M D Nettleman

Virginia Commonwealth University, Richmond, VA, United States

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Publications (33)156.05 Total impact

  • S M Retchin, P A Boling, M D Nettleman, S S Mick
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    ABSTRACT: 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.
    Academic Medicine 05/2001; 76(4):316-23. · 3.29 Impact Factor
  • M D Nettleman, T White, S Lavoie, C Chafin
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    ABSTRACT: 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. 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. 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). 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.
    The American Journal of the Medical Sciences 04/2001; 321(3):178-80. · 1.33 Impact Factor
  • [show abstract] [hide abstract]
    ABSTRACT: 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. The physician workforce in the United States has undergone considerable transformation over the past few decades. The changes involved have included both increases in the total number of physicians and shifts in specialty composition. For example, although the total number of physicians increased 65% between 1965 and 1992,1 the number of specialists per 100,000 population rose 121% during this interval while the number of primary care physicians increased only 13%.1 By 1998, more than two thirds of the 600,000 practicing physicians in the United States were specialists.2
    Academic Medicine 03/2001; 76(4):316-323. · 3.29 Impact Factor
  • T White, S Lavoie, M D Nettleman
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    ABSTRACT: To analyze the costs and benefits of influenza vaccination of healthy school-aged children. 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. 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. 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. 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.
    PEDIATRICS 07/1999; 103(6):e73. · 4.47 Impact Factor
  • R P Wenzel, J Girtman, D Costello, M D Nettleman
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    ABSTRACT: 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.
    Clinical Performance and Quality Healthcare 01/1999; 7(1):43-7.
  • R P Wenzel, M D Nettleman
    Clinical Infectious Diseases 01/1999; 27(6):1422-3. · 9.37 Impact Factor
  • P A Meier, M Fredrickson, M Catney, M D Nettleman
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    ABSTRACT: Meticulous care of intravenous catheters could be expected to minimize associated nosocomial bloodstream infections, but care is often suboptimal. 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. 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. 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.
    American Journal of Infection Control 08/1998; 26(4):388-92. · 2.73 Impact Factor
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    ABSTRACT: To determine if early interventions for septic shock were associated with reduced mortality. Retrospective cohort study. University hospital intensive care unit (ICU) and general wards. 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. None. 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. 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.
    Critical Care Medicine 07/1998; 26(6):1020-4. · 6.12 Impact Factor
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    ABSTRACT: 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. 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. 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). 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.
    Clinical Performance and Quality Healthcare 01/1998; 6(1):9-11.
  • S Smith, S Weber, T Wiblin, M Nettleman
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    ABSTRACT: To study the cost-effectiveness of vaccination for hepatitis A. Hypothetical analysis of students currently enrolled in medical school in the United States. A Markov-based model was developed using data from the literature, actual hospital costs, and an annual discount rate of 5%. The incidence rate was based on the lowest annual rate for the US population during the past decade. Over the lifetimes of students currently in medical school, the model estimated that there would be 286 hepatitis A cases with four deaths and 107 lost years of life. With routine vaccination, these numbers would decrease to 17, 0.3, and 6, respectively. The costs per life-year saved and quality adjusted life-year saved were $58,000 and $47,000, respectively. Serologic screening prior to vaccination was less cost-effective than universal vaccination. If the incidence of hepatitis A was underestimated by a factor of 5, the cost per life-year saved would decrease to $5,500. If the incidence of hepatitis was underestimated by a factor of 10, vaccination would result in a net cost savings. We conclude that the cost per life-year saved by routine hepatitis A vaccination was similar to many other standard medical modalities. For routine vaccination of medical students to be cost-saving, the incidence rate for hepatitis A must be at least 10 times higher than the rate presently reported for the general population. Serological screening prior to vaccination was not cost-effective.
    Infection Control and Hospital Epidemiology 11/1997; 18(10):688-91. · 4.02 Impact Factor
  • M D Nettleman, H Geerdes, M C Roy
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    ABSTRACT: Tuberculin skin testing using the purified protein derivative is recommended as part of a tuberculosis control program for health care workers. However, compliance with skin testing programs has been poor and their cost-effectiveness is unknown. A Markov-based decision analysis was performed to determine the cost-effectiveness of tuberculin skin testing over the entire lifetimes of physicians who are now in medical school. Assumptions were deliberately chosen to present a conservative estimate of cost-effectiveness. Indirect costs were not included. Annual testing cost $29,000 per life-year saved and $39,000 per case of pulmonary tuberculosis prevented. In contrast, particulate respirators have been shown to cost millions of dollars per case prevented. Skin testing every 6 months was cost-effective in a subpopulation at high risk of infection (> or = 1.8-fold). During their entire lifetimes, physicians now in medical school can expect to avert 137 cases of pulmonary tuberculosis, prevent 7 tuberculosis deaths, and save 182 life-years because of skin testing programs. Improved compliance with annual skin testing and prophylactic isoniazid could more than triple this benefit. If available, a moderately effective vaccine would be even more cost-effective than tuberculin skin testing programs. Tuberculin skin testing is cost-effective and should be an integral part of any tuberculosis control program. Vaccination may one day be a feasible and cost-effective alternative to skin testing programs.
    Archives of Internal Medicine 06/1997; 157(10):1121-7. · 11.46 Impact Factor
  • R P Wenzel, M B Edmond, M D Nettleman
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    ABSTRACT: Selected issues for hospital epidemiology are presented. The issues of infection control, employee health and quality assessment cross the traditional department and reporting lines and require a multidisciplinary approach utilizing the epidemiological method. Programs seeking enhanced value--high quality outcomes per dollar cost--will likely support such an approach.
    Virginia medical quarterly: VMQ 02/1997; 124(2):103-4.
  • M D Nettleman, J Alsip, M Schrader, M Schulte
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    ABSTRACT: To identify determinants of mortality after hip fracture, we performed a multicenter, retrospective study of 390 Medicare beneficiaries. Independent predictors of 30-day mortality included a history of congestive heart failure (odds ratio [OR] 32; 95% confidence interval [CI] 5, 192), angina (OR 26; 95% CI 4, 184), or chronic pulmonary disease (OR 11; 95% CI 2, 62). Postoperative use of aspirin was associated with a reduced risk of mortality (OR 0.24; 95% CI 0.08, 0.70). Cardiovascular events were the presumed cause of 63% of in-hospital deaths. Aspirin may have significant potential to reduce mortality in this population and deserves further study.
    Journal of General Internal Medicine 01/1997; 11(12):765-7. · 3.28 Impact Factor
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    ABSTRACT: To determine if compliance with annual tuberculosis skin testing correlated with the number of cases of tuberculosis seen in patients and healthcare workers. Survey using a written questionnaire. 159 Veterans' Administration facilities. Hospitals that reported that > 80% of their healthcare workers received annual skin tests saw 12.7 patient cases per 10,000 admissions and 4.0 healthcare worker cases per 10,000 personnel. Facilities in which < 20% of their healthcare workers were given annual skin tests saw 4.5 cases per 10,000 admissions and 1.6 cases in healthcare workers per 10,000 personnel (P < .001 for patients and P = .31 for healthcare workers). The ratio of the median number of patients placed in acid-fast bacilli (AFB) isolation to the median number of patients with confirmed tuberculosis was 12. There was no correlation of this ratio with the number of cases of tuberculosis in patients or healthcare workers seen in each facility. Compliance with annual tuberculosis skin testing was related directly to the rate of tuberculosis seen in patients. More standardized policies for placing patients in AFB isolation are needed to control for potentially costly variation among facilities. These measures should have highest priority in the control of tuberculosis in the healthcare setting, before implementing still more expensive interventions.
    Infection Control and Hospital Epidemiology 01/1997; 18(1):28-31. · 4.02 Impact Factor
  • M D Nettleman
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    ABSTRACT: Travelers to developing countries are at risk for diseases ranging from traveler's diarrhea to malaria. Immunizations, medications, and sensible precautions can ensure a safe trip in most areas of the world. This article presents an overview of how to prepare the international traveler.
    Gastroenterology Clinics of North America 10/1996; 25(3):451-69. · 3.00 Impact Factor
  • M D Nettleman, M J Bock
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    ABSTRACT: To identify determinants of missed medication doses in hospitalized patients. 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. A general medical ward and an intensive-care unit in a tertiary-care hospital. Adult inpatients. 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. 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.
    Clinical Performance and Quality Healthcare 01/1996; 4(3):148-53.
  • M D Nettleman, M Fredrickson, N L Good, S A Hunter
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    ABSTRACT: To assess the cost of the mandatory use of high-efficiency particulate respirators to treat patients with known or suspected tuberculosis. A questionnaire was used to determine the number of high-efficiency particulate respirators required and the number of cases of tuberculosis in employees that could potentially be prevented. Indirect costs included the training and fitness testing of employees. The clinical efficacy of respirators is not known. To provide a best-case scenario, it was assumed that the respirators could prevent as many as 25% of tuberculosis cases in health care workers. 159 acute care facilities administered by the Department of Veterans Affairs. Quality improvement, infection control, and employee health specialists. Cost of the respirators compared with their maximum predicted efficacy. The use of the respirators would cost $7 million per case of tuberculosis prevented and $100 million per life saved. High-efficiency particulate respirators are a costly means of trying to prevent tuberculosis. Costs could be reduced by reusing masks or by restricting the number of health care workers allowed to have contact with potentially infectious patients. As the health care budget undergoes further restrictions, specific means of accommodating the cost of new regulations must be found.
    Annals of internal medicine 08/1994; 121(1):37-40. · 13.98 Impact Factor
  • Infection Control and Hospital Epidemiology 04/1994; 15(3):200-2. · 4.02 Impact Factor
  • M D Nettleman, M J Bock, A P Nelson, J Fieselmann
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    ABSTRACT: To determine the importance of procedure-related complications on a general medical service. A retrospective cohort study with one-to-one matching. Complications were identified through chart review by nurse-technicians using standard definitions. The internal medicine service of a 900-bed university hospital. One hundred seven cases with noninfectious, procedure-related complications and 107 closely matched controls who underwent the same procedures without complication. None. The mortality rate was 28% for cases compared with 11% for controls, resulting in an excess mortality rate of 17% (p = 0.02). Cases who survived to discharge had an excess length of stay of seven days (p = 0.001). The excess cost per case was $12,913. Importantly, median reimbursement was only $2,064 higher for cases than for controls. Adjusting for age and APACHE II (severity of illness) score, procedure-related complications were associated with a 3.4-fold increase in the relative risk of in-hospital mortality (95% CI: 1.5 to 7.7). Surveillance data were useful in directing quality improvement activities that resulted in a 66% reduction in the rate of pneumothorax following thoracentesis. Procedure-related complications were associated with prolonged and expensive hospitalization and were a marker for patients at high risk for in-hospital mortality. Programs to reduce complications on the general medical service have an enormous potential to benefit both patients and hospitals.
    Journal of General Internal Medicine 03/1994; 9(2):66-70. · 3.28 Impact Factor
  • M D Nettleman, A P Nelson
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    ABSTRACT: To investigate the sensitivity and efficiency of medical record review for detecting adverse occurrences. 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. A university hospital. Inpatients on two general medical wards and the medical and cardiovascular intensive care units. 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. 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.
    Clinical Performance and Quality Healthcare 01/1994; 2(2):67-72.

Publication Stats

685 Citations
1k Views
156.05 Total Impact Points

Institutions

  • 1996–1999
    • Virginia Commonwealth University
      • Department of Internal Medicine
      Richmond, VA, United States
  • 1998
    • Wilford Hall Ambulatory Surgery Center
      Lackland Air Force Base, Texas, United States
  • 1992–1994
    • University of Iowa
      • • Department of Internal Medicine
      • • Division of General Internal Medicine
      Iowa City, IA, United States
  • 1993
    • University of Barcelona
      Barcino, Catalonia, Spain