Americans are not ready for socialized medicine

[tooblue]

Originally Posted by CardiacCoug

I'm glad your friend got treated, but since his was an emergency procedure for which you took him to the hospital, he's in a different class. It's the outpatient, elective stenting that could be denied in the future.

The last study I saw that compared practice patterns in Canada versus the US showed that around 70% of US patients who were having heart attacks underwent angiography while only 35% of Canadian patients who were having heart attacks underwent angiography. 31% of Americans had their coronary artery opened or bypassed while only 12% of Canadians had the artery opened or bypassed. This is an old study (1993), but I think the general difference in practice pattern still holds, although I would hope doctors in both countries are more aggressive with performing angiography and interventions these days since there is much more proof that it works.

http://content.nejm.org/cgi/content/full/328/11/779

Why would Canada encourage expensive procedures to keep patients alive when keeping patients alive will just cost the system more money? It's just not economical. There is no incentive to make expensive procedures available in a socialized health care system.

The point is my friend got the treatment he needed without delay and the doctors were not prohibited by the system in prescribing treatment. Your argument that there is no incentive to make expensive procedures available is not valid. Just as the Journal of Medicine you quoted is careful in assessing the situation so should you be.

As I have stated many times the Canadian system is not perfect but it is very good and no, it will not work in the US.

[CardiacCoug]

Originally Posted by ERCougar

Here's the study I was thinking about:
http://content.nejm.org/cgi/content/full/359/7/677

Essentially, a difference between the treatments that dwindles slowly until even at three years.

I'm not arguing for no more stents, but we certainly could cut back a little.

I absolutely agree that there is too much PCI performed for chronic stable angina or even in asymptomatic patients. We only tell stable outpatients that we will improve their chest pain, not that we are preventing a heart attack or prolonging their life (note -- this only applies to stable outpatients, not to patients with acute coronary syndromes, who definitely benefit from PCI as far as reduction in death and future MI, etc.)

Many studies like the recent COURAGE studies have major flaws, however. About 1/3 of the patients in the "medical therapy" arm crossed over to stenting, if I remember correctly. So these patients accrued the benefits of stenting but were assigned to the medical therapy arm of the "intention-to-treat" analysis. Also, most cardiologists think you would need follow-up of more like 10-20 years to see a mortality difference between people who have an artery kept open by a stent and those in whom the artery closes off very slowly.

Basically, even though it has been difficult to prove, common sense says that we should keep the major coronary arteries open if possible. Once the correct studies are done with long-term follow-up I think that will be proven. I'm just glad that they leave these decisions up to the individual patient and doctor for now, because there isn't enough evidence to guide every decision -- every situation is unique and for the government to impose some cookie-cutter type of algorithm to limit stenting would be wrong.