More PCIs Performed in New York State, Including Discretionary PCI, Than Ontario

June 11, 2010

June 11, 2010 (Albany, New York) — A comparison between the market-oriented financing of medical procedures in New York State vs the government-funded single-payer system in Ontario has shown there are markedly higher rates of discretionary and emergent PCI procedures in New York State compared with the Canadian province [1].

Individuals without a recent acute MI, for example, were 2.3 times more likely to undergo PCI in New York State than in Ontario, whereas the population-based rates of CABG surgery among nonacute-MI patients were not significantly different.

In an interview with heartwire , senior investigator Dr Edward Hannan (State University of New York, Albany) said that if it is assumed that the two locations share a similar disease burden--upper New York State borders southwestern Ontario--the results suggest that the market-oriented financing approach in the US healthcare system leads to more PCI procedures for nonacute MI, but better access for emergency cardiac invasive procedures.

"Still, I don't think there necessarily needs to be this trade-off between access to emergent care and increased PCIs for discretionary procedures," said Hannan. "We know that the cost of healthcare in the US is much higher than other countries, including Canada, but also higher than other countries in Europe, Japan, and so on, mainly because of what we spend on high-tech procedures. There is a fair amount of room in the amount of money that Canada spends on healthcare compared with what the US spends."

The results of the study are published online June 7, 2010 in Circulation.

Higher Rates of PCI for Nonacute MI

The researchers note that New York State historically has more than twofold higher rates of coronary revascularization than Ontario, and this has been attributed to different methods of financing healthcare between Canada and the US. Whereas the location of hospitals and funding of services in Canada are determined by the provincial governments, there are no formal restrictions in the US.

In this study, the researchers evaluated the evolution of coronary revascularization patterns between the two locations. In an observational study, they compared the temporal trends of cardiac invasive procedures in New York State and Ontario using population-based data from 1997 to 2006.

In terms of the number of doctors and hospitals in 2004–2006, New York State had 2.9 times more interventional cardiologists than Ontario, as well as 1.8 times more cardiac surgeons, 2.6 more hospitals with PCI capabilities, and 2.2 more hospitals with CABG facilities. The relative ratio of the doctors and hospitals was stable over the entire study period.

In 2004–2006, the population-based rate of coronary revascularization was 1.7 times higher in New York State than in Ontario, or 170 more procedures per 100 000 persons. The difference in the rates of coronary revascularization was the result of significantly more PCI procedures, with the relative ratio of PCI in New York State doubling that of Ontario.

Temporal Trends in Cardiac Invasive Procedures

Procedure (per 100 000) 1997–2000 2001–2003 2004–2006 Annual change (%)
Any coronary revascularization        
New York State 372.4 409.8 425.3 2.1
Ontario 182.4 227.3 255.1 5.2
Relative ratio (95% CI) 2.0 (1.9–2.2) 1.8 (1.7–1.9) 1.7 (1.6–1.8) --
New York State 246.7 310.3 353.9 5.7
Ontario 93.1 142.5 180.8 10.5
Relative ratio (95% CI) 2.6 (2.5–2.9) 2.2 (2.0–2.3) 2.0 (1.8–2.1) --
New York State 134.4 105.8 78.8 -7.5
Ontario 90.3 85.8 75.7 -2.5
Relative ratio (95% CI) 1.5 (1.4–1.6) 1.2 (1.1–1.3) 1.0 (0.9–1.2) --

In an analysis among patients without acute MI, those procedures classified as discretionary by the researchers, New York State had nearly two times as many coronary revascularizations than Ontario, a difference of 146.6 procedures per 100 000 adults. The discrepancy between the two locations was due to the difference in PCI procedures, which increased over the study period.

For patients with acute MI, just 1.3 times as many PCIs were performed in New York State compared with Ontario, or roughly 20 procedures more per 100 000 adults. This was due largely to significant increases in PCI among acute-MI patients in Ontario in recent years.

Rates of PCI, CABG, and Any Revascularization in Patients Without Acute MI

Procedure 1997–2000 2001–2003 2004–2006 Annual change (%)
New York State 179.3 228.2 268.2 6.4
Ontario 68.7 94.8 115.8 8.3
Relative ratio (95% CI) 2.6 (2.4-2.8) 2.4 (2.2-2.6) 2.3 (2.2-2.5)
New York State 102.4 80 60.1 -7.6
Ontario 78.8 72.7 62.4 -3.4
Relative ratio (95% CI) 1.3 (1.2-1.4) 1.1 (1.0-1.2) 1.0 (0.9-1.1)

With no study showing the benefit of PCI for reducing death or MI for patients with stable coronary artery disease compared with medical therapy, as well as recent evidence from the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) and the Bypass Angioplasty Revascularization Investigation in Type 2 Diabetes (BARI 2D) studies, the new report suggests that stable CAD patients in New York State are undergoing more unnecessary procedures than similar patients in Ontario.

"The main thing that we're seeing is this huge gap between the number of catheterizations and PCIs performed in New York State, including PCIs performed in the nonacute MI setting, and Ontario," said Hannan. "It raises the question as to whether they're completely necessary. The other thing we observed was a strong relationship between the number of catheterizations and the number of PCIs."

Hannan noted that interventional cardiologists are the key decision makers as to whether or not a patient is referred for PCI. In a previous study, they observed that despite what was indicated by clinical guidelines, there is a "tilt toward PCI" once the patient is sent to the cath lab. In that same study, they also observed that almost all patients eligible for PCI or CABG were sent for PCI.

"Financial Armageddon"

In an editorial accompanying the study, Dr Thomas Ryan (Boston University Medical Center, MA) points to the recent creation of the Cardiac Care Network of Ontario, established to address the long wait times for cardiac procedures [2]. Since its creation, wait times in Ontario have decreased to three days for PCI and 12 days for CABG.

Despite these improvements, however, there are still limitations to the Canadian provincial single-payer system, such as roadblocks to creating a provincewide regionalized approach to increase PCI access for ST-segment elevation MI (STEMI). In fact, 24/7 access to PCI is performed by just three of 12 Ontario hospitals with emergency PCI facilities, as of 2007, while just 10% of patients with STEMI undergo emergency PCI.

Regardless, Ryan notes that the rising cost of healthcare is unsustainable, leading some experts to caution the result would be a "financial Armageddon" [3]. In the US, healthcare accounts for 16% of the gross domestic product, and the country continues to run larger and larger annual deficits and have higher debt burdens.

"It is imperative that we members of the cardiovascular community provide workable solutions to improve quality and reduce the cost of healthcare, because if we fail it will bankrupt us," writes Ryan.


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