Northern exposure: Nuclear cardiology in the Canadian health care system

REVIEWS

Northern exposure: Nuclear cardiology in the Canadian health care sys tem

D. Douglas Miller, MD, FRCP(C), Maria C. Kiess, MD, FRCP(C), Michael R. Freeman, MD, FRCP(C), and

Raymond Taillefer, MD, FRCP(C)

The Canadian health care system may provide valuable insights into the future practice of nuclear cardiology in the United States. Rationing of medical care is not legislated by the Canadian health care system, although resource allocation is required of Canadian physicians and hospital administrators. Canadian nuclear cardiologists and physicians are not restricted in the ordering of diagnostic studies, despite the decreased availability in imaging systems and the centralization of equipment and personnel in Canada. Canadian imaging equipment is, in general, used more with less average idle time per unit. Delays in the performance of nonemergent imaging studies are more common in Canadian imaging laboratories. The number of out-of-hospital nuclear medicine laboratories is not increasing, because of government constraints on licensing and the general requirement that only radiologists or certified nuclear medicine physicians can operate these laboratories. A survey of 71 nuclear cardiology laboratories in the United States and Canada reveal that 21% of all cardiac imaging studies are performed for post-myocardial infarction risk stratification in Canada, compared with only 11% in United States laboratories. Rest and reinjection thallium imaging studies are performed more than twice as often in the United States laboratories. Canadian laboratories perform a higher average number of myocardial perfusion (2123 vs 1789) and ventricular function (773 vs 554) studies as compared with their United States counterparts. No other significant differences in clinical usage patterns were identified. A total of 130,000 nuclear cardiologies were performed in Canada in 1993, with less than 5% growth in the number of Canadian studies projected for 1994. Forty-five percent of Canadian perfusion studies are performed with 99mTc-labeled sestamibi frequently using a 2-day protocol (60%) with electrocardiogram gating (30%). Positron emission tomography (PET) can be performed in only six Canadian cities. Canadian PET centers are government funded, located in university teaching hospitals, and principally used for the purpose of research. Stress echocardiography is not widely performed in Canada because of the heavy clinical volume of standard echocardiographic studies at most hospitals, which reduces the time available for stress echocardiography. No separate billing code is available for stress echocardiography studies in Canada. Canadian cardiologists have accepted the value of rest and stress nuclear studies for the management of their patients and have concluded that it is more time efficient to perform clinical duties in lieu of stress echocardiographic studies. In conclusion, the realities of the Canadian health care system are that universal health care is valuable as long as it is consistent high quality medical care, and that the cost of universal coverage must be borne by the taxpayer using the system. The fact that nuclear cardiology has continued to thrive in the Canadian health care system suggests that future health care modifications in the United States will not exert a significant impact on the practice of nuclear cardiology. (J NUCL CARDIOL 1995;2:53-61.)

Key Words: health care economics .pract ice pa t te rns .myocard ia l perfusion imaging. positron emission tomography �9 echocardiography �9 resource allocation

53

54 Miller et al. JOURNAL OF NUCLEAR CARDIOLOGY Nuclear cardiology in the Canadian health care system January/February 1995

In 1961, Justice Emmett Hall, then Chief Justice of the Saskatchewan supreme court, recommended a national Medicare system be instituted in that province. The next year, doctors in Saskatchewan launched a bitter 23-day strike in protest against the provincial government's attempt to legislate ex- tended health care insurance to cover doctors' professional services-the strike closed down all but emergency services. Saskatchewan doctors eventu- ally won the right to continue billing and extra billing their patients directly.

In 1966, the federal Liberal government of Pierre Eliot Trudeau introduced the National Medical Care Act which mandated health care insurance across Canada. As with the Clinton Health Security Act of 1993, the basic tenets of the Canadian Medical Care Act are that all Canadian citizens must receive federally funded medical care that is portable and accessible. The introduction of Canadian government-sponsored medical coverage was gradual, re- quiring 6 full years to be implemented in all of the provinces after passage of federal legislation in 1966.

In 1984, the Canada Health Act was passed, entitling all residents (not just citizens of Canada) to insured health services, banning user fees and extra billing, and effectively removing the final barriers to universal access. In 1986, the Ontario Medical Asso- ciation launched a 25-day work action to protest enactment of this legislation in Ontario-this strike failed. "No one said it would be easy to create the finest health care system in the world."*

The saga of universal health care in America is currently being written. Legislative pathways toward university medical coverage are evolving rapidly and remain almost too numerous to count. The degree of acceptance and eventual success in implementation of the final US Health Care Plan remains uncertain. However, the pressures driving this reform makes it inevitable. Certain aspects of the Canadian health care experience may provide valuable insights into this process and into the future of medical practice in the United States.

It is the purpose of this report to review those

From the Saint Louis University Health Sciences Center, St. Louis, Mo., St. Paul's Hospital, Vancouver, British Columbia, St. Michael's Hospital, Toronto, Ontario, and Hotel-Dieu de Montreal, Montreal, Quebec.

Reprint requests: D. Douglas Miller, MD, Associate Professor of Medicine, Saint Louis University Health Sciences Center, 3635 Vista Ave. at Grand Blvd., Division of Cardiology, 14th floor, PO Box 15250, St. Louis, MO 63110.

Copyright �9 1995 by American Society of Nuclear Cardiology. 1071-3581/95/$3.00 + 0 43/72/61272 *Canadian Living Magazine, February 1993.

aspects of the fully matured (some might say senes- cent) Canadian health care system that are distinctive from the American medical system, and to identify those features that are most germane to the future practice of nuclear cardiology in a government- mandated, universal coverage, managed health care system in the United States. The reactions of the neighboring nuclear cardiology community north of the forty-ninth parallel to nearly 30 years of single- payor, government-allocated medical care could fore- shadow the impact of similar changes on American nuclear cardiology practice patterns in the next decade. These speculations are supported, whenever possible, by the results of a 1993-94 practice survey of 71 nuclear cardiology laboratories from across the United States and Canada.

PREVIOUS COMPARISONS BETWEEN THE AMERICAN AND CANADIAN

HEALTH CARE SYSTEMS

Recent studies have scrutinized the reasons for higher per capita health care expenditures in the United States compared with Canada since 1985.1 Investigators have pointed out that if American health care spending had been patterned on a Canadian system since 1985, the annualized savings would approximate $30 billion.

Hospital costs, including physicians' services, and health insurance plan administrative costs are the major factors contributing to this discrepancy, which has accentuated the cross-border gradient in relative and absolute health care spending. Previous studies have pointed out how lower hospital costs per patient, 2 capitation of global budgets and health care regulatory controls, 3 and reduced medicolegal pressures 4 can all contribute to lower expenditures for hospital care in Canada.

When 1987 acute care hospital expenditures per admission were compared between the United States and Canadian medical centers, 1 the United States had fewer hospital beds, fewer admissions, and a shorter mean stay (see Table 1). The higher per capita cost per admission in the United States was partially attributable to a 14% more complex case mix and to 4% greater costs for hospital labor and supplies. Canadian hospitals provided more outpatient and emergency room care. The estimated gross adjusted cost for in-patient care per admission was 24% greater in the United States, and 46% higher in California compared with Ontario.

The principal causes of greater expenditures in American hospitals were higher administrative costs

JOURNAL OF NUCLEAR CARDIOLOGY Miller et al. 55 Volume 2, Number 1;53-61 Nuclear cardiology in the Canadian health care system

Table I . Comparison of data on acute care hospitals in the United States and Canada, 1987*

United States Canada

Expenditures per capita ($) Number of hospital beds per 1000 populationt In-patient days per 1000 Mean length of stay (days) Occupancy rate (%) Emergency visits per 1000~ Expenditures per admission ($)

621 492 3.90 5.43

929 1590 7.2 11.2

65 81 320 677

4814 3463

*Data modified from Redelmeier and Fuchs. ~ tRefers to registered beds, as reported by the American Hospital Association and Statistics Canada. ~Defined as outpatient visits to a hospital facility with 2.4-hour staffing and offering immediate care.

Table 2. Selected diagnostic services per admission in California and Ontario, 1987"

Tertiary hospital ratio, Community hospital ratio, Stanford to Sunnybrook St. John's to Wellesley

MRI scanningt - - Echocardiography 1.49 1.44 V/Q lung scanning~ 1.29 0.63 Electrocardiographyw I. 11 1.02 CT of body 1.00 1.07

Stanford, Stanford University Medical Center, Stanford, Calif.; Sunnybrook, Sunnybrook Health Science Center, Toronto, Ontario; St. John's, St John's Hospital, Calif.; Wellesley, Wellesley Hospital, Toronto, Ontario. *Data shown are not adjusted for case mix; modified. tNo ratio because of unavailability of MRI at Canadian hospitals (Sunnybrook, Wellesley) in 1987. ~Represents either ventilation scanning, perfusion scanning or combined V/Q scanning. w measures obtained during electrophysiologic testing.

and less centralization of equipment and personnel than in Canada. A substudy of selected diagnostic services (Table 2), including magnetic resonance imaging (MRI), echocardiography, ventilation-perfusion (V/Q) lung scanning, electrocardiogram (ECG), and computed tomography (CT) did not support the hypothesis that American hospitals deliver more clinical diagnostic services. Nor were Canadian physicians restricted in their freedom to order diagnostic tests, despite the fact that, for example, California hospitals had five times more MRI scanners than did hospitals in Ontario. However, diagnostic and surgical equipment in Canada are used more fully than similar facilities in comparable American hospitals, with less average idle time for high-cost equipment in Canada.

The growing managed care emphasis on early discharge has created surges in the need for predischarge diagnostic services in American hospitals, and has led to reduplication of these services in outpatient diagnostic centers that are rarely found in Canada.

Variable and generally lower United States hospital census figures may also explain the reduced efficiency of equipment scheduling and personnel allotment compared with Canada.

MEDICAL EXPENDITURE DIFFERENCES BETWEEN THE UNITED STATES

AND CANADA

The overall quality of medical care received by Canadians approximates that achieved in the United States. A 1990 study by the Harvard School of Public Health reported that Canadians are the most satisfied with their health care system of the 10 leading industrialized countries, including the United States. The twenty-third Bethesda Conference on Access to Cardiovascular Care reported in 1991 that total and ischemic cardiovascular death rates in Canada and the United States were nearly identical (total = 329.6 vs 359.2 per 100,000 population). 5 Canadians spend approximately $60 billion on national health care


annually, an average of $1483 per capita compared with $2051 per capita in the United States.

The Canadian system has "held the line" on health care expenditures as a percentage of the gross national product (GNP), due in part to strict government control of budgeting. 6 These figures grew more slowly for Canada between 1980 (8%), 1990 (9%), and 1991 (10.2%) than did the corresponding figures in the United States (9% to 12.4% to 13.2%). This GNP-based comparison may not be entirely fair, in view of the more rapid growth of the Canadian GNP during this interval and other complexities in this calculation. 7

Despite its apparent cost-containment and access advantages, the Canadian health care system has been criticized broadly by the United States (and some Canadian) health care policy experts. 8 Canadian patients suffer from longer waiting times for specialized services, creating patient inconvenience and increasing morbidity, 9 while also delaying hospital discharges. Canadians pay approximately half of the United States' Medicare payment rate for coronary angiography and percutaneous transluminal coronary angioplasty (PTCA), but wait an average of 22.6 weeks for open heart surgery, 8.5 weeks for cardiac catheterization, and 11 weeks for PTCA. 5

Canadian taxpayers are also required to pay marginal tax rates that may exceed 48% in the upper income brackets to support their health care system. As general taxation revenues have fallen short of supporting these and other social programs, new "value added taxes" (i.e., the goods and services tax or GST) and hefty "sin taxes" have been imposed on alcohol and tobacco products to raise badly needed revenues. The Canadian health care system survives only as long as the Canadian taxpayer is prepared to foot the bill.

Although rationing of medical care is not legislated in Canada, the allocation of medical resources may create ethical dilemmas for some Canadian physicians, a~ Canadian patients of greater financial means can seek more rapid self-pay medical care in the United States, thereby creating a dual medical standard of care. These "out-of-plan" foreign medical services, which are not covered by the Canadian plan, should theoretically save the Canadian system money. Until recently, retired Canadian "snowbirds" who became ill while living half of their year in the United States Sun Belt were treated in the emergency rooms of American hospitals at considerable Canadian taxpayer expense, rather than being expeditiously jetted back to Canada for more definitive and much less expensive diagnostic and therapeutic interventions. Cutbacks in Canadian government reimbursement for medical care in the United States have

forced these "snowbirds" to carry private medical insurance in the United States. As such, Canadian government expenditures for medical services do not always reflect the total cost of medical care paid by Canadian citizens.

Total expenditures for the provision of health care services in Ontario comprise 30% of the provincial budget, rendering hospitals and physicians highly vulnerable to government spending cutbacks. Recent Ontario government policy has been to increase hospital budgets by 3.6% in FY 1992-93, but then to approve no further increases for at least 2 years. Physician services expenditures have also been con- tained by the government to less than the 3.6% increase negotiated in 1991-92.

POST-MYOCARDIAL INFARCTION (MI) MANAGEMENT-A SPECIFIC EXAMPLE

OF THE PRACTICAL IMPACT OF UNIVERSITY HEALTH CARE ON

PATIENT OUTCOMES

Despite comparable clinical characteristics, Ca- nadian myocardial infarction survivors undergo different predischarge management than their Ameri- can postinfarction counterparts. 9 Data from the multicenter SAVE study indicate that, although a higher percentage of Canadian patients had a docu- mented MI (51% vs 35 %), significantly more coronary angiography was performed in American patients after MI (68% vs 35% of all patients enrolled). Coronary revascularization was also more frequent in American patients before study randomization (31% vs 12%) and during 42 months of follow-up (17% vs 12%). Despite higher invasive testing and revascularization rates, there was no difference in death (23% vs 22%) or reinfarction (13% vs 12%) rates between American and Canadian SAVE study patients. This suggests that many of the expensive cardiovascular diagnostic and therapeutic procedures performed in the United States are unnecessary. Canadian patients did suffer higher rates of activity-limiting angina than their American counterparts (33% vs 27%), poten- tially causing functional limitations that may mitigate against an early return to work and increase prescrip- tion medication costs. Similar findings were demon- strated in the GUSTO study of thrombolytic therapy for myocardial infarction? 1 The SAVE study did not address the use of noninvasive risk stratification procedures before discharge or during follow-up. It would be reasonable to assume that the more conservative clinical approach to the invasive management of the patient after MI by Canadian physicians would be reflected in their noninvasive testing

JourtYAL OF NUCLEAR CARD~OLOCY Miller et al. 57 Volume 2, Number 1;53-61 Nuclear cardiology in the Canadian health care system

Myocardial Perfusion and Function Studies/Year

2500.

�9 United States (n=54) 2000.

Studies/Year 13 Canada (n=17)

(Mean) 1500-

1000-

500_

773

Perfusion Function

Figure 1. 1993-1994 nuclear cardiology laboratory survey results indicating average number of annual myocardial perfusion and ventricular function studies performed per laboratory in United States and Canada. Larger number of studies performed in Canadian laboratories reflects centralization of diagnostic services in that country.

70-

60-

% of 50- Studies (Mean) 40-

30-

20-

10-

O-

Myocardial Perfusion By Protocol �9 United States (n=54) [] Canada (n=17)

Rest Relnjectlon Exercise Pharmacologic Stress Stress

Protocol

Figure 2. 1993-1994 nuclear cardiology laboratory survey results summarizing data on protocol for myocardial perfusion imaging used by laboratories in United States and Canada. Of note, similar percentage of patients were studied with pharmacologic stress in both countries (29%). Rest only and reinjection e~ imaging were performed more than twice as often in United States laboratories.

patterns. This assumption was confirmed by our practice survey data (Figure 3).

These differences in patient post-MI management were not directly attributable to physician training or clinical experience, nor did they reflect widespread differences in general medical practice patterns between the two countries. 6't2 Although previous studies have not shown major differences in rates of diagnostic and therapeutic procedures between the United States and Canada, 13 the SAVE investigators postulated that government imposed budgetary restraints over general health care expenditures contributed to this discrepancy, and that this effect was most acutely felt in the use of expensive cardiovascular diagnostic and interventional procedures after MI. In addition, the lack of evidence that intervention alters patient outcome and the absence of substantial financial incentives for interventions may impact on the frequency of these procedures.

NONINVASIVE CARDIOVASCULAR TESTING PATTERNS IN THE UNITED

STATES AND CANADA

Three features of the Canadian system charac- terize the use of nuclear cardiology procedures in that country: (1) waiting lists from days to months exist before patient testing, (2) reimbursement is on a fee-for-service basis, with the provincial government and physician medical association setting reimbursement, and (3) there are no limitations or rationing imposed on patient testing procedures.

In Ontario, reimbursement for nuclear cardiology procedures is entirely on fee-for-services basis. Other provinces may have different forms of reimburse-

ment. The fee for medical services is set by the provincial medical associations, but the total budget for medical care is set by the government. Thus the total physician remuneration is capped, but the physicians decide the fee for each service. As the total envelope of dollars available is either cut or not allowed to increase, there will be pressure within the provincial medical associations to reevaluate the fee schedules and make adjustments according to "equal value" as may be required. This could have a negative impact on the fees presently awarded for certain procedures and diagnostic studies.

As is the case in the United States, nuclear cardiology studies are the most commonly performed nuclear medicine imaging procedure in Canada, consuming approximately 55% of total gamma cam- era use. A total of 130,000 nuclear cardiology studies were performed in Canada in 1993 compared with an estimated 2.5 million myocardial perfusion studies in the United States. Less than 5% growth in the number of Canadian studies is projected in 1994. In contrast with the United States, approximately 45% of Canadian myocardial perfusion studies are performed with 99mTc-labeled sestamibi, the remainder being carried out with 2~ Of interest, 60% of 99mTC

sestamibi perfusion studies in Canada are performed with a 2-day imaging protocol, and 30% are performed with ECG gating.

UNITED STATES-CANADA NUCLEAR CARDIOLOGY PRACTICE SURVEY

To document potential differences in the use of noninvasive procedures, a survey of 54 American and 17 Canadian nuclear cardiology laboratories was


5O 48 IBa, 40

%of Sludies 30 (Mean)

20

10

0

Myocardial Perfusion Studies By , Indication

17

BElt

�9 United States (n=54)

D Canada (n=17)

11 I I 11

15

m__ m ji-= .ml LrmL_ CAD Preoperative MI MI Risk Viability Revaac

Screen Assessment Diagnosis Stratification

Indication

Figure 3. 1993-1994 nuclear cardiology survey results summarizing clinical indication for myocardial perfusion studies in United States and Canadian laboratories. Great majority of studies were performed to screen for coronary artery disease (CAD). Use of stress myocardial perfusion imaging for post-MI risk stratification was nearly twice as frequent in Canadian laboratories, reflecting decreased availability and use of cardiac catheterization after MI in this country.

performed between November 1993 and May 1994 to determine hospital referral and practice patterns. Selected results from this survey are illustrated in Figures 1 to 3. The majority (more than 90%) of survey sites were large university-affiliated hospital nuclear medicine laboratories.

The greater centralization of nuclear cardiology services in Canadian hospitals is reflected by the higher number of perfusion and ventricular function studies performed at each site. There was no difference in the stress modality used (exercise vs pharmacologic) with myocardial perfusion imaging studies. The clinical indications for nuclear cardiology testing were largely comparable in the United States and Canada with one exception, the increased use of nuclear cardiac imaging for post-MI risk stratification in Canada (21% vs 11% in United States).

The United States-Canada practice survey re- vealed that 11% of Canadian nuclear cardiology examinations were performed to determine myocardial viability status compared with only 7% of American studies. Rest or reinjection Z~ imaging was more commonly applied for viability detection at American centers (14% and 18% of studies, respectively), but was rarely applied in Canadian laboratories, possibly because of the high volume of studies and the relative lack of imaging time available per patient. Canadian cardiologists also give considerable weight to the presence of chest pain and inducible ischemia, and will perform bypass surgery on their patients on the basis of these findings and operable coronary lesions, regardless of the severity

of left ventricular dysfunction and without ordering a confirmatory viability study.

These discrepancies may reflect several fiscal and practical differences between the two countries. First, the longer waiting times for specialized services, such as coronary angiography, may have trained the physicians to adopt a short-delay, noninvasive risk- stratification approach in this clinical setting. Second, with limitations of access to specialized testing in geographically centralized facilities, any Canadian physician wishing to order a cardiac catheterization must provide a medical justification for testing that might not be required of American doctors. Third, in addition to government and hospital controls, there is considerable physician peer pressure to avoid over- testing, which would consume limited resources and limit funds available from global budgets to reimburse other physicians for more appropriate studies.

POSITRON EMISSION TOMOGRAPHY IN CANADA

Six positron emission tomographic (PET) systems are currently operating across Canada, of which only two have whole body imaging capabilities. Although the total number of PET systems is far less than that in the United States (n = 75), the ratio of PET units per total population does not differ dramatically between Canada and the United States (1/4.4 million vs 1/3.3 million persons). The wide geographic distri- bution of PET centers in Canada (Vancouver, Ed- monton, Winnipeg, London, Toronto, Montreal)

JOURNAL OF NUCLEAR CARDIOLOGY Miller et al. 59 Volume 2, Number 1;53-61 Nuclear cardiology in the Canadian health care system

probably exacerbates limitations in access to this technology that are not encountered in the United States. Finally, Canadian PET centers are government-funded operations situated in university teaching hospitals mainly for the purpose of research. There are no exclusively "clinical" PET centers that physicians can directly refer patients to in Canada. As such, clinical availability of PET studies for viability detection (or CAD detection) is severely limited.

ROLE OF STRESS ECHOCARDIOGRAPHY IN CANADA

Despite publications demonstrating that the diagnostic value of exercise and pharmacologic stress echocardiography approximates that of stress myocardial perfusion imaging, 14,15 stress echocardiography is not widely practiced in Canada. This discrepancy illustrates many of the fundamental differences between medical practice in the United States and Canada. One experienced university-based Canadian echocardiographer has estimated that a number of stress echocardiographic studies, when corrected for population differences, would still be less than a third of that performed in the United States. This gap cannot be explained by the 1- to 2-year technology diffusion delay between the United States and Canada and is probably multifactorial. The potential reasons for the failure of clinical stress echocardiography in Canada are given below.

First, centralization of specialized diagnostic services creates intense pressure on echocardiography laboratories and personnel. The high volume of studies (11,000 echocardiograms in 1993 at the tertiary care, University of Toronto Hospital) leaves little opportunity for time-consuming stress echocardiography studies, other than those performed in funded research protocols. Second, there is little financial incentive for the performance of stress echocardiography, which is reimbursed as a stress test and standard echocardiogram, without a special billing charge being available. The higher rate of reimbursement for both in-hospital and outpatient nuclear studies is an equal disincentive to developing a stress echocardiography program, unless this is being done to create a new business in an underserved area. In addition, if a finite number of reimbursable tests could be billed for by a medical center, there would be little financial room for reduplication of noninvasive studies at tertiary referral centers with access to both technologies.

The high quality of Canadian academic nuclear cardiology laboratories has consolidated the niche for

these studies, which are well accepted by cardiology practitioners and by the government bureaucracy. The concept of comparable quality of stress echocardiography at reduced cost is not a real issue in Canada, where clinical cardiology practice is generally less entrepreneurial, and where there is little financial incentive to establish a "false economy" built around the relative cost differential between such tests. In addition, private practice cardiologists in Canada are generally too busy seeing patients to perform time-consuming stress echocardiography studies. It is perceived to be more cost-effective by clinicians to have a diagnostic colleague do a stress nuclear cardiology study while seeing two patients in the office in the same period of time. The relative paucity of cardiovascular specialists per capita in Canada leaves little time for stress echocardiography.

CONCLUSIONS

The overall effect of university medical coverage on health care delivery in Canada has been to delay the time from point of entry to the performance of specialized testing, to allocate and regionalize high technology services, to reduce the number of post- graduate training programs and positions, and to limit capital improvements and equipment purchases. Al- though Canadians are generally content with their health care coverage, the provincial budget ceiling for health care services often results in termination of certain medical services and closure of hospital beds when funds are expended before the end of the government's fiscal year. Physician dissatisfaction with this situation has resulted in sporadic work slow-downs and physician strikes.

Although lower in some provinces, the current technical charge and professional fee for single photon emission computed tomography (SPECT) myocardial perfusion imaging in Ontario is $400 and $200, respectively. Importantly, outpatient nuclear studies in Ontario can provide income that is distinct from capitated hospital budgets, the equivalent of "bonus" revenues for a cardiology division or practice group. The total number of out-of-hospital nuclear medicine laboratories is restrained since the government must approve all licenses, with the majority of these being held by radiologists or certified nuclear medicine physicians, not cardiologists.

PET imaging facilities are geographically dis- persed, and cannot be established without government approval. This severely reduces access to PET for clinical studies and has essentially eliminated so-called "clinical PET centers." In contrast to PET,


high-quality, single-photon nuclear cardiology procedures are available across Canada and are heavily relied on by clinicians routinely confronted with delays in coronary angiography, as a temporizing measure, a means to guide medical therapy, and for patient selections for more invasive procedures.

The economic arguments in favor of stress echocardiography are rendered moot by a Canadian billing system without special codes for stress echocardiograms and by the t remendous volume of clinical echocardiography studies performed in centralized diagnostic laboratories. The implications of these phenomena for the current practice of nuclear cardiology in Canada are self-evident. The future impact of similar changes in the United States health care system is implicit.

In the final analysis, Canadian physicians, patients, and government bureaucrats alike have recog- nized that the shared objective of containing health care expenditures is valuable so long as it is consistent with high quality medical care. The desire on the part of the health care provider, the Canadian government, to reduce federal spending and to minimize taxation has necessitated health care "changes," which may not directly equate with health care " re form" in a positive sense.

As has been the case in Canada for nearly three decades of universal medical care, the realities of increased labor costs, intensive care, and general medical services have driven the global cost of health care upward. The growing demand for increased efficiency in the United States must be balanced by a public recognition that health care needs are virtually limitless, and that the cost o f universal coverage must be borne by the taxpayer using the system. One reasonable way to control global expenditures without unduly burdening the taxpayer is to set health care priorities. Strategies for improving efficiency in health care delivery are fundamental , but they represent only a temporary substitute for the difficult decisions about health priorities and medical resource allocation.

While marke t forces can frequently achieve an intelligent and fair allocation of resources by allowing free choice ra ther than imposing external controls over usage and expenditures, the medical care mar- ketplace may be an exception to this norm. The current distortion in the prices for medical services and in the incentives (or disincentives) provided for American health care make it difficult to believe that a solely market-driven system can achieve efficient or compassionate resource allocation. Managed care and clinical practice guidelines, which have been increasingly successful in the American system, are

also gaining acceptance in Canada. 16 These ap- proaches can help to contain costs by driving down marke t prices and enforcing a degree of resource allocation. While government-mandated practice guidelines, developed in concert with physicians, should make medical care more cost-effective and objective in nature, they may also lead to restrictions in the investigations and in the t rea tment of patients who do not strictly fit these guidelines and may prevent physicians f rom making individual excep- tions. To date, Canadian physicians can order and get whatever tests and therapies they believe are indi- cated for their patients, although this may change in the future.

The Canadian model suggests that a government- controlled medical care system can achieve the fiscal benefits of managed care while at the same time accomplishing the societal and political objective of providing universal health care that is accessible, portable, and comprehensive.

Ms. Mary Swanson for assistance in compiling United States-Canada survey results, Mile. Suzy Couturier for providing Canadian nuclear cardiology demographic data, Dr. Harry Rakowski for his thoughtful comments on stress echocardiography in Canada, Ms. Lori Gallini for expert secretarial assistance, and the physicians across the United States and Canada who provided responses to the practice survey.

References

1. Redelmeier DA, Fuchs VR. Hospital expenditures in the United States and Canada. N Engl J Med 1993;328:772-8.

2. Newhouse JP, Anderson G, Roos LL. Hospital spending in the United States and Canada: a comparison. Health Aff (Mill- wood) 1988;7(5):6-16.

3. Evans RG, Lomas J, Barer ML, et al. Controlling health expenditures-the Canadian reality. N Engl J Med 1989;320: 571-7.

4. Coyte PC, Dewees DN, Trebilcock MJ. Medical malpractice- the Canadian experience. N Engl J Med 1991;324:89-93.

5. Collins-Nakai RL, Huysmans HA, Scully HE. Task force 5, access to cardiovascular care: an international comparison. J Am Coil Cardiol 1992;19:1477-85.

6. Fuchs VR, Hahn JS. How does Canada do it? A comparison of expenditures for physicians' services in the United States and Canada. N Engl J Med 1990;323:884-90.

7. Detsky AS. Northern exposure-can the United States learn from Canada? New Engl J Med 1993;328:805-6.

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9. Rouleau JL, Moye LA, Pfeffer MA, et al. A comparison of management patterns after acute myocardial infarction in Canada and the United States (SAVE Investigators). N Engl J Med 1993;328:779-84.

10. Harrison B, Noseworthy T. Is there a role for physicians in health and medical resource allocation? Annals RCPSC 1994;27:12-4.

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11. Mark DB, Naylor CD, Califf RM, et al. Less catheterization and revascularization following myocardial infarction in Canada is associated with more angina: initial results from the Canadian-US GUSTO Substudy (GUSTO investigators).

12. Anderson GM, Newhouse JP, Roos LL. Hospital care for elderly patients with diseases of the circulatory system: a comparison of hospital use in the United States and Canada. N Engl J Med 1989;321:1443-8.

13. lglehart JK. Canada's health care system faces its problems. N Engl J Med 1990;322:562-8.

14. Quinones MA, Verani MS, Haichin RM, Mahmarian JJ, Suarez J, Zoghbi WA. Exercise echocardiography versus

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15. Marwick T, Willemart B, D'Hondt AM, et al. Selection of the optimal nonexercise stress for the evaluation of ischemic regional myocardial dysfunction and malperfusion: comparison of dobutamine and adenosine using echocardiography and 99mTc-MIBI single photon emission computed tomography. Circulation 1993;87:345-54.

16. O'Neill MB, Johnston GM, Torbert J, et al. Modifying managed care for the Canadian Health System. Annals RCPSC 1993;26:349-52.

Documents

Northern exposure: Nuclear cardiology in the Canadian health care system