Rouleau J L, Moyé L A, Pfeffer M A, Arnold J M, Bernstein V, Cuddy T E, Dagenais G R, Geltman E M, Goldman S, Gordon D
Université de Sherbrooke, Que., Canada.
N Engl J Med. 1993 Mar 18;328(11):779-84. doi: 10.1056/NEJM199303183281108.
There are major differences in the organization of the health care systems in Canada and the United States. We hypothesized that these differences may be accompanied by differences in patient care.
To test our hypothesis, we compared the treatment patterns for patients with acute myocardial infarction in 19 Canadian and 93 United States hospitals participating in the Survival and Ventricular Enlargement (SAVE) study, which tested the effectiveness of captopril in this population of patients after a myocardial infarction.
In Canada, 51 percent of the patients admitted to a participating coronary care unit had acute myocardial infarctions, as compared with only 35 percent in the United States (P < 0.001). Despite the similar clinical characteristics of the 1573 U.S. patients and 658 Canadian patients participating in the study, coronary arteriography was more commonly performed in the United States than in Canada (in 68 percent vs. 35 percent, P < 0.001), as were revascularization procedures before randomization (31 percent vs. 12 percent, P < 0.001). During an average follow-up of 42 months, these procedures were also performed more commonly in the United States than in Canada. These differences were not associated with any apparent difference in mortality (22 percent in Canada and 23 percent in the United States) or rate of reinfarction (14 percent in Canada and 13 percent in the United States), but there was a higher incidence of activity-limiting angina in Canada than in the United States (33 percent vs. 27 percent, P < 0.007).
The threshold for the admission of patients to a coronary care unit or for the use of invasive diagnostic and therapeutic interventions in the early and late periods after an infarction is higher in Canada than in the United States. This is not associated with any apparent difference in the rate of reinfarction or survival, but is associated with a higher frequency of activity-limiting angina.
加拿大和美国的医疗保健系统在组织架构上存在重大差异。我们推测这些差异可能伴随着患者护理方面的差异。
为验证我们的假设，我们比较了参与“生存与心室扩大（SAVE）”研究的19家加拿大医院和93家美国医院中急性心肌梗死患者的治疗模式，该研究测试了卡托普利在心肌梗死后这类患者群体中的疗效。
在加拿大，入住参与研究的冠心病监护病房的患者中有51%发生急性心肌梗死，而在美国这一比例仅为35%（P<0.001）。尽管参与研究的1573名美国患者和658名加拿大患者具有相似的临床特征，但冠状动脉造影在美国比在加拿大更常进行（分别为68%和35%，P<0.001），随机分组前的血运重建手术也是如此（分别为31%和12%，P<0.001）。在平均42个月的随访期间，这些手术在美国也比在加拿大更常进行。这些差异与死亡率（加拿大为22%，美国为23%）或再梗死率（加拿大为14%，美国为13%）方面的任何明显差异均无关联，但加拿大活动受限性心绞痛的发生率高于美国（分别为33%和27%，P<0.007）。
在加拿大，患者入住冠心病监护病房或在心肌梗死后早期和晚期使用侵入性诊断和治疗干预措施的阈值高于美国。这与再梗死率或生存率方面的任何明显差异均无关联，但与活动受限性心绞痛的较高发生率有关。
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