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Ann Thorac Surg 1996;62:1239-1241
© 1996 The Society of Thoracic Surgeons
The Institute for Clinical Evaluative Sciences in Ontario, Clinical Epidemiology Unit, Sunnybrook Health Science Centre, University of Toronto, G-106, 2075 Bayview Ave, North York, Ontario M4N 3M5, Canada
To the Editor:
In many nations, some patients wait some period of time for some surgical procedures. The costly and wasteful alternative is to maintain excess operating room capacity with human resources on standby so that any patient, regardless of severity or urgency of need, can be offered the option of an immediate operation. Because supply has a way of creating its own demand in health care, maintenance of excess capacity may also lower the threshold for surgical intervention in undesirable ways [1]. That said, the experience of patients on waiting lists for operation can be regarded as an iatrogenic disease state and studied with the same epidemiologic rigor that is demanded for other diseases and practice patterns [1, 2]. The article by Maziak and associates [3] accordingly raised an important question: Can patients with left main stenosis safely wait for coronary artery bypass grafting? Their question is given point by earlier Toronto data suggesting that patients with left main disease might be at higher risk of death than other patients in the queue for revascularization [4].
I was therefore surprised that the accompanying editorial mixed ideologic commentary with insightful methodologic caveats. In their opening sentences, Drs Jollis and Califf [5] wrote of Adam Smith and the "invisible hand" of the free market as contrasted with the bogeyman of "central planning." But what happens without a strong measure of central planning in the strange quasi-markets of modern health care? The American experience is illustrative. More than 14% of America's gross domestic product is spent on health care (versus less than 9.5% in Canada), population health indices for the United States are bettered by many other Organization for Economic Cooperation and Development nations (including Canada), and more than 30 million Americans lack any health insurance, while perhaps 50 million more face financial stringency in the face of a major illness (in contrast to Canada, where this has not been an issue for 25 years). Ignoring this glass house, Drs Jollis and Califf [5] pitched stones at Maziak and associates: "Skeptics may believe that they have confused the terms ration and rational, the former describing the method by which health services are distributed by the Ontario Provincial Adult Cardiac Care Network."
If this is Canadian-style rationing, then surely it is fair to note that American-style rationing occurs by income and insurance cover. It is manifested in patient denial and "dumping," as well as delayed services for uninsured persons who seek care at American hospitals [6–9]. It is also underscored by socioeconomic and ethnoracial differences in health care utilization and health status that are among the largest in the industrialized world.
Your readers should know that the Cardiac Care Network of Ontario does not "distribute" cardiac services; it advises the provincial government on funding and policy issues. Clinical decision-making remains in the hands of cardiologists, surgeons, and patients. Interinstitutional transfers to deal with unmanageable waiting times are rare. As documented in our recent report on the experience of more than 8,000 consecutive patients booked for isolated coronary artery bypass grafting (CABG) in Ontario [10], only 0.26% of patients traveled out of region for the operation. Maziak and associates reported on the waiting times at one center where queues for CABG are particularly (and frustratingly) long. For all 1,200 patients with left main disease undergoing CABG at nine Ontario centers between 1991 and 1993, the median wait time was only 7 days (interquartile range, 2 to 24 days) [10].
Doctors Jollis and Califf asked about "patients with left main disease who never made it to operation." The death rate in the provincial cohort was 0.38% (31/8247) with an additional 3 who had operation indefinitely deferred owing to nonfatal myocardial infarctions. Among these 34 patients, 5 (or 14.7%) had left main disease, similar to the overall proportion of patients undergoing CABG with left main disease (14.2%) [10]. Thus, there was no increase in relative risk for patients with left main disease as compared with other patterns of anatomic disease. Although the confidence intervals for relative risk are wide (0.43 to 2.18), this is partly a happy epiphenomenon of the low event rates.
Among the hidden costs of the Canadian system, Drs Jollis and Califf mentioned the resources required by patients who cross the border to the United States for CABG. In 1991 Katz and colleagues [11] reported on British Columbia's decision to reduce the provincial CABG waiting list through an arrangement with Seattle hospitals. This bulk-purchase cross-border shopping made good sense at the time, but has not been repeated in that province or elsewhere. My best estimate, from various unpublished sources, is that operations in America account for no more than 3% of all CABGs performed on Ontario residents, with a certain concentration among older Canadian "snowbirds" wintering in the southern states.
Doctors Jollis and Califf highlighted the weak trends to higher postoperative mortality seen for patients with left main disease (2.5%) compared with those without left main disease (1.3%). This is a side issue. Other larger studies [12, 13] have already shown that left main disease is an independent risk factor for adverse postoperative outcomes in America, where waiting times are minimal. What Maziak and associates showed was that early operation for left main disease did not improve outcomes (operative mortality of 4.0%) compared with patients subjected to delays (1.7%). The obvious reason is that sicker patients went to operation faster, in keeping with guidelines on appropriate management of the waiting list [14]. Note, for example, a 64.0% incidence of class IV symptoms in patients waiting 10 days or less, versus 21.5% in those waiting longer than 10 days, or the respective 9.0% versus 0% preoperative use of intraaortic balloon pumping [3].
Doctors Jollis and Califf concluded that the "preliminary work" by Maziak and associates "should not be used as a basis for the justification of surgical waiting lists or for the central allocation of health care resources." Although queuing has definite drawbacks and more studies are indeed needed [1, 2, 9], I believe that allocation by queue in a universal health insurance system is inherently more equitable than allocation by income or insurance coverage in a nonuniversal nonsystem. Perhaps the editorial by Drs Jollis and Califf "should not be used as a basis for the justification of" the continued implicit rationing of services in American health care!
Such flag-waving aside, I have collaborated happily on research projects with Dr Califf in the past, and continue to do so. Those projects have included one Canadian-American comparison where "the American way" was much more expensive but did yield better quality-of-life for subsets of cardiac patients [15]. Such microlevel comparisons are nonetheless poor grounds for side-stepping macrolevel issues. I suggest that your editorialists and like-minded American readers have lots to learn from "the Canadian way" in health care delivery, just as Canadians continue to learn from the experiences of our good neighbours to the south [16].
References
Box 3254 Duke University Medical Center, Durham, NC 27710
2024 W Main St, Bay A-108, Durham, NC 27705
To the Editor:
It is clear from the spirited letter by Dr Naylor that we have succeeded in stimulating discussion about surgical queues. Despite the differences of opinion we have with Dr Naylor, we believe that our areas of agreement are far greater than our areas of disagreement. Doctor Naylor has previously published a comprehensive review [1] comparing the Canadian and American health systems, some of which he has reiterated in his letter. Doctor Naylor's previous review involved a balanced and fair presentation of the strengths and weaknesses of both systems. In that work, he listed "implicit rationing with long waiting lists for some services" as a weakness of the Canadian system. According to Ontario Provincial Adult Care Network data for March 1996, the wait for elective coronary bypass grafting ranged from 12 to 26 weeks across centers, with 1,414 patients in the queue.
Doctor Naylor points to the better population health indices of Canada as evidence for the superiority of governmentally administered health care. Again, we agree with his position in previous work that "since health care is a relatively minor determinant of aggregate population health indices, such indicators may not be a good reflection of comparative health systems performance" [1]. We also agree with Maziak and associates and Dr Naylor that comprehensive outcome measures are needed to determine the optimal allocation of limited health care resources [2]. In the case of bypass grafting queues, our purpose was to emphasize that costs beyond mortality also need to be measured, including psychologic consequences of waiting for patients and their families, as well as resources required to manage patients while in the queue.
In his reference to mortality differences between the early and delayed patients as demonstrating "early operation for left main disease did not improve outcomes," Dr Naylor did not acknowledge one of the main points of our editorial. The outcome of patients who cross over to early operation should be counted with those who undergo delayed operation. The study by Maziak and colleagues lacks an appropriate control group to draw conclusions about the safety of triaging patients with left main coronary disease to delayed operation.
We agree with Dr Naylor that much can be learned from experiences in both health care systems, as illustrated in the study by Maziak and associates. We also agree that the Canadian system represents a more equitable method for the distribution of acute health care resources and that better planning for rational allocation of resources would improve the United States system. Although the article that stimulated the editorial provides interesting information, we do not believe that the methodology of the study or any previous work clearly demonstrates that the current queuing system in Canada provides the best outcome at the most reasonable cost. Indeed, the estimated 100 deaths per year for patients waiting for an operation in Canada represents one example of the inefficiency of trying to allocate health care resources through global budgets. We disagree with Dr Naylor's contention that a system that allocates adequate resources to perform operation before deaths in the queue occur would be a "costly and wasteful alternative." The goal of Maziak and associates' study, a goal that we believe Dr Naylor supports, is to develop a triage system that identifies and treats patients before they die in the surgical queue.
We appreciate the opportunity to compare our agreements and disagreements with Dr Naylor. As he describes in his letter, the "cross-border" dispute should serve to focus our understanding of both systems and see that both can be improved. We look forward to continued collaboration and comparison of systems and outcomes.
References
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