Background A significant share of the cost of cancer care is concentrated in the end-of-life period. Although quality measures of aggressive treatment may guide optimal care during this timeframe, little is known as to whether these metrics affect costs of care. Methods We used population data to identify a cohort of patients who died of cancer in Ontario, Canada (2005 to 2009). Individuals were categorized as having received aggressive end-of-life care or not, according to quality measures related to acute institutional care or chemotherapy administration in the end-of-life period. Costs (2009 $CAN) were collected over the last month of life by linking health system administrative databases. Multivariable quantile regression was used to identify predictors of increased costs. Results Among 107,253 patients, the mean per patient cost over the final month was $18,131 for patients receiving aggressive care and $12,678 for patients receiving non-aggressive care (p<0.0001). Patients who received chemotherapy in the last 2 weeks of life also sustained higher costs compared to those who did not (p<0.0001). For individuals receiving end-of-life care in the highest cost quintile, early and repeated palliative care consultation was associated with reduced mean per patient costs. On multivariable analysis, chemotherapy in the 2 weeks of life remained predictive of increased costs (median increase $536; p<0.0001) whereas access to palliation remained predictive for lower costs (median decrease $418; p<0.0001). Conclusions Cancer patients who receive aggressive end-of-life care incur 43% higher costs than those managed non-aggressively. Palliative consultation may partially offset these costs and offer resultant savings.

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Objective: Administrative data validation is essential for identifying biases and misclassification in research. The objective of this study was to determine the accuracy of diagnostic codes for acute stroke and transient ischemic attack (TIA) using the Ontario Stroke Registry (OSR) as the reference standard. Methods: We identified stroke and TIA events in inpatient and emergency department (ED) administrative data from eight regional stroke centres in Ontario, Canada, from April of 2006 through March of 2008 using ICD-10-CA codes for subarachnoid haemorrhage (I60, excluding I60.8), intracerebral haemorrhage (I61), ischemic (H34.1 and I63, excluding I63.6), unable to determine stroke (I64), and TIA (H34.0 and G45, excluding G45.4). We linked administrative data to the Ontario Stroke Registry and calculated sensitivity and positive predictive value (PPV). Results: We identified 5,270 inpatient and 4,411 ED events from the administrative data. Inpatient administrative data had an overall sensitivity of 82.2% (95% confidence interval [CI 95% ] = 81.0, 83.3) and a PPV of 68.8% (CI 95% = 67.5, 70.0) for the diagnosis of stroke, with notable differences observed by stroke type. Sensitivity for ischemic stroke increased from 66.5 to 79.6% with inclusion of I64. The sensitivity and PPV of ED administrative data for diagnosis of stroke were 56.8% (CI 95% = 54.8, 58.7) and 59.1% (CI 95% = 57.1, 61.1), respectively. For all stroke types, accuracy was greater in the inpatient data than in the ED data. Conclusion: The accuracy of stroke identification based on administrative data from stroke centres may be improved by including I64 in ischemic stroke type, and by considering only inpatient data.

The potential for serious complications after venous air embolism and successful malpractice liability claims are the principle reasons for the dramatic decline in the use of the sitting position in neurosurgical practice. Although there have been several studies substantiating the relative safety compared with the prone or park bench positions, its use will continue to decline as neurosurgeons abandon its application and trainees in neurosurgery are not exposed to its relative merits. How can individual surgeons continue to use this position? Will individual, difficult surgical access cases be denied the obvious technical advantages of the sitting position? Limited use of the sitting position should remain in the neurosurgeon's armamentarium. However, several caveats must be emphasized. Assessment of the relative risk-benefit, based on the individual patient's physical status and surgical implications for the particular intracranial pathology, is of paramount importance. The patient should be informed of the specific risks of venous air embolism, quadriparesis and peripheral nerve palsies. Appropriate charting of patient information provided and special consent issues are essential. An anaesthetic input into the decision to use the sitting position is a sine qua non. The presence of a patient foramen ovale is an absolute contraindication. Preoperative contrast echocardiography should be used as a screening technique to detect the population at risk of paradoxical air embolism caused by the presence of a patent foramen ovale. The technique involves i.v. injection of saline agitated with air and a Valsalva manoeuvre is applied and released. Use of this position necessitates supplementary monitoring to promptly detect and treat venous air embolism. Doppler ultrasonography is the most sensitive of the generally available monitors to detect intracardiac air. The use of a central venous catheter is recommended, with the tip positioned close to the superior vena cava junction with the right atrium, to aspirate intravascular gas. Measures to minimize hypotension associated with the sitting position include a slow, staged positioning over 5-10 min and use of the 'G suit' inflated with compressed air applied to the lower extremities and pelvis. Use of the sitting or upright position for patients undergoing posterior fossa and cervical spine surgery presents unique challenges for the anaesthetist. With appropriate patient selection and preparation, and using prudent intraoperative monitoring and anaesthetic techniques, selected patients should still benefit from the optimum access to mid-line lesions, improved cerebral venous decompression, lower intracranial pressure and enhanced gravity drainage of blood and CSF associated with the sitting position.

Objective: The objective of the present analysis was to determine the publicly funded health care costs associated with the care of breast cancer (BCa) patients by disease stage. Methods: Incident cases of female invasive BCa (2005–2009) were extracted from the Ontario Cancer Registry and linked to administrative datasets from the publicly funded system. The type and use of health care services were stratified by disease stage over the first 2 years after diagnosis. Mean costs and costs by type of clinical resource used in the care of BCa patients were compared with costs for a matched control group. The attributable cost for the 2-year time horizon was determined in 2008 Canadian dollars. Results: This cohort study involved 39,655 patients with BCa and 190,520 control subjects. The average age in those groups was 61.1 and 60.9 years respectively. Most BCa patients were classified as either stage I (34.4%) or stage II (31.8%). Of the BCa cohort, 8% died within the first 2 years after diagnosis. The overall mean cost per BCa case from a public payer perspective in the first 2 years after diagnosis was $41,686. Over the 2-year time horizon, the mean cost increased by stage: I, $29,938; II, $46,893; III, $65,369; and IV, $66,627. The attributable cost of BCa was $31,732. Cost drivers were cancer clinic visits, physician billings, and hospitalizations. Conclusions: Costs of care increased by stage of BCa. Cost drivers were cancer clinic visits, physician billings, and hospitalizations. These data will assist planning and decision-making for the use of limited health care resources.

Background/Aims: The reliability of diagnostic coding of acute stroke and transient ischemic attack (TIA) in administrative data is uncertain. The purpose of this study is to determine the agreement between administrative data sources and chart audit for the identification of stroke type, stroke risk factors, and the use of hospital-based diagnostic procedures in patients with stroke or TIA. Methods: Medical charts for a population-based sample of patients (n = 14,508) with ischemic stroke, intracerebral hemorrhage (ICH), or TIA discharged from inpatient and emergency departments (ED) in Ontario, Canada, between April 1, 2012 and March 31, 2013, were audited by trained abstractors. Audited data were linked and compared with hospital administrative data and physician billing data. The positive predictive value (PPV) of hospital administrative data and kappa agreement for the reporting of stroke type were calculated. Kappa agreement was also determined for stroke risk factors and for select stroke-related procedures. Results: The PPV for stroke type in inpatient administrative data ranged from 89.5% (95% CI 88.0-91.0) for TIA, 91.9% (95% CI 90.2-93.5) for ICH, and 97.3% (95% CI 96.9-97.7) for ischemic stroke. For ED administrative data, PPV varied from 78.8% (95% CI 76.3-81.2) for ischemic, 86.3% (95% CI 76.8-95.7) for ICH, and 95.3% (95% CI 94.6-96.0) for TIA. The chance-corrected agreement between the audited and administrative data was good for atrial fibrillation (k = 0.60) and very good for diabetes (k = 0.86). Hospital administrative data combined with physician billing data more than doubled the observed agreement for carotid imaging (k = 0.65) and echocardiography (k = 0.66) compared to hospital administrative data alone. Conclusions: Inpatient and ED administrative data were found to be reliable in the reporting of the International Classification of Diagnosis, 10th revision, Canada (ICD-10-CA)-coded ischemic stroke, ICH and TIA, and for the recording of atrial fibrillation and diabetes. The combination of physician billing data with hospital administrative data greatly improved the capture of some diagnostic services provided to inpatients.

Nursing care documentation based on requirements for individual patients demonstrates that the rate of postoperative adverse events affects the amount of nursing resources needed in the PACU.

Objective Administrative data are used to describe the pancreatic cancer (pcc) population. The analysis examines demographic details, incidence, site, survival, and factors influencing mortality in a cohort of individuals diagnosed with pcc.Methods Incident cases of pcc diagnosed in Ontario between 1 January 2004 and 31 December 2011 were extracted from the Ontario Cancer Registry. They were linked by encrypted health card number to several administrative databases to obtain demographic and mortality information. Descriptive, bivariate, and survival analyses were conducted.Results During the period of interest, 9221 new cases of pcc (4548 in men, 4673 in women) were diagnosed, for an age-adjusted standardized annual incidence in the range of 8.6-9.5 per 100,000 population. Mean age at diagnosis was 70.3 ± 12.5 years (standard deviation). Five-year survival was 7.2% (12.8% for those <60 years of age and 3.6% for those >80 years of age). Survival varied by sex, older age, rural residence, lower income, site of involvement in the pancreas, and presence of comorbidity. ConclusionsThe mortality rate in pcc is exceptionally high. With an increasing incidence and a mortality positively associated with age, additional support will be needed for this highly fatal disease as demographics in Ontario continue to trend toward a higher proportion of older individuals.