Ko Dennis T, Krumholz Harlan M, Wang Yongfei, Foody JoAnne M, Masoudi Fredrick A, Havranek Edward P, You John J, Alter David A, Stukel Therese A, Newman Alice M, Tu Jack V
Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
Circulation. 2007 Jan 16;115(2):196-203. doi: 10.1161/CIRCULATIONAHA.106.657601. Epub 2006 Dec 26.
Previous comparisons of acute myocardial infarction (AMI) treatment between the United States and Canada are limited because they compared selected patients from randomized trials, used administrative data that lacked clinical detail, or did not consider regional differences in AMI treatment.
We compared medication use, invasive cardiac procedure use, and 30-day risk-standardized mortality rates of 38,886 fee-for-service Medicare beneficiaries hospitalized with AMI in the United States and 5634 similarly aged patients in Ontario, Canada, from 1998 and 2001. Baseline characteristics and illness severity across the US regions and Ontario were not substantially different. Cardiac catheterization use in AMI patients was significantly higher in the United States compared with Ontario (38.7% versus 16.8%, P<0.001), but significant regional variations existed, in which the northeastern United States had significantly lower utilization rates (25.6%) compared with other US regions. Beta-blocker use among ideal candidates was highest in the northeastern United States (77.6% versus 69.7% in the United States as a whole, P<0.001) and angiotensin-converting enzyme inhibitor use was highest in Ontario (69.1% versus 58.2% in the United States, P<0.001). Risk-standardized mortality rates at 30 days were not substantially different across the regions.
Previous studies have suggested a clear divergence in invasive cardiac therapy for AMI patients between the United States and Canada on the basis of health care financing and structural differences. Our findings of similar treatment patterns in the northeastern United States and Ontario suggest that regional practices may have a greater impact on treatment patterns than the respective health care delivery systems.
以往对美国和加拿大急性心肌梗死（AMI）治疗的比较存在局限性，因为这些比较要么是对随机试验中挑选出的患者进行比较，要么使用缺乏临床细节的行政数据，要么没有考虑AMI治疗的地区差异。
我们比较了1998年至2001年期间，美国38886名因AMI住院的按服务收费的医疗保险受益人和加拿大安大略省5634名年龄相仿患者的药物使用情况、侵入性心脏手术使用情况以及30天风险标准化死亡率。美国各地区和安大略省的基线特征和疾病严重程度没有显著差异。与安大略省相比，美国AMI患者使用心脏导管插入术的比例显著更高（38.7%对16.8%，P<0.001），但存在显著的地区差异，其中美国东北部的使用率（25.6%）显著低于其他美国地区。理想候选者中β受体阻滞剂的使用在美国东北部最高（77.6%，而美国整体为69.7%，P<0.001），血管紧张素转换酶抑制剂的使用在安大略省最高（69.1%，而美国为58.2%，P<0.001）。各地区30天的风险标准化死亡率没有显著差异。
以往的研究表明，基于医疗保健融资和结构差异，美国和加拿大在AMI患者的侵入性心脏治疗方面存在明显差异。我们在美国东北部和安大略省发现的相似治疗模式表明，地区实践可能比各自的医疗保健提供系统对治疗模式的影响更大。
