Better outcomes in Canada, half the cost

Submitted by Dean Giustini on April 24, 2007 - 00:45

[img_assist|nid=9|title=The 'pyramid of evidence'|desc=|link=node|align=right|width=212|height=155]Now that the excitement of the launch of Open Medicine is ebbing somewhat, I’d like to take a moment to mention one of the important papers in our inaugural issue, and to point readers to further peer-reviewed research to enhance their reading of the paper.

Let’s take a look at the systematic review (SR) in issue #1, written by two prominent clinicians in evidence-based medicine – Gordon Guyatt and P.J. Devereaux at McMaster University – and an interprofessional group of researchers from Canada and the United States.

Their paper, entitled A systematic review of studies comparing health outcomes in Canada and the United States, shows that Canada’s healthcare system is as good or better than the United States’ and delivers care at half the cost. While neither country can claim hegemony, politicians and policy makers will note that health outcomes may be superior in Canada versus the United States, and are consistently as good.

Why is this research important? First, systematic reviews are summaries of the literature based on thorough literature searches and widely-viewed as the highest form of evidence in healthcare. The literature review in a SR is followed by an in-depth critical appraisal of the studies found to identify the most valid for review. In this SR, Neera Bhatnagar, a health sciences librarian at the McMaster Library, did the literature review and included the databases she searched under Study Identification.

While many SRs look at a number of randomized controlled trials, Guyatt et al looked at “published and unpublished prospective or retrospective observational studies comparing health outcomes (mortality or morbidity) in Canada and the United States for patients of any age with the same diagnosis.” This is an important aspect of the review, and helps to understand how the researchers determined study eligibility, and classified them as of high or low quality.

It makes for interesting reading - even the study’s limitations. From my perspective, my one cavil is that I would have included the search terms in the article for search reproducibility. However, the following links will lead you to some searches I did in PubMed and Google scholar to give you an idea of how to find similar literature:

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Hey OM,

Did you know that "An average of about 17 years is required for new knowledge generated by randomized controlled trials to be incorporated into practice." New and more effective health care treatment practices often do not quickly find their way into clinical practice, despite attention garnered in professional journals and at medical conferences. Recent studies indicate an average of 17 years is needed before new knowledge generated through research, such as randomized clinical trials, is
incorporated into widespread clinical practice-and even then the application of the knowledge is very uneven.

See: Translating Research into Practice: Organizational Issues in Implementing
Automated Decision Support for Hypertension in Three Medical Centers Mary K.
Goldstein et al J Am Med Inform Assoc. 2004 Sep-Oct; 11(5): 368-376. doi:


Hi Dean,

Thanks for highlighting our article. It is very exciting to be part of the inaugural issue. Congratulations to everyone working on this important initiative. Dean, you mentioned that you would have included the search terms in the article. Well I just had to comment . . . If this was a Cochrane systematic review, I would definitely have included the strategies because we all know that Cochrane reviews can be quite lengthy. However, in this case I did not want a complicated list of search terms added at the end of the article in an appendix. Often the strategies I use can be quite lengthy and are unique for each database. It is also difficult to explain “explode”, why the wildcard is the “$” in some cases the “*” in others, how the “*” can also indicate terms restricted to the focus and what a floating subheading is. Instead we ask those interested in exploring the search to contact the authors. In Medline alone I used three different search strategies combining US and Canada with comparative studies or variations on the outcomes and other related terms. And as you can image, we threw a fairly large net to try and capture as many citations as possible. So, if anyone is interested in obtaining our search strategies, please contact me. BTW, I feel it is important for librarians to be working with researchers on systematic reviews given our knowledge and expertise in searching but that is a topic for another blog.

Neera Bhatnagar


Thank you for providing your rationale for not including your search terms for the Guyatt et all systematic review.

Do you think that health librarians should be explicit about why they are not including search terms for the systematic review? I noticed that you did not search any of the free search tools. Do you think that is unnecessary?

Dean Giustini - OM blogger

Hi, Dean,

As you know, I wrote a post over at my blog which was somewhat critical of the systemic review of health outcomes in Canada and the U.S. featured in the inaugural issue of OM.  The post can be accessed at:                        .

I made the point that all conflicts, not just industry conflicts, should be disclosed.  I am not making an ad hominem attack by suggesting the paper be discounted merely due to the authors’ affiliations.  I am asking that, in the spirit of openness, the authors disclose such conflicts thus better equipping readers to critically examine the paper.

But that raises another problem, one you touched on, that in order to critically examine the paper the reader needs to know the methods.  Again this is about open access.  The reader should not have to email the authors to know their methods any more than they should have to Google them to find their conflicts of interest.

May 03, 2007
Mims C. We're Number Two: Canada Has as Good or Better Health Care than the U.S. Scientific American May 2007

Despite spending half what the U.S. does on health care, Canada doesn't
appear to be any worse at looking after the health of its citizens

Some interesting analysis....Dean