Konrad Fassbender

Sarcopenia is associated with postoperative infection and delayed recovery from colorectal cancer resection surgery

Background:Skeletal muscle depletion (sarcopenia) predicts morbidity and mortality in the elderly and cancer patients.Methods:We tested whether sarcopenia predicts primary colorectal cancer resection outcomes in stage II–IV patients (n=234). Sarcopenia was assessed using preoperative computed tomography images. Administrative hospitalisation data encompassing the index surgical admission, direct transfers for inpatient rehabilitation care and hospital re-admissions within 30 days was searched for International Classification of Disease (ICD)-10 codes for postoperative infections and inpatient rehabilitation care and used to calculate length of stay (LOS).Results:Overall, 38.9% were sarcopenic; 16.7% had an infection and 9.0% had inpatient rehabilitation care. Length of stay was longer for sarcopenic patients overall (15.9±14.2 days vs 12.3±9.8 days, P=0.038) and especially in those ⩾65 years (20.2±16.9 days vs 13.1±8.3 days, P=0.008). Infection risk was greater for sarcopenic patients overall (23.7% vs 12.5%; P=0.025), and especially those ⩾65 years (29.6% vs 8.8%, P=0.005). Most (90%) inpatient rehabilitation care was in patients ⩾65 years. Inpatient rehabilitation was more common in sarcopenic patients overall (14.3% vs 5.6%; P=0.024) and those ⩾65 years (24.1% vs 10.7%, P=0.06). In a multivariate model in patients ⩾65 years, sarcopenia was an independent predictor of both infection (odds ratio (OR) 4.6, (95% confidence interval (CI) 1.5, 13.9) P<0.01) and rehabilitation care (OR 3.1 (95% CI 1.04, 9.4) P<0.04).Conclusion:Sarcopenia predicts postoperative infections, inpatient rehabilitation care and consequently a longer LOS.

Cost Trajectories at the End of Life: The Canadian Experience

A significant proportion of health care resources are consumed at end of life. As a result, decision and policy makers seek cost savings to enhance program planning. Most literature, however, combines the cost of all dying patients and, subsequently, fails to recognize the variation between trajectories of functional decline and utilization of health care services. In this article, we classified dying Albertans by categories of functional decline and assessed their utilization and costs. We used data from two years of health care utilization and costs for three annual cohorts of permanent residents of Alberta, Canada (April 1999 to March 2002). Literature, expert opinion, and cluster analysis were used to categorize the deceased according to sudden death, terminal illness, organ failure, frailty, and other causes of death. Expenditures were decomposed into constituent quantities and prices. We found that nearly 18,000 die per year in Alberta: sudden death (7.1%), terminal illness (29.8%), organ failure (30.5%), frailty (30.2%), and other causes (2.3%). Inpatient care remains the primary cost driver for all trajectories. Significant and predictable health care services are required by noncancer patients. Trajectories of costs are significantly different for the four categories of dying Albertans. Trajectories of dying are a useful classification for analyzing health care use and costs.

Utilization and costs of the introduction of system-wide palliative care in Alberta, 1993/2000

Background: De-institutionalization of health care services provided to terminally ill cancer patients is a cost-effective strategy that underpins health care reforms in Canada. The objective of this study therefore is to evaluate the economic implications associated with Canadian innovations in the delivery of palliative care services. Methods: We identified 16 282 adults who died of cancer between 1993 and 2000 in two Canadian cities with newly introduced palliative care programs. Linkage of administrative databases was used to measure healthcare resource utilization. We sought to describe the utilization of palliative care services and its consequences for overall health care system costs. Results: Use of palliative services increased from 45 to 81% of cancer patients during the study period. Identifiable public health care services cost

The Measurement of Indirect Costs in the Health Economics Evaluation Literature: A Review

28 093Cdn/patient (19 033US

A comparison of Charlson and Elixhauser comorbidity measures to predict colorectal cancer survival using administrative health data.

, 11 508GB£, 17 778t) for terminally ill cancer patients in their last year of life. Acute care accounted for two-thirds (67%) of these costs; physician (10%), residential hospice care (8%), nursing homes (6%), home care (6%) and prescription medications (3%) comprise the remainder. Increased costs associated with the introduction of palliative care programs were offset by cost savings realized when terminally ill cancer patients spent less time in hospital. Palliative home care and residential hospice care accounted for the bulk of this substitution effect. Cost neutrality was observed from the public perspective. Discussion: These results demonstrate that the introduction of comprehensive and community-based palliative care services resulted in increased palliative care service delivery and cost neutrality, primarily achieved through a decreased use of acute care beds.

Prognostic Factors in Patients With Advanced Cancer: Use of the Patient-Generated Subjective Global Assessment in Survival Prediction

In this paper we develop a framework to categorize the concepts used to estimate indirect costs in economic evaluation. We apply this framework in a literature review of economic evaluation studies. We searched all English language literature from 1994-96. Following the application of a search algorithm, which yielded 25 articles, we abstracted information from these articles to determine the methods used to identify the relative contribution of indirect costs of the cost-effectiveness ratio, the time horizon selected by the authors, the identification of those activities that were foregone, the time given up by these activities, and the valuation placed on this time. These methods were then assessed. Indirect costs, as they have been measured, significantly influence efficiency ratios. A wide variation exists among studies in how they incorporate each of the components of indirect costs. All of the four components that were identified will affect the measurement of indirect cost. Future guidelines in this area should address the entire measurement process.

Costs associated with resource utilization during the palliative phase of care: a Canadian perspective.

Cancer survival is related to features of the primary malignancy and concurrent presence of nonmalignant diseases (comorbidities), including weight‐related conditions (obesity, weight loss). The Charlson and Elixhauser methods are 2 well‐known methods that take comorbidities into account when explaining survival. They differ in both the number and categorization of comorbidities.

Cost Variations in Ambulatory and Home-Based Palliative Care

PURPOSE To determine whether elements of a standard nutritional screening assessment are independently prognostic of survival in patients with advanced cancer. PATIENTS AND METHODS A prospective nested cohort of patients with metastatic cancer were accrued from different units of a Regional Palliative Care Program. Patients completed a nutritional screen on admission. Data included age, sex, cancer site, height, weight history, dietary intake, 13 nutrition impact symptoms, and patient- and physician-reported performance status (PS). Univariate and multivariate survival analyses were conducted. Concordance statistics (c-statistics) were used to test the predictive accuracy of models based on training and validation sets; a c-statistic of 0.5 indicates the model predicts the outcome as well as chance; perfect prediction has a c-statistic of 1.0. RESULTS A training set of patients in palliative home care (n = 1,164) was used to identify prognostic variables. Primary disease site, PS, short-term weight change (either gain or loss), dietary intake, and dysphagia predicted survival in multivariate analysis (P < .05). A model including only patients separated by disease site and PS with high c-statistics between predicted and observed responses for survival in the training set (0.90) and validation set (0.88; n = 603). The addition of weight change, dietary intake, and dysphagia did not further improve the c-statistic of the model. The c-statistic was also not altered by substituting physician-rated palliative PS for patient-reported PS. CONCLUSION We demonstrate a high probability of concordance between predicted and observed survival for patients in distinct palliative care settings (home care, tertiary inpatient, ambulatory outpatient) based on patient-reported information.

The Alberta population-based prospective evaluation of the quality of life outcomes and economic impact of bariatric surgery (APPLES) study: background, design and rationale

Objective: This study aimed to evaluate prospectively the resource utilization and related costs during the palliative phase of care in five regions across Canada. Subjects: A cohort of 248 patients registered in a palliative care program and their main informal caregivers were consecutively recruited. Research Design: A prospective research design with repeated measures was adopted. Interviews were conducted at two-week intervals until the patient s passing or up to a maximum of 6 months. Measures: The survey questions prompted participants to provide information on the types and number of goods and services they used, and who paid for these goods and services. Results: The largest cost component for study participants was inpatient hospital care stays, followed by home care and informal caregiving time. In regard to cost sharing, the public health care system (PHCS), the family, and not-for-profit organizations (NFPO) sustained respectively 71.3%, 26.6%, and 1.6% of the mean total cost per patient. Conclusion: Such results provide a comprehensive picture of costs related to palliative care in Canada, by specifying the cost sharing between the PHCS, the family, and NFPO.

The cost of lung cancer in Alberta.

Restructuring health care in Canada has emphasized the provision of ambulatory and home-based palliative care. Acquiring economic evidence is critical given this trend and its tremendous demands on family caregivers. The purposes of this study were: 1) to comprehensively assess the societal costs of home-based palliative care; and 2) to examine the socio-demographic and clinical factors that account for variations in costs over the course of the palliative trajectory. One hundred and thirty-six family caregivers were interviewed every two weeks from time of palliative referral until death. Information regarding appointments, travel and out-of-pocket expenses, time devoted to caregiving, as well as demographic and clinical characteristics were measured. The mean monthly cost of care per patient was