RCHC Community Project Abstracts

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Meeting the Need: Is the Pediatric population in Coos County adequately covered by the medical community?
Date of project: 8/3/2009

There are eight pediatricians in Coos County serving the Coos Bay and North Bend communities. They meet regularly to address current and emerging concerns to their patient population. At a recent meeting, it became apparent that the current coverage for the pediatric community was unknown. This analysis seeks to reveal more information about the pediatric population in Coos County, including the population of the pediatric community, the number who receive at least annual care, and the principle means of payment for healthcare received. The data was collected using US Census information, collaboration with the two pediatric clinics, and with data from the catchment clinic in the county. This data indicates that no more than 55% of the pediatric population sees a pediatrician, and less than 60% receive care either from a school based clinic, a catchment clinic, or the pediatricians.

Screening for Dementia in the Primary Care Setting: Experiences at the North Bend Medical Center, Coos Bay, OR
Date of project: 6/29/2009

Background: Dementia has emerged as a large and growing health care problem but it is often not diagnosed until later in the disease progression. Early diagnosis has the potential to minimize the burden on patients, family and caregivers; however, no randomized trial has evaluated the efficacy of dementia screening in primary care. Introduction: The purpose of this project was to determine whether a brief screening for dementia in this particular type of primary care setting would identify patients with some memory or cognitive impairment that required further neurocognitive testing. Another purpose of this project was to identify barriers to screening for dementia in this setting. Methods: In order to accomplish these goals, all patients over 70 years old without particular memory concerns were screened for dementia during a two-week period at one Internal Medicine Clinic at North Bend Medical Center in Coos Bay, OR. Also, a survey of Family and Internal Medicine physicians at NBMC was conducted to identify their perceptions of undiagnosed dementia in the community and to determine what prevents them from routinely screening their patients. Results: 20% of the patients screened had an abnormal Mini-Cog screening and 30% had an abnormal MMSE screening. 83% of physicians felt that many of their patients might have undiagnosed dementia. 80% cited a lack of time as the principal factor preventing them from screening. Only 20% frequently used the Mini-Cog for screening. Discussion: The fact that these patients were discovered is information that can be used to explore the issue of whether or not screening asymptomatic elderly individuals in this setting would actually be beneficial in detecting previously undiagnosed dementia. Some of the barriers that physicians identified to screening could potentially be resolved.

Care Management for Foster Children at North Bend Medical Center
Date of project: 4/27/2009

An improved system of implementing health care recommendations for foster children and an increased ability to track this vulnerable population would provide benefits to these children to ensure their health care needs were being met. Pediatricians at North Bend Medical Center in Coos Bay, Oregon have served at least 140 foster children in the past three years and recently hired a Care Manager to ensure adherence to health care recommendations for specific populations. I explored the specific recommendations for health care visits, tests, and referrals for foster children and developed a system to implement and track these patients. Community connections were established between the Department of Human Services and the clinic. A summary of recommendations was compiled for distribution to clinicians to increase awareness. A “health profile” was created to consolidate health information of foster children for increased accessibility for clinicians and foster families. Lastly, a series of care management plans was created to improve adherence to current recommendations for the Care Manager to utilize. The documents created and connections established will provide a framework to ensure that foster children are receiving adequate health care.

Available resources for patients with mental health concerns
Date of project: 3/16/2009

Mental health issues, depression and anxiety in particular, are a concern common to urban and rural populations alike. Due to the generalized scarcity of resources often found in rural and frontier settings, access to care is a major concern given difficulties with both maintaining appropriate mental health services as well as the limited ability for patients to afford them given high rates of poverty and lack of insurance. By interviewing medical and mental health providers in Coos Bay and North Bend, this project seeks to identify available resources for patients with mental health concerns and qualitatively assess how well these are being utilized by the healthcare community.

Play it be Ear: Designing a Program of Pediatric Anticipatory Guidance for the Prevention of ED and After Hours Clinic Visits for Ear Pain
Date of project: 2/9/2009

Ear pain and parental concern for acute otitis media (AOM) drive a high proportion of acute care visits for children. For the past 5 years, otitis media has been consistently among the top three most frequent reasons for pediatric ED visits at Bay Area Hospital in Coos Bay, Oregon. The ED and the urgent care pediatric After Hours Clinic are vital components of the regional health infrastructure, though with limited resources that are often strained by misuse and overuse. Recent studies have demonstrated that such reduction in after-hours and emergency resource utilization for concerns of otitis media can be achieve through directed anticipatory guidance. Consequently, it became the goal of the project to develop standardized anticipatory guidance, to be provided to parents during the most appropriate well-child visit. A survey of charts in the After Hours Clinic was performed, as well as interviews with local pediatricians and emergency room physicians. Moreover, literature review was conducted to determine most current guidelines of establishing pediatric anticipatory education, as well as current approaches to diagnosis and treatment of ear infections. The final product of this project was a comprehensive brochure on the diagnosis and treatment of pediatric ear pain and possible ear infections, which parents and legal guardians of all pediatric patients undergoing 15 months well-child visits with one of the pediatricians in the North Bend Medical Center, Coos Bay, OR.

Pediatric Telephone Medical Care
Date of project: 12/29/2008

Since its invention in 1876, the telephone has been used as a tool for delivering health care. The first recorded use of the telephone in pediatric practice was reported in The Lancet in 1879, describing the evaluation of an infant with croup using the newly developed telephone (Melzer et al. 2006). As the future of patient care continues to improve, the addition of telephonic medical care to the health clinic is now on the forefront of interest and debate. The opportunity for parents to call into the clinic with their child’s symptoms, speak with a physician, and receive counsel and treatment over the phone, may not only save time, but may extend care to a greater number of families. For many reasons, the pediatricians at the North Bend Medical Center are interested in establishing a telephone medical service to further extend pediatric care to their community. To better assess their current patients’ interest in such a service, we provided a survey to the parents of visiting patients that assesses the number of children, the number of visits, the number of phone calls, the length of travel time, their interest in speaking with a medical assistant or physician, and their willingness to pay out of pocket for telephone services. When asked to assess, on a scale of 1 to 5, their interest in speaking with a physician over the phone about their child’s medical needs, 88.2% marked interest levels between 3 and 5. . Of all those who took the survey, 63.5% of parents would be willing to pay for telephone medical care if their insurance does not cover it. Telephone medical care is about extending health care to a greater rural pediatric population. Its about saving families the anxiety and time that accompany last minute appointments, and helping those who cannot afford an office visit receive care from their pediatrician. Though the implementation of this service may be months in the making, forward strides are being made to increase pediatric services.

Eating Well on a Budget
Date of project: 10/13/2008

Obesity is an epidemic in this country, affecting young people more and more. It is an epidemic that is seen in all social classes, but disproportionately affects people of lower socioeconomic status. The Coos Bay area is generally of lower income than the state as a whole. Several barriers to healthful shopping were identified throughout the project. While overweight and obese children were identified at the clinic, and all children had inquiry into their diets at each well child check, there lacked a comprehensive handout for patients who have trouble creating a menu to keep to their shopping budgets, while providing nutritious meals. This project was designed with the goal of creating an educational handout that would have nutritional information as well as a menu and recipes to demonstrate how a family of four might eat healthy meals for one month while sticking to a $400 budget, (this number based on DHS data showing that, on average, a person receiving food stamps is allotted approximately $100/month). Through working with a local chef, this pamphlet was created with the goal of being handed out in clinic, with the possibility of future distribution at local DHS offices.

Advancing Pertussis Prevention
Date of project: 8/4/2008

According to recent research the incidence of “Whooping cough” is increasing in Oregon. Infants are both at the highest risk of contracting a severe infection that may be fatal and too young to be fully protected by immunization. The most common sources of pertussis in children are caregivers and loved ones, who often carry the disease and don’t realize they are passing it onto children. While most people are vaccinated against whooping cough as infants, new research suggests, that because immunity diminishes in adolescence, adolescents and adults should receive booster vaccines. Implementation of the recent CDC recommendation for adult and adolescent vaccination at NBMC will substantially diminish exposure to B.pertussis and reduce the burden of infant pertussis in Oregon. Supported by free vaccine from the DHS Oregon Tdap Special Project and the collaboration of many of the NBMC departments and providers, a system was organized so that all adolescents and adults can be vaccinated in Pediatrics clinic. The vaccine was ordered and the new Tdap program was presented at the monthly Pediatrics conference.

Optimization of the After-Hours Clinic in Coos Bay, OR
Date of project: 6/30/2008

High use of the emergency department (ED) among pediatric patients is a major medical issue in Coos County, Oregon. The Bay Area Pediatric & Adolescent After Hours Clinic (AHC) was implemented in 2006 to decrease the ED flow of pediatric patients for non-emergency health conditions. This study was designed to gain an understanding of how the AHC has impacted ED visits in Coos Bounty and to identify potential improvements to the AHC. To learn about the AHC and its effect on the local ED, interviews were conducted with the AHC sponsors and founders. To identify areas of improvement, physicians and patients participating in the AHC were surveyed. The final product of this project was the development of an AHC brochure depicting the essentials of the AHC more comprehensively than materials currently available. Insights gained through interviews and surveys were incorporated into the construction of an information sheet. The ultimate goal was to increase awareness of the AHC and to provide information about this valuable community resource.

To immunize, or not to immunize: that is the question.
Date of project: 4/28/2008

Immunization continues to be a critical component of preventative care and public health. However, in recent years, there has been increasing attention on the possible negative effects of immunizations on children, contributing to decreasing immunization rates and the recurrence of several vaccine-preventable diseases. This study attempted to identify the concerns of parents of pediatric patients at North Bend Medical Center in Oregon regarding immunizing their children. The design consisted of interviews with physicians and parents, as well as a survey of 65 parents of clinic patients which inquired about their concerns about vaccines. The most common worries were related to the perceived link between vaccination and autism, as well as general safety issues such as pain and side effects. The survey results were used to create a handout for use in the clinic which briefly addressed these concerns and listed reliable, easily accessible sources for more detailed information.

Childhood Obesity in Coos Bay, Oregon
Date of project: 3/17/2008

Childhood obesity has become a significant health problem in the United States. The kids in Coos County, Oregon have not escaped this trend. With more unemployment and a smaller proportion of residents with a high school diploma, the children of Coos Bay are in fact at a higher risk of becoming overweight, and all the co-morbidities associated with that, than the rest of Oregon. How can the pediatricians of Coos Bay help combat this problem in the context of a busy clinic? Are there other resources available within the community to help? This project attempted to create a patient handout addressing these questions. To do this, research was done through the internet and medical journals. Community organizations like the public health department, the Boys and Girls Club, WIC and the school district were consulted. Furthermore, advice was elicited from local dietitians, social workers, nutritionists, physicians and other health care providers. In the end, a patient handout was created synthesizing the most relevant information for parents. They were taught how to recognize childhood obesity, the health consequences of this problem, suggestions for healthy living and contact information for programs that reinforced these healthy living tips. Furthermore, information was included for physicians who wish to refer their patient on to further counseling.

Recruiting and Retaining Physicians in Coos Bay: Assessment of Medical Student Interest in Rural Medicine and Rural Physician Perspectives on Their Practice
Date of project: 2/11/2008

Background. Coos Bay is a rural city on the southern Oregon coast that struggles to recruit and retain sufficient physicians. The purpose of this study is to assess medical student rural interest and Coos Bay physician perspectives as they relate to recruiting and retention. Methods. A literature search was conducted to identify common recruiting and retention issues. Physician recruiters and practicing physicians at NBMC were interviewed to identify unique issues and their commitment to this community. Finally, OHSU medical students were surveyed to assess their past and current level of interest in rural medicine. Findings. Key to physician happiness in is their practice. Most of the physicians interviewed are planning on retiring in Coos Bay. Medical student rural interest correlates with increasing student age, male gender, and rural upbringing. Specialties correlated with rural interest are family medicine, emergency medicine, obstetrics and gynecology, and pediatrics. Medical students showed increased rural interest following their rural clerkship. Conclusions. Successful medical practice is key to physician happiness and thus long term retention. OHSU’s third year rural clerkship is a great tool to increase interest in rural medicine. However, it can be further optimized by addressing housing issues, boredom, and misperceptions.

Your Changing Body: A Look at Sexual Education in Coos County
Date of project: 2/11/2008

My goal was to design a pamphlet that would provoke a conversation between the youth and adult, which can then be used as a foundation from which they could share their own morality and perspective regarding sexual health. I also wanted this pamphlet to be used as a starting point for a conversation regarding puberty and sexual health between parents and their children, as well as between pediatricians and their patients entering puberty. My goal was to also include resources, both within the Coos County area and on the internet, that parents, teachers, and youth could access to help educate them as to the options available from within their community when facing issues such as pregnancy, terminations, adoptions, and sexually transmitted infection (STIs) prevention and treatment.

Which Bay Patients are on Vytorin and What Do They Know About The ENHANCE Trial?
Date of project: 12/31/2007

Heart disease is a major cause of morbidity and mortality in the United States and is becoming more prevalent worldwide. HMG-CoA reductase inhibitors, "statins", have been found to be one of the most efficacious ways to treat hyperlipidemia and prevent myocardial infarction and stroke. Some patients are unable to achieve their LDL-C goals with statins alone. Vytorin (exetimibe/simvastatin) has increased in popularity due to its dual action to reduce LDL-C. There was a recent explosion in media attention toward Vytorin with release of the ENHANCE trial. Patients taking vytorin were coming to their appointments unclear as to whether or not they should continue taking their medication. The media was giving them the impression that Vytorin does not work or is actually doing them harm. A letter was written and mailed to approximately 300 Bay Clinic patients documented as being prescribed Vytorin. It was available to hand out at appointments. It included reputable contacts for information on the subject. This gesture upholds the role of physicians as educators and to ensure patients did not discontinue taking their medications without consulting their health care provider.

Primary Prevention of Child Sexual Abuse in Coos County, Oregon
Date of project: 10/15/2007

Child abuse is a significant problem in Coos County, OR, where child abuse and neglect rates are persistently higher than average for the state of Oregon. Despite the high prevalence of child abuse, there are no primary prevention programs that educate and empower adults to prevent child abuse. This project focused on creating a primary prevention program to aid adults in preventing child sexual abuse. With the assistance of the Coos County Child Advocacy Center, I created educational materials that met three goals. First, the program helps disseminate information about child sexual abuse and increases awareness. Second, the program teaches parents and organizations that serve youth actions they can take to prevent child sexual abuse. Third, the program teaches adults how to recognize and report child sexual abuse. The ultimate goal of this program is to help adults in the Coos County area decrease the incidence of child sexual abuse.

The Use of Herbal and Supplemental Medicine in Coos Bay, Oregon
Date of project: 8/6/2007

Many patients have incorporated herbal and supplemental medicines into their health care. There are an unidentified population of patients at the Bay Clinic, who use herbal/supplemental medicine without knowledge of proper usage or the risks. Additionally, there is a general lack of communication between patients and physicians concerning herbal/supplemental medicine usage. This study attempted to define how patients use herbal and supplemental medicine, assess what they know about it, and to facilitate a means to identify supplement users on a daily basis and open a line of conversation between patients and physicians through a brochure. Interviews were conducted with patients of the Bay Clinic who use herbal and supplemental medicine as the main method of investigation. Eighty percent of the patients admitted to supplement usage with the majority using it for long-term health maintenance or chronic health problems. All of the patients felt that supplements were safe and were generally unaware of the possible complications. A pamphlet was created using information gathered from the interviews and literature searches, and it included advice on reading supplement bottle labels, words of caution, interactions and side effects of the more commonly used supplements, and resources for more information. The pamphlets were distributed to the internal medicine faculty at the Bay Clinic and has served as a discussion aid.

Barriers to Care in Coos County
Date of project: 8/6/2007

Background: 15% of Coos County’s 41,997 inhabitants are on or below the poverty line, with 15% utilizing the Oregon Health Plan (OHP) and 1.5% utilizing cash assistance known as Temporary Assistance for Needy Families (TANF). Forty percent of the North Bend Medical Center pediatric patients have OHP health insurance. Objective: Identify barriers in accessing and maintaining healthcare and public services in Coos County. Methods: Semi-structured telephone interview of parents of pediatrics patients at North Bend Medical Center regarding obstacles to healthcare and public services. Interviews with a county nurse practitioner and case managers of the Department of Human Services (DHS). Literature review for barriers to pediatric health services in rural towns. Results: OHP was praised for its coverage of children, which gave families access to “great doctors.” Parents cited no difficulty getting appointments for their child’s health or for public services. The DHS office was considered well run with “helpful staff.” Cost and transportation are not common obstacles. The forms for TANF/OHP eligibility are considered confusing and are not finished with out the aid of case managers at DHS. Conclusions: Coos County’s public services are providing families below the poverty line with the necessary resources to accessing and maintaining healthcare for pediatric patients. A further investigation is warranted to investigate access to healthcare for children of the “working poor.”

How Rural Practice Diabetes Management Meets Medicare's 2007 Physician Quality Reporting Initiative And Other Measures Of Clinical Quality
Date of project: 7/2/2007

Pay-for-Performance is a recent movement in the United States medical system to affect changes in the quality and safety of patient care, by rewarding physicians who meet measures of quality and efficiency. The objective of this study is to determine how an internal medicine physician’s practice meets Medicare’s 2007 Physician Quality Reporting Initiative (PQRI) Physician Quality Measures and other quality measures for diabetes management. 144 patients with a diagnosis of diabetes mellitus of one internal medicine practice were randomly selected for a chart review of their diabetic management. Diabetic management was assessed using both process and intermediate outcome measures of clinical quality. Process measures of clinical quality include HbA1c (6 months,) Urine protein and albumin (1 year,) eGFR (1 year,) current ACE Inhibitor or Angiotensin Receptor Blocker treatment, lipid panel (1 year), and at least one referral to either a diabetic educator or nutritionist. Intermediate outcome measures of clinical quality, which coincide with PQRI Physician Quality Measures include last readings of HbA1c > 9.0, blood pressure < 140/90, and Low Density Lipoprotein (LDL) < 100 mg/dl. Process measures of clinical quality were satisfied in about 75% of patients. Intermediate outcome measure, HbA1c < 9.0 was satisfied in 96% of patients, a percentage well above the 2000s national average. Other intermediate outcomes had relatively lower success rates falling between 44% and 62%, still falling in the range of national averages in the 2000s.1 Further investigation into the etiologies of why a patient’s diabetes management does not meet these process and intermediate outcome measures is needed to better future diabetes care.

Bringing Community Connections Network To Your Practice and Patients
Date of project: 7/2/2007

Continuity of care, identification and access to community resources, and care by specialists are just some of the problems children with specials needs in rural areas may face. How can these children and their families obtain what they need if their primary care provider is unaware of the help that is out there? This study attempts to identify what primary care providers in Coos County and surrounding areas know about Community Connections Network (CCN). Forty-four care providers were identified and given a survey to asses their understanding and use of CCN, and to identify ways to help them bring CCN to their patients. They were also given up to date information on what CCN offers, who they serve, and how to refer in hopes that they might someday refer a child in need. While the resources and referral process used to identify children with special needs is generally understood, there is a lack of knowledge in the community about what is available for follow up care. Upon conclusion of this study, it was discovered that a little more than half of the primary care providers had heard of CCN, and only half of those had actually made a referral. Additionally, new methods of getting up to date information out to the community were identified.

Does the presence of a After Hours Pediatric Clinic Reduce the number of Pediatric Emergency Room visits in a Rural Oregon Community
Date of project: 4/30/2007

Increasing health care costs continue to be a major problem for the Oregon Health Plan (OHP). OHP continues to find ways to lower costs in order to provide more health care coverage to more people. The objective of this student was to evaluate the efficacy of an After Hours pediatric clinic (AHPC) in decreasing the number of pediatric emergency department visits, particularly in pediatric patients with OHP insurance. In an effort to decrease the number of ED visits OHP agreed to help subsidize the AHPC with a fixed rate per day, with the goal of decreasing the number of ED visits, by OHP patients, by an average of 4 visits per day. Two Coos County pediatric practices, consisting of 9 pediatricians, collaborated to start an After Hour pediatric clinic. The clinic was to be open from 5-8 pm on weekdays, and 8-noon on Saturdays, with the goal of decreasing pediatric emergency department visits.

Gasps in the Night: Improving CPAP Compliance in the Primary Care Setting of Coos Bay, Oregon
Date of project: 3/19/2007

Although continuous positive airway pressure (CPAP) is an effective treatment for obstructive sleep apnea (OSA), it is sometimes intolerable to patients and compliance can be a major obstacle. Primary care providers may not be aware of the resources available to improve compliance and without early intervention the patient may ultimately fail the therapy. In addition, appropriate screening tools need to be integrated into the Electronic Medical Record (EMR) to diagnose sleep apnea, facilitate appropriate referrals for sleep studies, and to follow up after therapy has been initiated. Therefore, it was undertaken to determine what kind of resources can be given to primary health care providers to improve CPAP compliance among their patients with OSA.

Optimizing Well-Child Visits in Coos Bay, OR
Date of project: 3/19/2007

Well-child visits make up a large part of a general pediatrician’s daily schedule. Due to time constraints and the plethora of information to be addressed, there is a growing desire among the pediatricians of North Bend Medical Center in Coos Bay, OR to make these visits more efficient and effective from both the physician and parents’ perspective. This project aims to identify the general structure of well-child checks (WCC) and the content covered during the visit that is important from both an educational standpoint and of concern to the parent/patient. The design involved a search through literature examining the content and purpose of WCC, improvement strategies, and barriers presenting in rural settings, as well as informal discussions with pediatricians and parents in North Bend Medical Center. As a means of pinpointing what topics directly concern the parent, a questionnaire listing common developmental, psychosocial, safety, and family issues was created. It is thought that specifying concerns through such a questionnaire will help tailor the visit to an educational discussion regarding issues that both the pediatrician and parent believe are in the best interests of the pediatric patient.

Parental safety education for infant children and implementation of the Baby Safe program in Coos County, OR
Date of project: 2/12/2007

There are high rates of child abuse and neglect in Coos County, Oregon. Struggling industry and associated poverty, along with difficulties associated with resource accessibility in rural Coos County have contributed to the problem. Although poverty, drug and alcohol abuse, and low education levels will continue in the community, education of mothers regarding infant safety may help to reduce the burden of child abuse and neglect. Working with the Bay Area Hospital MOMS program and the Bay Clinic pediatricians, I updated and developed an electronic program for the new Baby Safe program, a class for mothers designed to educate them how to safely care for their infant children from birth to one year of age. Along with the Baby Safe presentation, I provided local pediatricians and their staff with an overview of National, County, and hospital-based resources for educating and supporting mothers

Borderline Personality Disorder and Dialectical Behavioral Therapy in Coos Bay, OR
Date of project: 2/12/2007

Borderline personality disorder (BPD) is a DSM-IV Axis II disorder seen in approximately 2% of the population, with higher prevalence in primary care settings. Primary care providers (PCPs) are often challenged by patients with BPD, and in many cases do not recognize these patients who often have higher levels of health care utilization. A treatment for BPD that has proven effectiveness is dialectical behavioral therapy (DBT), a structured psychotherapeutic intervention, which is available in Coos Bay, Oregon as a college course. This project sought to improve health care for patients with BPD in the Bay Clinic of Coos Bay, who face significant limitations in available mental health providers in the area, and thus rely on PCPs for mental health treatment. Ten PCPs were interviewed regarding their knowledge about BPD and DBT, revealing limited knowledge of both of these subjects. Interviews of patients with BPD revealed a lack of communication about their diagnosis and treatment with their PCPs. Informative material about BPD and DBT was provided to PCPs at the clinic. A guide with yes-or-no questions was established and distributed in order to assist PCPs in evaluating patients for potential referral to DBT, and PCPs were provided with materials for patients about the course. Limitations included the use of handouts and lack of time and resources to evaluate outcomes.

When to transfer? Physician decision making while managing ST elevation MI patients in Coos Bay, OR; what to do when there is no interventional catheterization lab.
Date of project: 1/1/2007

Current recommendations suggest that either a patient receiving thrombolytics should have a door to needle time in the hospital of 30 minutes or a primary percutaneous coronary intervention (PCI), door to balloon time, of 90 minutes. This project attempted to examine how local physicians in Coos Bay, OR made decisions regarding the management of patients with ST elevation MI, given the lack of a local catheterization lab and the necessity of transferring patients if they are to receive PCI. Debate about the best strategies to improve speed of reperfusion and has spawned discussions within the community about whether there is a necessity for a local interventional cath lab in Coos County, OR. Currently, Physicians in Coos County must decide how to treat these patients appropriately and when to transfer them to Eugene, OR for PCI. Interviews of 10 local physicians were performed to generate ideas and issues associated with management of STEMI patients. All of the physicians were from the same practice and managed patients at Bay Area Hospital in Coos County, OR and responses were compiled and compared to current literature. All physicians interviewed endorsed a combination of thrombolytics for patients when not contraindicated, followed by PCI, and primary PCI for patients not eligible for thrombolytics, due to the inability of transfer to reliably occur within 90 minutes. There was also a wide variety of timing for subsequent transfer reported. None of the interviewed physicians felt that an interventional cath lab was appropriate for the community at this time, citing a lack of economic viability, lack of patient volume, and the need for surgical back up as necessary to the process. Physician strategies in the management of STEMI, while guided by current literature, revealed necessary alterations and individualizations when working with limited resources. The final outcome yielded the result that when making complex decisions about transferring patients for cardiac cath, physicians in rural areas must make an assessment both of the various risks and benefits to their patient while also considering the resource limitations they face.

Educating Expectant Parents: Creation of a Newborn Care Presentation
Date of project: 1/1/2007

Many expectant parents anticipate the arrival of their first child with excitement and anxiety. During the months approaching the due date, in addition to advice and reassurance sought from relatives and friends, parenting and birthing classes in communities offer structured education on newborn care to these parents-to-be. In Coos County, Oregon, free educational classes on newborn care, breastfeeding, and children's home safety are offered through the Bay Area Hospital's MOMS (Management of Maternity Services) program. Local pediatricians from North Bend Medical Center and Bay Clinic give presentations on these topical issues in scheduled monthly night courses. The current newborn care class, which consists of a pediatrician talk and bathing and dressing baby demonstrations, includes a stale and outdated slide-show on common and uncommon newborn characteristics from birth marks to neonatal jaundice. MOMS program coordinators and Coos County pediatricians have sensed that this made-in-the-1970s slide-show is ineffective in educating expectant parents and have voiced a need for an engaging and effective presentation on newborn care. The aim of this community project is to create a fresh, interactive, and updated newborn care educational presentation for expectant first-time parents in Coos County.

Environmental Factors which Contribute to Obesity in Rural Communities: A Case Study of Coos Bay, Oregon
Date of project: 10/16/2006

Studies suggest that the obesity epidemic disproportionately affects rural areas. However, it is difficult for people to change habits which contribute to obesity. Although patient education and counseling is an important step in changing behavior, even those patients who are aware of their condition and the necessary changes that need to be made to improve their health are unable to accomplish weight loss. Past efforts at changing behavior in Coos Bay have focused on counseling in the clinic setting, and are often ineffective due to time constraints and inability to exert influence over behavior outside of the clinic setting. Educational materials made available to rural physicians are un- or under-utilized. However, there are other methods for changing behavior. Studies show that the environment affects physical activity levels and obesity levels in a community. Environmental factors of rural communities like Coos Bay present unique challenges to successful weight loss when compared to larger cities like Portland. The main goal of this project was to study environmental factors of Coos Bay which may contribute to high rates of obesity and differ from those of more urban environments. This has important implications for the health of rural communities, and suggests that the health of a community can be substantially improved in an equitable manner by environmental modification.

Educating Parents in Coos County, Oregon: Development of a Postpartum Class at Bay Area Hospital
Date of project: 9/11/2006

Many parents of newborn infants are not receiving the information that they desire from their health care professionals. Well child care visits with the pediatrician usually occur at birth, 2 weeks, 2 months, and so forth. During these visits, anticipatory guidance is often limited by the time and preference of the physician. Mothers were indicating a desire for more information and pediatricians were confirming an increased number of phone calls and office visits regarding these same issues. In order to identify the topics of concern as well as propose an educational solution, investigatory interviews were conducted with 10 mothers, 3 pediatricians, and 4 maternal education staff members. Interview results confirmed that parents expressed to know more on the following topics: increased crying, a variety of baby health issues, mother's health issues, sibling adjustment, returning to work, feeding issues with returning to work, time management, and safety. Using the results of these interviews, as well as the published guidelines on anticipatory guidance, a class was developed entitled Postpartum 101: Practical Tips For Parents of 2-8 Week Old Infants. The hour long class consists of a powerpoint presentation, discussion questions, hands-on activities, and associated handout. The class is scheduled to be taught regularly by a local pediatrician and nurse under the auspices of the maternal education program at Bay Area Hospital.

Identifying a need for pediatric specialists in Coos Bay, Oregon
Date of project: 8/7/2006

Coos Bay, Oregon is 212 from Portland, 111 miles from Eugene and 84 miles from Roseburg. These areas serve as the three major referral centers for pediatric specialists. Due to the excessive distance from specialist care, the need for greater compliance and increased quality of healthcare in rural areas the need for particular specialists in this area must be addressed. The goal of this project was to determine the current referral base for pediatric patients of the two major clinics in Coos Bay and to identify a need for a particular specialist in the area. The population studied included pediatric patients seen by the researcher while working at Bay Clinic and North Bend Medical Center during a four week period. The data gathered included type of specialist referral, problem or reason for referral, and location of the specialist. This data was correlated with qualitative data obtained from various pediatricians at both clinics regarding specialist needs, problems referred and where patients are referred. Qualitative data gathered indicates that there is a great need for a child psychiatrist in Coos Bay. Currently, there is one part-time general psychiatrist handling all of the Oregon Health Plan (Medicaid) patients. The barriers to efficient recruitment of physicians in rural areas needs to be further studied.

Screening for Problem and Pathologic Gambling in Coos Bay, Oregon
Date of project: 8/7/2006

Pathologic gambling and problem gambling affect as many as 5 to 15 million Americans. Primary care physicians are ideally situated to screen for maladaptive gambling behaviors and assist in patient referral and treatment. Using an adaptation of the NODS DSM-IV diagnostic screen for gambling problems, this project sought to determine the prevalence and impact of problem and pathologic gambling for patients seeking primary care at Bay Clinic in Coos Bay, Oregon where no such screening been done. Of fifty-two respondents, six (11.5%) individuals were identified as being probable problem or pathologic lifetime or past year gamblers; with 50% having a history of substance use disorder and 83.3% with a history of depression or mania. For the four respondents meeting criteria for problem and/or pathologic gambling in the past year, an average of 108 days and $2,266 dollars was spent for the year. Further study is needed, particularly to resolve concerns regarding the specificity of the adapted screening tool and possible reporter bias. Still, this initial work shows a high prevalence of probable problem or pathologic gamblers in the Coos Bay region and provides impetus for continued standardized screening.

Teen Pregnancy In Coos County, Oregon
Date of project: 5/1/2006

Although the rate of teenage pregnancy continues to decline in the United States, it continues to have a number of serious implications and to place a large burden on society. Not only does becoming pregnant as an adolescent decrease the likelihood of an adequate education and a successful future for the mother, the child often suffers from being raised by a parent who is ill-equipped for the challenge of parenting. While recent trends have shown a decreased teenage pregnancy rate in Coos County, Oregon, recent population studies suggest that this number is now on the rise. In an attempt to identify some of the factors contributing to this alarming trend, I interviewed teenage girls and some of the people who care for them. While several possible causes were identified, main factors included erratic use of contraception and a seeming lack of awareness of the risks of their sexual behavior. No concise educational material was available that discussed these concerns, so a handout was developed to address some of these issues in a matter that was appropriate for teenagers.

The metabolic syndrome in Coos County, Or: Causative factors, and issues for treatment.
Date of project: 5/1/2006

The Metabolic Syndrome, which is defined by a combined set of cardiovascular risk factors, has a rising prevalence in the U.S. in recent years. Certain communities, including Coos County, OR have even higher rates than that of the general population. This study aimed at determining factors which increase the prevalence of the metabolic syndrome in Coos County, and looked at patient education as a means for aiding the problem. The study was carried out by interviewing physicians and patients, as well as consulting the county health department to help determine causative factors. Using this information, an education handout was developed and used during short teaching sessions with a representative sample of patients. Finally, patients were interviewed regarding their thoughts as to whether this was helpful for their overall knowledge of the disease. Conclusions taken from the study were that, although many factors contribute, patient education is one modifiable aspect that should be a focus for improving rates of the metabolic syndrome. While the teaching sessions used in the study may not have been time-efficient, they were met with positive feedback, and a more time efficient strategy may be the most ideal means.

Transforming Rural Primary Care: Electronic Medical Records (EMR) in Coos Bay, Oregon
Date of project: 2/13/2006

EMR has advantages over paper-only charting systems in accuracy, speed, portability, and information retrieval and sharing. Yet it is costly to initiate and introduces its own set of possibilities for error, to include digital security breach and computer “crash.” In any case, EMR is not widely used in the United States, with estimates ranging from 7-33% of primary care clinicians. However, it is being used in the continuity clinics of 46% of Family Practice residency programs. The Bay Clinic Internal Medicine practice in rural Coos Bay, Oregon, is transitioning to partial EMR from a paper-only system. It plans to uniformly implement EMR within one to three years, and interface with the pending internet-based EMR of Bay Area Hospital. Bay Clinic is one of the sites for a required Rural Medicine clerkship for third-year medical students from Oregon Health & Science University (OHSU), in Portland. Study observations are made using the “PRAXIS Version 3.2” EMR by Infor-Med Medical Information Systems, Inc., between February 15 and March 15, 2006. The medical student used the EMR for every patient encounter, primarily to chart. One internist used the EMR for roughly 50% of his patient encounters on a given day, primarily to chart. A second internist used the EMR for every patient encounter: to chart, set clinical reminders, e-mail staff, write clinic letters, and print prescriptions and patient handouts. Both internists increased their average number of patients evaluated per day by about 25% (self-report), as compared to their practices when using paper only. We do not believe that using computers in the exam room diminished provider-patient interaction. Future studies may focus on the quality of this interaction, and of charting in general, as influenced by EMR. We anticipate that using EMR at this rural site will continue to benefit rotating medical students in learning practice guidelines and workflow efficiency.

Bringing order to chaos: Improving the referral system at North Bend Medical Center
Date of project: 2/13/2006

The process of referring a patient from a primary care office to a specialist has become increasingly complicated in both dealing with insurance companies as well as the office-to-office referral. This has the unfortunate consequence of creating a barrier to patient care as well as adding an enormous financial burden to medical offices in the form of administrative duties. The pediatric clinic at North Bend Medical Center identified a need to address this problem in order to increase efficiency and save money. The goal of this project was to clearly define the problem, understand its cause, and develop a potential solution. This was accomplished through a literature search to understand the problem from a broader perspective, and interviews with key people involved in the referral process throughout the state of Oregon. Ultimately two potential solutions to the problem at NBMC were identified: one, the need for appropriate staffing in order to handle the increased demands of the referral process, and two, the need for a referral guide that identified specialists that NBMC commonly refers patients to, contact information, as well as the necessary procedure one must go through in order to refer a patient. For this project, the referral resource was created and has been well received in the office. In the intervening time, an additional office staff member has been hired to handle referrals that will start in the near future.

Palliative Care and Hospice Services in Coos Bay, OR: A Survey of Patient Knowledge and Opinion
Date of project: 1/2/2006

South Coast Hospice (SCH) has provided hospice services to Coos Bay, OR for over 25 years. Recently a pilot program for palliative care services was begun in cooperation with Bay Area Hospital. While SCH receives feedback from patients and their families, with generally positive results, they were interested in general public opinion of hospice as well as community knowledge of palliative care. To assess this a survey of random patients within a general internal medicine practice at North Bend Medical Center in Coos Bay, OR was conducted . I also interviewed a social worker at South Coast Hospice tasked with the development of the palliative care program, which yielded information about the progress and current status of the program at Bay Area Hospital. The survey indicated that few people had heard of palliative care, and those that had thought the term was synonymous with hospice. Further, half of those surveyed have had some exposure to hospice, with the majority having had a good experience. Those without exposure were generally in favor of the program and would consider having themselves or a loved one die at own home under hospice care. Concerns about hospice were varied, but the most identifiable concern was the expected cost of hospice services. These results were forwarded to South Coast Hospice to help them address community education and other potential barriers to hospice and palliative care.

Advancing Reach Out and Read in Coos Bay and North Bend
Date of project: 1/2/2006

The well-child examination offers a unique opportunity for health care providers to proactively affect the health and development of pediatric patients through efforts targeted at education, health promotion, and prevention. Time limitations of the visit, however, require that physicians tailor interventions with proven efficacy to issues of significant prevalence and impact. Reach Out and Read, a national literacy and language development program that brings reading into the well-child visit, has been effective at improving reading success, parental attitudes toward reading, parental interactions with children, and child language development. This report outlines efforts to advance the Reach Out and Read program in the Coos Bay/North Bend area through strategic planning, information gathering, resource identification, and application completion.

The Problem of Obesity in Coos Bay, OR
Date of project: 10/17/2005

This Community Project studies the prevalence and impact of obesity among internal medicine patients of the Bay Area Clinic (BAC) in Coos Bay, OR, and provides a convenient source of patient education in the form of a brochure. The first 50 internal medicine patients seen by my preceptor were evaluated and were categorized according to their BMI. Patients were categorized as “healthy weight” (BMI = 19-25), “overweight” (BMI = 25-30), or “obese” (BMI > 30). Of the 50 patients evaluated, 26% were of a healthy weight, 36% were overweight, and 38% were obese. Because of the high prevalence of obesity in this patient population, as well as the lack of convenient patient education materials on the topic, an informative/educational brochure was created with the goals of: 1.) informing patients of the health risks associated with obesity, 2.) providing patients with a list of useful diet and exercise resources, and 3.) providing patients with tips on weight loss.

A Suggested Protocol for the Management of ADHD in School-Aged Children of Coquille, Oregon
Date of project: 9/12/2005

Attention Deficit/Hyperactivity Disorder (ADHD) is the most common neurobehavioral disorder of childhood, affecting 3% to 12% of school-aged children. ADHD may cause children and their families significant problems; symptoms may result in academic underachievement and difficult relationships. However, pharmacologic treatment of ADHD is largely effective, and is promoted by the American Academy of Pediatrics and the American Academy of Family Physicians. As no standardized ADHD management algorithm was available to the physicians of Coquille Valley Medical Center, this study sought to merge national treatment recommendations with the community standard of care to develop an ADHD management strategy for the treatment of school-aged children with ADHD in Coquille, Oregon.

Stickers Don't Make You Smarter: Bringing Reach Out and Read to Coos Bay
Date of project: 8/8/2005

A growing body of evidence supports early childhood exposure to reading as an effective catalyst for linguistic and cognitive development. The Reach Out and Read program, established in 1989 by a group of Boston University pediatricians, promotes early literacy and language development by bringing reading into the pediatric exam room. Participating pediatricians give each patient between the ages of 6 months and 5 years a brand new book at each well-child exam. Additionally, they are trained to appropriately counsel caregivers about the importance of reading aloud with their children. Several pediatricians in the Coos Bay/North Bend area expressed a specific interest in establishing a Reach Out and Read program in their medical offices. For this community project, several critical components of this process were addressed: application submission, generation of community support for the program, and solicitation of financial assistance. A number of service organizations, businesses, and existing grants were identified as promising resources for the program. A grant proposal was drafted and submitted on behalf of the program to the Coquille Indian Tribe Community Fund. Finally, the Reach Out and Read model was presented to representatives from several organizations, each of whom expressed enthusiastic support for the program.

The Metabolic Syndrome in Coos Bay
Date of project: 7/4/2005

The Metabolic Syndrome (MetS) is a constellation of risk factors identified as a primary focus of concern by the National Cholesterol Education Program Adult Treatment Panel III (ATPIII). Patients with this syndrome have a significantly increased risk for developing diabetes mellitus and various manifestations of atherosclerotic disease. This study assesses the prevalence and impact of the Metabolic Syndrome among the Internal Medicine patients of the Bay Area Clinic in Coos Bay, Oregon. Eighty-eight consecutive patients seen in this clinic over a period of five weeks were evaluated according to the five criteria established by ATPIII. Thirty-five of these patients (39.7%) met the conditions for MetS by having three or more of the five risk factors. Using the population characteristics and specific risk factor profile revealed in this study, an intervention was designed to address the needs of MetS patients at the Bay Area Clinic.

Emergency Contraception: School Counselor and Pharmacist Practices and Attitudes in Coos County, OR
Date of project: 4/25/2005

The rate of teenage pregnancy has been declining in Oregon, yet it still remains unacceptably high. Nearly 26 per 1000 teenage girls ages 15-17 years old in Oregon will become pregnant this year, given current trends. Rural communities are plagued with even higher rates of teenage pregnancy, in large part due to the limited access to family planning and abortion care services. Emergency contraception (EC) provides a safe, easy to use, effective and relatively inexpensive method for preventing unintended pregnancy, yet it is extremely underutilized, particularly in rural communities. The reasons for this are not well understood, and are likely multi-facetted, with responsibility resting on physicians, pharmacists, patients, and educators. Physician attitudes and prescribing practices with EC have been fairly well documented, however little is known about pharmacist and school counselor attitudes and practices with respect to EC. The aim of this community project was to examine the attitudes and practices of Coos County middle and high school nurses and counselors regarding emergency contraception. Furthermore, the project also addressed pharmacist attitudes and dispensing practices for EC. The design was a written survey distributed to local school nurses and counselors, and community pharmacists. An informational pamphlet on EC was also developed and distributed to community clinics, schools and pharmacies. The overall response to the surveys suggest that school providers in the Coos Bay/North Bend area are open to the use of EC yet do not counsel students on it unless specifically requested by a student. It was also found that pharmacists dispense EC to all customers with a valid prescription, regardless of age, yet few pharmacies reported EC requests from teenagers.

Chronic Kidney Disease in Coos Bay- Recognition and Referral
Date of project: 5/10/2004

Chronic Kidney Disease (CKD) is a rapidly growing problem in the United States that is not readily recognized by primary care physicians, resulting in excessive healthcare costs, failure to ameliorate disease progression, and increased morbidity and mortality in these patients. One possible reason may be that PCPs are only relying on the serum creatinine as a marker for kidney function, rather than the calculated GFR, which is a truer indicator of renal capacity. Coos Bay, Oregon is a community that receives its nephrology care from a group practicing in Eugene, Oregon. This group of nephrologists is markedly concerned about the underrecognition of CKD and the consequences that come along with it. To express their concern, they recently mailed out a letter to all PCPs regarding this issue. This study was designed to demonstrate to the internal medicine physicians at the Bay Clinic in Coos Bay that many patients with CKD are not being recognized and referred, possibly because the physicians are not using the GFR, but rather are relying only on the serum creatinine. To help overcome this obstacle it was coordinated with the laboratory staff at the Bay Clinic to include a calculated GFR with every serum creatinine on lab reports. Finally, a handout containing recommended CKD guidelines was created and distributed to the internists at the Bay Clinic.

Are the Diet and Exercise Habits of Middle & High School Students in Coos County Influenced by the School Environment?
Date of project: 5/10/2004

The school environment has been shown to be a powerful determinant of child and adolescent diet and exercise habits. However, facets of school environment’s are believed to be unconducive to, as well as not fostering or promoting, healthy diet and exercise habits among students. In an effort to see whether the diet and exercise habits of students in Coos County School District are influenced by their school environment, 448 middle and high school students were surveyed. Specifically, their intake of fast food, candy and carbonated beverages, as well as their participation in school PE, or other physical activity was queried. They were also asked their responses to hypothetical situations where the school environment was modified, such as if vending machines were removed from campus, if they were not allowed to leave campus for lunch, or if PE were a required class. The results of the survey show that the school environment does indeed influence students’ diet and exercise habits. Furthermore, a majority of students indicated that they would relish changes to their school environment that would help foster healthier diet and exercise habits among them.

Success of OHP in Coos County, Oregon
Date of project: 1/5/2004

In 1989, the state of Oregon embarked on a controversial experiment in the financing of health care. The state planned to add many uninsured people to the Medicaid program and to pay for this expansion by reducing the Medicaid benefit package -- more people would be covered, but for fewer services. To keep the costs of this policy within affordable limits, the legislature determined that the services provided should constitute a basic healthcare package, and it sought to ensure that Medicaid recipients were, whenever possible, enrolled in managed care plans. This program was titled the Oregon Health Plan (OHP). Since implantation of OHP in 1994, there has been a statewide decrease in per capita health care costs, a greater than 50% reduction in uninsured children, and a nearly 50% reduction for adults. It appears that OHP has improved accessibility of health care in Oregon. The emphasis of my research project was on the impact of OHP on Coos county. Specifically I studied whether OHP has accomplished it’s goal of ensuring adequate health coverage to the people in Coos County and whether accepting OHP patients puts Coos county physicians and clinics at a financial disadvantage? In 1995, Doctors of Oregon Coast South (DOCS) was found in Coos County as a managed care program that would serve the county’s Medicaid population. Since that time, profitability for physicians and access to care for citizens have improved. The project investigates the relative success of the managed care program in Coos county, it’s downfalls and it’s possible future. This investigation reveals that even under a fully capitated managed care environment, the clinic can be successful and the community is well served by OHP. Following is a compilation of information I gathered for this project. Most of this information stem from different sources such as physicians, financial officers and other health care workers. Reports published by Oregon Health Policy and Research have also been used in conjunction with financial data provided by the clinic administrator, and legislative reports.

Assessing and enhancing women's awareness of heart disease in the Coos Bay area.
Date of project: 11/10/2003

Heart disease is the leading cause of death in women, but most women do not believe heart disease will affect them. The death rate from myocardial infarction is higher in women; this is believed to be due to women not pursuing immediate care, as well as the lack of physician awareness of cardiac symptoms in women. Coos County is one area in Oregon where the rate of deaths from heart disease in women is particularly high. The goal of this project was to increase the community¹s awareness of heart disease in women, as well as to provide medical personnel with new information on women¹s symptoms and management. First, a survey was performed to assess risk factors and views within the population. Next, a pamphlet was created, directed towards women, that discussed statistics, risk factors, and references for information on women¹s heart disease. It also listed some of the symptoms of cardiac ischemia and provided instructions for what to do if someone experiences them. Finally, a presentation of the survey results, pamphlet details, and some points for physician awareness was given to the staff at Bay Area Clinic at the completion of the project.

Who becomes a rural physician? Characterizing the Physicians of Oregon’s South Coast
Date of project: 9/29/2003

There have been efforts to characterize rural physicians in hopes of correcting the shortage of health care in rural areas, and several generally accepted assumptions have emerged. This project aims to determine if these “basic truths” apply to rural Oregon, particularly the South Coast area surrounding the community of Coos Bay. A survey addressing these questions was sent to 99 physicians with a 46% response rate. To further investigate the belief that rural experiences increase interest in rural practice, an analysis of OHSU graduates before and after the implementation of the rural clerkship was undertaken. The data presented indicates that many of the accepted truths do not in fact hold up for the populations investigated.

House Calls: The secret life of rural physicians?
Date of project: 9/29/2003

House calls were once the mainstay of physicians, especially those in rural areas. Over the last century they have decline precipitously while home healthcare has grown. The aim of this study was to ascertain the percentage of physicians making house calls. Further, if house calls are taking place, how common are they and what indications are considered deserving of a physician visit? Lastly the degree of training area physicians have in homecare was queried.

Respite Care in Coos Bay
Date of project: 8/18/2003

Respite care continues to be an underused and misunderstood component of health care. The purpose of this project was to identify the availability of respite care resources in the Coos Bay/North Bend, Oregon community and provide information to clinicians and patients. According to an informal needs assessment of physicians in the clinic, many of their patients had caregivers or were caregivers themselves. It was also noted that these patients had increased incidence of depression, anxiety, and other symptomology such as gastrointestinal or musculoskeletal conditions. In addition to addressing these clinical concerns, physicians at the Bay Clinic in Coos Bay, Oregon wanted to address the ongoing demand of caregiving with their patients. No information on respite care was readily available to provide patients. Furthermore, the physicians themselves were unsure what was available locally or how to best answer questions on the issue. The informal needs assessment survey suggested that a compelling and comprehensive notice in rooms along with information that could be taken home would benefit clinicians and patients. An extensive review of literature, websites, and interviews with local organizations yielded an informative presentation for clinicians and patient information poster/handout.

Elderly Suicide in Coos County, OR
Date of project: 7/7/2003

In the United States, one elderly person commits suicide every 99 minutes. Suicide rates among the elderly are increasing nationwide. Coos County has a higher suicide rate than that of the U.S. as a whole and that of Oregon, a statistic at least partially explained by the county's higher proportion of older people. The problem of suicide in Coos County became particularly apparent this year when over a 35-day period between May and June seven elderly residents took their own lives. The majority of elderly people who commit suicide are in regular contact with a physician-75% have seen a primary care physician within one month of their death. This project attempted to address the relatively underappreciated issue of elderly suicide by increasing physician awareness of the problem via a fact sheet and resource guide. The guide was distributed to physicians in Coos County and contains statistical data on suicide in Coos County, specific information regarding the recent cluster of suicides, identified risk factors for and facts regarding suicide in the elderly, and a discussion of potential prevention strategies. Biomedical and cultural factors in suicide etiology are discussed. The objective in development of the guide was to increase physicians' index of suspicion for this significant cause of mortality.

Eating to lose fat in Coos County, OR
Date of project: 7/7/2003

A low carbohydrate or Atkins diet has received much attention in the press recently, and has gained popularity among those battling excess weight. Coos Bay and North Bend, OR are no exception to the wave of popularity. They are also no stranger to the epidemic of obesity in this country, with a prevalence of obesity in Coos County of about 20%. The diet promotes weight loss through very low carbohydrate eating and fairly liberal consumption of protein and natural fats, without calorie restriction. It is thought to work by inducing lipolysis (and thus “burning fat”) as a result of so few carbohydrates to burn for fuel. Lipolysis leads to a state of ketosis which may be responsible for appetite suppression and loss of calories in the urine as ketones. At the Bay Clinic in Coos Bay, numerous patients were immediately identified who had tried this diet. In an effort to assess why the diet is so popular, how well it is working for people and the impact it has had on the community, a survey, several interviews and a current literature review were conducted. The results of the survey showed a relatively easy to follow diet plan and overall participant satisfaction. Most people had lost a significant amount of weight in 3-6 months. Most of these people had tried low fat diets before without lasting success. Numerous restaurants, health clubs and a nutrition consultant in town support the low carbohydrate approach to eating. There are a couple of stores in town that carry specifically low carbohydrate products. Finally, three recent studies have evaluated a low carbohydrate diet compared to a low fat diet to show more weight loss, longer adherence, and an absence of negative impact on lipid profiles for the low carbohydrate diet. From these data a patient and healthcare provider information sheet was designed to describe the diet, how it is done, answer some common questions and provide a list of resources for information on recent studies and relevant websites.

Does Diabetes Play Fair in Coos County? An Attempt to Even the Playing Field.
Date of project: 5/5/2003

Diabetes is one of the most devastating diseases to the population of the United States. It can be a difficult and frustrating for physicians to manage because the course of the disease is dictated by patient compliance. This project, conducted at Bay Clinic in Coos Bay, Oregon, has two parts. Part one will increase patient compliance through patient education in the form of a patient handout. Part two will show that there can be improvements in the screening exams and pharmacological management of diabetic patients by their primary care providers. Through the coordination of physician and patient, better diabetic management can be obtained in the areas of blood pressure, cholesterol, HbA1C, and renal screening.

Cardiovascular Rehabilitation in Coos Bay: Does Program Compliance Effect Hospital Readmission Rates?
Date of project: 3/24/2003

Cardiovascular disease is the number one cause of morbidity and mortality in the United States today. Although some 7 million Americans with the clinical spectrum of coronary heart disease are eligible for cardiac rehabilitation, only 11-20% are estimated to participate. Cardiac rehabilitation offers a variety of different benefits, from physical training to lifestyle modification education. The main goals of current day cardiac rehabilitation programs are to allow the patient to resume normal activities, modify and reduce risk factors such as hyperlipidemia, hypertension, and smoking cessation, and thus, lower morbidity and mortality. This study is an observational study which reviewed sixty geographically-matched patients who had been hospitalized for coronary heart disease between 1997 and 1999. The experimental group was defined as thirty patients who had enrolled in rehab initially but who had failed to complete more than 10 of the sessions. They were compared with thirty patients who had completed the program (36 sessions over a 12 week span) to see if either group had more hospitalizations for subsequent coronary events. 17% of the control patients had hospitalizations during the next three years compared with 27% of the patients who did not complete the program. Additionally, the patients who were non-compliant had more than one additional hospitalization overall than did the compliant patients. Conclusion: Cardiac rehabilitation program non-compliance was a negative predictor for future hospitalizations for acute coronary events in a small sample population. Program non-compliance also was a negative predictor for total hospitalizations during a fixed time frame.

Managing the Cost of Pharmaceutical Drugs in Small Town Oregon
Date of project: 2/10/2003

Increasing prescription drug costs are becoming a financial stressor for patients and a burden for office staff. Patients have been reporting to doctors and office staff that they cannot afford the prices of their medicine, thus choosing between buying their medicines or other basic necessities. Some patients report that they have been missing doses of their medicine or not purchasing it all together simply due to cost. Besides the obvious negative health outcome this has for the patient, it also frustrates the health care providers hoping to manage a patient's particular health problems. Furthermore, office staff often finds themselves trying to help the patient apply for social assistance programs or get in touch with other resources. Ultimately, this consumes a significant amount of time and resources for both the doctors and office staff. Furthermore, patients often have difficulty understanding ways in which they can cut their drug prescription costs, and consequently rely on office staff for help. To address this issue, a survey of Bay Clinic patients was performed to discover what patients currently spend per month on their medicines, how much money they save using office samples, and what cost saving measures they currently use to help control costs. Ultimately, after analyzing the data, it was determined that a simple piece of literature could be developed which could help the patient learn of ways to reduce their prescription drug bill.

The Waterfall Clinic Development of Future Funding
Date of project: 12/30/2002

The Oregon Health Plan serves as a safety net for individuals who earn income at or near the federal poverty limit. There is a weakness in this coverage plan. There are many who are classified as the “working poor”. They can be defined as those who live at 101%-185% of the federal poverty line. These are the individuals who work in service industries, or small businesses that do not provide adequate health coverage. They work hard, but lack resources to pay for medical care. My project was designed to assess this need in Coos County and help provide a solution for it. I worked closely with a local clinic known as the Waterfall Clinic. This clinic is a non-profit clinic designed to care for individuals without medical insurance. The clinic provides services on a sliding fee schedule, based on family size and income. Due to current difficulties with federal grant resources, the clinic is losing a large portion of its funding. My project involved identifying resources of funding, creating a marketing plan to attract funding, and writing a grant proposal to a local foundation for $20,000. There are a multitude of research studies that have shown how preventative care in a primary setting can prevent large expenditures in the emergency setting. By providing these services, Waterfall Clinic can help prevent serious morbidity and reduce the costs of health care for the community as a whole.

Colorectal Cancer Screening in the Bay Area
Date of project: 11/4/2002

Colorectal cancer screening, though effective in the prevention and detection of cancer, continues to be underutilized by the majority of the population in the United States. This study attempted to examine the issue of colorectal cancer screening in Coos Bay, Oregon during a six-week rotation. First, a limited chart review was performed on patients aged 50 to 80 who had undergone either fecal occult blood testing in the past year, flexible sigmoidoscopy in the past five years, or colonoscopy in the past ten years. This determined that 50% of patients whose charts were reviewed were current with colorectal cancer screening. Next, the study included observation of physician approaches to screening as well as discussions about the views of local internists and their patients in regards to colorectal cancer screening. Discussions with patients found that the majority of those that were declining screening were doing so out of embarrassment or fear of discomfort during the screening test. And, though all internists at the Bay Clinic agreed that colorectal cancer screening is important, their time spent discussing this with patients was limited, particularly if patients did not immediately express a high level of interest in screening. Thus, a patient handout was developed that could be used as a resource to educate patients about colorectal cancer screening.

Sex in the County, Coos County: Statistics, Sex Education, Social Change
Date of project: 11/4/2002

With the United States currently leading the developed world in teen pregnancy and birth rates, teenage sexual activity is a major medical issue to be addressed. In an attempt to approach the problem from its roots of education this project focused on gathering data from surrounding school districts about their means of educating the students. The study was supported by the Coos County Prenatal Task Force and utilized a survey designed to glean information taught in the schools about contraceptives, prenatal care, STDs, and county resources. The survey was conducted with physical education/health teachers at 10 surrounding schools and the information was collated and then compared for uniformity in the county as well as contrasted with nationally researched sex education methods. Based on these comparisons recommendations for educational interventions were made and presented to the task force for activation.

Asthma Screening, Health Education and Referral - Community Health Education Coalition Health Fair, Coos County, Oregon
Date of project: 9/23/2002

The National Asthma Education and Prevention Program (NAEPP) addressed the growing number and rate of asthma-related hospitalization and emergency room utilization in this country. For example, since 1994, the prevalence rate increased 75%, death rate increased 56%, and hospitalization rate increased 3%. To ensure effective control of the disease, NAEPP highly recommends multidisciplinary approach - education, prevention, social and medical interventions. Most of what is currently known about asthma distribution, utilization of ER, subsequent follow-up with a PCP and prevalence of high-risk population is based on surveys at the national level. Unfortunately, not enough data is available in small counties, such as Coos County, Oregon. To investigate the prevalence of asthma in rural Oregon community, we conducted a prospective screening study on adult population, ages 18 years above. The screening test was conducted as part of the Community Health Education Coalition (CHEC) Coos County Elder's health fair on Oct 12, 2002 in Pony Village Mall and Oct 22, 2002 in Mill's Casino in Coos Bay, Oregon.

A Bright Future for Well-Child Checks in Coos Bay, Oregon: Implementation of National Guidelines and Survey of Parental Satisfaction
Date of project: 8/12/2002

Bright Futures is a national child health promotion and disease prevention initiative that provides guidelines for health supervision visits (ie. well-child checks). The purpose of this project was to (1) compare well-child checks performed by pediatricians at NBMC & Bay Clinic in Coos bay, Oregon with Bright Futures guidelines, and (2) conduct a survey among parents regarding their satisfaction with patient education materials received during the visits. Well-child checks at NBMC and Bay Clinic correlate approximately 85% and 75% with Bright Futures guidelines, respectively. The survey completed at NBMC reveals a generally high level of satisfaction with patient education materials.

Children and Grief: Resources for Pediatricians in Coos County
Date of project: 2/11/2002

Children grieve according to their developmental stage and individual personalities. There is no "right" way to grieve and each child will go through the process in their own way. Pediatricians can be a vital source of support and information for families dealing with the loss of a loved one. In Coos County pediatricians also have the additional resource of the Light House Center, a support program for grieving children, teens, and families. Working with the Family Services Manager, I developed an educational and fund-raising presentation as a service to the Light House Center and the pediatricians of Coos County.

Follow-up Frequency of Benign Hypertension at BAC
Date of project: 2/11/2002

Hypertension is defined as systolic blood pressure >140 mmHg or diastolic blood pressure >90 mmHg. Approximately 50 million Americans have hypertension, making it one of the most prevalent and burdensome diagnoses seen by physicians in the United States each year. Benign hypertension, the most common form, is a mild to moderate elevation in blood pressure without target organ (i.e. kidney, retinal, coronary) damage. The incidence of high blood pressure increases with increasing age and is one of the most commonly seen health problems treated by primary care doctors in communities with older populations. Appropriate frequency of follow-up of patients with hypertension is a controversial subject. Recommendations vary according to the evaluating discipline (internal medicine vs. cardiology), severity of disease, age, and compounding factors including co-morbid conditions (e.g. diabetes, coronary artery disease, renal disease) and whether or not the patient is on anti-hypertensive medications. The current guidelines for follow up of benign, uncomplicated hypertension from the National Heart, Lung, and Blood Institute (NHLBI) and the National Institutes of Health recommend that patients be seen by their primary care physician every 3 to 6 months for follow-up evaluation of their disease.

Eye Health Care In A Coastal Oregon Community.
Date of project: 1/2/2002

This study sought to determine whether patients in a primary care clinic (Bay Clinic of Coos Bay, Oregon) received regular eye examinations as recommended by the guidelines of the American Academy of Ophthalmology (AAO), and whether their age, insurance status, and/or need for corrective lenses influenced how often they had regular eye exams. Brief questionnaires regarding utilization and insurance coverage of basic eye care services were distributed to Bay Clinic patients between January 10 and February 1, 2002. One-third of those surveyed were age 65 or greater; 97% of these required some vision correction, and 91% had eye exams within two years of the study. In contrast, only 77% of patients younger than 65 required lenses, and only 77% had exams within the past two years. Type of insurance coverage had little influence on time of last exam, with 79% of privately insured, 81% of publicly insured, 100% of those with public insurance privately supplemented, and 100% of uninsured patients having exams at most two years ago. Need for corrective lenses had significant effect on time of last exam: 90% of those who required vision correction had exams within two years, while only 48% of those not requiring lenses had exams over the same period. The report also discusses the importance of regular eye examinations and the guidelines of the AAO.

Physician Satisfaction in Coos Bay and Eugene, OR. A survey of family physicians, and internists with and without hospital roles.
Date of project: 5/6/2002

Due in large to financial pressures and lifestyle issues, a growing number of managed care organizations, hospitals and large physician-ownned groups are hiring "hospitalists" whose responsibility is to take care of inpatients, freeing up other prmary care physicians to concentrate on outpatient practice. Bay Clinic in Coos Bay, Or. is a group practice of internists where one of the internist wants to be hired by the clinic as a voluntary hospitalist, providing inpatient care for the remaining 9 internists. This request has been met with both support and opposition. The intent of this project is to compare satisfaction of the traditioal physician taking call and physicians with office-based practices only by administering a survey of physician satisfaction. The total response rate was 31% (Bay Clinic, Coos Bay:8/9, North Bend Clinic, Coos Bay:10/10, Oregon Medical Group and Peace Health Group: Hospitalists 2/12, Pysicians w/o hospital role=6/29 Physicians w/hospital role=3/34 (total 11/75). Results: Physicias without call reported the highest level of satisfaction across all categories: practice environment, hrs. worked/week vs. time for personal/home life interests and income vs. number of hours worked. Family physicians also reported high levels of satifaction compared to internists or physicians taking call. There is a need for further surveys of physician satisfaction in this new paradigm of hospitalist/office-based physician as this trend continues to increase.

Financial Implications of Early Death to South Coast Hospice
Date of project: 3/25/2002

At South Coast Hospice, reimbursements from Medicare and private insurance are insufficient to meet patient expenses by approximately 300,000 dollars a year. As a result, South Coast Hospice(SCH), like many other hospices relies heavily on grants and fundraising to meet expenses beyond reimbursement. For this project, data from SCH was used to calculate death trends and their financial impact on SCH. This information was then presented to area physicians along with studies suggesting ways to make hospice financially independent of grants and donations. The results of the data showed that 31 percent of all patients admitted to SCH die within seven days. Eight percent of patients desiring hospice die before admission. The median length of survival from the time of admission is 17 days. Meanwhile, patients who die within seven days cost 3 times as much to care for when compared with those living beyond 17 days. As a result, Medicare's reimbursement plan of $116.40 per patient per day makes patients who die early unaffordable. State data shows that for hospice to break even, patients must be enrolled in hospice for at least 33 days. Besides presenting the financial data of hospice to physicians, multiple prognostication studies were reviewed which suggest that poor prognostication contributes to the financial deficit of SCH. Physicians overestimate time to death by a factor of 3-5. In addition, prognostic information is frequently withheld, leading to unrealistic patient expectations and delayed hospice admission. Experts suggest that open communication and early discussion of hospice with patients, even with those who have a good prognosis, can improve patient satisfaction, facilitate earlier hospice admissions, and reduce the reliance of hospice on grants and donations.

Good Touch, Bad Touch: Addressing the Problem of Child Abuse in Coos Bay.
Date of project: 11/5/2001

Child abuse and neglect is a significant problem nationwide with over 1 million reported cases each year. For the past two years, Coos County has had the highest child abuse rates in the state of Oregon. In spite of these significant statistics, little is being done in Coos County in terms of primary and secondary prevention. The purpose of my community project was to bring a program into the schools that would address prevention of child abuse. Through research of resources, in collaboration with school nursing staff, I was able to develop a ready-made program for the school nurses to present to children in both the primary and intermediate grades. The program addresses good touches and bad touches, and instructs children on how to seek help if they are touched in a way that makes them feel sad or uncomfortable. The goal of this project is to reduce incidence of child abuse in Coos County by educating and empowering children.

Coos Bay Medical Informatics: Physician and Administration Perspectives, Expectations and Assessment of Implementing an Electronic Medical Record.
Date of project: 8/13/2001

The exponential expansion of costs in the U.S. health care system are driving the U.S. health care system towards a state of bankruptcy: 15% of the Gross Domestic Product is now being spent on health care. Despite the incredible availability of computers and electronic media, the American Health Care industry still relies mainly on paper to record and transmit information at many key points. The storage, maintenance, and access costs consume more than 40% health care institution budgets and 25% of the health care provider's time. At Indiana University Medical Center, an Electronic Medical Record has been created that contains most patient data (numeric coded test results, drug use, diagnosis, clinic activity, textual reports, and itemized charges) for an urban tax supported teaching hospital, a VA medical center, and their outpatient facilities. This Electronic Medical Record is well connected with the surrounding clinics that feed into the hospital forming a streamlined medical record that is well protected and efficient. Although, the interventions of technology are expensive, a series of carefully controlled clinical trials has shown consistently that by using the EMR, they were able to lower costs by 8-13%. In addition length of hospital stays were shortened by almost a full day, and delays in initiating drug therapy and concurrent drug interaction errors were lowered by one third. In the end of the 16 month randomized controlled clinical trial, involving more than 5000 inpatients, physicians using the workstations in their clinics, generated hospital bills $887, per patient, less than those who used paper charts to write all orders. Given the major advantages, there are still many hidden pitfalls that must be considered before implementing such a system. Some of those that come up, are data security, and data integrity, data safety and data ability. Although all of these concerns are quite valid, proper implementation of data encryption tactics can be used to fulfill the guidelines elucidated by the Health Insurance Portability and Accountability Act (HIPAA). These goals and guidelines are quite similar to those of The Data Protection Act of 1984 seen in the UK. Keeping the aforementioned research in mind, the question of "why" implementation of an electronic data record has been successfully shown time and again. The task of this project, seeks to clearly delineate the Bay Area Hospital and its surrounding clinics' expectations in regard to the incoming computer information system that they wish to implement. In addition and more importantly it strives to elucidate the varying goals between the physician, nurse, and administrative perspective of how such as system can be successfully implemented without breaking a budget of $3.5 million dollars earmarked over the next five years aimed to serve the Coos County patient population. In clear terms this project aims to answer the following questions: 1. What do physicians seek f

The Common Cold In Coos County: Patient & Physician Perspectives On Etiology And Therapy
Date of project: 7/2/2001

This project is designed to establish how the understanding of patients seen at Bay Clinic in Coos Bay correlates with current medical opinion with regard to the common cold and the use of antibiotics. Secondly, it aims to determine if the level of patient understanding influences the delivery of patient care in the rural setting. Patient knowledge of the causes, course, and treatment of the common cold are explored by the use of a questionnaire. Physician opinions and practices are evaluated by a written survey.

Not So Kool Coos Bay: Youth Tobacco Use In Rural Oregon
Date of project: 7/2/2001

Despite reductions in adult tobacco use and increasing attention to smoking prevention programs, the prevalence of adolescent smoking has remained relatively stable and may even be increasing in some groups. Recent studies have found that 28% to 36% of teens are current smokers (2) Nearly 20% of Oregon's high school juniors smoke, and many of them would like to quit.(4). This project looked at teen tobacco use among adolescents in a rural pediatric practice. Patients of the Coos Bay Clinic and SWOYA aged 12-17 were asked to fill out a survey about teen tobacco use. Of the adolescents participants (n=47), a majority of those surveyed (91.5%) did not smoke or use ST. Among the tobacco users (8.5%) they selected enjoying the feeling (37.5%), Can't stop (25%), and don't know (25%) as reasons for tobacco use. These same adolescents 43.8% take cigarettes from the household, 25% have friends purchase them, and 12.5% purchase their own. Among smokers only, having friends and family members who smoke were significant predictors. Having favorable attitudes towards smoking was not a predictor. These findings show that there is an important role for rural pediatricians, in the management of teen tobacco use.

Parental Attitudes about Vaccinations
Date of project: 5/6/2002

This project was designed to provide information to pediatricians in a pediatric clinic in Coos Bay, Oregon about choices made by parents of patients between the ages of 3 and 18 months regarding vaccinations. Parents attitudes, behavior, and needs for information were assessed using written questionnaires. The attitudes, experiences, and suggestions of some of the parents who completed the written questionnaires were further explored through telephone interviews. Twenty parents completed the wriiten survey. Nine respondents said they had concerns about the possible side effects of vaccinations. Only 1 parent chose not to have her child receive a vaccination when recommended because of concerns about side effects. All 20 parents stated that they were adequately informed about vaccinations. Nineteen of the parents rated physicians as "very useful" sources of information about vaccinations. Some parents relied much on family, friends, the internet, and the media for information. Five parents participated in the telephone interviews. Although all had concerns about possible adverse side effects, they each agreed that vaccinations are "necessary" and explained that the benefits outweigh the risks. The origin of parents concerns and their suggestions are presented in the following report.

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