A Multicomponent Model to Improve Hospital Care of Older Adults with Cognitive Impairment: A Propensity Score-Matched Analysis.

OBJECTIVES: To determine whether a multicomponent intervention improves care in hospitalized older adults with cognitive impairment. DESIGN: One-year retrospective chart review with propensity score matching on critical demographic and clinical variables was used to compare individauls with cognitive impairmenet on intervention and nonintervention units. SETTING: Large tertiary medical center. PARTICIPANTS: All hospitalized individuals age 65 and older with cognitive impairment admitted to medicine who required constant or enhanced observation for behavioral and psychological symptoms. INTERVENTION: Multicomponent intervention (geographic unit cohorting, multidisciplinary approach, patient engagement specialists (PES), staff education) or usual care. MEASUREMENTS: In-hospital mortality, length of stay, readmission, management of behavioral disturbances. RESULTS: After propensity score matching, 476 of the 712 intervention visits were pair-matched with 476 of the 558 usual care visits. Matching was successful in balancing baseline covariates between intervention and usual care units. Individuals admitted to the intervention unit had lower in-hospital mortality (1.1% vs 2.9%, p=0.05) and shorter stays (5.0 vs 5.8 days, p=0.04). There was no difference in discharge home (p=0.90) or 30-day readmission rates (p=0.44). Individuals on the intervention unit were less likely than those receivng usual care to have an order for constant (12.0% vs 45.8%, p<0.01) or enhanced (22.1% vs 79.6%, p<0.01) observation, to be taking benzodiazepines (26.3% vs 38.0%, p<0.01), to be taking nothing by mouth (29.6% vs 40.8%, p=0.01), to be on bedrest (17.0% vs 25.8%, p=0.01), to be taking antipsychotics (41.2% vs 54.0%, p<0.01), or to have restraints (3.2% vs 6.9%, p=.01). CONCLUSION: A multicomponent intervention of geographic cohorting, multidisciplinary approach, PES, and staff education may offer a new paradigm in the management of hospitalized older adults with cognitive impairment.

Histopathologic margin distance in survival in resection of cutaneous melanoma of the head and neck.

OBJECTIVES/HYPOTHESIS: Treatment of cutaneous melanoma involves surgical excision with wide clinical margins. No guidelines regarding safe histopathologic margin distance exist. This study examines the impact of histopathologic margin, measured from closest cut edge of the specimen, on overall survival in resection of cutaneous melanoma of the head and neck. We hypothesize that close histopathologic margins (<2 mm) are associated with decreased survival. STUDY DESIGN: Retrospective chart review. METHODS: A total of 637 patients were treated for cutaneous melanoma of the head and neck between 2001 and 2011. Demographics, tumor characteristics, histopathologic margin distance (from a pathology database), and survival data from state health registries and health system clinical data repositories were used to create a dataset. Cox regression models and Kaplan-Meier curves were used to analyze data, adjusting for age, tumor location, ulceration, and depth of invasion (DOI). RESULTS: When analyzing for overall survival, Cox multivariate regression analysis showed age (hazard ratio [HR] = 1.0-1.1), DOI (HR = 1.2-1.5), ulceration (HR = 1.3-3.8), and subsite (ear, HR = 1.0-3.9) were significant predictors of survival. Histopathologic margin distance was not significant for predicting survival. Three percent of histopathologic margins were <1 mm. CONCLUSIONS: In a large dataset of head and neck cutaneous melanoma, known factors associated with overall survival (age, DOI, ulceration, subsite) proved significant, validating the dataset. Examining the effect of histopathologic margin distance on survival, while controlling for these factors, we failed to reject the null hypothesis. Margin distance as measured by histopathology does not affect survival. LEVEL OF EVIDENCE: 4.

Cost-based decision analysis of postreduction imaging in the management of mandibular fractures.

IMPORTANCE: Immediate postreduction imaging is a standard practice in the management of mandibular fractures at many hospitals. However, the literature suggests that postreduction imaging in maxillofacial fractures fails to influence clinical decision making significantly. OBJECTIVES: To determine the cost-effectiveness of different clinical decision pathways regarding postreduction imaging as it relates to the experience of the surgeon, and to demonstrate that baseline postreduction imaging has utility based on the complication rate of the surgeon. DESIGN, SETTING, AND PARTICIPANTS: We developed a decision tree model using commercially available software. The model accounted for cost of imaging modalities, adequacy of reduction, complication rate, cost of initial operating room time, and, if applicable, operative charges for revision surgery in the event of a complication. A review of the University of Virginia clinical data repository of 100 patients with recent mandible fractures was used to estimate the cost associated with running an operating suite for mandibular fracture repair. The University of Virginia billing system also provided costs associated with a single computed tomogram, panoramic radiography, and intraoperative 3-dimensional computed tomography. A sensitivity analysis determined how variation in complication rate affects the cost of the decision pathways. INTERVENTION: Intraoperative imaging, postreduction imaging, or no imaging. MAIN OUTCOMES AND MEASURES: Sensitivity of the decision tree model to variation in complication rate. RESULTS: Using current hospital charges, the model is sensitive to variability in the complication rate with a breakpoint of 17.7%. It is most cost-effective to obtain a post-reduction panorex if the surgeon's complication rate is above 17.7% and most cost-effective not to obtain any postreduction imaging if the complication rate is below 17.7%. Intraoperative computed tomography is not cost-effective at any complication rate. Two-way sensitivity analysis allowed the model to be generalizable to varied institutional costs and surgical complication rates. CONCLUSIONS AND RELEVANCE: The utility of postreduction imaging from the standpoint of cost analysis depends on the complication rate of the facial traumatologist and institutional charge data. Based on this model, the facial traumatologist at our institution should obtain postreduction panorex imaging for patients with mandible fractures until their complication rate drops below 17.7%. The 2-way sensitivity analysis in this study allows the facial traumatologist to apply his or her complication rate and institutional cost data to determine whether routine postreduction imaging is necessary. LEVEL OF EVIDENCE: NA.