How other countries do it: international health systems

Background: Differences in medical care in the United States compared with Canada, including greater reliance on private funding and for-profit delivery, as well as markedly higher expenditures, may result in different health outcomes. Objectives: To systematically review studies comparing health outcomes in the United States and Canada among patients treated for similar underlying medical conditions. Methods: We identified studies comparing health outcomes of patients in Canada and the United States by searching multiple bibliographic databases and resources. We masked study results before determining study eligibility. We abstracted study characteristics, including methodological quality and generalizability. Results: We identified 38 studies comparing populations of patients in Canada and the United States. Studies addressed diverse problems, including cancer, coronary artery disease, chronic medical illnesses and surgical procedures. Of 10 studies that included extensive statistical adjustment and enrolled broad populations, 5 favoured Canada, 2 favoured the United States, and 3 showed equivalent or mixed results. Of 28 studies that failed one of these criteria, 9 favoured Canada, 3 favoured the United States, and 16 showed equivalent or mixed results. Overall, results for mortality favoured Canada (relative risk 0.95, 95% confidence interval 0.92–0.98, p = 0.002) but were very heterogeneous, and we failed to find convincing explanations for this heterogeneity. The only condition in which results consistently favoured one country was end-stage renal disease, in which Canadian patients fared better. Interpretation: Available studies suggest that health outcomes may be superior in patients cared for in Canada versus the United States, but differences are not consistent. Gordon H. Guyatt, MSc, MD is an internist and clinical epidemiologist at McMaster University, Hamilton, Ont. P.J. Devereaux, MD, is a cardiologist and clinical epidemiologist at McMaster University, Hamilton, Ont. Joel Lexchin, MSc, MD, is Professor of Health Policy, York University, Toronto, Ont. Samuel B. Stone, MD, is a resident in the Department of Surgery, McMaster University, Hamilton, Ont. Armine Yalnizyan, MA, is an economist with the Canadian Centre for Policy Alternatives, Ottawa, Ont. David Himmelstein, MD, is a primary care physician and is Chief of Social and Community Medicine, Cambridge Hospital, Cambridge, Mass. Steffie Woolhandler, MD, is a primary care physician at Cambridge Hospital and Associate Professor of Medicine, Harvard Medical School, Cambridge, Mass. Qi Zhou, PhD, is a statistician at McMaster University, Hamilton, Ont. Laurie J. Goldsmith, MSc, is a PhD candidate in the Department of Health Policy and Administration, University of North Carolina at Chapel Hill, Chapel Hill, NC. Deborah J. Cook, MSc, MD, is an internist and clinical epidemiologist at McMaster University, Hamilton, Ont. Ted Haines, MSc, MD is an occupational health researcher at McMaster University, Hamilton, Ont. Christina Lacchetti, MHSc, is a research associate at McMaster University, Hamilton, Ont. John N. Lavis, MD, PhD, is a health policy researcher at McMaster University Hamilton, Ont. Terrence Sullivan is Chief Executive Officer of Cancer Care Ontario, University of Toronto, Toronto, Ont. Ed Mills, DPH, MSc, is an epidemiologist at Simon Fraser University, Burnaby, BC. Shelley Kraus is a student at McMaster University, Hamilton, Ont. Neera Bhatnagar is a health sciences librarian at McMaster University, Hamilton, Ont. Competing interests: None declared. Correspondence: Dr. Gordon Guyatt, McMaster University, Faculty of Health Sciences, Clinical Epidemiology & Biostatistics, Room 2C12, 1200 Main Street West Hamilton, ON L8N 3Z5; (905) 525-9140, x22900; fax (905) 524-3841; [email protected]