Proliferation of cardiac technology in Canada: a challenge to the sustainability of Medicare

Abstract

Background: Critics remain skeptical about the long-term sustainability of Medicare in Canada because of the proliferation of health technology and escalating expenditures. The objective of this study was to examine the temporal trends in the utilization and costs of cardiovascular technologies for the evaluation and/or management of patients with ischemic heart disease in Canada.

Methods and results: This repeated cross-sectional population-based study of Ontario residents examined the temporal trends in the utilization and costs associated with echocardiography, stress (imaging and nonimaging) testing, coronary angiography, percutaneous coronary intervention (PCI), and bypass surgery between 1992 and 2001. Annual costs increased by nearly 2-fold over the 10-year study period and cumulatively accounted for more than $2.8 billion (Canadian) in expenditures. The proliferation in use of cardiac testing/interventions over time outstripped both demographic shifts and changes in the prevalence of coronary artery disease. Annual increases were widespread for all procedures (P<0.001) and ranged from 2% per year for nonimaging stress tests to 12% per year for PCI, after adjustment for age and sex. Generally, utilization rates were higher among the elderly, males, and those of low socioeconomic status. With few exceptions, annual increases in the utilization rates of cardiac tests and procedures were disproportionately higher among the elderly and women, but they were similar across socioeconomic subgroups. Increases in utilization appeared to reflect referrals toward higher-risk populations.

Conclusions: Although definitive conclusions about the appropriateness of temporal patterns cannot be ascertained, the proliferation of cardiac testing challenges the sustainability of Medicare in Canada, especially given uncertainty as to whether the accompanying incremental rise in total expenditures translates into significant outcome benefits in the population.