Robert A. Petzel

Health‐Related Quality of Life, Functional Impairment, and Healthcare Utilization by Veterans: Veterans' Quality of Life Study

Objectives: To describe the health status of veterans receiving care in a veterans integrated service network (VISN).

An internist joins the surgery service: does comanagement make a difference?

Objective: To determine the effect of internist comanagement of cardiothoracic surgical patients on patient outcome and resource utilization.Design: Before/after comparison.Setting: Tertiary care university-affiliated Veterans Affairs hospital.Patients: 165 patients (86 before the intervention and 79 after the intervention) undergoing cardiothoracic surgery.Interventions: All patients were seen preoperatively and at least daily through discharge by a comanaging staff internist who was a full-time member of the surgical team.Main outcome measures: Length of stay, in-hospital mortality, and laboratory and radiology utilization.Results: Significant shortening of postoperative length of stay (18.1 days before and 12.1 days after, p=0.05) and total length of stay (27.2 days before and 19.7 days after, p=0.03) was noted. The inhospital mortality rate for the patients undergoing surgery was 8.1% before the intervention versus 2.5% afterward (p=0.17). There were significant reductions in the total number of x-rays (p=0.02) and nearly significant reductions in total laboratory test utilization (p=0.06). Referring physicians and surgeons both believed that the contribution of the internist was important.Conclusions: The addition of an internist to the cardiothoracic surgery service at a tertiary care teaching center was associated with decreased resource utilization and possible improved outcomes. Before becoming more widely adopted, this intervention deserves further exploration at other sites using stronger study designs.

Medical technologists using molecular epidemiology as part of the infection control team

Two medical technologists were appointed as permanent members of a new epidemiology section in the diagnostic microbiology laboratory of a large Veterans Administration Medical Center in the fall of 1989. These positions accounted for 9% of the total microbiology staff and were created on a temporary basis 2 years earlier from a need to have dedicated technical expertise for use in the culture, isolation, and typing of nosocomial organisms. The technologists have evaluated outbreaks due to Clostridium difficile, methicillin-susceptible Staphylococcus aureus, and Serratia marcescens, and have begun work on a methicillin-resistant Staphylococcus aureus (MRSA)-typing scheme. Their major responsibility has been the development and application of molecular biology techniques for the typing of nosocomial isolates, including restriction enzyme analysis of genomic DNA, plasmid profiling with and without restriction enzyme analysis, ribosomal RNA probing of restricted genomic DNA, and selected DNA sequencing of target organisms. Medical supervision rests jointly between the directors of the infection control program and the microbiology laboratory. During their tenure, infections due to C. difficile have dropped from 95 cases per year to 57 cases annually, treatment of MRSA colonization with systemic agents has been curtailed, and a case control investigation involving S. marcescens was avoided. The inclusion of medical technologists in the infection control practice of large medical care facilities, particularly with the availability of molecular epidemiologic techniques and the emergence of increasing numbers of multiply-drug-resistant pathogens, will become an essential component of these programs.

Commentary: building human capital: discovery, learning, and professional satisfaction.

Physician satisfaction is an important contributor to a well-functioning health system. Mohr and Burgess report that physicians in the Veterans Health Administration (VA) who spend time in research have greater overall job satisfaction, that satisfaction tracks with aggregate facility research funding, and that satisfaction is higher among physicians working in VA facilities located on the same campus or within walking distance of an affiliated medical school. An environment conducive to research therefore not only advances science but also seems to be a key element of physician satisfaction. In addition to advancing scientific discovery and promoting greater physician satisfaction, these findings suggest that an environment of discovery and learning may yield benefits beyond specific academic endeavors and contribute more broadly to supporting health system performance.