Assessment of Knowledge Regarding Risks and Benefits of the Use of Non-Vitamin K Antagonist Oral Anticoagulants.

BACKGROUND: Non-vitamin K antagonist oral anticoagulants (NOAC) have replaced vitamin K antagonist (VKA) oral anticoagulants as the first-line treatment option for stroke prevention in high-risk patients with atrial fibrillation. With VKA therapy, disease and treatment-related knowledge is associated with improved adherence and outcomes. There is concern that due to the lack of need for ongoing visits for laboratory monitoring in patients on NOACs, there is less opportunity for education, leading to poor disease- and treatment-related knowledge in this patient group. METHODS: One hundred ninety-nine (199) patients presenting to 2 primary care clinics on NOAC therapy were surveyed regarding atrial fibrillation and their knowledge regarding NOACs. Chart review was completed to determine patient characteristics and data obtained was compared with survey results to determine the accuracy of the survey responses. RESULTS: Patients with a lower degree of NOAC knowledge tended to be older (P < .001), have higher Charlson Comorbidity Index scores (P = .001), use apixaban more often (P = .008), and have been on NOACs for a shorter time period (P = .007). CONCLUSIONS: There is an opportunity to improve NOAC-related knowledge in patients with atrial fibrillation. When developing educational interventions, patient characteristics associated with poor knowledge should be considered. Based on our results, these are patients who are older, more medically complex, are on apixaban, and have been on NOAC therapy for a shorter duration.

Tau polygenic risk scoring: a cost-effective aid for prognostic counseling in Alzheimer's disease.

Tau deposition is one of two hallmark features of biologically defined Alzheimer's disease (AD) and is more closely related to cognitive decline than amyloidosis. Further, not all amyloid-positive individuals develop tauopathy, resulting in wide heterogeneity in clinical outcomes across the population with AD. We hypothesized that a polygenic risk score (PRS) based on tau PET (tau PRS) would capture the aggregate inherited susceptibility/resistance architecture influencing tau accumulation, beyond solely the measurement of amyloid-ß burden. Leveraging rich multimodal data from a population-based sample of older adults, we found that this novel tau PRS was a strong surrogate of tau PET deposition and captured a significant proportion of the variance in tau PET levels as compared with amyloid PET burden, APOE (apolipoprotein E) ε4 (the most common risk allele for AD), and a non-APOE PRS of clinical case-control AD risk variants. In independent validation samples, the tau PRS was associated with cerebrospinal fluid phosphorylated tau levels in one cohort and with postmortem Braak neurofibrillary tangle stage in another. We also observed an association of the tau PRS with longitudinal cognitive trajectories, including a statistical interaction of the tau PRS with amyloid burden on cognitive decline. Although additional study is warranted, these findings demonstrate the potential utility of a tau PRS for capturing the collective genetic background influencing tau deposition in the general population. In the future, a tau PRS could be leveraged for cost-effective screening and risk stratification to guide trial enrollment and clinical interventions in AD.

Impact of robotic single and dual console systems in the training of minimally invasive gynecology surgery (MIGS) fellows.

The advantages of dual console use in robotic surgical education have not been described. The aims of this study are to compare fellow console time, surgical steps performed, and surgical takeovers between attending and fellow surgeons using dual versus single console robotic systems. Participants included minimally invasive gynecologic surgery (MIGS) fellows (N = 3) and subspecialty trained gynecologic surgeons (N = 5). Prospective data were obtained on 126 patients (N = 77 single console, N = 49 dual console) undergoing robotic hysterectomy. Variables included demographics, surgical characteristics (fellow, month of fellowship, attending surgeon, concomitant oophorectomy, additional surgical procedures, estimated blood loss, specimen weight), and outcomes (console time, docking time, console time/docking time ratio, total case time, number of surgical steps performed by the fellow, number of surgical takeovers, complications). After controlling for potential confounders, fellows spent a mean of 25.8 min longer (P < 0.001) at the console in dual console operations compared to single. Dual console surgeries had a greater number of steps performed by the fellow (OR[> 5 steps]: 3.37, P = 0.009), a higher console time/docking time ratio (P < 0.001), and more surgical takeovers between fellow and attending (OR [> 1 takeover]: 3.53, P < 0.001). There were no significant differences between the two groups regarding docking time (P = 0.15), case time (P = 0.79), or complications (P = 0.30). Our findings suggest dual console robotic training provide fellows the opportunity for more "hands-on" experience with longer console time, higher number of surgical steps performed, and added interaction with the attending surgeon when compared with single console training. These surgical metrics provide objectivity in competency-based robotic training without increasing the complications or surgical time.

Factors Associated with Burnout and Frustration among Minimally Invasive Gynecologic Surgery Fellows.

STUDY OBJECTIVE: Determine the prevalence of burnout and frustration among participants currently completing a fellowship in minimally invasive gynecologic surgery (FMIGS). DESIGN: Cross-sectional survey. SETTING: An anonymous survey was distributed to fellows in November 2018. PARTICIPANTS: Current FMIGS fellows. INTERVENTIONS: Not applicable. MEASUREMENTS AND MAIN RESULTS: A total of 57 of 83 (67.7%) FMIGS participants in American Association of Gynecologic Laparoscopists-accredited programs completed a survey regarding fellowship characteristics and experiences. Overall, 40 participants (70.2%) indicated that they were satisfied with their fellowship program experience. There were 33 participants (57.9%) who reported burnout, and 38 participants (66.7%) had experienced anxiety, depression, or extreme fatigue during the last month. Of those who reported burnout, 26 (76.5%) reported that they did not receive support from their fellowship program. Participants who experienced burnout were more likely to be in their second year (p = .003), spent less time per week doing scholarly activities (p = .048), and were less satisfied with their fellowship experience (p <.001). Participants who experienced anxiety, depression, or extreme fatigue had more cofellows in their program (p = .031), worked on average more hours per week (p = .020), and were more often required to practice obstetrics in their fellowship (p = .022). CONCLUSION: Burnout symptoms are common among physicians across multiple specialties. Our findings suggest that this issue is prevalent among FMIGS participants. In addition, there is a lack of access to emotional and psychologic support programs for fellows experiencing burnout. We hope that this study will prompt attention to this important topic by both individual programs and American Association of Gynecologic Laparoscopists as a society to increase awareness and access to resources and promote wellness for fellows.

ACOG Simulation Working Group: A Needs Assessment of Simulation Training in OB/GYN Residencies and Recommendations for Future Research.

OBJECTIVE: To evaluate current availability and needs of simulation training among obstetrics/gynecology (OB/GYN) residency programs. DESIGN: Cross-sectional survey. SETTING: Accreditation Council for Graduate Medical Education accredited OB/GYN residency programs in the United States. PARTICIPANTS: Residency program directors, gynecology simulation faculty, obstetrics simulation faculty, and fourth-year residents. RESULTS: Of 673 invited participants, 251 (37.3%) completed the survey. Among the survey responses, OB procedures were more broadly represented compared to the GYN procedures for simulation teaching: 8 (50%) of 16 OB procedures versus 4 (18.2%) of 22 GYN procedures had simulation teaching. Among the simulated procedures, a majority of residents and faculty reported that simulation teaching was available for operative vaginal delivery, postpartum hemorrhage, shoulder dystocia, perineal laceration repair, conventional laparoscopic procedures, and robotic surgery. There were significant differences between residents and faculty perceptions regarding the availability and needs of simulated procedures with a minority of residents having knowledge of Council on Resident Education in Obstetrics and Gynecology (47.2%) and American College of Obstetrics and Gynecology (27.8%) simulation tools compared to the majority of faculty (84.7% and 72.1%, respectively). More than 80% of trainees and faculty reported they felt the average graduating resident could perform vaginal, laparoscopic, and abdominal hysterectomies independently. CONCLUSIONS: Simulation is now widely available for both gynecologic and obstetric procedures, but there remains tremendous heterogeneity between programs and the perceptions of residents, program directors, and faculty. The variations in simulation training and readiness for performing different procedures following residency support the need for objective, validated assessments of actual performance to better guide resident learning and faculty teaching efforts.

Association of MAPT H1 subhaplotypes with neuropathology of lewy body disease.

BACKGROUND: Genetic variation at the microtubule-associated protein tau locus is associated with clinical parkinsonism. However, it is unclear as to whether microtubule-associated protein tau H1 subhaplotypes are associated with the burden of neuropathological features of Lewy body disease. OBJECTIVES: To evaluate associations of microtubule-associated protein tau haplotypes with severity of Lewy body pathology and markers of SN neuronal loss in Lewy body disease cases. METHODS: Five hundred eighty-five autopsy-confirmed Lewy body disease cases were included. Six microtubule-associated protein tau variants (rs1467967, rs242557, rs3785883, rs2471738, rs8070723, and rs7521) were genotyped to define common microtubule-associated protein tau haplotypes. Lewy body counts were measured in five cortical regions. Ventrolateral and medial SN neuronal loss were assessed semiquantitatively. Nigrostriatal dopaminergic degeneration was quantified by image analysis of tyrosine hydroxylase immunoreactivity in the dorsolateral and ventromedial putamen. RESULTS: The common microtubule-associated protein tau H2 haplotype did not show a strong effect on pathological burden in Lewy body disease. The rare H1j haplotype (1.3%) was significantly associated with a lower dorsolateral putaminal tyrosine hydroxylase immunoreactivity (and therefore greater dopaminergic degeneration) compared to other microtubule-associated protein tau haplotypes (P = 0.0016). Microtubule-associated protein tau H1j was also nominally (P ≤ 0.05) associated with a lower ventromedial putaminal tyrosine hydroxylase immunoreactivity (P = 0.010), but this did not survive multiple testing correction. Other nominally significant associations between microtubule-associated protein tau H1 subhaplotypes and neuropathological outcomes were observed. CONCLUSIONS: A rare microtubule-associated protein tau H1 subhaplotype (H1j) may be associated with more severe putaminal dopaminergic degeneration in Lewy body disease cases. Microtubule-associated protein tau H1j has been associated previously with an increased risk of PD, and therefore our exploratory findings provide insight into the mechanism by which H1j modulates PD risk. © 2019 International Parkinson and Movement Disorder Society.

Cost-Utility of Routine Testing in Chronic Urticaria/Angioedema: A Cohort Study.

BACKGROUND: Chronic urticaria/angioedema (CUA) guidelines recommend limiting tests to diagnose and assess prognosis, activity, and severity. Routine testing in CUA might substantially increase cost of disease without benefiting outcome. OBJECTIVE: To evaluate the utility of tests in CUA and how they influence the cost of disease. METHODS: We reviewed 725 electronic medical records of patients who were evaluated for CUA between 2010 and 2018 at a tertiary care center. The sample was gathered through the search of International Classification of Diseases Ninth and Tenth Revision codes pertaining to CUA. Analyses were made to evaluate changes in outcome for patients on whom at least 1 test was performed to evaluate CUA, the costs generated by these tests, and the tendencies to order specific tests from 2010 through 2018. RESULTS: Of 725 patients (age median, 47 years; women, 73.1%), 543 (74.8%) had at least 1 test performed. Tests had an elevated percentage of normal results (>90%). Five patients (0.9%) had a change in outcome and 8 patients were given a different diagnosis (0.1% each). Evaluation, management, and tests accounted for most of the costs. Costs remain similar between 2010-2014 (mean, $569) and 2015-2018 (mean, $569). CONCLUSIONS: In CUA, tests rarely uncover underlying conditions or lead to changes in management and outcome, but they substantially increase the costs generated by the disease. Adherence to current recommendations to limit testing might help in reducing the financial burden of CUA and improve delivery of care.

Assessment of an automated surveillance system for detection of initial ventilator-associated events.

Surveillance for initial ventilator-associated events (VAEs) was automated and compared with nonautomated review of episodes of mechanical ventilation. Sensitivity, specificity, positive predictive value, and negative predictive value of automated surveillance were very high (>93%), and automated surveillance reduced the time spent on detection of VAEs by >90%.

Assessment of virtual reality robotic simulation performance by urology resident trainees.

OBJECTIVES: To examine resident performance on the Mimic dV-Trainer (MdVT; Mimic Technologies, Inc., Seattle, WA) for correlation with resident trainee level (postgraduate year [PGY]), console experience (CE), and simulator exposure in their training program to assess for internal bias with the simulator. DESIGN: Residents from programs of the Southeastern Section of the American Urologic Association participated. Each resident was scored on 4 simulator tasks (peg board, camera targeting, energy dissection [ED], and needle targeting) with 3 different outcomes (final score, economy of motion score, and time to complete exercise) measured for each task. These scores were evaluated for association with PGY, CE, and simulator exposure. SETTING: Robotic skills training laboratory. PARTICIPANTS: A total of 27 residents from 14 programs of the Southeastern Section of the American Urologic Association participated. RESULTS: Time to complete the ED exercise was significantly shorter for residents who had logged live robotic console compared with those who had not (p = 0.003). There were no other associations with live robotic console time that approached significance (all p ≥ 0.21). The only measure that was significantly associated with PGY was time to complete ED exercise (p = 0.009). No associations with previous utilization of a robotic simulator in the resident's home training program were statistically significant. CONCLUSIONS: The ED exercise on the MdVT is most associated with CE and PGY compared with other exercises. Exposure of trainees to the MdVT in training programs does not appear to alter performance scores compared with trainees who do not have the simulator.

Noninvasive assessment of right heart function and hemodynamics during exercise in patients with pulmonary arterial hypertension.

OBJECTIVES: Noninvasive assessment of right heart function and hemodynamics in patients with pulmonary arterial hypertension (PAH) is most often performed at rest, whereas the symptoms, in general, present with exertion. Assessment during exertion is limited to symptom assessment and the 6-minute walk distance. We investigated the feasibility of obtaining echocardiographic data that could accurately reflect pulmonary artery pressures (PAP), particularly mean PAP and right ventricular function during exercise in patients with PAH. METHODS: We investigated right ventricular function and hemodynamics using echocardiography during symptom-limited exercise in 10 consecutive patients undergoing right heart catheterization (RHC) as part of their clinical evaluation for PAH. We further assessed these measurements for correlation with known predictors of outcome in PAH in an exploratory analysis. RESULTS: We were able to successfully obtain complete right heart measurements by echocardiography, including mean PAP, in the majority (9 of 10) of the subjects. One patient had an incomplete tricuspid regurgitation jet at rest and with exercise. Echocardiographic pulmonary vascular resistance correlated with RHC cardiac output and brain natriuretic peptide level, whereas tricuspid annular plane systolic excursion during exercise correlated with right atrial pressure on RHC, brain natriuretic peptide, and 6-minute walk distance. Tricuspid regurgitation velocity and mean PAP with exercise correlated moderately with mean PAP and cardiac output by RHC. CONCLUSIONS: Exercise echocardiography can provide meaningful data in patients with PAH, including measuring mean PAP. The presence of correlations in this small number of patients indicates promising targets for future investigation.

Endoscopic assessment of the oesophageal features of eosinophilic oesophagitis: validation of a novel classification and grading system.

OBJECTIVE: Abnormalities are commonly identified during endoscopy in eosinophilic oesophagitis (EoE). There is no standardised classification to describe these features. This study aimed to evaluate the interobserver agreement of a grading system for the oesophageal features of EoE. METHOD: The proposed system incorporated the grading of four major oesophageal features (rings, furrows, exudates, oedema) and the presence of additional features of narrow calibre oesophagus, feline oesophagus, stricture and crepe paper oesophagus. Endoscopic videos from 25 patients with EoE and controls were reviewed by 21 gastroenterologists. Interobserver agreement was assessed by estimating multi-rater κ and the proportion of pairwise agreement. RESULTS: Using the original grading system, agreement for rings, furrows and exudates was moderate (κ=0.38-0.46, 56-65% agreement) but poor for oedema (κ=0.23, 51% agreement). Identification of narrow calibre oesophagus had fair agreement (κ=0.30, 74% agreement) while feline oesophagus had poor agreement (κ=0.15, 68% agreement). After collapsing the severity grading for oedema and furrows and eliminating poorly performing features of feline oesophagus and narrow calibre oesophagus, a modified grading system demonstrated good agreement for the four major features of EoE (κ=0.40-0.54, 71-81% agreement) and additional features of stricture and crepe paper oesophagus (κ=0.52 and 0.58, 79% and 92% agreement). CONCLUSIONS: The proposed system for endoscopically-identified oesophageal features of EoE defines common nomenclature and severity scores for the assessment of EoE disease activity. The system has good interobserver agreement among practising and academic gastroenterologists.

Quality in colonoscopy reporting: an assessment of compliance and performance improvement.

BACKGROUND: An ASGE-ACG task force developed quality indicators (QI) for documenting quality endoscopic procedures. Acceptable compliance rates have not been determined. AIMS: To determine our degree of compliance to the intra-procedure colonoscopy QI prior to intervention, design an educational intervention to improve those with low compliance, and to compare the degree of compliance after intervention. METHODS: 300 patients undergoing colonoscopy in the pre-intervention time period followed by 300 patients after the educational intervention were reviewed. Endoscopists were instructed on the required QI and provided with their individual baseline compliance results. Dictated endoscopy reports were reviewed for compliance. RESULTS: Four QIs; documentation of bowel preparation adequacy, appendiceal orifice, photographs of cecum, and polyp shape, had low pre-intervention achievement (64%, 53%, 20%, and 15% respectively) and significant change was observed (83%, 68%, 63%, and 54% respectively, all p<0.001). Four QIs; documentation of ileocecal valve, polyp size description, polyp location description, and follow up recommendations, had high levels of achievement prior to intervention (92%, 98%, 97% and 81% respectively) and no significant change was observed (all p≥0.16). CONCLUSION: This study provides benchmarks for ASGE/QIs in colonoscopy cases in a large group practice model. It demonstrates that a quality improvement intervention can result in improved compliance.

Quality in EUS: an assessment of baseline compliance and performance improvement by using the American Society for Gastrointestinal Endoscopy-American College of Gastroenterology quality indicators.

BACKGROUND: An American Society for Gastrointestinal Endoscopy-American College of Gastroenterology (ASGE-ACG) task force recently developed quality indicators for the preprocedure, intraprocedure, and postprocedure phases of each endoscopic procedure. Benchmark rates and clinical significance of compliance have not been determined. OBJECTIVES: To establish baseline compliance rates to the preprocedure and intraprocedure quality indicators in our EUS cases, identify indicators with the lowest compliance rates, and establish change in compliance rates with a targeted performance improvement plan. METHODS: We measured baseline compliance to each of the preprocedure and intraprocedure EUS quality indicators in the EUS procedures performed at Mayo Clinic Jacksonville from March 1996 through August 2006. We developed a performance improvement plan that targeted the 4 indicators with the lowest compliance over the entire time period. Compliance rates in the year after plan implementation were compared with those from January 2004 to August 2006, when adjusting for endoscopist and direct access. RESULTS: We demonstrated areas of high quality as well as areas for improvement in compliance with the ASGE-ACG quality metrics in a large cohort of EUS cases. We achieved improvement in all 4 areas targeted for quality improvement, statistically significant at the 5% level for two of the quality indicators. LIMITATIONS: Limitations included our retrospective design and the use of unstructured procedure dictations that may limit application of our results. It is also unclear whether compliance was truly synonymous with performance. CONCLUSIONS: We established reference levels of compliance rate within our practice and showed that a targeted performance improvement plan that consisted of awareness, individual accountability, and documentation can result in improvement.

Prospective evaluation of factors affecting operating time in a residency/fellowship training program incorporating robot-assisted laparoscopic prostatectomy.

BACKGROUND AND PURPOSE: A current dilemma is how to incorporate robot assisted laparoscopic radical prostatectomy (RALP) into residency/fellowship programs while containing costs and maintaining acceptable operative times. We prospectively analyzed factors that affect the time of nine separate RALP steps performed in a residency/fellowship training program incorporating the da Vinci robot. MATERIALS AND METHODS: A prospective evaluation of 50 consecutive RALP performed by a single surgeon while incorporating trainees was completed. RALP was divided into nine segments, and time of each segment was recorded in minutes. Who performed each portion of the procedure (resident, fellow, or attending surgeon) was also analyzed. The effects of clinical and prostate cancer characteristics were analyzed statistically to investigate associations with procedure completion times for each of the nine segments. Outcomes, including complications and urinary continence, were recorded. RESULTS: Mean age was 58 years, and body mass index was 30 kg/m(2). Mean prostate size was 49.2 grams. Nine patients (18%) had pathologic T(3) disease, and 10 patients (20%) had positive surgical margins. Median total operative time was 276 minutes (range 245-330 min). There was no statistical association with any clinical parameter prolonging total operative time or those of the nine individual steps of the operation. Locally weighted smooth time plots demonstrate stable decreases in all segments with experience. The slowest decreases were seen in bladder neck and neurovascular bundle times. Anastomosis time fluctuated the most. CONCLUSION: RALP can be incorporated successfully into a residency/fellowship training program with acceptable operative times and outcomes even while the supervising physician is on his "learning curve."

Brain injury after cardiopulmonary arrest and its assessment with diffusion-weighted magnetic resonance imaging.

OBJECTIVE: To characterize the frequency and pattern of diffusion-weighted imaging (DWI) abnormalities detected as part of brain magnetic resonance imaging (MRI) and their association with short-term neurologic outcomes in patients successfully resuscitated after cardiopulmonary arrest (CPA). PATIENTS AND METHODS: We retrospectively analyzed a case series of patients who experienced CPA between May 1, 2000, and April 29, 2004, at St Luke's Hospital in Jacksonville, Fla. Eligible patients required treatment by the Code Blue team and had 1 DWI study before discharge or death. Two neuroradiologists jointly classified DWI abnormalities by anatomic location. Outcome was measured by Cerebral Performance Category score. RESULTS: Resuscitation was performed 628 times during the 48-month study period. Of 514 CPA survivors, 18 (3.5%) had MRI studies. The median age was 62 years (interquartile range [IQR], 49-73), and 10 were men. Median code duration was 16 minutes (IQR, 11-19 minutes), and median code-to-scan time was 72 hours (IQR, 28-229 hours). A DWI abnormality was noted in 9 (50%) of 18 patients. Cortical areas (global and regional) were the most common sites of restricted diffusion. Diffusion-weighted imaging abnormalities were present in 7 (70%) of 10 patients with a poor neurologic outcome at discharge. CONCLUSION: Magnetic resonance imaging is performed rarely after survival of CPA. In this study with limited sample size, a greater proportion of patients with normal DWI findings had a good neurologic outcome at the time of hospital discharge vs those with abnormal findings. Prospective studies of early and serial MRI (with DWI) are needed to confirm this association and to clarify the prognostic usefulness of such studies.

Vardenafil rescue rates of sildenafil nonresponders: objective assessment of 327 patients with erectile dysfunction.

OBJECTIVES: To prospectively investigate whether vardenafil can effectively treat patients for whom sildenafil (100 mg) has failed. The introduction of two new oral phosphodiesterase type 5 inhibitors (tadalafil and vardenafil) raises the question of whether the new agents will permit us to treat sildenafil nonresponders with another oral agent. METHODS: Patients were seen at one institution during a 5-year period. A total of 327 patients complaining of sildenafil-refractory erectile dysfunction underwent intracavernous pharmacologic injection and color duplex Doppler ultrasonography. Subsequently 59 of these men tried vardenafil home dosing. RESULTS: Of the 327 men in whom sildenafil failed, 16% were younger than 50, 21% were 51 to 60, 34% were 61 to 70, and 28% were older than 70 years. The Doppler diagnoses were arterial insufficiency in 154 (47%), mixed vascular insufficiency in 73 (22%), and cavernous venous occlusive disease in 57 (17%). Forty-three men (13%) had normal erectile responses to prostaglandin E1 (10 to 20 microg). Of the 59 men who tried vardenafil, 19% were younger than 50, 17% were 51 to 60, 40% were 61 to 70, and 23% were older than 70 years. The Doppler diagnoses were arterial insufficiency in 28 (42%), mixed vascular insufficiency in 10 (19%), and cavernous venous occlusive disease in 15 (29%). Six men (8%) had normal erectile responses to prostaglandin E1. Only 7 (12%) of the 59 men reported that home vardenafil dosing resulted in successful intercourse. CONCLUSIONS: An appropriate diagnostic evaluation and subsequent treatment algorithm have yet to be established for those for whom phosphodiesterase type 5 inhibitors fail. We found that most sildenafil nonresponders had severe arterial insufficiency and were older, with 62% older than 60 years. Our preliminary experience suggests that only a small percentage (12%) of sildenafil nonresponders can be salvaged with vardenafil.

A cost effective method of identifying and recruiting persons over 80 free of dementia or mild cognitive impairment.

For observational or prevention studies, accurately identifying by mail and telephone cognitively normal elderly volunteers would be cost effective. We describe how to recruit cognitively normal sib-pairs over age 80 using commercially available lists by age and ZIP code. We mailed an Institutional Review Board-approved letter to 24,366 persons over 85 around Jacksonville, FL, and received approximately 3,000 postcard replies with approximately 500 answering 3 screening statements affirmatively. Of these, we recruited 128 persons who underwent both in-person and telephone evaluations, the latter using the Telephone Interview of Cognitive Status-modified (TICS-m) and Clinical Dementia Rating scale (CDR). Blinded to the TICS-m and CDR data, clinicians made a consensus diagnosis for each participant, 120 were normal and 8 had mild cognitive impairment. With CDR, 119 patients (93%) screened as normal, and of these 115 (97%) were confirmed as normal with the consensus diagnosis. A TICS-m score cut-off of <29 resulted in a similar proportion of normals in the screened sample (97% or 103/106); however, 13 normal volunteers would have been excluded because they scored <29 on the TICS-m. Supplementing the sample, we recruited 12 age-matched cases having consensus diagnosis of dementia (n=2) or mild cognitive impairment (n=10). A CDR>0 correctly identified 12/12, whereas the TICS-m <29 correctly identified 7/12. Hearing loss present in 50% did not influence TICS-m or CDR performance. Using stringent entry criteria and the telephone CDR, this method accurately identified normal elderly persons.

Associations between the hospitalist model of care and quality-of-care-related outcomes in patients undergoing hip fracture surgery.

OBJECTIVE: To investigate the relationship between the hospitalist consultant model of care and both length of hospital stay (LOS) and hospital cost for patients undergoing hip fracture surgery. PATIENTS AND METHODS: We retrospectively studied 118 consecutive patients admitted with hip fracture (diagnosis related groups 79.35 and 81.52) between January 1, 2002, and December 31, 2002, at a community-based academic medical center. For each patient, consultations for preoperative medical evaluation and management of postoperative complications were performed by a hospitalist or a traditional medical consultant (nonhospitalist). We defined "hospitalist" as dedicated hospital-based physicians who provide their maximum professional time in inpatient health care delivery and who are completely free of outpatient responsibilities. Time to consultation (TTC), time to surgery (TTS), LOS, and total hospital costs were determined for each patient by review of the medical records and were compared between hospitalist and nonhospitalist consultants. RESULTS: Both TTC and TTS were significantly lower for hospitalist patients (P < .001 and P = .004, respectively). Although not statistically significant, cost and LOS also were lower for patients receiving hospitalist care. In the hospitalist group, median cost was an estimated dollar 1777 less, and median LOS was 1 day less than in the nonhospitalist group. CONCLUSION: Hospitalist Involvement in the medical management of patients undergoing hip fracture surgery may be associated with decreases in TTC, TTS, LOS, and total hospital cost. The results of this study have implications for consultative medical care of patients undergoing urgent surgery and their health outcomes.