CLINICAL AND COMMUNITY STUDIES ETUDES CLINIQUES ET COMMUNAUTAIRES

Rates of cardiac catheterization, coronary angioplasty and open-heart surgery in adults in Canada Lyall A.J. Higginson,* MD; John A. Cairns,4 MD; Wilbert J. Keon,t MD; Eldon R. Smith,§ MD Objective: To determine the rates of and waiting lists for cardiac catheterization, percutaneous transluminal coronary angioplasty (PTCA) and open-heart surgery in adults in Canada between Apr. 1, 1988, and Mar. 31, 1989. Design: Mail survey. Participants:The directors of all 48 adult cardiac catheterization laboratories and the chiefs of all 33 adult cardiovascular surgery programs in Canada. Main results: A total of 61 116 cardiac catheterization procedures were performed, a rate of 236 per 100 000 population. The mean waiting times for elective procedures were weighted to reflect more accurately the differences between centres in the number of patients awaiting the procedures. The mean wait for elective cardiac catheterization was 8.5 weeks. There were 10 097 PTCA procedures done, a rate of 39 per 100 000 population. The mean wait for elective PTCA was 11.0 weeks, the longest wait occurring in Quebec (15.4 weeks). A total of 16 240 open-heart procedures were performed, a rate of 63 per 100 000 population. The mean wait for elective open-heart surgery was 22.6 weeks, the longest wait occurring in Quebec and British Columbia (more than 32 weeks). The rates for all three procedures were much lower in Canada than in the United States. Conclusions: The results suggest that the cumulative wait for coronary angiography and PTCA or open-heart surgery may lead to major losses of productivity, delayed rehabilitation and reduced probability of return to previous levels of productivity. Regular collection of data such as ours shoulld help to understand better the resources required for these specialized cardiac procedures.

Objectif: Determiner les taux et les listes d'attente pour le catheterisme cardiaque, l'angioplastie coronarienne transluminale percutanee (ACTP) et la chirurgie a coeur ouvert chez les adultes au Canada entre le ler avril 1988 et le 31 mars 1989. Conception: Sondage postal. Participants: Les directeurs de 48 laboratoires de catheterisme cardiaque pour adultes et de 33 programmes de chirurgie cardio-vasculaire pour adultes au Canada. Resultats principaux: On a pratique 61 116 interventions de catheterisme cardiaque, a un taux de 236 par 100 000 habitants. Les temps moyens d'attente ont ete ponderes afin de mieux refl6ter les differences entre les centres en ce qui a trait aux nombres de patients qui attendaient l'interventions. L'attente moyenne pour un catheterisme cardiaque electif etait de 8,5 semaines. Au total, 10 097 interventions d'ACTP ont ete From the departments of *Medicine and tSurgery, University of Ottawa, Ottawa, Ont., $the Department ofMedicine, McMaster University, Hamilton, Ont., and jthe Department ofMedicine, University ofCalgary, Calgary, Alta.

Reprint requests to: Dr. Lyall A.J. Higginson, Rm. H-208, Heart Institute, Ottawa Civic Hospital, 1053 Carling Ave., Ottawa, ON KlY 4E9 -

For prescribing information see page 1 1 00

CAN MED ASSOC J 1992; 146 (6)

921

effectuees, a un taux de 39 par 100 000 habitants. L'attente moyenne pour l'ACTP elective etait de 1 1,0 semaines, l'attente la plus longue ayant eu lieu au Quebec (15,4 semaines). On a effectue 16 240 interventions a coeur ouvert, a un taux de 63 par 100 000 habitants. L'attente moyenne pour la chirurgie a coeur ouvert elective &tait de 22,6 semaines, l'attente la plus longue ayant eu lieu au Quebec et en Colombie-Britannique (plus de 32 semaines). Les taux des trois interventions etaient beaucoup moins eleves au Canada qu'aux Etats-Unis. Conclusions: Les resultats suggerent que l'attente cumulative pour la coronarographie et l'ACTP ou la chirurgie a coeur ouvert peut se solder par d'importantes pertes de productivite, un retard de readaptation et une probabilite reduite de retour aux niveaux anterieurs de productivite. Une collecte de donnees reguliere comme la notre devrait favoriser une meilleure comprehension des ressources necessaires pour ces interventions cardiaques specialisees.

ardiovascular disease continues to be the leading cause of death in Canada. Cardiovascular disease and specifically coronary heart disease place a very large burden on our health care delivery system. The treatment of coronary heart disease is expensive, with the need for specialized facilities, trained personnel, complex surgical procedures and increasingly sophisticated technology. Given the limited medical facilities and personnel, patients with coronary heart disease may have to wait to undergo specialized revascularization procedures. Very little information is available on the numbers of cardiovascular procedures performed in Canada and the waiting times associated with these procedures. In this report we summarize the results of a survey carried out by the Canadian Cardiovascular Society to obtain such information. C

Methods A task force of the Canadian Cardiovascular Society developed a questionnaire to determine the number of cardiac catheterization, percutaneous transluminal coronary angioplasty (PTCA) and open-heart surgical procedures performed in adults in Canada between Apr. 1, 1988, and Mar. 31, 1989. One PTCA procedure was counted for each session in a catheterization laboratory regardless of how many vessels were dilated or whether the procedure was successful. Open-heart surgery was defined as any procedure performed on the heart or great

vessels in which cardiopulmonary bypass was used. If more than one procedure was performed during a given operation it was counted as one procedure. If a patient was readmitted later in the year and underwent a second open-heart procedure, the second procedure was also counted. The survey also attempted to determine the number of patients waiting to undergo these procedures as of Jan. 11, 1990, and, for elective procedures, the length of time a patient would have to wait. A patient was considered to be awaiting an elective procedure if he or she was scheduled to undergo the procedure but was not admitted to an 922

CAN MED ASSOC J 1992; 146 (6)

acute care institution. The chiefs of cardiovascular surgical programs were asked questions about postponement of scheduled open-heart surgery. The questionnaire was sent in February 1990 to the directors of all 48 adult cardiac catheterization laboratories and the chiefs of all 33 adult cardiovascular surgery programs in Canada. If no response was received telephone calls were made to collect the information. On June 15, 1990, a second questionnaire was mailed to assess the reliability of the information that had been received. The results of the first survey were enclosed with the second mailing. By examining the initial results the respondents had an opportunity to corroborate their own results and to inform the society whether there were other institutions in the province that had not responded. The final numbers were compiled from the two mailings. The population of Canada was 25 911 000 as of June 1, 1988.1 The denominator used in calculating rates is total population, not population at risk. The rates for Nova Scotia, New Brunswick and Prince Edward Island were combined because cardiac procedures in patients from these provinces are done primarily in Nova Scotia. The mean waiting times for the elective procedures were weighted to reflect more accurately the differences between the centres in the numbers of patients awaiting the procedures. The following formula was used to calculate the weighted means. AX + BY +. . . A+B+. . .

where A and B are the numbers of patients per year at different centres, and X and Y are the mean numbers of days the patients waited at the respective centres.

Results With the two mailings the response rate was 100%. A total of 61 116 cardiac catheterization proceLE l 5MARS 1992

performed during the year surveyed, a rate of 236 per 100 000 population (Table 1). The rate was highest in Alberta (280 per 100 000 population). As of Jan. 11, 1990, 5012 patients were waiting to undergo elective cardiac catheterization. In proportion to population the number of patients waiting was greatest in Quebec (Table 1). The mean waiting time was 8.5 weeks.

dures

were

A total of 10 097 PTCA

procedures

were

per-

of 39 per

study period, during 100 000 population (Table 2). The rate was highest in Alberta (59 per 100 000 population). In all, 952

formed

the

a

rate

awaiting elective PTCA as of Jan. 1 1, proportion to population the number of patients waiting was greatest in Quebec and next

patients 1990.

were

In

greatest in Alberta (Table 2). The was

mean

waiting time

1 1.0 weeks. A total of 16 240

open-heart procedures

were

performed during the study period, a rate of 63 per 100 000 population (Table 3). The rate was highest in Ontario (70 per 1 00 000 population) and lowest in Alberta and Newfoundland (48 and 47 per 100 000 population respectively). As of Jan. 11, 1990, 4495 patients were waiting to undergo elective open-heart surgery. In proportion to population the number of patients waiting was greatest in British Columbia and next greatest in Ontario (Table 3). The mean waiting time was 22.6 weeks, the longest waits occurring in Quebec and British Columbia (more than 32 weeks).

Table 1:Rates of wdarch cahtrzton in CanadabtenAr 1,988n Mar 31'98,and nuribe of yrnsawIig eletv cardiac catheterization as ofJa.1190 tp6It

14iso.. Of.ptet Rakteof., cardiac

CArdiac d.ahtslalo*

Moan length o Wait wk

252,.

10.1. 14.0. 1.0.9

5. 5.0 7.9

2130.9

.9 90

20.9 5.1 19.0.

10.6 2.9' 8.5.

Province

Br-itihO,olumbia Alberta .Saskiatcewan, Manitoba OntarIo. Quebec Nva.Sco .a,New 'BruneikPrne edadItndt Newfoundland

,Canada.

28 213. 251.. 218. 194

~~~2490. 288.

7.48.

'Pr10t0ppbln Wn Canad betse ~ ar.4,18,w4nme fptet awaitng electivePTCA as ofJan.11, 1.990, by provinc Ma Nofpatients -length watng fwi,w letv PTCA* ProvinceRteo PG* -1.45. 40 BritishC.Golumbia

Alberta,:.

Saskatchewan

.Manitoba Ontaio.

Quebec Nova Sc~otiaNew Brunswlck/Pnnce lslandt Edward

.Newfoundand Canada,

59 31 47. 29

~~~~49

4.7. 2.5

3.78.

A

27-

2.7 6.2

9.2. 15.4

28

.1.829

3.8

1.

39

3.7

11.0

33

PO 100 000 ppation. tcormne&. MARCH 15, 1992

MED ASSOC J ~~~~~~~~~~~~~~~CAN

1992; 146 (6)

923

in Canada than in the United States. During 198889 the Canadian rate for PTCA was 39 per 100 000 population; it was 70 per 100 000 population in the United States in 1987.6 During the same period the rate of open-heart surgery in Canada was 63 per 100 000 population; in the United States in 1987 the rate of coronary artery bypass surgery was 137 per Discussion 100 000 population.6 Direct comparison requires The benefits of PTCA and heart surgery in qualification in that our survey reports all openreducing cardiac symptoms in coronary and valvular heart surgical procedures, most of which would have heart disease and extending the life expectancy of been coronary artery bypass grafting. Although a defined patient groups are well known.2- Our survey recent study has indicated that the profile of patients provides the most up-to-date statistics on cardiac undergoing surgery is similar in the two countries,7 catheterization, PTCA and open-heart surgery in the rates differ sharply. There may be several explanations for this difference. The largely non-governCanada. We found moderate variation in the rate of ment-funded medical care system in the United cardiac catheterization from province to province, States may promote overuse of cardiac procedures. with the highest rate (for Alberta) being 18.6% over A lack of resources in Canada may also contribute to the national average and the lowest rate (for Nova the difference. Scotia/New Brunswick/Prince Edward Island) being One manifestation of rationing of health care 17.8% below the national average. The rate of PTCA resources in Canada is a growing list of patients showed more marked variation, with the highest rate waiting to undergo cardiac procedures. Although (for Alberta) being 51.3% above the national average analysis of waiting lists may provide information and the lowest rate (for Newfoundland) being 33.3% about performance in the health care system, probbelow the national average. The rate of open-heart lems in interpreting the data have made health surgery showed more modest variation, with the sector administrators sceptical of the value of such highest rate (for Ontario) being 11. 1% above the data. The definition of "elective" and the indicanational average and the lowest rate (for Newfound- tions for procedures may vary from one location to land) being 25.4% below the national average. This another. In some settings very long waiting lists may variability from province to province reflects the affect physicians' patterns of referral for cardiac availability of facilities and specialists, the attitudes procedures. In many institutions there is no overall of specialists at referral centres and interprovincial waiting list, which precludes a meaningful expression referral patterns. The rather low rate of open-heart of average waiting time. The waiting list in some surgery and the high rate of PTCA in Alberta appear settings may include patients with tentative bookto reflect a philosophy of revascularization that ings, who may never undergo the procedure. There favours PTCA over heart surgery. may be patients on the waiting list who no longer The rates for these procedures are much lower require the procedure, yet their names have not been

Of the 33 surgery centres 22 had to postpone at least one scheduled open-heart procedure per week because of bed shortages (in 16 centres), nursing shortages (in 15), financial shortfall (in 4) and a shortage in technical support staff (in 3).

of pd atets .. F. * .1:4o

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h;M*

2:V2f

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MrE~~ 7i,f'tt

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CAN MED ASSOC J 1992; 146 (6)

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removed from the list. We attempted to anticipate shall report similar data collected for pediatric carthese problems by designing our survey methods to diovascular services in a subsequent article. give the best possible "snapshot" of the true waiting lists for the various procedures on Jan. 1 1, 1990. In 1988-89 the average wait for cardiac cathe- References terization across Canada was 8.5 weeks, the longest Canadian Almanac and Directory 1990, Canadian Almanac & wait occurring in Nova Scotia/New Brunswick/ 1. Directory Publ Co, Toronto, 1990: 6-75 Prince Edward Island (10.6 weeks) and Quebec (9.0 weeks). The average wait for PTCA was 1 1.0 weeks 2. Coronary artery surgery study (CASS): a randomized trial of coronary artery bypass surgery. Survival data. Circulation and for open-heart surgery 22.6 weeks, the longest 1983; 68: 939-950 waits for the latter procedure occurring in Quebec and British Columbia (more than 32 weeks). The 3. Gersh BJ, Kronmal RA, Schaff HV et al: Comparison of cumulative wait for cardiac catheterization and coronary artery bypass surgery and medical therapy in patients PTCA or open-heart surgery means that many pa65 years of age or older: a nonrandomized study from the Coronary Artery Surgery Study (CASS) Registry. N Engl J Med tients are unable to work or lead productive lives for 1985; 313: 217-224 several months before revascularization, which leads to major losses of productivity and very probably a 4. Mabin TA, Holmes DR Jr, Smith HC et al: Follow-up clinical decreased likelihood of a return to useful employresults in patients undergoing percutaneous transluminal coronary angioplasty. Circulation 1985; 71: 754-760 ment after revascularization. A long wait for surgery may necessitate repeat cardiac catheterization to ensure that the relevant anatomic features are known 5. Kent KM, Bentivoglio LG, Block PC et al: Percutaneous transluminal coronary angioplasty: report from the Registry of to the surgeon, further compromising the availability the National Heart, Lung, and Blood Institute. Am J Cardiol of these resources. Our study does not address the 1982; 49: 2011-2020 serious waste of acute care hospital resources consumed by patients awaiting these procedures. 6. 1987 Summary: National Hospital Discharge Survey (PHS publ 159, advance data), US Dept of Health and Human Services, We believe that regular collection of data such National Center for Health Statistics, Washington, 1988 as ours would be a helpful step toward a better understanding of the resources required for these 7. Morin JE, Symes JF, Guerraty AJ et al: Coronary artery bypass specialized cardiac procedures. Such information profile in Canada and the United States. Can J Cardiol 1990; 6: 3 19-322 seems essential for rational health care planning. We

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CAN MED ASSOC J 1992; 146 (6)

925