RCHC Community Project Abstracts

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Community Based Diabetic Retinopathy Screening: Non-mydriatic Imaging and Telemedicine
Date of project: 9/10/2007

Diabetic retinopathy ranks as the leading cause of preventable blindness in the United States. Early detection and treatment can preserve vision, yet a fraction (~25%) of those at the highest risk receive annual screening for diabetic retinopathy. A new process that combines non-mydriatic retinal imaging with telemedicine at the primary care level promises to change this discrepancy. Within ten years of widespread implementation, Australia now screens most of its populace annually. Comparable success in being reported in this country where the strategy is gaining acceptance. Virginia Garcia Memorial Health Center now annually screens ~55% of its diabetic registry after it teamed up two years ago with Pacific University's School of Optometry for remote retinal reading. The feasibility of setting up an analogous program at the WSC was investigated here. Barriers were identified to avoid pitfalls in process set-up to allow smooth integration of retinal image capture within a scheduled diabetic visit. Funds from a CareOregon grant will be used to purchase a non-mydriatic camera. With the aim of preventing blindness due to retinopathy, the goal is increase annual eye exam screening among the WSC diabetic registry from 37% to >70%, a national standard set by the Diabetes Disparities Collaborative.

Increasing Childhood Literacy Through Reach Out and Read, At The West Salem Clinic.
Date of project: 7/2/2007

Reading aloud to children is an important tool to increase childhood literacy. Exposure to books at a young age helps build literacy in children. Sixteen percent of parents of young children do not read to their children at all and almost a quarter only read to them once or twice a week (1). Reach Out and Read (ROR) is a national program that seeks to increase childhood literacy rates by providing a new book to a child at each well-child check health care appointment between the ages of 6 months to 5 years. The goal of this community project was to establish an ROR program at the West Salem clinic. There were three parts to the project. The first was to contact the national ROR program to request application materials, and then compile the information needed to complete the application. The second part of the project was contacting other ROR sites around the state for information about the logistics and funding for their ROR programs. The third part of the project was to establish funding sources for both the start-up costs and the continuing costs of running the program. Grants/solicitations were submitted to various businesses and funding sources. A database of possible funding sources was created for future years to help sustain the program.

Diabetic Retinopathy Screening at the West Salem Clinic
Date of project: 7/3/2006

Diabetes mellitus is a common disease in the United States with an unfortunate catalog of debilitating complications. One of these complications, retinopathy, is the main cause of blindness in our working population. While blood sugar control is the primary method of preventing and treating all diabetic complications, including retinopathy, specific treatment is available for retinopathy and vision preservation. This project focused on the ways that a rural and underserved community identifies diabetic patients with retinopathy, and investigated one means of improving the screening rate. Non-dilated eye exams, performed in the primary care office, using a retina camera and a remote retina specialist evaluating the retina images, is an effective way of bringing the screening to the people. Published reports and a local farm-worker clinic using this model were investigated. Purchasing a camera and initiating a screening program is a promising opportunity. If enough of those screened have insurance to pay for the exam, the clinic can afford to screen those patients who are uninsured. Further investigation is required to identify an accessible and affordable option for treatment for those are found to have a positive screen for retinopathy.

Increasing Access to Lactation Services in a Low-Income Population: Developing an Outpatient Program
Date of project: 3/20/2006

There are considerable barriers to breastfeeding for low-income, predominantly Latina women in Salem, OR. While lactation services are available to women during their postpartum hospital stay, most outpatient options are inaccessible for these patients. Following a model similar to that of a local pediatric clinic, West Salem Clinic, a federally qualified health center, would like to determine the feasibility of providing outpatient lactation services. Grant money would be needed to offset costs of this program. Additionally, West Salem Clinic should increase the volume of newborns seen to improve the viability of the program.

Barriers to Breastfeeding in a Low-Income, Predominantly Hispanic Community.
Date of project: 9/12/2005

Despite the clinical evidence that supports the nutritional and developmental advantages to breastfeeding, the initiation, duration and exclusivity of breastfeeding remain low in the United States. The barriers that exist for women wishing to breastfeed are multifactoral, especially for low income mothers. However, by providing support and education, primary care physicians are in a pivotal position to address breastfeeding complications during routine examinations and potentially increase breastfeeding rates. An analysis was conducted to assess what breastfeeding difficulties exist for mothers at the West Salem Clinic. Patients delivering within the last six months were interviewed about their desire to breastfeed, the support they received and complications they experienced. Problems such as perceived decrease in milk supply, sore or cracked nipples or latching difficulties were consistent with other published reports. However, barriers unique to this population included cultural perceptions, financial and educational obstructions as well as language difficulties. By identifying the obstacles that exist for breastfeeding mothers, primary care providers might be better able to offer more continued support, thereby improve breastfeeding outcomes.

Improving patient awareness of stroke disease
Date of project: 7/4/2005

According to the American Health Assocation (AHA), stroke is the leading cause of long term disability in the United States today. Four million Americans currently live with the chronic effects of strokes, with another 700,000 strokes occurring each year. In addition, studies show that for all strokes, 50-70% of patients are able to recover functional independence, with another 15-30% remaining permanently disabled. Due to the long-term medical care and disability that is so often needed, the annual cost of stroke treatment has soared to $57 billion annually in the United States alone. Thus, the need to recognize stroke risk factors and educate those at risk has become increasingly important to healthcare practitioners. The AHA, American Stroke Association and National Stroke Association all agree that studies have proven the existence of a variety of stroke risk factors, which are all classified as controllable or uncontrollable. Examples of controllable factors include smoking, obesity and alcohol consumption while uncontrollable problems include family history and age. By virtually any outcome measures defined, study questionnaire results show that baseline knowledge of strokes among West Salem Clinic patients is sufficient at best. In addition, comparison of questionnaires with corresponding patient chart info provide evidence that stroke knowledge actually declines linearly with stroke risk, exactly the opposite preferred trend. After completing the study questionnaire, all subjects were furnished with materials containing basic information regarding stroke disease background, risk factors and symptoms. In addition, other methods to improve patient awareness of stroke disease are considered.

Multiple Strategies Designed to limit Medication costs for the underserved at the West Salem Clinic
Date of project: 4/25/2005

Medication cots in the United States continue to trouble the patients taking the medications and the physicians prescribing them. This study attempted to identify and explain the many strategies the Northwest Human Services West Salem Clinic is using to combat therapeutic costs. The design was collection of information and data from multiple sources regarding several current methods currently being used at the clinic. All staff involved with patient care as well as staff specifically dedicated toward cost reduction programs were observed, studied, and queried regarding the ins/outs of these programs. This project will allow for a wonderful synopsis for clinics to possibly emulate the medication reduction cost programs currently being implemented at the NHSWSC.

Diabetes Mellitus is a common disease.
Date of project: 2/7/2005

Diabetes mellitus is a common disease that is seen by a family practitioner on a daily basis. Aggressive glycemic control and preventive monitoring have been shown to help prevent end-organ damage. Many patients in the West Salem Clinic have not had a dilated eye exam in the last year. A chart review of these patients was conducted to identify areas of improved compliance. Several areas were identified including lack of data entry, lack of referral tracking, and lack of referrals. The area of most influence is with having providers use the diabetic logs that have already been provided. Lack of insurance is a minor problem and several solutions are discussed.

Hepatitis C prevalence rates in West Salem Clinic Homeless versus low-income non-homeless
Date of project: 10/18/2004

The hepatitis C virus is a major public health problem and a leading cause of chronic liver disease. In the US, the CDC estimates that there are more than 2.7 million people with ongoing HCV infection. HCV is the leading cause of death from liver disease in the US. Homelessness is an important risk factor for HCV because of the environments ad behaviors associated with homeless communities such as poor hygiene, poor nutrition and high levels of IDU. The goals of the study were to determine the prevalence rates for HCV in the West Salem Clinic populations and to determine how the rates differed between the homeless and the low-income non-homeless. The study also aimed to look at a few of the associated risk factors for HCV such as drug use, alcoholism and STDs. The study showed that the rates of HCV are indeed higher in the homeless than in the low-income non-homeless, as recent literature has indicated. Further research is required to understand the specific associations between various risk factors and the rates of HCV at the West Salem Clinic. The preliminary data indicates a need for further patient education and intervention regarding HCV transmission, especially among the homeless.

Smoking Cessation Intervention at the West Salem Clinic
Date of project: 7/5/2004

According to the most recent survey done by the Centers for Disease Control, there are almost 50 million smokers in the United States, of which 70% want to quit smoking. At least one third of those who want to quit, will make at least one attempt each year, but only 7% will be successful. However, as little as three minutes of smoking cessation intervention provided by a physician, can increase the chances of quitting successfully by 50%. The U.S. Public Health Service research on smoking cessation has shown that efficacious cessation treatments for tobacco users are available and should become part of standard care giving. Furthermore, delivering treatment of tobacco users is cost-effective. Despite these national guidelines, physicians are struggling to implement smoking intervention into their daily clinical practice. Tobacco is the largest single cause of lung cancer and 82% of lung cancer deaths in Oregon can be linked directly to tobacco use. In recognition of the local tobacco problem and the national recommendations from the Department of Public Health, I have designed this research project to evaluate several aspects of smoking intervention needs, practices and procedures at the West Salem Clinic. I have additionally designed a tailored smoking assessment and intervention implementation program for the West Salem Clinic based on the results of this evaluation.

Screening for depression in the elderly
Date of project: 5/10/2004

Objective: To evaluate depression among individuals over the age of 65 presenting the primary care setting. Methods: The 15 Geriatric Depression Scale (GDS) was distributed to both Spanish and English speaking patients in the primary care setting. The question also included demographic information to identify possible risk factors for depression in the community being evaluated.

Lack of Health Care benefits
Date of project: 3/29/2004

In the past 6 weeks I have been very fortunate to work with Dr. Lance Loberg, Medical Director for NW Human Services community clinics. Because of the comprehensive care provided through this agency, I had the unique opportunity to see patients at the West Salem Clinic, Total Health in Monmouth and H.O.A.P. Mental Health clinic for the homeless and underserved. The experience of being immersed in the lives of such diverse populations enabled me to learn their different interests and life dreams as well as their common fears and frustrations. In a short time, it became frightingly apparent to me how many members of the Salem communty were living with diabetes and felt like they were fighting against more barriers than they could handle. With the decline in health care benefits and services, most patients had lot their mental health and prescription coverage. This left them using unavailable financial resources to provide for medical care and medications. Combined with the current unemployment rate and the increase in costs of living, many hard working people found it necessary to choose between their health and the basic welfare of their family.

Community Resources for Patients with Diabetes Requiring Yearly Eye Exam
Date of project: 1/5/2004

The West Salem Clinic is found actively engaged in implementing the Diabetes Collaborative II by applying the Chronic Care Model. Last year’s significant gains in improving the proportion of patients with HbA1c less than 8%, LDL-C less than 130mg/dl, and increased empowerment of self-management goals for patients with diabetes has given a new outlook in terms of dealing with chronic diseases such as diabetes. The Chronic Care Model, through its extensive integration of clinical information systems, self-management support, delivery system design, community resources and policies, health care organization, and decision support, has been monumental in achieving these tremendous advances in the care of patients with chronic diseases. As part of my community project, I explored community resources in the Salem area particularly in regards to eye clinics that provide charitable care and/or discounted fees for a yearly eye exam of uninsured patients with diabetes. I also attempted to do a survey on how the uninsured patients of the West Salem Clinic are fairing with regards to their recommended annual screening eye exam. As the result, I was able to find close to twenty eye clinics that offer or are willing to offer assistance for patients who do not have the resources to get an eye exam on their own. However, the part of my project that deals with the survey was not successful since I was able to contact only 3 out of 14 registered uninsured patients from WSC database. Most of the patients had either moved away or did not leave their contact information when they left the Mission (a temporary shelter that houses homeless individuals in the Salem area).

Resource Gathering, Early Planning and Evaluation of Group Visits for the West Salem Clinic in the Early Phases of Implementing the chronic Care Model.
Date of project: 11/10/2003

The management of chronic illness constitutes a formidable challenge to patients, practitioners, and the health care budget. The Chronic Care Model has been developed to address the increasing strain chronic illness is exerting on the health care system. The six pillars of the chronic care model are: Community resources and policies, Health care organization, Self-management Support, Delivery System Design, Decision support, and Clinical Information Systems. The West Salem Clinic is currently in the midst of a national two year Diabetes Collaborative aimed at implementing the chronic care model in the management of patients with Diabetes. In an effort to further progress to a chronic care model I researched and gathered resources on group visits and queried patients with diabetes on the interest in being involved in the group visit format, diabetes knowledge, self-management and health care utilization. I found that 60% of patients were interested in the group visit format, perceived knowledge of diabetes appears to be greater than actual knowledge, self-management appears to vary widely, and for this population utilization of their PCP for most patients occurs at every three months or less, with few patients requiring hospitalization for their diabetes.

Diabetic Disparity: The Educational Divide Between Hispanic and Caucasian Diabetic Patients
Date of project: 7/7/2003

Diabetes is highly prevalent chronic disease that affects Hispanics more often than Caucasians. Its prognosis can be significantly improved with proper education. Unfortunately diabetic Hispanics have historically been under-educated on their disease. Hispanic diabetic educational status was evaluated in a Salem, Oregon non-profit clinic to determine whether this historical discrepancy existed in this population. No statistically significant educational deficit was found between Hispanic and Caucasian populations, however it is suggested that further analysis be performed and more Spanish-language material be made available for patients.

Providing Comprehensive patient education materials in The West Salem Clinic.
Date of project: 3/24/2003

After assessing patient education materials at West Salem Clinic it was found that very little to no patient education materials were available or disseminated to the primarily low income patient population. A written survey was conducted in Spanish and English, and the providers and staff were interviewed regarding the need for patient education materials. These queries indicated a need for the development of a comprehensive, centrally located, set of patient education materials, and a convenient method of distributing this information to patients. The goal of this project was to acquire these materials in Spanish and English and to develop a system to distribute this information in the normal course of office visits.

"No Shows" at the West Salem Clinic
Date of project: 5/5/2003

This paper compares the national rate of patients not showing up for their doctors appointment with the rate of no shows at the West Salem Clinic located in West Salem, Oregon. This project was completed with the hope that this comparative information can be used by the administration of the West Salem Clinic to make any needed adjustments in their patient management practices. Method: Comparison of published research concerning no show percentages with internal clinic documents describing the percentage of no shows at the clinic. Results: A review of the research literature revealed a no show rate of 6% to 55% nationally. The average no show rate was in the low to middle 20% range. West Salem Clinic has a no show rate over the past six months of 12.43%. In the month of May 2003 the no show rate for the clinic was 13%. West Salem Clinic has a lower rate of no shows when compared with the national average.

Obesity
Date of project: 12/30/2002

Obesity is a growing epidemic in the U.S. today. Currently obesity related diseases claim 300,000 lives yearly. If this trend continues, obesity will overtake smoking as the number one preventable killer of United States citizens. Obesity costs our health care system more than 330 billion dollars annually, which is approximately 12% of the national health care budget. It is an enormous problem. At the present there are no effective “quick fix” therapies for obesity. Drug therapy has been un-affective and gastric bypass is an option for very few. Good old-fashioned dietary control through lifestyle change and physical activity seem to be the most effective and long-lasting way to prevent and treat obesity. Because treatment is so difficult, the war on obesity begins with prevention. Children who are obese become adults who are obese. Obese six-year-olds become obese adults 50% of the time, while adult obesity rates from obese teens rise as high as 70-80%. Are we succeeding at preventing this obesity epidemic? Data suggests that primary care doctors are poor at screening for and treating the complications of obesity. Childhood obesity has nearly doubled since the 60’s and we are still not actively treating this epidemic. I set out to define the gravity of this problem in the West Salem Clinic. Both low-income and Hispanic populations are the populations with the greatest increase in childhood obesity in the last 15 years. The West Salem Clinic treats mostly low-income families and the majority of the patients are Hispanic. Providers at the clinic have noticed the problem for years and I set out to define the prevalence of childhood obesity in the West Salem Clinic and compare it to the U.S. population. After defining the prevalence of this at-risk population, I developed a detection and screening process to identify and treat obese and overweight children. I provided the providers of the clinic with a checklist of evidence-based guidelines for identifying the complications associated with childhood obesity. This detailed checklist includes prevalence data to convince providers of the importance of screening. I also made up a short checklist to be inserted in the chart if any child is ever identified as overweight on the BMI growth chart. Overweight is defined as a BMI >85 percentile for age and sex while obesity is >95 percentile. This checklist contains solid evidence-based screening tests that should be done on every overweight or obese child. Identifying and treating the medical complications associated with childhood obesity is responsible but the obesity itself must be treated to truly take care of your patients. Most physicians encourage diet and exercise but most folks are unresponsive to these vague suggestions. Diet and exercise is accomplished through lifestyle change. Lifestyle change is very difficult and it must be encouraged and followed in a gradual step-wise fashion to prevent failure and assure lo

The Treatment of Chronic Pain at the West Salem Clinic
Date of project: 11/4/2002

Chronic pain is a commonly encountered patient problem in any primary care setting. Over the last decade, the treatment of chronic pain has undertaken a multidisciplinary approach spanning beyond analgesics and surgical interventions to include alternative therapies, physical and occupational rehabilitation, and mental health services. The West Salem Clinic patient population is composed of mostly low-income and homeless patients, many of whom suffer from chronic pain. The purpose of this study was to ascertain what interventions this specific patient population has received for the treatment of chronic pain and compare these treatments to the suggested multidisciplinary approach. Chronic pain patients were asked to complete an anonymous survey regarding pain treatments used. The study found that despite being financially challenged, a large percentage of these patients had received some form of alternative treatment (chiropracty, massage, or acupuncture) and would continue to pursue such treatments if access was provided. The West Salem Clinic chronic pain patients also underutilized mental health resources, including individual, group, spiritual counseling, and antidepressant use. This underutilization was surprising to the physicians given that mental health services are available through the clinic. This study helped focus attention on the need for mental health counseling and treatment in chronic pain patients of this population and generated renewed interest in the offering of such services to these patients.

Patient Information Sources in Salem, Oregon: An Evaluation of Patient Resources and Integration of Care
Date of project: 7/1/2002

A growing diversity of information sources are available to modern health care consumers in the United States. This study attempted to evaluate the prevalence of patient efforts to educate themselves regarding health care concerns, as well as the type of resources they used, if they shared those resources with their physician, and their perceived education regarding their health concerns. The design of the study was an anonymous 28 question survey distributed to patients during clinic visits at the West Salem Clinic. Surveys were distributed in English or Spanish, or patients were given assistance by the nursing staff if necessary. Surveys specifically addressed what types of information sources patients used, other health practitioners they had seen, if they felt their sources were reliable and accurate, if they shared their information with their physician, and whether they felt well informed about their health concerns. In total 49 usable surveys were received. The majority of patients were found to be interested in learning about the disease and actively seeking out information. Further, nearly half of patients had used complementary or alternative medicine at some time in the past. Overall patients felt well informed about the disease and felt that their physicians repsponded well to their initiating discussions regarding the information they collected.

Recognition of cardiac risk factors among Hispanic patients of the West Salem Clinic.
Date of project: 3/25/2002

This study sought to assess the major independent modifiable risk factors for coronary artery disease among the Spanish-speaking patients of the West Salem Clinic and to compare and contrast the results with these patients' self-assessments of their personal risk for the disease. The design is a self-assessment survey of 32 consecutive Spanish-speaking patients of the clinic and a review of their charts both attempting to assess cardiac risk factors including smoking, hypertension, hyperlipidemia, glucose intolerance, physical hypoactivity, and excessive body weight. Twenty patients' surveys and chart data were compared. Overall patients slightly underestimated their risk for CHD. Greatest discrepancy was found in the body mass category: 90% were overweight, including 80% who were obese wheras only 60% indicated that they were overweight. Among other findings, 85% did not know their cholesterol level and 80% never spoke with their health care provider about cholesterol; 50% did not know their ideal body weight; and 80% never spoke with their provider about their risk for diabetes. The report further provides some recommendations for patient education on these issues.

Smoking Cessation Efforts At West Salem Clinic.
Date of project: 1/2/2002

Cigarette smoking is extremely costly to both the individual and society. It is a well established contributor to morbidity and mortality, and remains the most preventable cause of premature death in our country. Among primary care physicians, there is a high level of agreement about their responsibility to assist in tobacco cessation. Nonetheless, there are significant gaps in practice. Using a brief questionnaire, I surveyed the patients I encountered throughout my rotation to determine what percentage at West Salem Clinic are current smokers, and also whether these smokers perceived that their provider was counseling them regarding the dangers of smoking and/or advising them to quit. 41% of those questioned identified themselves as current smokers; of these, 31% felt their provider explained the health risks of smoking every visit, 62% felt it was occasionally, and 7% felt they had never received an explanation from their West Salem Clinic provider regarding the dangers of tobacco use. 54% of smokers stated their provider asked them about current smoking status and advised them to quit at every visit, 4% felt this occurred occasionally, and 42% did not recall ever being asked about their current smoking status and/or advised to quit while at West Salem Clinic.

The Use of Medication Lists in a Community Health Center.
Date of project: 11/5/2001

OBJECTIVE: To determine the effectiveness and accuracy of medication lists. Specifically, whether they help to reduce medication regimen complexity, enhance patient education. To implement simple strategies to increase the value of an already established medication list system. DESIGN: A questionnaire was designed and given to randomly selected non-pediatric patients during a 3-week period. The questionnaire included various demographic information. It also included a list of the patient's medications taken per the patient and per the patient's chart as well as the reason the medication was prescribed per the patient and per the patient's chart. Finally, the questionnaire included a list of non-prescribed medications and alternative forms of care (i.e naturopathy). SETTING: The West Salem Clinic, a community health center serving low-income individuals in Salem, Oregon. RESULTS: A total of 28 patients were interviewed during the three week period. Patients were taking an average of 8.4 medications. The average age of patients was 61.7; there were 19 females and 9 males. The percentage of errors per the patient recollection of his or her medication was 36.4. The percentage of errors per the patient's chart was 18.2. Nearly 62 percent of patients were unaware of the reason for taking at least one medication. The majority of patients over 65 were insured via Medicare (80%) and the majority of patients under 65 were insured by the Oregon Health plan (75%). Non-prescribed medications were mentioned in 36.4% of responses and 18.2% of patients reported using alternative forms of medicine sometime in their lives (no patients were currently using alternative forms of medicine). CONCLUSIONS: Patients at West Salem Clinic are taking a relatively high number of medications. Errors were seen by both the patient and the patient's chart. Many patients did not understand why they are taking certain prescribed medications. Compared to other studies medication lists used by the clinic seem to have a decreased number of errors suggesting the efficacy of an already existing system. However, steps aimed at increasing patient education and awareness as well other adjustments can help improve an already efficacious system.

Help for the Homeless? An exploration of the Assistance Programs Available to the Homeless Population of Salem, Oregon.
Date of project: 5/6/2002

Conducted in the community of Salem, Oregon from May to June of 2002, this project sought to explore the needs of the city's homeless population in order to determine if adequate assistance programs are currently in place. Initial interviews with homeless individuals seeking medical treatment were followed by an attempt at characterizing the demographics of this position. Utilizing this initial data, a survey was prepared, and distributed to homeless individuals, that sought to identify which needs were not being satisfactorily met by Salem-area assistance program currently in place. Each agency was contacted and a description of the provided services was obtained, with emphasis on theconcerns raised by survey responders. It was then possible to compare the perceived needs of the homeless population with the services in place to address them. In general, the homeless of Salem, Oregon are pleased with the assistance they receive, but are not very aware of all the programs and agencies available. Further, there is limited communication between these various agencies, and each assistance program is not fully aware of the others in the community. To address this weakness, a current Salem-area resource guide, detailing the services offered to the homeless, was prepared and distributed to local agecies so that a more coordinated effort can be achieved.

Usefulness Of Medication Contracts In Treatment Of Chronic Pain
Date of project: 7/2/2001

The epidemiological characteristics of 25 patients with chronic pain on medication contracts who are receiving care at West Salem Clinic were studied through a 16 question survey. Furthermore, the effectiveness of their pain management and their overall satisfaction with their care before and after signing a medication contract was assessed. We found that of the patients on medication contract the majority were Caucasian females between the ages of 40-60 who are unemployed and have an educational level up to college. We also found that the 84% of the patients felt that their pain was inadequately controlled before a medication contract and that 82% were dissatisfied with their care. Currently (after being on a medication contract) 47% felt their pain was not being controlled and only 23% were dissatisfied with their care. Based on these observations, it is possible that medication contracts directly or indirectly have a positive effect on the management of patients with chronic pain issues.

The Economic Burden of Cigarette Smoking at the West Salem Clinic and the Effects of Cigarette Prices on Tobacco Use.
Date of project: 8/13/2001

The burden of cigarette smoking is not only manifested in disease but also in economic expense. This economic expense can be direct as in the amount spent to maintain one's smoking habit. As well the expense can be indirect as in the amount spent to ameliorate the untoward effects of the smoking habit. This study attempts to determine the economic burden of cigarette smoking in patients seen at the West Salem Clinic as well as determine the efficacy of increasing the costs of cigarettes as a means to curb smoking in this population.

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