RCHC Community Project Abstracts

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The Coca-Cola Crisis: The relationship between soda consumption and BMI in a Marion County clinic
Date of project: 10/12/2009

During a time where childhood and adult obesity is reaching epidemic proportions, the American Society of Family Physicians announced a highly controversial merger with Coca-Cola to promote consumption of its products as part of a healthy life style. This raised a highly charged debate as to whether or not family physicians could ethically support soft drink consumption in the face of numerous studies linking soft drink or soda consumption to increasing BMI. In Marion County, obesity rates are even higher than Oregon in general. This study sought to create a snap shot of the current obesity trends within a specific Marion County clinic and assess the association between soda consumption and BMI. Additionally, the study sought to assess the motivational factors that contribute to soda consumption. Soda consumption was assessed through surveys that were self reported and correlated to the most recently recorded clinic BMI. Over 200 patients were surveyed with only 74 responders. Of those responding, only 18 self identified as soda consumers. When assessed, it was found that there was a statistically significant positive association between soda consumption and BMI with an average BMI for soda consumers of 33.4 with a 95% CI (29.86-36.99) compared to 29.4 in the control group with a p-value of 0.012. This positive association supports numerous studies that have addressed a caloric as well as hormonal association between BMI and soda consumption. This relationship calls into question the ethics of supporting a healthy lifestyle that includes soda consumption that is associated with obesity and its myriad of co-morbidities.

Factors Associated with No-Shows and Methods for Intervention in a Stayton Family Medicine Clinic
Date of project: 9/7/2009

Patients who schedule clinic appointments and fail to keep them contribute to decreased opportunities for patient health prevention and disease monitoring and management, and also contribute to wasted clinic resources and decreased productivity. This project was conducted to identify and describe factors associated with why patients do not keep scheduled appointments, and discuss potential strategies to increase attendance at appointments. Methods: 110 electronic medical record (EMR) patient charts at a Stayton Family Medicine clinic were randomly selected from 442 no-shows identified from 2004-2009. Results: 442(<5%) no-shows were identified from 2004-2009, or about 1 no-show per provider per week. 110 patient charts were reviewed, 45(40.9%) male and 65(59.1%) female. Mean age was 37.4 years old (YO), with 17(15.5%) less than 12 YO, 8(7.3%) 12-17 YO, 40(36.4%) 18-40 YO, 31(28.2%) 40-64 YO; 14(12.7%) over 64 YO. Tobacco use was reported in 61(55.5%) patients, with 6(9.8%) previous tobacco users, 49(80.3%) current tobacco users, and 6(9.8%) recipients of secondhand smoke. The 6 cases of secondhand smoke were children 2-15 YO. Alcohol use was reported in 40(36.4%) patients. Mean number of medications reported was 3.7 and 4.5 for non-tobacco and tobacco users, respectively. Mean number of past medical history diagnoses reported was 4.3 and 6.0 for non-tobacco and tobacco users, respectively. Conclusion: The rate of no-shows at the Stayton clinic is much lower than the average rate found in many studies. Over half the no-show patients reviewed in the study were reported to be smokers. Most patients are relatively young with 59% who were less than 40 YO. Several factors must be considered in deciding which methods to implement to reduce no-show rates among patients.

Enhancing Domestic Violence Screening and Outreach at Santiam Medical Associates by Addressing Barriers Faced by Battered Woman in Rural Communities
Date of project: 4/27/2009

This project aims to evaluate the preparedness of Santiam Medical Associates to recognize and refer victims of domestic violence (DV) to resources. Another key objective was to illuminate the myriad of barriers faced by victims of DV in rural communities and the ways in which providers can become better equipped to assist these victims. It is thought that 1 in 10 women in Oregon between the ages of 20-55 (more than 85,000 women), have been physically or sexually assaulted by a current or former intimate partner in the last five years.1 Nearly one-third of American women (31%) report being physically or sexually abused by a husband or boyfriend at some point in their lives.2 Women in rural communities face specific challenges to accessing resources. Rural physicians can play an integral role in improving the lives of their battered patients if they are aware of the problem and provide a safe and confidential environment for women to disclose. During my rotation, I administered an anonymous survey to the employees of the Santiam Family Medical office to assess their awareness of DV, preparedness to ask about abuse, whether they felt equipped to refer patients to appropriate resources and their thoughts on barriers women face while seeking safety from abuse in Stayton. Based on the results of the survey, I collaborated with a non-profit domestic violence organization to develop a training workshop for the staff on addressing DV in a medical setting. In addition, I was able to provide prevention and education materials on DV for the physicians and staff to distribute to patients in need of information and community resources.

Access to Health Care in Rural Communities
Date of project: 2/9/2009

Access to health care in rural communities has long been recognized as a public health concern and much effort has been expended to study and remedy the problems with access to healthcare in these areas. In our study we examine access to healthcare, and quality of health care for health care providers in four communities in the mid-Willamette Valley in Oregon. All MD’s, DO’s, NP’s, and PA’s in the communities of Stayton, Sublimity, Aumsville, and Mill City OR were surveyed anonymously about their access to healthcare and whether they receive the screenings recommended by the US Preventative Services Task Force (USPSTF). Twenty seven providers where surveyed and 21 responded. Of these, 75% had a personal PCP, but less than half have had a physical exam in the last 2 years and 3 had never had a physical exam. Only 62% of USPSTF screenings were complete for this group and over half of these were self screenings.

Insomnia in the Elderly of Stayton, Oregon: Development of a Patient Handout for Improving Sleep Quality
Date of project: 10/13/2008

Insomnia, whether it be difficulty falling asleep, staying asleep or simply poor quality sleep, is a common problem, estimated to transiently affect up to one third of adults. During a five week rotation in a family practice clinic of Stayton, Oregon, insomnia was identified as a common complaint. Diagnosis was established on the basis of patient history and treatment with medications was initiated, but non-pharmacologic treatments of insomnia were not discussed. Acquisition of information pertaining to the issue included casual conversation with practitioners and a review of relevant medical literature, as well as easily accessible online resources of patient information. From these sources, a patient handout for improved quality sleep was developed. Further investigation into the relevance of sleep hygiene education and insomnia in the region was accomplished through interaction and discussion with residents of assisted living facilities in the Stayton/Sublimity area, including the Lakeside Assisted Living Community and McKillop Residence. Visiting these local facilities confirmed that insomnia and sleep disturbance is a common problem that affects this community, particularly in the elderly. The positive response to the handout supports its potential as an education tool to be used in the primary care setting in the future.

Addressing Low Rates of Colorectal Cancer Screening in a Rural Community
Date of project: 9/8/2008

Colorectal Cancer is one of the leading causes of cancer-related deaths in the United States today; however, timely screening with tests such as the fecal occult blood test and colonoscopies has greatly increased the number of cancers found in early, treatable stages, thereby reducing the incidence of late-stage and metastatic lesions as well as overall mortality from this disease. Despite the focus placed on preventative medicine by care providers at Santiam Memorial Hospital (SMH) in Stayton, Oregon, screening rates for colorectal cancer in Marion County (home of Stayton) remain below the national and state rates. Additionally, colorectal cancer incidence and mortality in Marion County are higher than those of the state and nation. In this project, Barriers to screening at SMH were investigated, as well as factors associated with low patient adherence to screening recommendations. Fecal occult blood tests are not regularly employed by all doctors at SMH, with efforts often focused entirely on colonoscopy referrals instead. Several suggestions for ways in which barriers might be overcome were then developed, including increased information for patients by way of videos, pamphlets, etc. and increased use of fecal occult blood testing as a less-invasive means for screening that patients might perceive as less intimidating and less embarrassing. Finally, several strategies to increase patient adherence were suggested, including re-writing patient information at a more understandable level for patients with low health literacy, and possibly organizing community forums in which trusted members of the community (including doctors and patients) can speak about their experiences with screening and with colorectal cancer itself. By increasing patient awareness of the risks of colorectal cancer, increasing patient awareness of the benefits of timely screening, and increasing follow up for patient referrals, Marion County should be able to bring its screening rates higher than the state and national averages, while bringing colorectal cancer-related mortality rates below the state and national averages.

A Look at the Availability of the HPV and Meningococcal Vaccines in the North Santiam Canyon
Date of project: 8/4/2008

Vaccination has become a huge part of preventative health in the U.S. and around the world. We've seen illnesses such as small-pox virtually eliminated from the population by successful vaccination programs. The first day I was in clinic, a girl came in requesting the HPV and Meningococcal vaccines and I was surprised to learn that neither of these were offered at the clinic I was at. This study looked at the availability of these two optional and expensive vaccines in the greater Santiam Canyon area. A phone survey of the local physicians was used to assess the availability of the vaccines and to ask about resources outside of these communities that they might utilize to provide this vaccine for their patients. Finally an informational handout was made that outlined basic information about each vaccine, resources available to help pay for them, and a phone number for a resource that provided the vaccine should their own clinic not provide them.

The Oregon Wellness Policy and Input from Local Providers in the North Santiam School District
Date of project: 4/28/2008

Purpose: The prevalence of childhood obesity has increased over the past several decades. Wellness Policies have been developed at both the national and state levels to combat this epidemic by providing healthy food in schools, promoting nutrition education and encouraging physical activity. This project attempted to gain a solid understanding of the Oregon Wellness policy requirements and ascertain what input the North Santiam School District, which encompasses the town of Stayton, receives from local health care providers. This information was compared to nearby districts including the similar Cascade and the much larger Salem-Keizer School Districts. Design and Methods: This was an observational study. Methods included in-depth interviews with food service directors in the North Santiam, Cascade and Salem-Keizer School Districts along with the cooks at the private St. Mary’s Elementary in Stayton (Appendix B). A thorough Ovid Pub Med search of the terms “nutrition” and “school” was also conducted and papers read for background information. Results: The Oregon Wellness Policy is an evolving set of guidelines for schools relating to all food, including entrees, al la carte items and beverages served on school property during an extended school day (Appendix A). Involvement from local health care providers, in all districts interviewed, was minimal. No district had a physician currently serving on their Wellness Committee. Future: This study was intended to identify areas for future research, including: surveying clinicians’ knowledge regarding the Oregon Wellness Policy and identifying barriers to their involvement with local school wellness committees. Action should then be taken to educate local providers on areas where they could participate in school nutrition.

Identification and Analysis of Barriers to Influenza Vaccination and Development of Patient Brochure as a Mode of Intervention in Stayton, OR
Date of project: 2/11/2008

Seasonal influenza is a significant contributor to morbidity and mortality of Americans, particularly in at risk populations (adults > 50 years, children < 5 years, and persons with chronic disease, immunosuppression, or compromised respiratory function). The most effective means of influenza prevention remains yearly vaccination. This study attempted to identify barriers to influenza vaccination in a Stayton, OR family practice clinic. The design was five week observation of clinic and hospitalized patients with diagnosed influenza or influenza-like illness and their response to a family physician’s intervention regarding influenza vaccination. From these observations, a survey was developed and distributed over 7 clinic days, which asked patients to indicate if they received this year’s flu vaccine and if not, why? Based on survey data, gaps in patient knowledge, as well as systemic barriers to vaccination were identified. Interviews with local influenza vaccination sites were conducted in person and by phone to gather information about shot availability, cost, and type of vaccine offered. While patients were generally aware of availability of yearly flu vaccine, the majority declined due to misconceptions or lack of information regarding the influenza vaccine. No intervention, outside of physician counseling, was identified to target the local population’s low utilization of the flu vaccine during this brief observation period. Therefore, the end product of this project was the development of a patient brochure tailored to the responses of the “Influenza Vaccine Survey” to be distributed in clinic, and a recommended change in policy for local influenza vaccination sites.

The Unintended Model: Bringing Health Care Services to Rural Oregon
Date of project: 10/15/2007

Santiam Memorial Hospital (SMH) in Stayton, Oregon is a unique small hospital with a rich history, influential present, and a hopeful future that strives to provide health care services to residents of the mid-Willamette valley in Marion and Linn counties. This qualitative study investigates how SMH administration, employees, and contracted providers have expanded their capacity for health care delivery in a challenging rural setting by cultivating successful staff and community relationships. The utility in exploring this unique situation includes elucidating strategies that may enable rural hospitals and providers to develop a greater capacity to meet the health care needs of other rural populations. The method of investigation primarily consisted of interviews and observation. I discovered that the ability of SMH and contracted providers to successfully deliver health care to their service population is tightly linked to local industry cooperation and successful community relations.

A Summary of Continued Medical Education in Rural Health Care
Date of project: 8/6/2007

Stayton, Oregon is a unique rural community due to its close proximity to the more urbanized population of Salem. Despite it's location, Stayton has established itself as a self-sustaining center of health care. The local 40 bed Santiam Memorial Hospital serves over 30,000 people with services including an emergency room, two operating rooms, a labor and delivery ward, laboratory services, and imaging services that include ultrasound, MRI, CT, and X-ray. There are no subspecialty units located within the hospital, however many specialists from Salem will travel to Stayton to manage a clinic one or two days per week. Because of these services, few local residents have to travel outside city limits to meet their health care needs. Despite the medical diversity of this small town, Stayton has few opportunities of continued medical education (CME) for its local physicians.

Influenza and other respiratory illnesses
Date of project: 2/12/2007

Influenza, also known as “the flu,” is a viral infection of the nose, throat and lungs that affects roughly 10-20% of Americans each year. Occasionally, a certain subset of people stricken with influenza will attain a high level of sickness that requires acute care. Every year, approximately 200,000 people are hospitalized and 36,000 die because of influenza and its complications. Up to March 1, 2007, 84 cases of influenza have been diagnosed in the state of Oregon. This study attempts to identify the incidence of laboratory-diagnosed influenza in a Stayton, Oregon family practice clinic and compare it with the statewide incidence as well as the incidence of other respiratory illnesses seen in the clinic. The design was a prospective study of patients diagnosed with influenza during a five-week rotation. From this study, it was determined that Stayton alone contributed to 5% of the influenza cases diagnosed in Oregon, which is notable because according to the 2005 population census, Stayton represents 0.2% of the Oregon population (7,700 out of 3,641,056). Also, greater than 50% of the Stayton family practice clinic patient population (25% pediatrics and >35% 65 years old and over) are considered at risk for influenza. This study demonstrates the high incidence of influenza in Stayton, OR and the subsequent need for heightened awareness by both patients and physicians to ensure rapid detection of the disease for effective primary and secondary prophylactic treatment as well as to highlight the importance of promoting influenza vaccine not only to at-risk groups, but also to the general population. The final product of this study was the development of a patient handout, because none previously existed at the family practice clinic, to increase patient awareness and education on the matter.

Patient awareness of smoke cessation resources in a Stayton family medicine clinic and Physician intervention.
Date of project: 10/16/2006

Cigarette smoking has been identified as the most important source of preventable morbidity and premature mortality worldwide. Smoking is responsible for approximately one in five deaths in the United States. According to the a survey done by the Centers for Disease Control in 2002, there were 50 million smokers in he United States, of which 70% wanted to quit smoking. 41% of those smokers make at least one attempt each year, but only 7% are successful. The majority of these people (90%) attempt to quit “cold turkey.” Countless studies have shown that although this is the most common way to quit it is by far the least effective. Those who use other resources have up to a 30-45 % success rate compare with a less than 10% overall success rate for quitting cold turkey. This study was done to evaluate patients’ awareness of these resources in a Stayton family medicine clinic as well as to determine if they are being encouraged to quit by us as care givers. Through an electronic chart review it was shown that 80% of the smokers in this clinic have documentation in their chart that quitting was discussed. A survey was done and showed the following percentage of patients that knew about each of the resources available: 100% nicotine gum or nicotine patch; 57% Zyban pill; 0% SMART shot; 100% hypnosis, 71% acupuncture; 14% Chantix pill; 42% free telephone counseling. If we can better educate our patients concerning the use of quitting resources it is more likely that they will attempt to quit using them the next time. This will significantly increase the number of patients who are successful quitters and obviously markedly improve their health and the health of the community

Does Increased Field Burning Affect the Trends of Emergency Room Visits for Respiratory Symptoms at Santiam Memorial Hospital?
Date of project: 8/7/2006

This rural health research project sought to determine if peak grass seed burning within Stayton Fire District boundaries affected the number of Emergency Room visits to the Santiam Memorial Hospital for respiratory symptoms. This study considered primary and secondary respiratory diagnoses on ER admissions reports during the peak burning periods in August of 2005 and 2006. Considered diagnoses included acute and chronic forms of bronchitis, sinusitis, rhinitis, asthma, emphysema, pneumonia, conjunctivitis and upper respiratory infections (8 categories). The number of ER admissions for respiratory symptoms was compared with the acreage of field burning in the Stayton Fire District over 21 to 24 day periods with the 7 or 8 days of heaviest burning acreage wedged between two equal length periods of significantly lighter burning. While a positive trend of increased respiratory symptoms was present in 2006, in 2005 the trend was negative. Due to a limited sample size and several probable confounding factors, there was not much statistical significance to this study but perhaps a framework has been established for further inquiry.

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