The 2023 Impact of Inflammatory Bowel Disease in Canada: Direct Health System and Medication Costs.

Healthcare utilization among people living with inflammatory bowel disease (IBD) in Canada has shifted from inpatient management to outpatient management; fewer people with IBD are admitted to hospitals or undergo surgery, but outpatient visits have become more frequent. Although the frequency of emergency department (ED) visits among adults and seniors with IBD decreased, the frequency of ED visits among children with IBD increased. Additionally, there is variation in the utilization of IBD health services within and between provinces and across ethnocultural and sociodemographic groups. For example, First Nations individuals with IBD are more likely to be hospitalized than the general IBD population. South Asian children with Crohn's disease are hospitalized more often than their Caucasian peers at diagnosis, but not during follow-up. Immigrants to Canada who develop IBD have higher health services utilization, but a lower risk of surgery compared to individuals born in Canada. The total direct healthcare costs of IBD, including the cost of hospitalizations, ED visits, outpatient visits, endoscopy, cross-sectional imaging, and medications are rising rapidly. The direct health system and medication costs of IBD in Canada are estimated to be $3.33 billion in 2023, potentially ranging from $2.19 billion to $4.47 billion. This is an increase from an estimated $1.28 billion in 2018, likely due to sharp increases in the use of biologic therapy over the past two decades. In 2017, 50% of total direct healthcare costs can be attributed to biologic therapies; the proportion of total direct healthcare costs attributed to biologic therapies today is likely even greater.

The 2023 Impact of Inflammatory Bowel Disease in Canada: Indirect (Individual and Societal) and Direct Out-of-Pocket Costs.

People living with inflammatory bowel disease (IBD) and their caregivers are faced with indirect and out-of-pocket costs that they would not otherwise experience. These costs impact one's ability to contribute to the economy to their fullest potential. The indirect costs of IBD in Canada are estimated to be at least $1.51 billion in 2023 and include costs associated with lost productivity resulting from a combination of missed work (absenteeism), decreased workplace productivity (presenteeism), unemployment, premature mortality, and caregiving costs. Unemployment is the largest contributor to indirect costs ($1.14 billion), followed by costs of absenteeism and presenteeism ($285 million). Caregiving costs for children with IBD are estimated to be nearly $58 million. Canadians with IBD also pay $536 million every year for care that is not covered by universal or supplemental private health insurance; this includes allied healthcare (e.g., care provided by psychologists), medication, and other supportive therapy. Combined, the indirect and out-of-pocket costs of IBD in Canada are estimated at more than $2 billion CAD in 2023. This is substantially higher than the estimate of $1.29 billion in Crohn's and Colitis Canada's 2018 Impact of IBD report with differences attributable to a combination of rising prevalence, inflation, and the addition of presenteeism and caregiving costs to the total indirect costs.

The 2023 Impact of Inflammatory Bowel Disease in Canada: The Influence of Sex and Gender on Canadians Living With Inflammatory Bowel Disease.

Sex (the physical and physiologic effects resulting from having specific combinations of sex chromosomes) and gender (sex-associated behaviours, expectations, identities, and roles) significantly affect the course of inflammatory bowel disease (IBD) and the experience of living with IBD. Sex-influenced physiologic states, like puberty, the menstrual cycle, pregnancy, and andropause/menopause may also impact and be impacted by IBD. While neither Crohn's disease nor ulcerative colitis is commonly considered sex-determined illnesses, the relative incidence of Crohn's disease and ulcerative colitis between males and females varies over the life cycle. In terms of gender, women tend to use healthcare resources at slightly higher rates than men and are more likely to have fragmented care. Women are more commonly prescribed opioid medications and are less likely than men to undergo colectomy. Women tend to report lower quality of life and have higher indirect costs due to higher rates of disability. Women are also more likely to take on caregiver roles for children with IBD. Women with IBD are more commonly burdened with adverse mental health concerns and having poor mental health has a more profound impact on women than men. Pregnant people with active IBD have higher rates of adverse outcomes in pregnancy, made worse in regions with poor access to IBD specialist care. The majority of individuals with IBD in Canada do not have access to a pregnancy-in-IBD specialist; access to this type of care has been shown to allay fears and increase knowledge among pregnant people with IBD.

The value of screening for cognition, depression, and frailty in patients referred for TAVI.

Background: Current surgical risk assessment tools fall short of appreciating geriatric risk factors including cognitive deficits, depressive, and frailty symptoms that may worsen outcomes post-transcatheter aortic valve implantation (TAVI). This study hypothesized that a screening tool, SMARTIE, would improve detection of these risks pre-TAVI, and thus be predictive of postoperative delirium (POD) and 30-day mortality post-TAVI. Design: Prospective observational cohort study, using a historical cohort for comparison. Participants: A total of 234 patients (age: 82.2±6.7 years, 59.4% male) were included. Half were screened using SMARTIE. Methods: The SMARTIE cohort was assessed for cognitive deficits and depressive symptoms using the Mini-Cog test and PHQ-2, respectively. Measures of frailty included activities of daily living inventory, the Timed Up and Go test and grip strength. For the pre-SMARTIE cohort, we extracted cognitive deficits, depression and frailty symptoms from clinic charts. The incidence of POD and 30-day mortality were recorded. Bivariate chi-square analysis or t-tests were used to report associations between SMARTIE and pre-SMARTIE groups. Multivariable logistic regression models were employed to identify independent predictors of POD and 30-day mortality. Results: More patients were identified with cognitive deficits (χ2=11.73, p=0.001), depressive symptoms (χ2=8.15, p=0.004), and physical frailty (χ2=5.73, p=0.017) using SMARTIE. Cognitive deficits were an independent predictor of POD (OR: 8.4, p<0.01) and 30-day mortality (OR: 4.04, p=0.03). Conclusion: This study emphasized the value of screening for geriatric risk factors prior to TAVI by demonstrating that screening increased identification of at-risk patients. It also confirmed findings that cognitive deficits are predictive of POD and mortality following TAVI.

A Case for the Standardized Assessment of Testamentary Capacity.

BACKGROUND: With an increasingly aged, frail population that holds a disproportionate amount of wealth, clinicians (especially those with expertise in older adults) may be asked with more frequency to offer a clinical opinion on testamentary capacity (TC), the mental capacity to make a will. METHOD: This paper reviews the legal criteria as well as the empirical research on assessment tools for determining testamentary capacity (TC). We also review the relevance of instruments used for the assessment of other decisional capacities in order to evince the potential value of developing a standardized assessment of TC for clinician experts. RESULTS: The legal criteria, often referred to as a "test", for determining requisite TC (Banks v. Goodfellow) have remained much the same since 1870 with minimal clinical input and, as such, there has been little development in TC assessment instruments. Decisional instruments designed to assess Consent to Treatment may have relevance for TC. CONCLUSION: We make the case for a semi-structured interview that includes standardized criteria for the legal test for TC, supplemented by a validated brief neuropsychological assessment, which together comprise a Contemporaneous Assessment Instrument (CAI) for TC.

The test of time: a history of clock drawing.

OBJECTIVE: The clock drawing test (CDT) has become one of the most widely used cognitive screening instruments in clinical and research settings. Its effectiveness, acceptability, and quick and easy administration have made it a staple for cognitive screening in dementia and a wide range of brain disorders. Despite a spike in popularity since the 1990s, its origins are relatively unknown. The goal of this review is to chronicle its saga and chart its usage over time. METHODS: PsycInfo, Medline, and PubMed literature searches were performed from earliest record to June 2016, in addition to manual cross-referencing of bibliographies, with a focus before 1990. Summary of relevant articles and books up until 1989 is included, as well as clinical applications and surveys that track CDT usage over time. RESULTS: While MacDonald Critchley's well-known textbook from 1953, The Parietal Lobes, is often cited as the first mention of the CDT, its recorded use actually stretches back more than a century to 1915. A review of the literature shows that the CDT began as a test for aphasia-related disorders and constructional apraxia until its entry into contemporary cognitive screening in the 1980s when it primarily became a cognitive screen. Its usage took off in 1989 with over 2000 publications since. CONCLUSIONS: Despite a fairly obscure existence for decades, the CDT has emerged as an effective and ideal cognitive screening instrument for a wide range of conditions. Its use continues to increase, and it has been incorporated into several widely used cognitive screening batteries. Copyright © 2017 John Wiley & Sons, Ltd.

Assessing Capacity in the Elderly: Comparing the MoCA with a Novel Computerized Battery of Executive Function.

BACKGROUND/AIMS: Clinicians are increasingly being asked to provide their opinion on the decision-making capacity of older adults, while validated and widely available tools are lacking. We sought to identify an online cognitive screening tool for assessing mental capacity through the measurement of executive function. METHODS: A mixed elderly sample of 45 individuals, aged 65 years and older, were screened with the Montreal Cognitive Assessment (MoCA) and the modified Cambridge Brain Sciences Battery. RESULTS: Two computerized tests from the Cambridge Brain Sciences Battery were shown to provide information over and above that obtained with a standard cognitive screening tool, correctly sorting the majority of individuals with borderline MoCA scores. CONCLUSIONS: The brief computerized battery should be used in conjunction with standard tests such as the MoCA in order to differentiate cognitively intact from cognitively impaired older adults.

Getting clocked: screening for TBI-related cognitive impairment with the clock drawing test.

PRIMARY OBJECTIVE: Undetected cognitive impairment resulting from Traumatic Brain Injuries (TBIs), particularly the 75-95% classified as mild (mTBI), poses a significant public health challenge as untreated symptoms, can persist and cause lasting disability. These cognitive deficits are often missed by standard screening tests, creating a need for alternative cognitive screening tools. The Clock Drawing Test (CDT), a popular, brief cognitive screening instrument, was used to evaluate cognition in persons with TBI. DESIGN: The effectiveness of the CDT was assessed on its own and in tandem with a validated computerised screening battery, including the Stroop Test, Symbol Digit Modalities Test (SDMT), and Paced Visual Serial Addition Test 2-second trials (PVSAT-2). METHODS AND PROCEDURES: The clock drawing component of the Montreal Cognitive Assessment (MoCA) of 223 subjects attending an outpatient TBI clinic was scored using two different methods. MAIN OUTCOMES AND RESULTS: The CDT screened for cognitive impairment most effectively when scored using the Clock Drawing Interpretation Scale (CDIS). Cognitive impairment was detected in 19.4% of the elusive cohort of persons with mTBI. CONCLUSIONS: The results of this study suggest that the CDT is effective at screening for cognitive impairment in persons with TBI. The CDT could be a valuable supplementary tool in TBI clinics as well as an effective cognitive screening instrument in busy primary care settings.