Better informing everyday fall risk assessment: experimental studies with contemporary technologies.

BACKGROUND: Age-related mobility issues and frailty are a major public health concern because of an increased risk of falls. Subjective assessment of fall risk in the clinic is limited, failing to account for an individual's habitual activities in the home or community. Equally, objective mobility trackers for use in the home and community lack extrinsic (ie, environmental) data capture to comprehensively inform fall risk. We propose a contemporary approach that combines artificial intelligence (AI) and video glasses to augment current methods of fall risk assessment. METHODS: Two case studies were performed to provide a framework to assess extrinsic factors within fall risk assessment via video glasses. The first was AI-based detection of environment and terrain type. We developed convolutional neural networks (CNN) via a bespoke dataset (>145 000 images) captured from different settings (eg, offices, high streets) via free-licenced video on social media. AI automated a textual description to uphold privacy while describing the scene (eg, indoor and carpet). In the second case study, we provided video glasses to participants within a university campus (two men, 17 women; aged 21-60 years) to capture data for automatically labelling environment and objects (eg, fall hazards) via a CNN object detection algorithm. The case studies ran from Dec 5, 2022, to March 24, 2023. FINDINGS: To date, results show promise for the efficient, and accurate AI-based approach to better inform fall risk. Each component of the framework achieved at least 75% accuracy across a range of walks (indoor and outdoor and multiple terrains) from a dataset of 6283 new images. The AI achieved a mean average precision score of 0·93 for the identification of fall risk hazards. INTERPRETATIONS: The AI-based approach provides a contemporary means to better inform fall risk while providing an ethical means to uphold privacy. The proposed approach could have significant implications for improving overall health and quality of life, enabling ageing in place through habitual data collection with contemporary wearables to decentralise fall risk assessment. A limitation was the lack of data collection on older adults within real world, unscripted settings. However, the next phase of this research is the deployment of the AI on real-world data from a cohort of more than 40 participants within UK-based homes. FUNDING: National Institute of Health and Care Research (NIHR) Applied Research Collaboration (ARC) North-East and North Cumbria (NENC), Faculty of Engineering and Environment at Northumbria University.

Misjudging drinking water quality risk: Adopting a barrier approach for meaningful risk assessment to address latent risks.

The water quality risk assessment is the foundation for every drinking Water Safety Plan. The need to conform with a 'Corporate' risk assessment model commonly dominated by asset management frequency data can cause misjudgement of microbial risk. Well-performed risk assessments should identify potential risks. Risk assessments which place too much emphasis on historical evidence to demonstrate 'likelihood' of microbial contamination are unsuitable for drinking water quality because they fail to recognise 'latent' risks associated with absent or underperforming barriers to contamination. Most outbreaks occur when these 'latent' factors align to create a failure. Good risk assessments need to provide foresight. This is achieved if drinking water quality risk assessments are based on a 'barrier' approach. Where adequate and reliable multiple barriers to contamination are present the likelihood of a hazardous event should then be categorised as rare. Where barriers are absent, inadequate, or unreliable, then a higher likelihood is appropriate, depending on the nature and extent of the barrier shortfall. Practical examples show how the 'barrier' approach can be applied. The barrier risk assessment directly informs the operational monitoring programme, enabling regular confirmation that the challenge and barrier performance are consistent with the predictions of the risk assessment.

Enhancing Free-Living Fall Risk Assessment: Contextualizing Mobility Based IMU Data.

Fall risk assessment needs contemporary approaches based on habitual data. Currently, inertial measurement unit (IMU)-based wearables are used to inform free-living spatio-temporal gait characteristics to inform mobility assessment. Typically, a fluctuation of those characteristics will infer an increased fall risk. However, current approaches with IMUs alone remain limited, as there are no contextual data to comprehensively determine if underlying mechanistic (intrinsic) or environmental (extrinsic) factors impact mobility and, therefore, fall risk. Here, a case study is used to explore and discuss how contemporary video-based wearables could be used to supplement arising mobility-based IMU gait data to better inform habitual fall risk assessment. A single stroke survivor was recruited, and he conducted a series of mobility tasks in a lab and beyond while wearing video-based glasses and a single IMU. The latter generated topical gait characteristics that were discussed according to current research practices. Although current IMU-based approaches are beginning to provide habitual data, they remain limited. Given the plethora of extrinsic factors that may influence mobility-based gait, there is a need to corroborate IMUs with video data to comprehensively inform fall risk assessment. Use of artificial intelligence (AI)-based computer vision approaches could drastically aid the processing of video data in a timely and ethical manner. Many off-the-shelf AI tools exist to aid this current need and provide a means to automate contextual analysis to better inform mobility from IMU gait data for an individualized and contemporary approach to habitual fall risk assessment.

Health and socioeconomic resource provision for older people in South Asian countries: Bangladesh, India, Nepal, Pakistan and Sri Lanka evidence from NEESAMA.

BACKGROUND: The global population is ageing rapidly, with low- and middle-income countries (LMICs) undergoing a fast demographic transition. As the number of older adults in LMICs increases, services able to effectively address their physical and mental health needs will be increasingly important. OBJECTIVE: We review the health and socioeconomic resources currently available for older people in South Asian countries, Bangladesh, India, Nepal, Pakistan and Sri Lanka, to identify gaps in available resources and assess areas for improvement. METHODS: We conducted a search of grey and published literature via Google Search, Compendex, EBSCO, JSTOR, Medline, Ovid, ProQuest databases, Scopus and Web of Science. Data on population demographics, human resources, health funding and social protection for older people were extracted. Local informants were consulted to supplement and verify the data. RESULTS: In the study countries, the number of health professionals with expertise in elderly care was largely unknown, with minimal postgraduate training programmes available in elderly medicine or psychiatry. Older adults are therefore cared for by general physicians, nurses and community health workers, all of whom are present in insufficient numbers per capita. Total average healthcare expenditure was 2.5-5.5% of GDP, with 48.1-72.0% of healthcare costs covered by out-of-pocket payments. Pakistan did not have a social pension; only India and Nepal offered financial assistance to people with dementia; and all countries had disproportionately low numbers of care elderly homes. CONCLUSIONS: Inadequate healthcare funding, a shortage of healthcare professionals and insufficient government pension and social security schemes are significant barriers to achieving universal health coverage in LMICs. Governing bodies must expand training programmes for healthcare providers for older adults, alongside increasing social protection to improve access to those in need and to prevent catastrophic health expenditure.

Multimorbidity and its socio-economic associations in community-dwelling older adults in rural Tanzania; a cross-sectional study.

OBJECTIVES: This paper aims to describe the prevalence and socio-economic associations with multimorbidity, by both self-report and clinical assessment/screening methods in community-dwelling older people living in rural Tanzania. METHODS: A randomised frailty-weighted sample of non-institutionalised adults aged ≥ 60 years underwent comprehensive geriatric assessment and in-depth assessment. The comprehensive geriatric assessment consisted of a history and focused clinical examination. The in-depth assessment included standardised questionnaires, screening tools and blood pressure measurement. The prevalence of multimorbidity was calculated for self-report and non-self-reported methods (clinician diagnosis, screening tools and direct measurement). Multimorbidity was defined as having two or more conditions. The socio-demographic associations with multimorbidity were investigated by multiple logistic regression. RESULTS: A sample of 235 adults participated in the study, selected from a screened sample of 1207. The median age was 74 years (range 60 to 110 inter-quartile range (IQR) 19) and 136 (57.8%) were women. Adjusting for frailty-weighting, the prevalence of self-reported multimorbidity was 26.1% (95% CI 16.7-35.4), and by clinical assessment/screening was 67.3% (95% CI 57.0-77.5). Adjusting for age, sex, education and frailty status, multimorbidity by self-report increased the odds of being financially dependent on others threefold (OR 3.3 [95% CI 1.4-7.8]), and of a household member reducing their paid employment nearly fourfold (OR 3.8. [95% CI 1.5-9.2]). CONCLUSIONS: Multimorbidity is prevalent in this rural lower-income African setting and is associated with evidence of household financial strain. Multimorbidity prevalence is higher when not reliant on self-reported methods, revealing that many conditions are underdiagnosed and undertreated.

Independent changes in bone mineralized and marrow soft tissues following acute knee injury require dual-energy or high-resolution computed tomography for accurate assessment of bone mineral density and stiffness.

Musculoskeletal injuries often induce local accumulation of blood and/or fluid within the bone marrow, which is detected on medical imaging as edema-like marrow signal intensities (EMSI). In addition to its biological effects on post-injury recovery, the displacement of low-attenuating, largely adipocytic marrow by EMSI may introduce errors into quantitative computed tomography (QCT) measurements of bone mineral density (vBMD) and resulting bone stiffness estimates from image-based finite element (FE) analysis. We aimed to investigate the impact of post-injury changes in marrow soft tissue composition on CT-based bone measurements by applying CT imaging at multiple spatial resolutions. To do so, dual energy QCT (DECT) material decomposition was used to detect EMSI in the tibiae of nineteen participants with a recent anterior cruciate ligament tear. We then measured bone density and FE-based apparent modulus within the EMSI region and in a matched volume in the uninjured contralateral knee. Three measurement methods were applied: 1.) standard, QCT density calibration and density-based FEM; 2.) a DECT density calibration that provides density measurements adjusted for marrow soft tissues; and 3.) high-resolution peripheral QCT (HR-pQCT) density and microFE analyses. When measured using standard, single-energy QCT, vBMD and apparent modulus were elevated in the EMSI compared to the contralateral. After adjusting for marrow soft tissue composition using DECT, these measurements were no longer different between the two regions. By allowing for high-resolution, localized density analysis, HR-pQCT indicated that trabecular tissue mineral density was 9 mgHA/cm3 lower, while density of marrow soft tissues was 18 mgHA/cm3 higher, in the EMSI than the contralateral region, suggesting that EMSI have opposite effects on the measured density of trabecular bone and the underlying soft marrow. Thus, after an acute injury, altered composition of marrow soft tissues may artificially inflate overall measurements of bone density and apparent modulus obtained using standard QCT. This can be corrected by accounting for marrow soft tissue attenuation, either by using DECT-based density calibration or HR-pQCT microFE and measurements of local density of trabeculae.

Evaluation of a low-resource screening strategy for ophthalmic pathologies and associated neurological morbidity in an older Tanzanian HIV-positive population.

Globally, 43 million people are living with HIV, 90% in developing countries. Increasing life expectancy with combination antiretroviral therapy (cART) results in chronic complications, including HIV-associated neurocognitive disorders (HAND) and eye diseases. HAND screening is currently challenging. Our aim was to evaluate clinical utility of retinopathy as a screening measure of HAND in older cART-treated individuals in Tanzania and feasibility of smartphone-based retinal screening in this low-resource setting. A cross-sectional systematic sample aged ≥ 50-years attending routine HIV follow-up in Tanzania were comprehensively assessed for HAND by American Academy of Neurology criteria and received ophthalmic assessment including smartphone-based retinal imaging. HAND and ophthalmic assessments were independent and blinded. Diagnostic accuracy was evaluated by AUROC curves. Of 129 individuals assessed, 69.8% were visually impaired. Thirteen had retinopathy. HAND prevalence was 66.7%. Retinopathy was significantly associated with HAND but HIV-disease factors (CD4, viral load) were not. Diagnostic accuracy of retinopathy for HAND was poor (AUROC 0.545-0.617) but specificity and positive predictive value were high. We conclude that ocular pathology and HAND appear highly prevalent in this low-resource setting. Although retinal screening cannot be used alone identify HAND, prioritization of individuals with abnormal retinal screening is a potential strategy in low-resource settings.

A quantitative assessment of dual energy computed tomography-based material decomposition for imaging bone marrow edema associated with acute knee injury.

PURPOSE: This study developed methods to quantify and improve the accuracy of dual-energy CT (DECT)-based bone marrow edema imaging using a clinical CT system. Objectives were: (a) to quantitatively compare DECT with gold-standard, fluid-sensitive MRI for imaging of edema-like marrow signal intensity (EMSI) and (b) to identify image analysis parameters that improve delineation of EMSI associated with acute knee injury on DECT images. METHODS: DECT images from ten participants with acute knee injury were decomposed into estimated fractions of bone, healthy marrow, and edema based on energy-dependent differences in tissue attenuation. Fluid-sensitive MR images were registered to DECT for quantitative, voxel-by-voxel comparison between the two modalities. An optimization scheme was developed to find attenuation coefficients for healthy marrow and edema that improved EMSI delineation, compared to MRI. DECT method accuracy was evaluated by measuring dice coefficients, mutual information, and normalized cross correlation between the DECT result and registered MRI. RESULTS: When applying the optimized three-material decomposition method, dice coefficients for EMSI identified through DECT vs MRI were 0.32 at the tibia and 0.13 at the femur. Optimization of attenuation coefficients improved dice coefficient, mutual information, and cross-correlation between DECT and gold-standard MRI by 48%-107% compared to three-material decomposition using non-optimized parameters, and improved mutual information and cross-correlation by 39%-58% compared to the manufacturer-provided two-material decomposition. CONCLUSIONS: This study quantitatively evaluated the performance of DECT in imaging knee injury-associated EMSI and identified a method to optimize DECT-based visualization of complex tissues (marrow and edema) whose attenuation parameters cannot be easily characterized. Further studies are needed to improve DECT-based EMSI imaging at the femur.

Radiology in the Era of Value-Based Healthcare: A Multi-Society Expert Statement From the ACR, CAR, ESR, IS3R, RANZCR, and RSNA.

BACKGROUND: The Value-Based Healthcare (VBH) concept is designed to improve individual healthcare outcomes without increasing expenditure, and is increasingly being used to determine resourcing of and reimbursement for medical services. Radiology is a major contributor to patient and societal healthcare at many levels. Despite this, some VBH models do not acknowledge radiology's central role; this may have future negative consequences for resource allocation. METHODS, FINDINGS AND INTERPRETATION: This multi-society paper, representing the views of Radiology Societies in Europe, the USA, Canada, Australia, and New Zealand, describes the place of radiology in VBH models and the health-care value contributions of radiology. Potential steps to objectify and quantify the value contributed by radiology to healthcare are outlined.

Radiology in the Era of Value-based Healthcare: A Multi-Society Expert Statement from the ACR, CAR, ESR, IS3R, RANZCR, and RSNA.

Background The Value-Based Healthcare (VBH) concept is designed to improve individual healthcare outcomes without increasing expenditure, and is increasingly being used to determine resourcing of and reimbursement for medical services. Radiology is a major contributor to patient and societal healthcare at many levels. Despite this, some VBH models do not acknowledge radiology's central role; this may have future negative consequences for resource allocation. Methods, findings and interpretation This multi-society paper, representing the views of Radiology Societies in Europe, the USA, Canada, Australia, and New Zealand, describes the place of radiology in VBH models and the health-care value contributions of radiology. Potential steps to objectify and quantify the value contributed by radiology to healthcare are outlined. Published under a CC BY 4.0 license.

Rationing care by frailty during the COVID-19 pandemic.

The coronavirus disease 2019 (COVID-19) pandemic is disproportionately affecting older people and those with underlying comorbidities. Guidelines are needed to help clinicians make decisions regarding appropriate use of limited NHS critical care resources. In response to the pandemic, the National Institute for Health and Care Excellence published guidance that employs the Clinical Frailty Scale (CFS) in a decision-making flowchart to assist clinicians in assessing older individuals' suitability for critical care. This commentary raises some important limitations to this use of the CFS and cautions against the potential for unintended impacts. The COVID-19 pandemic has allowed the widespread implementation of the CFS with limited training or expert oversight. The CFS is primarily being used to assess older individuals' risk of adverse outcome in critical care, and to ration access to care on this basis. While some form of resource allocation strategy is necessary for emergencies, the implementation of this guideline in the absence of significant pressure on resources may reduce the likelihood of older people with frailty, who wish to be considered for critical care, being appropriately considered, and has the potential to reinforce the socio-economic gradient in health. Our incomplete understanding of this novel disease means that there is a need for research investigating the short-term predictive abilities of the CFS on critical care outcomes in COVID-19. Additionally, a review of the impact of stratifying older people by CFS score as a rationing strategy is necessary in order to assess its acceptability to older people as well as its potential for disparate impacts.

Stimulation of the tibial nerve: a protocol for a multicentred randomised controlled trial for urinary problems associated with Parkinson's disease-STARTUP.

INTRODUCTION: Parkinson's disease is the second most common chronic neurodegenerative condition with bladder dysfunction affecting up to 71%. Symptoms affect quality of life and include urgency, frequency, hesitancy, nocturia and incontinence. Addressing urinary dysfunction is one of the top 10 priority research areas identified by the James Lind Alliance and Parkinson's UK. OBJECTIVES: Conduct a randomised controlled trial (RCT) targeting people with Parkinson's disease (PwP) who have self-reported problematic lower urinary tract symptoms, investigating the effectiveness of transcutaneous tibial nerve stimulation (TTNS) compared with sham TTNS. Implement a standardised training approach and package for the correct application of TTNS. Conduct a cost-effectiveness analysis of TTNS compared with sham TTNS. METHODS AND ANALYSIS: An RCT of 6 weeks with twice weekly TTNS or sham TTNS. Participants will be recruited in 12 National Health Service neurology/movement disorder services, using a web-based randomisation system, and will be shown how to apply TTNS or sham TTNS. Participants will receive a weekly telephone call from the researchers during the intervention period. The trial has two coprimary outcome measures: International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form and the International Prostate Symptom Score. Secondary outcomes include a 3-day bladder diary, quality of life, acceptability and fidelity and health economic evaluation. Outcomes will be measured at 0, 6 and 12 weeks.A sample size of 208 randomised in equal numbers to the two arms will provide 90% power to detect a clinically important difference of 2.52 points on the Internatioanl Consultation on Incontinence Questionnaire - Short Form (ICIQ-SF) and of 3 points in the International Prostate Symptom Score total score at 12 weeks at 5% significance level, based on an SD of 4.7 in each arm and 20% attrition at 6 weeks. Analysis will be by intention to treat and pre defined in a statistical analysis plan ETHICS AND DISSEMINATION: East of Scotland Research Ethics Service (EoSRES), 18/ES00042, obtained on 10 May 2018. The trial will allow us to determine effectiveness, safety, cost and acceptability of TTNS for bladder dysfunction in PWP. Results will be published in open access journals; lay reports will be posted to all participants and presented at conferences. TRIAL REGISTRATION NUMBER: ISRCTN12437878; Pre-results.

Global ageing: successes, challenges and opportunities.

The world's population is ageing rapidly, with significant increases in the numbers of the oldest old. This places great pressure on societies to adapt to this changing demography. Pertinent issues include provision of education and resource for long-term conditions. The priorities older people hold need to be fully understood and their contributions to society, often diverse and far-reaching, recognised with sincerity. Currently, health systems for older people can often feel reactive, fragmented and disjointed. These systems can harbour inequity and ageism, and leave both patients and health-care providers dissatisfied. Regarding the global context, the most rapidly ageing populations are in low- and middle-income countries. This partly reflects huge successes in the treatment and control of communicable diseases but gives rise to the challenge of the 'double burden', managing both communicable and non-communicable diseases simultaneously. Moreover, multimorbidity (suffering two or more chronic conditions) is commonplace and presents further challenges with regards to providing coordinated care. In order to harmonise effective and sustainable change, collaboration at local, national and international levels is key in order to foster a platform for learning and information sharing. Therein lies huge opportunities for countries to share their individual experiences, both past and present, to improve preparedness for global ageing.

Crossover Assessment of Intraoral and Cuffed Ventilation by Emergency Responders.

OBJECTIVES: A cuffed bag valve mask (BVM) is the most common device used by emergency medical responders to ventilate patients. The BVM can be difficult for users to seal around the patient's mouth and nose. An intraoral mask (IOM) with snorkel-like design may facilitate quicker and better ventilation particularly under austere conditions. METHODS: Both a BVM and IOM were utilized by 27 trained emergency medical technicians and paramedics to ventilate a lightly embalmed cadaver. Ventilation efficacy, workload, and usability were assessed for both devices across four study conditions. RESULTS: The IOM was superior to the BVM in delivered tidal volume ratio (measure of leak, p < 0.03) and minute ventilation (p < 0.0001). Workload, ergonomic and usability assessments indicated that the IOM facilitated gripping through the reduced hand interface size (p < 0.01), decreased user effort (p < 0.001), and reduced upper limb workload (p = 0.0088). CONCLUSIONS: In the assessed model, the IOM represented a better choice for airway management than the standard cuffed BVM. An emergency medical device that is intuitive, efficacious and less demanding has the potential to reduce responder stress and improve resuscitation efforts, especially during austere rescue and patient transport.

Multiple approaches to surface water quality assessment provide insight for small streams experiencing oil and natural gas development.

Historic, current, and future oil and natural gas development can affect water quality in streams flowing through developed areas. We compared small stream drainages in a semiarid landscape with varying amounts of disturbance from oil and natural gas development to examine potential effects of this development on surface water quality. We used physical, chemical, and biological approaches to assess water quality and found several potential avenues of degradation. Surface disturbance likely contributed to elevated suspended sediment concentrations and spill history likely led to elevated stream polycyclic aromatic hydrocarbon concentrations. In combination, these environmental stressors could explain the loss of aquatic macroinvertebrate taxon at sites highly affected by oil and natural gas development. Our results provide insight into advantages and disadvantages of approaches for assessing surface water quality in areas affected by oil and natural gas development. Integr Environ Assess Manag 2019;00:000-000. © 2019 SETAC.

Concurrent Assessment of Cartilage Morphology and Bone Microarchitecture in the Human Knee Using Contrast-Enhanced HR-pQCT Imaging.

Osteoarthritis (OA) is a prevalent articular disease characterized by whole joint degradation, including articular cartilage and bone. Presently, no single imaging modality is well suited to concurrently capture these changes. Recent ex vivo animal studies have demonstrated the efficacy of utilizing contrast agents in conjunction with micro-CT as a means of evaluating cartilage and bone alterations concurrently, though no work as of yet has been performed in large animal models or humans. This study sought to develop and validate a novel joint imaging technique, contrast enhanced high resolution peripheral quantitative computed tomography (CEHR-pQCT), to concurrently assess bone microarchitecture and cartilage morphology in the whole human knee. Fresh frozen cadaveric knees were harvested (n = 10) and scanned using magnetic resonance imaging (MRI), HR-pQCT without contrast, and HR- pQCT following intra-articular injection of nonionic contrast media. Cartilage morphology and bone microarchitecture were evaluated in weight bearing regions of interest in both the tibia and femur. Joints were then disarticulated, and the articular cartilage thickness measured by needle probe. Measures of cartilage morphology, thickness and volume, were found to be significantly less when measured by CEHR- pQCT compared to magnetic resonance imaging in all regions. Compared to needle probing, cartilage thickness measured by CEHR-pQCT was less in the lateral tibia and greater in the medial tibia. Bone microarchitecture was found to be significantly different when measured with CEHR-pQCT compared to HR-pQCT, where cortical bone mineral density (BMD) was depressed, and trabecular bone mineral density was greater. This study demonstrates that CEHR-pQCT can be used to concurrently measure cartilage morphology and bone microarchitecture; however, systematic errors impact both measures. This is the first study using contrast media in combination with HR-pQCT in whole joints. Additionally, all imaging parameters, as well as the contrast media, were selected to be directly transferable to in vivo studies, laying the foundation to perform in vivo scanning of knee cartilage and bone.

Prevalence of Frailty in Older Community-Dwelling Tanzanians According to Comprehensive Geriatric Assessment.

OBJECTIVES: To investigate the prevalence of frailty using a Comprehensive Geriatric Assessment (CGA) in older community-dwelling adults living in rural northern Tanzania. DESIGN: Cross-sectional survey. SETTING: Five randomly selected villages in Hai District, Kilimanjaro region, Tanzania. PARTICIPANTS: All adults aged 60 and older living in the selected villages were eligible to participate, including older adults with cognitive impairment provided a close relative was able to assent on their behalf. All participants were community dwelling because institutionalization is very rare. MEASUREMENTS: Participants were screened using a short frailty screening tool, the Brief Frailty Instrument for Tanzania (B-FIT), comprising an abbreviated test of cognitive function and the Barthel Index, which assesses functional independence. Based on B-FIT score, a frailty-weighted, stratified sample was selected for in-depth assessment using CGA and characterized as frail or not frail. RESULTS: Two hundred thirty-six CGAs were performed in 1,207 people screened, 91 of whom were deemed frail. After adjusting for stratification, the prevalence of frailty was 19.1% (95% confidence interval=15.2-23.1). CONCLUSION: This is the first study in sub-Saharan Africa to report the prevalence of frailty in community-dwelling older adults according to a CGA. The strengths of reporting frailty according to a CGA include the ability to consider likely medical diagnoses based on clinical assessment and to assess individuals' social circumstances and environment.

Considering the cost of a simultaneous versus staged approach to resection of colorectal cancer with synchronous liver metastases in a publicly funded healthcare model.

BACKGROUND: Simultaneous resection for colorectal cancer with synchronous liver metastases is an established alternative to a staged approach. This study aimed to compare these approaches with regards to economic parameters and short-term outcomes. METHODS: A retrospective cohort analysis was conducted between 2005 and 2016. The primary outcome was cost per episode of care. Secondary measures included 30-day clinical outcomes. A multivariate analysis was performed to determine the adjusted effect of a simultaneous surgical approach on total cost of care. RESULTS: Fifty-three cases were identified; 27 in the staged approach, and 26 in the simultaneous group. Age (P = 0.49), sex (P = 0.20), BMI (P = 0.74), and ASA class (P = 0.44) were comparable between groups. Total cost ($20297 vs $27522), OR ($6830 vs $10376), PACU ($675 vs $1182), ward ($7586 vs $11603) and pharmacy costs ($728 vs $1075) were significantly less for the simultaneous group (P < 0.05). The adjusted rate ratio for total cost of care in the staged group compared to simultaneous group was 1.51 (95%CI: 1.16-1.97, P < 0.05). The groups had comparable Clavien-Dindo scores (P = 0.89), 30-day readmissions (P = 0.44), morbidity (P = 0.50) and mortality (P = 1.00). CONCLUSIONS: Our study demonstrates that a simultaneous approach is associated with a significantly lower total cost while maintaining comparable short-term outcomes.