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Objectives: To characterize the cost of caring for an outpatient in Canada with Alzheimer disease (AD) based on disease severity, and to describe how costs change with increases in disease severity. Method: Community-dwelling patients with mild-to-moderate AD were enrolled in a 3-year, naturalistic, observational study. Assessments included cognition (Mini Mental Status Examination), global ratings (Global Deterioration Scale [GDS]), and daily function (Functional Autonomy Measurement System) as part of the Canadian Outcomes Study in Dementia. Direct (medical and nonmedical) and indirect costs were collected using resource use questionnaires. Costs at baseline were compared with costs at follow-up and correlated with disease severity. Results: Total costs associated with treating AD were significantly higher with greater disease severity. The mean total cost to treat patients with very mild AD (GDS = 2) was $367 per month, compared with $4063 per month for patients with severe or very severe AD (GDS = 6). From baseline to follow-up, the greatest changes in cost were observed in the group of patients with the most severe AD as measured by all scales. The largest component of total cost was indirect costs at most severity levels, though medication costs contributed the most in patients with very mild AD. Significant independent contributors to cost were being female, having more impaired activities of daily living, and exhibiting more neuropsychiatric symptoms. Conclusions: Costs for treating a patient with AD were strongly associated with disease severity, even though none of the patients were institutionalized. Delaying the progression of AD may reduce indirect costs and burden to caregivers. [ABSTRACT FROM AUTHOR]

Background: The current state of transcatheter aortic valve implantation (TAVI) training for Canadian cardiac surgical residents is unknown. Our goals were to establish a national inventory of TAVI educational resources, elucidate the role of residents in TAVI programs, and determine the attitudes and perspectives of residents and program directors regarding the importance of TAVI technology and training.Methods: We sent Web-based surveys and reminders to all Canadian cardiac surgical residents and program directors between February and July 2017. We used descriptive analyses to summarize data in an aggregate and anonymous manner. We analyzed patterned responses to open-ended survey questions using thematic analysis.Results: Seventy-eight of 92 residents (85%) and 11 of 12 program directors (92%) completed the survey, with broad representation from across Canada. A minority of residents (14 [18%]) and program directors (4 [36%]) reported that TAVI training in their program was adequate. Only 3 program directors (27%) reported that their residents had access to TAVI simulation training. Although most residents (76 [97%]) and program directors (10 [91%]) agreed that TAVI was important to the trainee's future practice, about two-thirds (54 [69%] and 7 [64%], respectively) agreed that TAVI should be a focus of fellowship training. A perceived lack of interest from interventional cardiologists to teach surgical residents, competition from TAVI fellows and lack of formalized time during residency were identified as perceived barriers to TAVI training.Conclusion: As Canadian surgical residency training moves toward a Competence by Design curriculum, there remains a pressing need to create uniform learning objectives and expectations in the TAVI curriculum. [ABSTRACT FROM AUTHOR]

Background: Transcatheter aortic valve replacement (TAVR) is approved for use across the entire spectrum of risk, including low-surgical-risk patients for severe aortic stenosis (AS). TAVR has been shown to be cost-effective compared with surgical aortic valve replacement (SAVR) in Canada. However, the affordability of implementing TAVR for low-risk AS patients from the hospital's payers' perspective is unknown., Methods: A budget impact analysis was conducted using a 1-year time horizon to quantify the total cost of health care resource utilisation to initially treat low-risk AS patients and manage subsequent adverse events. Differences in cost between TAVR and SAVR were calculated for 100 patients for various scenarios of TAVR uptake (10% to 70%) in low-risk AS patients. Event rates and associated costs were obtained from published literature and provincial datasets. Costs were reported in 2021 Canadian dollars. One-way sensitivity analysis on key TAVR input parameters was conducted., Results: Mean index hospitalisation costs of SAVR and TAVR per patient were $41,956 and $37,669, respectively. The average total costs of managing a low-risk AS patient in 1 year for TAVR and SAVR were $45,897 and $42,659, respectively. The incremental budget impacts of increasing TAVR uptake from 10% to 50% and 70% were 3% and 4.5%, respectively. One-way sensitivity analysis on key variables showed that the main contributors to the cost difference were the intensive care unit stay, permanent pacemaker rate, and hospital length of stay., Conclusions: The incremental annual cost of implementing TAVR in low-risk AS patients was small, making TAVR likely an affordable strategy., (Copyright © 2022 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Background: Injection drug use-associated infective endocarditis (IDU-IE) is a growing epidemic. The objective of this survey was to identify the beliefs and practice patterns of Canadian cardiac surgeons regarding surgical management of IDU-IE., Methods: A 30-question survey was developed by a working group and distributed to all practicing adult cardiac surgeons in Canada. Data were analyzed using descriptive statistics., Results: Of 146 surgeons, 94 completed the survey (64%). Half of surgeons (49%) would be less likely to operate on patients with IE if associated with IDU. In the case of prosthetic valve IE owing to continued IDU, 36% were willing to reoperate once and 14% were willing to reoperate twice or more. Most surgeons required commitments from patients before surgery (73%), and most referred patients to addiction services (81%). Some surgeons would offer a Ross procedure (10%) or homograft (8%) for aortic valve IE, and 47% would consider temporary mechanical circulatory support. Whereas only 17% of surgeons worked at an institution with an endocarditis team, 71% agreed that there was a need for one at each institution. Most surgeons supported the development of IDU-IE-specific guidelines (80%)., Conclusions: Practice patterns and surgical management of IDU-IE vary considerably across Canada. Areas of clinical unmet needs include the development of a formal addiction services referral protocol for patients, the development of an interdisciplinary endocarditis team, as well as the creation of IDU-IE clinical practice guidelines., (Copyright © 2021 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Herein, we describe the unique interplay among biomedical ethics, principles of distributive justice, and economic theory to highlight the role of health technology assessments to compare therapeutic options for aortic valve replacement. From the perspective of the Canadian health care system, transcatheter aortic-valve implantation is associated with higher costs but also higher incremental health benefits compared with surgical aortic-valve replacement. At current willingness to pay thresholds, transcatheter aortic-valve replacement is likely cost effective across the spectrum of risk, from inoperable patients to those at low surgical risk. However, we highlight the nuances within each subgroup of surgical risk that merit careful consideration by the heart team. Moreover, incorporation of patients and their preferences in decision-making is key. In particular, in young, low-risk patients, there remains uncertainty regarding the optimal treatment, with unique concerns around valve durability, selection of valve prosthesis, and consideration for special procedures such as the Ross procedure. Nonetheless, current research suggests that, universally, patients prefer a less invasive approach compared with a more invasive approach. Finally, we highlight that there remain critical issues around timeliness of access to care and unacceptable geographic inequities across Canada. Further research into alternative funding mechanisms and integrated cross-sector care pathways is necessary to address these issues., (Copyright © 2020 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Background and Aim: The opioid epidemic has become a major public health crisis in recent years. Discharge opioid prescription following cardiac surgery has been associated with opioid use disorder; however, ideal practices remain unclear. Our aim was to examine current practices in discharge opioid prescription among cardiac surgeons and trainees., Methods: A survey instrument with open- and closed-ended questions, developed through a 3-round Delphi method, was circulated to cardiac surgeons and trainees via the Canadian Society of Cardiac Surgeons. Survey questions focused on routine prescription practices including type, dosage and duration. Respondents were also asked about their perceptions of current education and guidelines surrounding opioid medication., Results: Eighty-one percent of respondents reported prescribing opioids at discharge following routine sternotomy-based procedures, however, there remained significant variability in the type and dose of medication prescribed. The median (interquartile range) number of pills prescribed was 30 (20-30) with a median total dose of 135 (113-200) Morphine Milligram Equivalents. Informal teaching was the most commonly reported primary influence on prescribing habits and a lack of formal education regarding opioid prescription was associated with a higher number of pills prescribed. A majority of respondents (91%) felt that there would be value in establishing practice guidelines for opioid prescription following cardiac surgery., Conclusions: Significant variability exists with respect to routine opioid prescription at discharge following cardiac surgery. Education has come predominantly from informal sources and there is a desire for guidelines. Standardization in this area may have a role in combatting the opioid epidemic., (© 2020 Wiley Periodicals LLC.)

Background: A recent clinical trial showed that self-expandable transcatheter aortic valve replacement (TAVR) was non-inferior to surgical aortic valve replacement (SAVR). However, the cost-effectiveness of self-expandable TAVR in the intermediate-risk population remains unknown., Methods: A cost-utility analysis from the Canadian health care system payer's perspective was undertaken to compare self-expandable TAVR with SAVR. A fully probabilistic Markov model over the patient's lifetime was constructed to estimate differences in costs (2016 Canadian dollars) and effectiveness (quality-adjusted life-years [QALYs]), discounted at 1.5% per annum. Incremental cost-effectiveness ratios (ICERs) were calculated. Efficacy inputs were obtained from the Surgical Replacement and Transcatheter Aortic Valve Implantation trial, and costs were primarily obtained from the Canadian Institute of Health Information. Probabilistic analysis (PA) and one-way deterministic sensitivity analyses were conducted around key point estimates to address uncertainty., Results: In the base case analysis, with discounting, the total lifetime costs (mean ± standard deviation) in the TAVR and SAVR arms were $44,299 ± $7,260 and $32,994 ± $13,434, respectively, whereas total effectiveness values were 6.42 ± 1.33 QALYs and 6.28 ± 1.32 QALYs, respectively. This yielded an incremental cost of $11,305 and incremental effectiveness of 0.15 QALYs when TAVR was compared with SAVR for an ICER of $76,736/QALY. In the PA, there was moderate uncertainty, with 52.8% and 57.2% of simulations less than willingness-to-pay thresholds of $50,000 and $100,000, respectively. In the sensitivity analysis, when the cost of TAVR valve system was priced at $17,397 (base case $22,000 Canadian dollars), TAVR was found to be cost-effective at a willingness-to-pay threshold of $50,000/QALY., Conclusions: Self-expandable TAVR was found to be cost-effective; however, there was moderate uncertainty, reflecting the non-inferiority nature of the data., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: Although transcatheter aortic valve implantation has been shown to be noninferior to surgical aortic valve replacement in patients with severe aortic stenosis at intermediate surgical risk, the cost-effectiveness of this strategy in this population is unknown. Our objective was to conduct a cost-utility analysis comparing transcatheter aortic valve implantation with surgical aortic valve replacement in the population with intermediate risk severe aortic stenosis., Methods: A fully probabilistic Markov model with 30-day cycles was constructed from the Canadian third-party payer's perspective to estimate the difference in cost and effectiveness (measured as quality-adjusted life years) of transcatheter aortic valve implantation versus surgical aortic valve replacement for intermediate-risk patients over a lifetime time horizon, discounted at 1.5% per annum. Clinical trial data from The Placement of Aortic Transcatheter Valve 2 informed the efficacy inputs. Costs (adjusted to 2016 Canadian dollars) were obtained from the Canadian Institute of Health Information and the Ontario Schedule of Benefits. Incremental cost-effectiveness ratios were calculated., Results: In the base-case analysis, total lifetime costs for transcatheter aortic valve implantation were $10,548 higher than surgical aortic valve replacement but added 0.23 quality-adjusted life years, for an incremental cost-effectiveness ratio of $46,083/quality-adjusted life-years gained. Deterministic 1-way analyses showed that the incremental cost-effectiveness ratio was sensitive to rates of complications and cost of the transcatheter aortic valve implantation prosthesis. There was moderate-to-high parameter uncertainty; transcatheter aortic valve implantation was the preferred option in only 52.7% and 55.4% of the simulations at a $50,000 and $100,000 per quality-adjusted life years willingness-to-pay thresholds, respectively., Conclusions: On the basis of current evidence, transcatheter aortic valve implantation may be cost-effective for the treatment of severe aortic stenosis in patients with intermediate surgical risk. There remains moderate-to-high uncertainty surrounding the base-case incremental cost-effectiveness ratio., (Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The objectives were to compare actual respiratory syncytial virus (RSV) hospitalization rates and costs in a cohort of Inuit infants to hypothetical palivizumab prophylaxis strategies for infants of all gestational ages in the Eastern Canadian Arctic., Methods: Incidence and costs of RSV hospitalization were collected for infants admitted to the Baffin Regional Hospital in 2002, before the initiation of palivizumab. There was a comparison of the actual costs to the costs associated with 8 palivizumab strategies stratified by age (<6 months, <1 year) and location (overall, town [Iqaluit], rural communities). It was assumed that each category would receive universal palivizumab prophylaxis resulting in a 78% decrease in RSV admissions. The net costs incurred, number needed to treat (NNT), and incremental costs per hospitalization avoided were calculated for each comparison., Results: There was a great variation in the rates and costs associated with RSV admissions between Iqaluit and the communities. For infants <1 year of age residing in Iqaluit, the mean admission cost was $3915, and palivizumab prophylaxis had an NNT of 20.4 and cost of $162,551 per admission avoided. For rural infants <6 months, the mean cost of admission was $23,030, and palivizumab prophylaxis resulted in an NNT of 3.9 to 2.5 and cost savings of up to $8118 per admission avoided., Conclusions: Due to the high rates and costs associated with RSV admissions, administration of palivizumab in rural communities in the Canadian Arctic to infants less than 6 months of age could result in net cost savings.

Introduction: Canadian, Inuit, full term infants have the highest rate of respiratory syncytial virus (RSV) infection globally, which results in substantial costs associated hospitalisation., Methods: Decision-analytical techniques were used to estimate the incremental cost-effectiveness ratio (ICER) for palivizumab compared to no prophylaxis for Inuit infants of all gestational age. The time horizon was that of life-time follow-up, and costs and effectiveness were discounted at 5% per year. Costs (2007 CAD$) for palivizumab, hospitalisation (including medical evacuation, intensive care unit [ICU]), physician visits, and transportation were calculated based on the Canadian payer's perspective. Benefits on decreasing RSV hospitalisation were expressed as quality-adjusted life-years (QALYs). One-way and probabilistic sensitivity analysis (PSA) were conducted, varying: mortality rates, utilities, length of stay in hospital and ICU., Results: For all of Baffin Island infants (<1 year), the ICER was $39,435/QALY. However, when infants were grouped by age and area of residence, those residing in Iqaluit (<1 year) had an ICER of $152,145/QALY, while those residing in rural areas (outside of Iqaluit) had an ICER of $24,750/QALY. Prophylaxis was a dominant strategy (cost saving) for rural infants under 6 months of age, with the PSA demonstrating that it was dominant 98% of the time., Conclusions: The ICERs suggested that palivizumab is a cost-effective option for the prevention of RSV for Inuit infants on Baffin Island compared to no prophylaxis. Palivizumab is highly cost effective in Arctic infants <1 year of age specifically residing outside of Iqaluit and is a dominant strategy for those under 6 months of age in rural areas. However, palivizumab is not cost effective compared to no treatment for infants of all ages residing in Iqaluit.