Technological change around the world: Evidence from heart attack care

Health Affairs

Volumn 20, Issue 3, 2001, Pages 25-42

  Moreland, Abigail ^a   McClellan, Mark ^a   Kessler, Daniel ^a   Saynina, Olga ^a   Hobbs, Michael ^a   Ridout, Steve ^a   Richardson, Jeff ^a   Robertson, Iain ^a   Closon, Marie ^a   Perelman, Julian ^a   Fassbender, Konrad ^a   Tu, Jack ^a   Curry, Grant ^a   Austin, Peter ^a   Pilote, Louise ^a   Eisenberg, Mark J ^a   Terkel, Christiansen ^a   Søndbø, Kristiansen Ivar ^a   Madsen, Mette ^a   Rasmussen, Søren ^a   Michael, Goldacre ^a   Yeates, David G R ^a   Robinson, Michael ^a   Keskimäki, Ilmo ^a   Hakkinen, Unto ^a   Veikko, Salomaa ^a   Mähönen, Markku ^a   Dormont, Brigitte Simone ^a   Milcent, Carine ^a   Zaleski, Isabelle Durand ^a   Ethel Sherry, Gordon ^a   Haklai, Ziona ^a   Kark, Jeremy ^a   Shmueli, Amir ^a   Atella, Vincenzo ^a   Fabbri, Daniele ^a   Vanuzzo, Diego ^a   Pilotto, Lorenza ^a   Pilotto, Laura ^a   Imanaka, Yuichi ^a   Yoshihiro, Kaneko ^a   Noguchi, Haruko ^a   Toyo, Eiwa ^a   Young Hoon, Kim ^a   Bong min, Yang ^a   Haug, Charlotte ^a   Mcguire, Alistair ^a   Raikou, Maria ^a   Windmeijer, Frank ^a   Boyd, James ^a   Hou, Mak Koon ^a   Hong, Phua Kai ^a   Tze, Pin Ng ^a   Ling, Sim Ling ^a   Suok kai, Chew ^a   Caren, Tan ^a   Hampus, Lyttkens Carl ^a   Dozet, Alexander ^a   Lindgren, Anna ^a   Höjgård, Sören ^a   Öhlin, Hans ^a   Paccaud, Fred Michel ^a   Burnand, Bernard ^a   Wietlisbach, Vincent ^a   Holly, Alberto ^a   Gardiol, Lucien ^a   Eggli, Yves ^a   Mei Shu, Lai ^a   Lo Joan, C ^a   Heidenreich, Paul ^a   Mcdonald, Kathryn M ^a   Newhouse, Joseph P ^a   more..

^a NONE

Author keywords

[No Author keywords available]

Indexed keywords

ARTICLE; COMPARATIVE STUDY; DEVELOPED COUNTRY; ECONOMICS; EVIDENCE BASED MEDICINE; HEALTH; HEALTH CARE DELIVERY; HEALTH SERVICES RESEARCH; HEART INFARCTION; HUMAN; LONGITUDINAL STUDY; ORGANIZATION AND MANAGEMENT;

DELIVERY OF HEALTH CARE; DEVELOPED COUNTRIES; EVIDENCE-BASED MEDICINE; HEALTH SERVICES RESEARCH; HUMANS; LONGITUDINAL STUDIES; MYOCARDIAL INFARCTION; WORLD HEALTH;

EID: 0242485576     PISSN: 02782715     EISSN: None     Source Type: Journal    
DOI: 10.1377/hlthaff.20.3.25     Document Type: Article

References (20)

1. See M.B. McClellan and D.P. Kessler for the TECH Investigators, "A Global Analysis of Technological Change in Health Care: Preliminary Report from the TECH Research Network," Health Affairs (May/June 1999): 250-255.
2. The TECH Investigators include the following research teams. Perth, Australia: Michael Hobbs and Steve Ridout, University of Western Australia; Victoria, Australia: Jeff Richardson and lain Robertson, Monash University Australia; Belgium: Marie Closon and Julian Perelman, Ecole de Santé Publique de l'Université Catholique de Louvain; Alberta, Canada: Konrad Fassbender, University of Alberta; Ontario, Canada: Jack Tu, Curry Grant, and Peter Austin, Institute for Clinical Evaluative Science, Toronto; Quebec, Canada: Louise Pilote and Mark J. Eisenberg, McGill University; Denmark: Terkel Christiansen and Ivar Sondbo Kristiansen, Syddansk Universitet-Odense Universitet, Mette Madsen and Soren Rasmussen, National Institute of Public Health; England: Michael Goldacre and David G.R. Yeates, Oxford University, Michael Robinson, Nuffield Institute for Health; Finland: Ilmo Keskimäki and Unto Häkkinen, National Research and Development Centre for Welfare and Health (STAKES), Veikko Salomaa and Markku Mähönen, National Public Health Institute; France: Brigitte Dormont and Carine Milcent, Université de Paris X Nanterre, Isabelle Durand-Zaleski, Hospital Henri Mondor, Santé Publique; Israel: Ethel-Sherry Gordon and Ziona Haklai, Ministry of Health, Jeremy Kark and Amir Shmueli, Hebrew University; Italy: Vincenzo Atella, University of Rome, Tor Vergata II, Daniele Fabbri, University of Bolognia, Diego Vanuzzo, Lorenza Pilotto, and Laura Pilotto, Centra Malattic Cardiovascolari, Udine; Japan: Yuichi Imanaka, Kyoto University, Yoshihiro Kaneko, National Institute of Population and Social Security Research, Haruko Noguchi, Toyo Eiwa University; Korea: Young-Hoon Kim, Korea University Medical Center, Bong-min Yang, Seoul National University; Norway: Charlotte Haug, Norwegian Patient Registry; Scotland: Alistair McGuire and Maria Raikou, City University, Frank Windmeijer, Institute for Fiscal Studies, James Boyd, Scottish Home and Health Department; Singapore: Koon Hou Mak, Kai Hong Phua, Ng Tze Pin, Ling Ling Sim, Suok-kai Chew, and Caren Tan, National Heart Centre; Sweden: Carl Hampus Lyttkens, Alexander Dozet, Anna Lindgren, Sören Höjgard, and Hans Öhlin, Lund University; Switzerland: Fred Paccaud, Bernard Burnand, and Vincent Wietlisbach, Institute of Social and Preventive Medecine (IUMSP), Alberto Holly, Lucien Gardiol, and Yves Eggli, Institute of Health Economics and Management (IEMS), University of Lausanne; Taiwan: Mei-Shu Lai, Bureau of National Health Insurance, Joan C. Lo, Institute of Economics Academia Sinica; United States: Paul Heidenreich, Daniel Kessler, Mark McClellan, Kathryn McDonald, Abigail Moreland, and Olga Saynina, Stanford University, Joseph Newhouse, Harvard University.
3. For a more detailed discussion, see E.M. Braunwald, "Shattuck Lecture - Cardiovascular Medicine at the Turn of the Millenium," Nov England Journal of Medicine 337, no. 19 (1998): 1360-1369; and D.M. Cutler et al., "Are Medical Prices Declining? Evidence for Heart Attack Treatments," Quarterly Journal of Economics 113, no. 4 (1998): 991-1024.
4. For a more detailed discussion, see E.M. Braunwald, "Shattuck Lecture - Cardiovascular Medicine at the Turn of the Millenium," Nov England Journal of Medicine 337, no. 19 (1998): 1360-1369; and D.M. Cutler et al., "Are Medical Prices Declining? Evidence for Heart Attack Treatments," Quarterly Journal of Economics 113, no. 4 (1998): 991-1024.
5. Most countries were able to provide national data or data from large regional databases for the analysis. U.S. data include all elderly, non-health maintenance organization (HMO) beneficiaries with new heart attacks, and all heart attack patients in California. Canadian data are from three provinces, as described in the text. U.K. data are from the Oxford region and Scotland. Several centers provided data from the MONICA project: Swiss data are from several prefectures surrounding Lausanne, and Italian data are from the Friuli region. Both of these samples are confined to the nonelderly. Australian data are from the states of Western Australia (Perth and surrounding areas) and Victoria. Only two countries did not have approximately representative regional or national data. French data are from all public and nonprofit private hospitals, which represent about two-thirds of heart attack stays. Japanese data are from a selected sample of six large, academically oriented hospitals. We discuss the potential nonrepresentativeness of the French and Japanese results in more detail below. All other research teams analyzed national data sets.
6. See M.B. McClellan and D.P. Kessler, eds., A Global Analysis of Technological Change in Health Care: Heart Attacks (Ann Arbor: University of Michigan Press, forthcoming). Following previous validated studies in multiple countries, all research teams used a consistent case definition for AMI patients based on discharge data, applying the same exclusions to avoid cases unlikely to represent true new AMIs. See M.B. McClellan et al., "Trends in Intensive Procedure Use and Outcomes in the United States and Canada" (forthcoming). We have also compared comorbidities and comorbidity trends across countries, and (in other work) have estimated multivariate models with and without various sets of comorbidity control variables. See J.V. Tu et al., "Development and Validation of the Ontario Acute Myocardial Infarction Mortality Prediction Rules," Journal of the American College of Cardiology 37 (2001). In general, these models show that after demographic adjustment, little to no difference exists between trend results estimated using models that account for comorbidities and those without.
7. See M.B. McClellan and D.P. Kessler, eds., A Global Analysis of Technological Change in Health Care: Heart Attacks (Ann Arbor: University of Michigan Press, forthcoming). Following previous validated studies in multiple countries, all research teams used a consistent case definition for AMI patients based on discharge data, applying the same exclusions to avoid cases unlikely to represent true new AMIs. See M.B. McClellan et al., "Trends in Intensive Procedure Use and Outcomes in the United States and Canada" (forthcoming). We have also compared comorbidities and comorbidity trends across countries, and (in other work) have estimated multivariate models with and without various sets of comorbidity control variables. See J.V. Tu et al., "Development and Validation of the Ontario Acute Myocardial Infarction Mortality Prediction Rules," Journal of the American College of Cardiology 37 (2001). In general, these models show that after demographic adjustment, little to no difference exists between trend results estimated using models that account for comorbidities and those without.
8. See M.B. McClellan and D.P. Kessler, eds., A Global Analysis of Technological Change in Health Care: Heart Attacks (Ann Arbor: University of Michigan Press, forthcoming). Following previous validated studies in multiple countries, all research teams used a consistent case definition for AMI patients based on discharge data, applying the same exclusions to avoid cases unlikely to represent true new AMIs. See M.B. McClellan et al., "Trends in Intensive Procedure Use and Outcomes in the United States and Canada" (forthcoming). We have also compared comorbidities and comorbidity trends across countries, and (in other work) have estimated multivariate models with and without various sets of comorbidity control variables. See J.V. Tu et al., "Development and Validation of the Ontario Acute Myocardial Infarction Mortality Prediction Rules," Journal of the American College of Cardiology 37 (2001). In general, these models show that after demographic adjustment, little to no difference exists between trend results estimated using models that account for comorbidities and those without.
9. Since essentially the whole population of many of the countries is included, standard errors are not needed for reaching conclusions about differences in the treatment trends observed in participating countries' populations.
10. In this and subsequent exhibits, results are plotted for countries only for the years in which complete and valid data could be obtained. Because the time periods of valid data differ across countries, the years of results plotted differ across countries. One consequence of this is that the earliest data shown for an "early start" country, such as the United States, may be for a year that is subsequent to the earliest data shown for some "late start" countries. The determination of "early start" status was made primarily based on a comparison of procedure rates across time. For example, in the case of catheterization, U.S. procedure rates are much higher at any given time than in virtually all other countries, so it seems reasonable to conclude that the U.S. rate started growing first. Unless otherwise noted, we focus on absolute rates of growth, not relative ones, for several reasons. First, we are often interested in rates soon after procedures start to diffuse; in this case, the denominator is close to zero, so we would get very high relative rate growth even if the absolute rate growth is negligible. Second, what matters most for changes in costs and possibly outcomes in a country is the change in share of patients getting a procedure, not the relative increase in procedures. Finally, in examining the data, many of the absolute growth rates are similar despite some differences in levels, and a relative rate comparison would obscure that point.
11. Bypass surgery rates in Israel may be underestimated, because private facilities that perform elective invasive cardiology and bypass surgery (but do not admit AMI patients) did not have data available for linkage.
12. For references to the extensive literature on these trials, contact the authors, 〈Mark_McClellan@odp.eop.gov〉.
13. That is, heart attack patients who undergo catheterization after transfer are not included; because a much larger share of procedures occur after such referrals in these countries, the procedure rates appear particularly low.
14. The absence of any central collection of data on treatments in Japan precludes a complete analysis of trends in intensive procedures. The Japanese sample consists of a set of six relatively large "voluntary" hospitals, which are likely to have more intensive treatment practices than many other, smaller Japanese hospitals. These hospitals show both high catheterization rates and rapid growth, but the rates for all of Japan are likely to be somewhat lower. The French data consist of all public and private not-for-profit hospitals, which have somewhat lower rates of procedure use than private for-profit hospitals in recent years (unfortunately, no trend data are yet available for private hospitals). This higher rate may reflect the differences in reimbursement incentives between the public and private sectors (that is, the private hospitals rely on fee-for-service payments). Thus, although the observed French rates are somewhat lower than U.S. rates (with a similar rate of growth), it is likely that the French rates for the country as a whole are greater, making it difficult to reach definitive conclusions about whether catheterization rates in France lag behind those in the United States and Israel.
15. McClellan and Kessler, A Global Analysis of Technological Change in Health Care.
16. Early trials of tPA versus streptokinase detected no difference in effects. However, trials in the 1990s evaluated more rapid and sophisticated delivery protocols suggested by clinical experts and have shown a small advantage of tPA in restoring coronary blood flow and in long-term survival. In particular, the GUSTO trial observed a one-percentage-point difference in risk of short-term death that persisted at one year. More recent trials involving tPA have evaluated alternative ways and adjuvant treatments for delivering the drug, also with modest improvements in outcomes. See, for example, I.K. Jang et al., "A Multicenter, Randomized Study of Argatroban versus Heparin as Adjunct to Tissue Plasminogen Activator (TPA) in Acute Myocardial Infarction: Myocardial Infarction with Novastan and TPA (MINT) Study," Journal of the American College of Cardiology 33, no. 7 (1999): 1879-1885.
17. For example, the protocol for Montreal General Hospital states that the groups most likely to benefit from tPA should get it. In a Quebec registry of AMI collected in 1995-1996 among forty-four Quebec acute care hospitals and 3,741 patients with AMI of whom 1,357 received thrombolytic therapy, 68.2 percent received streptokinase and 31.8 percent received tPA. J. Brophy, "Falling Hospital Mortality for Acute Myocardial Infarction in Quebec Hospitals," Canadian Journal of Cardiology 14, no. 11 (1998): 1358-1362.
18. See H. Tunstall-Pedoe for WHO MONICA Project Principal Investigators, "The World Health Organization MONICA Project (Monitoring Trends and Determinants in Cardivascular Disease): A Major International Collaboration," Journal of Clinical Epidemiology 41 (1988): 105-114; and H. Tunstall-Pedoe et al., for the WHO MONICA Project, "Estimation of the Contribution of Changes in Coronary Care to Improving Survival, Event Rates, and Coronary Heart Disease Mortality across the WHO MONICA Project Populations," Lancet 355 (2000): 688-700.
19. See H. Tunstall-Pedoe for WHO MONICA Project Principal Investigators, "The World Health Organization MONICA Project (Monitoring Trends and Determinants in Cardivascular Disease): A Major International Collaboration," Journal of Clinical Epidemiology 41 (1988): 105-114; and H. Tunstall-Pedoe et al., for the WHO MONICA Project, "Estimation of the Contribution of Changes in Coronary Care to Improving Survival, Event Rates, and Coronary Heart Disease Mortality across the WHO MONICA Project Populations," Lancet 355 (2000): 688-700.
20. Tunstall-Pedoe et al., "Estimation of the Contribution of Changes."