Clinical impact of compound sarcopenia in hospitalized older adult patients with heart failure.

OBJECTIVES: Skeletal muscle loss or sarcopenia is a frequent complication in heart failure (HF) and contributes to adverse clinical outcomes. We evaluated if age (primary) and chronic disease (secondary) related sarcopenia, that we refer to as compound sarcopenia, impacts clinical outcomes in hospitalized patients with HF. DESIGN: Cross-sectional study using hospitalized patient data. SETTING: Data from the Agency for Healthcare Research and Quality through the Healthcare Cost and Utilization Project (HCUP). PARTICIPANTS: Hospitalized adult patients with a primary or secondary diagnosis of HF (n = 64,476) and a concurrent random 2% sample of general medical population (GMP; n = 322,217) stratified by age (<50 years of age [y], 51-65y, >65y) from the Nationwide Inpatient Sample (NIS) database (years 2010-2014). MEASUREMENTS: In-hospital mortality, length of stay (LoS), cost of hospitalization per admission (CoH), comorbidities and discharge disposition, with and without muscle loss phenotype, were analyzed. Muscle loss phenotype was defined using a comprehensive code set from international classification of diseases-9 (ICD-9). RESULTS: Muscle loss phenotype was observed in 8673 (13.5%) patients with HF compared to 5213 (1.6%) GMP across all age strata. In patients with HF, muscle loss phenotype was associated with higher mortality, LoS, and CoH. Patients with HF (>65y) and muscle loss phenotype had higher mortality (adjusted OR: 1.81; 95% CI 1.56-2.10), CoH (adjusted OR 1.48; 95% CI 1.44-1.1.52), and LoS (adjusted OR 1.40; 95% CI 1.37-1.43) compared to >65y GMP with muscle loss phenotype. CONCLUSION: Muscle loss phenotype is more commonly associated with increasing age in hospitalized patients with HF. Clinical outcomes were significantly worse in patients with HF aged >65y compared to younger patients with HF and all age strata in GMP with and without a muscle loss phenotype.

Economic Impact of Hospitalizations in US Adults with Sarcopenia.

BACKGROUND: Sarcopenia is characterized by progressive loss of muscle mass with corresponding decline in strength and/or physical function. The economic burden of sarcopenia-associated disability is considerable in the US. OBJECTIVE: To estimate the cost of hospitalizations in US adults with sarcopenia categorized by age, sex, and race/ethnicity. DESIGN, SETTING AND PARTICIPANTS: A retrospective, prevalence based, economic burden study, consisting of 4011 adults aged ≥40 years with and without sarcopenia. METHODS: Data on prevalence of low lean mass, functional limitations, and hospitalizations were obtained from the National Health and Nutrition Examination Survey (1999-2004); cost of hospitalizations was obtained from the Healthcare Cost and Utilization Project - National Inpatient Sample (2014), and population estimates were obtained from the US Census (2014). Probability and cost of hospitalizations were estimated by multiple logistic regression and negative binomial regression models, respectively. RESULTS: The total estimated cost of hospitalizations in individuals with sarcopenia was USD $40.4 billion with an average per person cost of USD $260. Within this category, average per person cost was highest for Hispanic women (USD $548) and lowest for Non-Hispanic Black women (USD $25); average per person cost was higher for older adults (≥65 years) (USD $375) than younger adults (40-64 years) (USD $204) with sarcopenia. The total cost of hospitalizations in individuals with sarcopenia (≥65 years) was USD $19.12 billion. Individuals with sarcopenia had greater odds of hospitalization (OR, 1.95; p<.001) compared to those without and had an annual marginal increase in cost of USD $2315.7 per person compared to individuals without sarcopenia. CONCLUSION: Sarcopenia places considerable economic burden on the US healthcare system. The ethnic disparity and economic burden associated with sarcopenia warrant further investigation.

Sarcopenia: revised European consensus on definition and diagnosis.

Background: in 2010, the European Working Group on Sarcopenia in Older People (EWGSOP) published a sarcopenia definition that aimed to foster advances in identifying and caring for people with sarcopenia. In early 2018, the Working Group met again (EWGSOP2) to update the original definition in order to reflect scientific and clinical evidence that has built over the last decade. This paper presents our updated findings. Objectives: to increase consistency of research design, clinical diagnoses and ultimately, care for people with sarcopenia. Recommendations: sarcopenia is a muscle disease (muscle failure) rooted in adverse muscle changes that accrue across a lifetime; sarcopenia is common among adults of older age but can also occur earlier in life. In this updated consensus paper on sarcopenia, EWGSOP2: (1) focuses on low muscle strength as a key characteristic of sarcopenia, uses detection of low muscle quantity and quality to confirm the sarcopenia diagnosis, and identifies poor physical performance as indicative of severe sarcopenia; (2) updates the clinical algorithm that can be used for sarcopenia case-finding, diagnosis and confirmation, and severity determination and (3) provides clear cut-off points for measurements of variables that identify and characterise sarcopenia. Conclusions: EWGSOP2's updated recommendations aim to increase awareness of sarcopenia and its risk. With these new recommendations, EWGSOP2 calls for healthcare professionals who treat patients at risk for sarcopenia to take actions that will promote early detection and treatment. We also encourage more research in the field of sarcopenia in order to prevent or delay adverse health outcomes that incur a heavy burden for patients and healthcare systems.

Financial impact of sarcopenia or low muscle mass - A short review.

BACKGROUND & AIMS: Low muscle mass is associated with increased falls, medical complications, length of hospital stay and loss of independence. An increasing number of studies has also shown the association between sarcopenia and health care expenditure. The following narrative review summarizes the current evidence on the economic relevance of low muscle mass (MM) or sarcopenia. METHODS: An extensive search of the literature in Medline identified twelve studies in English, which evaluated direct and indirect health care expenditure in patients with low muscle mass or sarcopenia (low MM and strength or mobility). RESULTS: Three studies analysed the cost of age-related loss of MM or strength in large surveys of the general, older population. Six retrospective analyses evaluated perioperative medical costs related to low MM in primarily older patients from different medical areas. One prospective study presented hospital costs related to sarcopenia in patients with gastric cancer. Two studies presented data from general hospital patients. Despite the difference in diagnostic criteria, study population and statistical design, low MM and sarcopenia were consistently identified as predictors of increased health care expenditure in community, perioperative and general hospital settings. CONCLUSIONS: Low MM and sarcopenia are prevalent and associated with significantly higher health care costs. Considering the demographic change, which will lead to an increasing number of patients with sarcopenia, every effort should be made to identify and treat patients with sarcopenia. The use of a unified definition and diagnostic criteria would allow a better comparison of data.

Health Care Costs Associated With Muscle Weakness: A UK Population-Based Estimate.

Sarcopenia and muscle weakness are responsible for considerable health care expenditure but little is known about these costs in the UK. To address this, we estimated the excess economic burden for individuals with muscle weakness regarding the provision of health and social care among 442 men and women (aged 71-80 years) who participated in the Hertfordshire Cohort Study (UK). Muscle weakness, characterised by low grip strength, was defined according to the Foundation for the National Institutes of Health criteria (men < 26 kg, women < 16 kg). Costs associated with primary care consultations and visits, outpatient and inpatient secondary care, medications, and formal (paid) as well as informal care for each participant were calculated. Mean total costs per person and their corresponding components were compared between groups with and without muscle weakness. Prevalence of muscle weakness in the sample was 11%. Mean total annual costs for participants with muscle weakness were £4592 (CI £2962-£6221), with informal care, inpatient secondary care and primary care accounting for the majority of total costs (38%, 23% and 19%, respectively). For participants without muscle weakness, total annual costs were £1885 (CI £1542-£2228) and their three highest cost categories were informal care (26%), primary care (23%) and formal care (20%). Total excess costs associated with muscle weakness were £2707 per person per year, with informal care costs accounting for 46% of this difference. This results in an estimated annual excess cost in the UK of £2.5 billion.

The health economics burden of sarcopenia: a systematic review.

Despite of better knowledge about sarcopenia, an optimal understanding of its consequences from a public health perspective remains a challenge. Specifically, the economic burden of the illness is unclear. As a support for the public health policy makers and other health actors, our objective was to perform a systematic review of the literature comparing healthcare costs between sarcopenic and non-sarcopenic patients (under the registration number CRD42018099291). A search for relevant articles was conducted on the Medline and Scopus databases. Rigorous eligibility criteria were established (e.g., subjects with sarcopenia, both men and women, mean age of the sarcopenic population) and applied by two investigators to identify suitable studies. The first screening phase, performed by 2 independent reviewers, covered 455 references. Fourteen relevant studies were included in the final analysis. Overall, we noted an important heterogeneity between studies in the way of assessing sarcopenia (i.e. operational definitions, tools and cut-offs used). There were also large variations between studies in their cost analysis settings (i.e., discrepancies in time horizon, types and sources of economic data). Most of the studies focused on hospitalization costs following surgery for a specific disease such as cancer. Finally, 11 out of the 14 studies reported higher healthcare costs for sarcopenic patients. However, most of the included studies have important methodological bias (e.g. potential confusion factors rarely taken into account), and low to moderate quality scores. More standardized research, taking into account all the limitations of the published studies, should be conducted to assess the true impact of sarcopenia on healthcare consumption.

Impact of Visceral Obesity and Sarcopenia on Short-Term Outcomes After Colorectal Cancer Surgery.

BACKGROUND: With the increased prevalence of obesity and sarcopenia, those patients with both visceral obesity and sarcopenia were at higher risk of adverse outcomes. AIM: The aim of this study was to ascertain the combined impact of visceral obesity and sarcopenia on short-term outcomes in patients undergoing colorectal cancer surgery. METHODS: We conducted a prospective study from July 2014 to February 2017. Patients' demographic, clinical characteristics, physical performance, and postoperative short-term outcomes were collected. Patients were classified into four groups according to the presence of sarcopenia or visceral obesity. Clinical variables were compared. Univariate and multivariate analyses evaluating the risk factors for postoperative complications were performed. RESULTS: A total of 376 patients were included; 50.8 and 24.5% of the patients were identified as having "visceral obesity" and "sarcopenia," respectively. Patients with sarcopenia and visceral obesity had the highest incidence of total, surgical, and medical complications. Patients with sarcopenia or/and visceral obesity all had longer hospital stays and higher hospitalization costs. Age ≥ 65 years, visceral obesity, and sarcopenia were independent risk factors for total complications. Rectal cancer and visceral obesity were independent risk factors for surgical complications. Age ≥ 65 years and sarcopenia were independent risk factors for medical complications. Laparoscopy-assisted operation was a protective factor for total and medical complications. CONCLUSION: Patients with both visceral obesity and sarcopenia had a higher complication rate after colorectal cancer surgery. Age ≥ 65 years, visceral obesity, and sarcopenia were independent risk factors for total complications. Laparoscopy-assisted operation was a protective factor.

Inpatient costs and blood transfusion rates of sarcopenic patients following thoracolumbar spine surgery.

OBJECTIVE Sarcopenia, the muscle atrophy associated with aging and disease progression, accounts for nearly $18.5 billion in health care expenditures annually. Given the high prevalence of sarcopenia in patients undergoing orthopedic surgery, the goal of this study was to assess the impact of sarcopenia on inpatient costs following thoracolumbar spine surgery. METHODS Patients older than 55 years undergoing thoracolumbar spine surgery from 2003 to 2015 were retrospectively analyzed. Sarcopenia was measured using total psoas area at the L-4 vertebra on perioperative CT scans. Hospital billing data were used to compare inpatient costs, transfusion rate, and rate of advanced imaging utilization. RESULTS Of the 50 patients assessed, 16 were sarcopenic. Mean total hospital costs were 1.75-fold greater for sarcopenic patients compared with nonsarcopenic patients ($53,128 vs $30,292, p = 0.04). Sarcopenic patients were 2.1 times as likely to require a blood transfusion (43.8% vs 20.6%, p = 0.04). Sarcopenic patients had a 2.6-fold greater usage of advanced imaging (68.8% vs 26.5%, p = 0.002) with associated higher diagnostic imaging costs ($2452 vs $801, p = 0.01). Sarcopenic patients also had greater pharmacy, laboratory, respiratory care, and emergency department costs. CONCLUSIONS This study is the first to show that sarcopenia is associated with higher postoperative costs and rates of blood transfusion following thoracolumbar spine surgery. Measuring the psoas area may represent a strategy for predicting perioperative costs in spine surgery patients.

Medical costs of a low skeletal muscle mass are modulated by dietary diversity and physical activity in community-dwelling older Taiwanese: a longitudinal study.

BACKGROUND: Age-related loss of skeletal muscle mass (SMM) and function (sarcopenia) are associated with poor health outcomes and an economic burden on health care services. An appropriate diet and physical activity have been proposed for prevention and treatment of sarcopenia. Nevertheless, the effects on medical service utilization and costs remain unclear. This study determined the effects of SMM in conjunction with diet quality and physical activity on medical service utilization and expenditure in community-dwelling older Taiwanese. METHODS: In total, 1337 participants from the Elderly Nutrition and Health Survey in Taiwan (1999-2000) were enrolled. An SMM index [SMMI, calculated by dividing SMM (kg) by height (m2)] was used as the marker of sarcopenia. Participants with the lowest SMMI quartiles (<11.4 kg/m2 for men and 8.50 kg/m2 for women) comprised the high-risk group, and the remainder comprised the low-risk group. Dietary information (dietary diversity: low and high) and physical activity (low and moderate) were obtained at baseline. Annual medical service utilization and expenditure were calculated from National Health Insurance claims until December 31, 2006. Generalized linear models were used to determine the association between the SMMI and annual medical service utilization and costs in conjunction with dietary diversity or physical activity. RESULTS: After 8 follow-up years, regardless of gender, participants in the high-risk group reported significantly more hospitalization (days and expenditure) and total medical expenditure. Participants in the high-risk group who had low dietary diversity made fewer annual outpatient (14%), preventive care (19%), and dental (40%) visits, but exhibited longer hospitalization (102%) than did those who had a low SMMI and high dietary diversity. Similar patterns were observed in the corresponding medical expenditures. The findings were similar when considering physical activity. Being in the low-risk group in conjunction with having high dietary diversity or more physical activity was associated with the lowest annual adjusted mean hospitalization days with expenditure, and also total expenditure. CONCLUSIONS: A lower SMMI was associated with more hospitalization days and costs. However, high dietary diversity and more physical activity can attenuate the effects of lower SMMI on medical service utilization and expenditure.

Preventing mobility disability in Europe: a health economics perspective from the SPRINTT study.

In a global context of population aging, gaining better knowledge of the mechanisms leading to loss of autonomy has become a major objective, notably with the aim of implementing effective preventive health policies. The concept of frailty, originally introduced in gerontology and geriatrics as a precursor state to functional dependency, appears as a useful tool in this specific context. The "Sarcopenia and Physical fRailty IN older people: multi-componenT Treatment strategies" (SPRINTT) project will provide a unique opportunity to explore health economics issues associated with frailty. In terms of health economics, the loss of autonomy approach retained here focuses on the economic and social causes and consequences of the onset of frailty in older adults, and examines the challenges not only in terms of health system efficiency but also in terms of social protection.

Association of Radiologic Indicators of Frailty With 1-Year Mortality in Older Trauma Patients: Opportunistic Screening for Sarcopenia and Osteopenia.

Importance: Assessment of physical frailty in older trauma patients admitted to the intensive care unit is often not feasible using traditional frailty assessment instruments. The use of opportunistic computed tomography (CT) scans to assess sarcopenia and osteopenia as indicators of underlying frailty may provide complementary prognostic information on long-term outcomes. Objective: To determine whether sarcopenia and/or osteopenia are associated with 1-year mortality in an older trauma patient population. Design, Setting, and Participants: A retrospective cohort constructed from a state trauma registry was linked to the statewide death registry and Comprehensive Hospital Abstract Reporting System for readmission data analyses. Admission abdominopelvic CT scans from patients 65 years and older admitted to the intensive care unit of a single level I trauma center between January 2011 and May 2014 were analyzed to identify patients with sarcopenia and/or osteopenia. Patients with a head Injury Severity Score of 3 or greater, an out-of-state address, or inadequate CT imaging or who died within 24 hours of admission were excluded. Exposures: Sarcopenia and/or osteopenia, assessed via total cross-sectional muscle area and bone density at the L3 vertebral level, compared with a group with no sarcopenia or osteopenia. Main Outcomes and Measures: One-year all-cause mortality. Secondary outcomes included 30-day all-cause mortality, 30-day readmission, hospital length of stay, hospital cost, and discharge disposition. Results: Of the 450 patients included in the study, 269 (59.8%) were male and 394 (87.6%) were white. The cohort was split into 4 groups: 74 were retrospectively diagnosed with both sarcopenia and osteopenia, 167 with sarcopenia only, 48 with osteopenia only, and 161 with no radiologic indicators. Among the 408 who survived to discharge, sarcopenia and osteopenia were associated with higher risks of 1-year mortality alone and in combination. After adjustment, the hazard ratio was 9.4 (95% CI, 1.2-75.4; P = .03) for sarcopenia and osteopenia, 10.3 (95% CI, 1.3-78.8; P = .03) for sarcopenia, and 11.9 (95% CI, 1.3-107.4; P = .03) for osteopenia. Conclusions and Relevance: More than half of older trauma patients in this study had sarcopenia, osteopenia, or both. Each factor was independently associated with increased 1-year mortality. Given the prevalent use of abdominopelvic CT in trauma centers, opportunistic screening for radiologic indicators of frailty provides an additional tool for early identification of older trauma patients at high risk for poor outcomes, with the potential for targeted interventions.

Sarcopenia predicts costs among patients undergoing major abdominal operations.

BACKGROUND: Although sarcopenia has been identified as a predictor of poor, postoperative, clinical outcomes, the financial impact of sarcopenia remains undetermined. We sought to evaluate the relationship between sarcopenia and hospital finances among a cohort of patients undergoing a hepato-pancreatico-biliary or colorectal resection. METHODS: Clinical, financial, and morphometric data were collected for 1,169 patients undergoing operative resection between January 2011 and December 2013 at the Johns Hopkins Hospital. Multivariable regression analysis was performed to assess the relationship between sarcopenia and total hospital costs. RESULTS: Using sex-specific cutoffs for total psoas volume, 293 patients were categorized as sarcopenic. The presence of sarcopenia was associated with a $14,322 increase in the total hospital cost (median covariate-adjusted cost, sarcopenia versus no sarcopenia: $38,804 vs $24,482, P < .001). Patients who presented with sarcopenia demonstrated a higher total hospital cost within the subgroup of patients who developed a postoperative complication (sarcopenia versus no sarcopenia: $65,856 vs $59,609) and among those patients who did not develop a postoperative complication (sarcopenia versus no sarcopenia: $26,282 vs $23,763, both P < .001). Similarly, total hospital costs were higher among patients presenting with sarcopenia regardless of the length of stay for index admission (observed:expected, length of stay < 1: sarcopenia versus no sarcopenia: $25,038 vs $22,827; observed:expected, length of stay > 1: sarcopenia versus no sarcopenia: $43,283 vs $38,679, both P < .001). CONCLUSION: As measured by sarcopenia, patient frailty is inversely related to total hospital costs. Sarcopenia represents a novel tool for forecasting patient outcomes and operative costs and can be used to inform quality improvement and cost containment strategies.

Financial impact of sarcopenia on hospitalization costs.

BACKGROUND/OBJECTIVES: This study aims to increase knowledge regarding the association of sarcopenia with hospitalization costs among a wide-ranging sample of adult hospitalized patients. SUBJECTS/METHODS: A prospective study was conducted among hospitalized adult patients. Sarcopenia was identified according to the European Working Group on Sarcopenia in Older People, as low muscle mass, assessed by bioelectrical impedance analysis and low muscle function evaluated by handgrip strength. Hospitalization cost was calculated for each patient based on discharge diagnosis-related group codes and determined on the basis of a relative weight value. Costs were defined as the percentage of deviation from the cost of a patient with a relative weight equal to one. Multivariable linear regression models were performed to identify the factors independently associated with hospitalization costs. RESULTS: A total of 656 hospitalized patients aged ⩾18 years (24.2% sarcopenic) composed the study sample. Sarcopenia increased hospitalization costs by [euro ]1240 (95% confidence interval (CI): [euro ]596-1887) for patients aged <65 years and [euro ]721 (95% CI: [euro ]13-1429) for patients aged ⩾65 years. Sarcopenic overweight was related to an increase in hospitalization costs of [euro ]884 (95% CI: [euro ]295-1476). CONCLUSIONS: Sarcopenia is independently related to hospitalization costs. This condition is estimated to increase hospitalization costs by 58.5% for patients aged <65 years and 34% for patients aged ⩾65 years.

Frailty in Clinical Practice.

Frailty is a geriatric syndrome characterized by reduced homeostatic reserves, exposing the organism to extreme vulnerability to endogenous and exogenous stressors. Since disability is considered as an almost irreversible condition at advanced age, frailty has been indicated as a promising target for specific interventions in order to prevent disability. From a theoretical viewpoint, the concept of frailty has been well established, but its operationalization is still subject to controversy. This impediment leads to the postponement of the integration of frailty in the clinical setting. In the present article, we discuss the main issues regarding the frailty syndrome in the clinical setting, describe possible solutions (especially on the basis of our experience derived from the frailty clinic we have set up in Toulouse, France), and present the most relevant research perspectives in the field.

One-year postoperative resource utilization in sarcopenic patients.

BACKGROUND: It is well established that sarcopenic patients are at higher risk of postoperative complications and short-term health care utilization. Less well understood is how these patients fare over the long term after surviving the immediate postoperative period. We explored costs over the first postoperative year among sarcopenic patients. METHODS: We identified 1279 patients in the Michigan Surgical Quality Collaborative database who underwent inpatient elective surgery at a single institution from 2006-2011. Sarcopenia, defined by gender-stratified tertiles of lean psoas area, was determined from preoperative computed tomography scans using validated analytic morphomics. Data were analyzed to assess sarcopenia's relationship to costs, readmissions, discharge location, intensive care unit admissions, hospital length of stay, and mortality. Multivariate models were adjusted for patient demographics and surgical risk factors. RESULTS: Sarcopenia was independently associated with increased adjusted costs at 30, 90, and 180 but not 365 d. The difference in adjusted postsurgical costs between sarcopenic and nonsarcopenic patients was $16,455 at 30 d and $14,093 at 1 y. Sarcopenic patients were more likely to be discharged somewhere other than home (P < 0.001). Sarcopenia was not an independent predictor of increased readmission rates in the postsurgical year. CONCLUSIONS: The effects of sarcopenia on health care costs are concentrated in the immediate postoperative period. It may be appropriate to allocate additional resources to sarcopenic patients in the perioperative setting to reduce the incidence of negative postoperative outcomes.

Paradoxes with weight disorders for health systems.

The body mass index (BMI) has served public health and clinical medicine well in the recognition of obesity. However, its use has generated some instructive paradoxes and misunderstandings which argue for the appreciation of body compositional disorders (BCD) as such and, in particular, for the parallel evaluation of muscle mass with a definition of 'orthosarcal' conditions to enable the early detection of sarcopenia. Across the life-span, and with gender and ethnic differentials, BCD is basic to the full spectrum of nutritionally-related disorders and diseases. In the case of metabolic diseases like diabetes, muscle, fatness and its distribution, and even bone seem to play pathogenetic roles. Optimal body fat and distribution are relevant to child development, maternal health and healthy ageing, with much more to learn about the mechanisms. The economic and societal costs of obesity tend to increase progressively with the BMI, but the health outcomes, at least for mortality, are J-or U-shaped. With some established chronic diseases, like diabetes, renal failure or cardiac failure, overfatness may be protective; sometimes this may be because contaminant fat-soluble endocrine disrupters are segregated in fat tissue. This means that some of the relatively favourable survival in the elderly who have more body fat is at the expense of the health care system. Younger children with chronic energy deficiency, on the other hand, may succumb before expenditure saves them. In these respects, our species is more vulnerable than we have thought. Fortunately, a better understanding of BMI and health is emerging.