Canada provides universal health insurance to all citizens, whereas 47 million Americans are uninsured. There has not been a study comparing access to emergency operative care between the 2 countries. As both countries contemplate changes in health care delivery, such comparisons are needed to guide health policy decisions. The purpose of this study is to determine whether or not there is a difference in access to emergency operative care between Canada and the United States.
All patients diagnosed with acute appendicitis from 2001 to 2005 were identified in the Canadian Institute for Health Information database and the US Nationwide Inpatient Sample. Severity of appendicitis was determined by ICD-9 codes. Patients were further characterized by age, gender, insurance status, race, and socioeconomic status (SES; income). Univariate and multivariate analyses were performed to determine the odds of appendiceal perforation at different levels of SES in each country.
There were 102,692 Canadian patients and 276,890 American patients with acute appendicitis. In Canada, there was no difference in the odds of perforation between income levels. In the United States, there was a significant, inverse relationship between income level and the odds of perforation. The odds of perforation in the lowest income quartile were significantly higher than the odds of perforation in the highest income bracket (odds ratio, 1.20; 95% confidence interval, 1.16-1.24).
The results suggest that access to emergency operative care is related to SES in the United States, but not in Canada. This difference could result from the concern over the ability to pay medical bills or the lack of a stable relationship with a primary care provider that can occur outside of a universal health care system.
OBJECTIVE--To determine the prevalence, geographic variation, and charges to Medicare of alcohol-related hospitalizations among elderly people in the United States. DESIGN--A cross-sectional prevalence study using 1989 hospital claims data from the Health Care Financing Administration (HCFA). Rates were determined using (1) hospital claims records from the HCFA's Medicare Provider Analysis and Review Record (MEDPAR) database for all Medicare Part A beneficiaries aged 65 years and older; (2) county population estimates for 1985 from the Bureau of the Census; and (3) per capita consumption of alcohol by state in 1989 as estimated by the US Department of Health and Human Services. SETTING--Data include all hospital inpatient Medicare Part A beneficiaries aged 65 years and older in the United States in 1989. RESULTS--The prevalence of alcohol-related hospitalizations among people aged 65 years and older nationally in 1989 was 54.7 per 10,000 population for men and 14.8 per 10,000 for women. Comparison with hospital records showed that MEDPAR data had a sensitivity of 77% to detect alcohol-related hospitalizations. There was considerable geographic variation; prevalence ranged from 18.9 per 10,000 in Arkansas to 77.0 per 10,000 in Alaska. A strong correlation existed between alcohol-related hospitalizations and per capita consumption of alcohol by state (Spearman correlation coefficient, .64; P
Medicare's Incentive Payment (MIP) program provides a 10% bonus payment to providers who treat Medicare patients in rural and urban areas where there is a shortage of generalist physicians.
To examine the experience of Alaska, Idaho, North Carolina, South Carolina, and Washington with the MIP program. We determined the program's utilization and which types of physicians received payments.
Retrospective cohort design, utilizing complete 1998 Medicare Part B data. Physician specialty was determined through American Medical Association data. Rural status was determined by linking the physician business ZIP code to its Rural-Urban Commuting Area code (RUCA).
There were 2,220,275 patients and 39,749 providers in the cohort, including 9,769 (24.6%) generalists, 21,331 (53.7%) specialists, and 8,649 (21.8%) nonphysician providers. Over $4 million in bonus payments (median payment = $173) were made to providers in HPSAs. Specialists and urban providers received 58% and 14% of the bonus reimbursements, respectively. Two million dollars in payments were not distributed because the providers did not claim them. Over $2.8 million in bonus claims were distributed to providers who likely did not work in approved HPSA sites.
The MIP bonus payments given to providers are small. Many providers who should have claimed the bonus did not, and many providers who likely did not qualify for the bonus claimed and received it. Consideration should be given to focusing and enlarging the bonus payments to specific providers, rather than rewarding all providers equally. Policy makers should also consider a system that prospectively determines provider eligibility.
To conduct an economic analysis of the implementation of the Ottawa Knee Rule.
The decision analysis compared usual practice based on physician judgment with practice based on a clinical decision rule, which allows more selective use of radiography. The study participants were all adults with blunt knee trauma. The likelihood and cost of radiography, missed fracture, lost productivity, and medicolegal actions were defined by published data and an expert panel. Separate analyses considered US Medicare and Canadian hospital costs. Sensitivity analyses considered a range of values for each variable in the model, including costs in a US fee-for-service setting. The study outcome was the mean cost per patient.
The mean cost savings associated with practice based on the Ottawa Knee Rule was $31 (95% confidence interval 22 to 44) to $34 (95% confidence interval 24 to 47) per patient. These results were robust to reasonable changes in the values of variables in the model.
Implementation of the Ottawa Knee Rule would be associated with meaningful reductions in societal health care costs both in the United States and Canada without a reduction in quality of care.
Comment In: Ann Emerg Med. 1999 Oct;34(4 Pt 1):535-710499954
Although warfarin therapy reduces the risk of stroke among patients with atrial fibrillation (AF), the risk of hemorrhagic complications and other concerns may make clinicians reluctant to prescribe this treatment for elderly patients. Aspirin is a lower-risk alternative to warfarin but is also less effective. This study examines the use of antithrombotic therapy with warfarin or aspirin at hospital discharge among 182 Medicare beneficiaries 65 or older with chronic AF who were admitted to nine Alaska hospitals during 1996. Sixty-five percent of patients without contraindications were discharged on warfarin, and an additional 16% received aspirin. The rate of anticoagulation with warfarin was much higher among patients aged 65-74 (95%) than among those 75 or older (45%). The relatively low rate of warfarin use for very elderly patients may represent an opportunity to improve care. Although these patients have the highest risk of hemorrhagic complications, they also have the greatest potential to benefit from anticoagulation.
Scientific Director, Institute for Circumpolar Health Research, Associate Professor, School of Public Health, University of Alberta, Associate Professor, Institute of Health Policy Management and Evaluation, University of Toronto, Yellowknife, NT.
This commentary responds to Marchildon and Sherar's (2018) paper, "Doctors and Canadian Medicare: Improving Accountability and Performance," in which they explore questions around governance and physician accountability in Canada. This response situates the issues raised in a northern context by sharing experiences with primary care reform in the Northwest Territories and exploring the implications these changes have had for physician accountability and reported system improvements. Physician leadership and accountability are further explored in the northern context, where health systems for Indigenous communities include multiple jurisdictions and transitions in governance advance the self-government, land claims and treaty rights of Indigenous peoples.