Acute health care among Indigenous patients in Canada: a scoping review

ABSTRACT

A recent report by the Chief Public Health Officer of Canada demonstrates the inferior health status of Indigenous Peoples in Canada when compared to non-Indigenous populations. This scoping review maps out the available literature concerning acute health care for Indigenous Peoples in Canada in order to better understand the health care issues they face. All existing articles concerning health care provided to Indigenous Peoples in Canada in acute settings were included in this review. The targeted studied outcomes were access to care, health care satisfaction, hospital visit rates, mortality, quality of care, length of stay and cost per hospitalisation. 114 articles were identified. The most studied outcomes were hospitalisation rates (58.8%), length of stay (28.0%), mortality (25.4%) and quality of care (24.6%) Frequently studied topics included pulmonary disease, injuries, cardiovascular disease and mental illness. Indigenous Peoples presented lower levels of satisfaction and access to care although they tend to be over-represented in hospitalisation rates for acute care. Greater inclusion of Indigenous Peoples in the health care system and in the training of health care providers is necessary to ensure a better quality of care that is culturally safe for Indigenous Peoples.

Introduction

In 2016, 1 673,780 Indigenous people were identified in Canada, representing 4.76% of the Canadian population [1]. Indigenous Peoples include three major groups: First Nations (61%), Inuit (4%) and Métis (32%) Peoples [2]. It is important to recognise that within these three groups, there are over fifty different Indigenous nations and over six hundred Indigenous communities, each of them with their own traditions and experiences [3]. Although Indigenous communities are distinct from one another, they share certain common experiences. An example of such experiences is the Residential School Program imposed by the Government of Canada until 1996. This program aimed to assimilate Indigenous Peoples by forcing Indigenous children to attend boarding schools directed by religious authorities and the Canadian government. This program led to significant intergenerational trauma due to the tearing of Indigenous children from their culture and community in addition to the abuse inflicted upon them in these schools [4,5]. The Residential School Program is only one example of many government policies and measures, which aimed to assimilate Indigenous Peoples in Canada. These policies of cultural assimilation are reflected in the current relations between Indigenous Peoples and government institutions such as health care services.

In Canada, the health care of Indigenous Peoples is mainly managed by the federal government since the adoption of the Indian Act in 1985. However, important differences in health care management between Indigenous communities persist. Indigenous communities in the province of Quebec have the authority to manage their own health care services whereas others communities depend on the federal government. The health care coverage and access also differ for Indigenous Peoples living on-reserve and off-reserve and for those who identify as Métis [1]. These differences in health care management have a direct impact on the health care provided to Indigenous Peoples in Canada.

A recent report by the Chief Public Health Officer of Canada establishes that Indigenous Peoples in Canada have a shorter life expectancy at birth than non-Indigenous populations. Indigenous Peoples are also less likely to report a very good or excellent state of health [2]. Additionally, several studies demonstrate significant disparities between Indigenous and non-Indigenous populations in Canada regarding health status [6–9].

The clear health disparities between Indigenous and non-Indigenous populations in Canada raise questions regarding inequalities in access, use and quality of health care. The primary objective of this scoping review is to map out the available literature on acute health care provided to Indigenous Peoples in Canada. In doing so, it aims to better understand the health care issues Indigenous Peoples face and identify areas that have not been fully explored in the current literature. In this study, acute health care refers to emergency department care, intensive unit care or hospitalisation for acute health problems.

Methods

This scoping review aims to identify all available literature regarding acute health care (emergency care, intensive care or hospitalisation for acute health problems) provided to First Nation, Inuit and Métis Peoples of North America in order to better understand the health care issues they face. The studied outcomes are patient satisfaction, access to care, hospitalisation rates and emergency department visit rates, mortality, quality of care, length of stay and cost. To determine these outcomes, a preliminary exploration of the available literature on health care provided to Indigenous Peoples was conducted by two authors in order to identify recurring themes. We searched Medline, Embase, Cochrane Library, Web of science and PsycInfo databases up until 1 February, 2021. These databases were selected in collaboration with librarians to ensure a maximum number of studies were found. An example of the research strategy is presented below. In summary, the research strategy focused on three main concepts: Indigenous Peoples, North America and acute health care. An example of the detailed research strategy is presented in Figure 1.

Figure 1.

Research strategy for medline

Articles which did not correspond to the objective of the scoping review were excluded from the analysis. This process is described in the flow chart presented below (Figure 2). Articles were excluded based on the fact they did not correspond to the studied population or the type of health care. Articles discussing public health, veterans’ health or paramedical health care were therefore excluded from this analysis. Articles that were not in English or in French were also excluded. The selection of articles was assessed by two independent authors (L.P.V., A.P., E.D., C.S.P). Canadian and American articles were divided into separate groups given the major differences between their health care systems.

Figure 2.

Flow diagram

Data from each article were collected by three independent readers, every article being reviewed by two readers (L.P.V., E.D., C.S.P). The data was entered independently in a data collection form and two readers then discussed the results to ensure an objective data extraction process. To assess the quality of the different articles retrieved, we used the STROBE Statement checklist for cohort studies, cross-sectionals studies and case-control studies [10]. These checklists provide a score based off of a total of 22 items. We also used a STROBE checklist for abstracts [10] which provides a score out of 11. The checklist to assess the quality of qualitative studies [11] provides a score out of 32 and the checklist for case reports provides a score out of 13 [12]. For each of these checklists, a criterion was considered not fulfilled if one of its sub-items was missing. Two independent readers (L.P.V., C.S.P, E.D.) completed the quality analysis for each article.

Results

114 articles studying the Indigenous Peoples in Canada and acute health care were retrieved. Figure 3 presents the distribution of articles according to the studied province although articles often collected data from more than one province or territory. Acute care provided to Indigenous Peoples has been most studied in the provinces of Alberta, Manitoba and Ontario. As indicated in Figure 4, most studies were retrospective (n = 86) and 14 articles were prospective. The rest of the articles were either case reports (n = 4), qualitative (n = 6), descriptive (n = 2), cross-sectional (n = 1) or comparative studies (n = 1).

Figure 3.

Distribution of articles by province

Figure 4.

Studies’ design

The general characteristics of the articles are presented in Table 1. Most articles studied hospitalisation (73,7%) and the most frequently studied population were First Nations (47.3%). Figure 5 illustrates the distribution of articles by year of publication. The number of studies discussing acute health care for Indigenous Peoples exponentially increased in the 2000’s as only 17 studies were published before 2000. Table 2 shows the distribution of articles according to their studied outcomes. The most frequently studied outcome was hospitalisation rates (58,8%), followed by length of stay (28.0%), mortality (25.4%) and quality of care (24.6%). The most studied health conditions are pulmonary diseases (n = 27), injuries and poisonings (n = 16), cardiovascular diseases (n = 9) and psychiatric illnesses (n = 8) as presented in Table 3.

Table 1.

Main features of articles

Indigenous Peoples by group: First Nations Métis Inuit Non specified Indigenous peoples	54 14 21 45
Age of population cohorts	All ages: 57 Paediatric*: 29 Adults*: 28
Type of acute health care Hospitalisation Emergency department visits Intensive care unit admissions Surgical intervention Other/Non defined	84 29 8 6 5
Journals which published >1 retrieved articles	Am J Public Health: 4 Am J Resp Crit Care: 2 BMC Public Health: 2 C J Public Health: 4 Can J of Cardiol: 3 Can J of Psychiat: 2 Chest: 2 CJEM: 3 CMAJ: 6 CMAJ Open: 2 Chron Dis Inj Can: 2 Ethnic Health: 2 Health Rep: 4 Int J Infect Dis: 2 Int J Circumpol Heal: 7 J Pediatr: 2 J Rheumatol: 2 Pediatr Infect Dis J: 3 Pediatr Pulm: 2 PLoS One: 3

* Given that the age of majority differs between provinces, the distinction between paediatric and adult patients was adjusted according to the province of origin of the studies. The age of majority is 18 years old in Alberta, Prince-Edward-Island, Manitoba, Ontario, Quebec and Saskatchewan and is 19 years old in British Columbia, New-Brunswick, Nova-Scotia, Nunavut, Newfoundland and Labrador, Northwest territory and Yukon.

Figure 5.

Distribution of articles by year of publication

Table 2.

Distribution of articles by studied outcomes

Outcomes	Number of articles (%)
Health care satisfaction	9 (7.9%)
Access to care	14 (12.3%)
Hospitalisation rate	67 (58.8%)
Emergency department visit rate	26 (22.8%)
Mortality	29 (25.4%)
Quality of care	28 (24.6%)
Length of stay	32 (28.0%)
Cost	7 (6.1%)

Table 3.

Studied health conditions

Illness	Number of articles
Pulmonary diseases Injuries and poisonings Cardiovascular diseases Psychiatric diseases Rheumatologic diseases Neurological diseases Endocrine-related conditions Paediatric-related diseases Gastrointestinal diseases Infectiology-related diseases Obstetrical and gynaecological conditions Nephrological-related conditions	27 16 9 8 5 5 5 5 4 4 4 1

The complete tables for each of the 114 studies are presented in Appendix 1. Studies are distributed according to their health condition of interest.

Health care satisfaction

Nine articles collected information concerning Indigenous Peoples’ health care satisfaction. One article reported great satisfaction of Indigenous Peoples while consulting through telemedicine [13]. Another article concluded that the health care satisfaction is inferior for Indigenous patients suffering from mental illness when compared to non-Indigenous patients [14]. The other seven studies reported several cases of stigmatisation and racism in the health care system. Study participants evoked certain barriers in their access to health care such as long wait times, trouble communicating and difficult interactions with health care professionals. Most of these issues were attributed to cultural differences and misinterpretations, often exacerbated in a bustling hospital setting [15,16]. Another important problem reported was the misperception by many health care professionals that Indigenous patients are seeking health care in order to receive drugs [17,18]. Others mentioned that health care providers tend to attribute illnesses to alcohol or drug consumption without completing a thorough history with the patient [17]. An Indigenous patient also stated not always inquiring about illness or treatment options due to communication barriers and subsequent difficulties understanding the information provided [15]. It has also been mentioned that some Indigenous patients are afraid of visiting hospitals and will avoid them by all means [17,19]. Many Indigenous patients felt they were treated differently and appreciated when health care professionals treated them as they would any other patient while also recognising and respecting their Indigenous identity [15,18].

Tang published two articles in which he interviewed health care professionals working in an urban emergency department in Canada as well as Indigenous patients. In his study published in 2008, Indigenous patients expressed often experiencing discrimination in the emergency department setting. Four health care providers were questioned on this subject and presented similar answers. They maintained that they provide the same quality of care to all patients including Indigenous patients, however, certain contradictions were raised in the testimonies of different health professionals. A health care provider said: “As an ED staff person, you tend to have a vision of every Aboriginal person having a drug and alcohol issue […]” [20]. This same provider later admitted to being more guarded when meeting an Indigenous patient. In Tang’s study published in 2015, health care providers were asked to describe their perception of Indigenous patients. A few health care providers provided similar answers which can be summarised by the following statement by health care provider 11: “A lot of them are on welfare or drug pushers […]. They don’t seem to have jobs, not well dressed, dirty, unkempt, using drugs, not taking care of themselves”. [21] Another health care provider explained why, in his opinion, Indigenous patients are dissatisfied with the health care they receive: “We’ll meet all of their needs, and when that doesn’t happen, there is a great deal of frustration of their part which makes it almost confrontational at times, it can be incredibly challenging to remain compassionate and non-judgemental about patients we see, when that kind of situation arises”. [21]

Access to health care

Articles discussing access to care presented data that for the most part cannot be grouped given the great diversity of studied outcomes. Four articles reported an inferior access to care when compared to non-Indigenous Canadians. This decreased access is characterised by a longer time between onset of symptoms and hospital presentation [22,23], a lower proportion of patients with access to prenatal care [24] and a lower satisfaction towards health care in general [16]. Five articles reported no difference in access to care for Indigenous Peoples when compared to other Canadians [25–29]. One study reported that specialist follow-up visits after an episode of arrhythmia occurs approximately 80 days earlier for Indigenous patients [30]. Firestone reported that 60% of questioned Indigenous patients consider their access to care to be excellent or good whereas 11% of them consider it to be poor [31]. A study reported that Indigenous patients mainly use the emergency department to access health care [19]. Another study reported that, for psychiatric patients, hospitalisation rates are higher if the primary source of health care is an hospital rather than a nursing centre [32]. Finally, one study was a case report and no conclusions can therefore be drawn [33].

Hospitalisation rates

67 articles studied hospitalisation rates. 48 studies found higher hospitalisation rates for Indigenous patients. 16 studies mentioned no difference whereas 3 articles mentioned reduced hospitalisation rates for Indigenous patients. 6 articles did not provide any comparison between hospitalisation rates for Indigenous and non-Indigenous patients [34–39]. For articles concerning multiple health issues, 10 articles concluded to higher hospitalisation rates for Indigenous patients [31,40–48]. With regards to pulmonary diseases, seven articles concerning pneumonia [22,49,50], LRTI (lower respiratory tract infection) [51], bronchiolitis [52] or H1N1 Influenza A [23,53] showed increased hospitalisation rates. 4 articles showed no difference in hospitalisation rates for asthma and COPD (chronic obstructive pulmonary disease) [40], LRTI [54,55] and aspiration pneumonia [22]. Senthilselvan’s study on asthma presented increased hospitalisation rates for age groups ranging from 0–4 and 35–64 years old. Meanwhile the group aged from 15 to 34 years old showed no difference in hospitalisation rates and the group aged from 5 to 14 years old had decreased hospitalisation rates [56]. As for unintentional injuries, 8 articles presented higher hospitalisation rates [57–64] whereas two articles mentioned no difference [65,66]. Three articles studied intentional injuries, two of which showed an increased hospitalisation rate for Indigenous patients [64, 67] while the other showed no difference [60]. With regards to poisonings, two articles published in 2007 by Myers mentioned a risk ratio for hospitalisation for acetaminophen overdose of approximately 4 [68,69]. For cardiovascular diseases, three articles provided results of increased hospitalisation rates [70–72] and one article mentioned decreased hospitalisation rates [73]. Atzema reported increased hospitalisation rates related to hypertension and congestive heart failure and found no difference for acute coronary syndromes, strokes and atrial fibrillation [74]. Kapral also found no difference in hospitalisation rates for strokes [75]. Increased hospitalisation rates were reported for pyelonephritis [76], acute complications of dialysis [77], epilepsy [78] and traumatic brain injury [79] and for all types of arthritis except ankylosing spondylitis [80]. One article found no difference in hospitalisation rates for cancer-related complications [81]. For mental health issues, five articles presented increased hospitalisation rates [32,82–85]. Carrière’s article showed increased hospitalisation rates for all mental illnesses except for personality disorders [82] and Soleimani’s article mentioned increased hospitalisation rates for women but decreased rates for men [85]. Articles about paediatric-related illnesses concluded to increased hospitalisation rates for acute otitis media [86], as well as for infections, congenital anomalies, respiratory, cutaneous, neurological and endocrine diseases and found no difference in hospitalisation rates for other health problems [87]. Finally, three articles showed higher hospitalisation rates for diabetes-related complications [88–90] and one article showed no difference between Indigenous and non-Indigenous patients [91].

Emergency department visit rates

26 articles presented results regarding emergency department visit rates. 17 studies found higher emergency department visit rates for Indigenous patients. 6 articles showed increased emergency visit rates for Indigenous patients with asthma or COPD [92–97] while one article reported no difference [40]. Two articles reported higher visit rates for LRTI [98,99]. Ospina’s article showed increased visit rates for all Indigenous communities except for Métis people for whom no difference was reported [92]. In articles discussing multiple acute health conditions, 2 articles found higher visit rates [31,40] while 4 articles reported no difference [26,27,43,100]. Most articles found higher emergency department visit rates for cardiovascular problems [30,70,74] with the exception of Atzema’s study which reported higher visit rates for all illnesses except for hypertension [74]. One article found higher visit rates for epilepsy [78]. For diabetes-related complications, one study found higher emergency department visit rates for all Indigenous patients [88] whereas another study found that only First Nation patients living off-reserve had higher visit rates [101]. Only one study found lower emergency department rates for Indigenous patients [94]. Four studies did not present a comparison with non-Indigenous patients and conclusions could therefore not be drawn [102–105]. Finally, Newton found that Indigenous patients had double the rate of emergency visits for self-harm [106] and for psychiatric illnesses [107] when compared to non-Indigenous patients.

Mortality

Mortality was studied as an outcome in 29 studies. 8 articles reported an increased mortality, 10 articles found no difference in mortality rates and 5 articles reported a decreased mortality for Indigenous patients. 7 articles provided mortality data without providing comparison to non-Indigenous patients and therefore no conclusion can be drawn for these results [105,108–113]. With regards to pulmonary diseases, two articles mentioned increased mortality for Indigenous patients hospitalised for pneumonia [114] and COPD [40], two studies revealed no difference in mortality for H1N1 Influenza A and asthma [40,115] and three studies showed decreased mortality for Indigenous patients hospitalised for pneumonia [22,49,50]. For injuries and poisonings, two studies reported a higher mortality rate for Indigenous patients [57,60] and one study found no significant difference [116]. Studies reported no difference in mortality rates caused by strokes [75] or obstetrical diseases [24]. As for cardiovascular diseases, most articles reported an increased mortality rate for Indigenous patients [70,71,73,117] although some articles did not report any difference in mortality rates [74,118]. For articles discussing multiple health problems, three studies reported increased mortality for Indigenous patients [46,47,119] and one article reported no change in mortality [45]. Finally, Oppenheimer’s study in 2007 found an increased mortality rate for Indigenous patients hospitalised for blastomycosis of joints and bones [28].

Quality of care

A total of 28 studies discussed the quality of care in their results. Quality of care was often studied for cardiovascular diseases. Atzema found no difference between Indigenous and non-Indigenous patients regarding the use of beta-blockers after an acute coronary syndrome or echocardiography in follow-up of atrial fibrillation [74]. Three studies found no difference in the use or percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) [25,71,117] whereas one study found no difference for CABG but a decreased rate of Indigenous patients receiving PCI [72]. Two studies found Indigenous patients less likely to undergo a coronary angiogram [72,117] and one study mentioned that Indigenous patients tend to wait longer before their coronary angiogram [25]. For pulmonary diseases, two studies found no difference in the quality of care for people with lower respiratory tract infections [55,115] and one study concluded that Indigenous patients with asthma or COPD were 55% less likely to see a specialist and 66% less likely to have a spirometry [96]. For injuries, one study found that Indigenous patients wait longer for their follow-up [106], are less likely to opt for palliative health care and undergo more surgeries [116]. Two studies showed a decreased chance for Indigenous patients to consult a specialist for their health problem [48,120]. For neurological illnesses, Indigenous patients tend to have fewer surgeries for spinal cord trauma [121] and longer wait times before follow-up after a traumatic brain injury [122]. As for strokes, the only difference found was that Indigenous patients were less likely to receive thrombolysis [75]. No difference in health care quality was noted for rheumatological diseases [28] or in neonatal intensive care [24]. Two studies by Newton demonstrated that Indigenous patients receive less follow-up after a visit to the emergency department for mental illness [103,107]. A study found that Indigenous patients presenting with appendicitis underwent more open surgeries and waited longer between their time of presentation at hospital and the beginning of their surgery [123]. Rose’s study found that Indigenous patients underwent more forefoot and below the knee amputations and fewer toe or above the knee amputations for diabetes-related complications [90]. Finally, seven articles did not provide any comparison with non-Indigenous patients [33,109–112,124].

Length of stay

For Indigenous patients with pneumonia or COPD, three studies revealed an increased length of hospital stay [55,56,114], two studies found no difference [54,115] and five studies showed decreased length of stay when compared to non-Indigenous patients [22,49,50,92,93]. Two articles mentioned longer hospitalisations for burn injuries [58,116]. For articles discussing multiple acute health problems, two studies showed a longer length of stay for Indigenous patients [42,46], one study reported a shorter length of stay [119] and four studies showed no difference [26,27,45,104]. Although no statistically significant difference was noted, Laupland found that over 17% of Indigenous patients were delayed in their discharge because of transportation issues or lack of resources in their community [45]. For psychiatric diseases, length of stay was found to be longer in one study [14] and shorter in two other studies [32,84]. One article found no difference between the length of stay in the emergency department for Indigenous and non-Indigenous patients [103]. Six studies did not provide any comparison with non-Indigenous patients [33,36,37,52,108,112]. There was no difference in length of stay for Indigenous patients with traumatic brain injury [122], blastomycosis of bones [28] or appendicitis [123]. Finally, Indigenous neonates stayed longer in the intensive care unit when hospitalised [24].

Cost

Seven studies discussed cost of health care for Indigenous patients. Five articles concluded to increased health care cost for Indigenous patients living in remote areas [36,51] as well as for Indigenous patients in general [22,91,125]. One study showed no statistically significant difference in health care cost [126] and one article provided no comparison with non-Indigenous patients [37].

Discussion

In this study, we found 114 articles that studied acute health care provided to Indigenous patients. Most studies presented results for Indigenous patients of all ages, focused on hospitalisation rates and were mainly retrospective. Only six articles out of 114 were qualitative, which is surprising considering the importance of qualitative studies in understanding the perception of health care of Indigenous patients. All provinces and territories of Canada were represented in the retrieved articles. Hospitalisation rates was the most studied outcome as it was analysed in more than half of all articles. 48 articles out of 67 reported higher hospitalisation rates for Indigenous patients when compared to non-Indigenous patients and 17 articles out of 26 found higher emergency department visit rates. Access to care was studied in 14 articles from which four articles noted a decreased access to care, five reported no difference and one reported a better access for Indigenous patients. For mortality, it is difficult to draw conclusions as eight articles reported an increased mortality, 10 articles reported no difference and five articles reported a decreased mortality for Indigenous patients. As for quality of care, care for cardiovascular diseases was similar for major interventions. The main difference in access to care was that Indigenous patients had less follow-up with specialists or longer wait times than non-Indigenous patients [48,96,103,107,120,122]. Studies discussing length of stay provided diverging results and no clear conclusion can be drawn seeing as nine studies showed increased length of stay, nine showed no difference and eight showed a decreased length of stay. Cost for health care seems to be higher for Indigenous patients since out of 6 studies, 5 articles reported higher costs. Finally, nine articles discussed satisfaction with health care. Most of them reported cases of miscommunication and misinterpretation between Indigenous patients and health care professionals that had an impact on satisfaction with care [15,16]. Throughout these studies, Indigenous patients often mentioned not being satisfied with their access to health care and encountering multiple barriers in the health care system. These barriers include long wait times [15,16],, difficulty communicating [15] as well as prejudices and discrimination [17,19–21]. Indigenous patients mentioned simply wanting to be treated like any other patient by practitioners who respect their Indigenous identity [15,18].

According to our research, no previous review has gathered all articles dealing with disparities in health care between Indigenous and non-Indigenous patients all illnesses combined. Our scoping review highlights important disparities between Indigenous and non-Indigenous patients in Canada, especially with regards to access to care, satisfaction with health care and hospitalisation or emergency department visit rates.

A systematic review on the experiences of Indigenous patients during hospitalisation for acute care was published in 2017 [127]. This review found 21 qualitative articles which provided three themes characterising the experience of Indigenous patients. Firstly, Indigenous patients reported feeling like they were going into a foreign land when they were hospitalised as health care practitioners are not always accustomed to their culture and traditions [128,129]. Furthermore, communication difficulties were frequent because of language barriers and/or cultural differences [130–132]. Finally, relationships with practitioners were sometimes difficult because of diverging views of health care and prejudices they may have had. This review is consistent with our findings which tend to confirm that many Indigenous patients have experienced negative encounters with health care professionals. As for access to care, our study did not provide any clear conclusions but some important elements have nonetheless emerged. A study published in 2018 aimed to identify barriers to health care access and presents similar results as our review. In this study, the most important barriers for Indigenous patients were long wait times, substandard quality of care and discrimination. This article provides an interesting perspective, especially regarding long wait times. Indeed, long wait times are experienced by all patients seeking health care in Canada. However, this article underlines the way in which different cultures and past experiences lead to different interpretations of certain events and these differences must be recognised in order to provide culturally safe care [132].

The use of health services by Indigenous Peoples has been studied for various health conditions in Australia over the past years. A review published in 2016 discussed the use of the emergency room by Indigenous Peoples living on Torres Island. Indigenous patients consulted at the emergency department more often than other Australians [133]. An article studying visits to the emergency department by Indigenous patients in 2004–2005 arrived to the same conclusion but also found that Indigenous patients were more likely to leave the emergency department before being seen by a health care practitioner [134]. A study with the same aim has recently been published in Canada and the results are very similar to those found in Australia [135]. Another study published in Australia about intensive care unit admissions also obtained similar results. Indigenous patients were over-represented in the ICU and more frequently required emergency admissions although no difference was found in mortality [136].

Some authors have suggested solutions to improve the quality of health services provided to Indigenous patients. A study in Australia suggested that health care services managed by Indigenous patients are the best way to maximise their access to care [137]. A scoping review published in 2009 grouped articles regarding Indigenous patients’ experience within emergency departments in Canada [138]. The author’s concluded that developing cultural competency is essential in order to upgrade the quality of health care. In order to achieve this, it is necessary to have a shared understanding of Indigenous communities and to collaborate with them. It is also essential to prevent discrimination by providing appropriate training to professionals and by promoting access to health care services [138]. A systematic review published in 2015 obtained the same conclusions. It identified training health care workers and recruiting Indigenous workers as the most effective interventions to improve cultural competency. These interventions improve patient’s satisfaction of care [139]. Another strategy for improving quality of care is integrated care [140]. Health care provided in a multidisciplinary approach, which encompasses all aspects of health can reduce disparities in health care and help communities achieve a better state of health. This approach involves the patient as an active partner in his health care and aims to include psychological and spiritual aspects of health care [140].

Changes in the health care system must be made to improve the quality of health care provided to Indigenous Peoples in Canada. Solutions to reconcile Indigenous cultures with hospital practices to provide health care in a culturally safe organisation should be explored. Future health care workers must be taught about the cultures and traditions of Indigenous Peoples in regard to health care. To increase cultural competency and prevent racism, future health care providers must recognise and understand cultural differences, in order to adapt their practice to each patient. Furthermore, no studies have focused on understanding the fundamental causes behind the differences in the prevalence of health problems disproportionately affecting Indigenous Peoples. Interventions to reduce the disproportionately high prevalence of certain diseases affecting Indigenous Peoples need to be explored. Finally, very few qualitative studies were performed with Indigenous Peoples in Canada. Studies examining ways in which health care could be improved with Indigenous communities would be important. Indeed, it is essential to include Indigenous communities in the discussions about health care to ensure their perspectives and traditions are respected.

Given that our study is a literature review, its quality depends of the quality of the articles included. The articles retrieved are mostly retrospective or prospective cohort studies (median STROBE score = 15/22). The quality scores differ for qualitative studies (median = 21/32), case reports (Median = 7/13) and abstracts (median = 7/11). No randomised control trials have been published about health care issues of Indigenous Peoples in Canada in an acute care setting. 18 articles were published before 2000 and the quality of their evidence may therefore differ from current standards. It is important to mention that although all included Indigenous Peoples live in Canada, important differences exist between each community. Indeed, access to care may vary depending on the location of the community. Furthermore, every community has a unique history and traditions as well as a unique perspective on health care. The health care system in Canada also varies depending on the territory and nation of Indigenous Peoples. This thus limits the generalisation of our results as data retrieved from a specific community may not apply to others. Our study is at risk of a publication bias since articles with positive results are more likely to be published than negative studies. To minimise this bias, incomplete articles were included in the analysis and available data was used. A publication bias would increase the proportion of articles showing disparities between health care provided to Indigenous and non-indigenous Canadians. Studies regarding Indigenous Peoples completed by non-Indigenous authors are at risk of interpretation bias which is difficult to estimate. This review presents the same risk since the authors are non-Indigenous. To diminish the importance of this bias, articles were included with objective inclusion criteria and studied outcomes were clearly defined. Also, subjective data was drawn directly from published data and does not reflect personal opinions. To prevent subjectivity in data interpretation, at least two different authors were involved in the reading of articles and extraction of data. Another limit of this article is the small number of articles that exist relative to certain specific topics such as health care costs making it impossible to draw conclusions about their impact on Indigenous Peoples. Finally, the small number of existing qualitative studies may affect the generalisability of conclusions about satisfaction with health care since only a small proportion of Indigenous patients and communities were questioned on this particular topic.

Conclusion

Indigenous Peoples in Canada still face significant inequalities in their access to health care when compared to non-Indigenous Canadians. They also carry a greater burden of health problems requiring acute health care, particularly in regards to pulmonary, cardiovascular, traumatic and psychiatric illnesses. Furthermore, their satisfaction with health care is lower than that of other Canadians which in turn limits their use of health care services. Given the historical context of colonialism in Canada and the persistence of significant disparities between Indigenous and non-Indigenous populations, it is essential to include Indigenous communities in the organisation of health care. Indigenous Peoples are most well informed of their reality and are best suited to identify their needs. It is essential to ensure that Indigenous Peoples in Canada have access to culturally safe health care, which embraces their unique perspective on health.

Disclosure statement

No potential conflict of interest was reported by the author(s).

PULMONARY DISEASES (n = 27)
Main author (year, journal)	Setting	Topic	Populations’ characteristics	Outcomes	Main results	STROBE
Alaghehbandan (2005, Am J of Epidemiology) (49)	Newfoundland and Labrador Retrospective	Pneumonia Hospitalisation	Indigenous people (Gr 1) Non-Indigenous people (Gr 2) All ages F/M	Hospitalisation rates (/1000) (p < 0.0001) In-hospital mortality Length of stay	Gr 1: 11.6 (Innu: 16.9; Inuit 8.4); Gr 2: 3.0 Lower for Indigenous Shorter for Indigenous	7/11
Alaghehbandan (2007, Int J Infect Dis) (50)	Newfoundland and Labrador Retrospective	Pneumonia Hospitalisation	Innu and Inuit from Labrador (Gr 1) Non-Indigenous people from Newfoundland (Gr 2) All ages F/M	Standardised hospitalisations rates (/1000) (95% CI) Mortality (p < 0.00001) Median length of stay (days)	Gr 1: 4.82 (4.21-5.37); Gr 2: 1.03 (0.96-1. Gr 1: 2.1%; Gr 2: 10.1% Gr 1: 3.0; Gr 2: 5.0	18/22
Alharbi (2012, BMC Infect Dis) (105)	Manitoba Retrospective	LRTI ED visits	Indigenous people <5 y.o. F/M	ED visits rates Mortality	112/193 (58%) 0%	15/22
Banerji (2001, CMAJ) (35)	Nunavut Prospective	LRTI Hospitalisation	Inuit <6 months old F/M	Annualised incidence rate of admission (/1000)	484	12/22
Banerji (2001, Int J Circumpol Heal) (34)	Nunavut Prospective	Bronchiolitis Hospitalisation	Inuit <1 y.o. F/M	Rate of hospital admission (/1000)	306	10/22
Banerji, Greenberg et al (2009, Pediatr Infect Dis J) (51)	Nunavut Retrospective	LRTI Hospitalisation	Inuit Baffin Island (Gr 1) Iqaluit (Gr 2) Rural communities (Gr 3) High-risk communities (Gr 4) <1 y.o. F/M	Odds ratio for hospitalisation (95% CI) Average cost per admission (< 1 year old/ < 6 months old) Annual admission rate/1000 live births without use of Palivizumab (<1 year old/ <6 months old)	Inuit: 3.8 (1.1-12.8) Gr 1: 19,014$/21,145$; Gr 2: 3915$/ 3621$; Gr 3: 21,345$/23,030$; Gr 4: 20,770$/ 22,673$ Gr 1: 166/245; Gr 2: 63/72; Gr 3: 216/328; Gr 4: 349/512	14/22
Banerji (2013, Int J Circumpol Heal) (36)	Nunavut, Quebec, Northwest territory Prospective	LRTI Hospitalisation	Inuit Northwest Territory (Gr 1) Nunavut (Gr 2) Nunavik (Gr 3) <1 y.o. F/M	Hospitalisation rates/1000 live births Median length of stay (days) Cost per admission	Gr 1: 38; Gr 2: 236; Gr 3: 445 Gr 1: 5; Gr 2: 6; Gr 3: 5 Gr 1: 36,542$; Gr 2: 55,265$; Gr 3: 23,203$	14/22
Charland (2011, Epidemiol Infect) (98)	Quebec Retrospective	Influenza, Bronchitis, Pneumonia ED visits	Mohawks of Kahnawá:ke reserve Non-Indigenous people All ages F/M	Standardised Risk Ratios to visit ED for Mohawks all ages (95% CI)	Influenza: 1.58 (1.49-1.67) Influenza + Pneumonia: 1.51 (1.44-1.58) Influenza + Bronchitis: 1.48 (1.44-1.53) Respiratory infection: 1.21 (1.19-1.23)	15/22
Creery (2005, Int J Circumpol Heal) (37)	Nunavut Retrospective	Bronchiolitis Hospitalisation	Inuit < 1 y.o. F/M	Annual admission rate of children <1 year old Average length of stay (days) Overall average cost per admission Cost per admission to Baffin Regional Hospital Cost per admission to CHEO	197/1000 5.7 14,273$ 12,029$ 45,688$	17/22
Gershon (2014, PLoS One) (40)	Ontario Retrospective	Asthma, COPD Hospitalisation, ED visits	Metis of Ontario (Gr 1) Other Ontarians (Gr 2) ≥ 20 y.o. F/M	Standardised rates/1000 for people with Asthma (95% CI) Standardised rates /1000 for people with COPD (95% CI) Standardised all-cause mortality/1000 Metis/Ontarians	All-cause ED visits: Gr 1: 761.7 (729.0-795.8); Gr 2: 563.9 (562.9-565.0) Asthma ED visits: Gr 1: 26.3 (21.2-32.2); Gr 2: 21.5 (21.3-21.7) All-cause hospitalisations: Gr 1: 118.9 (104.5-134.7); Gr 2: 93.1 (92.6-93.5) Asthma hospitalisations: Gr 1: 5.8 (3.2-9.8); Gr 2: 4.7 (4.6-4.8) All-cause ED visits: Gr 1: 910.7 (861.3-962.2); Gr 2: 674.3 (672.5-676.2) COPD ED visits: Gr 1: 26.7 (20.4-34.3); Gr 2: 32.2 (31.9-32.5) All-cause hospitalisations: Gr 1: 176.3 (155.9-198.5); Gr 2: 132.7 (132.0-133.4) COPD hospitalisations: Gr 1: 32.9 (25.1-42.3); Gr 2: 25.0 (24.7-25.3) Asthma: 68.0/65.0 (p = 0.67) COPD: 39.0/29.0 (p = 0.01)	21/22
Houston (1979, CMAJ) (114)	Saskatchewan Prospective	Pneumonia Hospitalisation	Indigenous people (Gr 1) Whites (Gr 2) <14 y.o. F/M	Mortality Average length of stay (days)	Gr 1: 4/102; Gr 2: 0/64 Whites Gr 1: 26.9; Gr 2: 8.7	11/22
Hui (2016, Pediatr Infect Dis J) (54)	All provinces Prospective	LRTI Hospitalisation, ICU admissions	Indigenous people (Gr 1) Non-Indigenous people (Gr 2) <1 y.o. F/M	Hazard ratio of hospitalisation (95% CI; p) % of ICU admission (p = 0.334) Mean Length of stay (days) (p = 0.598)	Gr 1: 1.2 (0.7-2.2; p = 0.383) Gr 1: 17.4%; Gr 2: 21.5% Gr 1: 9.0; Gr 2: 8.3	16/22
Jung (2011, Am J Resp Crit Care) (115)	All provinces Prospective	H1N1 Influenza A Hospitalisation ICU admissions	Indigenous people (Gr 1) Non-Indigenous people (Gr 2) All ages F/M	Hospitalised critically ill patients (384 patients) Mortality (p = 0.25) Frequency of reception of antivirals (p = 0.50) Mean ICU length of stay (days) (p = 0.72) Mean hospital length of stay (days) (p = 0.20)	Gr 1: 16.7% Gr 1: 15.6%; Gr 2: 23.8% Gr 1: 92.2%; Gr 2: 94.4% Gr 1: 17.0; Gr 2: 14.6 Gr 1: 23.2; Gr 2: 24.4	9/11
Marrie (2004, Can Respir J) (22)	Alberta Retrospective	Pneumonia Hospitalisation	First Nations people (Gr 1) Non-First Nations people (Gr 2) ≥ 18 y.o. F/M	Hospital discharge rate for community acquired pneumonia/1000 (95% CI) Hospital discharge rate for aspiration pneumonia/1000 (95% CI) Mean distance to closest hospital (km) Mortality odds ratio (95% CI) Median length of stay (days) Odds ratio for daily hospital cost higher than the median cost of 722.71$ (95% CI)	Gr 1: 22.1 (20.7-23.6); Gr 2: 4.4 (4.4-4.5) Gr 1: 1.29 (0.96-1.6); Gr 2: 0.27 (0.26-0.29) Gr 1: 21; Gr 2: 6 Gr 1: 0.49 (0.37-0.66) Gr 1: 6.1; Gr 2: 7.8 Gr 1: 1.25 (1.14-1.36)	14/22
McCuskee (2014, Pediatr Infect Dis J) (52)	Ontario Retrospective	Bronchiolitis, Pneumonia Hospitalisation	First Nations people of Sioux Lookout Zone (Gr 1) Non-First Nations people (Gr 2) <1 y.o. F/M	Admission rate for < 1 year old (p = 0.011) Admission rate for <6 months old Mean length of stay	Gr 1: 4.4%; Gr 2: 2.5% Gr 1: 5.6% 3.2 days	17/22
Morrison (2014, Health Place) (23)	Manitoba Retrospective	H1N1 Influenza A Hospitalisation	First Nations people on-reserve All ages F/M	Access to care (p<0.001) Odds ratio for hospitalisation	On-reserve First Nations have a longer delay between infection and hospitalisation. OR = 2.34 (1.16-4.73)	18/22
Mostaco-Guidolin (2013, Am J Public Health) (53)	Manitoba Retrospective	H1N1 Influenza A Hospitalisation	First Nations people Non-First Nations people All ages F/M	Hospitalisation risk ratio (p < 0.001)	In all First Nations age groups during the first wave, they were significantly higher than those in non-First Nations age groups.	15/22
Ospina (2015, Am J Resp Crit Care) (92)	Alberta Retrospective	COPD Hospitalisation	Indigenous (Gr 1) First Nations (Gr 2) Metis (Gr 3) Inuit (Gr 4) Non-Indigenous (Gr 5) All ages F/M	Risk ratios for hospitalisation for all causes (95% CI) Risk ratios for hospitalisation for AECOPD (95% CI) Median hospital length of stay (days)	Gr 1: 1.31 (1.24-1.37); Gr 2:1.60 (1.52-1.69); Gr 3: 0.80 (0.72-0.88); Gr 4: 0.71 (0.64-0.79) Gr 2: 1.44 (1.26-1.65); Gr 3: 1.10 (0.89-1.36); Gr 4: 0.67 (0.52-0.86) Gr 2: 5; Gr 3: 5; Gr 4: 4 All shorter than for Non-Aboriginals.	10/11
Ospina (2016, CJEM) (93)	Alberta Retrospective	COPD ED visits	Indigenous (Gr 1) First Nations (Gr 2) Métis (Gr 3) Inuit (Gr 4) Non-Indigenous (Gr 5) ≥ 35 y.o. F/M	Adjusted Risk Ratio for ED visits rates (95% CI) Median ED length of stay (hours)	Gr 1: 1.72 (1.67-1.77); Gr 2: 2.02 (1.97-2.08); Gr 3: 1.28 (1.22-1.35); Gr 4: 0.94 (0.90-0.98) Gr 1: 2.8; Gr 2: 2.9; Gr 3: 2.4; Gr 4: 2.2; Gr 5: 3.7	16/22

Poling (2014, Can J of rural medicine) (108)	Ontario Retrospective	Pneumonia Hospitalisation	First Nations people (87%) Non-Indigenous people All ages F/M	% of death resulting from pneumonia Mean length of stay (days)	3% 5.32	15/22
Rosychuk (2010, Pediatr Pulm) (99)	Alberta Prospective	Croup ED visits	Indigenous people (Gr 1) Alberta’s population (Gr 2) ≤ 2 y.o. F/M	ED visit rates/1000 infants for croup (95% CI)	1999-2000: Gr 1: 28.1 (23.7-32.4); Gr 2: 43.4 (41.8-44.9) 2004-2005: Gr 1: 29.7 (24.9-34.5); Gr 2: 34.1 (32.8-35.4)	17/22
Rosychuk (2010, Pediatr Pulm) (94)	Alberta Prospective	Asthma ED visits	Indigenous people (Gr 1) Alberta’s population (Gr 2) <18 y.o. F/M	Directly standardised rates per 1000 for ED visits for asthma (95% CI)	1999-2000: Gr 1: 28.1 (26.0-30.2); Gr 2: 21.1 (20.5-21.6) 2004-2005: Gr 1: 29.7 (27.5-31.9); Gr 2: 19.8 (19.3-20.2)	17/22
Rowe (2009, Chest) (95)	Alberta Retrospective	Asthma ED visits	Indigenous people (Gr 1) Alberta’s population (Gr 2) ≥ 18 y.o. F/M	ED visits rates (95% CI)	Gr 1: 14.9 (13.2-16.5); Gr 2: 6.8 (6.6-6.9)	16/22
Senthilselvan (1995, J Clin Epidemiol) (56)	Saskatchewan Retrospective	Asthma Hospitalisation	Indigenous people (Gr 1) Saskatchewan population (Gr 2) <65 y.o. F/M	Hospitalisation risk ratios for Gr 1 for 1985-1989 (95% CI) Hospitalisation rates/1000 for Gr 1 in 1989 Average length of stay	0-4 y.o.: 2.97 (2.75-3.20); 5-14 y.o.: 0.78 (0.67-0.92) 15-34 y.o.: 0.99 (0.81-1.21); 35-64 y.o.: 2.83 (2.42-3.33) 0-4 y.o.: Asthma: 21.73; Bronchitis: 53.47; LRTI: 4.11 35-64 y.o.: Asthma:3.43; Bronchitis: 5.24; LRTI: 3.24 Greater for Indigenous children under 14 years of age	15/22
Sin (2002, Chest) (96)	Alberta Retrospective	Asthma, COPD ED visits	Indigenous people (Gr 1) Non-Indigenous people (Gr 2) All ages F/M	Risk ratio for ED visits for Gr 1 (95% CI) Quality of care	2.10 (2.01-2.19) Indigenous 55% less likely to see a specialist and 66% less likely to undergo spirometry	13/22
Sin (2004, Arch Pediat Adol Med) (97)	Alberta Retrospective	Asthma ED visits	Indigenous people (Gr 1) Non-Indigenous people (Gr 2) 0-10 y.o. F/M	Risk ratio for ED visits for Gr 1 (95% CI)	1.20 (1.11-1.29)	17/22
Wang (1995, J Pediatr) (55)	Nova Scotia, Quebec, Ontario, Manitoba, British Columbia Prospective	LRTI ICU admission	Indigenous people (Gr 1) Non-Indigenous people (Gr 2) <2 y.o. F/M	Odds ratio for ICU admission (95% CI) 95% CI odds ratio for ventilation Prolonged hospitalisation in days	Gr 1: 3.1 (1.0-9.2) Gr 1: 0.3-2.3 Gr 1 1.2 (1.1-1.4)	17/22

LRTI: Lower respiratory tract infection, ED: Emergency department, y.o.: years old, F/M: Female/Male, Gr: Group, COPD: Chronic obstructive pulmonary disease, ICU: Intensive care unit, AECOPD: Acute exacerbation of chronic obstructive pulmonary disease

INJURIES AND POISONINGS (n = 16)
Author (year, journal)	Setting	Topic	Populations’ characteristics	Outcomes	Main results	STROBE
Alaghehbandan (2010, Int J Circumpol Heal) (57)	Newfoundland and Labrador Retrospective	Unintentional injuries Hospitalisation	Indigenous people (Gr 1) Innu (Gr 2) Inuit (Gr 3) Metis (Gr 4) Non-Indigenous people (Gr 5) ≤ 19 y.o. F/M	Hospitalisation rates/100,000 (95% CI) Risk ratio for hospitalisation for Aboriginals (95% CI) Mortality/100,000 (p <0.001)	Gr 2: 1329.2 (1008.3-1650.2); Gr 3: 972.1 (731.3-1212.9); Gr 4: 1142.3 (857.3-1427.4); Gr 5: 614.2 (597.1-631.3) 0-4 y.o.: 1.78 (1.30-2.45); 5-9 y.o.: 1.62 (1.18-2.22); 10-14 y.o.: 1.83 (1.38-2.42); 15-19 y.o.: 2.28 (1.76-2.95) Gr 1: 84.3; Gr 5: 10.2	18/22
Alaghehbandan (2012, Burns) (58)	Newfoundland and Labrador Retrospective	Burns Hospitalisation	Low % of Indigenous people areas (Gr 1) High % of Indigenous people areas (Gr 2) ≤ 16 y.o. F/M	Hospitalisation rates/100,000 Median length of stay (days)	Total: (p <0.001)) Gr 1: 20.3/ Gr 2: 51.4 Gr 1: 5.0; Gr 2: 3.0	16/22
Anne George (2013, Int J Circumpol Heal) (59)	British Columbia Retrospective	Injuries Hospitalisation Primary care visits	First Nations people (Gr 1) Non-First Nations people (Gr 2) All ages F/M	Standardised risk ratio to be hospitalised Standardised risk ratio to visit primary care	Gr 1: 1.3-3.7; Gr 2: 0.6-1.9 * RR varies with health service delivery areas Gr 1: 1.2-2.1; Gr 2: 0.8-1.3	13/22
Bell (2011, Inj Prev) (60)	British Columbia Retrospective	Injuries Hospitalisation	First Nations people on reserve (Gr 1) People off reserve (Gr 2) <17 y.o. F/M	Hospitalisation rates/100,000 for Mortality rates/100,000 * p ≤ 0.05	Unintentional injuries: Gr 1: 622.2*; Gr 2 322.1 Intentional self harm: Gr 1: 7.5; Gr 2: 8.3 Injuries involving third party: Gr 1: 67.5*; Gr 2: 32.4 Unintentional injuries: Gr 1: 368.1*; Gr 2: 240.4 Intentional self harm: Gr 1: 168.7*; Gr 2: 97.7 Injuries involving third party: Gr 1: 23.0; Gr 2: 14.7	18/22
Boeckx (1977, Paediatrics) (109)	Manitoba Case report	Gasoline sniffing and tetraethyl lead poisoning Hospitalisation	Indigenous people 14 and 16 y.o. F/M	Mortality Type of treatment	1 death/ 2 cases CASE 1: 24h of EDTA and Dimercaprol. Then treatment with penicillamine. Discharge after 4 weeks with continued penicillamine. Returned 3 times to the hospital. The third time: treatment with Phenobarbital and Dilantin failed. He was diagnosed with aspiration pneumonia treated with Cloxacillin and Gentamicin. He died 72h after admission. CASE 2: Multivitamins, IV fluids and glucose. Then 5 days of EDTA twice. Then penicillamine for 4 weeks. He was readmitted and treated again because of gasoline sniffing 6 months later.	7/13
Bougie (2014, Health Rep) (65)	All provinces except Quebec Retrospective	Unintentional injuries Hospitalisation	Areas with a high % of First Nations people (Gr 1) Areas with a low % of Indigenous people (Gr 2) All ages F/M	Rate ratios for unintentional injury hospitalisations	Gr 1: Females: 1.25; Males: 1.20 Gr 2: Females: 1.20; Males: 1.23	17/22
Brussoni (2014, Prev Sci) (66)	British Columbia Retrospective	Injuries Hospitalisation	Indigenous people (Gr 1) North American Indians (Gr 2) Non-Indigenous people (Gr 5) All ages F/M	Standard relative risk of injury hospitalisation (95% CI)	Gr 1: 1.049 (0.994-1.107) Gr 2: 1.040 (0.984-1.098)	14/22
Brussoni (2016, BMC Public Health) (62)	British Columbia Retrospective	Injuries Hospitalisation	Indigenous people (Gr 1) On-reserve metropolitan (Gr 2) On-reserve non-metropolitan (Gr 3) Off-reserve metropolitan (Gr 4) Off-reserve non-metropolitan (Gr 5) British Columbia (Gr 6) All ages F/M	Standard relative risk of hospitalisation (95% CI)	Gr 1: 2.61 (2.58-2.64) Gr 2: 2.44 (2.34-2.54) Gr 3: 3.04 (2.98-3.10) Gr 4 1.99 (1.93-2.04) Gr 5: 2.51 (2.46-2.56) Gr 6: 1.0	18/22
Brussoni (2018, PLoS One) (63)	British Columbia Retrospective	Unintentional transport injuries Hospitalisation	Indigenous people (Gr 1) British Columbia population (Gr 2) All ages F/M	Standardised rate ratios (95% CI)	Gr 1, Females: 2.13 (2.03-2.24) Gr 1. Males: 1.69 (1.63-1.75)	15/22
Callegari (1989, Burns Incl Therm Inj) (116)	Alberta Retrospective	Burns Hospitalisation	Indigenous people (Treaty Indians and Metis) (Gr 1) Non-Indigenous people (Gr 2) All ages F/M	Deaths % Treatment: Gr 1/ Gr 2 (p <0.05) Number of days in hospital (p <0.05)	Gr 1: 4.8%; Gr 2: 4.3% Non operative: 34.4%/ 46.9% Surgical with healing: 60.85%/48.85% Surgical with death: 3.2%/1.8% Palliation: 1.6%/2.4% Gr 1: 42.3 days; Gr 2: 25.4 days	16/22
Finès (2013, Chron Dis Inj Can) (61)	All provinces except Quebec Retrospective	Unintentional injuries Hospitalisation	High % First Nations people areas (Gr 1) High % Inuit areas (Gr 2) High % Metis areas (Gr 3) Low % Indigenous people areas (Gr 4) All ages F/M	Age-standardised hospitalisation rate for injuries/10,000 person-years (95% CI) Males/Females	Gr 1: 145.94 (144.13-147.77)/ 103.47 (101.95-105.02) Gr 2: 100.47 (95.14-106.09)/ 86.87 (81.77-92.28) Gr 3: 111.76 (107.71-115.97)/ 73.63 (70.51-76.87) Gr 4: 54.53 (54.36-54.70)/ 37.13 (37.04-37.29)	16/22
Myers (2007, BMC Public Health (68)	Alberta Retrospective	Acetaminophen overdose Hospitalisation	Indigenous people (Gr 1) Alberta’s general population (Gr 2) All ages F/M	Risk ratio for hospitalisation for acetaminophen overdose for Gr 1	RR = 4.04 (p < 0.0005)	16/22
Myers (2007, CJEM) (69)	Alberta Retrospective	Acetaminophen overdose Hospitalisation	Indigenous people (Gr 1) Alberta’s general population (Gr 2) All ages F/M	Risk ratio for hospitalisation for Gr 1 (95% CI)	RR = 4.78 (4.24-5.39)	17/22
Newton, 2015 (CJEM) (106)	Alberta Retrospective	Self harm ED visits	First Nations people (Gr 1) Alberta’s general population (Gr 2) <18 y.o. F/M	Standardised visit rates/100,000 (95% CI) % of follow up visits for children at 30 days	2002-2003: Gr 1: 243.5 (194.8-292.1); Gr 2: 101.2 (93.2-109.1) 2010-2011: Gr 1: 201.5 (156.5-246.4); Gr 2: 70.8 (64.4-77.2) Gr 1: 11.6% Families receiving no subsidy: 65.3% Families receiving human services program subsidy: 6.2% Families receiving government-sponsored program subsidy: 16.9%	17/22
Oliver (2012, Health rep) (64)	All provinces except Quebec Retrospective	Unintentional injuries Hospitalisation	High % First Nation people areas (Gr 1) High % Metis areas (Gr 2) High % Inuit areas (Gr 3) Low % Indigenous areas (Gr 4) 0-19 y.o. F/M	Hospitalisation risk ratio (95% CI)	Gr 1: 2.3 (2.3-2.4); Gr 2: 2.4 (2.2-2.6); Gr 3: 2.2 (2.1-2.4) * RR are higher for Indigenous people for all types of injuries: fall, transportation, struck, poisoning, cut/pierce, fire, environmental, drowning, suffocation.	16/22
Oliver (2014, Chron Dis Inj Can) (67)	All provinces except Quebec Retrospective	Intentional injuries Hospitalisation	High % First Nation people areas (Gr 1) High % Metis areas (Gr 2) High % Inuit areas (Gr 3) Low % Indigenous people areas (Gr 4) All ages F/M	Age-standardised hospitalisation rates per 10,000 person-years for females (95% CI) Age-standardised hospitalisation rates per 10,000 person-years for males (95% CI)	Total self-inflicted: Gr 1: 28.44 (27.53-29.39); Gr 2: 19.14 (17.37-21.09); Gr 3: 44.04 (40.46-47.95); Gr 4: 6.25 (6.19-6.31) Total self-inflicted: Gr 1: 14.39 (13.75-15.06); Gr 2: 9.56 (8.33-10.96); Gr 3: 21.50 (19.07-24.23); Gr 4: 3.77 (3.73-3.82)	17/22

MULTIPLE ACUTE HEALTH PROBLEMS (n = 15)
Author (year, journal)	Setting	Topic	Populations’ characteristics	Outcomes	Main results	STROBE
Carrière (2016, Health Rep) (41)	All provinces except Quebec Retrospective	Acute care Hospitalisation	First Nations people on-reserve (Gr 1) First Nations people off-reserve (Gr 2) Metis (Gr 3) Inuit (Gr 4) Non-Indigenous people (Gr 5) All ages F/M	Age-standardised acute care hospitalisation rates/100,000 (95% CI)	Gr 1: 17,042 (16,901-17,183); Gr 2: 11,190 (11,005-11,379); Gr 3: 9535 (9360-9713); Gr 4: 13,227 (12,865-13,598); Gr 5: 6459 (6440-6479)	17/22
Firestone (2014, BMJ) (31)	Ontario Retrospective	ED visits, Hospitalisation	First Nations people (Gr 1) Non-First Nations people (Gr 2) ≥ 18 y.o. F/M	Number (%) of ED visits for acute reason (95% CI) Gr 1/Gr 2 Number (%) of ED visits for non-acute reasons (95% CI) Gr 1/Gr 2 Perception of availability of healthcare among First Nations adults (95% CI) Hospitalisation rates	None: 50.2% (43.9-57.5)/80.1% 1: 24.7% (18.7-30.1)/13.1% 2-5: 20.7% (15.3-26.1)/6.3% ≥ 6: 4% (1.6-6.9)/0.6% None: 54.3% (47.6-61.2)/81.2% 1: 22.4% (17.3-28.5)/12.2% 2-5: 20.4% (14.5-25.4)/6% ≥ 6: 2.9% (1-5.6)/0.6% Excellent: 16.7% (11.4-22.1); Good: 43.3% (36.1-49.6) Fair: 28.9% (23.3-35.2); Poor: 11.1% (7.9-15.6) Slightly higher among the First Nations population	18/22
Kashuba (1994, C J Public Health) (42)	Alberta Retrospective	Acute diseases Hospitalisation	Blood Indian Band people (Gr 1) Alberta’s population (Gr 2) All ages F/M	Hospital separation rate ratio for Gr 1 Patient days rate ratio for Gr 1 Age-adjusted separation rate ratio for Gr 1	Males: 2.59; Females: 2.65 Males: 2.18; Females: 2.26 Infectious and parasitic diseases: 4.09 Neoplasms: 0.32 Endocrine, nutritional and metabolic diseases: 7.48 Diseases of blood: 2.09 Mental disorders: 6.81 Diseases of the nervous system: 3.23 Diseases of the circulatory system: 1.58 Diseases of the respiratory system: 2.92 Diseases of the digestive system: 2.43 Diseases of the genitourinary system: 1.66 Diseases of the skin: 5.16 Diseases of the musculoskeletal system: 1.88 Conditions originating in the perinatal period: 1.14 Injury and poisoning: 2.79	13/22
Kendall (2016, Harm Reduct J) (43)	Ontario Retrospective	ED visits, Hospitalisation for people who use drugs	Indigenous people (Gr 1) Ottawa’s population (Gr 2) ≥ 16 y.o. F/M	Risk ratio for Gr 1 to have ≥ 2 ED visits (95% CI) Risk ratio for Gr 1 to have ≥ 1 hospitalisation (95% CI)	1.58 (0.98-2.55) 2.39 (95% CI 1.38-4.13)	19/22
Khan (2008, Crit Care Med) (119)	British Columbia Retrospective	Critical diseases Hospitalisation, ICU admissions	First Nations people (Gr 1) European descent people (Gr 2) ≥ 18 y.o. F/M	Median hospital length of stay (days) ICU median length of stay (days) ICU mortality, % (95% CI) Adjusted OR for hospital mortality (95% CI)	Gr 1: 16; Gr 2: 16 Gr 1: 5.7; Gr 2: 8.3 Gr 1: 22.2 (17.4-27.0); Gr 2: 19.0 (18.0-20.1) Gr 1: 1.24 (1.21-1.29)	19/22
Kliewer (2002, CCM and Manitoba Health) (44)	Manitoba Retrospective	Hospitalisation	Metis people (Gr 1) Manitoba’s general population (Gr 2) >15 y.o. F/M	Age-standardised hospitalisation rates/1000	Gr 1, males: 293.4; Gr 1, females: 454.2 Gr 2, males: 228.6; Gr 2, females: 301.9	15/22
Lafond (2016, J Eval Clin Pract) (104)	Saskatchewan Retrospective	ED visits, Hospitalisation	First Nations people (Gr 1) (n = 203) Non-First Nations people (Gr 2) (n = 200) All ages F/M	Emergency department admissions Adjusted mean length of stay (days) (p=0.064) Delay in discharge for Gr 1	Gr 1: 82.8%; Gr 2: 92.5% Gr 1: 12.01; Gr 2: 9.05 17.7% (Delays were related to transportation, bed availability, lack of medical equipment in the community and lack of family support)	20/22
Laupland (2006, J Crit Care) (45)	Alberta Prospective	Critical illnesses ICU admission	Indigenous people (Gr 1) Non-Indigenous people (Gr 2) ≥ 18 y.o. F/M	Annual incidence of critical illness/100,000 Annual incidence of critical illness rate ratio (95% CI; p) Odds ratio for in-hospital death for Status-Aboriginals (95% CI; p) Median ICU length of stay (p = 0.9) Overall median length of hospital stay (p <0.1)	Gr 1: 620.6; Gr 2: 302.6 2.1 (1.78-2.35; p < 0.001) 1.40 (0.88-2.23; p = 0.15) Gr 1: 1.8 days; Gr 2: 1.9 days Gr 1: 9 days; Gr 2: 11 days	16/22
Martens (2005, C J Public Health) (46)	Manitoba Retrospective	Hospitalisation	First Nations people (Gr 1) Manitoba’s general population (Gr 2) All ages F/M	Overall hospitalisation rate per person (p <0.05) Premature mortality rate/1000 (p<0.05) Overall hospital days of care per person (p<0.05)	Gr 1: 0.35; Gr 2: 0.16 Gr 1: 6.61; Gr 2: 3.30 Gr 1: 1.75; Gr 2: 1.05	15/22
Martens (2010, MCHP) (47)	Manitoba Retrospective	Hospitalisation	Metis people (Gr 1) Manitoba’s general population (Gr 2) All ages F/M	Total mortality rates/1000 Premature mortality rates/1000 Hospital separation rates/1000	Gr 1: 9.7; Gr 2: 8.4 (RR for Gr 1 = 1.15) Gr 1: 4.0; Gr 2: 3.3 (RR for Gr 1 = 1.21) Gr 1: 194; Gr 2: 154	16/22
Rivers (2013, J Adolescent Health) (19)	British Columbia Prospective	Health care access	Marginalised young men (22% were Indigenous people) 19-25 y.o. Male	Perception of health care Access to health care	Most youth had positive experiences with nurses and doctors. They preferred immediate access services (emergency room, clinics). Most youth avoided care until their problem couldn’t be ignored. Marginalised young men were more likely to have accessed emergency room.	13/22
Shah (2003, Am J Public Health) (48)	Ontario Retrospective	Hospital admissions for ambulatory care-sensitive conditions (ACSC)	Indigenous people (Gr 1) Ontario’s general population (Gr 2) All ages F/M	Risk ratio for admission for ACSC Risk ratio for utilisation of specialist procedures Risk ratio for utilisation of acute care for insensitive conditions	Gr 1: 2.54 (p <0.001) Gr 1: 0.64 (p <0.001) Gr 1: 1.39 (p <0.001)	14/22
Stergiopoulos (2016, Psychiatr Serv) (26)	British Columbia, Manitoba, Ontario, Quebec, New Brunswick Retrospective	ED visits	Indigenous people (Gr 1) White people (Gr 2) Black people (Gr 3) Adults F/M	Unmet need for health care Adjusted RR for ED visits for Gr 1 (95% CI; p) Adjusted RR for hospital days for Gr 1 (95% CI; p)	Gr 1: 52%; Gr 2: 50%; Gr 3: 32% 0.85 (0.71-1.01; p = 0.07) 0.91 (0.64-1.29; 0.60)	14/22
Waldram (1991, Artic Med Res) (27)	Saskatchewan Prospective	ED visits	Indigenous people (Gr 1) Non-Indigenous people (Gr 2) All ages F/M	Time from onset of symptoms to contact with a physician (not statistically significant) % of patients who visited an ED in the past year (not statistically significant)	Gr 1: 3.8 days Gr 2 5.0 days Gr 1: 51% Gr 2: 47.6%	11/22
Wen (1996, Ethnic Health) (100)	Ontario Retrospective	ED visits	Indigenous people (Gr 1) Ontario’s general population (Gr 2) 16-64 y.o. F/M	% of people who had an ED visits in the past year Odds ratio for Gr 1 to visit the ED (95% CI)	Gr 1: 32.2%; Gr 2: 22.6% 1.39 (1.00-1.94)	17/22

CARDIOVASCULAR DISEASES (n = 9)
Author (year, journal)	Setting	Topic	Populations’ characteristics	Outcomes	Main results	STROBE
Atzema (2015, PLoS One) (74)	Ontario Retrospective	ACS, CHF, AF, Stroke, HTN Hospitalisation, ED visits	Metis people (Gr 1) Ontario general population (Gr 2) ≥ 20 y.o. F/M	Age and sex-adjusted rate ratios of one-year disease-specific hospitalisations for Gr 1 (95% CI; p) Age and sex-adjusted all-cause mortality/100 in the year after diagnosis Gr 1/Gr 2 (95% CI) Age and sex-adjusted cardiovascular mortality in the year after diagnosis/100 Gr 1/Gr 2 (95% CI) Frequency of beta-blocker use within 3 months after ACS diagnosis (95% CI) Frequency of outpatient echocardiogram within 6 months after AF diagnosis (95% CI) Rate ratio for ED visits for Gr 1 in the year after diagnosis (95% CI)	ACS: 1.23 (0.95-1.61; p = 0.12) CHF: 1.93 (1.34-2.78; p <0.001) Stroke: 1.03 (0.54-1.98; p= 0.93) AF: 1.23 (0.73-2.08; p = 0.44) HTN: 2.27 (1.88-2.74; p <0.001) ACS: 11.5 (5.7-17.2)/ 16.2 (16.1-16.4) CHF: 25.2 (13.1-37.3)/ 22.80 (22.5-23.1) Stroke: 20.7 (13.0-28.5)/ 14.8 (14.6-15.0) AF: 16.6 (7.3-25.4)/ 7.8 (7.4-8.1) HTN: 1.8 (0.89-2.6)/ 1.3 (1.2-1.3) ACS: 9.8 (4.7-14.8)/ 11.4 (11.3-11.6) CHF: 13.0 (6.5-19.5)/ 9.3 (9.1-9.5) Stroke: 25.4 (13.4-37.3)/ 21.8 (21.4-22.1) AF: 10.0 (2.4-17.7)/ 4.8 (4.6-5.0) HTN: 0.82 (0.24-1.4)/ 0.54 (0.52-0.56) Gr 1: 77.8% (67.8-85.9); Gr 2: 66.9% (66.6-67.3) Gr 1: 52.9% (38.5-67.1); Gr 2: 42.1% (41.5-42.6) CHF: 2.03 (1.47-2.80) HTN: 1.51 (0.95-2.40)	19/22
Bresee (2014, CMAJ) (118)	Alberta Retrospective	AMI Coronary angiography, PCI, CABG	First Nations people (Gr 1) Non-First Nations (Gr 2) >18 y.o. F/M	Adjusted odds ratio of coronary angiography within 1 day after AMI (95% CI) Adjusted hazard ratios for likelihood of PCI after coronary angiography (95% CI) Adjusted hazard ratios for likelihood of CABG after coronary angiography (95% CI) Adjusted hazard ratios for all-cause mortality for Gr 1 after coronary angiography (95% CI)	Gr 1: 0.73 (0.62-0.87) Gr 1: 0.92 (0.83-1.02) Gr 1: 1.03 (0.85-1.25) Medical management: 1.38 (1.07-1.77) PCI: 1.38 (1.06-1.80); CABG: 0.91 (0.56-1.47)	19/22
King (2009, Am J Cardiol) (25)	Alberta Retrospective	AMI ED visits, PCI, CABG	First Nations people (Gr 1) Caucasian’s people (Gr 2) All ages F/M	Time to ED presentation (hours): Gr 1/ Gr 2 (p=0.015) % of patients who saw provider ≤ 72h to ED presentation (p=0.002) Accompanying person fluent in English Time from ED presentation to cardiac catheterisation: Gr 1/Gr 2 (p = 0.001) % of patients who had PCI (p <0.001) % of patients who had CABG (p=0.022)	<1h: 23%/20%; 1-2 h: 26%/25%; 3-6 h: 11%/27%; 7-12h: 5.7%/1.8%; 13-24h: 34%/27% Gr 1: 21%; Gr 2: 12% Gr 1: 100%; Gr 2: 93% (p=0.940) <3h: 18%/42%; 3-6h: 7.7%/5.1%; 6-24h: 0.0%/9.4%; >24h: 46%/27%; Not done: 28%/16% Gr 1: 62%; Gr 2: 63% Gr 1: 2.6%; Gr 2: 6.0%	15/22
Lyons (2013, Can J of Cardiol) (70)	Alberta Retrospective	Heart failure Hospitalisation, ED visits	Status Indigenous people (Gr 1) Other Albertans (Gr 2) ≥ 20 y.o. F/M	Odds ratio of death for Gr 1 (95% CI) Hospitalisations per patient in the year after hospitalisation for HF Gr 1/Gr 2 ED visits per patient in the year after hospitalisation for HF Gr 1/Gr 2	1 year: 1.18 (1.02-1.38); 3 years: 1.43 (1.22-1.66); 5 years: 1.39 (1.16-1.67) All causes: 1.68/1.03 (p <0.0001) HF related: 0.21/0.14 (p = 0.004) All causes: 4.95/2.30 (p <0.0001) HF related: 0.32/0.19 (p = 0.0003)	10/22
Rosychuk (2016, BMC Emerg Med) (30)	Alberta Retrospective	AF and flutter ED visits	First Nations people (Gr 1) Non-First Nations people (Gr 2) > 35 y.o. F/M	ED visits Time for specialist follow-up visits	“First Nations seniors also had approximately three times as many ED presentations as would have been expected by the population proportion”. Gr 1 <65 y.o.: 103 days; Gr 1 >65 y.o.: 182 days	16/22
Shavadia (2020, Can J of Cardiol) (117)	Saskatchewan Prospective	ACS Hospitalisation	First Nations people (Gr 1) Saskatchewan’s population (Gr 2) All ages F/M	In-hospital mortality (95% CI)	OR = 1.88 (0.63-4.8)	8/11
Shultz (2018, Can J of Cardiol) (71)	Manitoba Retrospective	AMI, CHF, IHD, Stroke Hospitalisation, PCI, CABG	First Nations people (Gr 1) Non-First Nations people (Gr 2) All ages F/M	AMI group Hazard ratio for mortality for Gr 1 (95% CI) Hazard ratio for hospitalisations for Gr 1 (95% CI) Hazard ratio of revascularization following coronary angiogram for Gr 1 (95% CI) Non-AMI group Hazard ratio for mortality for Gr 1 (95% CI) Hazard ratio for hospitalisations for First Nations (95% CI) Hazard ratio of revascularization following coronary angiogram for Gr 1 (95% CI)	All-cause: 1.30 (0.96-1.75); Cardiovascular: 1.57 (1.05-2.35) All-causes: 1.35 (1.17-1.55); AMI: 1.30 (0.92-1.85); CHF: 1.54 (1.06-2.24); IHD: 1.46 (1.20-1.78); Stroke: 0.71 (0.33-1.52) PCI: 0.88 (0.75-1.02) CABG: 1.19 (0.94-1.49) All-cause: 1.52 (1.28-1.79); Cardiovascular: 1.50 (1.17-1.94) All-cause: 1.40 (1.29-1.51); AMI: 2.26 (1.79-2.85); CHF: 1.71 (1.38-2.12); IHD: 1.33 (1.17-1.50); Stroke: 1.47 (1.05-2.06) PCI: 0.85 (0.73-0.99) CABG: 1.26 (1.10-1.45)	19/22
Wei-Randall (2013, Health Rep) (72)	All Canada Retrospective	AMI Hospitalisation, PCI, CABG, Coronary angiogram	High-% First Nations people identity areas (Gr 1) Low-% Indigenous people identity areas (Gr 2) ≥ 20 y.o. F/M	Age-standardised hospitalised AMI events rates Age-standardised % of patients who had a coronary angiogram (95% CI) Age-standardised % of patients who had revascularization (95% CI) Age-standardised % of patients who had PCI (95% CI) Age-standardised % of patients who had CABG (95% CI)	Gr 1: 276.8/100,000; Gr 2: 157.1/100,000 (p <0.05) Gr 1: 51.1% (49.9-52.3); Gr 2: 58.1% (57.9-58.3) Gr 1: 39.6% (38.5-40.7); Gr 2: 46.8% (46.6-47.0) Gr 1: 30.7% (29.6-31.8); Gr 2: 38.1% (37.9-38.3) Gr 1: 9.3% (8.6-10.0); Gr 2: 9.2% (9.1-9.3%)	15/22
Young (1993, Am J Public Health) (73)	Northwest Territory Retrospective	Cardiovascular diseases Hospitalisation	First Nations people (Gr 1) Inuit (Gr 2) General population of Canada (Gr 3) All ages F/M	Age-standardised mortality rates/100,000 for diseases of the circulatory system (men/women) Hospitalisation rates/100,000 for diseases of the circulatory system Male/Female	Gr 1: 195/187; Gr 2: 205/149; Gr 3: 349/198 Keewatin Region (90% Inuit): 438/404; Northwest Territory: 891/640; All Canada: 1914/1472	15/22

ACS: Acute coronary syndrome, CHF: Congestive heart failure, AF: Atrial fibrillation, HTN: Hypertension, AMI: Acute myocardial infarction, PCI: Percutaneous coronary intervention, CABG: Coronary artery bypass grafting, IHD: Ischaemic heart disease

PSYCHIATRIC DISEASES (n = 8)
Author (year, journal)	Setting	Topic	Populations’ characteristics	Outcomes	Main results	STROBE
Carriere (2018, Statistics Canada) (82)	All provinces excluding Ontario and Quebec Retrospective	Mental disorders Hospitalisation	First Nations people on-reserve (Gr 1) First Nations people off-reserve (Gr 2) Non-Indigenous people (Gr 3) All ages F/M	Rate ratios for age-standardised hospitalisation rates/100,000 (95% CI)	Total: Gr 1: 2.4 (2.3-2.5); Gr 2: 2.0 (1.9-2.1) Substance-related: Gr 1: 7.0 (6.6-7.4); Gr 2: 4.3 (3.8-4.8) Mood: Gr 1: 1.2 (1.1-1.3); Gr 2: 1.6 (1.4-1.8) Schizophrenic/Psychotic: Gr 1: 1.8 (1.6-2.0); Gr 2: 1.9 (1.6-2.2) Anxiety: Gr 1: 2.3 (2.0-2.7); Gr 2: 1.7 (1.3-2.3) Organic: Gr 1: 1.1 (0.9-1.3); Gr 2: 1.0 (0.7-1.3) Personality: Gr 1: 1.2 (0.9-1.5); Gr 2: 1.3 (0.9-2.1) Other: Gr 1: 1.7 (1.6-1.9); Gr 2: 1.5 (1.3-1.8)	15/22
D’Arcy (1979, Can J Psychiat) (83)	Saskatchewan Descriptive	Mental illnesses Hospitalisation	Indigenous people (Gr 1) Non-Indigenous people (Gr 2) All ages F/M	Admissions per 10,000 population Gr 1/Gr 2	Total: 41/36; Psychoses: 16/19; Psychoneuroses: 12/7; Personality/Behaviour: 9/6; Mental Retardation: 1/0; Other/Unknown: 3/4	6/22
Dalrymple (1995, Can J Psychiat) (14)	Ontario Retrospective	Mental illnesses Hospitalisation	Indigenous people (Gr 1) Non-Indigenous people (Gr 2) All ages F/M	Consumer satisfaction survey (% Gr 1/% Gr 2) Length of stay in 1991-1992 (days)	Schizophrenia and other psychoses: 31.5%/37.8%; Mood disorders: 15.7%/21.3%; Substance abuse disorders: 0%/3.8%; Anxiety, Adjustment, Conduct and personality disorders: 0%/2.9%; Other disorders: 42.1%/33.9% Gr 1: 69.5; Gr 2: 32.8	14/22
Lavoie (2018, Int J Equity Health) (84)	British Columbia Retrospective	Mental health related-ambulatory care sensitive conditions Hospitalisation	First Nations people (Gr 1) British Columbia people (Gr 2) All ages F/M	Access to care Hospitalisation rate for mental health conditions Length of stay	First Nation communities served by nursing station have the lowest rate of hospitalisation. Communities served by health centres have highest rate of hospitalisation (poorer access to care). First Nations living off-reserve had significantly higher hospitalisation rates People in Gr 2 stay 4-6 days longer than Gr 1 in the hospital.	17/22
Lavoie (2020, Can J of Pub Health) (32)	Manitoba Retrospective	Mental illnesses Hospitalisation	First Nations people (Gr 1) Manitoba’s population (Gr 2) All ages F/M	Hospitalisation rates/1000 (95% CI; p) Adjusted rate of length of stay	Gr 1: 26.00 (17.59-38.42; p < 0.0001) Gr 2: 12.55 (12.34-12.75; p = 0.8596) Gr 1: 9.79 (7.08-13.52; p = 0.0466) Gr 2: 23.68 (23.60-23.76; p=0.5596)	17/22
Newton (2012, CMAJ) (103)	Alberta Retrospective	Mental health crisis ED visits	First Nations people (Gr 1) Alberta’s population (Gr 2) <18 y.o. F/M	Median length of stay in hours (95% CI) Age and sex-adjusted standardised visit rate/100,000 for Gr 1 (p = 0.004) Age and sex-adjusted standardised visit rate/ 100,000 for Gr 1 of 15-17 y.o. Hazard ratio for time to physician follow-up visit for Gr 1 (95% CI)	Gr 1: 2h27 (1h05-5h40); Gr 2: 3h (1h30-5h21) 2002-2003: 1368.0 2007-2008: 1664.0 Females: 7047.6 Males: 5787.3 Psychiatrist: 0.47 (0.32-0.70)	16/22
Newton (2016, Pediatr emerg care) (107)	Alberta Retrospective	Anxiety and stress disorders ED visits	First Nations people (Gr 1) Alberta’s population (Gr 2) < 18 y.o. F/M	ED visit rates/100,000 (95% CI) Follow-up visits	2002-2003: Gr 1: 263.49 (218.43-308.55); Gr 2: 126.87 (119.16-134.57) 2010-2011: Gr 1: 345.59 (294.18-397.00); Gr 2: 168.95 (160.51-177.39) Gr 1 children had less follow-up visits after discharge. Median time to follow-up visits = 32 days.	17/22
Soleimani (2016, BMC Psychiatry) (85)	Alberta Retrospective	Psychotic symptoms Hospitalisation	First Nations people (Gr 1) Alberta’s general population (Gr 2) 13-17 y.o. F/M	Hazard ratio for inpatient hospitalisation within 90 days of first ED visit (95% CI)	Gr 1 females: 4.18 (1.24-14.06) Gr 1 males: 0.57 (0.13-2.49)	17/22

PERCEPTION OF HEALTH CARE (n = 6)
Author (year, journal)	Setting	Topic	Populations’ characteristics	Outcomes	Main results	STROBE
Baker (2000, Western J Nurs Res) (15)	New-Brunswick Qualitative	Satisfaction of cross-cultural hospital care	Mi’kmaq people All ages F/M	Patient satisfaction	Major source of misunderstanding is different ways of thinking. Indigenous want their whole family to stay with them at all times, but it is not compatible with hospital rules and it can bother other patients. Majority of caregivers give good care, but every participant has experienced a misunderstanding with caregivers. Mi’kMaq feel isolated in the hospital and have difficulties to understand hospital’s rules. Mi’kMaq have difficulties to understand their treatment, but they never ask questions. They sometimes think they didn’t give the chance to caregivers to understand their needs. Mi’kMaq appreciated when their family were allowed to visit them and when they felt they received the same treatment as anybody else. They also appreciated when caregivers were kind.	23/32
Cameron (2014, Adv Nurs Sci) (16)	All provinces Qualitative	Inequalities in access to health care Emergency care services	First Nations people (Gr 1) Other Canadians (Gr 2) All ages F/M	Satisfaction of health care Barriers in access to care Access to care % of people who did not receive needed health care in the past year	Participants reported stories of racism, stigmatisation, language difficulties, intimidation, harassment and fear. They felt that professionals did not always take time to explain things properly or to assess participant’s needs and concerns. Limited access to comprehensive and specialised care, long waiting time, barriers in the communication and understanding of medical jargon, barriers in the interaction with professionals. 35% of Gr 1 felt that their access to health care was worst than Gr 2. Gr 1: 18% Gr 2: 12%	24/32
Goodman (2017, Soc Sci Med) (17)	British Columbia Qualitative	ED visits, Hospital visits	Indigenous people living in Vancouver’s inner city 19-70 y.o. Female/ Male	Satisfaction of health care	They feel they are treated differently than other patients. Some are scared to go to the hospital. Several reported only seeking healthcare once their illness or symptoms had become severe. The security or staff of the hospital often threatens them. Hospital policies exacerbate cultural barriers. There is facility devoted space for Indigenous, but Indigenous don’t know it exist and when they looked for it, it was not accessible. Presence of stereotypes associating Indigenous to substance use. Because of that, requests for pain medication are often perceived as drug seeking. Health care professionals care more about proving the patient took drug than providing medical care. Lack of empathy, Incompetent addiction medicine training.	20/32
Hole (2015, Qual Health Res) (18)	British Columbia Qualitative	Health care at a community hospital	Urban Indigenous people 19-75 y.o. F/M	Things appreciated in health care Bad perceptions of health care	Being recognised as Indigenous, heard and respected. People with lower income wait longer in the waiting room. Professionals think that Indigenous are drunk and treat Indigenous differently than others. It’s hard for the staff to give good care when they are short-staffed and exhausted. It’s when the staff is stressed that all the bad commentaries tend to come out. Hospital rules exclude Indigenous realities. Indigenous staff is not allowed to speak up about the problems. Professionals are too concentrated in having access to the patient to do medical procedures rather than letting the patient have family support. The professionals sometimes hide information from the family. Professionals have access to a lot of pain reliever medication, but they don’t want to give them because they are afraid that the patient will get addicted.	18/32
Tang (2008, Ethnic Health) (20)	Western Canadian province Qualitative	ED visits, hospital visits	Indigenous people All ages F/M	Patients’ satisfaction Health care professionals’ perceptions	Health care professionals often think that the cause of the symptoms is alcohol even when the patient claims he did not drink. Some Indigenous get kicked out of the ED because the security thinks they are drunk or that they aren’t really sick. A lot of Indigenous won’t go to the hospitals unless they are almost dying. Some feel they have to wait longer for getting health care professional’s attention towards an important health problem. Believe they provide the same quality of care to any patients. There is no judgment towards patients of First Nation status. Some professionals think you can give them the best care in the world and they will not be able to access it because they can’t or they do not want to. One ED professional recognised that sometimes health care professionals tend to generalise that all Indigenous have a drinking problem and have a low social economic background. Another said he is more guarded with an Indigenous patient.	20/32
Tang (2015, Sociol Health Illn) (21)	Western Canadian province Qualitative	ED visits	Indigenous people All ages F/M	Health care providers opinions towards indigenous people: Indigenous people perception towards health care providers:	Indigenous have addictions and they present physical signs of their addiction. Many are on welfare and don’t have a job nor take care of themselves. They want to be seen as needy people. They misuse the money from tax payers. Some Indigenous just come to the hospital to have food and drugs. There are other population groups which misuse the health care system and have poverty issues but the stigma is not the same as with Indigenous. When all their requests are not met, they become frustrated and it’s hard to remain compassionate and non-judgemental when those behaviours are seen. Providers always think that you’re a drug addict or a drunk. Sometimes, Indigenous are getting escorted out of the hospital because the staff think they are here just to get drugs or to get free food.	21/32

a All the information from this table comes from the articles directly, it does not represent our opinion

RHEUMATOLOGIC DISEASES (n = 5)
Author (year, journal)	Setting	Topic	Populations’ characteristics	Outcomes	Main results	STROBE
Barnabe (2016, J Rheumatol) (38)	Alberta Comparative	RA, AS, PsD Hospitalisation	First Nations people (Gr 1) Non-First Nations people (Gr 2) All ages F/M	Hospitalised infection rates/1000 for Gr 1	RA: 29.7; AS: 19.8; PsD: 22.4	5/11
Barnabe (2016, J Rheumatol) (126)	Alberta Prospective	RA Hospitalisation ED visits	Indigenous people (Gr 1) Non-Indigenous people (Gr 2) All ages F/M	Cost estimates for Gr 1 patients (95% CI)	Hospital: −5406$ (−11,552 – 470) Emergency room: 660$ (−38 – 1357)	6/11
Barnabe (2017, Arthrit Care Res) (80)	Alberta Retrospective	RA, AS, PsD, CRA Hospitalisation	First Nations people (Gr 1) Non-First Nations people (Gr 2) All ages F/M	Crude all-cause hospitalisation rates/100 (95% CI) Arthritis-specific hospitalisation/100 (95% CI)	RA: Gr 1: 38.9 (38.2-39.7); Gr 2: 25.1 (24.9-25.3) AS: Gr 1: 37.5 (35.8-39.2); Gr 2: 20.2 (19.9-20.6) PsD: Gr 1: 36.8 (34.1-39.7); Gr 2: 17.9 (17.6-18.3) Crystal-related arthritis: Gr 1: 34.1 (32.5-35.7); Gr 2: 23.9 (23.7-24.1) RA: Gr 1: 2.3 (2.1-2.5); Gr 2: 3.4 (3.3-3.4) AS: Gr 1: 1.0 (0.7-1.3); Gr 2: 1.3 (1.2-1.4) PsD: Gr 1: 1.7 (1.2-2.4); Gr 2: 1.4 (1.3-1.5) CRA: Gr 1: 1.6 (1.2-1.9); Gr 2: 1.6 (1.6-1.7)	17/22
Levy (2013, Arthritis Rheum) (102)	Ontario Retrospective	Childhood-onset SLE Hospitalisation ED visits	Indigenous people (Gr 1) White people (Gr 2) Asian people (Gr 3) Black people (Gr 4) South Asian people (Gr 5) < 18 y.o. F/M	Distribution of patients ED visit in the first year of diagnosis % of patients hospitalised % of patients who required at least 3 hospitalisations	Gr 1: 1.3%; Gr 2: 42% Whites; Gr 3: 24%; Gr 4: 15%; Gr 5: 13% 43% 38% 12%	10/11
Oppenheimer (2007, South med J) (28)	Manitoba, Ontario Retrospective	Blastomycosis of bones and joints Hospitalisation, ICU admission	Indigenous people (First Nations/ Metis) (Gr 1) Non-Indigenous people (Gr 2) All ages F/M	Time from first symptoms to admission (days) Time from admission to diagnosis (days) Duration of hospital stay (days) % of death	Gr 1: 31 ± 30; Gr 2: 95 ± 150 Gr 1: 10 ± 30; Gr 2: 15 ± 30 Gr 1: 30 ± 20; Gr 2: 22 ± 30 Gr 1: 8%; Gr 2: 3%	15/22

RA: Rheumatoid arthritis, AS: Ankylosis spondylitis, PsD: Psoriatic disease, CRA: Crystal-related arthritis, SLE: Systemic lupus erythematous

NEUROLOGICAL DISEASES (n = 5)
Author (year, journal)	Setting	Topic	Populations’ characteristics	Outcomes	Main results	STROBE
Ahmed (2020, Can J of Surg) (121)	Saskatchewan Retrospective	Traumatic spinal cord injury Hospitalisation	Indigenous people (Gr 1) Saskatchewan’s population (Gr 2) All ages F/M	Time from admission to surgery, h, median (p=0.20) Proportion of surgical management (%)	Gr 1: 20.0 Gr 2: 15.0 Gr 1: 71% Gr 2: 85%	16/22
Blackmer (1999, Brain injury) (122)	Saskatchewan Retrospective	Traumatic brain injury Hospitalisation	Indigenous people (Gr 1) Non-Indigenous people (Gr 2) All ages F/M	Acute care length of stay (days) Time to follow-up (days) (p <0.0001)	Gr 1: 33.33; Gr 2: 35.23 (p = 0.734) Gr 1: 56.50; Gr 2: 28.10	15/22
Jetté (2008, Epilepsia) (78)	Alberta Retrospective	Epilepsy Hospitalisation, ED visits	First Nations people (Gr 1) Non-Indigenous people (Gr 2) All ages F/M	Odds ratio for hospitalisation (95% CI) Odds ratio for ED visits (95% CI) Mean hospital length of stay	Gr 1: 2.8 (1.49-5.13) Gr 1: 2.3 (1.09-4.98) 2 ± 12 days	16/22
Kapral (2020, CMAJ Open) (75)	Ontario Retrospective	Stroke or transient ischaemic attack Hospitalisation	First Nations people (Gr 1) Ontario’s population (Gr 2) 20 y.o. and over F/M	Rate of hospital admission per 100,000 (95% CI) % of mortality at 7 days (95% CI) % of mortality at 1 year (95% CI) % of patients with neuroimaging (95% CI) % of thrombolysis (95% CI) % of carotid revascularization (95% CI)	Gr 1: 641.2 (539.8-756.2); Gr 2: 540.2 (527.6-552.9) Gr 1: 12.0 (8.9-15.9); Gr 2: 8.5 (8.0-9.0) Gr 1: 33.8 (28.2-40.2); Gr 2: 28.1 (27.1-29.1) Gr 1: 94.6 (85.9-100.0); Gr 2: 96.0 (94.2-97.9) Gr 1: 6.3 (3.9-9.7); Gr 2: 11.0 (10.3-11.7) Gr 1: 1.4 (0.5-3.0); Gr 2: 2.7 (2.4-3.0)	20/22
Lasry (2016, Can J Neurol Sci) (79)	Quebec Retrospective	Traumatic brain injury Hospitalisation	Cree population (Gr 1) Entire province of Quebec population (Gr 2) All ages F/M	Rate ratios for hospitalisation (95% CI)	Gr 1: 1.86 (1.56-2.17)	4/11

ENDOCRINE-RELATED CONDITIONS (n = 5)
Author (year, journal)	Setting	Topic	Populations’ characteristics	Outcomes	Main results	STROBE
Booth (2005, Diabetes Care) (88)	Ontario Retrospective	Complications of diabetes ED visits, Hospitalisation	Indigenous people Ontario’s general population ≥ 18 y.o. F/M	Risk ratio for ED visits or hospital admission for diabetes for Indigenous	1.8	17/22
Campbell (2014, Diabetol Metab Syndr) (89)	Alberta Retrospective	Complications of diabetes, Hospitalisation	First Nations people (Gr 1) Non-First Nations people (Gr 2) ≥ 18 y.o. F/M	Adjusted odds ratio for hospitalisation for Gr 1 (95% CI)	30 y.o.: 3.94 (3.11-4.99) 55 y.o.: 4.75 (3.24-6.97) 80 y.o.: 5.74 (3.36-9.80)	15/22
Pohar (2007, BMC health serv res) (91)	Saskatchewan Retrospective	Diabetic patients Hospitalisation	Indigenous people (First Nations, Inuit, Metis) (Gr 1) General population (Gr 2) All ages F/M	Odds ratio for hospitalisation for diabetic patients (p <0.05) Age-standardised per capita health care cost for Gr 1 (95% CI) Age-standardised per capita health care cost for Gr 2 (95% CI)	Gr 1: 2.2; Gr 2: 2.1 Without diabetes: 1 395$ (1 394-1 397) With diabetes: 3 204$ (3 201-3 206) Without diabetes: 875$ (875-875) With diabetes: 2 257$ (2 256- 2 258)	16/22
Rose (2008, Foot Ankle Surg) (90)	Manitoba Retrospective	Diabetic ulcers, Hospitalisation	Indigenous people (First Nations, Metis) (Gr 1) Non-Indigenous people (Gr 2) All ages F/M	% of patients with amputation Gr 1/Gr 2	Toe only: 39%/ 53% Forefoot: 13%/ 7% Below knee: 45%/ 33% Above knee: 3%/ 7%	17/22
Shah (2020, CMAJ Open) (101)	Ontario Retrospective	Diabetes complications Hospitalisation, ED visits	First Nations people on-reserve (Gr 1) First Nations people off-reserve (Gr 2) Ontario’s population (Gr 3) All ages F/M	% admitted to hospital for ambulatory-care-sensitive-conditions Emergency department visits for hypo- or hyperglycaemia (%)	Gr 1: 2.5 (2.1-2.9) Gr 2: 2.4 (2.1-2.7) Gr 3: 1.2 (1.2-1.2) Gr 1: 1.1 (0.9-1.3) Gr 2: 1.8 (1.5-2.0) Gr 3: 0.8 (0.8-0.9)	18/22

PAEDIATRIC-RELATED DISEASES (n = 5)
Author (year, journal)	Setting	Topic	Populations’ characteristics	Outcomes	Main results	STROBE
He (2017, CMAJ) (87)	Quebec Retrospective	Hospitalisation	First Nations people (Gr 1) Inuit people (Gr 2) Non-Indigenous people (Gr 3) <1 y.o. F/M	Adjusted rate ratios for infant hospitalisation (95% CI)	Any cause: Gr 1: 1.43 (1.37-1.50); Gr 2: 1.37 (1.24-1.52) Infections: Gr 1: 1.66 (1.54-1.78); Gr 2: 1.31 (1.10-1.57) Injuries/accidents: Gr 1: 1.16 (0.97-1.39); Gr 2: 1.36 (0.86-2.15) Congenital anomalies: Gr 1: 1.35 (1.15-1.59); Gr 2: 1.40 (1.01-1.95) Perinatal-originated conditions: Gr 1: 0.95 (0.75-1.19); Gr 2: 0.92 (0.58-1.45) Respiratory system: First Nations: 1.91 (1.80-2.03) Inuit: 1.82 (1.59-2.08) Digestive system: Gr 1: 1.49 (1.31-1.69); Gr 2: 1.01 (0.73-1.39) Nervous system: Gr 1: 1.64 (1.43-1.89); Gr 2: 1.64 (1.20-2.25) Genitourinary system: Gr 1: 1.75 (1.45-2.11); Gr 2: 0.61 (0.32-1.16) Musculoskeletal system: Gr 1: 1.34 (0.60-2.98) Circulatory system: Gr 1: 1.50 (0.86-2.61) Endocrine system: Gr 1: 1.49 (1.29-1.73); Gr 2: 2.61 (1.50-4.53) Skin and subcutaneous tissue: Gr 1: 3.00 (2.58-3.49); Gr 2: 2.86 (1.57-5.23) Blood: Gr 1: 0.96 (0.57-1.60) Mental/neurodevelopmental disorders: Gr 1: 1.20 (0.50-2.95) Neoplasms: Gr 1: 0.91 (0.50-1.71)	18/22
Reime (2007, Paediatr Perinat Epidemiol) (24)	All of Canada Retrospective	ICU admissions	Indigenous people (Gr 1) White people (Gr 2) Neonates F/M	No access to prenatal care Mortality (p <0.001) Adjusted odds ratio for Gr 1 for specific treatments (95% CI) Length of stay (days) (p<0.05)	Gr 1: 7.2%; Gr 2: 1.6% Gr 1: 7.1%; Gr 2: 7.4% Transparenteral nutrition: 0.77 (0.60-1.00) Blood transfusion 1.07 (0.78-1.46) Surfactant 0.78 (0.57-1.06) Assisted ventilation 0.86 (0.67-1.09) Surgery 0.73 (0.54-0.99) Antenatal steroids 1.04 (0.81-1.34) Incubator 0.85 (0.65-1.12) Gr 1: 4.5 days; Gr 2: 2.9 days	19/22
Stammers (2014, Pediatr Blood Cancer) (81)	Manitoba Retrospective	Cancer complications Hospitalisation	First Nations people (Gr 1) Non-First Nations people (Gr 2) <15 y.o. F/M	Risk ratios for hospital admission days for treatment complications for Gr 1 (95% CI; p)	Low risk: 0.853 (0.27-1.55; p= 0.371) Intermediate/High risk: 1.140 (0.52-2.48; p=0.748)	18/22
Thanh (2015, J Pediatr) (125)	Alberta Retrospective	Health care utilisation for low birth-weight population	Indigenous people (Gr 1) Alberta’s population (Gr 2) <1 y.o. F/M	Health services use cost coefficient	Gr 1: 1560 (1359-1762; p <0.001)	18/22
Thomson (1994, Can Fam Physician) (86)	Saskatchewan, Ontario Retrospective	Acute otitis media Hospitalisation	First Nations people (Gr 1) Ontario and Saskatchewan’s general population (Gr 2) <5 y.o. F/M	Hospitalisation rates/100 for otitis media (Gr 1/Gr 2) Relative risk of hospitalisations for otitis media for Gr 1 (95% CI) Hospitalisation rates/100 for upper respiratory tract infection (Gr 1/Gr 2) Relative risk of hospitalisation for upper respiratory infection for Gr 1 (95% CI)	Boys 1-4 y.o.: 6.7/1.1; Girls 1-4 y.o.: 5.6/0.8 0-1 y.o.: 2.1/0.3 Boys 1-4 y.o.: 6.1 (5.1-7.3); Girls 1-4 y.o.: 6.7 (5.4-8.2) 0-1 y.o.: 6.1 (0.6-67.0) Boys 1-4 y.o.: 24.7/5.2; Girls 1-4 y.o.: 22.9/3.8 Saskatchewan’s boys 0-1 y.o.: 27.1/4.8 Saskatchewan’s girls 0-1 y.o.: 27.4/3.1 Ontario’s 0-1 y.o.: 5.2/0.7 Boys 1-4 y.o.: 4.7 (4.3-5.1); Girls 1-4 y.o.: 6.1 (5.6-6.7) Saskatchewan’s boys 0-1 y.o.: 5.7 (4.8-6.7) Saskatchewan’s girls 0-1 y.o.: 8.9 (7.4-10.6) Ontario’s 0-1 y.o.: 7.7 (1.5-38.9)	12/22

GASTROINTESTINAL DISEASES (n = 4)
Author (year, journal)	Setting	Topic	Populations’ characteristics	Outcomes	Main results	STROBE
Beres (2010, J Pediatr Surg) (123)	Northern Canada Retrospective	Appendicitis Hospitalisation, Surgery	Northern Indigenous people (Gr 1) Local population (Gr 2) Children F/M	Type of appendectomy (%) (p=0.02) Length of stay (days) (p = 0.98) Intervals between arrival and operating room Mean operative time	Laparoscopic: Gr 1: 57%; Gr 2: 73% Open: Gr 1: 43%; Gr 2: 27% Gr 1: 2.9 ± 2.0; Gr 2: 2.9 ± 3.0 Gr 1: 10.3h; Gr 2: 7.0h (p = 0.0002) Gr 1: 49.0 ± 20.2 min; Gr 2: 54.5 ± 17.6 min	15/22
Carey (1977, Can Assoc Radiol J) (124)	Ontario Case reports	Lead shot appendicitis Hospitalisation	Inuit people 56 and 57 y.o. F/M	Type of treatment	CASE 1: Rectal suppositories to clear the lead shot (no effect). Sigmoidoscopy to evacuate the lead shot (no success). Laparotomy to remove the appendix, 3 lead shots, to mobilise lead shots through the rectum. 2 weeks after the surgery, enemas, purgatives and repeated sigmoidoscopy were done to dislodge the lead shots still present (no success). Another surgery was done to remove the rest of the lead shots. CASE 2: Catheterisation of bladder (wrong diagnosis of urinary retention). Sigmoidoscopy (no success). Barium examination of the colon. Open appendicectomy for peritonitis.	7/13
Cohen (1989, Am J Public Health) (120)	Manitoba Retrospective	Gall bladder diseases Hospitalisation, Surgery	First Nations (Gr 1) Non-First Nations (Gr 2) All ages F/M	% of patients who received their operation from a general practitioner	Gr 1: 34.2%; Gr 2: 18%	14/22
Harper (2015, Int J Circumpol Heal) (29)	Labrador and Nunavut Cross-sectional	Acute gastrointestinal illness Primary care visits	Inuit people All ages Male/Female	% of patients who visited clinic or hospital (95% CI) Reasons for not seeking care Rigolet/Iqaluit	Rigolet: 4.8% (1.5-14.4) Iqaluit: 16.9% (11.2-24.7) Illness not serious enough: 82%/50%; Would not make a difference: 2%/10%; Dislikes or distrusts doctors or nurses: 2%/3%; On the land: 5%/1%; Language barriers: 0%/0%	16/22

INFECTIOLOGY-RELATED DISEASES (n = 4)
Author (year, journal)	Setting	Topic	Populations’ characteristics	Outcomes	Main results	STROBE
Dallaire (2006, C J Public Health) (39)	Quebec Retrospective	Acute infections Hospitalisation	Inuit people <5 y.o. F/M	Hospitalisation rates/1000 for Inuit (95% CI) 0-11 months old/12-23 months old/2-4 y.o.	Pneumonia: 198 (145-251)/ 119 (77-160)/ 30 (17-44) Bronchitis/Bronchiolitis: 107 (68-147)/ 23 (5-40)/ 5 (0-10) Upper respiratory tract infections: 28 (8-49)/ 0/ 1 (−1 – 3) Urinary tract infections (female): 17 (−2 – 36)/ 33 (7-60)/ 2 (−2 – 6) Urinary tract infections (male): 18 (−2 – 38)/ 121 (−11 – 35)/ 2 (−2 – 6) Fever NOS: 14 (2-27)/ 3 (−3 – 8)/ 1 (−1 – 3) Acute otitis media: 11 (0-22)/ 3 (−3 – 8)/ 1 (−1 – 3) Pyelonephritis/pyelitis (female): 11 (−6 – 27)/ 6 (−5 – 17)/ 6 (−1 – 12) Cellulitis: 9 (−1 – 18)/ 14 (−1 – 29)/ 8 (1-14) Meningitis: 9 (−1 – 18)/ 6 (−2 – 14)/ 1 (−1 – 3) Laryngitis/Tracheitis: 3 (−3 – 8)/ 9 (−1 – 18)/ 3 (0-6)	17/22
Landy (2010, Int J Infect Dis) (33)	Northern Canada Case report	Gonococcal septic shock, ARDS and Multisystem organ failure Hospitalisation	Indigenous people 36 y.o. Female	Time for transfer to tertiary care Type of treatment Length of stay	13h (because of artic winter and distance) Fluid resuscitation, intubation and vasopressors prior to transfer. Empiric ceftriaxone and vancomycin were administered after blood cultures. Ethanol infusion was started then discontinued when the anion gap became normal. The patient improved with mechanical ventilation, vasopressor support, ceftriaxone, corticosteroids and supportive ICU care. 12 days in ICU, 2 days in general medicine	7/13
Mashru (2017, J Telemed Telecare) (13)	Ontario Descriptive	Infectious diseases Hospitalisation	Sioux community people All ages F/M	Patient satisfaction towards telemedicine consultation	Patient understood how the session would run: 98% Help was available if there were problems: 100% Able to hear specialist comfortably: 98%; Satisfied with picture quality: 94%; Privacy was respected: 100%; Would use telemedicine again: 94%; Would recommend to family/friends: 92%; Overall satisfied with appointment: 98%	15/22
Nicolle (1996, Clin Infect Dis) (76)	Manitoba Retrospective	Acute pyelonephritis Hospitalisation	First Nations people Non-Indigenous people (Gr 2) All ages F/M	Mean hospitalisation rates/10,000 Rate ratios for hospitalisation for Gr 1 patients (95% CI)	Women: 9.01 ± 0.47; Men: 3.24 ± 0.27 First Nations women: 46.11 ± 4.86 First Nations men: 4.76 ± 1.59 Women: 5.12 (4.23-6.20) Men: 1.47 (0.85-2.53)	14/22

OBSTETRICAL AND GYNAECOLOGICAL CONDITIONS (n = 4)
Author (year, journal)	Setting	Topic	Populations’ characteristics	Outcomes	Main results	STROBE
Houd (2004, Int J of Circump Health) (110)	Quebec Retrospective	Delivery Hospitalisation	Inuit people (Gr 1) All ages Female	Perinatal death rate	7/1000	12/22
Lessard (1987, CMAJ) (111)	Northwest Territory, Alberta Retrospective	Delivery Hospitalisation	Inuit people (Gr 1) 14-44 y.o. Female	Stillbirth rate Medical intervention for nulliparous women Medical interventions for multiparous Primary caesarean sections rates	9.7/1000 deliveries Induction: 6%; Augmentation: 4%; Analgesia: 17% Induction: 6%; Augmentation: 1%; Analgesia: 3% Nulliparous: 5.6%; Multiparous: 2.5%	10/22
Oluyomi-Obi (2010, Obstetrics) (112)	Manitoba Case reports	H1N1 Influenza A and pregnancy Admission to ICU	Indigenous people (5/6 patients) 16-29 y.o. Female	Admission to ICU Mortality Quality of care Median length of stay (days)	6 patients 2 women and 1 baby 3/6 patients intubated ECMO 2/6 patients Emergency caesarian delivery: 3/6 20.5	19/22
Van Wagner (2012, Birth) (113)	Quebec Retrospective	Delivery Hospitalisation	Inuit people (Gr 1) All ages Female	Mortality Active management of third stage	1 maternal death, 4 foetal deaths (0.29%), 5 neonatal deaths (0.36%) 49.8%	21/22

NEPHROLOGICAL CONDITIONS (n = 1)
Author (year, journal)	Setting	Topic	Populations’ characteristics	Outcomes	Main results	STROBE
Molnar (2018, Can J Kidney Health Dis) (77)	All provinces except Quebec and Manitoba Retrospective	Complications in dialysis patients Hospitalisation	Indigenous people (Gr 1) Caucasian people (Gr 2) All ages F/M	Adjusted hazard ratio for all-cause hospitalisations (95% CI) Hazard ratio for infection-related hospitalisations (95% CI)	Gr 1: 1.20 (1.12-1.28) Gr 1: 1.30 (1.11-1.53)	18/22