RCHC Community Project Abstracts |
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Interpreter use in Klamath Falls, Oregon
Date of project: 10/12/2009
United States Federal law requires that limited English proficient (LEP) patients be guaranteed effective communication in the course of a hospital or clinic visit. In order to assess the effectiveness of communication between providers and LEP patients in Klamath Falls, Oregon, Family Medicine and Pediatric clinics in this town were given a short survey on LEP patient population and interpreter use. All responding clinics have patients who are Limited English Proficient (LEP) and all utilize health care interpreters who are not certified (either bilingual staff or people to serve as interpreters brought in by the patient) as their primary method of interpretation. While these interpreters may have the skills required to be certified health care interpreters, this cannot be determined without undergoing the testing that leads to interpreter certification. This means that it is currently uncertain whether LEP patients are encountering accurate and effective communication in Family Medicine and Pediatric clinics in Klamath Falls, Oregon.
Fibromyalgia—More than a Pain in the Neck?
Dealing with the Diagnosis at the Klamath Family Practice Clinic
Date of project: 10/12/2009
Fibromyalgia is a challenging condition affecting 3-5% of the world’s population, and is characterized by a classic triad of chronic diffuse pain, fatigue, and sleep disturbances. Many providers feel somewhat uncomfortable with fibromyalgia, and primary care physicians, especially those in rural areas, are often those who deal most frequently with the diagnosis. It is important that such providers have increasing familiarity with the condition. This community project, therefore, attempted to determine how comfortable providers at the Klamath Family Practice were with the diagnosis of fibromyalgia and to provide them with educational materials regarding the condition. A survey and educational materials were given to the medical providers to achieve this aim. While most of the providers felt familiar with the etiology and treatment options for the disease, some retained discomfort with the management of the disorder. All had suggestions to improve clinical interactions with fibromyalgia patients, relating primarily to increasing patient education regarding the patient role in treatment. The providers found the supplied educational materials informative and comprehensive, and retained them for additional reference.
2009 H1N1 Influenza – The Response of Klamath Falls, OR to “Swine Flu”
Date of project: 9/7/2009
The 2009 H1N1 flu virus spread rapidly throughout the world and created significant concern bordering on panic wherever it went. Klamath Falls, an area with around 50,000 individuals (15,000 of them minors) in southern Oregon, was no exception. The aim of this project was to explore the effect of, and response to, the “swine flu” in the community. To this end I drew off experiences working at the Klamath Pediatric Clinic, developed an educational handout to give to patients and their families, and interviewed public health and school district officials. I was also able to participate in the local hospital’s infection control meetings as they developed their policies regarding 2009 H1N1 and sit in on lectures and webcasts from the AMA/CDC and OHSU Grand Rounds.
Rural Medicine in the Digital Era
Date of project: 8/3/2009
Electronic medical records have been heralded as a cornerstone in the effort to eliminate waste and mistakes in medicine. Yet even today only a quarter of practitioners use EMR. The rates may be even lower in rural areas where practices are generally smaller and run on tighter budgets. This study will help to understand the key barriers to EMR adoption among rural primary care practitioners. Data was collected through formal and informal interviews with providers in Klamath Falls, OR. Through these conversations it became clear that while all of the providers were considering EMR, there were three types of barriers to adoption including financial, investigational and personal barriers. Given these barriers a low cost subscription EMR designed specifically for primary care practitioners would likely be the most beneficial design to encourage adoption of EMR among rural PCPs.
Health Literacy and Readability of Patient Education Materials at the Klamath Falls Pediatric Clinic
Date of project: 6/29/2009
Health Literacy is defined by the Institute of Medicine as “the degree to which individuals can obtain, process, and understand the basic health information and services they need to make appropriate health decisions.” Limited health literacy may affect some 90 million American adults, and has been postulated as a link between socioeconomic inequality and health disparities. In the pediatric realm, limited health literacy skills among parents or caregivers have been associated with poor health outcomes. This study assessed a measure of health literacy among the primary caregivers (usually parents) of patients at the Klamath Pediatric Clinic in Klamath Falls, OR. One concern regarding health literacy is that patient education materials may be written at levels that are inappropriate for the average patient or caregiver. To determine whether this is the case at the KPC, a number of the handouts distributed at this clinic were assessed for their readability. The average grade level at which caregivers read was compared with the average grade level at which patient handouts were written. Caretaker health literacy was approximated using the Rapid Estimate of Adult Literacy in Medicine-Short Form, administered to parents and caregivers by the medical student prior to appointments in the clinic. Common handouts given to parents, including those about well-child care, normal development and some common childhood illnesses were assessed for their readability using the Flesch-Kincaid Grade Level Formula. According to the REALM-SF, 15 out of 40 caregivers (37.5%) read at a 7th or 8th grade level and therefore are at risk of low health literacy. The average grade level of all the handouts assessed was 6.3, with a range from a 1st grade level to a 10th grade level. Thus, some of the patient education materials used in the clinic may be written at a level that is too advanced for some of the parents of children in the clinic to understand.
The Frequency and Types of Dermatological Diagnoses in a Rural Primary Care Practice in Klamath Falls, Oregon
Date of project: 6/29/2009
Dermatological disease is frequently encountered in the primary care setting. Some studies show that up to 36.5% of patients who presented to their primary care physician (PCP) had at least one skin problem. The current literature regarding dermatological disease in primary care has mainly been done in urban areas, and little data exists regarding the frequency of dermatological diseases seen by PCPs in rural areas. The goal of this project was to determine the frequency and types of distinct dermatological diagnoses in a family practice in Klamath Falls, Oregon, from July 2006 through July 2009, in order to establish a baseline of data regarding dermatological disease in a rural primary care setting. A total of 437 unique dermatological cases were seen by the PCP during the three year interval, amounting to 2.7% of total patient visits. The diagnosis of actinic keratosis was most common (18.1%) and is attributed to the high amounts of sun exposure in many of the area's occupations and popular outdoor activities. These results will be used to inform rural primary care practices and direct continuing medical education. Due to the high number of sun-related diagnoses, a sun safety poster from the American Academy of Dermatology was chosen and offered to be placed in exam rooms as an educational tool for patients.
Health of the Klamath Tribes
Date of project: 3/16/2009
The purpose of this project was to educate myself and my peers about Indian Health Service and unique health and healthcare delivery issues faced by AI/NA patients, within the context of the Klamath Tribes as sole provider of IHS services in Klamath County. The Indian Health Service (IHS) is a unique healthcare delivery system that provides health services to nearly 2 million American Indians and Alaska natives (AI/NA) residing on or near reservations and 600,000 patients in urban areas. The Portland Area Office of IHS is one of 12 area offices around the country, serving 42 federally-recognized Tribes in Idaho, Oregon and Washington State. The project population was patients at the medical clinic of the Klamath Tribes Health & Family Services Wellness Center. Investigation methods included a meeting and extended tour with the Health General Manager, observation of patients at the Wellness Center, discussion of health and healthcare delivery issues with the clinic’s primary providers and use of Internet resources. Results: common health issues included opioid dependency, diabetes, hypertension and obesity, infant mortality, substance abuse and mental illness. Healthcare delivery issues included limited funding, need for providers, limited resources for a growing patient population, and lack of an electronic health record (EHR).
Comparing Trends in Cardiac Disease between Multnomah and Klamath Counties
Date of project: 2/9/2009
Background: Coronary heart disease (CHD) is the single leading cause of death in the United States. Mortality from CHD and overall incidence of CHD has been declining since the 1960’s. This trend has not been as significant in African Americans, Hispanic Americans, American Indians, individuals of lower socioeconomic status, and rural populations. Differing trends in heart disease have been observed within different sub-populations in Oregon. The purpose of this study was to compare trends in heart disease in the most urban area of Oregon, Multnomah County, to heart disease trends in a rural region, Klamath County. Methods and Results: Yearly, age adjusted heart disease death rate, coronary heart disease (CHD) death rate, myocardial infarction death rate, and risk factor data, including data on smoking, obesity, physical activity, diabetes, and cholesterol awareness data for Klamath and Multnomah counties was analyzed. Trends in heart disease mortality from 1995 to 2005 were compared. Heart disease death rates were found to be consistently been higher in Klamath County than in Multnomah County. Hispanics and Native Americans residing in Klamath County had significantly higher mortality rates from cardiac disease. There was a decreasing trend in heart disease mortality and myocardial infarction mortality in Multnomah County from 1995-2005 that was not apparent in Klamath County. Prevalence of major risk factors such as smoking and obesity was also found to be significantly higher in Klamath County. Conclusion: Klamath County exhibits several disparities related to recent trends in heart disease. Primary prevention programs with improved outreach that are more specifically targeted towards those living in rural areas need to be established. Better access to health care is necessary in rural Oregon. Physician shortages must be addressed to improve both preventive and specialized care.
Recruitment and Retention of Physicians in Klamath Falls, Oregon
Date of project: 12/29/2008
Recruitment and retention of physicians in rural communities continues to be a problem throughout the United States. This study aimed to characterize the unique challenges and solutions to the problem of physician recruitment and retention faced by the larger rural community of Klamath Falls, Oregon. Due to its status as a large rural community, Klamath Falls is not eligible for many of the state and federal government programs that have helped smaller rural communities recruit physicians, such as loan repayment programs. This study identified three areas of concern when it came to recruiting new physicians: frequent on-call duties, poor reimbursement rates due to large Medicare population, and lack of loan repayment programs. Through interviews with physicians, citizens, and business members possible solutions to these barriers were discussed. Future direction for this project would entail identifying strategies and resources to aid in overcoming the barriers of retention and recruitment of physicians.
Childhood Obesity Knowledge in 9th Graders at Klamath Union High School
Date of project: 10/13/2008
Since the 1960's, childhood obesity has increased in the United States foru fold from 4% to 16.3% in 2006. In Klamath County, the current rate is even higher at 24.4% in 2007 making childhood obesity a serious epidemic. This is also 5% higher rate than the rest of Oregon. The Klamath Basin United Way 'Trends and Solutions of Klamath County 2006' survey noted obesity as the #8 health concern among children. In addition, a panel of experts surveyed listed obesity/eating disorders as the #1 problem not addressed in the community. Even more surprising, obesity/eating disorder education was listed as the #1 service needing the most improvement. I sought out on my project to prove the United Way study was correct with the assessment that obesity education needs improvement. In order to do so, I taught three classes on obesity to 82 ninth graders at Klamath Union High School. I gave them a survey to fill out before and after the class about their knowledge on obesity. The results showed that less than fifty percent of the students had knowledge in many of the different complications of obesity. Of those, hypercholesterolemia and sleep apnea were two complications that they learned the most about.
Pediatric Obesity: Documentation and Intervention
Date of project: 9/8/2008
Pediatric obesity is a rising epidemic that poses new challenges for clinicians to manage. The goal of this study is to design a clinic documentation tool that can be used to collect data and help focus possible interventions and subsequent progress in a Klamath Falls, Oregon pediatric clinic for patients with a BMI percentile greater than 85%. The design was gathering clinical information on how to manage obese patients, both from the literature and interviews with providers. Observations were made at Klamath Pediatric clinic on how documentation tools were implemented in the clinical outpatient workflow. This data was then synthesized into a document that could be implanted to help manage obese pediatric patients. The document consisted of a single piece of paper in which the front is filled out by the patient's family before the provider has seen the patient, and the back side is filled out by the provider during the office visit. The final product is a tool to manage overweight and obese pediatric patients by assessing obesity risk factors, probe possible interventions, and set goals.
Establishing a Needle-exchange program in Klamath County
Date of project: 3/17/2008
Hepatitis C infection is increasing in incidence throughout the state of Oregon, and particularly in Klamath County. Estimates of hepatitis C rates tend to under-estimate the true incidence: because most hepatitis C infections are asymptomatic, many people do not know they are infected. A majority of acute cases of hepatitis C are associated with injection drug use. Needle exchange programs, where clients can turn in needles and syringes used for drug injection in exchange for new ones, has been demonstrated to reduce the transmission of Hepatitis C and HIV, without increasing IV drug use. The aims of this project are to justify the need for needle exchange in Klamath County, present the data for the effectiveness of needle exchange as a tactic to reduce disease, and identify the steps needed to establish such a program.
Use of Vicscosupplementation in Patients Suffering from Osteoarthritis of the Knee: Improving Outcomes for the Patients of Klamath Family Practice Center
Date of project: 10/15/2007
Osteoarthritis is a widespread problem, especially among older adults. Due to the pain and immobility associated with the condition its effect on quality of life is often detrimental. The relatively large number of patients seen for osteoarthritis at the Klamath Family Practice Clinic made the relevance of osteoarthritis treatment to the Klamath Falls community quite clear. The rural quality of the community adds a further level of importance, since employment and household responsibilities tend to be physical and dependent upon mobility. Hyaluronic Acid injections are a relatively new form of treatment of osteoarthritis of the knee. They represent a new tool for primary care physicians in helping their patients to overcome the disabling effects of osteoarthritis of the knee. I interviewed a number of patients who had received the Hyaluronic Acid injections and a pair of doctors who have given the injections to their patients to assess the efficacy and subjective value of this therapy. I also reviewed current literature on the therapy. Research showed that the injections are moderately effective in controlling pain and improving mobility, with better duration of effect (up to ~12 months) than current non-surgical therapies. Subjective data showed a large perceived benefit for most patients and doctors utilizing the treatment, with exceptions tending toward patients with more advanced disease.
Evaluation of chronic pain management patient burden on CEFP clinic, Klamath Falls, OR. Are we simply refilling opioid medications?
Date of project: 9/10/2007
Klamath Falls, is a larger than rural community in S. Oregon. However, due to its proximity to other outer lying rural areas, CEFP serves as the hub in the wheel and center of focus for much regional primary care. There is only on Pain Management specialist in Klamath Falls, and this provider does not take OHP. Thus the burden of low income pain management falls mainly on CEFP. Currently many urgent care visits are taken up by medication refills and frustration of residents in trying to deliver appropriate care is evident. Most notably, loss of professional autonomy is cited by residents in their frustrations in dealing with this patient population. This does not allow for continuity of care and addressing of other patient health issues. In fact these patients are seen more often but with less emphasis on other health maintenance issues. A 6 mos interval of chronic pain management visits was queried from CEFP electronic medical record system. 158 unique patients involving a total of 1075 patient visits in the last 6 mos. These patients were chart reviewed to identify continuity of same provider care and top categorical assignment of other co-morbid health conditions in an attempt to identify strategies to better improve delivery of health maintenance. These results will help the faculty and residents determine if:
1) they are meeting their health care mission to their patients
2) if a pain refill medication clinic is specifically needed to relieve burden on the urgent care practice and allow patient visits to focus more on other health issues.
Evaluation of the Potential for Expanded Use of the Cascade’s East Family Practice Residency Program Mobile Health Clinic
Date of project: 7/2/2007
Southern Oregon includes much vast and scarcely populated territory. This is particularly true in the region served by the medical providers in Klamath Falls. Healthcare resources are intensely focused in Klamath Falls itself, with very minimal services available in the rest of the territory which encompasses almost 10,000 square miles. In addition to the geography, there are social and economic considerations which further pose barriers to effective healthcare access for the most rural residents.
The Cascade’s East Family Practice Residency Program has initiated a mobile clinic in an effort to reach out to the vulnerable and underserved populations in the area. Currently the well equipped vehicle is targeting its service delivery to the homeless populations with monthly visits to the area shelters. Given the success of these initial efforts, there is great potential for successfully meeting further needs by expanding the services of the mobile clinic.
A needs assessment was conducting to identify and prioritize potential uses of the mobile unit. The demographic and health data for the region was reviewed as well as the current health services. A list of needs and potential mobile clinic activities was then developed. Finally, the available resources and potential funding sources were evaluated and recommendations were developed for next steps.
Antenatal Depression in Klamath Falls, OR; development of a patient handout for use in patient education for at risk women
Date of project: 3/19/2007
Depression during pregnancy and in the postpartum period is a major public health concern in the United States affecting approximately 20% of all pregnant women. This study attempted to assess the process of identifying women at risk and educating them on available options in the Klamath Falls Family Practice Residency Clinic. The design was observation of family physician's, obstetrician's, and psychiatrist's interaction with pregnant patients and patients with mental health problems during a five week rotation in a high-risk area. One faculty psychiatrist is the primary referral source for patients with medication questions. For counseling services patients are referred to Klamath County Mental Health. Patient openness to discuss the topic of depression and mental health concerns in general was observed. While the topic of depression was addressed when a patient initiated the discussion there appeared to be no standard method for screening pregnant patients for depression or discussing treatment options in the event of depression occurring. Also, although there were information handouts regarding depression, there was nothing specifically targeting pregnant or postpartum women. Thus the main goal and final product of this project was development of a patient handout for pregnant patients and those considering pregnancy with concern about depression and anti-depressant treatment.
"Exercise by Prescription"
Date of project: 3/19/2007
A routine of exercise and physical activity has been shown to decrease morbidity in patients suffering from things such as heart disease, cerebrovascular disease, hypertension and osteoporosis. Physical Inactivity however has been correlated with many external factors beyond the patients’ control. This study attempts to identify key barriers to physical activity in a rural population, specifically among the elderly. The design was the questioning of patients over 50 who came to Klamath Family Practice, and the Merle West Medical Center in Klamath Falls Oregon. Each patient who was being seen as a follow up for hypertension, Diabetes, or was having a complete physical exam was questioned on the primary reason that they did not perform a routine form of physical activity and or exercise. 2 different focus groups of 10 and 12 senior citizens at Klamath Senior Center & Center for Aging were also questioned about the same issue. This study found that the major barriers included weather in Klamath, safety and motivation along with other barriers.
Whereas there was a great deal of emphasis on the importance of physical activity, the barriers to those activities were not being addressed by physicians and/or residents. In fact it was rare that a consultation was held at all to discuss physical activity for many patients who would obviously benefit. Therefore my intervention sought to decrease the burden of those same barriers in an effort to motivate the patients to seek out the recommended amount of physical activity set forth by “Healthy People 2010.” This included but was not limited to, making trail maps for walking and jogging, convincing local fitness centers and rentals shops to give discounts to patients mentioning “exercise by prescription” from their doctor. Such a sheet of information and incentives give the physicians in office, something to have in hand in order to have a worthwhile discussion about exercise with patients and to hopefully further impact preventive care in Klamath Falls.
Rural Healthcare Dialogue Project
Date of project: 1/1/2007
Many private and public groups are currently involved in health care reform initiatives. The primary goal of this project is to decentralize and enrich the discussion of health care reform by engaging rural Oregonians in a conversation regarding their perceptions and expectations about healthcare, and to ensure that their opinions are relayed to the leaders of health care reform initiatives. Additionally, this project aims to foster leadership and activism among medical students and community members. Third year medical students will hold town-hall-style meetings in rural Oregon cities while on their required rural clerkships. These meetings will be open to the public, and provide education regarding the current state of health care in Oregon and the US, and discourse of several standardized discussion questions that focus on improved coverage and the finances of health care reform. Medical students serve as facilitators and document the general thoughts and sentiments for the group. Their results are communicated via a one-page summary document and one-page personal reflection document. At its conclusion, the findings will be shared with the Medicaid Advisory Committee, the Office of Private Health Partnerships, and the Oregon Health Policy Commission. So far, ten medical students have participated in the project, hosting meetings in eight cities. The findings to date are quite varied; however, several themes and lessons have emerged. First, many people lack understanding of the structure of our healthcare system, which creates a barrier to informed discussion. Second, the immigrant population is in favor of universal basic healthcare coverage while non-immigrants are generally opposed to coverage of non-citizens, and oppose tax increases to improve coverage. Third, students have responded positively to the experience, stating it has inspired them to continue participating in health care reform efforts. And last, rural health care providers believe that medical schools can influence future providers to practice in rural areas by recruiting students from rural cities, and by creating a rural medicine “fast track,” that specializes in training rural physicians.
Rural Healthcare Dialogue Project
Date of project: 1/1/2007
Many private and public groups are currently involved in health care reform initiatives. The primary goal of this project is to decentralize and enrich the discussion of health care reform by engaging rural Oregonians in a conversation regarding their perceptions and expectations about healthcare, and to ensure that their opinions are relayed to the leaders of health care reform initiatives. Additionally, this project aims to foster leadership and activism among medical students and community members. Third year medical students will hold town-hall-style meetings in rural Oregon cities while on their required rural clerkships. These meetings will be open to the public, and provide education regarding the current state of health care in Oregon and the US, and discourse of several standardized discussion questions that focus on improved coverage and the finances of health care reform. Medical students serve as facilitators and document the general thoughts and sentiments for the group. Their results are communicated via a one-page summary document and one-page personal reflection document. At its conclusion, the findings will be shared with the Medicaid Advisory Committee, the Office of Private Health Partnerships, and the Oregon Health Policy Commission. So far, ten medical students have participated in the project, hosting meetings in eight cities. The findings to date are quite varied; however, several themes and lessons have emerged. First, many people lack understanding of the structure of our healthcare system, which creates a barrier to informed discussion. Second, the immigrant population is in favor of universal basic healthcare coverage while non-immigrants are generally opposed to coverage of non-citizens, and oppose tax increases to improve coverage. Third, students have responded positively to the experience, stating it has inspired them to continue participating in health care reform efforts. And last, rural health care providers believe that medical schools can influence future providers to practice in rural areas by recruiting students from rural cities, and by creating a rural medicine “fast track,” that specializes in training rural physicians.
Patient Centered Education Materials in Klamath Falls
Date of project: 10/16/2006
Klamath Falls, OR has a population of around 42,000 people. For many this would call into question it’s designation as a rural community in the state of Oregon. Due to its larger population, however, Klamath Falls provides medical services to many residents of surrounding communities that are completely devoid of medical care. With such a large portion of the patient population located so far from the clinic, I felt that the creation of some patient education materials would help patients learn more about their healthcare outside of the clinic. To accomplish this I created the brochure “Finding Breast Cancer Early with Breast Self Exam” and the handout “Is the new HPV vaccine right for you or your daughter?” The brochure on breast self exam was created in enough time to get some feedback from patients coming in for their annual well woman exam. Overall, they were appreciative of the brochure, but for the most part they ignored it. This didn’t allow for a lot for feedback, and instead it made me question whether my initial assumption about the necessity of such materials was true. I do feel that both of these handouts will be helpful to some of the future patients in my preceptor’s practice, but I also wonder what other ways there are to provide education outside of the clinic. This project definitely got me thinking about other options.
Improving Birth Outcomes Among Pregnant Adolescents in Klamath Falls, OR
Date of project: 7/3/2006
U.S. adolescent pregnancy rates remain higher than any other industrialized nation. According to the Oregon Office of Rural Health, while Klamath Falls’ adolescent pregnancy rates are no higher than the Oregon average, the actual birth rate among pregnant teens is about 1.4 times higher than the Oregon average. Reasons for this have been investigated in prior community health projects, and include lack of access to or knowledge of abortion clinics, as well as the general attitude toward abortion in the community. The focus of this project was the health of those teenage mothers who do choose to give birth. Adolescent pregnancy is associated with various obstetric and birth problems such as premature labor and low-birth weight infants. Reasons for this are related to unique physical, psychological, and social factors present in adolescence. Several prior studies provide a strong argument for instituting specific programs that target this special population in order to improve pregnancy outcomes. Based on these findings, this project used two approaches to improve pregnancy outcomes – a community-based approach and a healthcare provider approach. A teenage pregnancy and parenting workshop course was developed and implemented in the community. Further, a brochure was developed for healthcare providers which provided important information to address in the care of pregnant adolescents. A talk was also given to the residents of Cascades East Family Practice regarding the issue.
Medical Record Documentation
Date of project: 3/20/2006
Medical therapy for heart failure including ACE-I/ARB and beta-blockers extend life and improve symptoms in patients with heart failure, as well as decreasing hospitalizations. They are therefore the cornerstone of therapy for heart failure. At the Cascades East Family Practice Residency, quality assurance/ chart reviews are done on inpatients that are discharged from the hospital, but this is typically not done on their outpatient clinic population. The patient population of CEFPC has a high level of medical comorbities, polypharmacy, limited follow-up as well as substance abuse and psychiatric co morbidities. I felt this made this population high risk for not receiving appropriate medical therapy.
An audit was performed on pts with the ICD-9 code for heart failure, presenting for appointments over a six month period and from this list 26 patients were selected. Of the sample 34% of patients were on ACEI/ARB and beta- blocker. 27% were on an ACE only, 12% were on a beta blocker only and 27% were on neither. In conclusion, treatment with Angiotensin agents and B-blockers could be improved. There may exist absolute or relative contraindications for some patients, however these could be better documented in the problem/med list. In addition in patients with heart failure it would be useful to briefly summarize the results of the most recent echocardiogram including ejection fraction (EF), hypertrophy, valvular lesions, bundle branch block, and atrial fibrillation.
Helmet Use in Klamath Falls
Date of project: 3/20/2006
Safety helmet use within the pediatric population continues to be an important part of preventive health. The bicycle is associated with more childhood injuries than any other consumer product except the automobile with head injuries accounting for the majority of bicycle-related deaths and hospital admissions. There are many factors that contribute to the use of safety helmets including access to obtaining a helmet, education regarding appropriate use of helmets, as well as many compliance issues. This study attempted to examine the percentage of children without access to a safety helmet and questioned what particular barriers to helmet ownership exist within the Klamath Pediatric Clinic population. The design included a seven question survey including age and sex of the child, whether the child owned a safety helmet and asked how often the child wore the helmet during bicycling, skateboarding/roller blading, and skiing/snowboarding. The survey was initially given to all parents who came to the pediatric clinic with children 3-18 years old. When this proved to be of low yield, parents were questioned verbally in the waiting area of the clinic, using the same questionnaire as a guide.
Stroke Disease in Klamath Falls: Public Awareness of Symptoms and Risk Factors
Date of project: 2/13/2006
Cerebrovascular accidents are serious medical events that are responsible for significant morbidity and mortality in the United States. In the case of thrombotic or embolic strokes, early intervention with thrombolytic therapy often leads to improved outcomes. However, early intervention often depends upon patient and public awareness of stroke symptoms and understanding of the need to seek medical attention promptly. This study attempted to determine knowledge of stroke disease and risk factors of residents of Klamath Falls, Oregon. This was accomplished by a voluntary, written survey of outpatients at the Klamath Family Practice Center (KFPC). The survey was designed to determine patient knowledge of stroke causes, symptoms, and risk factors, as well as patients’ individual risk factors for stroke and the distance they live from the local hospital emergency room. Analysis of survey responses showed deficiencies in patient knowledge of causes of stroke (57% sensitivity, 86% specificity), risk factors of stroke disease (57% sensitivity, 86% specificity), and symptoms of a stroke (67% sensitivity, 81% specificity). Additionally, there was little or no correlation between individual patients’ risk factors and their knowledge of stroke disease and its symptoms. Based on the results of the survey, efforts were made to improve public awareness of stroke symptoms and risk factors.
Increasing the Awareness of the Scope of Diabetes Mellitus in Klamath Falls, Oregon.
Date of project: 1/2/2006
Approximately 7% of the United States population carries the diagnosis of diabetes, and it is estimated that about 33-50% of the diabetic population remains undiagnosed. 41 million more people are diagnosable as glucose intolerant. Considering the well-known complications of the disease – retinopathy, nephropathy, neuropathy and heart disease – and the fact that these complications can be prevented from both developing and progressing, as was proven in the Diabetes Control and Complications Trial, it is imperative that physicians are sensitive to the risk factors, lab tests, and the symptoms of DM. The ADA currently has recommendations for screening based on risk factors, and specific numbers for fasting plasma glucose and oral glucose tolerance test levels for a diagnosis. But the altered metabolism of neurons that leads to neuropathy begins at a blood sugar level of ~160, which is a diagnosis of glucose intolerance with the OGTT. With this result, insurance companies will not pay for routine diabetic care, such as a yearly dilated eye exam. It is thought that neuropathy and retinopathy begin 10 and 7 years before the diagnosis of type 2 diabetes occurs. Therefore, serious preventable complications are occurring long before patients are diagnosed, if they are diagnosed at all. To help with diagnosis, it might be beneficial to do a symptom screening, which is not currently offered by the ADA. The earliest symptom patients are aware of tends to be peripheral neuropathy, but there are others including blurry vision, polydipsia and polyuria, chronic infections, and impotence. The goal of this project was to offer a history-based checklist for symptoms that raise the suspicion of diabetes.
Medicare Part D
Date of project: 1/2/2006
Medicare part D, is a new prescription drug plan being started by the government beginning this year January 1. There is lots of confusion regarding general information, how to sign up, and which plan to choose. This program affects a large amount of the community in Klamath Falls, since all people on Medicare currently are eligible. In addition there are many penalties and nuances of the program. The goal of the project was to find out more information on Medicare D and what it was about, to see the population’s grasp of the new program, and to see what was out there to help those who needed aid. A quick survey was distributed through the practice to see if people knew about Medicare part D. The only community resource in K. Falls was contacted, interviewed, and observed to see what educational opportunities were available to the public. Of the eligible parties only 55.8% were familiar with the new program showing a definite need to further educate those eligible.
Increasing Awareness and Screening of Postpartum Depression in Klamath Falls
Date of project: 10/17/2005
Postpartum depression occurs in approximately 10-22% of women nationally. Risk factors for developing postpartum depression include being a single parent or in an unstable relationship, living at a lower socioeconomic level and having a lack of social and emotional support. Given childbirth is considered such a joyous time in a woman's life, having symptoms of depression can cause women to feel guilty or ashamed. As a result, postpartum depression is under-reported and often physicians do not readily inquire about it. It is an important illness to recognize because not only can it be debilitating for a woman, but it can interfere with essential maternal-infant bonding and can have long-term consequences for the child such as behavioral, cognitive and social developmental problems. Many women in Klamath Falls become mothers at a young age and lack financial resources, stable relationships and emotional and social support. Based on these displayed risk factors, one can infer that postpartum depression is a problem for some women in Klamath Falls. It is therefore important for women to be informed and adequately screened for postpartum depression. As a community project, postpartum and pregnant patients were surveyed to assess the need and interest for more information and screening for postpartum depression. Similarly, several doctors were consulted and expressed interest in providing women written information on postpartum depression and better access to a definitive screening tool. Based on this feedback, an educational pamphlet was created for women with information on understanding the disease, recognizing the symptoms, and knowing the treatments and was made available in the clinic. Similarly, a screening tool specific to postpartum depression was made accessible to the doctors in the clinic to facilitate more consistent screening.
Spanish and English Asthma Action Plans in Klamath Falls, OR
Date of project: 10/17/2005
Asthma is a serious health concern among the pediatric population in the United States. It affects approximately 9 million children under 18 and accounts for at least 2.9 million visits to pediatricians each year. Asthma is the most common chronic illness of childhood, and hospitalization rates for childhood asthma have increased despite improvements in asthma therapy. While asthma affects people of all races and ethnicities, the under-treatment of asthma among certain racial and ethnic minorities is well documented. There are two main causes that have been found thus far as reasons for this disparity. The first reason is lack of access to appropriate health care for minorities and underprivileged populations in general. The second reason is that the health care provided is inconsistent with the guidelines of the National Asthma Education and Prevention Program of the National Heart, Lung, and Blood Institute (NHLBI). While the lack of provisions of adequate health care for all of the nation’s children is appalling, this paper will be focusing on the second issue, the general lack of adherence among pediatricians and family practitioners nationwide, including Klamath Falls, Oregon, to follow the guidelines of the NHLBI, by not distributing appropriate information on asthma to the Spanish-speaking population or to the general population as a whole. The purpose of my project was to assess how many primary care clinics in Klamath Falls, Oregon, provided asthma action plans in English or in Spanish to their patients and to provide asthma action plans to those clinics that didn’t have any.
Recruitment of rural physicians: the challenges of a hospital and a private clinic in Klamath Falls, Oregon
Date of project: 9/12/2005
A present and future healthcare concern facing the United States is the shortage of physicians practicing in rural areas. Doctors disproportionately prefer urban-suburban practices, and this makes the recruitment of rural physicians a challenging task. This report documents the hospital and clinic recruitment process of the rural town of Klamath Falls, Oregon. Data were gathered from interviews with the physicians involved in the recruitment process at the Klamath Falls hospital and private clinic, and from published journal articles. The strategies for recruiting included hiring a recruiting service and establishing a local residency program and expanding medical student clerkship programs. The recruitment incentives the hospital and clinic offer to candidates include higher salaries, assistance in setting up a practice, establishing a clientele and assistance with spousal employment. Besides attracting physician candidates with the beautiful environment, physicians are drawn to Klamath Falls because of the low cost of living, the broader scope of the medical practice, the casual lifestyle and the lack of traffic congestion. Nonetheless, the recruitment is low due to the complaints of increased on-call hours, low reimbursement and no educational loan support. I recommend two broad strategies for increasing physician recruitment. First, Klamath Falls should emphasize its stunning natural surroundings. More importantly, Klamath Falls should increase its efforts to reach out to rural training programs nationwide.
Educating pregnant teens about their options and the resources available to them in Klamath Falls, Oregon
Date of project: 8/8/2005
Though teen pregnancy rates have been on the decline in the United States for many years, they remain higher than in any industrialized country. As a medical student found in 2002, while the teen pregnancy rate in Klamath County is no higher than that of Oregon as a whole, the teen birth rate is higher because more teens choose to raise their children than elsewhere in the state. This is potentially problematic because teen parents and their children are subject to a unique set of public health problems. One of the reasons discovered for why Klamath County teens chose to become parents is lack of access to pregnancy termination, a fact that was confirmed by discussions with Klamath Falls physicians and a health educator. Resources do exist for Klamath Falls teens seeking pregnancy termination, although these resources are limited. Realizing that Klamath Falls teens may not have information available to them about pregnancy termination, and also that termination is not the choice every pregnant teen will make, an informational brochure was created to be distributed to nurses at Klamath Falls high schools. This brochure listed resources for teens that choose to become parents, those who choose to place their baby for adoption, and those who choose to terminate their pregnancy. To address the issues of teen pregnancy prevention, a second informational brochure was created for the nurses, this one describing various birth control options and informing teens of local family planning resources.
Meningococcal Disease in Klamath Falls, OR
Date of project: 7/4/2005
Meningococcal disease is an important cause of morbidity and mortality in the United States. This project attempted to identify barriers to the utilization of vaccination against Meningococcal disease in Klamath County. These barriers surfaced following a small outbreak of meningococcal disease in Klamath Falls. The two major barriers identified had the same underlying issue - a lack of education. The first barrier, lack of knowledge of the citizens of Klamath Falls, was identified through informal surveys. The response to this barrier was to create a pamphlet aimed at increasing patient awareness of meningococcal disease and the vaccines that exist to prevent it. The second barrier, lack of knowledge of health care providers, was gauged through informal interviews. Though multifactorial, it was due, in large part, to the fact that a new meningococcal vaccine was very recently released and most providers did not possess the most current knowledge surrounding this vaccine. This was addressed by creating a concise, clinically relevant summary of meningococcal vaccinations in the form of a memo. These two measures were designed to target the root of the problem, the need for education of both patients and providers.
Meth Use During Pregnancy
Date of project: 7/4/2005
Methamphetamine use during pregnancy is quickly becoming a major problem in rural Oregon. This study attempted to identify the health effects of meth use during pregnancy on the mother and the baby and the resources available in Klamath Falls for meth cessation. The design was a meeting with Molley Boham RN, instructor of prenatal classes at Cascades East Family Practice, and Merlaine Zwartverwer RN Maternity Care Coordinator for Cascades Comprehensive Care to determine the extent of meth use during pregnancy with their patients. A medline search for methamphetamine and pregnancy articles was then done, as well as an extensive Internet search, focusing on meth use in Oregon. I also consulted with Dr. Sohl, perinatologist for Southern Oregon. There are multiple opportunities to reach pregnant women including office visits at Cascades East, office visits with Dr. Sohl, prenatal classes by Molley and home visits by Merlaine. However, there is currently no handouts or material about meth use being used. Therefore, the final product of this project was development of a patient handout for pregnant women coming to Cascades East or in Merlaine's program. Also, a presentation was given to all physicians at Cascades East to educate them about meth.
Bipolar Education in Klamath Falls
Date of project: 7/4/2005
Current prevalence estimates of bipolar disorder in the pediatric population are thought to be about the same as those in the adult population, approximately 1%. Existing evidence indicates that bipolar disorder beginning in childhood or early adolescence may be a different, possibly more severe form of the illness than older adolescent- and adult-onset bipolar disorder. Recently, as the understanding of childhood bipolar disorder has grown, provider education about bipolar disorder has increased the rate at which diagnoses occur. With this large rise in the number of bipolar cases, physicians need to utilize all resources available to help them treat their patients including the patients themselves. The purpose of this project was to improve patient education about their disease. To accomplish this a survey was conducted of current patients and their parents to determine their current knowledge of the disorder. Reporting on these questionnaires showed that all parents sought out alternative resources to fill gaps in their knowledge. Information from the questionnaire was used to help in the creation of an educational brochure about bipolar disorder. This document was given to the Klamath Pediatric Clinic for distribution to current and future patients.
How Oregon Health Plan Cutbacks Have Affected Rural Oregon:
Trends in Emergency Department Use at Blue Mountain Hospital, John Day, Oregon
Date of project: 1/3/2005
In early 2003, Oregon’s Medicaid program underwent a number of revisions in order to comply with new budgetary limitations that were a result of the state’s fiscal crisis. Among the changes were reduced benefits and increased cost sharing via premiums and co-payments. Rural communities in Oregon face a unique set of healthcare challenges, to which these Oregon Health Plan cutbacks were added. The purpose of this study was to compare emergency department use at Blue Mountain Hospital in John Day, Oregon, in the months preceding and following the cutbacks. Total ED visits and payer type data were gathered using the hospital’s computerized billing system. The results were analyzed at 95% confidence intervals for both percent changes in absolute number of visits per month and proportion of ED visits due to each group; T-values and relative risk were calculated where appropriate. OHP managed care visits decreased 24%, and the proportion of all ED visits for which they were responsible fell from 13% to 9% (RR 0.904), whereas OHP fee-for-service visits increased 95% per month, their proportion rising from 2% to 4% (RR 1.79). Uninsured visits rose a statistically insignificant 6% and their proportion of total ED visits was practically unchanged. Following the cutbacks, the percentage of Grant County citizens eligible for OHP who were enrolled dropped from a monthly average of 86% to 72%. In addition to the sudden drop in OHP enrollment and resultant decreased use of the ED by OHP managed care beneficiaries, new barriers to healthcare may have caused the significant rise in ED visits by OHP fee-for-service patients. Although the number and proportion of visits by the uninsured was unchanged, deteriorating health and continued lack of state support will force this growing group to turn to emergency departments for care.
A new way to save on prescription drugs? Educating the physicians and Medicare patients of Klamath Family Practice on the Medicare-Approved Drug Discount Cards
Date of project: 1/3/2005
The cost of prescription drugs continues to be a major health issue in the United States, especially for elderly patients on Medicare. The goal of the project was to educate the physicians and Medicare patients of Klamath Family Practice about Medicare-approved drug discount cards so that patients could take maximum advantage of the offered savings. First, the project was designed to interact with Medicare patients and try to understand how they currently try to save money on prescription drugs and determine how familiar they were with the new Medicare-approved drug discount cards. After determining that the physicians and patients knew very little about this new program from lack of available information, the program was thoroughly researched to determine if Medicare patients would benefit from these new discount drug cards or not. The physicians were educated about the new program, and the final product of this project was the development of a poster for the lobby and a brochure to educate Medicare patients about this new program and help them save money on prescription drugs.
A Brief Overview of HIV/AIDS in Rural America
Date of project: 10/18/2004
While still accounting for only a small fraction of total cases, the incidence of newly reported HIV infection in rural America is increasing at a worrisome rate. This growing patient population faces a different set of challenges than their urban counterparts: access to care, medical compliance, and uncurbed risky behaviors are all issues that plague the rural HIV + community to a greater extent than those who live in an urban setting. This paper examines some of the key differences between these two patient populations as reported in the literature and then briefly describes the services offered to HIV + patients in Klamath Falls, and how this community side=steps some of the most striking difficulties faced by HIV+ individuals in rural setting.
Prevalence of Eating Disorders in a Klamath Falls Pediatric Clinic
Date of project: 8/9/2004
Eating disorders represent a significant cause of morbidity and mortality and typically present in adolescents and college-aged young women. Pediatricians have a unique opportunity to detect and treat these disorders.6 At the Klamath Pediatric Clinic it was noted that a large proportion of the visits were for mental health, however none of these were for the treatment of eating disorders. The purpose of this study was to specifically screen for eating disorders to determine if the prevalence was low or if the disorders were not being identified. A screening questionnaire was developed and given to patients at the clinic aged 10 and over, over a two week period. None of these patients screened positive for anorexia or bulimia, however the prevalence of obesity appeared to be fairly high. In addition, a brochure was developed to use as an informational and screening handout for concerned patients and an initial assessment form was made to use for a patient presenting with an eating disorder. I also visited the mental health treatment center for the area, which had the ability to provide outpatient treatment for eating disorders.
Patient Participation in the Legislative Process in Klamath Falls, OR: Identifying Patterns and Perceived Obstacles
Date of project: 7/5/2004
Patient initiated discussions concerning dissatisfaction with various health and health care policies are common in the rural primary care setting. Anecdotally, however, patients report not sharing these opinions with their legislators, while lawmakers describe a situation in which they feel uninformed about the ideas of the citizens in the communities they represent. A disconnect exists, whereby opportunities for constructive sharing of opinions and factual knowledge are missed. In order to describe the patterns of participation in the legislative process amongst the patients of a primarily adult Family Practice clinic, a patient survey was administered that inquired about both past experience if contacting legislators, perceived barriers to making such contact, and interest in obtaining information designed to facilitate this contact in the future. 33% of survey respondents had contacted their legislators in the past, an average of 2.6 times. 30% of those contacts were in regards to a health or health care issue. For those respondents who wanted to contact legislators but did not do so, common reasons cited included “I don’t know how to contact them”, “I’m not confident about how to present my ideas”, and “I don’t think it will make a difference”. 57% of all respondents said it would be helpful to have information about legislators and how to contact them, while 63% said having this information would make it more likely that they would contact their legislators in the future. In response to the survey answers, a patient information guide was designed in order to provide both accurate contact information for the appropriate Representatives and Senators, as well as suggestions for effective ways to communicate with legislators, and additional resources for more information.
Hyperbilirubinemia: Incidence, Accuracy, and Compliance with Guidelines in a Clinical Setting.
Date of project: 7/5/2004
Jaundice, which occurs in most newborn infants, is usually benign. Still, the potential neurotoxic effects of bilirubin, which can cause jaundice, are serious enough that newborns must be identified and monitored for severe hyperbilirubinemia, kernicterus, or acute bilirubin encephalopathy. This project attempts to determine the incidence of jaundice in the Klamath Pediatric Clinic in Klamath Falls, Oregon, as well as the accuracy of computer records on jaundice compared to charts in the clinic. Recently, the American Academy of Pediatrics published updated clinical practice guidelines on the management of hyperbilirubinemia. Therefore, this project also attempts to review how the clinic follows these new guidelines and gives recommendations for improvement.
ADHD vs. Bipolar Affective Disorder: a Comparison of the Two Mental Health Problems in the Pediatric Population of Klamath Falls.
Date of project: 5/10/2004
Mental illness is an important medical problem in the pediatric population that affects communities ranging from large metropolitan areas like Portland to small towns such as Klamath Falls. Although the prevalence of attention deficit hyperactivity disorder (ADHD) and bipolar affective disorder (BAD) are significantly different in the pediatric population, they are often confused with one another due to the overlap of common symptoms. Therefore it is important to identify children with these disorders and make an accurate diagnosis to ensure that they receive the proper medical and psychological treatment. Analysis of ICD9 codes from 2003 demonstrated almost 1,000 visits for ADHD and BAD at The Klamath Pediatric Clinic. These numbers were confirmed by my own record keeping during a three week period which showed 16% of all visits were for mental health issues. Given the number of patients with ADHD and BAD, a screening tool was utilized to try to find differences in the presentation of these two illnesses at the time of diagnosis. Results from questionnaires handed out in the clinic showed higher scores by patients with BAD (24 versus 15; p 0.011). In addition, three specific categories including irritability, thought content, and disruptive behavior were significantly higher in children with BAD. The results of this project suggest that mental illnesses, specifically ADHD and BAD are an important healthcare issue at The Klamath Pediatric Clinic and that there may be ways to better screen for and treat these patients.
Uncovering Available means to reduce prescription drug costs, and improving patient access to this information
Date of project: 5/10/2004
Increasing prescription drug prices place significant financial strains on numerous segments of the population. The reduced medication compliance that results from this reality adversely impacts both the directly involved individuals health and the overall healthcare system. While this is not a problem with an easy solution, numerous programs currently exist that could benefit those less then able to pay. These programs are underutilized, however. Using mainly discussions with providers, obervation patient questions, and internet seraches, the following resource categories were discovered: PAP programs, Medicare drug cards, and miscellaneous state-specific programs. Additionally, a previous student handout on the use of overseas pharmacies was consulted. Though the handout's recommendations were technically illegal, the fact remains that millions of Americans do obtain their medications at discounted rates from overseas pharmacies - without real FDA enforcement. As such, an attempt was made to help make the practice as safe as possible. From all this information a handout was created, inteded to maximize patient self-sufficiency and benefit while minimizing resource costs.
North Ridge Estates: A Case of Hazardous Asbestos Waste in Rural Oregon
Date of project: 3/29/2004
In 2001, the Oregon Department of Environmental Quality began clean-up procedures at a residential housing development in Klamath Falls, which had been deemed a past and present public health hazard due to asbestos contamination. The health risks associated with asbestos exposure have been well documented, and include lung cancer, mesothelioma, asbestosis, and pleural disease. I conducted a literature review of medical, historical, and governmental documents, and focused on the following four questions: 1) How much asbestos exposure were the 68 residents of North Ridge Estates subjected to? 2) What are the realistic present and future health concerns for that community? 3) Do adequate screening tests exist to help identify those people most at risk for developing asbestos-related disease? 4) What efforts are being made to monitor the residents of North Ridge Estates, and which agency, if andy, is responsible for monitoring the health of this community?
Evaluation of Childhood Obesity in a Rural Pediatric Clinic
Date of project: 11/10/2003
The incidence of childhood and adolescent obesity is rapidly increasing in the United States. Related to this is a substantial increase in the incidence of type 2 diabetes in children. The short term and long term effects this will have on both the individual and the health care system are drastic. Modifiable risk factors for obesity include sedentary lifestyle and poor eating habits. This project looks at helath behaviors among patients of a rural pediatric clinic. Grade school and high school aged patients at Klamath Pediatric CLinic were given a survey covering several healthy lifestyle issues such as exercise regiments, eating practices, and amount of time spent watching television. Those who were given the survey were also measured for BOdy Mass Index (BMI). Finally, the educational tools provided by the clinic regarding obesity and healthy eating and exercise behaviors were assessed. The findings suggest that the health behabiors that correlate with obesity in the population studied were short duration of exercise (p<0.01) and less than 3 exercise sessions per week (p<0.025). Other behaviors such as eating habits and watching television did not correlate with obesity in this population. Based on this study, it is recommended that the community work to improve child participation in physical activities.
OHP at Work in Rural Oregon
Date of project: 9/29/2003
Although Medicaid provides health insurance for millions of Americans, there are problems associated with it that can hinder easy access to quality healthcare. Doctors frequently cite the low levels of reimbursement for services provided to Medicaid patients. Their offices must limit the number of patients on Medicaid in their practice so the higher reimbursement received from private insurers can make up for the losses incurred by treating Medicaid patients. Patients dependent on the government for their healthcare comment that they are not treated with the same respect as other patients, and can have a difficult time finding a physician willing to care for them at all. In 1993, a small group of physicians in Klamath Falls recognized these problems and decided they would takes some steps toward change. That year, Cascade Comprehensive Care (CCC) was birthed in Klamath County as a managed care program that would serve the county’s Medicaid population. Since that time, profitability for physicians and access to care have improved, and for the most part, the patients seem pleased. This project investigates the successes of CCC to present it is an alternative for managing patients on Medicaid. Statewide research is cited to show the relative success of this program, and the results of a survey completed by patients at the Klamath Pediatric Clinic are presented to show the success of this clinic which serves a population with a large contingent of Medicaid patients.
Screening for Maternal Domestic Violence at the Klamath Pediatric Clinic
Date of project: 7/7/2003
Maternal domestic violence has been correlated to physical, emotional, psychosocial and behavioral problems and/or delays in children. The purpose of this study was to determine the rate of maternal domestic violence in the Klamath Pediatric Clinic (KPC) patient population using a five question survey. An additional aim of the study was to educate the staff on how to screen for domestic violence and how to refer patients to the local social service resources. Of the 120 surveys completed 17.5 percent of the respondents reported a history of abuse. One woman had been hurt within the last year. Four percent of the respondent's partners had ever threatened to hurt her child(ren) and two and five tenths percent reported a history of child abuse. One woman reported being afraid of her current partner. The results of the survey were presented to the medical staff at a lunchtime meeting. Representatives of local child abuse and domestic violence resource centers also presented information at the meeting on how to refer patients who screen positive for domestic violence. After the meeting the clinic's medical staff expressed more confidence in the feasibility of screening for domestic violence and in their ability to properly refer abused mothers and children to local resources. In conclusion, it is recommended that the medical staff of KPC begin routinely screening for domestic violence and intervene when necessary.
Diabetes Mellitus at Klamath Family Practice Evaluating the Amount of Medical Care Given and Improving Analysis of Blood Glucose Self-Monitoring.
Date of project: 3/24/2003
Diabetes Mellitus is significant national, state, and local problem. At Klamath Family Practice management of diabetes mellitus involves diabetic self-monitoring of blood glucose. The goals of the community project were therefore twofold. One goal was to quantify the amount of care at Klamath Family Practice dedicated to patients with diabetes mellitus. The second goal was to evaluate and improve diabetic self-monitoring of blood glucose by instituting a system for downloading patients’ glucose meter readings into a software program, which could save and graph readings for provider analysis and diabetic management. The community project showed that approximately 19.6% of patients seen per day at Klamath Family Practice have diabetes mellitus. Evaluation of diabetic self-monitoring at Klamath Family Practice revealed that 34.1% of patients already owned Accu-checkÒ meters, 27.3% had OneTouchÒ meters, 22.7% had GlucometerÒ meters, and 15.9% did not know which brand of meter they owned, had another brand, or owned no meter. Equipment for downloading readings from the three most common brands of meters owned by patients was evaluated. LifeScan, the maker of OneTouchÒ meters, supplied meters capable of data transfer and the computer equipment necessary to download patient readings. However, other OneTouchÒ meters exist that use less expensive test strips and from which data can also be downloaded in the clinic, and this information will be made available to patients. Klamath Family Practice may also choose to offer data downloading for Accu-checkÒ and GlucometerÒ meters.
Discovering Diabetes Education in Klamath County: Diabetes CareLink
Date of project: 11/4/2002
Problem: 16 million people in the United States are estimated to have diabetes. Diabetes is a chronic disease and therefore requires time, money, and education. The Task Force on Community Preventive Services (Task Force) found that diabetes self-management education (DSME) provided in the community setting resulted in improved glycemic control and recommended that DSME take place in community gathering places for adults with type 2 diabetes. According to the Oregon Public Health Department, of the 705 deaths in Oregon from diabetes in 1995, 4% occurred in Klamath Falls. People with diabetes in Klamath Falls would greatly benefit from better glycemic control and hence from DSME. Population: The population studied were residents of Klamath County of all ages with type 2 diabetes. Methods: I interviewed the diabetes educator of Diabetes CareLink, a DSME program in Klamath Falls, and several participants. I also attended a community diabetes education seminar, conducted a survey, and attended a local diabetes support group. Findings: Survey results showed increased understanding of diabetes among participants of Diabetes CareLink. Diabetes CareLink meets the Task Force’s criteria of a DSME by providing group or individual classes. Discussion: Diabetes CareLink is a good example of a DSME that is working in a rural community.
Implementation of the Client Self Assessment (CSA) into Lutheran Community Services NW Treatment Center in Klamath Falls
Date of project: 11/4/2002
Substance abuse treatment success is highly correlated with client motivation. While there is no guaranteed method of increasing client motivation, one could assume that engaging clients in their own treatment would be one method for doing so. The Client Self Assessment (CSA) is a client-centered instrument that may help engage clients in monitoring their own progress in treatment. It is a weekly self-assessment tool that measures the emotional state, substance use, difficulty in reducing use, and treatment satisfaction of clients. Clients and therapists can then monitor over time how treatment is going and provide “real-time” feedback to the therapists. Benefits include: improvement of record-keeping, ability to show trends over time, allows time for clients to reflect on previous week’s activities, and allows therapists to intervene more quickly with “real-time” feedback. The CSA was implemented into Lutheran Community Services NW in Klamath Falls for a trial bases. Therapists were interviewed after 3 weeks of using the instrument. Overall, there was a favorable response to using the CSA. It engaged clients in discussion and in monitoring their own treatment as well as provided weekly record-keeping for the therapists. The center plans on continuing to use the self-assessment form.
Increasing Immunization Rates at Klamath Family Practice
Date of project: 8/12/2002
Vaccination rates affect everyone, because each unimmunized person risks transmitting the disease to other vulnerable populations. Unvaccinated children risk acquiring serious, even fatal diseases such as tetanus, diptheria, pertussis, measles, meningitis, epiglottitis, mumps, rubella or polio. Nationwide, vaccination rates typically remain above 90% (MMWR Morbidity Mortality Weekly Report, 2001). However, as of June 2002, Klamath Family Practice Center's Immunization Coverage Rate was only 60% by babies' first birthdays (Figure 1; AFIX, 2002), and coverage rates remained below 40% through year 2 (Figure 1). It was observed that Klamath Family Practice lacked a system for encouraging parents to bring children in for immunizations, so parents were interviewed to determine reasons for failures to vaccinate. The most common were forgetting well-child appointments and misconceptions about immunication, so a protocol was developed to address these issues. Parents filled out follow-up reminders at each visit which were later mailed to them, nurses provided education brochures and immunications checklists, and doctors responded to questions and concerns. Measles and pertussis rates even in immunized children directly correlate with the number of unvaccinated children, and cases of chickenpox dramatically declined after its addition to the immunication schedule in 1995. At-risk populations are the most common cause of doctor visits already, so increased immunization rates provide a safer environment for the very young, elderly and immunocompromised residents of Klamath Falls.
Examination of Adolescent Pregnancy in Klamath County: Is there really a high teenage pregnancy rate?
Date of project: 7/1/2002
This study sought to evaluate the validity of the widely held belief that Klamath county has continued to have a high incidence of teen pregnancy and if valid seek an explanation for this higher than normal rate. Vital statistics from the Oregon Department of Human Services were reviewed for the year of 2000 and revealed that Klamath County has teen pregnancy rate that is not significantly different from that of the state of Oregon. Klamath County does however have a significantly higher teen birth rate and a significantly lower abortion rate. These results fail to support the belief that pregnancy rates are higher but are able to explain why such a belief exists as the actual birth rate is higher than the state average. A discussion was then held with three staff members from the Klamath County Health Department who specifically work with teenagers to offer theoretical explanations for why the birth rate is significantly higher in Klamath county. Reasons cited include poor access for pregnancy termination, poor education of teenagers about pregnancy, denial, and in some cases a desire to have children at a young age.
Prevention of Athletic Injuries in the 21st Century: Where do physicians fit in? A study of high school athletics in Klamath Falls.
Date of project: 3/25/2002
It is estimated that 25 million scholastic and 20 million organized, community-based youth participate in sports annually in the United States. Injuries are the second leading cause of emergency room visits for youth and the second leading cause of injury in schools. Studies have shown that up to one half of all injuries sustained while playing organized sports by children and adolescents may be preventable. There are many reasons why sports injuries occur. Studies have identified the following frequent factors: lack of coaching education, inadequate preparticipation physical exams, hazardous playing fields, conditioning and training errors, inadequate safety equipment, poor fitness, poor nutrition, improper technique, inadequate supervision, lack of proper evaluation and body growth and development. Some of these "risk factors" are more modifiable than others. Specifically, the sports physical, lack of coaching education, training errors, lack of supervision, and lack of proper evaluation can be influenced directly with the help of physicians as health care providers and as respected community members. Other important aspects of injury prevention are the emergency response system and some means of surveillance to identify where to focus our resources.
Paramedic Decision-making Regarding Method of Transport and Destination
Date of project: 2/11/2002
The goal of this study was to understand what factors contribute to paramedics' decisions regarding method of transport and destination of critically ill and injured patients. This is a descriptive study based on the experience of prehospital care providers in a rural area. Factors identified primarily focused on operational considerations for trauma patients including: limitations of aeromedical transport, transport time, multiple patient scenes and factors that prolong scene time. Also identified were neurologic injuries, as neurosurgical care is not available in this community.
Herbal Remedies and Supplements: Education for Physicians and Parents at Klamath Pediatric Clinic
Date of project: 2/11/2002
This project was designed to provide education to the patients and parents of the Klamath Pediatric Clinic regarding herbal remedy use and safety in children. To better understand the needs of the community an informal survey was performed to determine baseline alternative and complimentary medicine use and knowledge among the patients at the clinic. Of those surveyed, 32.9% of parents believed they were adequately informed about available over-the-counter herbs and supplements, while 67.1% felt they were not well informed. 54.8% believe the products are safe, while 24.7% think they are unsafe and 20.4% are unsure. 83.7% of parents could not remember their physician ever inquiring about herbal remedies. 3.8% of parents responded that their children had used either Chamomile or Echinacea. A literature search reviewing recent and historical information about herbal and supplemental remedies was also completed. Using this information and the data from the survey as a guide, patient information handouts about safety and efficacy and were designed and implemented as part of patient education at the clinic.
Getting Wired In Klamath Falls.
Date of project: 1/2/2002
In the past 12-24 months, electronic communications have begun to be accepted into the world of health care. Currently, 62% of consumers seeking health care information are interested in getting it from their own physician. Over two-thirds of U.S. consumers rate communications with their physician as a primary reason for physician selection. 54% of consumers would switch their physician for the ability to interact online. The Klamath Pediatric Clinic web site was created in August of 2001 as a result of a survey that indicated similar consumer interest in a physician web page. An email system was also set up that allowed patients and their families to access their doctor via email. However, since it's establishment, the site has received few visitors and only one email has been sent through this system in the last 6 months. The intent of this project was to determine why there's a disparity between the initial survey results and actual utilization of the web site. A survey was created which addressed general Internet use, awareness of and interest in the Klamath Pediatric Clinic site, as well as features that would motivate consumers to use the web site. Project goals include determining if and why individuals are not utilizing this resource, determining what features would motivate consumers to use the web site, and utilizing the survey results to direct further action in order to increase overall use of the web site. Survey Results: The majority of responders utilize the Internet at least three times per week. 69% of those surveyed were not aware of the Klamath Pediatric Clinic web site. 62% of desired features are currently offered on the site. 86% of those surveyed are interested in visiting this site. These findings suggest that the reason consumers are not utilizing the Klamath Pediatric Clinic web site is because of lack of awareness. Thus, advertising was increased with the hopes of increasing consumer awareness of the site. Business cards and pamphlets with the web site address were made available in the clinic. A link to the web site was created through the search engine, www.google.com.
An Evaluation Of U.S. And Canadian Online Pharmacies For Medicare Patients At Klamath Falls.
Date of project: 1/2/2002
Approximately half of the patients seen at Klamath Family Practice Center are on Medicare, which does not cover outpatient prescription drugs, and many of these patients struggle with high costs of their prescription medications. This study evaluates 6 online pharmacies, 2 in U.S. and 4 in Canada in terms of their prices and selections in comparison to Klamath Falls Safeway Pharmacy. Results indicate that U.S. online pharmacies offer little or no savings over local prices. In fact, many of the drugs they carry may actually cost more than at local pharmacies. Out of the four Canadian online pharmacies evaluated, three offer significant savings of 24.10-30.80% over local prices. The fourth Canadian pharmacy offers a much lower 4.60% saving mainly due to its high dispensing and shipping fees. In Conclusion, www.canadameds.com and www.canadiandrugstore.com are found to be highly recommendable online pharmacies for their low prices and good selections on prescription medications.
Overseas Pharmacies Online Cutting Prescription Drug Prices.
Date of project: 11/5/2001
Troubled by stories of patients who had chose to go without medications because the cost was too high and after the frustration of having prescribed a medication only to find out that it was not covered by a particular insurance company's formulary, I decided to see if there may be a way to purchase drugs cheaper overseas. Studies have noted that Americans regularly pay up to twice as much as Europeans and Canadians for the same drug, and my preceptor had mentioned that a few of his patients had purchased discounted drugs across the border in Mexico and Canada. I was curious to have an idea of what type of patient would benefit most from lower prescription drug costs and what the patients' perspective was on why drug costs were so high. I offered a questionnaire to patients over the course of a week in the clinic. Thirty-five patients responded to the questionnaire and the results are detailed in Table 1. The questions were not designed to provide hard data, but rather to offer a subjective framework and personalize the project for the community. The average age of the patient was 57, with oldest being 90 and the youngest being 18. There was an even distribution among income categories. However, the common denominator appeared to be in answering the question that asks if they would benefit from lower prescription drug prices. Invariably, the answer was "yes". One frustrated patient wrote, "Please tell me if there is anything that does not cost both arms and both legs." The elderly patient with a mid to low income appeared the most affected by a long list of medications and little or no supplemental insurance to cover the bill. Also interestingly, most did not choose to answer the question that asked why the cost of drugs is so high in our country. The question fell at the end of the survey and may account for why some chose to skip it, but more likely a blank answer indicated that the respondent did not know the answer to the difficult question. In the recent years, the pharmaceutical industry has been by far the most profitable industry in the country (2,3). Drug companies are beginning to offer indigent programs for patients that meet an income level, on average, of less than 15,000 dollars per year. These are praise-worthy programs and my preceptor and his staff have worked hard to identify patients who fit the appropriate profile. For instance, Merck offers up to three drugs completely free of cost for three months when the proper application has been completed. While programs such as these are certainly beneficial, they often do not cover all medications and those patients with incomes above the cut-off are still paying hefty sums. Not to mention, patients without insurance are left to pay directly out of pocket. Before large scale reforms and national price control measures begin to be entertained in public debate, patients and physicians must do all they can to find other ways to help defray some of the cost. With this
Surfing Lessons in Klamath Falls?
Date of project: 5/6/2002
One third of the US population uses the Internet regularly. One half of these people have used the Internet to look up medical information in the last year. Half of these admit that what they read influenced their decision regarding treatment. There are 26,000 health-related websites as of March 2001. The public needs help in finding quality web pages, evaluating sites for reliability, and discovering the resources that are available. Klamath Falls is a diverse rural population with significant Internet use and poor statistical information regarding individual use and Internet access. In the future, a study to further investigate needs and use would be a great student project, and there are numerous local grants available. For the sake of this project, however, a brochure was created instructing the public where to look for medical information, and how to evaluate what they find.
Treatment For Hepatitis C In Klamath County Under The Oregon Health Plan: A Novel Local Approach To Care Management
Date of project: 9/24/2001
This project seeks to describe an innovative, local clinician-designed, formal managed care protocol and treatment program for hepatitis C patients in Klamath County enrolled in the Oregon Health Plan. Results of the first 6 months of this program are presented , discussed, and compared with a recent study of hepatitis C monotherapy treatment compliance at a VA center. Hepatitis C is a highly prevalent disease whose treatment cost is high. It is estimated that 1.8% of the US population is infected with hepatitis C. According to the results of the 2000 census, approximately 1,148 citizens in Klamath County have been infected by hepatitis C. Since 75% of patients who contract hepatitis C develop chronic hepatitis C with ongoing viremia, approximately 861 patients in Klamath County may have chronic hepatitis C. Interestingly, when one consults the Oregon Health Division website, Klamath County only has one reported cases of hepatitis C from 1995-2000.
Increasing Information Accessibility Using Physician Webpages: The Development of the Klamath Pediatric Clinic Webpage
Date of project: 7/2/2001
This project sought to address the need for increased access to community and health resources by creating a physician webpage. A webpage was developed for the Klamath Pediatric Clinic after researching available site options and content material. Patients and patients' parents were given an informal questionnaire that asked about Internet use and health topics they would like more information on. Results: 73% of respondents stated that either they or someone in their family used the Internet on a regular basis (defined as usage >1x/month). 70% stated they had at some point used the Internet to look up medical/health information, and 92% said they would use the Internet to look up medical information if they thought it were easily accessible. When asked what community resources they would like more information on, the following results were seen: 20% said mental health; 19% said social services, 17% said family planning; 9% said a specific medical condition; 6% said substance abuse. These results were used to tailor the site's resources and links. Goals the website hopes to accomplish include increasing overall resource accessibility and health information, and more efficient communication between Clinic personnel and patients. The website address is: http://doctor.medscape.com/klamathpediatrics
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