Disparities in the hospital cost of cardiometabolic diseases among lesbian, gay, and bisexual Canadians: a population-based cohort study using linked data

Abstract

Objectives

Sexual identity has been recognized as a social determinant of health; however, evidence is limited on sexual minority status as a possible contributor to inequalities in cardiometabolic outcomes and the related hospital burden. This study aimed to investigate the association between sexual identity and hospital costs for cardiometabolic diseases among a cohort of Canadians using linked survey and administrative data.

Methods

Data from the 2007–2011 Canadian Community Health Survey were linked to acute-care inpatient records from the 2005/2006–2012/2013 Discharge Abstract Database. Multiple linear regression was used to assess the association between self-reported sexual identity and inpatient resource use for cardiometabolic diseases.

Results

Among the population ages 18–59, 2.1% (95% CI 1.9–2.2) identified as lesbian, gay, or bisexual (LGB). LGB individuals more often reported having diabetes or heart disease compared with heterosexuals. The mean inflation-adjusted cost for cardiometabolic-related hospitalizations was found to be significantly higher among LGB patients (CAD$26,702; 95% CI 26,166–60,365) than among their heterosexual counterparts ($10,137; 95% CI 8,639–11,635), in part a reflection of longer hospital stays (13.6 days versus 5.1 days). Inpatient costs remained 54% (95% CI 8–119) higher among LGB patients after controlling for socio-demographics, health status, and health behaviours.

Conclusion

This study revealed a disproportionate cost for potentially avoidable hospitalizations for cardiometabolic conditions among LGB patients, suggesting important unmet healthcare needs even in the Canadian context of universal coverage.

Introduction

There is increasing evidence from different countries that sexual minorities—including lesbian, gay, and bisexual (LGB) individuals—experience significant health inequalities across a range of physical, mental, and behavioural health indicators (Booker et al. 2017; Branstrom et al. 2016; Fredriksen-Goldsen et al. 2013; King et al. 2008; Rice et al. 2019; Stinchcombe et al. 2018). LGB persons are often described as having poorer health status and well-being compared with their heterosexual peers, a pattern widely attributed to social stresses stemming from underlying stigma, prejudice, and discrimination (Frost et al. 2015; Meyer 2003).

The availability of national data on sexual minorities to inform public health policy and practice to address health inequalities has grown in Canada and elsewhere in recent years (Bradford and Mustanski 2014; Dharma and Bauer 2017). The data have pointed to higher unmet healthcare needs among LGB individuals, even in the Canadian context of single-payer universal healthcare coverage (Brennan et al. 2010; Tjepkema 2008). However, research on LGB health has tended to focus on sexual health and on mental health and behavioural disorders. While it has been posited that prejudice-related minority stresses may be syndemically damaging to physical and mental health (Byg et al. 2016; Frost et al. 2015), cardiometabolic outcomes among sexual minorities tend to be understudied, and much of the available literature has limited generalizability, focuses on risk factors, or is based on self-reported data (Caceres et al. 2017). Some studies from the United States have found that sexual minority status is associated with risk factors such as smoking and obesity that can lead to higher risk of type 2 diabetes mellitus and other cardiometabolic diseases (Beach et al. 2018; Fredriksen-Goldsen et al. 2013). In Canada, based on self-reported data, Stinchcombe et al. (2018) found that smoking and cancer tended to be more prevalent among gay and bisexual men compared with among heterosexuals, whereas Brennan et al. (2010) found rates of hypertension to be lower. Lesbian and bisexual women have been found more likely to be former smokers or to report having asthma (Stinchcombe et al. 2018). Evidence on unhealthy diet as a behavioural risk factor for chronic noncommunicable diseases by sexual identity group is notably deficient (Meads et al. 2018).

While data on sexual identity collected by Statistics Canada are increasingly used to highlight health inequalities experienced by sexual minorities (Dharma and Bauer 2017), little is known about the association between sexual identity and the risk of adverse cardiometabolic outcomes. Even less is known about the economic burden of sexual minority health disparities related to cardiometabolic illness. A rapid review of the literature revealed that there is limited research quantifying the use of more expensive health services, such as acute-care hospitalization, for cardiometabolic conditions across sexual identity groups. We are unaware of any Canadian studies on individuals’ sexual identity as a potential factor influencing the length of hospital stays for diabetes, heart disease, and common comorbid conditions or the associated costs to the healthcare system. Expanded opportunities for data linkage across population surveys and hospital records through Statistics Canada’s Social Data Linkage Environment allow us to address this information gap, offering information on diagnosed chronic conditions and their many compelling social correlates that would not be available in a single unlinked source (Gupta and Crouse 2019; Trudeau 2017).

The objectives of this study were to investigate the use of linked survey and administrative data to create a cohort of acute-care inpatients with diabetes and other cardiometabolic diseases by sexual identity status, and to examine whether sexual identity is associated with increased cost to the hospital system for these conditions. Relationships between sexual identity and underlying social and health disparities were also described. It was hypothesized that the hospital cost for cardiometabolic diseases would be higher among patients who identify as LGB, underscoring the need to distinguish sexual minority status as a psychosocial patient attribute that may assist in the prediction of high hospital resource utilization as a driver for prevention. Diabetes, hypertension, and heart disease are widely held as ambulatory care sensitive conditions, that is, conditions for which the need for hospital admission can be largely prevented or delayed through appropriate management in primary and community care (Gibson et al. 2013; Sanmartin et al. 2011). Reducing the costs associated with cardiometabolic-related hospitalization is an important consideration for both health ministries (funders of public healthcare resources) and patients (evidence of severity of symptoms and harm).

Data and methods

Data sources

We used multiple years of data from the Canadian Community Health Survey (CCHS) linked to the hospital Discharge Abstract Database (DAD). The CCHS is conducted annually by Statistics Canada, and collects information on a range of health-related topics from a sample of approximately 65,000 respondents each year representative of the community-dwelling population ages 12 and over. The DAD contains demographic, administrative, and diagnostic data on all acute-care hospital stays in all provinces except Quebec.

Multiple years of CCHS cycles (2007–2011) and DAD datasets (2005/2006–2012/2013) were pooled together to obtain sufficient sample sizes of LGB individuals and cardiometabolic hospitalizations. A probabilistic approach was used in the microdata linkage process, based on given and family names, birthdate, sex, and postal code of residence among survey respondents who agreed to share and link their information with other databases (approximately 85% of all respondents, with the rate varying by year). Details on the linkage process and its suitability for analysis are described elsewhere (Ramage-Morin et al. 2017; Statistics Canada 2018). The de-identified linkable datasets were accessed in the secure facilities of the New Brunswick Research Data Centre at the University New Brunswick in Fredericton, Canada, in accordance with the study protocol (Gupta and Sheng 2019).

Sexual identity

The key independent variable of interest was patients’ sexual identity, as self-reported in the CCHS. The inclusion of data on sexual identity among respondents ages 18 to 59 followed evaluations of cognitive testing of questionnaire options on sexual orientation and relationships. Based on results indicating that people were more willing to answer questions on sexual identity than on sexual behaviours, the former concept was adopted in the national survey (Statistics Canada 2004). Respondents were asked whether they considered themselves to be heterosexual, homosexual (lesbian or gay), or bisexual. In the first Statistics Canada survey to include a question on sexual identity, 1.7% of Canadians 18–59 years reported that they considered themselves to be homosexual and 1.3% reported themselves to be bisexual (Statistics Canada 2017). In this study, multiple annual surveys were pooled to allow sufficient sample sizes for focused investigation, an approach made possible thanks to similarity in survey methodology and questionnaire wording across rounds (Tjepkema 2008). Persons who self-identified as homosexual or bisexual were defined as belonging to a sexual minority group.

Hospital burden of cardiometabolic diseases

The outcome variable was inpatient cost estimates for each acute-care stay for cardiometabolic ambulatory care sensitive conditions, based on the resource intensity weights (RIWs) available in the DAD. Since 2005, diagnostic data in DAD records have been consistently coded to the International Classification of Diseases, 10th revision, Canadian adaptation (ICD-10-CA) (Canadian Institute for Health Information 2009). Eight years of discharge databases were used for this analysis: fiscal years 2005/2006 through 2012/2013. All admissions and readmissions were flagged where the most responsible diagnosis (that is, the condition responsible for the greatest use of resources over the length of stay) was for diabetes (types 1 and 2) and other metabolic diseases (ICD-10-CA codes E10-E16, E70-E90), hypertensive diseases (codes I10-I15), and cardio- and cerebrovascular diseases (codes G08, G45, H34.0, H34.1, I20-I99). Validity of the diagnostic data in the DAD has been shown to be high for diabetes (sensitivity > 81% and specificity > 93%) and acute myocardial infarction (sensitivity > 88% and specificity > 92%), and moderately high for hypertension (sensitivity > 74% and specificity > 71%) and certain other cardiac diagnoses (specificity > 93% but sensitivity < 61% for arrhythmia and congestive heart failure) (Austin et al. 2002; Jiang et al. 2016). To estimate inpatient costing, following the methodology of the Canadian Institute for Health Information, aggregate information on the national cost of a standard hospital stay was applied to the RIW for each DAD record, that is, a reflection of the resource use for different types of patients relative to total acute inpatient expenditures (excluding physician remuneration) (Glussich 2015). Variations in the RIW take into account detailed clinical and financial data on the resources used, adjusted for patients’ comorbidities. The latest 2012/2013 standard cost (in Canadian dollars) was applied to all data to control for inflation and other differences in relative cost-efficiency across time and locations.

Statistical analysis

Multiple linear regressions were used to assess the association between sexual identity and hospital costs, controlling for a number of patient characteristics widely related in the literature with differences in cardiometabolic health and healthcare outcomes, including age, sex, place of residence, body mass index, income adequacy, and educational attainment. Income adequacy deciles were assigned by Statistics Canada based on total household income from all sources relative to the incomes of all other respondents in the province, adjusted for household and community size. Variables on income distribution were not derived in the CCHS for the three territories, so these sparsely populated geographies were excluded. Individuals in the two lowest income deciles were considered as having a low income (Sanmartin et al. 2011). The analysis further controlled for modifiable risk factors (unhealthy diet, tobacco use) and health status (self-report of having been diagnosed with diabetes, heart disease, or hypertension). The characteristics at the time of the survey were assumed to represent those at the time of the hospital episode.

The present analysis was limited to respondents with non-missing data for sexual identity and other person-level variables of interest. Means, proportions, and regression parameters were estimated, applying bootstrapped survey weights adjusted for agreement to link, to represent the average population over the period of observation accounting for the complex sampling methods (Thomas and Wannell 2009). Descriptive unweighted counts were rounded to a base of 5 and adjusted to reinforce the confidential nature of the data using Statistics Canada control algorithms. Bivariate chi-square tests and t tests were used to assess the associations between sexual identity and the key risk and protective factors for cardiometabolic diseases. Predicted differences in the mean cost per hospital stay were estimated using simple linear regression by sexual identity group according to patient comorbidity level. The simple and multiple regression models used the logarithm of hospital costs to reduce the effects of skewed data. Confidence intervals (CIs) were set at 95%. All analyses were conducted using the Stata statistical software version 15.

Results

Five years of pooled national CCHS cycles yielded 319,690 respondents ages 12 and over, of whom 270,210 (84.5%) agreed to share and link their data. In terms of the target population for this analysis, 123,410 respondents were ages 18–59 and residing in any of the nine Canadian provinces (excluding Quebec). The response rate for the question on sexual identity from the pooled survey data was 97.9%. The 120,850 respondents with valid information on sexual identity, income decile, and other basic socio-demographics (age, sex, place of residence) were linked to 4940 acute-care hospital records between 2005/2006 and 2012/2013 with one of the cardiometabolic diseases included in this study as the most responsible diagnosis. Of these, 4785 (96.1%) had complete information for all survey-based behavioural and health status variables of interest.

Among the household population with valid information on sexual identity, 2.1% (95% CI 1.9–2.2%) self-identified as belonging to a sexual minority group (n = 2570). Those who did not provide a valid response to the survey question tended to be somewhat older than those with sexual identity information (mean age of 39.5 years versus 38.8 years) and more often male (54.3% versus 49.8%).

Of individuals included in the analysis, sexual minority groups were significantly younger than their heterosexual peers (3.1 years younger on average; p < 0.05), more urban (89.8% versus 83.8%), more often having a low income (22.4% versus 17.2%), and more often smokers (34.6% versus 24.0%) (Table 1). They also reported significantly more often having been told by a health professional they had diabetes (4.1% versus 3.7%) or heart disease (2.4% versus 1.8%). There was no significant difference (p > 0.05) between the LGB and heterosexual groups in terms of sex distribution (51.8% and 50.1% female, respectively), body mass index (mean of 25.7 kg/m² and 26.0 kg/m², respectively), or daily fruits and vegetables consumption (4.8 times and 4.7 times, respectively).

Table 1.

Characteristics of the household population ages 18–59, by sexual identity group

	Lesbian, gay, or bisexual (n = 2570)	Heterosexual (n = 118,280)	p value
Age
Years (mean)	35.7*	38.8	0.00
Sex distribution
Female (%)	51.8	50.2	0.25
Place of residence
Urban (%)	89.8*	83.8	0.00
Distribution by province/region
Atlantic provinces (%)	8.5	8.9	0.07
Ontario (%)	50.2	51.2	0.05
Prairie provinces (%)	19.0*	22.6	0.00
British Columbia (%)	22.3*	17.2	0.00
Body mass index
BMI in kg/m2 (mean)	25.7	26.0	0.46
Income distribution
Low income (%)	22.4*	17.2	0.00
Educational attainment
At most secondary schooling (%)	12.3	13.5	0.65
Fruits and vegetables consumption
Total daily consumptions (mean)	4.8	4.7	0.09
Tobacco use
Currently smokes (%)	34.6*	24.0	0.00
Reports having a cardiometabolic condition
Diabetes (%)	4.1*	3.7	0.02
Heart disease (%)	2.4*	1.8	0.00
Hypertension (%)	9.6	10.2	0.46

Means and proportions are bootstrap weighted for population representation

Atlantic provinces Newfoundland and Labrador, Nova Scotia, New Brunswick, and Prince Edward Island; Prairie provinces Manitoba, Saskatchewan, and Alberta; Low income two lowest household income deciles

*Significantly different from the heterosexual group (p < 0.05)

Source: 2007–2011 Canadian Community Health Survey share files

LGB patients represented 2.5% of all acute-care admissions for cardiometabolic disease over the period of observation (n = 125 admissions among 90 individuals). The mean length of stay was more than twice as long among LGB patients (13.6 days; 95% CI 10.5–33.9) than among their heterosexual peers (5.1 days; 95% CI 4.6–5.5) (Table 2). In turn, the mean cost for hospital stays (in constant Canadian dollars) was observed to be significantly higher among LGB patients ($26,702; 95% CI 26,166–60,365) than among heterosexual patients ($10,137; 95% CI 8,639–11,635). There was no significant difference in the resource impact of diagnosed comorbidities on the patient’s stay by sexual identity group. The (unadjusted) predicted mean cost for cardiometabolic-related admissions was 48% (95% CI 10–100%) higher among LGB patients than among heterosexual patients.

Table 2.

Characteristics of acute-care hospitalizations for cardiometabolic diseases among patients ages 18–59, by sexual identity group

	Lesbian, gay, or bisexual (n = 125)	Heterosexual (n = 4815)
Length of stay
Mean number of acute-care days	13.6* (10.5–33.7)	5.1 (4.6–5.5)
Comorbidity level
Mean resource impact of comorbidities	0.2 (0.0–0.3)	0.3 (0.2–0.3)
Inpatient resource use
Mean cost (inflation-adjusted Can$)	26,702* (26,166–60,365)	10,137 (8,639–11,635)
Predicted mean cost difference	1.48* (1.10–2.00)	–

Numbers in parentheses represent 95% confidence intervals. Comorbidity level refers to the cumulative resource impact on the patient’s stay of other illnesses beyond the most responsible reason for hospitalization. Predicted difference in mean cost by sexual identity group is based on a simple log-linear regression. All values are bootstrap weighted for population representation

*Significantly different from the heterosexual group (p < 0.05)

Source: 2007–2011 Canadian Community Health Survey linked to 2005/2006–2012/2013 Discharge Abstract Database

Results from the multiple linear regression model revealed that inpatient costs remained significantly higher among LGB patients: 54% (95% CI 9–118%) higher than that for heterosexual patients, after controlling for age, sex, place of residence, body mass index, and socio-economic status (Table 3, model 1). The significance of the association still held (54% higher; 95% CI 8–119%) when further controlling for fruits and vegetables consumption, tobacco use, and reporting having a cardiometabolic condition (Table 3, model 2). It is possible survey respondents may have been informed of having a cardiometabolic condition during a hospital stay subsequent to interview. Hospital costs were not independently associated with the other socio-demographic and lifestyle patient attributes, aside from age.

Table 3.

Results from the linear regressions (adjusted coefficients and 95% confidence intervals) for predictors of hospital resource use for cardiometabolic diseases among patients ages 18–59

	Model 1 (n = 4940)		Model 2 (n = 4785)
	eβ (95% CI)	p value	eβ (95% CI)	p value
Sexual identity
Lesbian, gay, or bisexual (ref: Heterosexual)	1.54* (1.09–2.18)	0.01	1.54* (1.08–2.19)	0.02
Age
Years	1.01* (1.00–1.02)	0.01	1.01* (1.00–1.02)	0.01
Sex
Female (ref: Male)	0.99 (0.86–1.15)	0.92	0.99 (0.86–1.14)	0.87
Place of residence
Rural (ref: Urban)	0.99 (0.88–1.12)	0.85	0.98 (0.87–1.11)	0.81
Province/region of residence
Atlantic provinces (ref: Ontario)	0.91 (0.81–1.02)	0.12	0.92 (0.82–1.03)	0.16
Prairie provinces	0.97 (0.81–1.17)	0.78	0.99 (0.82–1.18)	0.88
British Columbia	0.99 (0.83–1.17)	0.87	0.97 (0.82–1.16)	0.75
Body mass index
BMI in kg/m2	1.00 (0.99–1.01)	0.73	1.00 (0.99–1.01)	0.68
Income group
Income decile	0.99 (0.97–1.00)	0.14	0.98 (0.97–1.00)	0.10
Educational attainment
Postsecondary (ref: At most secondary schooling)	1.17 (0.98–1.40)	0.08	1.15 (0.97–1.37)	0.10
Fruits and vegetables consumption
Total daily consumption			1.01 (0.99–1.04)	0.28
Tobacco use
Currently smokes (ref: Does not smoke)			0.99 (0.86–1.14)	0.88
Reports having a cardiometabolic condition
Diabetes, heart disease, or hypertension (ref: None)			0.95 (0.82–1.09)	0.46

Parameters are estimated from log-linear regressions of the cost of acute-care hospital stays (in constant Canadian dollars), and bootstrap weighted for population representation. Results are further adjusted for fiscal year of discharge

ref reference group

*p < 0.05

Source: 2007–2011 Canadian Community Health Survey linked to 2005/2006–2012/2013 Discharge Abstract Database

Discussion

Cardiometabolic diseases impose high social and economic costs; there is a continued need for research to inform opportunities to reduce the impact on individuals, health systems, and populations, including disadvantaged groups. The present findings that lesbian, gay, and bisexual Canadians ages 18–59 were significantly more likely than their heterosexual peers to be current smokers or to report a lifetime diabetes diagnosis were consistent with figures from the USA (Beach et al. 2018; Blosnich et al. 2014). Drawing on data from the Canadian Community Health Survey linked to the Discharge Abstract Database, we further found that inflation-adjusted costs for potentially avoidable hospitalizations for cardiometabolic diseases were significantly higher among LGB individuals than among their heterosexual counterparts (CAD$26,702 versus $10,137; p < 0.05). Hospital resource use remained 54% (95% CI 8–119%) higher among LGB patients when controlling in a multiple regression analysis for a range of socio-demographic, health status, and health behaviour indicators. This is, to the best of our knowledge, the first nationally representative investigation into cardiometabolic-related hospital resource use among LGB patients.

Higher costs of hospital stays may reflect a number of factors such as disease progression and comorbidities, pre-admission primary and community care, hospital characteristics, planning for post-discharge care, and patient characteristics including the underlying social determinants of health and use of healthcare services (Buttigieg et al. 2018). Our analysis showed that LGB individuals were significantly more often in a low-income bracket compared with heterosexuals (22.4% versus 17.2%; p < 0.05). There is evidence from the literature that lower socio-economic groups use disproportionately more hospital services, but income alone does not account for high hospital use (Lemstra et al. 2009; Sanmartin et al. 2011). The reasons for differences in hospital lengths of stays across patient social contexts (after adjusting for age, sex, and diagnosed comorbidities) are largely unknown; research elsewhere has suggested that facilities might discharge earlier or later based on perceptions of the supportive home environment, a factor that itself may lead to inequities in quality of healthcare for certain minority populations (Gorantla et al. 2015).

Contrary to expectations, an independent association between smoking and inpatient resource use was not found here. Selective survival bias, that is, bias attributable to the (unmeasured) earlier net probability of death from tobacco use before hospitalization, could help explain unobserved impacts of smoking on acute cardiovascular-related outcomes (and other high-mortality problems) using population-based data (Banack et al. 2018; Gakidou and King 2006).

Strengthening interventions in cardiometabolic disease prevention and management among vulnerable groups requires evidence on patient-important outcomes, including morbidity and quality of life (Montori et al. 2007). Clinical practice guidelines for diabetes recognize that improving outcomes among certain population groups requires grounding healthcare delivery and resources within the social factors affecting health, particularly where there is strong evidence of a disproportionate burden of disease, such as among Indigenous populations in Canada (Diabetes Canada Clinical Practice Guidelines Expert Committee 2018). However, the evidence base for extending special considerations among sexual minority groups is weak. One of the challenges to quantitative research on sexual identity and cardiometabolic health has been the relatively small samples of sexual minorities, even in large-scale surveys such as the CCHS (Denier and Waite 2019). In this study, cardiometabolic risk and protective factors and the associated hospital burden were systematically analyzed using multiple years of pooled data, based on a novel probabilistic linkage process of consistent person-level survey response options with validated record-level hospital diagnoses. Despite pooling 5 years of CCHS data with 8 years of hospital records, the number of identified admissions for cardiometabolic diseases among LGB patients remained small. Potentially avoidable hospitalization is a statistically rare event; our data linkage revealed that patients hospitalized for cardiometabolic diseases represent fewer than 0.4% of Canadians 18–59 years, a finding consistent with estimates by Sanmartin et al. (2011) of the proportion hospitalized for ambulatory care sensitive conditions. Nevertheless, this study retained the analytical power to ascertain a significant and generalizable association between LGB identity and increased hospital resource use associated with cardiometabolic diseases.

Limitations

It is possible that the prevalence of sexual minorities has been underestimated in this cohort analysis using existing datasets, since questions on sexual identity, such as those included in the CCHS, tend to underidentify those with same-sex partners or attractions but who do not identify as LGB (Denier and Waite 2019; Dharma and Bauer 2017). Future research may be enhanced by the inclusion of questions on sexual behaviours in more recent cycles of the CCHS, not yet linkable to the DAD for research use at the time of this study. More routine collection of sexual and gender identity data in healthcare settings would further enhance research opportunities. While such information is currently rarely collected, there is growing evidence that patients are willing to disclose this information (Pinto et al. 2019).

The present study was also limited to the dichotomous construct of heterosexual versus non-heterosexual, without distinction for transgender or other sexual or gender minorities that may be conceptualized and measured along a continuous scale (Wolff et al. 2017). While survey respondents who did not provide valid information on sexual identity were excluded from the present analysis, research from the United Kingdom has suggested that the health status of those who did not identify as heterosexual, homosexual, or bisexual was generally poorer than that for heterosexual individuals (Booker et al. 2017). We controlled for patients’ sex, but sample size limitations (n = 90 individual LGB inpatients) precluded split-sample analyses by sex, other intersecting identity factors such as ethnicity or disability, or between homosexual and bisexual individuals, or disaggregation by single cardiometabolic conditions such as hyperglycaemic type 1 versus type 2 diabetes.

Conclusions

Sexual minority status is increasingly recognized as a social determinant of health, that is, contributing to the health of individuals and populations as shaped by socio-political factors (Logie 2012). The associations of sexual identity with hospital resource use for cardiometabolic conditions have been largely unexplored, in part related to the analytical constraints of using self-reported survey data alone or clinical data alone. This study’s findings using novel linked survey and administrative hospital datasets highlight the need for increased awareness and action to prevent cardiometabolic disease complications and reduce health inequalities associated with sexual identity in the Canadian context. Further research is needed to better understand the unmet health needs of sexual minorities in contexts of both single-payer and mixed coverage systems. Further research is also needed to explore the impact that stigma and discrimination towards LGB individuals have on cardiometabolic health and how addressing related social stressors might help reduce associated costs of healthcare services delivery.

Funding information

This study received financial support from Diabetes Canada, the New Brunswick Health Research Foundation, the Heart and Stroke Foundation of New Brunswick, and Diabetes Action Canada.

Compliance with ethical standards

The funders and partners had no role in the study design, data analysis, results interpretation, or decision to submit the manuscript for publication. This study complied with the University of New Brunswick’s Research Ethics Board, which does not require an internal institutional review for research projects using data accessed through the NB-RDC.

Conflict of interest

The authors declare that they have no conflict of interest.