can be gratifying; mortgage interest is tax deductible, and beer is cheap. But don't be mistaken life in the United States is not like a vacation in Disneyland.
Substantial tax advantages and an overall lower cost of living are unarguable facts. Canadians are being taxed to death, and the new goods and services tax only adds to the burden. Jacques A. Bouchard, MD I feel that physicians consid3013 Meadowbrook Blvd. ering a move south should considCleveland Heights, Ohio er the many pros of such a relocaI am a Canadian urologist who tion, not just some of the cons. immigrated to the United States J. Stuart, MD solely because I was unable to find Philip 1 1 1 South 10th St. anywhere to practise in Ontario Olean, NY other than in the far North. This stemmed from the policies of the Ontario Ministry of Health that force hospitals to restrict the num- Pneumococcal vaccine ber of new physicians granted for elderly people staff privileges. Because of these oppressive policies many recent I n "Periodic health examinaand future graduates of residency tion, 1991 update: 2. Adminprograms in Ontario will also be istration of pneumococcal forced to look southward for posi- vaccine" (Can Med Assoc J 1991; tions. US hospitals welcome Can- 144: 665-671) the Canadian Task adian physicians with open arms Force on the Periodic Health Exand spend millions of dollars each amination recommends that year recruiting them. pneumococcal vaccine be adminDr. Copeman paints a rather istered to all immunocompetent one-sided, pessimistic picture of patients aged 55 years or more in life and practice in the United institutions. Since the average age States. Although billing practices in most long-term care instituare more complex in that they tions is between 80 and 85 years' deal with multiple third-party what is the evidence for the vacpayers they are not insurmount- cine's efficacy in this age group? able. Malpractice insurance is considerably higher (although Ruby Friman, MD, CSPQ rates in Canada are beginning to Division of Geriatrics Mortimer B. Davis-Jewish approach those in some parts of SirGeneral the United States), but this is Montreal, Hospital Que. generally offset by much higher fees (approximately two to three Reference times higher per procedure). Violence and racial strife are 1. Kane RL, Garrard J, Buchanan JL et al: Improving primary care in nursing certainly problems in large urban homes. J Am Geriatr Soc 1991; 39: centres everywhere, but this does 359-367 not typify life in most parts of this country. There are plenty of safe, [The principal author responds:] beautiful towns and small cities with crime rates lower than in The recommendations on immuToronto or Montreal; they have nization are based on a number of good schools and excellent recre- studies, which I will summarize. ational amenities. Many of these However, Dr. Friedman is quite locations are not far from the correct in noting that age-specific border, so that visiting friends responses cannot be determined and family can be a lot easier than from these studies. A case-control study that living in the northern wilderness matched two controls to each case of Ontario. AUGUST 1, 1991
(defined by recovery of pneumococci from a sterile site) included only subjects over the age of 55 years.' The mean age was 69.5 and the standard deviation 9.5 years. The rate of vaccine efficacy was found to be 70%, which was identical to that found in a previous study of adults.2 A randomized controlled trial was conducted in which 5750 immunized subjects were compared with 5153 controls;3 13.5% of the cases and 8.5% of the controls were 80 years and over. Among the immunized subjects 99 cases of pneumonia were observed (12.2 cases per 1000 over the 6-year study period) compared with 227 cases (44 cases per 1000) among the control group. Death rates were 6.2 v. 19 per 1000 in the two groups respectively. The response by age group was not provided. However, randomization led to a larger proportion of older patients in the vaccinated group. If vaccination were less efficacious in this group it would bias the results to underestimate efficacy. A similar trial conducted in France that included patients up to the age of 85 years came to the same conclusions.4 Again, the results were not stratified by age. Finally, the only study that did not demonstrate efficacy was a cohort study with limited power. The method used to select people for vaccination is also suspect. It would not be feasible to conduct a study examining the efficacy of immunization in a single subgroup, given outcomes that are relatively rare. For example, assuming a pneumonia rate of 3% in a control group and a risk reduction rate of 75% (the values observed in the trials) in those over 80 years 406 subjects per group would be needed. Since the reason to conduct such a study would be the hypothesis that the efficacy rate is lower in elderly people this sample size is a conservative estimate. On the basis of two well-conducted randomized CAN MED ASSOC J 1991; 145 (3)
203
Substantial tax advantages and an overall lower cost of living are unarguable facts. Canadians are being taxed to death, and the new goods and services tax only adds to the burden. Jacques A. Bouchard, MD I feel that physicians consid3013 Meadowbrook Blvd. ering a move south should considCleveland Heights, Ohio er the many pros of such a relocaI am a Canadian urologist who tion, not just some of the cons. immigrated to the United States J. Stuart, MD solely because I was unable to find Philip 1 1 1 South 10th St. anywhere to practise in Ontario Olean, NY other than in the far North. This stemmed from the policies of the Ontario Ministry of Health that force hospitals to restrict the num- Pneumococcal vaccine ber of new physicians granted for elderly people staff privileges. Because of these oppressive policies many recent I n "Periodic health examinaand future graduates of residency tion, 1991 update: 2. Adminprograms in Ontario will also be istration of pneumococcal forced to look southward for posi- vaccine" (Can Med Assoc J 1991; tions. US hospitals welcome Can- 144: 665-671) the Canadian Task adian physicians with open arms Force on the Periodic Health Exand spend millions of dollars each amination recommends that year recruiting them. pneumococcal vaccine be adminDr. Copeman paints a rather istered to all immunocompetent one-sided, pessimistic picture of patients aged 55 years or more in life and practice in the United institutions. Since the average age States. Although billing practices in most long-term care instituare more complex in that they tions is between 80 and 85 years' deal with multiple third-party what is the evidence for the vacpayers they are not insurmount- cine's efficacy in this age group? able. Malpractice insurance is considerably higher (although Ruby Friman, MD, CSPQ rates in Canada are beginning to Division of Geriatrics Mortimer B. Davis-Jewish approach those in some parts of SirGeneral the United States), but this is Montreal, Hospital Que. generally offset by much higher fees (approximately two to three Reference times higher per procedure). Violence and racial strife are 1. Kane RL, Garrard J, Buchanan JL et al: Improving primary care in nursing certainly problems in large urban homes. J Am Geriatr Soc 1991; 39: centres everywhere, but this does 359-367 not typify life in most parts of this country. There are plenty of safe, [The principal author responds:] beautiful towns and small cities with crime rates lower than in The recommendations on immuToronto or Montreal; they have nization are based on a number of good schools and excellent recre- studies, which I will summarize. ational amenities. Many of these However, Dr. Friedman is quite locations are not far from the correct in noting that age-specific border, so that visiting friends responses cannot be determined and family can be a lot easier than from these studies. A case-control study that living in the northern wilderness matched two controls to each case of Ontario. AUGUST 1, 1991
(defined by recovery of pneumococci from a sterile site) included only subjects over the age of 55 years.' The mean age was 69.5 and the standard deviation 9.5 years. The rate of vaccine efficacy was found to be 70%, which was identical to that found in a previous study of adults.2 A randomized controlled trial was conducted in which 5750 immunized subjects were compared with 5153 controls;3 13.5% of the cases and 8.5% of the controls were 80 years and over. Among the immunized subjects 99 cases of pneumonia were observed (12.2 cases per 1000 over the 6-year study period) compared with 227 cases (44 cases per 1000) among the control group. Death rates were 6.2 v. 19 per 1000 in the two groups respectively. The response by age group was not provided. However, randomization led to a larger proportion of older patients in the vaccinated group. If vaccination were less efficacious in this group it would bias the results to underestimate efficacy. A similar trial conducted in France that included patients up to the age of 85 years came to the same conclusions.4 Again, the results were not stratified by age. Finally, the only study that did not demonstrate efficacy was a cohort study with limited power. The method used to select people for vaccination is also suspect. It would not be feasible to conduct a study examining the efficacy of immunization in a single subgroup, given outcomes that are relatively rare. For example, assuming a pneumonia rate of 3% in a control group and a risk reduction rate of 75% (the values observed in the trials) in those over 80 years 406 subjects per group would be needed. Since the reason to conduct such a study would be the hypothesis that the efficacy rate is lower in elderly people this sample size is a conservative estimate. On the basis of two well-conducted randomized CAN MED ASSOC J 1991; 145 (3)
203
