Hospital and physician services in Canada are funded by public (government) sources. This article will describe the practice of cardiac surgery in this setting. Federal legislation has prescribed the principles of accessibility, universality, comprehensiveness, portability, and public administration for essential healthcare services in Canada. Provincial and territorial governments are responsible for the provision of services, receiving federal tax and cash transfers that supplement provincial/territorial funds for hospital, physician, and community health services. Hospitals negotiate annually for global budgets. Physicians work as independent contractors in hospitals (and communities) and are usually paid as specified by fee-for-service contracts negotiated at intervals with governments. Cardiac surgical services have been planned conjointly with government. Forty-two centers in Canada serve a population of 28 million. All but three of these centers are located in tertiary teaching hospitals; all but one do more than 200 pumps annually. The rate of cardiac operations is 80 per 100,000 population. In Ontario, the Provincial Adult Cardiac Care Network makes recommendations to governments about the distribution of the 7,600 pumps annually (population, 11 million), rationalizing waiting lists based on an urgency rating scale. Patients requiring emergent/urgent operations are well served. The average waiting time for an elective cardiac operation is 10.5 weeks. The waiting list mortality is less than 0.5%. The Provincial Adult Cardiac Care Network also determines the placement of new programs and participates in creating hospital funding formulas developed from a combination of resource and acuity intensity weighting. Most surgeons hold full-time academic appointments but are funded largely by practice income. Surgical fees average $2,000 (Canada) per case. Overhead, including malpractice insurance, is approximately 45%. All Canadian patients enjoy reasonably timely access to good cardiac surgical care. Further constraints on physician compensation and (academic) hospital funding will compromise this balance.
Acute coronary insufficiency (ACI) has a one year mortality rate approximating 40 percent with medical treatment alone. This report reviews our experience over 24 months with preoperative intra-aortic balloon pump assist (IABPA) in 42 patients with ACI. Abnormal left ventricular (LV) hemodynamics were present in the majority of patients; the ejection fraction was less than 40 percent in 14 patients. The endocardial viability ratio (EVR) was less than 0.7 in eight patients. The mean coronary artery score was 13, compared to 9 in an otherwise comparable group of patients with stable angina. Left main coronary stenosis greater than 75 percent was present in seven patients and combined with significant stenosis (less than 72 percent) in the dominant right system in four patients. Four patients had proximal stenoses greater than 90 percent in all three major coronary arteries. IABPA was initiated in 11 patients prior to angiography because of refractory rest pain. One of these six patients died. Twenty-five other patients were supported before and six after induction of general anesthesia. Thirty-three of 36 revascularized patients survived. Of four patients with perioperative myocardial infarctions (12 percent), three had IABPA after induction of general anesthesia. Inotropic support and duration of stay both in intensive care and in the hospital were less than in similar patients treated before the use of IABPA.