Biomedical subjects
M D Nettleman
Publications and source records attributed to M D Nettleman.
Cost-effectiveness of culturing for Chlamydia trachomatis. A study in a clinic for sexually transmitted diseases.
We have evaluated the cost-effectiveness of using cell culture to test for chlamydial infections in 9979 patients at a clinic for sexually transmitted diseases. From results of cultures, we have established prevalence data and, using decision-theory analysis, have calculated costs and probabilities of various outcomes. According to their histories and presenting signs and symptoms, patients were classified as at high or low risk for chlamydial infections. Empiric treatment of all patients attending the clinic was the most cost-effective strategy, followed by empiric treatment of high-risk women and culture-based treatment of low-risk women. Obtaining cultures for men at high and low risk was not cost-effective. If universal treatment is not provided, the most cost-effective strategy appears to be empiric therapy in patients at high risk for chlamydial infections and therapy based on diagnostic test results in women at low risk.
Antioxidants and the mutagenicity of benzo(a) pyrene and some derivatives.
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Proportional payment for pelvic inflammatory disease: who should pay for chlamydial screening?
The occurrence of acute pelvic inflammatory disease (PID) caused by Chlamydia trachomatis could be reduced if chlamydial screening were more widely instituted, but financial support for such programs remains limited. Logically, the agencies that could most cost-effectively fund screening programs are those that benefit most from reduction in costs incurred by PID. Therefore, the authors retrospectively analyzed charges for 630 women with acute PID presenting to a county hospital over a 2-year period. Sixteen per cent of patients required hospitalization. Of the total charges, 54% were not paid by any agency, 18% were paid by the county, and 22% by the state. A computer model was developed for analysis of screening programs in high-risk women (prevalence, 17%). The savings in charges for acute cases of PID alone did not make it cost-effective for any single agency to fund chlamydial screening. However, the model showed that it would be cost-effective for the county and the state jointly to fund a screening program using a direct antigen test costing under $7 per test.
Penicillin resistant Neisseria gonorrhoeae in low prevalence areas: implications for cost-effective management.
Though ampicillin is no longer recommended as first-line therapy for infections caused by Neisseria gonorrhoeae, the cost and efficacy of this policy in low prevalence areas has not been investigated. The problem was highlighted by an outbreak of penicillin-resistant N. gonorrhoeae in an area where the proportion of resistance had previously been only 0.14%. A decision analysis was performed to determine the cost-effectiveness of beta-lactamase screening and alternative therapies for patients attending sexually transmitted diseases clinics. Empiric therapy with an inexpensive agent active against resistant strains, such as ciprofloxacin, was the most cost-effective approach and remained more cost-effective than alternative strategies whenever the proportion of resistant isolates exceeded 3%. Ceftriaxone was less cost-effective. In low prevalence areas, and in areas where the return rate of recalled patients is high, ampicillin therapy was cost-effective, but beta-lactamase screening should be performed routinely.
Cost-effectiveness of prophylactic AZT following needlestick injury in health care workers.
In response to health care workers' concerns about contracting infection with the human immunodeficiency virus (HIV) in the workplace, several institutions now offer prophylactic azido-deoxythymidine (AZT) for needlesticks sustained while exposed to HIV-infected patients. The authors designed a model to evaluate the cost-effectiveness of AZT prophylaxis. If AZT were 100% effective, prophylaxis would cost $2,388 per life-year gained and $66,876 per life saved using a societal perspective. For each $100 increase in the cost of AZT, the cost per life-year saved increased $1,190. Reducing the efficacy of AZT to 75, 50, and 25% raised the costs per life-year gained to $3,184, $4,775, and $9,551, respectively. If AZT were given for all needlesticks without regard to the HIV status of the source, the costs of prophylaxis would rise substantially. It is concluded that AZT, if moderately effective, can be cost-effective as a prophylactic agent but only if used in instances where the source is known to have an HIV infection.
Epidemiology of bone fractures occurring during hospitalization.
OBJECTIVE: To investigate the incidence and epidemiology of nosocomial bone fractures. DESIGN: Observational, case series. SETTING: Tertiary care center. PATIENTS: All patients sustaining a fracture during hospitalization during the 18-month study period from July 1989 through December 1990. RESULTS: Twenty nosocomial fractures were identified. Twelve of these resulted from falls (3.5 fractures from falls/100,000 patient days). Fracture rates were higher on the neurology service than on other services. Patients who fell and sustained a fracture were significantly older than patients who fell but did not sustain a fracture (74 versus 58 years, respectively, p < .05). Falls occurring on weekends and holidays were approximately three times more likely to result in fracture than falls occurring on other days (p = .06). CONCLUSIONS: Nosocomial fractures were infrequent events but were more common in the elderly and in persons with significant neuropsychological impairment. Persons who sustained fractures during hospitalization were similar to those who fell and fractured bones in a community setting.
Adverse occurrences during hospitalization on a general medicine service.
OBJECTIVE: To investigate the sensitivity and efficiency of medical record review for detecting adverse occurrences. DESIGN: A prospective observational study. Adverse occurrences were defined broadly as events that caused or had potential to cause adverse patient outcomes. Between August 1, 1990 and March 1, 1991 a research nurse reviewed written medical records and attended nursing morning report. SETTING: A university hospital. PATIENTS: Inpatients on two general medical wards and the medical and cardiovascular intensive care units. RESULTS: There were 317 occurrences identified (0.2 per patient day): 56% were medication related, 20% were new medical conditions, 11% were procedure complications, 5% were patient dissatisfaction related, 4% were equipment related, and 3% were accidents. Review of physician progress notes was the most sensitive means of detecting new conditions (sensitivity 73%), procedure complications (sensitivity 100%), equipment-related occurrences (sensitivity 71%), and adverse drug reactions (sensitivity 89%). Review of nursing notes was the most sensitive means of detecting patient dissatisfaction (sensitivity 69%) and accident-related occurrences (sensitivity 100%). Passive reporting through incident reports identified only 9% of all adverse occurrences. Surveillance was time-consuming: concurrent review of all written sources in a 250-bed hospital would require 5.5 technicians. CONCLUSIONS: Surveillance for adverse occurrences is expensive. If selected adverse occurrences were identified as being important for quality improvement, surveillance could be focused efficiently on limited sources. The number of adverse occurrences discovered by surveillance will be heavily dependent on the choice of data source (physician progress notes, nursing notes, etc.). Comparisons among hospitals can be made only when systems for detection have similar validity.
The epidemiology of missed medication doses in hospitalized patients.
OBJECTIVE: To identify determinants of missed medication doses in hospitalized patients. DESIGN: A prospective study of 63,031 medication doses was performed. Missed doses were detected through active surveillance. To analyze the potential impact of missed antibiotic doses, we performed a retrospective cohort study of adults with bacterial meningitis. SETTING: A general medical ward and an intensive-care unit in a tertiary-care hospital. PATIENTS: Adult inpatients. RESULTS: There were 906 missed doses (1.4% of all doses). The risk of missing a dose increased directly with the number of daily doses per patient (P<.01). An individual dose was more likely to be missed if the medication was short-acting than if it was long-acting (odds ratio, 1.4; 95% confidence interval, 1.2 to 1.6). Antimicrobials were the most frequently ordered short-acting agents and the most frequently missed class of drug. Patient absences from the floor were common, but only 3% of missed doses occurred during a scheduled absence. A survey revealed that nurses thought missed doses were the predictable result of a system involving multiple personnel and procedural steps. Missed doses were not associated with increased mortality in the cohort study. CONCLUSIONS: Missed doses correlated strongly with the number of daily doses. Efforts to decrease missed doses should focus on minimizing the number of daily doses and streamlining the administration system.
Patient satisfaction--what's new?
The past decade has seen increased attention focused on patient satisfaction; however, there are no universally accepted means of measuring patient satisfaction. A review of recent studies reveals some interesting findings. Satisfaction has been shown to be related directly to patient expectations; however, intuitive physician judgments about patient expectations may not correlate with true expectations. Further, patient satisfaction may not correlate with the level of clinical outcome. Recent advances have changed our understanding of this complex field.
Staphylococcus aureus bacteremia: the cost-effectiveness of long-term therapy associated with infectious diseases consultation.
OBJECTIVE: To investigate the cost-effectiveness of long-term therapy for Staphylococcus aureus bacteremia and to determine if an infectious diseases consultation affected the duration of therapy. METHODS: A decision analysis was performed based on data from the literature. To determine if consultation was related to therapy duration, a retrospective cohort study was performed using tightly matched pairs. RESULTS: The excess cost per life saved by long-term antibiotics was $500,000. The excess cost per life-year saved was $18,000. Nine pairs were matched. Patients who received consultation were more likely to receive long-term therapy than controls (median 41 days vs 15 days for controls, P = .04). CONCLUSIONS: The estimated cost per life-year saved by long-term therapy was similar to other accepted medical interventions. Infectious diseases consultation can encourage prolonged duration of antibiotic therapy for S aureus bacteremia.
E-mail medicine: dawn of a new era in physician-patient communication.
Computer-based electronic mail has opened up new opportunities for physician-patient communication. In many ways, electronic communication is more convenient than either the telephone or the postal service. However, it is important to recognize the limitations of electronic mail. In this article, we review important issues and recommend minimal standards for physician-patient communication via electronic mail.
Costs of providing primary care: comparison of an academic general medicine practice with an MGMA benchmark.
Market-based healthcare reform has placed great financial pressures on academic departments of internal medicine. The current emphasis and increased recruiting for primary care have not been accompanied by a financially supportive institutional culture or favorable third-party reimbursement system for the generalist practitioners. In one department's analysis, there was a large difference in revenue (-$130,000) compared to a Medical Group Management Association (MGMA) standard, yet a reduced level of compensation for primary-care physicians, $61,000 less per full-time equivalent (FTE). Total overhead per FTE in our department was $80,000 greater than comparable practices of the MGMA standard. We have estimated the institutional strategic costs of having primary-care clinics in three separate locations in the city of Richmond ($74,000/FTE). No viable cost-cutting options placed the primary-care program in positive balance, but the analysis contributed to a creative institutional approach for a solution.
Institutional epidemiologists' roles in evaluating medical devices.
As the prevalence and variety of medical devices have increased, so too has the need for active involvement by epidemiologists. Traditionally, epidemiologists enter the chain of events after devices are marketed. It is proposed that a more proactive approach should be taken and that epidemiologists should be involved at all stages of product development.
The indirect effect of managed care: a true story.
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