McGlynn E A, Naylor C D, Anderson G M, Leape L L, Park R E, Hilborne L H, Bernstein S J, Goldman B S, Armstrong P W, Keesey J W
RAND, Santa Monica, CA 90407-2138.
JAMA. 1994 Sep 28;272(12):934-40.
To compare the appropriateness of coronary angiography and coronary artery bypass graft (CABG) use between the United States and Canada.
Retrospective randomized medical record review.
All hospitals performing coronary angiography and/or CABG surgery in two Canadian provinces (Ontario and British Columbia); in New York State, 15 randomly selected hospitals that provide coronary angiography and 15 randomly selected hospitals that provide CABG surgery.
All patients were randomly selected. For coronary angiography, 533 patients in Canada and 1333 patients in New York were selected; for CABG, 556 patients in Canada and 1336 patients in New York were selected.
Percentage of patients in each country who had coronary angiography or CABG for necessary, appropriate, uncertain, or inappropriate indications as rated by criteria developed separately in each country and the complications of those procedures.
For coronary angiography, 9% of Canadian cases and 10% of New York cases were rated inappropriate using Canadian criteria compared with 5% and 4%, respectively, using US criteria. For CABG, 4% of Canadian cases and 6% of New York cases were rated inappropriate by Canadian criteria compared with 3% and 2%, respectively, using US criteria. A lower proportion of procedures were performed on persons aged 75 years or older in Canada than in New York for both coronary angiography (5% vs 11%; P < .001) and CABG (6% vs 14%; P < .001). Women were also represented in lower proportions among angiography cases in Canada than in New York (28% vs 35%; P = .023). Canadian patients with left main coronary disease waited significantly longer between angiography and CABG than did New York patients (P < .0001).
Rates of inappropriate use of cardiac procedures were low in Canada and New York, which suggests that the regionalization of cardiac procedures that characterizes both health care systems contributes to better clinical decision making. Differences in the use of cardiac procedures among the elderly in the two countries merits further comparative examination.
比较美国和加拿大冠状动脉造影及冠状动脉旁路移植术（CABG）使用的合理性。
回顾性随机病历审查。
加拿大两个省份（安大略省和不列颠哥伦比亚省）所有进行冠状动脉造影和/或CABG手术的医院；在纽约州，随机选择15家提供冠状动脉造影的医院和15家提供CABG手术的医院。
所有患者均为随机选取。对于冠状动脉造影，加拿大选取了533例患者，纽约选取了1333例患者；对于CABG，加拿大选取了556例患者，纽约选取了1336例患者。
根据各国分别制定的标准，每个国家因必要、适当、不确定或不适当指征接受冠状动脉造影或CABG的患者百分比，以及这些手术的并发症。
对于冠状动脉造影，按照加拿大标准，加拿大病例中有9%被评为不适当，纽约病例中有10%被评为不适当；而按照美国标准，这一比例分别为5%和4%。对于CABG，按照加拿大标准，加拿大病例中有4%被评为不适当，纽约病例中有6%被评为不适当；按照美国标准，这一比例分别为3%和2%。在加拿大，接受冠状动脉造影和CABG手术的75岁及以上老年人的比例均低于纽约（冠状动脉造影分别为5%和11%；P <.001；CABG分别为6%和14%；P <.001）。在加拿大，接受冠状动脉造影的女性患者比例也低于纽约（28%对35%；P =.023）。患有左主干冠状动脉疾病的加拿大患者在冠状动脉造影和CABG之间等待的时间明显长于纽约患者（P <.0001）。
加拿大和纽约心脏手术使用不当的发生率较低，这表明这两个医疗体系中以心脏手术区域化为特征的模式有助于更好地进行临床决策。两国老年人心脏手术使用情况的差异值得进一步比较研究。
