Cutbacks

Bypass burden?

Older patients undergoing coronary artery bypass grafting (CABG) are more expensive to treat than younger ones. cohorts. Toronto researchers looked at 205 older (age 65 or more) and 202 younger patients and found the mean costs of providing CABG in older and younger patients ranged from $16,500 and $15,600 respectively for elective, uncomplicated cases, to $33,600 and 23,700 for nonelective, complicated cases. The authors report that most of the increased costs could be attributed to longer intensive care unit and ward stays. They conclude that future research should focus on reducing the number of complications in older patients undergoing CABG and on identifying modifiable factors that contribute to longer ICU and ward stays. [CMAJ 1999;160(6):805-11]

An accompanying editorial warned that the enduring clinical success of bypass surgery, when combined with an aging population, will likely mean an even greater strain on health care resources. [CMAJ 1999;160(6):823-5]

CIHR challenged to fund trials

Lost amid the applause concerning the creation of the new Canadian Institutes of Health Research (CIHR) is the recurring failure of the organization's predecessor - the Medical Research Council of Canada - to support randomized controlled trials (RCTs), writes internationally renowned researcher David Sackett. In his editorial, Sackett takes the MRC to task for turning down 40% of RCT applications in the last 2 competitions even though they were deemed scientifically sound by the council's own committee. He recommends the CIHR expand its funding for RCTs from the current 3% of its total budget, to 12%, matching the proportion spent by US National Institutes of Health. [CMAJ 1999;161(11):1414-15]

Home care v. hospital care

Does home care work and is it cheaper? Researchers reviewed 148 papers published between 1975 and early 1998 and found 14 that compared home care with hospital care for eight specific health conditions, as well as mixed medical and surgical problems. They found no convincing evidence that patients admitted to home care had better or worse health outcomes than patients who stayed in hospital. The effects on health system costs were mixed: for hip fracture there appeared to be overall cost savings, whereas for hip and knee replacement, home care resulted in higher overall costs. [CMAJ 1999;160(8):1151-5]

Nurses angry

Registered nurses from Newfoundland to BC took on the system last spring, demanding more money, more staff and better working conditions after years of cutbacks, layoffs and increasing workloads. BC began the trend in the fall of 1998, when 26,000 nurses started working to rule. They then imposed a ban on overtime and finally held 48-hour rotating strikes. Newfoundland's 4,500 RNs went on strike for nine days in March, Manitoba's 11,000 RNs eventually settled for an 11% pay increase and Saskatchewan's 8,400 nurses defied a court injunction to strike for nine days in April. The looming nursing shortage will give weary nurses even more clout at negotiating time. [CMAJ 1999;160(10):1490-1]

Report cards

The development of report cards to rate aspects of health care has become a cause celèbre recently but proponents and skeptics agreed that the quality of the cards is the key to devising a yardstick for measuring system performance.

The CMA hosted a meeting of approximately 35 participants representing a cross-section of health care groups, research organizations and governments. Participants looked at the first phase of an Ontario Hospital Association (OHA) project to develop report cards for hospitals in that province, and examined the broad parameters of developing, using and disseminating report cards for health care. [CMA News 1999;9(1):3]

A simple way to shorten hospital stay

Length of stay in hospital is known to be influenced by patient and institutional characteristics, but no studies have attempted to intervene in the practice patterns of physicians. In a pilot study, researchers compared length of stay on two general medical wards before and after providing physicians with a checklist for planning management and discharge. Length of stay was significantly shorter during the four-week intervention period than during the control period on one of the wards (11 v. 14.7 days). Readmission rates did not increase, and house staff found the checklist useful. The authors suggest the need for larger studies and identification of other physician-dependent factors affecting length of stay. [CMAJ 1999;160(12):1735-7]

Waiting-list problems

Waiting-list stories were a regular feature in the media during 1999. In BC, some physicians complained that their government's web site documenting waiting-list times for surgery is inaccurate and misleading (www.hlth.gov.bc.ca/waitlist). The list features data from 33 hospitals. [CMAJ 1999;161(2):181-2]

In Calgary, physicians were concerned about their legal obligation when a patient is placed on a waiting list. The lack of legal clarity prompted them to draft a form letter pointed out the risk and offering other options - including care at private centres in Alberta and elsewhere. [CMAJ 1999;161(2):183-4]

In Toronto, researchers looked at queuing for angiography. They divided 357 patients booked for coronary angiography at the Sunnybrook site of Toronto's Sunnybrook and Women's College Health Sciences Centre into three groups to identify why some patients waited longer than others. The three groups were based on whether the referring physician practised at Sunnybrook, practised at another centre but performed angiography at Sunnybrook or had no previous association with Sunnybrook. The authors report that while most (65.3%) patients received angiography within the recommended maximum waiting time, physician affiliation alone accounted for 9.3% of the variation between the three groups of patients. [CMAJ 1999;161(7):813-7]

A related editorial questions the decentralized, ad hoc fashion in which waiting lists are run in this country. [CMAJ 1999;161(7):823-4]