Use of Cardiac Procedures and Outcomes in Elderly Patients with Myocardial Infarction in the United States and Canada
Jack V. Tu, M.D., Ph.D., Chris L. Pashos, Ph.D., C. David Naylor, M.D., D.Phil., Erluo Chen, M.B., M.P.H., Sharon-Lise Normand, Ph.D., Joseph P. Newhouse, Ph.D., and Barbara J. McNeil, M.D., Ph.D.
Background Acute myocardial infarction is a leading cause ofmorbidity and mortality in the United States and Canada. Weperformed a population-based study to compare the use of cardiacprocedures and outcomes after acute myocardial infarction inelderly patients in the two countries.
Methods We compared the use of invasive cardiac procedures andthe mortality rates among 224,258 elderly Medicare beneficiariesin the United States and 9444 elderly patients in Ontario, Canada,each of whom had a new acute myocardial infarction in 1991.
Results The U.S. patients were significantly more likely thanthe Canadian patients to undergo coronary angiography (34.9percent vs. 6.7 percent, P< 0.001), percutaneous transluminalcoronary angioplasty (11.7 percent vs. 1.5 percent, P<0.001),and coronary-artery bypass surgery (10.6 percent vs. 1.4 percent,P<0.001) during the first 30 days after the index infarction.These differences in the use of cardiac procedures narrowedbut persisted through 180 days of follow-up. The 30-day mortalityrates were slightly but significantly lower for the U.S. patientsthan for the Canadian patients (21.4 percent vs. 22.3 percent,P = 0.03). However, the one-year mortality rates were virtuallyidentical (34.3 percent in the United States vs. 34.4 percentin Ontario, P = 0.94).
Conclusions Short-term mortality after an acute myocardial infarctionwas slightly lower in the United States than in Ontario, butthese differences did not persist through one year of follow-up.The strikingly higher rates of use of cardiac procedures inthe United States, as compared with Canada, do not appear toresult in better long-term survival rates for elderly U.S. patientswith acute myocardial infarction.
Source Information
From the Institute for Clinical Evaluative Sciences in Ontario, North York, Ont., Canada (J.V.T., C.D.N., E.C.); the Department of Medicine, Sunnybrook Health Science Centre, University of Toronto, Toronto (J.V.T., C.D.N.); Abt Associates, Cambridge, Mass. (C.L.P.); the Departments of Biostatistics (S.-L.N.) and Health Policy and Management (J.P.N.), Harvard School of Public Health, Boston; the Kennedy School of Government, Cambridge, Mass. (J.P.N.); and the Department of Health Care Policy, Harvard Medical School, Boston (J.V.T., C.L.P., S.-L.N., J.P.N., B.J.M.). The opinions and conclusions in this study are those of the authors, and no official endorsement by the Ontario Ministry of Health is intended or should be inferred.
Address reprint requests to Dr. Tu at the Institute for Clinical Evaluative Sciences, G-106, 2075 Bayview Ave., North York, ON M4N 3M5, Canada.
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