title: The contributions of First Nations ethnicity, income, and delays in surgery on mortality post-fracture: a population-based analysis.
abstract: We examined the independent contributions of First Nations ethnicity and lower income to post-fracture mortality. A similar relative increase in mortality associated with fracture appears to translate into a larger absolute increase in post-fracture mortality for First Nations compared to non-First Nations peoples. Lower income also predicted increased mortality post-fracture.
  
  
  BACKGROUND
  First Nations peoples have a greater risk of mortality than non-First Nations peoples. We examined the independent contributions of First Nations ethnicity and income to mortality post-fracture, and associations with time to surgery post-hip fracture.
  
  
  METHODS
  Non-traumatic fracture cases and fracture-free controls were identified from population-based administrative data repositories for Manitoba, Canada (aged≥50 years). Populations were retrospectively matched for sex, age (within 5 years), First Nations ethnicity, and number of comorbidities. Differences in mortality post-fracture of hip, wrist, or spine, 1996-2004 (population 1, n=63,081), and the hip, 1987-2002(Population 2, n=41,211) were examined using Cox proportional hazards regression to model time to death. For hip fracture, logistic regression analyses were used to model the probability of death within 30 days and 1 year.
  
  
  RESULTS
  Population 1: First Nations ethnicity was associated with an increased mortality risk of 30-53% for each fracture type. Lower income was associated with an increased mortality risk of 18-26%. Population 2: lower income predicted mortality overall (odds ratio (OR) 1.15, 95% confidence interval (CI) 1.07-1.23) and for hip fracture cases (OR 1.18, 95%CI 1.05-1.32), as did older age, male sex, diabetes, and >5 comorbidities (all p≤0.01). Higher mortality was associated with pertrochanteric fracture (OR 1.14, 95% CI 1.03-1.27), or surgery delay of 2-3 days (OR 1.34, 95% CI 1.18-1.52) or ≥4 days (OR 2.35, 95% CI 2.07-2.67).
  
  
  CONCLUSIONS
  A larger absolute increase in mortality post-fracture was observed for First Nations compared to non-First Nations peoples. Lower income and surgery delay>2 days predicted mortality post-fracture. These data have implications regarding prioritization of healthcare to ensure targeted, timely care for First Nations peoples and/or individuals with lower income.
authors.affiliation: Department of Medicine (C5121), University of Manitoba, 409 Tache Avenue, Winnipeg, MB, R2H 2A6, Canada. bleslie@sbgh.mb.ca
authors.forename: W D
authors.initials: WD
authors.lastname: Leslie
authors.forename: S L
authors.initials: SL
authors.lastname: Brennan
authors.forename: H J
authors.initials: HJ
authors.lastname: Prior
authors.forename: L M
authors.initials: LM
authors.lastname: Lix
authors.forename: C
authors.initials: C
authors.lastname: Metge
authors.forename: B
authors.initials: B
authors.lastname: Elias
mesh_terms: D017677:Age Distribution; D000368:Aged; D000369:Aged, 80 and over; D016022:Case-Control Studies; D005260:Female; D005592:Fracture Fixation; D006620:Hip Fractures / Q000208:ethnology / Q000401:mortality / Q000601:surgery; D006801:Humans; D007182:Income / Q000706:statistics & numerical data*; D007198:Indians, North American / Q000706:statistics & numerical data*; D008297:Male; D008350:Manitoba / Q000453:epidemiology; D008875:Middle Aged; D058866:Osteoporotic Fractures / Q000208:ethnology* / Q000401:mortality / Q000601:surgery; D016103:Spinal Fractures / Q000208:ethnology / Q000401:mortality / Q000601:surgery; D013997:Time Factors; D014954:Wrist Injuries / Q000208:ethnology / Q000401:mortality / Q000601:surgery