RCHC Community Project Abstracts

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Screening for Chlamydia Trachomatis
Date of project: 10/12/2009

Chlamydia is the most common sexually transmitted bacterial infection in the U.S. with particularly deleterious consequences for women. Alicia Hills, communicable disease nurse and educator at the Department of Public Health in Baker County, has been tracking the rise in Chlamydia positivity throughout Baker County since 2007. Data from DHS in Oregon demonstrates an increase in the incidence of Chlamydia in Baker County overall from 2003 to the present. The rise in positivity may be attributed to greater access to female providers since 2003, an increased risk for false-positive tests due to the lower prevalence of Chlamydia in Baker County as compared to the average for Oregon state, and easier screening methods implemented by clinicians in the area. A universal Chlamydia screening protocol was discussed and implemented at the Eastern Oregon Medical Association and the Baker County Public Health Clinic. In addition, educational pamphlets from DHS discussing sexually transmitted infections will now be offered to patients being screened for Chlamydia. Emergency room physicians agreed to encourage at-risk patients to be tested at the Public Health Clinic. A powerpoint presentation used to educate adolescents and young adults in Baker County about sexually transmitted infections was revised and updated.

Early Formation of Lifelong Health Habits in Baker City, Oregon: a Brief Assessment and Educational Tool
Date of project: 9/7/2009

The adult population seen at the Baker Clinic has been noted to have a number of health problems associated with lifelong negative health habits, including tobacco use, alcohol abuse, and poor nutrition/obesity. Even when faced with serious health consequences of these negative habits, many patients find it extremely difficult to make these life changes as adults. The school-based clinic staffed by the Baker Clinic was noted to be an ideal venue to approach high school students at a time when lifelong habits are still being formed, in order to encourage healthy habit formation which might lead to improved lifelong health. A brief 6-question questionnaire was distributed among students at the clinic in order to obtain a rough estimate of knowledge in the areas of nutrition, exercise, tobacco and alcohol abuse. A one page educational tool was subsequently created for distribution to this same population, focusing on areas of weakest knowledge/poorest habit formation, namely poor calcium intake and excessive soda consumption.

Assessment of Barriers To Hospice Referral In Baker City, Oregon
Date of project: 2/9/2009

Hospice services have long been recognized as an important component in the spectrum of healthcare but certain barriers to referral still exist. This study attempted to assess potential barriers to referral in Baker City, Oregon by looking at perceptions, attitudes, and knowledge of hospice services by local primary care providers. Initial information was gathered through personal interviews with patients, hospice workers and physicians. The results of the interviews were that referral habits likely varied by age and experience of the physician, with older physicians being less likely to refer. Similarly, a lack of knowledge was thought to inhibit referral. An anonymous survey was then collected from 6 out of the 9 primary care physicians in town which assessed attitude, knowledge, perceived benefits and perceived barriers to referral. The results showed that every physician surveyed had a high level of knowledge about hospice services and requirements and that this did not likely affect referral rate. There was consistency between local opinion and what was found regarding age of physician with the one responding senior physician being less likely to refer. This was determined to be likely due to a poor interaction history between the physician and local hospice services. Additional responses from the other senior physicians in town could not be obtained, so no generalizations could not be made. However, it was evident that the greater factor that influences many aspects of small town life is determined by how well people work together.

Will Baker City Lose Its Only Nursing Facility? An analysis of the St. Elizabeth Care Center
Date of project: 10/13/2008

The St. Elizabeth Care Center is the only Nursing Facility in Baker City, OR. The Care Center serves a population of approximately 16,000 residents in Baker County, a disproportionately large percentage of which are senior citizens. When it was discovered that the Care Center faced a fiscal crisis that threatened its closure, an investigation was made into the impact this closure would have on the community’s seniors. Consensus input from those involved in long-term care in Baker suggested that closure would constitute the loss of a critical resource. A further investigation was made into the causes of the Care Center’s financial instability and changes were suggested to prevent closure.

Emergency Contraception in Baker County: Compliance with Laws Governing Access and Dispensing
Date of project: 4/28/2008

In August of 2006, the FDA approved the emergency contraceptive Plan B to e available over-the-counter in pharmacies nationwide. In 2007, during the Oregon Legislative Assembly passed House Bill 2700, which requires health insurance plans in Oregon to cover prescription contraceptives. It also requires emergency rooms to provide information about emergency contraceptives to all female victims of sexual assault, and to administer emergency contraceptives to these patients while they are in the emergency room if they so desire. Interviews with the county's five pharmacists revealed that four of the five pharmacies in Baker County carry Plan B and dispense it over-the-counter to those 18 and older, and with a prescription to those 17 and under. Conversations with Emergency Department staff at St. Elizabeth Health Services revealed compliance with the spirit of the law, as it applies to victims of sexual assault. Access to emergency contraception in Baker County is further improved by the efforts of the health department, where it is available for free. The final area investigated in this project was the state of the high school health curriculum, which competently addresses contraceptives, including Plan B, and teaches students how to access birth control. A letter detailing these findings was distributed to health department workers as well as 7 physicians and 4 nurse practitioners in Baker City.

Fluoride Varnish: Parent Educational Pamphlet for Baker City.
Date of project: 10/15/2007

Early childhood dental decay can lead to a variety of continuing health problems including extreme pain, difficulty chewing, poor weight gain, malocclusion, spread of dental infection into the body, and a decrease in overall health. Many communities in the United States add fluoride to the water supply to help decrease dental disease in their community. Oregon is ranked 48th out of 50th in the amount of citizens who receive fluoride in their water supply, which places Oregon children at a high risk for early childhood dental decay. Other risk factors for dental decay include low socioeconomic status and children living in rural communities. Fluoride varnish is one way to increase the fluoride a child can receive to prevent early childhood caries. Fluoride varnish has been used in European countries for the past 25 years to prevent early childhood caries. Fluoride varnish is also endorsed by the American Dental Association. Although the use of fluoride varnish is not approved for the use of caries prevention by the FDA, it is a common "off-label" use of the product. Early in 2007, Baker County began a fluoride varnish program for children within the county starting at the age of 9 months. Although the program has been enrolling children, there is little parent education on the benefits of fluoride, the services available to their children, and the importance of early dental health. Therefore, my project included producing a parent brochure with educational material about dental health and the benefits of fluoride varnish. Hopefully, the handout will help to increase enrollment in the fluoride varnish program.

Is your car or truck maintenance more current than your patients?
Date of project: 7/2/2007

In Oregon we have yet to reach the Healthy People 2010 goals for Cervical Cancer screening and Colon Cancer mortality (Oregon Partnership for Cancer Control, 2005). These are only two of the multiple goals we have yet to achieve, but it shows that we need to improve the current system of patient education and motivation. Although there are many obstacles to reaching the recommended goals, my project focused on literacy, simplification, and consolidation through 3 population specific handouts. Throughout the project I found it odd that most cars are provided with a maintenance schedule that states at predetermined intervals the vehicle needs to have routine care, yet our personal health screening recommendations are not in a usable format for the general population. They are constantly evolving depending on the latest research, and the vaccine schedules can be extremely difficult to understand. While in Baker City, Oregon I created one handout each for men and women 18 and older that included vaccinations and cancer screenings based on the current recommendations of the U.S. Preventative Service Task Force (USPSTF), CDC, and American Academy of Family Physicians. I also created a schedule in a checklist format for parents that included recommendations for vaccines, well child exams, dental, hearing, and vision for children birth to 18, based on USPSTF, CDC, American Academy of Family Physicians, and American Academy of Pediatric Dentists. The goal was to assist patients in using the available resources in a simple and accurate format in order to improve screenings and vaccinations. They were provided to Eastern Oregon Medical Associates and Baker County Health Department.

The Impact of Methamphetamine on Community Health in Baker City
Date of project: 4/30/2007

Methamphetamine (MA) is a stimulant drug with a high abuse potential and multiple adverse health consequences ranging from psychosis, intoxication-related trauma and self-mutilation to burns, abscesses and endocarditis. MA is unique among stimulant drugs of abuse in that it can be manufactured locally using simple and widely available starting materials. This drug may particularly impact rural areas as lower density population provides more privacy for clandestine MA labs. Small communities are less able to absorb the cost of MA-related visits to the emergency room, lost productivity and broken families. The methamphetamine epidemic has received much media attention, but how deep does the problem really go and what resources are needed?

Reach Out and Read in Baker City.
Date of project: 3/19/2007

The importance of health literacy, as well as the importance of early intervention to reading acquisition, has been increasingly recognized. Baker County has a low percentage of children entering school ready-to-learn, and while there is a well-established Literary Council, more emphasis on early intervention is desired. The Reach Out and Read program has health professionals emphasize the importance of parents reading to children, and donates books to those children during well-child visits. Eastern Oregon Medical Associates (EOMA) is the largest primary care provider for children in Baker County, and recently moved to a new office, in which they were wondering how to entertain children in their waiting room. A Reach Out and Read program was developed, which included the following steps. Community data were collected and an application was submitted. Community support was generated through the local Literary Coalition. 200 book donations were collected, and a grant was drafted for submission to the Juan Young Trust. Books were placed in the waiting room with enthusiastic response from parents and children.

Eastern Oregon Medical Associates Weighs In: Assessment of the prevalence of overweight and obese patients in a rural community health clinic and provider education about screening, prevention, and treatment of obesity.
Date of project: 2/12/2007

The obesity epidemic in the United States is well known to primary care providers. Obesity is a contributing factor to patients acquiring diabetes, hypertension, coronary artery disease, arthritis, certain cancers, and other diseases. Lowering an overweight or obese patient’s weight by just 10% can decreased their cardiac risk factors and can increase their quality of life.1 Primary care clinics are the cornerstone of prevention, screening, and treatment of obesity but according to providers at Eastern Oregon Medical Associates (EOMA), advice on healthy eating and exercise often falls on deaf ears. Physicians at this rural health clinic feel that they have an overwhelming number of overweight and obese patients but are unaware of the most effective ways of counseling these patients about weight loss. They were also eager to learn of any new treatment options. This project aimed to determine just what the rates of overweight and obese adult patients were in the clinic and to educate the providers on the most recent research and recommendations on screening, prevention, and treatment. EOMA uses an electronic medical record system that automatically calculates BMI with each patient visit. To determine the prevalence of overweight and obesity, data was collected for all patients 15 years and older who had a BMI of greater than 24 by using the EMR system’s search function. Data was categorized by overweight (BMI>24 but <30) and obese (BMI>/=30) and then further categorized into gender and age. It was found that EOMA has a prevalence of 12.6% overweight patients and 13.5% obese patients; much lower than the national prevalence. Research using several different methods (Medline database search, Cochrane database search, and use of NIH and CDC data) was used to find the most current information and recommendations on screening, prevention, and treatment of obesity. This information was compiled into a report that included the clinic data and was presented to all providers at EOMA.

Say Cheese: Public Opinion Regarding Community Water Fluoridation in Baker City, OR
Date of project: 1/1/2007

Dental caries (tooth decay) poses a significant health risk to the residents of Baker County. Reputable health-professional organizations such as the CDC, WHO, AAFP, American Public Health Association, and Institute of Medicine support community water fluoridation as a safe, effective, and inexpensive way to prevent dental health problems. A majority of the US population has access to fluoridated water, but Baker County has not yet implemented this proven health improvement measure. In order to gauge public opinion regarding community water fluoridation in Baker, a survey was developed with the support and input of several local health providers, and widely distributed amongst varied segments of the community. Analysis of the survey results revealed barriers to public acceptance of water fluoridation. The gaps in dental health knowledge will be addressed as part of a following public health education campaign to be developed by nursing students. The group of local healthcare providers and students involved will organize the Baker medical community through meetings and strategy sessions in order to educate, collaborate, and hopefully unite in the campaign of fluoridation. In addition, the logistics of instituting fluoridation in the Baker County water supply was researched and outlined.

Proper usage of child safety seats and booster seats in Baker County, OR: development of a brochure to educate patients for dispersal at the Baker County Health Department
Date of project: 10/16/2006

Motor vehicle accidents are the leading cause of death and disability in children. This is often preventable with the proper use of child safety seats and booster seats. While these devices are often used by parents, in Oregon 85% of child safety seats and 51% of booster seats were installed incorrectly. Baker County has NHTSA certified child passenger safety technicians who can assist parents in inspecting and installing child safety seats and booster seats. The Baker County Health Department immunizes 97% of the children in the County and is an ideal location to reach parents and educate them regarding proper usage of child safety seats and booster seats and to direct them towards local resources for inspection and installation. A brochure was produced for dispersal at the health department which included information on local and internet resources, Oregon Law, and the proper usage of child safety seats and booster seats.

Chronic Pain Management and Prominent Issues Among Rural Health Professionals in Baker City, OR.
Date of project: 9/11/2006

Chronic pain management continues to be a major issue in the health care arena. Particularly in rural communities where access to multidisciplinary pain centers is acutely limited, the issue of proper care and treatment of pain remains a prominent concern for health professionals. The primary objective of this project was to understand the approach to pain management in a rural family practice clinic in Baker City, Oregon and identify available community resources that aid in the treatment of patients with chronic pain. Informal discussions with physicians, nurses, physical therapists, and pharmacists helped in elucidating current attitudes of chronic pain management and the challenges associated with its adequate treatment. Analysis of patient records allowed closer study of prevalent diagnosis and the medications used for pain treatment. The overall conclusion of this student is that there is an ever growing need to continually evaluate and discuss challenges in pain management and assess the adequacy of current protocol. The adoption and consistent use of pain contracts between patients and physicians is one desirable step towards the better monitoring, and therefore, better care of patients in pain.

"Health in Action!" in Baker County: How do we determine its effectiveness?
Date of project: 8/7/2006

When you attempt to MOVE an entire county, how do you monitor your successes and failures along the way? In Oregon’s Baker County a MOVING FORCE has begun in the form of a community project titled “Health In Action!”. This paper is aimed at developing a means to which “Health In Action!” can gather and eventually begin to analyze data concerning their efforts to MOVE the county. The design was based largely on discussions amongst facilitators of “Health In Action!”. Specific needs for data collection and analysis were primary topics of conversation. Other sources of information included recent studies conducted throughout the United States that were geared toward public health surveillance and program evaluation. It was concluded that to further improve community needs assessments in Baker County with regards to “Health In Action!”, questionnaires would be developed and utilized at four specific activities sponsored by the program. In conclusion, questionnaires were categorically created to facilitate the required data collection and future analysis.

Determining the Efficacy of Fluoride Varnish in Preventing Caries in Children – Research Prior to the Start of a New Public Health Initiative in Baker County.
Date of project: 7/3/2006

Fluoride Varnish is a widely accepted dental caries prophylactic treatment in America despite being an off-label use. It is easy to apply and regarded as safe. The Baker County Public Health Department is interested in starting a Fluoride Varnish program for children in Baker County. They enlisted me to research the efficacy, safety and technical features of such an initiative and then give a presentation to their staff. I did a literature review of articles found searching Pubmed for all the Randomized Controlled Trials published after 1999 using the terms “fluoride,” “varnish,” and “dental,” limiting my research to studies on the preventative effect on caries in children. I also reviewed the latest relevant professional and independent reviews and meta-analyses searchable under the same terms. I concluded that the evidence in favor of Fluoride Varnish was strongest for permanent teeth despite some controversy over the degree of added benefit when using a fluoride toothpaste and that the most recent evidence suggested a similar protective benefit in deciduous teeth -- though this is more controversial. Furthermore this benefit appears to be greatest in children “at risk” for poor oral health (low socioeconomic status, low fluoride water content, or poor dentition). In the end it was agreed that a biannual Fluoride Varnish program was the most practical solution that offered benefit.

Incorporating Dental Health into the Role of the Primary Care Provider in Baker City, OR.
Date of project: 5/1/2006

Dental disease is problematic in the United States, especially in the population of poor underserved children. Baker City, similar to many rural areas is composed of a large number of persons below the federal poverty line. The children in Baker City, therefore, are at a greater risk of developing dental caries and other dental complications. In an effort to incorporate the primary care provider into the dental screening and health of the pediatric population in Baker, a project was designed to help screen children seen in the clinic and assist in referring these patients to the appropriate dentist. The primary question that this project was intended to answer when is the best time for children to have their first dental examination, and how can primary care practitioners assist in this screening? To aid in this dilemma, a brochure was generated based on information gathered from a local dentist and an extensive literature search. In conclusion, pediatricians and family health care providers may be able to play an important role in improving the dental health of their patients who have difficulty obtaining access to professional dental care.

Assessment of Baker High School Students' Perception of the Appropriateness of Antibiotic Use for Upper Respiratory Tract Infections
Date of project: 3/20/2006

Antibiotic resistance is no less a public health problem in rural settings than it is in urban settings. One factor contributing to the development of antibiotic resistance is inappropriate prescription of these drugs for viral respiratory tract infections. In this study I developed a short presentation focusing on the differences between viruses and bacteria and the most frequent causes of respiratory tract infections. The presentation was given to high school sophomores in health classes at Baker City High School. A pre- and post-presentation questionnaire was employed to gauge the success of this presentation; post-test results indicate that students had a better understanding of the differences between viruses and bacteria after the presentation.

Baker County Sexual Health Education: The Good, The Bad and The Ugly
Date of project: 2/13/2006

Baker County has a several high-risk sexual health populations, including high school students, patients in inpatient alcohol and drug treatment facilities, and prisoners. Sexual health education for these groups has been limited in the past. A focus group of public health RNs identified a problem with poor resources for delivering STD education in these settings. They expressed a desire for an easy-to-give and easy-to-understand presentation that they could use to give educational talks to these high risk groups. They also described the lack of resources in the clinics for sexual education during family-planning or sexual health visits. They described a need for an easily accessible photographic flip-book for use with patients in the clinics. With their guidance, I developed a one hour Power Point presentation and a short color photo flip-book about STD risks, prevention and treatment in Baker County. Together we discussed a plan for putting these new resources to use in the community.

Babies First! in Baker County
Date of project: 10/17/2005

Home visit services by public health nurses have been repeatedly shown to improve health outcomes (Olds & Kitzman, 1993). Oregon’s Babies First! Program was started in 1990 to provide public health nurse visitation services to families of infants who were at risk for poor health or developmental outcomes. In 2004, 63 of 151 births to mothers residing in Baker County (40%) were paid for by Medicaid/Oregon Health Plan (OHP), yet the Baker County Babies First! program few clients because of poor community reputation and a lack of physician referrals. This project developed a referral slip and presentations to physicians to increase awareness of the services available, and the program revisions. The information and referral slips were well-received by physicians, but further work remains to strengthen Babies First! in Baker County.

Tracking Childhood Immunization Records: the Utilization of Oregon Immunization ALERT in Baker City.
Date of project: 9/12/2005

In Baker City the public health department is the only entity that immunizes pediatric patients. There is no system in place for the transfer of patient information between the health department and the rest of the medical community in Baker City. Oregon Immunization ALERT is a statewide database of immunization information for Oregon’s pediatric population whose aim is to track the immunization status of every child 0-18 years of age with the ultimate goal of insuring complete and timely immunizations for all. Baker County Health Department enters each child’s records on ALERT, but the community doctors and hospital personal do not access the program. Increasing the usage of ALERT at Eastern Oregon Medical Associates (EOMA) medical office and by introducing ALERT to the St Elizabeth Hospital Emergency Department could serve to bridge this gap between the health department and the community health care providers. Practitioners at EOMA were retrained on how to access ALERT and the importance of following the immunization status of their patients was readdressed. This resulted in plans put forward to incorporate ALERT records for each patient age 0-12 into their electronic records system with the ability to update the records at each office visit. The nurses and doctors in the emergency department were introduced to ALERT, given access codes, and trained on its use with an emphasis placed on using it to determine DTaP status. The results in St. Elizabeth’s emergency department are less certain. There was resistance to the use of a computer based program and uncertainty of ALERT’s value in the emergency setting. A follow up letter with reminders of passwords and how to access ALERT will be sent to the emergency department in two months time. By accessing ALERT, physicians will be better informed on the immunization status of their patient and better able to encourage prompt vaccination or catch up immunizations as needed. By increasing the knowledge of a patient’s DTaP status in the emergency department, the risk of adverse immunization reactions will decrease.

Awareness of Diabetic Foot Complications in Baker City, OR
Date of project: 8/8/2005

Diabetic foot complications are associated with significant morbidity and mortality. Patient education has been shown to decrease diabetic foot complications. Therefore, the purpose of this study was to assess patient education in a rural community. The level of education in Baker City diabetics was found to be low compared to other studies. Complications reported among diabetics were also low, suggesting that the lower level of education has not adversely affected this population. However, the complication rates could be reduced and education was shown to have a positive effect on reducing complications. Additionally, annual foot exams, podiatry referrals and medication management were lacking, and could be improved with education. Thus, a patient education brochure regarding diabetic foot care would be appropriate.

Identifying Obstacles to On-time Childhood Immunization in Baker County
Date of project: 3/21/2005

Background: 77.6% of Baker County’s 24-month-old children were fully immunized with the CDC’s recommended 4:3:1:3:3 series of vaccines (4 DTaP, 3 Polio, 1 MMR, 3 Hib, 3 HepB) in 2004 (vs. 69.8% of all Oregon children vs. 90% Healthy People 2010 goal). Objective: Identify obstacles to full immunization coverage of children at 24 months of age in Baker County. Methods: Telephone survey of parents of the 130 children ages 12 to 24 months in the Baker County Health Department immunization records regarding obstacles to on-time immunization. Interviews with the county immunization nurse, Baker City family practitioners, and Oregon state immunization program staff. Literature review for vaccination rate improvement methods. Results: One nurse at the Baker County Health Department immunizes 96.3% of that county’s children. Parents cite difficulty getting an appointment within the month and the need for reminders for vaccination schedules and for individual appointments. Cost and transportation are not common obstacles. Children’s immunization records are not checked at their doctor appointments. Conclusions: Baker County’s child immunization coverage may be improved by decreasing the appointment wait time, instituting a recall/reminder system for all children, and checking immunization status at every encounter with the health care system.

Improving the Infant vision screening program in Baker City, OR
Date of project: 1/3/2005

Infant vision screening is an important part of infant care during the first years of life. Early screening and early treatment for infant eye deficits (e.g. strabismus, amblyopia, and retinoblastoma) provides for better long-term vision outcomes and allows for the use of less invasive treatments. Despite the common incidence of infant visual problems, many children are not examined by an eye care professional until after they fail their first visual acuity test in public school at 5-6 years of age. This study attempted to examine the current system in place for infant vision screening in the city of Baker, OR and to explore methods of improving these system. Design elements included quantifying the percentage of Baker infants receiving eye exams in 2004, identifying barriers to care within the existing system, and implementing solutions to overcome these barriers. The data indicated that fewer than 15% of infants in Baker were participating in the existing vision screening program in 2004. The major barriers to care in Baker were identified as poor parental awareness and lack of physician education in regards to the importance of infant vision screening. Solutions to these problems included educating the physicians who were caring for infants about vision screening, convincing these physicians to act as a direct referral source for the infant vision screening program, and providing these physicians with educational handouts about infant vision screening that they could give to their patients. With these additional measures in place, it is expected that a much higher percentage of Baker infants will receive vision screening exams during 2005 in comparison to all previous years.

Hypertension in Baker City, Oregon: Treatment, Awareness, Compliance, and Lifestyle
Date of project: 10/18/2004

Hypertension is a major risk factor for many cardiovascular diseases, renal disease, and retinopathy. Hypertension is implicated in 800,000 deaths per year in the United States, and is highly prevalent in the portion of the American population over 60 years of age. A study of patients’ knowledge of hypertension was conducted in Baker City, Oregon in October and November 2004. Patients diagnosed with hypertension were interviewed regarding their awareness, compliance, and lifestyle choices related to hypertension. Interviewed patients are moderately aware of their condition, are compliant with physician recommendations, and have altered their lifestyles to reduce hypertension-related health problems. Summary statistics suggest that interviewed patients had similar levels of compliance compared to those reported in the literature. In most cases, the physician’s response to elevated patient blood pressure was to adjust medication dosages.

High Cholesterol: A simple means of patient education
Date of project: 9/13/2004

High cholesterol is known to play a major role in heart disease and is one of the more common health care issues Americans face. This study attempts to identify the effectiveness of cholesterol screening and the accuracy of information given to patients at St. Elizabeth Hospital and Eastern Oregon Medical Associates Family Practice Clinic in Baker City, OR. Physician interaction with patients who either have high cholesterol or risk factors for coronary heart disease were observed during a 5 week rotation in Baker City. The annual Health Fair is the primary resource outside of the physician’s office that patients can get their cholesterol, as well as several other health issues, screened for health maintenance. The director of this program was contacted for information regarding the number of patients that use the health fair and what health information was given to patients regarding the different health conditions they were being screened for. Although there seems to be a mechanism for roughly identifying those with high total cholesterol, there did not seem to be an effective method of identifying and educating patients who would benefit, based on their individual cholesterol values, family history and other health issues, from preventative steps to help them avoid high cholesterol and heart disease in the future. The endpoint of this study was the creation of a patient handout to be used in the clinic to explain the basics of cholesterol and its role in heart disease, as well as helping the patient understand that cholesterol and heart disease goals are developed in regards to the specific patient. In addition, the handout incorporates the latest updates to cholesterol management by the NCEP, is formatted in a brief and simple document, and encourages patients to develop a regular dialogue with their health care provider about how to maintain healthy cholesterol levels.

Assessing the Resources Available to At-Risk Pediatric Patients
Date of project: 8/9/2004

Individuals under the age of eighteen comprise approximately one fourth of the population of Baker County, Oregon. Nearly one fifth of these individuals live below the poverty line, which produces significant ramifications on this society as a whole. Physicians serving this population may offer not only medical services, but also refer other resources to these patients. Through interviews with representatives of community organizations and literature review, services available to pediatric patients who are of low-income families in Baker County were researched. In order to facilitate the awareness and utilization of these resources, patient education material highlighting medical, educational, social, spiritual, and recreational resources available to low-income Baker County pediatric patients was developed and distributed to various agencies in Baker City.

Assessment of services available to seniors in Baker City, Oregon
Date of project: 7/5/2004

The population of those over 65 in the United States is rapidly expanding, a trend that has profound implications for health care practitioners and organizations serving seniors. Rural communities in particular are seeing a surge in this population. Observation of physicians in Baker City, Oregon and their interactions with elderly patients demonstrated that primary care practitioners are often called upon to connect seniors with appropriate resources, both medical and social. Navigating the numerous agencies and trying to determine which services are provided can be frustrating for physicians, seniors and their families. A survey of services available to seniors was conducted, as well as interviews with organizations providing resources. It was concluded that while there are a multitude of opportunities for seniors in Baker City, a large portion of seniors were not making use of se services. Although there are a number of reasons for this, it is hypothesized that utilization of services may increase if health care providers are able to more easily access contact information. In order to aid practitioners in this endeavor, a comprehensive list of services for seniors in the Baker City area was produced.

Hepatitis C infection Baker County - educating local healthcare professionals and at-risk populations
Date of project: 5/10/2004

At larger than expected segment of Baker Countys population is at-risk for hepatitis C infection. Concurrently, Baker lacks sufficient resources for referrals for therapy with many of these people lacking insurance, making a consult from a gastroenterologist out of the question. Baker City's referral hospital is 130 miles across state miles in Boise, also home to the closest gastroenterologists. Although one local family practitioner has started administering antiviral treament, access for treament is still quite limited but has room for expansion. However, few local health care workers, including the county health department, have undergone training regarding the newest therapies and outpatient management techniques of the disease. Therefore, the goal of this project was to provide training and information for local health care workers involved in the care of hepatits C-infected patients, as well as educating Baker's intravenous drug use population regarding the risks and options for hepatitis C infection. To affect this end, a patient information pamphlet was crated, in addition to in-person presentations to both healthcare providers, as well as at-risk populations. The pamphlet explains basic infection about hepatits C, including outlining methods of transmission, stressing the importance of abstinence from alcohol, discouraging needlesharing, and receiving vaccinations against hepatitis A and B. These preventive interventions may aid in reducing the number of new infections, as well as educating those already infected who may be eligible to advocate for treatment. It may also remind providers to screen and consider treatment for hepatitis C and ensure improved hepatitis A and B vaccination rates.

The St. Elizabeth Health Services Annual Blood Draw: The Evidence For and Against the Use of Routine Blood Testing as a Health Screening Tool
Date of project: 3/29/2004

Many of the leading causes of death and disability can be prevented given the appropriate interventions. Thus, providing preventive services is a cornerstone of modern day primary care practice. Routine screening examinations and laboratory tests are major mechanisms by which preventive medicine is carried out in practice and should ideally be based upon recommended guidelines developed from the best currently available evidence. The focus of my community project was to research the evidence in support of and against the use of routine blood testing as a health-screening tool for the St. Elizabeth Health Services Health Fair in Baker City, Oregon. I planned to submit my results as well as my recommendations to the governing authorities of this event for further review. As a result of my investigation I found sufficient evidence to support the practice of routine lipid screening for men >35 and women >45 years of age. Insufficient evidence existed to support routine screening of CBC, CMP, TSH, PSA, LDH and Uric acid. Conflicting recommendations existed regarding the practice of fasting glucose screening mainly due to the fact that no clinical trial has been conducted to establish whether systematic screening of asymptomatic individuals for type 2 diabetes improves health outcomes compared with initiating treatment after clinical diagnosis. Sufficient evidence did exist, however, to recommend routine screening of fasting glucose in individuals with hypertension or hyperlipidemia. Given the high prevalence of these comorbidities in the U.S., especially among the population screened at the annual blood draw, routine fasting blood glucose testing may indeed prove to be an effective health screening practice in Baker County despite the lack of current evidence in support of it.

Planned Cesarean Section Pre-Admission Protocol
Date of project: 9/29/2003

Planned cesarean sections place extra demands on the personnel of a small rural hospital such as Harney District Hospital (HDH) in Burns, Oregon. This project looked to identify items that must be addressed before the patient is taken to the operating room. Those steps that were time critical the morning of the procedure were established, and delineated from other items that could be completed the day before the procedure. A checklist and timeline was created to assist nurses in more efficiently preparing patients for their cesarean sections. A patient instruction sheet to be sent home the day before admission was also created to have patients arrive at the hospital better prepared and ready for surgery.

Knowledge and epidemiology of diabetic risk factors among The Baker City high school population
Date of project: 11/10/2003

Adult onset diabetes and the devastating sequela that result there from are not only occurring in greater prevalence in this country, but are also occurring younger. After making the disturbing diagnosis of adult onset diabetes in a 28 year old patient and observing her remarkable ignorance of the disease and its consequences, the question was asked, "how much does the younger generation know about diabetes and how many of them are currenly at risk for developing adult onset diabetes"? This study was designed to assess the current knowledge of diabetes among the high school aged students in Baker City Oregon, whether they appreciate the effects of the disease, its preventablitiy and treatments, to educate them as to the seriousness of the disease, and finally, to determine the prevalence of diabetic risk factors among them. The study was conducted with the participation of 4 high school health classes (3sophomore classes and 1 junior) and was seperated into three major parts: a 10 question test consisting of baskic but pertinent diabetic questions, a 30 minute lecture following the test, and the collection of fasting sugar levels, blood pressures and abdominal cirumferences to ascertain the prevalence of certain risk factors. In addition, both high school health teachers were present during the lectures and received the nexessary materials and instruction to present an updated lecture to their classes in the future. The goals of this project closely mirror the three segments to which it was administered namely, to determine if a need exists in Baker City to better educate high school students of the effexts and precalence of adult onset diabetes ( as indicated by either a gross ignorance of the disease, a high prevalence of risk factors, or both), and to equip those students, as well as their health teachers, with the information to help aid themselves and others in the prevention of diabetes.

Rate versus Rhythm Control and Rates of Stroke in the Treatment of Patients with Non-Rheumatic Atrial Fibrillation in Baker County, Oregon
Date of project: 9/29/2003

Atrial fibrillation is the most common clinical cardiac arrhythmia1. Traditionally, rhythm control has been the standard of care for atrial fibrillation, though recent randomized controlled trials maintain the equivalence of rate and rhythm control in the treatment of AF. The manner of treatment, either with rate or rhythm control along as well as anticoagulation, was reviewed for the last 30 AF patients admitted to the St. Elizabeth Hospital in Baker County, Oregon. 78% of patients included in the study were treated with single agent or combination therapy aimed at reducing ventricular rate by AV nodal blockade. 22% were treated with antiarrhythmic medication. Interestingly, 85% of those treated for rhythm control had previously failed rate control therapy. 36% of all patients included for analysis were taking warfarin for anticoagulation. 52% of all patients had a history of anticoagulation, though 31% of these had to discontinue warfarin secondary to complications of hemorrhage. The prevalence of stroke in the history of the patients in this study was 15%. Though all of these patients were in the rate control group, none of them were on warfarin anticoagulation at the time of stroke. Though in contrast to the findings of major studies evaluating rate versus rhythm control, only the patients in the rate control group had a history of stroke and also were the only ones to experience side effects that necessitated the change from one treatment modality to another. Although the small sample size and incomplete patient records in this study may have affected the results, it appears that rate control is the preferred treatment modality of Baker County physicians.

A Glance at Immunizations in Baker City, OR
Date of project: 7/7/2003

Childhood immunizations continue to pose a challenge within the public health sector. Baker City, OR, possesses a rare immunization program in that the County Health Department immunizes 94.5% of the children in Baker County. The immunization rate of children ages 12-35 months in Baker County is 64%. This project examined immunization rates of the county as a whole in comparison to immunization rates of pediatric patients under the care of one Baker City physician. A list of patients between the ages of 12 months and 5 years was obtained from the Baker Clinic database. Permission was obtained from the patients' parents or guardians, and the patients' immunization records were then reviewed through the County Health Department. A total of 46 patient immunization records were reviewed. The immunization rates for children aged 12-35 months and 36 months to 5 years were 72.7% and 91.6% respectively. While these rates were higher than those of the county rates, the immunization goal still aims for close to 100%. Further investigation may be warrented to evaluate any missed opportunities or barriers that may impede immunizations. A clinic-based immunization program may also be necessary, but challenges remain in order to reach this stage.

Continuing Education of Emergency Physicians at a Level IV Trauma Center - A Solution to Boost Medical Morale
Date of project: 2/10/2003

Many rural communities are struggling financially. The medical community experiences these same fiscal challenges. Such is the case in Baker City, Oregon where the community hospital is $18 million in debt and local healthcare providers struggle to maintain positive revenue position. Morale is down throughout the medical community. This situation has brought about many changes. One of these changes is primary care physicians leaving their practices to become ER physicians. These emergency medicine providers are in a unique position. By updating and strengthening their emergency skills, they can improve patient clinical outcomes and boost the morale of the medical and patient communities with concomitant financial success of the local medical institutions. The Emergency Procedures Training Program for Rural Oregon can provide customized instruction to these ER providers, enabling them to assist in this improvement of their community.

Time to Acute Myocardial Infarction Diagnosis and Reperfusion Therapy in Baker City, Oregon versus National Average
Date of project: 12/30/2002

Objective - Acute myocardial infarction (AMI) is the largest cause of morbidity and mortality within the United States. Reperfusion therapy, which consists of thrombolysis and/or percutaneous transluminal coronary angioplasty (PTCA), is the cornerstone of contemporary AMI therapy. The benefits of both modalities are greatest when given within two hours of symptom onset. One might expect the time from emergency department (ED) presentation to thrombolysis would be shorter at St. Elizabeth Hospital, a rural hospital in Baker City, Oregon, when compared to a national, urban average. Conversely, it may be assumed that time from ED presentation to PTCA will be longer in Baker City than in large, urban institutions. This project compares time to 1st ECG, thrombolysis, and PTCA in patients with AMI presenting to St. Elizabeth Hospital from 1/01 to 9/02 versus a national, urban average. Methods - The average urban time from presentation to 1st ECG, thrombolysis, and PTCA was obtained from the National Registry of Myocardial Infarction 2 study. Average time to first ECG, thrombolysis, and minimum time to PTCA for nineteen patients presenting to St. Elizabeth Hospital with AMI was determined by chart review. Results - Time from presentation to 1st ECG and thrombolysis was found to be four and six minutes earlier in Baker City than the national average, respectively. Time to PTCA was considerably longer, 386 minutes, for patients presenting at St. Elizabeth Hospital. Discussion - While shorter at St. Elizabeth, the difference in time to thrombolysis is not significant enough to impact patient outcome relative to the national average. However, the time to PTCA was appreciably different, with patients in Baker City having to wait over three hours longer than patients in an urban environment. This time difference is composed of an observation period following thrombolysis and transfer time to St. Alphonsus Hospital. This project focused on treatment delay and its impact on time to reperfusion therapy in rural versus urban communities. Future projects might determine if patients in Baker City wait longer to seek medical attention than their urban counterparts, thus delaying the administration of thrombolytics.

Hormone Replacement Therapy in Baker City, Oregon
Date of project: 9/23/2002

The Women's Health Initiative Study about Hormone Replacement Therapy (HRT) has had an important effect on the prescribing practices of physicians. To assess the effect on the practices of Baker City physicians, a short survey was sent to the medical providers in Baker City who were most likely to prescribe HRT. The survey asked questions about how they learned of the study and if the data reported had caused them to change their prescribing habits. The most common modes of learning of the study were through the lay press and self-study. The study caused the majority of the providers to reduce the number of HRT prescriptions they write, especially for women with risk factors for coronary heart disease, stroke, breast cancer, and pulmonary embolism.

How Residents Of Baker City Choose Their Primary Care Physicians.
Date of project: 1/2/2002

The purpose of this project was to evaluate how people in Baker City choose their primary care physicians. It was thought that information about how people choose their doctors could be beneficial to rural physicians seeking to increase their patient loads. Selected patients in Baker City were asked to complete a questionnaire about how they chose their doctor. Results of the study revealed that residents of Baker City rely on recommendations from trusted sources about as much as those in previous studies did. In addition, Baker City residents rely more on personal knowledge of their physicians and whether insurance will cover the doctor visits, than did patients in previous studies. This is thought to be due to the higher percentage of Medicaid patients in rural areas and to the nature of a smaller community where patient might be more likely to know their physician outside of their medical role.

The Detection and Treatment of Depression in Post-Myocardial Infarction Patients in Baker County, Oregon
Date of project: 9/24/2001

Depression is common in patients recovering from a myocardial infarction. Approximately 1 in 6 patients with MI experience major depression and even greater numbers experience significant depressive symptoms following the event. Post-MI depression is an independent risk factor for angina, ventricular arrhythmias, future myocardial infarctions, and mortality following MI. However, given the acuity of the event, depression may often be under-recognized while diligently managing the patient's acute medical care. This study was designed to ascertain the detection rates of post-MI depression in an internal medicine clinic in Baker City and subsequent treatment practices and mortality. This study compared the prevalence of depressed post-MI patients in this Baker clinic to that of multiple national studies in which patients were comprehensively screened for depression following MI. National post-MI screening revealed a prevalence of depression between 16-23%. The documented Baker rates of depression following MI were 14.6% over the last three years, and 7.7% during the past year. However, the Baker general patient population had a lifetime prevalence of depression of 16%, comparable to the national average of 15%, indicating that depression in the post-MI patient population may not be recognized at the same rate. Regarding treatment of depression in patients at risk for MI, several studies suggest that the use of Tricyclic antidepressants is contraindicated, as they may potentiate a Class 1A antiarrhythmic effect leading to increased risk of mortality. In its place, selective serotonin reuptake inhibitors are now being recommended as first-line treatment for post-MI patients not only due to decreased cardiac side effects compared to older antidepressants, but also due to its inhibition of platelet activation. In the Baker City clinic, all documented depressed post-MI patients were treated pharmacologically. One third of the patients were treated with an SSRI alone, another third were treated simultaneously with an SSRI and a tricyclic (usually for another simultaneous condition such as chronic pain), and the last third were treated with antidepressants from other classes. Despite the use of TCAs in some of these patients, none of the depressed patients suffered mortality or a recurrent MI in the last 3 years. Although post-MI patients are being successfully detected and treated for depression, an improvement can be made in identifying more at risk patients and reconsidering the use of TCAs in this population.

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