Need for alternative trial designs and evaluation strategies for therapeutic studies of invasive mycoses.

Studies of invasive fungal infections have been and remain difficult to implement. Randomized clinical trials of fungal infections are especially slow and expensive to perform because it is difficult to identify eligible patients in a timely fashion, to prove the presence of the fungal infection in an unequivocal fashion, and to evaluate outcome in a convincing fashion. Because of these challenges, licensing decisions for antifungal agents have to date depended heavily on historical control comparisons and secondary advantages of the new agent. Although the availability of newer and potentially more effective agents makes these approaches less desirable, the fundamental difficulties of trials of invasive fungal infections have not changed. Therefore, there is a need for alternative trial designs and evaluation strategies for therapeutic studies of invasive mycoses, and this article summarizes the possible strategies in this area.

Marketplace reforms and primary care career decisions.

A dramatic shift in the postgraduate career choices of medical school graduates toward primary care occurred during the mid-1990s. While some attributed this shift to changes in medical school curricula, perceptions stemming from marketplace reforms were probably responsible. For the most part, these perceptions were probably generated through informal communications among medical students and through the media. More recently, additional marketplace influences, such as the consumer backlash toward managed care and unrealized gains in primary care physicians' personal incomes, may have fostered contrasting perceptions among medical students, leading to career choices away from primary care, particularly family practice. The authors offer two recommendations for enhancing the knowledge of medical students concerning workforce supply and career opportunities: an educational seminar in the second or third year of medical school, and a public-private partnership between the Bureau of Health Professions and the Association of American Medical Colleges to create a national database about the shape of the primary care and specialty workforces, accessible through the Internet for educators, students, and policymakers. The authors conclude that appropriate career counseling through these efficient methods could avoid future abrupt swings in specialty choices of medical school graduates and may facilitate a more predictable physician workforce supply.

School absenteeism, parental work loss, and acceptance of childhood influenza vaccination.

BACKGROUND: Influenza causes school absenteeism and may cause parents to miss work to care for sick children. However, it is not known whether these factors influence parental acceptance of childhood vaccination. METHODS: A survey was mailed to parents of 1,805 children attending 3 elementary schools. It included questions about school absenteeism and employment status for adults who stayed home to care for an ill child. Parents were asked if they would consider vaccinating their child against a common wintertime respiratory virus. RESULTS: Of the 972 surveys returned (54% return rate), 954 could be analyzed. Only 13% of respondents stated that they would not consider vaccination for their child. Sixty-nine percent of children had been absent from school because of a nonasthma respiratory illness, with an average of 2.54 days missed per child. Among respondents whose child had missed any school, 33% would definitely consider vaccination compared with 24% of respondents whose child had not missed school (P < 0.01). As children missed more school days, vaccine acceptance increased. In 53% of families, an adult had to miss work to care for the ill child. Vaccine acceptance was higher if an adult caretaker had to lose time from work because of a child's illness (35% versus 25% for non-working caretakers, P < 0.01). CONCLUSION: Vaccine acceptance was closely linked with the amount of absenteeism caused by respiratory illness in the previous year. Parents who had to miss work to care for an ill child were more accepting of the vaccine than were other parents.

Economic impact of influenza vaccination in preschool children.

OBJECTIVE: The economic impact of routine vaccination of preschool children with inactivated influenza vaccine was investigated. DESIGN: A decision analysis was performed using data from the literature. Direct and indirect costs of each vaccination strategy were calculated and compared with a strategy of not vaccinating. SETTING: Two settings were evaluated: a setting in which vaccination was available during flexible hours and a setting in which vaccination was available only during usual work hours (8:00 am-5:00 pm). RESULTS: Vaccination resulted in a net cost savings in both settings. The net savings per vaccine recipient were $21.28 in the flexible setting and $1.20 in the restricted setting. Although the analysis was performed for the inactivated vaccine, sensitivity analysis showed that the nasal vaccine could also result in a net cost savings depending on the price of the cold-adapted vaccine when it is licensed. CONCLUSION: Vaccinating preschool children is economically advantageous. Serious consideration should be given to recommending vaccination in this age group.

How residents spend their nights on call.

PURPOSE: Night call is a significant part of residents' education, but little information about their night-call activities is available. This study recorded residents' activities during night-call rotations on internal medicine and pediatrics wards. METHOD: In June and July 1997, on-call pediatrics and internal medicine residents at an urban academic medical center were accompanied by trained observers on the general wards between the hours of 7 PM and 7 AM. The types and duration of activities were recorded. RESULTS: Residents were observed for 106 nights. Internal medicine and pediatrics residents spent their time similarly. They spent 5.3 hours and 5.7 hours per night, respectively, on "basic" activities such as eating, resting, chatting, and sleeping, and an average of 2.6 hours and 2.2 hours, respectively, on chart review and documentation. In both programs, discussing the case with team members averaged 1.5 hours per night and use of the computer averaged slightly more than half an hour. Internal medicine residents spent approximately 1.5 hours on patients' history and physical examinations while pediatrics residents spent 1.3 hours. With each new patient, internal medicine residents spent an average of 19.7 minutes and pediatrics residents spent 16.5 minutes. The only significant difference between the two groups of residents was that the pediatrics residents spent more time per night on procedures than did the internal medicine residents (37 minutes versus 14 minutes, p < 0.01). CONCLUSIONS: Residents from both programs spent a surprising amount of time each night on chart review and documentation. In fact, they spent more time with charts than with patients. Whether this activity truly contributes to residents' education or improved patients' outcomes is not clear.

Patient education and emergency room visits.

Patients visit emergency rooms for urgent and non-urgent care. Because emergency room visits are more costly than visits to primary care clinics and are less likely to involve preventive care, third party payers and institutions have always tried to shift patients away from the emergency room and towards primary care clinics where appropriate. Hypothesizes that an intervention based in an adult primary care clinic might enable this, especially if it involved patients who used both the clinic and the emergency room. Surveys patients to determine why they used the emergency room and to identify barriers to using the primary care clinic instead. Based on the survey results, an intervention was developed to facilitate use of the primary care clinic. Discusses the methodology used in the survey and analyses results. Concludes that it is difficult to change patient behaviour to fit the demands of the health care system. Possibly, it would be better to change the system to fit the behaviour patterns of the patients.

Potential cost savings attributable to influenza vaccination of school-aged children.

OBJECTIVE: To analyze the costs and benefits of influenza vaccination of healthy school-aged children. DESIGN: The analysis was based on data from the literature. Total costs included direct medical costs for vaccination, physician visits, and treatment as well as indirect costs. Indirect costs were in the form of lost productivity when working parents stayed home to care for ill children or to take children to an office for vaccination. The total costs of vaccination strategies were compared with the total cost of not vaccinating. For the base case, the vaccine was assumed to have no effect on rates of otitis media. SETTING: Two hypothetical scenarios were investigated 1) individual-initiated vaccination and 2) vaccination in a group-based setting. The former scenario required the child to be accompanied to a clinic by a parent during usual work hours. RESULTS: Vaccination resulted in a net savings per child vaccinated of $4 for individual-initiated vaccination and of $35 for group-based vaccination. The savings were caused primarily by averted indirect costs. Moderate increases in the cost of vaccination or reductions in the rate of influenza would eliminate the savings for individual-initiated vaccination but not for group-based vaccination. Alternatively, if influenza vaccination was effective in reducing rates of otitis media, the net savings from vaccination would be substantially higher than the base case. CONCLUSION: Vaccination of school-aged children against influenza could have substantial financial benefits to society, especially if performed in a group-based setting. influenza, cost-effectiveness, vaccination, children, cost.

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.

Impact of a dedicated intravenous therapy team on nosocomial bloodstream infection rates.

BACKGROUND: Meticulous care of intravenous catheters could be expected to minimize associated nosocomial bloodstream infections, but care is often suboptimal. METHODS: To examine the ostensible benefits of a professional, dedicated intravenous therapy team, we compared the secular trends in nosocomial bloodstream infections before and after such a team was established. RESULTS: After the introduction of the team at the Veterans Administration Medical Center, the rate of primary nosocomial bloodstream infection decreased by 35% (1.1 to 0.7 infections/1000 patients-days, P < .01), including a 51% decrease in bloodstream infections caused by Staphylococcus aureus (P < .01). The excess cost of the team was $252,000 per year. The excess costs per life saved and infection prevented were projected to be $53,000 and $14,000, respectively. CONCLUSIONS: The introduction of a dedicated intravenous therapy team was associated with a significant reduction in nosocomial bloodstream infections. Further work is needed to maximize the cost-benefit ratio of this intervention.

Septic shock: an analysis of outcomes for patients with onset on hospital wards versus intensive care units.

OBJECTIVE: To determine if early interventions for septic shock were associated with reduced mortality. DESIGN: Retrospective cohort study. SETTING: University hospital intensive care unit (ICU) and general wards. PATIENTS: Forty-one consecutive patients prospectively identified with positive blood cultures and septic shock. Although all patients were eventually treated in an ICU, ten (24%) patients were on a general ward at the onset of septic shock, and 31 (76%) were in an ICU setting. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Over a period of 9 mos, a cohort of 41 patients who had positive blood cultures and septic shock was prospectively identified. The 28-day crude mortality was 46% (19 deaths). We compared the management of septic shock and outcome for patients on a general ward vs. those patients in an ICU setting. Of the ten patients on the ward at time of shock onset (median age 55.5 yrs; median Acute Physiology and Chronic Health Evaluation [APACHE] II score of 18.5), seven (70%) died. In contrast, the 31 patients receiving intensive care when shock developed were older and more ill (median age 66 yrs; median APACHE II 24), yet had a mortality of 39% (12 deaths). The odds ratio (OR) for death for ward patients compared with ICU patients was 3.57 (p=.17). In a multivariate logistic regression analysis, two risk factors for mortality were important: APACHE II score (p=.015) and ward status (p=.08). Candida species in the bloodstream is known to have a high attributable mortality. When type of bloodstream pathogen (Candida species vs. bacteria) was added to the model, APACHE II (OR 2.64 for 10-unit increase) remained significant (p=.014), but ward status (OR 3.97) became statistically nonsignificant (p=.222). The patients who were on a general ward when their shock developed had a median delay of 67 mins before transfer to an ICU setting. Ward patients received an intravenous fluid bolus after a median delay of 27 mins, whereas those in the ICU who received a fluid bolus did so after a median of 15 mins (p=.48). Ward patients also had a median delay of 310 mins to receive inotropic support compared with a median 22.5 mins (p=.037) for the patients in an ICU setting when shock started. CONCLUSIONS: The data suggest that for patients with septic shock on wards, there were clinically important delays in transfer of patients to the ICU, receipt of intravenous fluid boluses, and receipt of inotropic agents. However, the most powerful predictors of mortality were APACHE II scores and bloodstream infection with Candida species.

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.

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.

Predictors of survival and the role of gender in postoperative myocardial infarction.

PURPOSE: To identify risk factors for mortality after postoperative myocardial infarction. METHOD: Retrospective study of 266 patients. RESULTS: The crude in-hospital mortality rate was 25%. This was more than twice as high as the mortality rate in patients admitted from home with an acute myocardial infarction. Women with postoperative infarction were the same age as men, but had a lower Acute Physiology and Chronic Health Evaluation (APACHE) II score prior to infarction (P = 0.03) and a higher crude mortality rate. Multivariate analysis showed that female gender (relative risk 2.2, 95% confidence limits 1.2 to 4.2), current cigarette smoking (relative risk 2.3 [1.2 to 4.7]), a history of congestive heart failure (relative risk 2.1 [1.04 to 4.1], resuscitation status (relative risk 8.1 [2.0 to 32.9]), and high preoperative APACHE II score were significant independent predictors of in-hospital mortality. CONCLUSION: Postoperative myocardial infarction is one of the most serious events a patient can experience. Women and current smokers are at especially high risk for mortality after postoperative myocardial infarction.