Two findings emerged from a recent Archives of Internal Medicine report on heart-failure mortality rates. One affirms the notion that the U.S. is a leader in acute care, but the other finding offers evidence that there's room for improvement in the management of chronic conditions.
The report, which was released Nov. 28, compared 30-day and one-year mortality rates of American and Canadian heart-failure patients measured between 1998 and 2001. The findings: after risk standardization, the 28,521 U.S. Medicare beneficiaries studied had a lower 30-day mortality rate than the 8,180 similarly aged patients at hospitals in Ontario, Canada (8.9% vs. 10.7%), but one-year adjusted mortality rates were essentially the same (32.2% in the U.S. vs. 32.3% in Canada).
"I think that the paper provides interesting insight which has both good news and bad news," said researcher Harlan Krumholz, M.D., a professor of medicine at the Yale University School of Medicine in New Haven, Conn. "I think each side was looking to be vindicated."
Krumholz said the study reinforces that the "U.S. is quite good at acute care," while "Canadians may be doing better at managing chronic care."
"Maybe there are lessons here for both sides," he added.
Among the patients studied, U.S. patients averaged 80.1 years of age, stayed in the hospital for 6.1 days, and 57.3% were female. Canadian patients averaged 79.7 years of age and 8.5 days in the hospital, and 53.4% were female. Cardiologists were the attending physicians for 18.8% of the Americans, and 19.4% for the Canadians. Patients younger than 65 or older than 105 were excluded from the study, as were U.S. patients hospitalized with heart failure the previous year and Canadian patients hospitalized within the three previous years.
What's puzzling, Krumholz said, is that healthcare professionals in both nations are exposed to essentially the same medical literature and have comparable training. So the differences in outcomes, he said, are probably the result of the context in which care is delivered and the way healthcare systems are configured.
The Archives of Internal Medicine report noted that similar findings have been found with heart-attack and post-surgical patients, and "may reflect better access in Canada to outpatient follow-up and prescription drugs, which are universally covered in the Canadian healthcare system."
The study found that U.S. patients were more likely to receive left ventricular ejection fraction assessment -- a test of the heart's pumping function -- by a rate of 61.2% to 41.7%, but Krumholz could not say what impact this had on survival rates.
Patients considered "ideal candidates" for beta blockers received prescriptions at discharge 32.5% of the time in the U.S., and 29.7% of the time in Canada. For angiotensin-converting enzyme, or ACE, inhibitors, ideal candidates received them at discharge 78.3% of the time in the U.S., compared with 77.6 % in Canada.
The report noted that this was an area that could be easily improved.
"In both countries, a considerable number of elderly patients were prescribed neither therapy despite the proven benefits, suggesting an opportunity to improve the care of HF patients regardless of where they are treated," according to the report.
Krumholz said he didn't believe current quality-improvement efforts, which have been gaining traction since the years covered in the study, would alter the findings significantly. What he thought may change patient outcomes, however, was the new Medicare prescription drug benefit.
"It's not a perfect benefit, but it will be interesting to see if these findings will be different," he said, adding that "quality measures for heart failure are rather meager."
The study was a collaboration between U.S. and Canadian researchers, and Krumholz described it as an opportunity to "take advantage of the natural experiment that occurs across the borders" and said that the possibility of further collaboration was still under discussion.
He said the ultimate goal would be to "learn what's working best and apply it across borders."
Read the abstract.