba (FNHSSM), the Manitoba Renal Program (MRP, a clinical services organization), and researchers situated at the University of Manitoba. It was funded by the Canadian Institutes for Health Research (#387891).
Ethics
Ethical approval followed the Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans and was performed in accordance with the Manitoba Personal Health Information Act. Individual consent was not required as all identifying details were removed. Ethics approval from the University of Manitoba Health Research Ethics Board (File number H23085), Health Information Research Governance Committee (HIRGC) and Health Information Privacy Committee (HIPC). Approval to include Manitoba FN data was also obtained from HIRGC.
Data sources
Data sources are detailed elsewhere [27] and are held at the Manitoba Centre for Health Policy. All records were de-identified.
Study populations
Manitobans included were registered FN over 10 years of age who started chronic dialysis between Jan 1, 2000 and Dec 31, 2019. Current clinical practice guidelines in Manitoba recommend yearly screening for all at risk individuals, including all FN individuals over 10 years of age [27]. We used a local case definition to ascertain instances of chronic dialysis [28]. The case definition for chronic dialysis was to be on dialysis for ≥ 90 consecutive days or until death or transplant with no more than 15-day gaps between sessions to avoid those with acute kidney injury. Dialysis was determined through tariff codes in the Medical Claims database, kidney transplants were identified using tariff codes or hospital procedure codes, and mortality was ascertained from the Manitoba Health Insurance Registry. Results were then compared to all other Manitobans.
Outcomes
The primary outcome was to assess the number and percentage of FN chronic dialysis patients who were uninformed and therefore underserviced FN ESKD patients (UFNEP). UFNEP was defined as an individual starting dialysis < 3 months after their first appointment with a nephrologist. Nephrology appointments were obtained from the Medical Claims database. In order to capture a secular trend, we reported the percentage of FN chronic dialysis patients who were UFNEP by year. We also reported the number of FN individuals who saw a nephrologist 3–6 months, 6–12 months, and ≥ 12 months prior to starting dialysis. Additionally, we compiled dialysis starts of non-FN individuals in order to report the percentage of overall chronic dialysis patients in Manitoba who were FN and the overall percentage of UFNEP who were FN by year.
Variables
Certain laboratory parameters are important to monitor among those with CKD [29, 30]. To help determine quality of care among FN dialysis patients who had a CKD diagnosis > 1 year before their first nephrology visit, we looked back retrospectively to assess the measurement of these parameters to help assess quality of care within 2 years following their initial CKD diagnosis. We assessed the number of patients who received the following laboratory tests: serum calcium, serum potassium, serum phosphate, hemoglobin, hemoglobin A1C, estimated Glomerular Filtration rate (eGFR), and urine albumin to creatinine ratio (ACR). Additionally, we assessed follow-up primary care visits and prescriptions of diuretics, ACE inhibitors, and ARBs.
We collected various demographic and clinical characteristics at the time of the first nephrology visit and stratified by UFNEP status. Age, sex, and health region of residence were obtained from the Manitoba Health Insurance Registry. We ascertained serum creatinine and urine albumin to creatinine ratio (ACR) from the Shared Health Diagnostic Services database. We calculated estimated glomerular filtration rate (eGFR) from serum creatinine, age, and sex with the CKD-Epidemiology Collaboration study equation for adults and the Pediatric Schwartz formula for children, imputing 3rd percentile height [31, 32]. When urine ACR was not available, we converted urine protein to creatine ratio test results to urine ACR values using an equation developed by Weaver and colleague [33].
We also reported the Elixhauser Comorbidity Index [34] using an algorithm from Quan and colleagues that assessed ICD codes from Medical Claims and Hospital Discharge Abstracts [35]. Diabetes, hypertension, and congestive heart failure (CHF) are comorbidities assessed in that algorithm and were reported separately due to their importance for CKD. Additionally, we reported the time between a CKD diagnosis and nephrology referral using a local case definition to ascertain diagnoses of CKD [28]. The case definition for CKD was either 2 abnormal estimated eGFR or urine ACR test results > 90 days apart in laboratory data, an ICD-9 or ICD-10 diagnosis code indicative of CKD in Medical Claims or Hospital Discharge Abstracts, or a prescription indicative of CKD in the Drug Program Information Network Data.
Statistical analysis
The primary outcomes were descriptive in nature and were reported as frequency and proportion. We compared continuous baseline characteristics, and secondary variables between UFNEP strata using the Mann-Whitney U test, given that the distributions of continuous data were non-normal. We compared categorical variables using the Chi-squared test because it was a cross-sectional analysis with a large enough sample size of expected cell counts. The level of statistical significance was 0.05 for all analyses as it is the conventional standard. Continuous baseline characteristics were summarized as median with interquartile range and categorical baseline characteristics were summarized as frequency and proportion. All analysis was conducted using SAS 9.4.
Results
During the study period (2000 to 2019) the proportion of all dialysis starts who were FNs rose from 20% to 30%. (Fig. 1), while the proportion of Manitobans who were FNs only rose modestly from 9% to 12% according to the most recent Census data at the beginning and end of those time periods [36].
Fig. 1.
Percentage of overall chronic dialysis patients who are First Nations by year of dialysis start
As shown in Table 1, overall, 1686 FN individuals initiated dialysis within the study period. Of those a subset of 396 (23.5%) were seen for the first time by a nephrologist (kidney specialist) less than 3 months prior to the start of dialysis. Due to the short duration between their formal diagnosis with renal disease by a specialist and their start of dialysis they had insufficient time to have adequate workup for CKD and therapy for ESKD prevention. We thus consider and termed these individuals underserviced FN ESKD patients (UFNEP). Additionally, 337 (20%) FN individuals were seen by nephrologists between 3 and 12 months before dialysis initiation, and the remainder, 953 (56.5%) individuals had more than 12 months lead time before dialysis started. The proportion of UFNEP individuals starting dialysis fell throughout the study period. (Fig. 2)
Table 1.
Timing of nephrology visit relative to chronic dialysis start among First Nations patients
| Timing of nephrology visit | Number of FN patients |
|---|---|
| All | 1686 |
| < 3 months prior to starting dialysis* | 396 (23.5%) |
| 3–6 months prior to starting dialysis | 130 (7.7%) |
| 6–12 months prior to starting dialysis | 207 (12.3%) |
| ≥ 12 months prior to starting dialysis | 953 (56.5%) |
*Defined as uninformed ESKD patient (UFNEP)
Fig. 2.
Percentage of First Nations chronic dialysis patients who started dialysis < 3 months after their first nephrology visit by calendar year of dialysis start
Compared to those diagnosed between 3 and 12 months before initiating dialysis, UFNEP individuals (Table 2) tended to male (54.5% vs. 48.2%, p = 0.028) and had a significantly lower renal function with a lower glomerular filtration rate or eGFR) at initial nephrology visit (8 vs. 25.5 ml/min/1.73 m2 p < 0.001). Despite their advanced eGFR at their first nephrology visit there was not a significant difference between the diagnosis of CKD in their home communities, (as determined by bloodwork drawn in the community) and their first nephrology visit. Over 40% in both groups had a CKD diagnosis (43% vs. 47% p = NS) more than 1 year before their nephrology visit. While an identical proportion had diabetes as a diagnosis (74.2%), the UFNEP group was generally more unwell as evidenced by significantly higher Elixhauser co-morbidity index (5 vs. 3 p < 0.001), HTN (70.7% vs. 57.1% p < 0.001) and CHF (31.1 vs17.4% p < 0.001). There appeared to be no difference in proportion of UFNEP vs. non-UFNEP in relation to remoteness of home location compared to those living in the central nephrology hub in Winnipeg.
Table 2.
Baseline characteristics of First Nations chronic dialysis patients stratified by whether they started dialysis within 3 months of their first nephrology visit
| Variable* | Overall (n = 1686) | UFNEP (<3 months) (n = 396) | non-UFNEP (≥ 3 months) (n = 1290) | p-value |
|---|---|---|---|---|
| Age | 52 (42, 61) | 53 (44, 61) | 52 (41, 60) | 0.043 |
| Sex (% Male) | 838 (49.7%) | 216 (54.5%) | 622 (48.2%) | 0.028 |
| eGFR (ml/min/1.73 m2) | 21.5 (10, 41) | 8 (5, 12) | 25.5 (15, 41) | < 0.001 |
| Urine ACR (mg/mmol) | 261.6 (43.6, 459.3) | 297.1 (23.8, 509.5) | 299 (86.2, 505) | 0.65 |
|
Days between CKD diagnosis and nephrology referral |
253.5 (0, 1321) | 228 (1, 1234.5) | 272 (0, 1349) | 0.88 |
|
≥ 1 year between CKD diagnosis and nephrology referral |
782 (46.4%) | 172 (43.4%) | 610 (47.3%) | 0.178 |
| Elixhauser Comorbidity Index | 4 (2, 6) | 5 (3, 7) | 3 (2, 5) | < 0.001 |
| Diabetes | 1252 (74.2%) | 294 (74.2%) | 957 (74.2%) | 0.98 |
| Hypertension | 1016 (60.3%) | 280 (70.7%) | 736 (57.1%) | < 0.001 |
| Congestive Heart Failure | 348 (20.6%) | 123 (31.1%) | 235 (17.4%) | < 0.001 |
|
Health Region Interlake-Eastern RHA Northern Health Region Southern Health-Santé Sud Prairie Mountain Health Winnipeg RHA |
334 (19.8%) 681 (40.4%) 127 (7.5%) 163 (9.7%) 381 (22.6%) |
82 (20.7%) 150 (37.9%) 37 (9.3%) 34 (8.6%) 93 (23.5%) |
252 (19.5%) 531 (41.2%) 90 (7.0%) 129 (10.0%) 288 (22.3%) |
0.40 |
*Continuous variables presented as median (interquartile range)
Information was available on 454 (58%) of the 782 individuals whose CKD diagnosis was at least 1 year or more prior to the nephrology referral (Table 3). In the case of UFNEP and non-UFNEP individuals the vast majority had an eGFR performed (90.2 vs. 91.2% p = NS) while fewer had appropriate urine ACR testing (77.4 vs. 78.1% p = NS). Ancillary tests: HbA1C (72.5 vs. 80.7% p = NS), hemoglobin (89.2 vs. 93.2% p = NS), and potassium (88.2 vs. 89.2% p = NS) were also not significantly different in both groups. Tests that are important to renal care, (i.e. calcium (65.7% vs. 61.4% p = NS) and phosphate (61.8 vs. 57.4% p = NS)), but of a slightly more specialized nature were performed less often, but still performed in a majority of cases.
Table 3.
Patients with follow-up testing within 2 years of initial CKD diagnosis among FN HD patients with a CKD diagnosis > 1 year before their first nephrology visit, 2006–2019
| Laboratory Test (% 1 or more) | Overall (n = 454) | UFNEP (<3 months) (n = 102) | non-UFNEP (≥ 3 months) (n = 352) | p-value |
|---|---|---|---|---|
| Calcium | 283 (62.2%) | 67 (65.7%) | 216 (61.4%) | 0.43 |
| Potassium | 404 (89.0%) | 90 (88.2%) | 314 (89.2%) | 0.78 |
| Phosphate | 265 (58.4%) | 63 (61.8%) | 202 (57.4%) | 0.43 |
| Hemoglobin | 384 (84.6%) | 91 (89.2%) | 293 (83.2%) | 0.141 |
| eGFR | 413 (91.0%) | 92 (90.2%) | 321 (91.2%) | 0.76 |
| Urine ACR | 354 (78.0%) | 79 (77.4%) | 275 (78.1%) | 0.89 |
| HbA1C | 358 (78.8%) | 74 (72.5%) | 284 (80.7%) | 0.077 |
Of the 782 individuals whose CKD diagnosis was at least one year prior to the first nephrology visit (Table 4), just under 70% were appropriately on an ACEI or ARB to prevent progression of CKD, but there was no difference between the UFNEP and non-UFNEP group. This is despite a very high number (95.9 vs. 98.5% p = NS) having had a primary care visit in that time frame. A higher proportion in the UFNEP group were on diuretics, reflecting their higher co-morbidities and higher proportion of CHF (49.4 vs. 37.7% p = 0.006).
Table 4.
Other care indicators < 2 years after CKD diagnosis among First Nations chronic dialysis patients with a CKD diagnosis ≥ 1 year before their first nephrology visit, 2000–2019
| Care Indicator (% 1 or more) | Overall (n = 782) | UFNEP (<3months) (n = 172) | non-UFNEP (≥ 3 months) (n = 610) | p-value |
|---|---|---|---|---|
| Diuretic prescription | 315 (40.3%) | 85 (49.4%) | 230 (37.7%) | 0.006 |
| ACEi or ARB prescription | 533 (68.2%) | 119 (69.2%) | 414 (67.9%) | 0.74 |
| Primary care visit | 766 (97.9%) | 165 (95.9%) | 601 (98.5%) | 0.059 |
Discussion
Despite representing only 12% of the population during the study period, around 30% of those starting dialysis were FN. This higher burden of illness is particularly difficult for all Manitoban patients living in remote areas as this means relocating away from family, friends and supportive communities for dialysis in large unfamiliar urban centres [11].
Progressive CKD and dialysis can be mitigated, slowed down or at least anticipated by early screening, appropriate treatment and timely referral to kidney specialists [13–26, 28]. Unfortunately, we found almost a quarter of FN patients (23.5%) started chronic dialysis within 3 months of seeing a nephrologist. This timeframe is not of a sufficient duration to slow the course of the disease and does not provide enough time to emotionally prepare for the life altering treatment of dialysis. These referrals were late despite over 95% having primary care visits, equal use of screening tests (eGFR and ACR) and equal use of preventative medications (ACEI). In addition, those with a later referral had more co-morbidities and higher prevalence of diseases such as HTN and CHF. One would surmise that sicker patients would prompt more timely referrals rather than more delayed referrals.
While there was no significant differences in screening tests such as eGFR and urine ACR in those with short vs. longer durations between nephrology referral to dialysis initiation, these screening tests show poor attention to the underlying condition as approximately 10% of those with known CKD did not have a follow up test of renal function (eGFR) within 2 years and basic urine tests were only repeated in 22% contrary to recommended guidelines [13]. In addition, almost a third of those with known CKD did not have basic preventative medication (ACEI/ARB) prescribed.
The potential reasons for the apparent gap in care was not directly studied. Primary care providers (PCP) may not recognize or are not familiar with the treatment of early CKD. In addition, the model of care available in rural and remote FN is understaffed and available staff are chronically overworked [37] making preventative care a secondary priority to addressing acute problems. Appointments to specialists mean travel to large urban centres often over 500–1000 km away, which is disruptive and challenging. While those in urban centres experienced similar outcomes, many FN live in lower socio-economic inner-city areas which have similar challenges to medical access. FN experience high levels of interpersonal, institutional and systemic racism [38], which may mean that their issues are dismissed more readily, or perpetuate distrust of a system that often treats them poorly and might be hesitant to seek care until symptoms are dire. Still, our results suggest that primary care was sought but that protective medication was used by just under 70% of FNs living with CKD. We recognize that our data cannot distinguish prescriptions given and filled. Thus, the result of interpersonal and systemic racism, as well as barriers to accessing prescription drugs, may explain why less than 70% of FNs with CKD were on renal function protective drugs.
Better resourcing of existing strained primary care services on FN communities and in urban environments would likely help to improve some of these parameters, in fact the number of UFNEP has decreased during the study period indicating some efforts are being made. However, a FN centric approach with FN community-based health navigators to help advocate for at risk patients and guide them through the system to better care might reduce barriers to access culturally safe care [27]. FN-centered care would also be free of systemic and interpersonal racism, which could encourage those at the margins, who would not even have been part of this study as they may have avoided western medicine and screening all together, to come forward for care. FN nurses and community-based health workers could help design and then use algorithms to guide the addition of preventative medications (ACEI/ARB) and treatment of hypertension and diabetes [13]. Newer medications that were not yet being used during the study period (SGLT2s, MRAs and GLP-1) [18–26], make continuity and prevention focused care all the more important. Given increasing complexity, a structured team approach guided by algorithms and integrated with the provincial kidney health specialty team.
In addition to community-run algorithms for renal care, electronic reporting and auto-referral to nephrology when certain criteria are met would be another way to not only prevent the progression of CKD, but to ensure referrals to specialist care were timely.
While these initiatives would be expensive, the cost of one year of dialysis is $70,000 per year in large urban centres and can be up to $250,000 per year in some remote northern communities. Avoiding even one year of dialysis with these measures clearly is an investment and not an additional cost to the health care system [39]. Further and perhaps more importantly, better preventative and management care of CKD will improve the quality of life of First Nations.
The strengths of this study are that it is a robust picture of physician practice and prescribing as all prescribing and primary care visits are tracked province wide. In addition, the majority of all lab tests done in Manitoba are available for analysis. Point of care testing is an exception, but generally is rarely done in isolation as usually confirmatory tests are sent out.
There are limitations to this study. We do not know why some individuals had a short duration between nephrology visit and starting dialysis. There are conditions other than diabetic nephropathy that progress more rapidly (e.g. vasculitis) that are harder to screen for and prevent that may have led to some of these cases, although the proportion of diabetes in each group was identical which argues against a significant proportion of alternative causes of renal failure as a cause for the delay in referral. Patient factors such as attendance at PCP and specialist visits is unknown, as is the adherence to medical therapy.
We were unable to obtain blood pressure readings. It is known achieving blood pressure targets improves outcomes and albuminuria. If we had this information we could have broadened our focus to other antihypertensive medicines. Instead we focused on medications most directly improving albuminuria, (ACEI and ARB) and on diuretics addressing CHF.
Conclusion
Our study shows a need for improvement in the primary care management of CKD, aiming to slow down disease progression through the use of prescription drugs that protect renal function. A more in-depth examination of the patient journey may help provide insight into the patient perspective. This may help guide the development of community prevention and treatment clinics and a better pathway to engage patients in lifelong prevention activities that are free of systemic racism and embrace FN cultural ideals.
Acknowledgements
The authors acknowledge the Manitoba Centre for Health Policy for use of data contained in the Manitoba Population Research Data Repository under project #2020-039_(HIPC#2019/2020-35). The results and conclusions are those of the authors and no official endorsement by the Manitoba Centre for Health Policy, Manitoba Health, University of Manitoba, or other data providers is intended or should be inferred. Data used in this study are from the Manitoba Population Research Data Repository housed at the Manitoba Centre for Health Policy, University of Manitoba and were derived from data provided by Manitoba Health, First Nations Health and Social Secretariat of Manitoba, the Winnipeg Regional Health Authority, and Shared Health Diagnostic Services.
Authors’ contributions
JZ wrote the bulk of the manuscript, RW was primarily responsible for the statistics and wrote the statistical methods section and prepared the figures and tables. JZ, LM, TC, RW and JL help design the study and review data, provided feedback and reviewed the manuscript.
Funding
Funding was provided by a grant from the Canadian Institute of Health Research. (CIHR grant #387891)
Data availability
Data used in this article was derived from administrative health and social data as a secondary use. The data was provided under specific data sharing agreements only for approved use at Manitoba Centre for Health Policy (MCHP). The original source data is not owned by the researchers or MCHP and as such cannot be provided to a public repository. The original data source and approval for use has been noted in the acknowledgments of the article. Where necessary, source data specific to this article or project may be reviewed at MCHP with the consent of the original data providers, along with the required privacy and ethical review bodies. Please contact the lead author, James Zacharias, with any questions about the data. Email: jzacharias@hsc.mb.ca.
Declarations
Ethics approval and consent to participate
The Canadian Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans was followed. This is compliant with the declaration of Helsinki. Approval from the University of Manitoba Health Research Ethics Board (File number H23085) was obtained. The Health Information Privacy Committee (HIPC) and the Health Information Research Governance Committee (HIRGC). HIRGC, anchored within FNHSSM, holds the responsibility of authorizing/approving/ reviewing ethics applications which include Manitoba FNs in regional research projects. Because this study used data from de-identified administrative databases that did not include names and addresses, a waiver to obtain individual informed consent was provided by the Health Information Privacy Committee (HIPC, recently renamed the Provincial Health Research Privacy Committee (PHRPC), in accordance with the Manitoba Personal Health Information Act.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Data used in this article was derived from administrative health and social data as a secondary use. The data was provided under specific data sharing agreements only for approved use at Manitoba Centre for Health Policy (MCHP). The original source data is not owned by the researchers or MCHP and as such cannot be provided to a public repository. The original data source and approval for use has been noted in the acknowledgments of the article. Where necessary, source data specific to this article or project may be reviewed at MCHP with the consent of the original data providers, along with the required privacy and ethical review bodies. Please contact the lead author, James Zacharias, with any questions about the data. Email: jzacharias@hsc.mb.ca.