U.S. patients do better — at first, study finds
Heart treatment less aggressive in Canada But follow-up care, drug access better here
Elderly Americans with heart failure are treated more aggressively in hospital and fewer die within a month than Ontario patients, says a new study. But after a year, the overall death rate in both countries is the same — about a third — implying that access to followup care and prescription drugs is better in Canada, says the study published today in Archives of Internal Medicine.
“ Canada has a catch- up effect and our hypothesis is we have a more cohesive system,” said Dr. Dennis Ko, a Toronto cardiologist and lead author of the study. “ Both countries are probably doing something right, although different. A lot of work still needs to be done to pick up the good parts in each.”
U. S. hospitals are bigger, have more specialists and cardiac facilities that can perform more invasive procedures than those in Ontario, largely because of budget restraints, the study says.
“ This difference in resource availability likely translated into Canadian physicians admitting higher- risk heart failure patients while not hospitalizing some lower- risk patients who would have been hospitalized in the United States,” says the study. But even after they were admitted, American patients fared better in the short term, which “ may relate to the intensity and timeliness of U. S. hospital care,” it says. They also referred more patients to other hospitals. The study also found that almost twothirds of the U. S. patients underwent an assessment procedure, usually an echocardiogram or ultrasound, to see how well the heart was pumping, compared to 41.7 per cent of the Canadians. American patients were also more likely to undergo cardiac catheterization — where a tube inserted into a blood vessel is guided to the heart to get diagnostic information — as well as percutaneous coronary intervention, a non- surgical method of unblocking arteries, before being discharged. But after the first month and up to a year, the U. S. patients died at a higher rate than those in Ontario, which in the end left little difference overall in death rates between the two countries. Only a third of patients in both countries were prescribed beta-blockers and 75 per cent ACE inhibitors when they left hospital, even though the medications have been shown to lower death rates from heart failure, Ko said.
“ In both countries, the use of life- saving medications could go up.”
Beta blockers, which slow the heart rate and lower blood pressure, have been used for many years, he said. But evidence began to emerge in the mid’ 90s that they could have some side effects, and doctors may have stopped prescribing them for that reason. ACE inhibitors, which produce the same results, are better prescribed but “ there is still room to move up,” Ko said. The study looked at the care and mortality rates among 28,521 Americans over age 65 on medicare, and 8,180 in Ontario, who were hospitalized for heart failure between 1998 and 2001.
At 30 days, 8.9 per cent of American patients had died, significantly lower than the 10.7 per cent in Canada, but after a year, the rate was a third in both countries. The rates were standardized to account for the fact the Canadian patients were sicker.
Heart failure is the most common cause of hospitalization for people 65 and over in both countries.
“ Per- capita health care costs are considerably lower in Canada than in the United States,” the study says, “ but Canadian budgetary restraints have resulted in limited access to specialized care, such as invasive cardiac procedures and physician specialists.” But “many challenges exist in the United States,” it says, including lack of health care access for many uninsured patients and lack of prescription drugs for elderly and chronically ill patients.