RCHC Community Project Abstracts

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Analysis of mental health disorders at Dunes Family Health Care, in Reedsport, OR.
Date of project: 10/12/2009

Background: Studies show that primary care physicians in rural communities have to play a larger role in mental health care when compared to urban physicians. This is due to the fact that in many rural communities primary care clinics are the only accessible mental health resource for much of the population. There are many that believe that primary care physicians lack the training, skills, and time necessary to shoulder this larger burden. Introduction: The goal of this project was to determine at what frequencies mental illnesses are seen in clinic at Dunes Family Health Care in Reedsport, OR; what the demographics of these patients are; and what treatments are commonly implemented. It was hoped that this data would be valuable to Dunes Family Health Care clinicians as it could be used to better help allocate the clinics’ mental health resources in the future. Methods: Using the clinic’s electronic database, lists of patients with the most common mental illnesses were attained using the corresponding ICD9 codes. Records were pulled from the 2008 calendar year. Random charts were selected from the lists and reviewed on the basis of age at the time of visit in 2008, gender, number of visits for this problem in 2008, new problem in 2008 or follow up, and common treatments. Results: A total of 191 individual patients were identified using the diagnostic codes which accounted for an estimated 15.5% of the total patients seen in 2008. Depression was the most common diagnostic category with 38.8% of the diagnoses. Close behind was Anxiety with 31%. Next was ADHD with 16%, followed by Bipolar disorder and Dementia both with about 6%. PTSD had 2.5%. Schizophrenic disorders yielded 0%. Discussion: Much of the data correlates well with prior studies, specifically with regard to depression and anxiety data, including type and frequencies of medication regimens. Unfortunately, this study had significant limitations. The sample size was not very large for many of the categories which significantly reduces our ability to trust that the data is representative of the population in question. This was likely due, in part, to the fact that ICD9 codes were many times not recorded for a variety of reasons. Also, ICD9 codes may not be the best tool for this type of analysis because patients are often given the wrong code.

Exploring Insider Perspectives on the Future of Rural Medicine
Date of project: 9/7/2009

The growing deficit of rural healthcare providers has been studied and approached from several different angles. This project seeks to understand the barriers to fostering more healthcare providers from within rural communities by investigating available resources and obtaining perspectives of different members from the community of Reedsport, OR. This was done by surveying and interviewing healthcare providers at the Dunes Family Health Care clinic (DFHC), faculty and staff at Reedsport High School (RHS), and the senior class at RHS. A particular look was taken into potential barriers of inadequate educational and financial resources, lack of student awareness of the range of healthcare careers, and lack of interest in health and science. A presentation was also given to the senior class of RHS to address these areas and a follow-up survey was given to assess changes in awareness and interest.

Thinking about Health Care in the USA: A Health Care Primer
Date of project: 8/3/2009

Health care reform has been one of the big political and social topics of 2009. With a president committed to reform and an equally committed opposition the tenor of the debate has been flooded with misinformation and intentional misunderstanding. The physicians at Dunes Family Health Care felt that their voices needed to be heard on the subject and that it was in part their responsibility to educate their patients. To do this they wanted to develop a tool that they could use to talk to their patients about the basic traits of the US health care system and the key elements of proposed reforms. Patient literacy levels and sophistication are limiting factors in this discussion. A health care primer was developed in a tri-fold color pamphlet form in order to help the physicians with their discussion. A significant effort was made to simplify the presentation of this complex issue. But, ultimately the level of discussion in the finished pamphlet requires an amount of education or literacy that makes it inaccessible still to many of their patients. This seems unavoidable to a certain extent because the health care system is at some point irreducibly complex and can only be simplified so far before the discussion becomes dishonest or meaningless.

Practice Innovation at Dunes Family Health Clinic: Are DFHC patients receptive to the idea of phone and email visits as alternatives to office visits?
Date of project: 6/29/2009

Much of the excitement surrounding "Medical Home" style practice transformation involves streamlining patient-doctor interactions to make more appropriate use of time for all parties. One assumption called into question is whether doctor and patient need to physically see each other for a legitimate interaction to take place. If this is no longer the case, then the door is opened for new paradigms of patient visits, namely email and telephone visits. These services are currently scarce, primarily due to lack of reimbursement. But would providers and patients utilize these services even if they were reimbursed? This student sought to gauge patient sentiment at Dunes Family Health Clinic toward the idea of alternative doctor-patient encounters. A sample population of DFHC patients (n=189) completed a survey to answer these questions.

Health Literacy at Dunes Family Health Care
Date of project: 4/27/2009

Purpose: To determine the prevalence of patients at risk for poor health literacy at Dunes Family Health Care (DFHC), analyze the readability of the patient education materials (PEMs) provided to the patients, and determine what additional steps can be taken to ensure better physician-patient communication. Methods: Health literacy was assessed using the Rapid Estimate of Adult Literacy in Medicine, Revised (REALM-R). The REALM-R was administered to all English Speaking patients or their caregivers, if the patient was >18 years of age, at DFHC. Those who scored <6 were considered at risk for low literacy. Results: One-third of patients were found to be at risk for poor health literacy. Males were more likely to be at risk for poor health literacy. Fifty percent of high school graduates were found to be at risk for poor health literacy. Nearly 90% of those at risk for poor health literacy had completed at least one year of high school or beyond. PEMs at DFHC were written at a mean grade level of 7.4, well below the national average of 10th grade. Conclusion: A significant percentage of patients at DFHC are at risk for poor health literacy, and therefore poor compliance and worse health outcomes. Fortunately, the PEMs are written at a level lower than that of the national average but are still written at a level too high for patients at DFHC.

Two Year Analysis of Total Joint Replacements at the Lower Umpqua Hospital
Date of project: 3/16/2009

Hospital procedure volume has been shown to be inversely proportional to postoperative complications. The objective of this study was to determine if total knee and hip arthroplasties can be effectively and safely performed in a low procedure volume hospital such as the Lower Umpqua Hospital in Reedsport, Oregon. The medical records of patients undergoing elective, primary total knee and hip arthroplasties between January 2007 and December 2008 were reviewed for outcomes occurring three months after the procedure. Results were compared to a large Medicare cohort treated with similar procedures. At this hospital, the rates of complications were minimal to none. There was an acceptable rate of manipulation under anesthesia and no dislocations. One superficial infection was noted, but no deep infections. No deaths, DVT’s, PE’s, MI’s or pneumonias were experienced in this cohort. In conclusion, total knee and hip arthroplasties can be effectively and safely performed at the Lower Umpqua Hospital, a low procedure volume hospital.

Coming Out of the (Sample) Closet: Pharmaceutical Samples at Dunes Family Health Care, Reedsport, OR
Date of project: 2/9/2009

Introduction: Pharmaceutical samples are commonplace in most medical offices in the United States, including Dunes Family Health Care in Reedsport, Oregon. The goal of this study was to assess the current inventory of drug samples at Dunes Family Health Care, and to survey the providers’ attitudes toward the presence of drug samples and industry detailers in the office. Materials and Methods: A comprehensive inventory of all drug samples was performed. The products were then further stratified by cost and therapeutic purpose. Voluntary surveys regarding pharmaceutical samples were distributed to all clinic providers with a license to prescribe medication. Results: There were a total of 2305 individual sample units in the clinic, which comprised 81 distinct drugs. The average retail cost per dose was $3.75 (range $0.25 - $21.00). The most common categories of medications in the office were those for asthma and hypertension, each accounting for 13% of the total number of distinct drugs. Survey results demonstrated a decrease in use of drug samples over the past five years. Lack of patient insurance was the most common reason for dispensing pharmaceutical samples. Most providers believe that drug samples save their patients money. Conclusion: Physician opinion regarding pharmaceutical samples varies among providers at Dunes Family Heath Care. There are numerous complex interactions at work when providing sample medications. The best way to ensure a positive outcome is a close relationship with one’s patients and a thorough knowledge of their medical history and social situation.

Reedsport Nutrition Information Site
Date of project: 12/29/2008

Good nutrition is becoming rarer and rarer in Oregon as well as the nation, leading to troubling trends in obesity. The purpose of this project was to provide an easily accessible resource that contained information on good nutrition and had tools for self-evaluation. It was decided the best medium for this project would be a website. Clinicians could then provide the site address to patients interested in nutrition or those struggling with being overweight or obese. Further, patients who benefitted from the site could refer friends as well, increasing the target population to all residents of the county and beyond. The interactive nature of the site was aimed at making it more personal than a handout and thus serving as a personal nutrition consultation. As a consolidated source of information, its utility is hoped to be greater than other sources on the web that may contain each of its individual aspects.

Management of Chronic Pain in Reedsport, Oregon
Date of project: 8/4/2008

It is estimated that between 15% and 30% of the population of the United States suffers from chronic pain. In Reedsport, Oregon, the number individuals in chronic pain are estimated to be higher than the national average because of a higher percentage of: population over 45 years of age, non-hispanic white adults, and population below poverty level. In addition, unique local factors contribute to the number of people in chronic pain, (e.g. occupations requiring manual labor and high risk recreational activities). After seeing a number of chronic pain patients with abuse and diversion of their medications during a five-week medical student rotation, this medical student wondered if anything could have been done differently for these patients. Thorough observation of office policies and procedures, and interactions between physicians and their chronic pain patients at Dunes Family Health Care (DFHC) were documented. A literature search employing OVID Medline and other professional websites was used to compare what was observed in clinic and the existing standard of treatment recommendations. Emphasis was placed on recommendations from the Institute of Clinic Systems Improvement, the American Academy of Family Physicians, and the Oregon Health Plan. On the final day of the rotation, these observations and recommendations were presented to the DFHC physicians. A pamphlet aimed towards eliciting patient expectations during the course of chronic pain treatment was also produced with the intention of distribution to patients at the start of medical therapy.

Before the Fall: Fall Assessment and Prevention in the Greater Reedsport Area
Date of project: 6/30/2008

Injuries related to falls place a large toll on society. This project assessed the burden of falls in the Reedsport Oregon service area and developed interventions to reduce this medical burden, through means of prevention. The medical doctors appear to do an excellent job at discussing fall risk with their patients. Both the local clinic and hospital treat many fall related injuries each year. The local clinic could focus a month of time to further prevent falls in the community through education and community service. A fall prevention handout was created and an educational month was proposed.

Colon Cancer Screening in Rural Oregon A Small Case-Series for Reedsport, OR.
Date of project: 4/28/2008

Purpose: To establish demographic data for those undergoing colonoscopies in rural Oregon. To determine whether current screening with colonoscopy is cost-effective for Reedsport, and Dunes Family Practice. Methods: I performed a chart review of 145 cases dated between 01/03/07 and 03/26/08. Records were evaluated for general demographic data. pertinent past medical/surgical/family/smoking history, presenting symptoms, prior and current colonoscopic & pathologic findings. Results: All 145 cases were included in series (83 females, 62 males). Mean age was determined to be 64.83 years. Approx. 25% had prior history of polyps, 3 % with colon cancer previously. 79% had a positive colonoscopy, with 23% having any type of polyp. Of those with polyps, approximately 47% (15 cases) had adenomatous and 6% (2 cases) with malignant findings. Incidence of colon polyps and cancer was calculated to be 22 per 100 individuals per year and 1.4 per 100 individuals per year, respectively. Total life-years gained for cases was calculated to be 20 yrs. Conclusions: Incidence of colon polyps and cancer found to be significantly higher than national and Oregon average. This is likely due to demographic factors including age and prior health status. Current screening with colonoscopy was found to be cost-effective based on general acceptance of screening procedures with cost per life-year gained <$25,000.

Antibiotic resistance data for Lower Umpqua Hospital and the surrounding area for 2007.
Date of project: 3/17/2008

Emerging antibiotic resistance of bacteria is a major problem in healthcare. It is a frequent cause of morbidity and mortality in hospitalized patients and is a major financial burden. As resistance patterns increase, newer and more expensive antibiotics must be used. Several strategies have been postulated to prevent these resistance patterns. They include: minimizing inappropriate use of broad spectrum antimicrobials, knowledge of local resistance patterns, prompt initiation of empirical therapy, using proper dosing and dosing regimens, prompt narrowing of antimicrobial therapy, and antimicrobial cycling. To date, antibiotic resistance in rural hospitals has not been well studied. At the Lower Umpqua Hospital (LUH) in Reedsport, OR, due to a low volume of cultures, antibiograms are not routinely done. Thus, to aid the physicians in understanding the local resistance pattern of their hospital, antibiotic resistance data was gathered for LUH between 2007-08, and 2008-present. Additionally, resistance patterns were gathered for the two nearest hospitals: Peace Harbor in Florence, OR and Bay Area Hospital in Coos Bay, OR in order to both compare the different communities and provide further information is aid in antimicrobial prescribing, since the these three hospitals often share patients. This information was presented to the physicians of LUH in order to help in the prescribing of the cheapest, narrow spectrum antibiotics possible for their patients. Generally, the resistance patterns at LUH were better than that of the surrounding hospitals.

Reedsport Elementary: What health complaints occur at school?
Date of project: 2/11/2008

Taking care of the health needs of America's children seems to be a shifting priority over the last several decades. Health care concerns for children are not limited to the medical community but also affects school system. Reedsport Elementary has been able to secure a school nurse position which has been financed by a two year federal grant, and the specific health problems suffered by the school's children was quantified and categorized. Incidence logs from 33 consecutive school days were reviewed and data extracted. Data separated into health complaints and outcome of visit. An accurate, though limited, snapshot of health concerns at elementary school given in report. School nurse benefit difficult to quantify based on cases seen due to mass of other work that they do that is unseen. If school nurses contribute to overall safety and education of children at school they will always be an asset to staff and curriculum.

Pathological and Problem Gambling in Reedsport, Oregon
Date of project: 12/31/2007

Our state government and the local economy on the Southern Oregon coast are hooked on the profits from state run lottery and the jobs and tourism brought in by Indian Casinos. Unfortunately, problem and pathological gambling are a significant public health problem. Countless studies have shown an association between problem/pathological gambling and drug use, suicide, crime, bankruptcy, divorce, and job loss. Reedsport, Oregon is uniquely located within approximately 20 miles of a casino in both the North and South directions, putting its population at increased risk for these problems. Using the NODS gambling screen, this study looks at the prevalence of gambling problems in the patient population at Dunes Family Health Care in Reedsport, Oregon. After identifying this problem, a patient handout was prepared listing local resources available for those with gambling problems to get help. This handout was distributed to local casinos, shopping centers, family resource center, the family medicine clinic and the library.

Leadership Interviews Regarding Balanced Scorecards at Lower Umpqua Hospital
Date of project: 9/10/2007

Quality improvement is very important in any setting, but especially in a small rural hospital where the surpluses are few, and any lapse in quality may affect community usage & therefore financial viability. The Balanced Scorecard has been proposed as an ideal way for small rural hospitals to strive for quality improvement through the idea that an organization’s mission/strategies and the execution of these are important factors in performance improvement. When Lower Umpqua Hospital joined 19 other rural Oregon hospitals it made the commitment to implement a Balanced Scorecard as way to measure performance against other such hospitals & strive for quality improvement. The purpose of this project is to assess the attitudes, perceptions & beliefs about implementation of a balanced scorecard amongst the leadership at Lower Umpqua Hospital, through key informant interviews. The 5 board members & 6 key administrative staff were interviewed; results were then summarized in an informant report to be used in future strategic planning & board meetings.

General Surgery & Lower Umpqua Hospital: A Case Study and Perspective of Surgery in Rural America
Date of project: 8/6/2007

The presence of a general surgeon is essential for health care in rural communities. Across America many rural communities and hospitals are underserved in terms of general surgery coverage. Lower Umpqua Hospital (LUH) in Reedsport, Oregon has experienced this shortage of rural surgeons first hand. Six years ago, LUH lost its first full-time surgeon. Since that time, LUH has had two additional general surgeons come and go, with the last leaving in March 2007. At times when the hospital has found itself without a surgeon it has turned to locums tenens for surgical coverage. Locums tenens surgeons change as frequently as once a month, significantly interrupting continuity of care and communication between the patient, surgeon and primary care provider. LUH is dependent on its surgical productivity for income and for keeping surgical patients within the rural health care system. This project investigated how surgical productivity varies when LUH has a full-time general surgeon versus locums tenens coverage and found that when LUH loses a surgeon, and must turn to locums tenens for surgical coverage, surgical productivity decreases considerably. This loss in surgical productivity has significant and far reaching effects on LUH, the community of Reedsport and the primary care providers of Dunes Family Health Care.

Increasing Exercise in Reedsport.
Date of project: 7/2/2007

Exercise can help prevent and improve many chronic conditions. Reedsport, a small town on the Oregon coast, offers an incredible venue for an active lifestyle – there are lakes, rivers, sand dunes, beaches, pools, gyms and great trails for walking. Family practice physicians at Dunes Family Health Care (DFHC) in Reedsport spend a considerable amount of time counseling patients on the benefits of exercise. Despite the encouragement of the healthcare community and the favorable environment for physical activity, many of the patients at DFHC struggle to incorporate exercise into their daily routine. To help address these issues, I created www.reedsportwalks.com - an interactive, self-sustaining, online forum to help the Reedsport community lead a healthy, active life. The site contains information regarding the importance of exercise, how to start exercising by setting reasonable goals, and how to overcome barriers like chronic pain and time constraints. There is also a comprehensive list of exercise ideas specific to Reedsport including a walking map of the surrounding area and schedules for the pool and local gyms. The site was set up as a google group, making it easy to access, self-sustainable, and interactive. Ideas on how to expand the site include: publishing a page on specific exercise ideas for kids and teens, organizing a community fitness event or weekly walking group, or expanding the site to include healthy options for eating out in Reedsport.

Antimicrobial Prophylaxis in the Surgical Patient at the Lower Umpqua Hospital in Reedsport, OR
Date of project: 4/30/2007

Postoperative surgical site infection (SSI) is a major source of illness in the surgical patient. According to many experts, the level of bacterial burden is the most significant risk factor in the development of SSI, but modern surgical techniques and the use of prophylactic antimicrobials have reduced this risk. Despite the evidence of effectiveness and the publication of guidelines for antimicrobial prophylaxis to prevent SSIs, substantial inconsistencies exist in the use of prophylactic antimicrobials for patients undergoing surgical procedures. After the literature review, medical records of the patients who had a surgical procedure and were discharged from the Lower Umpqua Hospital from 10/01/2006-03/31/2007 were reviewed. After the data was collected and analyzed, the results from this project were compared to the results obtained by the National Surgical Infection Prevention Project.

Urinary Incontinence: Dribbling into the Golden Years
Date of project: 3/19/2007

Reedsport, OR is an old logging town with an aging population. Unfortunately, its community is suffering from illnesses that increase with growing old, including urinary incontinence. Urinary incontinence affects up to half of all women eclipsing hypertension, depression, and diabetes in prevalence (Sutherland, 2004). It is associated with troubling morbidity such as falls, urinary tract infections, skin breakdown, depression, and social isolation (Resnick, 2004). Many women believe that urinary incontinence is a normal part of aging. Although the medicines and conditions that predispose urinary incontinence increase with age, UI is neither inevitable nor untreatable. With treatment, up to 90 percent of those with UI can improve (Khan, 2004). In towns like Reedsport, patients routinely wait up to 4 months for an appointment with an urologist. Fortunately, an urologist is only needed for the most recalcitrant cases, and family practitioners have the tools to diagnosis and treat the majority of patients. With this project I described the Reedsport community and why it carries a large burden from this problem. I also interviewed patients to better understand the problem and its impact. Then, I performed a literature review to learn how to best identify and treat UI. Finally, I created tools for diagnosis and patient education.

Depression in the Elderly - Community Resources in Reedsport, Oregon
Date of project: 2/12/2007

Depression is a common problem in the elderly population. Literature shows that exercise and social interaction have a tendency to improve and maintain good mood. The goals of this project are to first explore the resources in the community for the senior population, then to evaluate the utilization of these services by conducting a survey, and lastly to develop a patient handout to increase awareness of local resources and to encourage physicians to incorporate exercise and social interaction into treatment plans for elderly with dysthymic mood. Many activities and programs through the senior centers and the senior & disability services are available locally. However, only 50% of those with dysthymic mood use the senior center, while 78% of those with good mood utilize the services. In addition, those with lower mood score are less likely to have a regular exercise schedule. In a rural setting where social workers are not readily accessible, it is beneficial for physicians to know the local resources in order to effectively help their patients.

Perspectives on end of life preparedness and POLST implementation by providers in Reedsport, Oregon.
Date of project: 1/1/2007

End of life planning is an emotionally charged topic of discussion for medical personnel, patients, and families. Throughout the country, the use of heroic and expensive treatment for those with terminal conditions is the subject of debate by medical personnel as well as ethicists. End of life practices vary by hospital and certainly by demographics. This project seeks to explore the attitudes and practices of seven medical practitioners in a family health clinic in a coastal community in Oregon. The unique environment that is embodied in this town is similar to other small rural communities across the country. Reedsport has a critical access hospital that contains 22 acute care beds with accommodations for two ICU beds. It also has an extended care facility associated with the hospital. Its ER is staffed primarily by local family doctors. The family practice clinic serving this health district is located immediately adjacent to the hospital. This presents a unique opportunity to evaluate the practice and implementation of end of life measures in different medical settings by the same medical practitioners. Many if not all of the patients who are admitted to the local hospital by the ER physicians are also the patients of these same practitioners of community based medicine. Attitudes toward end of life issues were sampled by personal interview and completion of a small survey. Strategies are discussed for the increased implementation of POLST forms in the practices of these providers and in their community.

Proposal for the implementation of a vision screening protocol in the clinical practice of Dunes Family Health Care, Reedsport, OR
Date of project: 10/16/2006

Vision problems impact patients of all age. Impaired vision affects 10 to 15 percent of preschoolers. It is also a common problem among older adults and has been identified as an independent risk factor associated with increased risks of falls and potential fractures in this population. Routine vision screening in the general population can lead to earlier detection of poor vision and appropriate referrals to prevent or reduce vision-related disabilities. A comprehensive literature review was conducted to summarize recommendations on vision screening in the general population. Sources include the USPSTF, AAFP, AAO, AAP, and the NIH. A protocol was then designed to implement, in time-efficient manner, the recommended vision screening tools and tests. The proposal was presented to the family practioners of Dunes Family Health Care in hopes of persuading the adoption of the protocol to improve the detection of vision impairments in the patient population.

Successful Aging: Does Reedsport have what it takes to help its citizens over 65 age successfully.
Date of project: 9/11/2006

In 2004, there were 36.3 million Americans over 65 years old; by 2030 this number will reach 71.5 million, a whopping 20% of the U.S. Population. In order for the aging population to age successfully - to have low incidence or risk or disease, to maintain mental and physical function and to actively engage in life - there must be certain community resources in place to help this happen. Reedsport is a community with many resources in the areas of community involvement, transportation and housing all of which influence how well people age. Reedsport offers those over 65 many opportunities to stay connected to the community, but the transportation and housing have room for improvement.

A 5-year retrospective analysis of all-terrain vehicle (ATV) injuries in children presenting to the Emergency Room in Reedsport, OR
Date of project: 8/7/2006

Reedsport, Oregon is located three miles from the Oregon Dunes National Recreational Area which attracts all-terrain vehicle (ATV) riders from all over the country. The frequency of ATV trauma is increasing nationally and this retrospective review of ATV-related injuries presenting to the local ER over the past 5-year period revealed that ATV trauma is a significant problem in Reedsport, OR. Children under 16 account for 16% of the overall morbidity and appeared to be more vulnerable to head/neck injuries when compared with adults, despite demonstrating good helmet usage upon subsequent analysis. However, children were less likely to be hospitalized or transferred to another hospital than adults, which may indicate that their injuries were not as severe. Tandem riding (i.e., riding as a passenger) was a risk factor for ATV-related injury in children, which is consistent with the literature on pediatric ATV-related injury, and therefore provides a potential target for legislative intervention.

Choosing the Path Less Traveled: Walking for Health in Reedsport, Oregon
Date of project: 7/3/2006

This paper introduces the concept of the “walkable” community and discusses opportunities for incorporating exercise into the daily routines of residents in the Reedsport, Winchester Bay, and Gardiner area. Past community health efforts and student research projects have reiterated the importance of health promotion in this population. Interviews with local residents and a literature search revealed the need for a more extensive list and map of pedestrian routes in the area to highlight a variety of walking and jogging options close to home. A survey of the Dunes Family Health Care clinicians demonstrated that exercise is important to medical providers, and a patient survey identified the need for better outreach to make health handouts available at multiple locations in the area. The final product is an easily reproducible brochure of walking and jogging trails in the Reedsport, Winchester Bay, and Gardiner area.

Tobacco Cessation Counseling: Are We Wasting Our Breath?
Date of project: 5/1/2006

Tobacco use is a major public health concern and affects 21% of all Oregonians and 29% of residents of Douglas County, a rural area in Southwestern Oregon that includes the town of Reedsport (population 4500). It is the leading cause of premature death and disability in the state, and the medical and economic consequences of its use are well-documented and well-publicized. The purposes of this project were to research current evidence-based literature and clinical practice guidelines, and compare the current recommendations to individual practices at Dunes Family Health Care (DFHC) clinic, the major health-care provider for the town of Reedsport. This was done in order to identify areas for improvement with the intent of potentially improving patient quit rates. A questionnaire detailing their current practices regarding tobacco cessation counseling was distributed to all providers at the clinic. Results demonstrated that physicians at DFHC are consistently asking their patients about tobacco use and advising them to quit. However, similar to providers around the country, they are often not assisting patients in the quitting process by recommending over-the-counter nicotine replacement therapy, prescribing approved cessation pharmacotherapy, or referring patients to tobacco quit lines, all methods that have been shown to potentially double patient quit rates. In a presentation to providers at the clinic, each of their cited barriers to effective and comprehensive tobacco cessation counseling were addressed and strategies for improvement were given. Ideally, this project will have empowered physicians to provide their patients with the tools necessary to optimize their chances for a successful quit attempt.

Adolescent Injury in Reedsport, Oregon
Date of project: 3/20/2006

Unintentional injury remains the leading cause of adolescent and young adult morbidity and mortality in the U.S. The leading causes of non-fatal injury for 13-24 year-olds are: being struck by or against an object, falls, motor vehicle accidents, overexertion and cuts or piercing. Reedsport, Oregon, a town of 7,900 located on the central coast has an aging population in which adolescents comprise 11% of its population. A recent unintentional motor-vehicle-related fatality of a teenager and injury of another in this small town has raised awareness on the lack of data for the incidence of adolescent injury in the community, including what types of injuries are occurring and what are the associated variables. A medical records search for Reedsport adolescents aged 13-24, who were seen and treated in the ER of the Lower Umpqua Hospital during calendar year 2005 for injuries or trauma was completed. A total of 100 charts were reviewed and descriptive statistics on injuries compiled. Reedsport adolescent injury patterns appear comparable to national statistics, although there is a lower incidence of motor-vehicle related accidents among Reedsport adolescents seen at this ER. The value of implementing a systematic adolescent preventive services program and a specific model for doing so are also discussed.

Osteoporosis: Fractures in an Aging Population
Date of project: 2/13/2006

Osteoporosis is a skeletal disease characterized by loss of bone mass and strength, leading to the increased likelihood of fragility fractures. Osteoporosis primarily affects the elderly and fractures due to osteoporosis are a principle cause of morbidity and mortality. The goal of this project is to increase awareness of patients and providers on prevention, screening, and treatment of osteoporosis. This was accomplished by examining the current practices of screening for osteoporosis by area providers and identifying the incidence of fragility fractures at Reedsport. A literature review was done to educate providers about the latest in bisphosphonate therapy, and finally a brochure was made to empower patients with knowledge about osteoporosis. From September 2004 to January 2006, there were a total of 53 total fractures in patients 60 years and older treated at Lower Umpqua Hospital. Forty six of the fractures were from low-intensity traumas and only 15% of these patients were previously diagnosed with osteoporosis or osteopenia. It appears osteoporosis is currently under-diagnosed in Reedsport. This is mainly due to provider’s views of the high cost of treatment for their patient’s and ineffective treatment options.

Nuclear Medicine in Reedsport, OR. Myth or Reality?
Date of project: 1/2/2006

As the needs for nuclear studies are expanding in Reedsport, Oregon, the Lower Umpqua Hospital wants to introduce a gamma camera to be a part of their imaging facility. Being a small 22-bed critical access hospital for the area of 8,000 people puts certain financial restrictions on the scope of services the hospital can provide. Mainly a feasibility analysis for implementation of radionuclide studies into the hospital operations, this project attempts to evaluate the needs of the community and financial viability of the new imaging service. The potential barriers to entry, ways to mitigate them, and functional advantages of the hospital were explored. The analysis confirmed the immediate needs of the community for nuclear studies and supported the far-reaching plans to expand the scope of hospital services in the future. Pro-forma financial statements based on the realistic assumptions showed potential ability to break even on operations but inability to get any direct return on investment. The findings were shared with the hospital administration, staff of the radiology department, and physicians from the Dunes Family Health Care clinic. A pro-forma spreadsheet for profitability analysis was created for the hospital administration. Further research on how to make it profitable is suggested.

Bariatric Surgery in Reedsport, OR
Date of project: 10/17/2005

Obesity is a growing problem in the United States and the popularity of bariatric surgery continues to increase. This research project was designed to address many of the issues that are specific to offering bariatric surgery in a rural hospital. A literature review was conducted to determine how morbidity and mortality rates are affected by bariatric surgery performed in a rural setting. Possible reasons for these differences were discussed. Patient demographic factors associated with perioperative complications were identified in order to be able to screen for relatively low-risk patients. The most common complications were discussed, as well as projected rates for these complications. Finally, the plans for the new bariatric program at Lower Umpqua Hospital in Reedsport, Oregon were outlined and potential benefits and drawbacks of the program were discussed.

Lifestyle Modifications to Prevent and Treat Hypertension in Reedsport, Oregon.
Date of project: 9/12/2005

Hypertension is epidemic in developed countries today. In United States, 50 million adults, or approximately 25%, have hypertension (defined as blood pressure > 140/90 mm Hg) and/or use anti-hypertensive medications1. More than half of all adults aged 60 years or older have hypertension2. As Reedsport and its surrounding communities contain large proportion of elderly population, many patients at the Dunes Family Health Care (DFHC) have hypertension and its complications. Thus, hypertension is an important and common health problem treated at DFHC. The purpose of this project is to increase public awareness of hypertension by creating an informative pamphlet. The results from a survey indicate that participants place lifestyle changes, mainly diet and exercise, as best methods to prevent and treat hypertension over anti-hypertensive medications, even though almost half of participants are currently taking anti-hypertensive medications. Thus, lifestyle changes in regards to diet and exercise are emphasized in the pamphlet, with main focus on Dietary Approaches to Stop Hypertension (DASH) diet as well as community resources available to Reedsport residents to make exercise and dietary changes to lower and maintain healthy blood pressure.

Diabetes Management in Reedsport, Oregon, Is It Under Control?
Date of project: 8/8/2005

Rural communities such as Reedsport, Oregon lack the majority of specialists that are present in urban communities. Because of this, most chronic diseases are cared for solely by the family physician. This project addresses the chronic care of diabetes in the Reedsport. This is done through chart reviews and a questionnaire of the physicians at the Dunes Family Health Care Clinic. It addresses the question of how diabetes is currently being managed in Reedsport, Oregon and suggests areas of improvement for increased quality of care in diabetic management.

A Quality Improvement Evaluation of Initial and Final ER Radiology Readings at Lower Umpqua Hospital
Date of project: 7/4/2005

Reedsport, a town of 4,400 residents, is situated on Highway 101 in the midst of the Oregon Dunes National Recreation Area on the central Oregon coast. The timber and fishing industries traditionally had been the major industries in the area, but in recent years natural resource extraction has declined. Reedsport has more recently become more of a retirement community, as well as a destination for out-of-town visitors who come for the wide range of outdoor activities available. Dune Fest, held in the nearby community of Winchester Bay each summer, draws thousands of people to the area for ATV races and associated events. Because there are so many visitors to the Reedsport area, many of the people presenting in the ER of Lower Umpqua Hospital are not from Reedsport or nearby towns, but are instead people who have come to ride ATVs on the dunes. This project was undertaken because many of the individuals inolved in the process of taking and reading ER radiographs did not have a good understanding of how the sytem worked, especially how discrepancies are handled.

Don't let Osteoporosis get you down: Fall prevention in Reedsport, Oregon
Date of project: 4/25/2005

Osteoporosis is a disease that affects ten million Americans. Each year, one and a half million of them will sustain a fracture. The purpose of this project was to gather research about fall prevention in order to prevent fractures in people with osteoporosis. The Cochrane Database of Systematic Reviews was accessed to find the latest research concerning fall prevention. Of trials identified that were likely to be beneficial, six specific interventions were suggested. Of these interventions, those most applicable to the inhabitants of Reedsport were chosen for a patient education handout. Final recommendations included specific modifications of the home environment and behavior at home, evaluation and treatment by a physical therapist, and withdrawal of psychotropic medication.

Skateboarding Safety in the Community of Reedsport, Oregon
Date of project: 3/21/2005

In 1996 it was estimated that approximately 5.8 million kids between the ages of five to eighteen years old participated in skateboarding. Of those 5.8 million, an estimated 750,000 skateboarded on a weekly basis (1). It is likely that this estimate will increase as the popularity of skateboarding surges. Paralleling the revival of skateboarding, there has been an increase in skateboard-related injuries. Most recently, the number of injured individuals younger than 20 years has increased from an estimated 24,000 in 1994 to approximately 51,000 in 1999 (1). Numerous studies have concluded that skateboarding-related injuries are more severe and have more serious consequences than those injured while roller skating or in-line skating (3). Reedsport has recently opened a skateboard park for its youth. The goal of my community project was threefold: 1. Assess how the skateboarding youth of Reedsport compare with national statistics regarding injury frequency and patterns. 2. Determine what methods to prevent injury were utilized among kids. 3. Promote helmet safety. Survey of Lower Umpqua Hospital’s emergency department records demonstrated that over 19 months a total of 345 encounters were recorded for trauma, ATV, and skateboarding accidents. Of the 345, 26 (8%) were related to skateboarding. The age range for skateboarding injuries was 8 – 29 years with an average of 16.6 years. 93% (23/26) were male. Skateboarding injuries were categorized by area injured including head, thorax, and extremities. 65% (17/26) of skateboard injuries were to extremities. Of extremity injuries 71% (12/17) were fractures. Alternatively stated, 46% of the 26 skateboarding injuries were fractures. Head injuries comprised 23% (6/26) of skateboard related injuries with one of these injuries also qualifying as a trauma secondary to a closed head injury. Injuries to the thorax comprised 12% (3.26) of the skateboard injuries. Multiple casual observations (> 10 occasions) of kids using the skate park revealed that most kids are not using a helmet when skateboarding, particularly older teenagers. In addition, on no occasion was a supervising adult present. To promote helmet safety and awareness I designed a locally based helmet safety pamphlet featuring many of the local skateboarders. The pamphlet was distributed to local skate shops (Pandemonium, Waxer’s), the elementary and junior/senior high schools, the local emergency department and the Dunes Family Health Care clinic. A summary of the pamphlet was also sent home to all the parents of children attending the junior/senior high school. I also collaborated with the outdoor editor of the local newspaper “The World” and wrote an article focusing on helmet safety and awareness. Lastly, I solicited sponsorship from five companies (The Tony Hawk foundation, Bell, Viking helmets, Wal-Mart, The Oprah Winfrey show) for 20 skateboard helmets. Waxer’s donated 3 helmets with elbow and knee pads. The rest of the sponsorship requests are pending at this time. If in the future more helmets are donated then I will return to Reedsport and work with the local fire department to distribute the helmets to kids in need on during the town’s annual “Skate Jam.”

Lessons Learned from a Pertussis Outbreak in Reedsport
Date of project: 2/7/2005

Reedsport was hit by a pertussis outbreak in fall 2004. People were inexperienced and unprepared about management of outbreak. I interviewed the participants who were involved in the outbreak, including representatives from Douglas County Health Department (DCHD), Dunes Family Health Care clinic, Oregon State Health Department, schools, parents and local pharmacies. From their different perspectives I summarized the lessons learned from the outbreak and formulated some suggestions for them so that the community will be more prepared for future outbreaks.

Financial Burden on Lower Umpqua Hospital (LUH) Due to Traumatic ATV Accidents of Uninsured Patients’ During 2004
Date of project: 1/3/2005

Reedsport, Oregon is located within the Oregon Dunes National Recreation (ODNR) area, a vast landscape of sand dunes that is used, among other activities, for riding all-terrain vehicles (ATV). Riding is open all year long, but there is a four-day event at the end of July known as DunesFest during which riders come from all over the nation to race their ATV’s and party. Alcohol is not strictly regulated on the dunes and, this, combined with periods of heavy ATV traffic, results in a significant number of trauma accidents throughout the year. Given that ATV riding is an expensive sport, nearly all riders could afford insurance. However, many of those that are injured are either inadequately insured or, more likely, do not have health insurance. This puts a great financial burden on LUH, as one of its very important functions within the community is acting as a “safety net” hospital, treating many uninsured patients’ for unforeseen illness and acute injury. The added impact of expensive ATV traumas that go unpaid compromises the ability of the hospital to act as a safety net. This research showed that uninsured ATV traumas were costly to the hospital during 2004 and that during the month of July the amount unpaid was a significant percentage of the total billed. Additionally, it was shown that July, August and September were particularly hard hit by uninsured ATV trauma and that most of the patients were either from out of town or from a different state. Finally, the results were used to formulate a plan to contact a state legislator to discuss the feasability of mandating accident insurance for all ATV riders riding within the ODNR area.

Pneumonia: A retrospective review of cases in 2003 at Lower Umpqua Hospital in Reedsport, Oregon
Date of project: 10/18/2004

Pneumonia remains a common and deadly disease, afflicting more than 4.5 million people a year in the US alone. It is the 6th leading cause of death and the most common infectious cause. Furthermore, it has increased as a cause of hospitalization, especially among those who are above the age of 65. The population of Reedsport, OR has become increasingly older in age, and with this increase in elderly may come in increase in the prevalence of pneumonia. With other issues such as lack of adequate influenza vaccine, increased health care costs, and increased antibiotic resistance, small independent community hospitals such as Lower Umpqua are faced with numerous future challenges in care for its patients. This project, which will study pneumonia cases over the time period of January 1, 2003 to December 31, 2003 at Lower Umpqua Hospital (LUH), will allow for a review of aspects of presentation, diagnosis and treatment of this sometimes fatal disease. Goals of this project include identifying demographics of patients presenting with pneumonia to LUH, identifying co-morbidities, identifying diagnostic strategies utilized by admitting physicians, identifying strategies of treatment, and determining outcome of treatment choices. Finally, I hope to compare results of my data to national standards or other retrospective studies of pneumonia over a selected time period. Data examined in this project include month of presentation to LUH, patient demographics (sex, age), co-morbidities, diagnostics (symptoms, signs, labs, imaging), localization, tests of bacteriology (sputum, blood), aspects of treatment, length of stay, and eventual outcome. The hope is that these results will be used as a baseline for future comparisons of the incidence of community and nosocomial acquired pneumonia at LUH, will allow the admitting physicians to see trends currently employed in diagnostics and treatment at their hospital, and finally a way to determine if patients at LUH are currently receiving the most efficient and effective treatment as defined by national organizations as the American Thoracic Society and the Infectious Disease Society of America.

The Pneumococcal Polysaccharide Vaccine in Reedsport, Oregon
Date of project: 9/13/2004

Pneumococcal infection causes an estimated 40,000 deaths annually in the United States, accounting for more deaths than any other vaccine-preventable bacterial disease. Approximately half of these deaths could be potentially avoided through the use of the pneumococcal polysaccharide vaccine. The highest mortality from pneumococcal infection occurs among the elderly and patients who have underlying medical conditions (Center for Disease Control and Prevention (CDC) 1997). The purpose of this community health project was to estimate the percentage of high-risk patients at Dunes Family Health Care (DFHC) who are vaccinated, and to develop an educational tool to help raise awareness of the dangers and ways of preventing Pneumococcus. The project consisted of a chart review of one hundred seventy high-risk patients, a questionnaire for DFHC physicians, and an assessment of resources available through the Douglas County Health Department. Based on the data obtained, a patient pamphlet was created for DFHC physicians to review and distribute.

Demographic changes in the Lower Umpqua Hospital Emergency Room from July of 1994 to July of 2004.
Date of project: 7/5/2004

America's emergency rooms have been subjected to a significant amount of change in the last decade. This study compared the demographics of Lower Umpqua Hospital's emergency room over a two-week period in 2004 to that same period in 1994 to see how it compared to the national averages. The approach that I took was to identify the patients seen over each period using the logbooks, find their charts, record the different information that I was interested in, and then analyze the data. Major trends that were found included an eighty-two percent increase in the number of patients seen, a five year average age increase in patients seen, and three times as many ATV related visits from 1994 to 2004.

Off Highway Vehicle Injuries at Lower Umpqua Hospital in 2002 and 2003.
Date of project: 5/10/2004

Introduction: In May 2003, the US Forest Service implemented a policy banning the possession of alcohol outside of designated areas in the Oregon Dunes National Recreation Area. The goal of that policy was to reduce the risks of using Off Highway Vehicles (OHV) to both the people using them and the natural environment. Organizers of a OHV centered event called Dunefest also attempted to increase regulation of riders in an attempt to increase safety. Methods: A retrospective chart review was conducted of all patient charts presenting to the Lower Umpqua Hospital emergency room between July 1 and August 31 of 2002 and 2003. 165 charts were abstracted for the following variables: date, time, patient age, Dunefest weekend, insurance status, EMS usage, alcohol use prior to the incident, protective equipment used at time of incident, type of injury, and disposition. Chi-square and Fisher’s exact test were used to analyze the data. Results: The average age of injured riders was 27.9 with 34 patients being 16 years old or younger. No significant change in the number of OHV related injuries was found other than a decrease in the number of patients without helmets. Alcohol use was associated with higher rates of admission or transfer to higher levels of care, lack of documented insurance, presentation to the ER between 2100 and 0700, and lack of helmet usage. Thirty-one (19%) patients had no documented insurance representing a significant potential financial burden for the hospital. Conclusions: While the new US Forest Service policy did not appear to reduce the number or severity of injuries presenting to LUH ER, the number of unhelmeted patients declined. Riding OHV’s while under the influence of alcohol was associated with greater risk of injury and higher morbidity. Efforts to decrease the operation of OHV’s under the influence of alcohol should continue. Physicians may utilize the ER encounter to screen for alcohol use among injured patients and apply brief interventions to educate patients and their friends and families about risks of combining alcohol with OHV recreation. Future studies will be needed to better determine the effects of the policy.

Medical Billing in the Emergency Room in Reedsport, OR
Date of project: 3/29/2004

Medical billing is an essential aspect of a physicians practice. Determining the appropriate code entails a subjective evaluation of the complexity of a visit. Accurate coding requires a delicate balance between maintaining financial viability and avoiding bureaucratic intervention. In this report, I analyzed the current billing trends in the ER at Lower Umpqua Hospital in Reedsport, OR. 115 ER visits from 11 physicians were reviewed and billing codes were assigned according to the 2004 CPT guidelines. The actual codes were then collected and compared with the evaluated codes. On average, physicians billed for 86% of the total potential billing. This equates to 145 under-billing in the ER, which results in decreased revenue for the hospital. Financial burdens to rural health care systems in Oregon have resulted in the loss of some services and even the closing of hospitals. Improved understanding and application of the current CPT guidelines for medical billing can help stabilized financial viability and ensure continued health care in rural communities.

Barriers to Obstetric Care in Reedsport, Oregon
Date of project: 1/5/2004

With the loss of C-section coverage in 2002, the physicians at Dunes Family Health Care could not continue to provide deliveries at Lower Umpqua Hospital (LUH) in Reedsport due to the terms of the hospital's liability insurance. The object of this project was to examine the barriers to providing obstetric care in Reedsport, because many rural communities are dealing with this issue, and determine what might make rural obstetrics more stable.

Patients' Views About End of Life Care in an Aging Population
Date of project: 9/29/2003

Physician-assisted suicide was legally enacted in 1997 in Oregon. One year later in 1998, a survey was taken of patients in Reedsport, OR examining opinions about physician-assisted suicide. Since then, a significant demographic change has occurred, shifting the mean age of the population upwards. This project studied patients’ attitudes and knowledge base about end of life care in this aging community, including both physician-assisted suicide and hospice care.

Chronic Non-malignant pain in a rural primary care clinic
Date of project: 11/10/2003

Problem: Treatment of chronic non-malignant pain (CNMP) is a common and often frustrating aspect of primary care medicine. Limited time may be lost to technical talks done in the office, impacting the preventative or screening services Chronic Non-malignant Pain Patients (CNMPPs) receive. A proposed ORPRN project will explore concerns that more time is spent on texhnixal tasks in a CNMPPs' office visit, and less time spent on preventative services and other activities designed to encourage the patient's active participation in their own health. Additionally, this project considers how technical tasks, such as prescribing narcotics and monitoring compliance, impact physicians' attitudes toward treating CNMPPs. Population: 7 MDs and 1 NP at Dunes Family Health Care Clinic (DFHCC) surveyed on their CNMPP population. Methodology: CNMP Questionnaire. Findings: Health care providers express frustration over certain aspect os CNMPP management, however concerns over CNMPPs receiving poorer quality of preventative or screening sercixes is of xonxcern to only about half of those health care providers surveyed.

Evaluate Immunization Delivery and Suggestion of Strategies
Date of project: 8/18/2003

Immunizations are one of the most successful preventive interventions. Unfortunately, not all children receive this intervention equally or on a timely basis. The objective of this study was to evaluate immunization delivery, address barriers to immunization, and suggest strategies by which rates can be improved at Dunes Family Health Center (DFHC) in Reedsport, OR. In conjunction with the Oregon Immunization Program, a retrospective analysis of all children ages 12-35 months, who received at least one vaccination at DFHC with dates of birth ranging from July 16, 2000 and July 15, 2002, was conducted. Analysis of 103 immunization records yielded coverage rates for children 2 years of age, as well as percentages of late starts and missed opportunities. The up-to-date coverage rate at DFHC for children at age 2 years that are fully covered with 4 DTaP: 3 Polio: 1 MMR: 3 Hib: 3HepB is 46%; 6% of children were found to be up-to-date by the date of assessment. The percentage of late starts is 14%, and that of missed opportunities is 28%. Decreasing both the percentage of late starts and missed opportunities by addressing barriers and deficiencies in immunization delivery would improve coverage rates.

Assessment of OHP Changes on OHP Patients at Dunes Family Health Care Last Five Years
Date of project: 7/7/2003

The Community Health Improvement Partnership (CHIP) provides a vehicle that allows local health care and public leaders and residents to collaboratively assess health care needs of the community. A result of this collaboration revealed a perceived health resource problem of lacking affordable health care. A project was undertaken to assess this perceived need of the community and evaluate what impact changes in the Oregon Health Plan (OHP) may have had on OHP patients at the Dunes Family Health Care (DFHC) clinic. Results of the analysis reveal the percent of Reedsport Service Area (RSA) population below Federal Poverty Level and require health assistance is well above State and national average. Analysis of DFHC patient data reveals the OHP patient base has remain steady at about 15 percent of total patient population for the past four years, which is higher than the national Medicaid average of 12.7 percent. OHP reimbursement at the DFHC has steadily increased in the past four years with a possible slight projected drop in 2003. The perceived low-income health assistance needs in the RSA is supported by socio-economic and DFHC clinic data. However, changes in the OHP in the past four years have not affected the number OHP patients or their frequency of office visits at DFHC. The DFHC OHP population has averaged 3.5 annual visits per patient compared with 1.5 visits per non-OHP patients in the past four years. This difference in number of visits may justify further evaluation as the debate continues over cost, level of coverage, and eligibility of the OHP.

Getting It Out There:Developing a Health Care Resource Guide in a rural Community
Date of project: 5/5/2003

The Community Health Improvement Partnership (CHIP) has been undertaking a large-scale health needs assessment in Reedsport, OR over the last two years. This has been done by written survey and town hall meetings. These efforts have yielded a set of health issues that the community finds important. The CHIP committee is now at a stage to start implementing solutions to these findings. As my project, I participated in the CHIP committee on health information and referral. The community had indicated that it was difficult to find the appropriate health resources. To that end, the committee has begun compiling a list of healthcare resources and organizing them in a searchable database to be linked to the Lower Umpqua Hospital website and printed for use in establishments that provide resources for a large number of people. The resource directory is expected to be a comprehensive document outlining services, points of contact, hours, etc. It is expected that it will take about 6 months to complete, therefore; an interim guide will be used that simply provides resource names and phone numbers.

The Community Health Improvement Partnership (CHIP) and Reedsport, OR: A Prescription Drug Assistance Program for Seniors.
Date of project: 3/24/2003

In cooperation with Office of Rural Health at Oregon Health & Science University, the small rural town of Reedsport, OR has initiated a process of evaluating and addressing the community healthcare needs through the Community Health Improvement Partnership (CHIP) (McGinnis, 1999). The goal of the project outlined here is to use some of the information and infrastructure that has been laboriously compiled through the efforts of numerous people within and outside the community to address one of the major healthcare disparities identified through the CHIP process. Several students have worked as part of the CHIP process in Reedsport, following the project through its different phases (Morgan, 2002; Kerr-Valentic, 2003). These past projects have described the coalescence of the CHIP council, its decision-making, and the identification of the community healthcare needs. The next step in the process is the design and implementation of specific programs to address those community needs. This project proposes one such program, the creation of an organized prescription assistance program for seniors.

Teaching A Coastal Community To Fish: Participating In A Community Health Improvement Partnership In Reedsport, Oregon
Date of project: 2/10/2003

The rural Reedsport, Oregon healthcare community has recently begun participating in a Community Health Improvement Partnership (CHIP) through the OHSU office of Rural Health. This community project seeks to describe the organization of the CHIP program in rural Oregon, and follows the citizens of Reedsport through the process of analyzing a community survey process, and conducting a town meeting/brainstorming session to address local healthcare problems. The survey identified a healthcare system that lacks surgical and obstetrics providers, adequate drug and alcohol rehabilitation, and services for the elderly. The community meeting revealed that community wellness, hospital staffing (surgeon), affordable healthcare, inexpensive medications, and youth and senior services deserve more attention in the Reedsport health service area. Improvements in these areas will require continued work by the CHIP Council people and other community members to develop specific plans and ideas for using community funds to improve the health status of this rural town.

Creating a health information library in a coastal community: the never-ending project.
Date of project: 12/30/2002

Education continues to be a primary goal of population-based health care. This project begins to address the health education needs of a rural community through the establishment of a patient resource library. Informal interviews and observations, coupled with an internet-based search helped to formulate the two goals of this project: 1) laying the groundwork for a patient resource library with respect to location and physical construction, and 2) assembling examples of and guidelines for creating/selecting effective educational materials. Special attention was given to assessing the readability of existing patient information in light of the large segment of the population with low health literacy. Many well-used handouts were assessed as being written at reading levels exceeding those recommended by professional health educators. However, it may not be advisable to provide only low-literacy information, as this has been found to lead to decreased patient satisfaction.

Impact of Surgery on Lower Umpqua Hospital, Part II: Provision of Obstetrical Services, a Community Needs Assessment
Date of project: 11/4/2002

Following an era of business success, growth of faculty, and outstanding service, Lower Umpqua Hospital is now searching to hire a general surgeon. A prior study examined the economic impact of surgery at the Lower Umpqua Hospital (Melvin, 2001). In this project, we assess the community impact of services provided by surgery. In particular, the Lower Umpqua Hospital has recently announced it will not provide routine obstetrical care (Vail, 2002). The Dunes Family Health Care also announced it will not provide third trimester prenatal care (Law, 2002). Community demographic and socio-economic climate, and health care services currently provided are described. A needs assessment describes the current market share, community vital statistics, and economic implications. Finally, the impact of cessation of services is addressed in terms of community reaction, a call for community response, and case-scenarios.

Spiritual Involvement and Belief Survey: Reedsport, Oregon
Date of project: 9/23/2002

The town of Reedsport, Oregon contains a family health clinic, a medical clinic, and a hospice. There are nine medical providers and nine hospice & homehealth nurses who serve approximately 9,200 people (beyond the 4,400 in Reedsport). The Spiritual Involvement and Beliefs Scale (Hatch, 1998) was utilized with additional questions to assess: 1) the level of spirituality between patients and providers, 2) whether patients desired more physician or hospice nurse inquiry into spiritual matters, and 3) whether the providers desired more information on ways to discuss spirituality with their patients. Sixty-one clinic patients and one of three hospice patients completed the voluntary survey along with 8 of the 9 medical providers and 6 of the 9 nurses. There was no difference in the level of spirituality between the patients and medical providers (T-test, p < 0.32), nor between the medical providers and nurses (T-test, p < 0.45). Nineteen of sixty-one clinic patients (31%) desired more physician inquiry into spiritual matters, while over two-thirds did not. The former wanted discussion on “positive thinking” ( N = 4), “prayer” (3), the “mind/body connection” (3), and more specific requests such as a referral for spiritual counseling. These patients prayed with greater frequency (T-test, p < .05) and participated in more spiritual activities (T-test, p < .05) that the latter group of patients. Due to the small sample size, no analysis was performed between the single hospice patient and the nurses. The providers varied in their desire for more information on ways to inquire. Only two of the eight medical providers (25%) who completed the survey wanted more information, while four of the six (66%) nurses desired the information.

Exercise For Residents Of Reedsport, Oregon The Importance Of and Opportunities For.
Date of project: 8/12/2002

The obesity trend in the United States of America is on the rise. In Oregon, the number of overweight and obese rose from 55% in 1998 to 57% in 2002. Obesity has been proven to be associated with an increased incidence of heart disease, stroke, diabetes, high blood pressure, osteoarthritis, and some cancers. During my rural rotation at Dunes Family Health Clinic as a third year medical student in Reedsport, OR, I calculated the BMI on 53 of the patients I saw in clinic and found that 87.3% of the patients I saw were overweight or obese. Because obesity and lack of exercise are often coexisting conditions, I created a patient pamphlet which includes information on reasons why to exercise regularly, how to start a exercise program, and ideas for exercise in the Reedsport area.

Emergency Eminent: Dunefest 2002
Date of project: 7/1/2002

OBJECTIVE: To assess the emergency preparedness of the Umpqua Lower Hospital's Emergency Room, EMS system, and Operating Room for Dunefest 2002. To offer suggestions for next year's Dunefest based on the problem areas identified through this assessment. METHODS: Dunefest planning meetings, sponsored by the Reedsport Chamber of Commerce, were attended. Records of past Dunefests were reviewed, including ER and EMS logs, and these were discussed with personnel who were present those years. An assessment was made concerning the state of preparedness for Dunefest 2002. After the event, preparedness was reassessed based on experiences in on ambulance rides, in the ER and OR, and through discussion with hospital and EMS administrators. RESULTS: Chart review and previous Dunefest experience from 1999, 2000, and 2001 dictate the importance of increasing law enforcement and decreasing the number of people camped at the event site. This year, EMS was well prepared and easily handled their responsibilities. Increased staffing in the OR allowed for the multiple orthopedic cases that were expected; however, some supplies were low or unavailable. The ER physicians were challenged in keeping up with the number of emergencies resulting from the event. The hospital is most likely losing money through the event, due to the increased influx of uninsured patients. CONCLUSIONS: This year's preparation was adequate. An internal audit is recommended to determine whether Dunefest is resulting in a net loss in the hospital's finances. The Dunefest committee for 2003 should consider a fee for event insurance to offset the costs of treating the uninsured accident victims. The OR and ER should be stocked at least three days prior to the Dunefest events. A backup plan should be devised for overburdened ER physicians during the event.

Are New York Times headlines a reality in Reedsport, Oregon?
Date of project: 3/25/2002

According to the American College of Physicians-American Society of Internal Medicine, physicians in general practice stand to lose approximately $8,000 each this year. In Oregon the 2001 Medicare cuts may translate into an overall loss of $14,700,000. For Oregon physicians this problem is made even worse by the fact that the costs of delivering health care in Oregon continue to rise each year. Malpractice premiums alone have increased by double digits for most physicians in Oregon, up to 56% higher for some Oregon physicians. In addition, approximately 50% of Oregon family physicians are age 50 and over. The high cost of providing medical care and poor reimbursement rates may trigger the retirement of many of these older physicians. A national survey has shown that before the Medicare cuts, approximately 80% of physicians were considering leaving or scaling back practice. If the above is true this could potentially create a shortage of access to primary care for Medicare patients both nationally and in Oregon.

"Assessing the Understanding of Respiratory Syncytial Virus in a Rural Community"
Date of project: 2/11/2002

The major cause of lower respiratory infections in children worldwide is a virus, respiratory syncytial virus (RSV). Usually self limited, RSV can be treated at home, but up to 3% of infants infected require hospitalization. The purpose of this community project was to gain an understanding of the Reedsport, Oregon, area residents' comprehension of a viral respiratory illness symptoms and treatments. From this information, an educational handout specifically about RSV bronchiolitis was created. 124 patients at the Dunes Family Health Care Clinic ranked various "cold and flu" symptoms by frequency of office visits and answered different true/false questions. Results showed the symptoms of difficulty breathing, a cough with phlegm, and fever greater than 101F accounted for the greatest number of clinic visits. Results from the "true/false" section of the questionnaire revealed over one half of the responders (51%) erroneously answered "true" to the following question: "A viral respiratory infections needs antibiotics to be treated properly." Based upon the results, it was concluded that many patients probably don't understand the difference between viral and bacterial respiratory infection and the subsequent treatments. From this conclusion, a handout was created to educate patients about infant bronchiolitis and RSV.

Assessment Of The Signs And Symptoms Of Acute Myocardial Infarction Of The Elderly In The Emergency Setting In Reedsport, Oregon.
Date of project: 1/2/2002

The purpose of this study was to examine elderly patients who presented to the emergency department (ED) in Reedsport, Oregon for symptoms of acute myocardial infarction (AMI). The objective was to determine what diagnoses were ultimately found for these persons, and then to determine if the presenting signs and symptoms of the elderly with a discharge diagnosis of myocardial infarction (MI) were representative of the national average. The ultimate goal was to determine whether the elderly with AMI are being underdiagnosed in Reedsport, and, if so, can improvements be made to diagnose them? A case review was done of approximately one year's prior time of all persons greater than 70 years of age presenting to the emergency room (ER) with symptoms of AMI. These cases were reviewed for chief complaint, associated symptoms, electrocardiogram (ECG), cardiac markers (Troponin-I, CK-MB, and myoglobin), and other various findings. It was found that 9% of subjects selected were ultimately diagnosed with an AMI. 35% had other cardiac problems (13% related to angina and 22% related to non-ischemic etiologies), and 56% had diagnoses unrelated to cardiac origin. The ECGs, cardiac marker findings, and other studies are described. It is thought that due to limitations in specificity and sensitivity of the ECG and cardiac markers, but moreover, the prevalence of atypical presentations of AMI in the elderly, that it is possible that a number of MIs in the elderly are not being diagnosed in Reedsport. Recommendations for improvement are given.

Atrial Fibrillation and Stroke Prevention at Dunes Family Health Care (Reedsport, Oregon).
Date of project: 11/5/2001

OBJECTIVE: This study sought to examine the approach of five physicians in a small, rural family practice clinic in Reedsport, Oregon in regards to preventing ischemic stroke in patients with nonvalvular atrial fibrilllation. This study also attempted to determine what effects the application of three current risk stratification models would have upon therapy indications for the patients in this practice. METHODS: There were two components to this study, (1) a chart review to determine the risk factors of and treatment for patients with recurrent paroxysmal and persistent nonvalvular atrial fibrillation and (2) a written survey of the provider's approach to anti-thrombotic therapy in patients with atrial fibrillation. The providers' practices were compared to current national guidelines for anti-thrombotic therapy in AF patients. RESULTS: There was found to be a high rate of anti-thrombotic therapy among patients with AF, even among those patients at low risk for stoke. The application of three models of risk-stratification resulting in very different results, the fractions of the cohort classified as low-risk varying from 7% to 37%. Finally, not all providers used risk-stratification for patients with atrial fibrillation, and when used, there is much variation in the use of risk factors by physicians in the decision whether to anticoagulate. CONCLUSIONS: Patients at Dunes Family Health Care have excellent rates of anticoagulation and anti-thrombotic therapy. Though the reasons for anticoagulation cannot be assessed, whether patient preference or physician advise, patients at low-risk for stroke may be better served by less aggressive therapy. Finally, when used, the providers studied had limited use of risk-stratification and may do well do incorporate more identifiable factors in the stratification of their patients.

Evaluation of Acute Stroke Treatment in Reedsport, OR: A look at thrombolytic therapy in this rural setting.
Date of project: 5/6/2002

Unlike some of the rural settings in Oregon, Lower Umpqua Hospital in Reedsport currently does not have a protocol for thrombolytic use in acute stroke. The goal of this project was to evaluate standard acute stroke treatment in Reedsport and the surrounding rural communities, then to assess what it would entail to incorporate thrombolytic therapy into the hospital’s stroke treatment. The evaluation for the project involved many components, including: 1) assessment of local stroke epidemiology, 2) assessing Reedsport physician support of acute stroke therapy, 3) assessing patient recognition and response to signs and symptoms of stroke, and their current utilization of EMS services, 4) analyzing the hospital and EMS needs for providing acute stroke treatment, and 5) questioning physicians from areas that provide thrombolytics for acute stroke. The report will address various aspects of providing acute stroke treatment in a rural setting vs. an urban setting. The findings in this report are meant to be informational and do not suggest whether acute stroke thrombolysis should or should not be integrated in the Reedsport ER protocol. The report does, however, provide a basic set of guidelines for helping establish acute stroke treatment in Reedsport should they decide to pursue this.

Colorectal Cancer Screening Practices at the Dunes Family Health Care Clinic
Date of project: 9/ 24/2001

This study sought to examine the colorectal cancer (CRC) screening practices and rates among the family practice providers at Dunes Family Health Care in Reedsport, Oregon, as well as to increase patient awareness about the disease. There were four components of the study: a) written survey of the providers' screening preferences, b) chart review to determine screening rates, c) review of the adjoining hospital's surgery logbook to examine colonoscopy rates, d) creation of an article on screening for CRC to be included in the clinic's newsletter to patients. The providers' screening practices were also compared to national guidelines for screening recommendations. There was found to be an overall high rate of screening at the Dunes clinic, although this was provider-dependent. There was some variation in preference for screening exams among the providers, but all screening plans were within the bounds of most guidelines. Finally, some suggestions were made on how to increase screening rates, and patient groups at increased risk of not receiving screening were identified.

Surgery in Reedsport, OR: Its Impact On Lower Umpqua Hospital.
Date of project: 8/13/2001

Most hospitals rely on their surgical facilities for financial stability. The capability to support full-time surgical staff becomes particularly important to the survival of rural hospitals, which often reside in low-populated and economically limited areas. Lower Umpqua Hospital (LUH), located along the Southern Oregon Coast in Reedsport, is an example of a rural hospital that has experienced financial hardship. After many substantial efforts and changes, including the hiring in 1995 of one general surgeon based in Reedsport and five surgeons who share their surgery time between Reedsport and other nearby towns, LUH currently enjoys financial recovery. This project seeks to understand how the recruitment of Dr. Toshio Nagamoto, the first and only surgeon living and working full-time in Reedsport, has affected the financial security of the Lower Umpqua Hospital (LUH). A timeline was first developed to illustrate the surgical services available to LUH over the years. The first surgeon to significantly increase the surgical services offered at LUH was an orthopedic surgeon hired in 1994, who shared operating time between Coos Bay and Reedsport.The general surgeon, the first and only surgeon to be based in Reedsport, was hired in 1995, and LUH has since brought on five additional surgeons, all sharing operating time between LUH and other hospitals along the Southern Coast. Hospital financial statistics reveal that Dr. Nagamoto's general surgery practice generates the majority of the total hospital revenue earned from all surgery at LUH. Gross revenue at LUH has increased by 110%, as compared to increasing by 67% in the five years preceding him. Additionally, LUH has increased total staffing by 64%, including a 30% increase in the surgical nursing staff, since 1995. The average daily census at LUH as risen from an all-time low of less than 2/day at one point in 1991, to a yearly average approaching 8/day this year. Remarkably, total surgery visits have increased by 2.7 times since the averages seen from 1992-1994. The average inpatient days of service and average intensive care unit patient days have increased since 1995 as well. Hospital financial data indicate the positive impact of a resident surgeon on the financial security of LUH. This data indicates the benefit and ultimate necessity of gaining a full-time local surgeon for LUH and for the community of Reedsport, Oregon.

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