Institute for Clinical Evaluative Sciences, Schulich Heart Centre, Sunnybrook Health Sciences Centre, Department of Medicine, University of Toronto, Ontario, Canada.
Circulation. 2010 Jun 22;121(24):2635-44. doi: 10.1161/CIRCULATIONAHA.109.926881. Epub 2010 Jun 7.
Healthcare reform initiatives in the United States have rekindled debate about the role of government regulation in the healthcare system. Although New York State (NYS) historically has had twice as many coronary revascularizations performed as Ontario, the relative evolution of coronary revascularization patterns in both jurisdictions over time is unknown.
We conducted an observational study comparing the temporal trends of cardiac invasive procedures use in NYS and Ontario using population-based data from 1997 to 2006 stratified by procedure indication. For nonacute myocardial infarction patients, the age- and sex-adjusted rate of percutaneous coronary intervention (PCI) was 2.3 times (95% confidence interval, 2.2 to 2.5) greater in NYS than in Ontario in 2004 to 2006. In contrast, population-based rates of coronary artery bypass grafting among nonacute myocardial infarction patients were not significantly different. For acute myocardial infarction patients, differences in coronary revascularization rates between NYS and Ontario narrowed substantially over time. In 2004 to 2006, the relative ratio was 1.3 times higher for PCI (95% confidence interval, 1.2 to 1.5) and 1.4 times higher (95% confidence interval, 1.1 to 1.8) for coronary artery bypass grafting in NYS relative to Ontario. However, a larger relative gap (relative ratio, 2.0; 95% confidence interval, 1.7 to 2.3) was observed among acute myocardial infarction patients undergoing emergency PCIs in NYS compared with Ontario.
The market-oriented financing approach in NYS is associated with markedly higher rates of PCI procedures for both discretionary indications (eg, PCI in nonacute myocardial infarction patients) and emergent indications (eg, primary PCI) compared with the government-funded single-payer system in Ontario.
美国的医疗改革举措重新引发了关于政府监管在医疗体系中作用的辩论。尽管纽约州（NYS）历史上进行的冠状动脉血运重建术是安大略省的两倍，但这两个司法管辖区的冠状动脉血运重建模式随时间的相对演变尚不清楚。
我们进行了一项观察性研究，比较了 1997 年至 2006 年基于人群的数据，按手术指征对纽约州和安大略省的心脏介入手术使用的时间趋势进行了比较。对于非急性心肌梗死患者，2004 年至 2006 年，纽约州经皮冠状动脉介入治疗（PCI）的年龄和性别调整后发生率是非急性心肌梗死患者的 2.3 倍（95%置信区间，2.2 至 2.5）。相比之下，非急性心肌梗死患者人群中冠状动脉旁路移植术的发生率没有显著差异。对于急性心肌梗死患者，纽约州和安大略省之间的血运重建率差异随时间大大缩小。2004 年至 2006 年，纽约州 PCI 的相对比值（95%置信区间，1.2 至 1.5）高 1.3 倍，冠状动脉旁路移植术的相对比值（95%置信区间，1.1 至 1.8）高 1.4 倍。然而，在纽约州进行急诊 PCI 的急性心肌梗死患者中，相对差距较大（相对比值为 2.0；95%置信区间为 1.7 至 2.3）。
纽约州以市场为导向的融资方式与安大略省政府资助的单一支付者系统相比，与选择性适应证（例如，非急性心肌梗死患者的 PCI）和紧急适应证（例如，直接 PCI）相关的 PCI 手术率明显更高。
