Background
Methods
Study setting
Design and data sources
Case definition of diabetes
Studied population
Dependent variables: health indicators
Independent variables: individual and neighbourhood-level measures
Patient-level variables
Geographical-level (DAs) variables
Other DA-level variables: immigration, material and social indices
Statistical analyses
Sensitivity analyses
Results
Immigration, material and social dimensions
Dimension | |||
---|---|---|---|
Axes (derived from 3 PCAs) | Immigration | Material | Social |
Eigenvalue | 3.73 | 1.91 | 1.87 |
Percentage of variance explained by the axis | 62.2 | 63.5 | 62.3 |
Eigenvalue of the second most important axis | 0.64 | 0.65 | 0.76 |
Component loadings associated with variables
1
| |||
Proportion of people with maternal language other than French or English** | 0.92 | − | − |
Proportion of people who does not speak French or English** | 0.79 | − | − |
Proportion of recent immigrants (arrived < 5 years ago in Canada)** | 0.75 | − | − |
Proportion of immigrants that arrived 5-10 years ago** | 0.73 | − | − |
Proportion of immigrants that arrived 10-15 years ago** | 0.77 | − | − |
Proportion of immigrants that arrived 15-25 years ago** | 0.75 | − | − |
Average income** | − | -0.82 | − |
Employment rate*** | − | -0.73 | − |
Proportion of people without high school certificate* | − | 0.84 | − |
Proportion of separated, divorced or widowed people* | − | − | 0.86 |
Proportion of people living alone** | − | − | 0.86 |
Proportion of single-parental families** | − | − | 0.63 |
CMA of Montreal | Socially wealthy (Q1) | Socially deprived (Q5) | Materially wealthy (Q1) | Materially deprived (Q5) | |||||
---|---|---|---|---|---|---|---|---|---|
Low immigration (Q1) | High immigration (Q5) | Low immigration (Q1) | High immigration (Q5) | Low immigration (Q1) | High immigration (Q5) | Low immigration (Q1) | High immigration (Q5) | ||
Number of DAs | 6,009 | 339 | 95 | 214 | 200 | 230 | 40 | 184 | 502 |
Total population | 3,606,770 | 183,780 | 66,070 | 119,950 | 137,220 | 138,455 | 43,145 | 99,540 | 302,645 |
Immigration score2 | 0 (3.7) | −4.5 (0.5) | 5.1 (1.4) | −4.5 (0.5) | 5.3 (1.5) | −4.4 (0.5) | 4.6 (1.0) | −4.6 (0.5) | 6.3 (1.9) |
Social deprivation score2 | 0 (1.9) | −2.5 (0.7) | −2.6 (0.8) | 2.8 (1.1) | 2.3 (0.7) | −1.8 (1.3) | −1.2 (1.6) | 1.7 (2.1) | 0.7 (1.3) |
Material deprivation score2 | 0 (1.9) | −1.3 (1.5) | −0.5 (1.8) | 1.6 (1.5) | 1.7 (1.5) | −2.5 (0.7) | −2.4 (0.7) | 2.5 (0.9) | 2.7 (0.8) |
DA-level variables
3
| |||||||||
% of people with maternal language other than French or English | 21.5 (19.5) | 3.3 (2.6) | 49.6 (11.6) | 3.3 (2.3) | 42.4 (11.4) | 3.6 (2.8) | 39.7 (8.4) | 3.1 (2.6) | 55.8 (14.8) |
% of people who do not speak French or English | 1.6 (2.8) | 0.02 (0.2) | 4.9 (3.9) | 0.03 (0.18) | 4.2 (3.6) | 0.01 (0.14) | 2.9 (1.3) | 0.04 (0.25) | 6.5 (4.6) |
% of recent immigrants* (<5 years) | 4.5 (6.6) | 0.2 (6.6) | 5.8 (7.5) | 0.3 (0.8) | 13.0 (7.4) | 0.2 (0.7) | 6.8 (6.4) | 0.2 (0.6) | 13.4 (9.1) |
% of immigrants* (5–10 years) | 2.5 (3.6) | 0.1 (0.5) | 5.5 (4.2) | 0.1 (0.4) | 7.0 (5.1) | 0.2 (0.5) | 5.5 (3.4) | 0.1 (0.4) | 6.8 (4.9) |
% of immigrants* (10–15 years) | 2.6 (3.6) | 0.1 (4.6) | 6.8 (5.2) | 0.1 (0.4) | 6.7 (4.2) | 0.1 (0.5) | 5.9 (3.0) | 0.1 (0.4) | 7.6 (4.5) |
% of immigrants* (15–25 years) | 3.4 (4.0) | 0.2 (6.7) | 9.2 (3.9) | 0.2 (0.5) | 6.9 (4.3) | 0.2 (0.6) | 8.9 (3.7) | 0.2 (0.6) | 8.2 (4.7) |
Average income (x 1000) | 34.3 (16.2) | 40.2 (11.3) | 37.6 (15.1) | 27.7 (6.2) | 23.6 (6.0) | 46.1 (11.6) | 53.2 (13.9) | 25.2 (5.2) | 20.4 (3.9) |
Employment rate | 62.2 (12.0) | 73.2 (8.6) | 63.7 (9.9) | 53.6 (15.7) | 50.0 (9.2) | 77.4 (7.5) | 69.8 (5.9) | 49.9 (13.9) | 48.2 (7.7) |
% of people without high school certificate | 22.0 (10.7) | 19.4 (9.0) | 18.7 (10.0) | 31.9 (9.1) | 26.1 (12.8) | 12.6 (4.4) | 10.7 (4.1) | 38.9 (7.3) | 35.0 (8.6) |
% of separated, divorced or widowed people | 18.3 (6.8) | 12.4 (2.4) | 10.4 (2.2) | 30.6 (7.9) | 24.6 (4.8) | 14.2 (4.2) | 14.0 (4.6) | 27.2 (10.2) | 28.9 (4.7) |
% of people living alone | 13.4 (10.1) | 3.4 (2.2) | 4.6 (5.0) | 23.8 (10.1) | 23.7 (8.6) | 4.8 (4.0) | 10.6 (8.2) | 19.8 (12.5) | 14.2 (7.2) |
% of single-parental families | 18.1 (10.7) | 7.7 (5.4) | 8.3 (5.6) | 26.0 (11.4) | 31.2 (12.2) | 10.9 (7.0) | 10.9 (6.8) | 21.0 (12.7) | 27.2 (11.3) |
Health indicators of the study cohort
Immigration | Trend test** | ||||||
---|---|---|---|---|---|---|---|
Variables | TOTAL | Q1 - Low | Q2 | Q3 | Q4 | Q5 - High | β (p - value) |
TOTAL study cohort, n (%) | 111,556 (100) | 19,833 (17.8) | 20,838 (18.7) | 22,240 (19.9) | 23,318 (20.9) | 25,327 (22.7) | − |
Patient-level variables | |||||||
Average age (SD) | 61.3 (13.1) | 60.7 (12.9) | 60.9 (13.0) | 61.8 (13.1) | 61.9 (13.3) | 61.2 (13.3) | 0.184 (<.0001) |
Sex, n (%) | |||||||
Women | 54,305 (48.7) | 9,266 (46.7) | 9,853 (47.3) | 10,847 (48.8) | 11,581 (49.7) | 12,758 (50.4) | 0.039 (<.0001) |
Men | 57,251 (51.3) | 10,567 (53.3) | 10,985 (52.7) | 11,393 (51.2) | 11,737 (50.3) | 12,569 (49.6) | − |
Incident diabetes cases, n (%) | 30,621 (27.4) | 5,286 (26.6) | 5,742 (27.6) | 6,226 (28.0) | 6,520 (28.0) | 6,847 (27.0) | 0.005 (0.3353) |
Diabetes with complications, n (%) | 10,286 (9.2) | 1,740 (8.8) | 1,923 (9.2) | 2,093 (9.4) | 2,213 (9.5) | 2,317 (9.2) | 0.011 (0.1393) |
Hypertension, n (%) | 19,267 (17.3) | 3,364 (17.0) | 3,674 (17.6) | 3,958 (17.8) | 4,092 (17.6) | 4,179 (16.5) | −0.009 (0.1193) |
Dyslipidemia, n (%) | 8,821 (7.9) | 19,833 (8.2) | 1,795 (8.6) | 1,803 (8.1) | 1,786 (7.7) | 1,801 (7.1) | −0.046 (<.0001) |
Dementia, n (%) | 1,977 (1.8) | 362 (1.8) | 401 (1.9) | 421 (1.9) | 407 (1.8) | 386 (1.5) | −0.047 (0.0031) |
Chronic pulmonary disease, n (%) | 4,153 (3.7) | 775 (3.9) | 835 (4.0) | 882 (4.0) | 827 (3.6) | 834 (3.3) | −0.049 (<.0001) |
Renal disease, n (%) | 4,136 (3.7) | 828 (4.2) | 827 (4.0) | 860 (3.9) | 779 (3.3) | 842 (3.3) | −0.065 (<.0001) |
Connective tissue disease or ulcer disease, n (%) | 1,308 (1.2) | 216 (1.1) | 224 (1.1) | 262 (1.2) | 252 (1.1) | 354 (1.4) | 0.057 (0.0041) |
Liver disease, n (%) | 2,433 (2.2) | 442 (2.2) | 488 (2.3) | 495 (2.2) | 500 (2.1) | 508 (2.0) | −0.031 (0.0300) |
Tumor (incl. leukemia, lymphoma, metastatic tumor), n (%) | 5,510 (4.9) | 1,009 (5.1) | 1,065 (5.1) | 1,172 (5.3) | 1,112 (4.8) | 1,152 (4.6) | −0.032 (0.0012) |
Neighbourhood (DA)-level variables | |||||||
Living in the urban core, n (%) | 96,862 (86.8) | 12,889 (65.0) | 17,046 (81.8) | 20,501 (92,2) | 22,146 (95.0) | 24,280 (95.9) | 0.722 (<.0001) |
Average material deprivation score (SD) | 0.52 (1.82) | 0.33 (1.66) | 0.06 (1.78) | 0.08 (1.84) | 0.41 (1.75) | 1.51 (1.60) | 0.290 (<.0001) |
Average social deprivation score (SD) | 0.33 (1.89) | 0.04 (2.04) | 0.23 (2.08) | 0.48 (2.03) | 0.45 (1.86) | 0.42 (1.44) | 0.093 (<.0001) |
Immigration | Trend test ** | ||||||
---|---|---|---|---|---|---|---|
Dependent variables | TOTAL | Q1 - Low | Q2 | Q3 | Q4 | Q5 - High | β (p - value) |
TOTAL study cohort, n (%) | 111,556 (100) | 19,833 (17.8) | 20,838 (18.7) | 22,240 (19.9) | 23,318 (20.9) | 25,327 (22.7) | − |
All-cause death, n (%) | 6,453 (5.8) | 1,172 (5.9) | 1,205 (5.8) | 1,364 (6.1) | 1,352 (5.8) | 1,360 (5.4) | −0.021 (0.0203) |
All-cause hospitalization, n (%) | 35,928 (32.2) | 6,370 (32.1) | 6,711 (32.2) | 7,304 (32.8) | 7,605 (32.6) | 7,938 (31.3) | −0.006 (0.1635) |
CVD event, n (%) | 6,064 (5.4) | 1,109 (5.6) | 1,216 (5.8) | 1,201 (5.4) | 1,299 (5,6) | 1,239 (4.9) | −0.034 (0.0003) |
ED frequent users (≥4), n (%) | 29,247 (26.2) | 4,617 (23.3) | 5,049 (24.2) | 5,844 (26.6) | 6,443 (27.6) | 7,294 (28.8) | 0.075 (<.0001) |
GP frequent users (≥20), n (%) | 29,568 (26.5) | 5,669 (28.6) | 5,572 (26.7) | 5,894 (26.5) | 6,139 (26.3) | 6,294 (24.8) | −0.040 (<.0001) |
MD specialists frequent users (≥5), n (%) | 29,975 (26.9) | 4,238 (21.4) | 5,306 (25.5) | 6,333 (28.5) | 6,771 (29.0) | 7,327 (28.9) | 0.092 (<.0001) |
Sub-cohort admissible to public drug plan, n (%) | 71,620 (100) | 11,169 (15.6) | 12,058 (16.8) | 13,894 (19.4) | 15,669 (21.9) | 18,830 (26.3) | − |
Antidiabetic drugs, n (%) | 61,395 (85.7) | 9,462 (84.7) | 10,247 (85.0) | 11,749 (84.6) | 13,429 (85.7) | 16,508 (87.7) | 0.059 (<.0001) |
Continuous immigration score | Immigration quintiles | |||
---|---|---|---|---|
Health indicators | Not adjusted for material & social deprivation scores | Adjusted for material & social deprivation scores | Not adjusted for material & social deprivation quintiles | Adjusted for material & social deprivation quintiles |
OR (95% CI)2 | OR (95% CI)2 | OR (95% CI)3 | OR (95% CI)3 | |
All-cause deaths | 0.88 (0.78 – 0.99)* | 0.89 (0.80 – 1.00) | 0.90 (0.81 – 0.99)* | 0.87 (0.78 – 0.96)* |
All-cause hospitalizations | 0.96 (0.91 – 1.00) | 0.92 (0.87 – 0.97)* | 0.97 (0.92 – 1.01) | 0.93 (0.89 – 0.98)* |
CVD events | 0.82 (0.74 – 0.91)*** | 0.79 (0.70 – 0.87)*** | 0.86 (0.78 – 0.94)** | 0.84 (0.77 – 0.93)** |
ED frequent users (≥4) | 1.51 (1.43 – 1.60)*** | 1.43 (1.35 – 1.52)*** | 1.38 (1.31 – 1.45)*** | 1.28 (1.21 – 1.34)*** |
GP frequent users (≥20) | 0.79 (0.74 – 0.83)*** | 0.69 (0.65 – 0.73)*** | 0.82 (0.78 – 0.86)*** | 0.75 (0.71 – 0.79)*** |
MD specialists frequent users (≥5) | 1.50 (1.41 – 1.60)*** | 1.83 (1.73 – 1.94)*** | 1.49 (1.41 – 1.58)*** | 1.64 (1.55 – 1.73)*** |
Antidiabetic drugs | 1.32 (1.20 – 1.43)*** | 1.20 (1.11 – 1.32)*** | 1.21 (1.12 – 1.31)*** | 1.12 (1.03 – 1.22)** |