Originally published in MedPage Today

by Michael Smith, MedPage Today North American Correspondent

It is rare that a simple matter of patient choice causes an international flap.

But that’s what happened when 60-year-old Danny Williams of St. John’s, Newfoundland, decided to go to the U.S. for heart surgery.

That’s because Williams isn’t just any old Newfoundlander — he’s the premier of Canada’s easternmost province, the head of its government.

The disclosure Tuesday that Williams was in an undisclosed location in the U.S., having an undisclosed procedure that he couldn’t get in Newfoundland, brought catcalls from both sides of the border.

The New York Post, for instance, in an article headlined “Oh (no), Canada” used the news to take a whack at healthcare reform in the U.S. And the American Thinker blog — among many others — argued that Williams’ choice is evidence of the inferiority of Canada’s “technologically second-rate and rationed system.”

In Canada, cardiac specialists defended the premier’s decision as a matter of choice and at the same time noted that — with few exceptions — most cardiac procedures are both available and done well in Canada.

On the other hand, Newfoundland — with a population of about 500,000, less than Wyoming — is less well equipped. Doctors in the province do coronary artery bypass grafts (CABG) and other common procedures, but often send patients elsewhere in the country for transplants or rare operations.

By way of contrast, doctors in Ontario — Canada’s most populous province — handle more than 11,000 cardiac procedures a year in 11 specialized cardiac centers, according to Kori Kingsbury, CEO of Ontario’s Cardiac Care Network.

It’s one of the places a Newfoundland patient might go if appropriate care wasn’t available in that province, but Kingsbury said most of those 11,000-odd procedures are, in fact, performed on Ontario residents.

Still, a “handful” of Ontario patients go to the U.S. every year for surgery, usually because they need emergency treatment and live close to the border, she told MedPage Today.

And every year, a few Americans cross the border the other way seeking care, she said, although she did not immediately have exact numbers.

But for the most part, any required surgery can be obtained in a timely fashion in the province, Kingsbury said. In December, for instance, the median wait time for an elective isolated CABG was 14 days and urgent or emergency care was performed much more quickly.

The exceptions to that rule are rare, complex procedures the experts in which reside in the U.S., according to cardiac surgeon Chris Feindel, MD, of Toronto’s University Health Network.

But the only nonexperimental example he can think of is repair of a rare aneurysm in the descending aorta, where the best care for the procedure is at Baylor University in Texas, Feindel told reporters.

Because the condition is so rare, “there’s really no center across the country that has a large experience with these,” he told the Canadian Press.

In general, though, top-level cardiac care is readily available, according to Robert Roberts, MD, president of the University of Ottawa Heart Institute in the nation’s capital.

Roberts, who was head of cardiology at Baylor for 23 years before moving to Canada five years ago, said 99% of what can be done in the U.S. is done both routinely and well at his center.

Premier Williams’ decision may have been influenced by the knowledge that Newfoundland does not fare as well as the rest of the country in some cardiac outcomes.

According to the Canadian Institute for Health Information, the province has the highest rate of acute myocardial infarction, at 351 per 100,000 patients in 2007-2008.

More revealing is the unplanned hospital readmission rate after a heart attack, which is regarded as a measure of quality of care. In 2007-2008, 6.2% of Newfoundland patients were readmitted, significantly higher than the national rate of 5.2%.

And 30-day inhospital mortality — another marker of care quality — is also higher than the national average at 10.9% compared with 9.4%, the institute said.

Kathy Dunderdale, the province’s deputy premier, told reporters that Williams made the decision after weeks of consultation with his doctors and is expected make a full recovery.

But she would not comment on his location or what procedure he needed, saying only that he could not get the care he needed in the province.

A spokesman for the local health authority did not return telephone calls asking what procedures are not available in the province.

Dunderdale also did not comment on who will pay for the surgery. Usually, if it’s deemed medically necessary for a patient to travel outside the province for care, the taxpayer-funded medicare system picks up the tab.

But Williams — sometimes known as “Danny Millions” — is personally wealthy, having made a fortune in cable television.

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