Are we spending too much to combat
our number one killer? Mortality from cardiac diseases
has remained extraordinarily steady over the past 15
years. But spending on those diseases has not.
In fact, our spending on cardiac
diagnosis and management poses "a challenge to the sustainability
of Medicare," according to a review in the January 24
issue of Circulation.
Two papers in the issue track spending
on cardiac diagnosis and management in Ontario and the
US in recent years, and the picture they present is
one of ever-diminishing returns for ever-greater outlay.
From 1992 to 2001, the number of
echocardiographs carried out in Ontario rose by 62%.
The number of stress tests rose by 38%. Perfusion rates
were up 133%. The number of catheterization procedures
increased by 137%. And percutaneous coronary intervention
procedures rose by 180%.
Ontarians spent just under $3 billion
on cardiac care in 2001, about 14% of a total health
budget of $22 billion. What they got in return was less
easy to quantify, especially as outcomes have remained
remarkably flat.
"We've seen a very small, basically
insignificant decline in mortality from acute MI," says
Sunnybrook cardiologist Dr David Alter, lead author
of the Ontario study. "At the same time, we're still
seeing a slow increase in the number of cardiac hospitalizations."
The key question is: are we reducing
what would otherwise be growing cardiac mortality, or
are we throwing money down a black hole?
US cardiac management offers some
clues, suggests Dr Alter. "We're on the same track as
them just several years behind."
CARDIAC
SPENDTHRIFTS
The US has about three times as many cath labs per capita
as Canada does, and nearly twice as many cardiologists.
And, sure enough, Americans have about three times as
many catheterizations as Canadians. "The evidence seems
to suggest that use of these procedures closely mirrors
capacity," says Dr Alter. "Much of it seems to be technology-driven."
Despite this, the proportions of patients proceeding
to revascularization procedures in the US and Ontario
were remarkably similar, at 50% versus 46%.
Even more telling, a 2004 Circulation
study of longterm mortality among Canadian and American
acute MI patients found only minimal differences despite
vastly higher use rates of all cardiac procedures in
the US. Risk reduction in the States was due to higher
rates of coronary angioplasty and coronary artery bypass
graft (CABG) surgery during initial hospitalization.
So are secondary interventions
a waste of money? There's no easy answer. "The same
intervention will be much more effective if targeted
at a high-risk group." This, says Dr Alter, is the silver
lining in the Ontario data. Use of cardiac procedures
is increasing fastest among women and low-income patients,
precisely the groups who were most underserved in the
past.
AMERICAN
LESSONS
In the US, where racial inequalities in access are an
overriding concern, the trends are less encouraging,
according to Dr F Lee Lucas, author of the parallel
study on US cardiac care rates. Rates for women and
non-white men, their top underserved groups, have been
rising, but the increase has only barely kept pace with
the rates for white men. "White males are still more
likely to undergo cardiac procedures than non-white
males or women," says Dr Lucas.
Canadians can take comfort from
the fact that they're still in the early stages of the
cardiac care explosion that swept America in the 80s
and 90s, according to Dr John Ayanian, in an accompanying
editorial.
CABG
CONSUMPTION
There is another possible upside to all this. Improvements
in angioplasty have led to lower rates of restenosis
among stented patients. This could lead to lower costs
per patient and fewer return visits, the latest US data
suggest. Even more crucially, these improvements have
also enabled us to reduce CABG rates.
Cardiology's growth spurt in the
US came at a time when CABG was basically the only game
in town for MI patients. Trouble is, it's horrendously
expensive. In Ontario, this procedure alone accounted
for 42% of all cardiac care spending in 2001.
When Dr Alter's study of cardiac
spending ended in 2001, CABG rates were still rising
in Canada, but had already been falling in the US for
a few years. "Since then," he says, "Canadian rates
have also seen a small downturn." Even a small decrease
in CABG rates translates into big dollar savings. We
may be no better than Americans at controlling spending,
but with better, cheaper treatment options than they
had, we may yet avoid the worst excesses of cardiac
care inflation.
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