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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{ 10 comments }
The ones that I saw personally were not border-crossing for convenience, they came from major metro areas. It would have been far more geographically convenient to go to their local centers. They were coming for fairly ordinary surgery, not some one-center-in-the-world sub-sub-sub-specialty work. When I would ask, the response would invariably be about getting the surgery done in a timely manner. The wait list number is at variance with what the recipients of care were telling me. It seemed to revolve around the Disneyland effect. You wait in line to wait in line. The wait time for the consultation, the wait time for imaging, the wait time for surgical consultation, the wait time for surgery, are in series, not parallel.
I’m not sure this is much different than what anyone in more rural areas of the United States would experience. The last time I saw a primary care doctor, I had to wait 7 weeks. A relative of mine needs orthopedic surgery; the earliest available slot on the surgeon’s schedule is 2 months out.
The wealthy and/or the impatient will often travel somewhere else. It’s just how it is.
To somehow read this as an indictment of the Canadian health care system does not seem warranted.
The major centers in Toronto or Montreal weren’t good enough? A few years back, there was such a lack of neonatal beds in this G8 nation that a woman with multiple pregnancy was flown to a Montana town of 50,000 for care and delivery. Jay Leno was right – If the US enacts these so-called reforms, where will the Canadians go for care?
When it’s two-tiered healthcare in the USA it’s because of our evil capitalistic system; we should become like Canada.
When it’s two-tiered in Canada, it’s because some are rich impatient snobs.
Anonymous, this guy does not live in the middle of the cornfield. If you live in a big city in the US, you can see a doctor in a few days. Now, if you are a Medicaid recipient (read “charity to the state”), it may be more difficult…
In most if not all parts of the world, access to everything including healthcare is determined to a great extent by the person’s socio-economic status. Individual cases of travelling for getting healthcare are not a determinant of overall quality of the nation’s health system. Lets face it, lots of people from the US go abroad for treatment giving rise to full-fledged industry of medical tourism. I don’t think that we can conclude that health/medical care in the US is inferior to that in many emerging economies such as India.
Coming from such a low population region of the country, Williams would have to go outside the province if he needed anything at all involving a specialist. How many cardiac specialists would one expect in a city of 500,000 let alone a whole province with that population. In terms of public perception, however, any such act would result in criticism even if he had stayed in country. That said, care in Ontario would at least have avoided uninformed commentary on the quality of Canadian health care.
I run a patient support site (Peace in Chronic Illness) which has people from all over the world, including quite a few from Canada. My observation in talking to patients in close to four years is that the Canadians consistently do not have what they need. I don’t really know what the problem is but wait times are bad. One woman actually lives in Newfoundland, in a very small remote town. Still, I was very surprised when she told me once that she needed to wait a week for an xray to be read. When she told me that, all I could think was that my vet reads xrays in under an hour. It might have been that they needed a specialist to take a look at it but a week?
Don’t be fooled. Most Canadians receive excellent care at home. I have received care for 2 live births, one miscarriage, total hysterectomy for borderline ovarian cancer (caught in time), tonsilectomy, and broken wrist not to mention all the regular doctor visits for the price of parking. I have family members who have had cancer and heart disease – all of whom feel that they were treated properly and in a timely fashion. We are a nation of 33 million people who often live closer to major hospitals in the US and are sent for treatment there – all paid for by our medical system. You have 10X as many people – that’s why you can offer more care to rare cases – it won’t change if you get public health care. You win more gold medals than us in the Olympics and it isn’t because we have socialism here! Once you get public health It will mean that you will get wait lists because lots of your fellow citizens can’t afford to get health care – better a wait list than a barrier to care! Just like your vet – lots of pet owners don’t access vet care cause they can’t afford it or they ask for the cheaper care! There is no waiting for deep pockets!
Re: Danny William; had an uncle who passed away about 10 years ago now at age 82. He was from Vancouver BC Canada. He had angina and wanted a quadruple bypass. Doctors in BC told him no as it would kill him. Told him to go home and live his life. He and his wife decided to take a vacation to Mexico where he had a mild heart attack. He was flown to Texas and stabilized. Two days later the surgeon there talked him into the quadruple bypass – paid for by the Canadian taxpaper of course. He agreed and underwent surgery. 48 hrs later he was dead from multiple strokes. There was no question that the surgery was performed properly…the problem was it should never have been undertaken. The Canadian doctors were right. They, however, were not driven by the profit motive – their only concern was the patient’s welfare. The Canadian government did pay for the surgery so the Texas hospital gains whether the patient survives or not. Should have had to supply a warranty if you’re going to run on the profit motive. ie you survive 30 days or it’s free!
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