RCHC Community Project Abstracts

Back to subject search page or search by preceptor site Prevalence of HTN in the Pt population seen by a Clinician at the PFMC and Patient’s Attitudes towards Management of HTN Project Date: 4/27/2009 About 29% of US population has high blood pressure and only 54% of these patients are on anti-hypertensive treatment, and only 33% of these pts on treatment have good control (1). HTN is associated with a high morbidity and mortality. Even though pharmacologic treatments have shown promising results in managing HTN, the side effects, the cost, and pt’s attitudes towards taking medications limit their use in successful management of HTN. As I was doing my rural rotation, I noticed that almost a third of the pts had HTN and so I decided to do this project to determine the prevalence of HTN in this population. I was also curious to find out what patients (with/without HTN) think is the most important factor in managing a high BP. Comparing Trends in Cardiac Disease between Multnomah and Klamath Counties Project Date: 2/9/2009 Background: Coronary heart disease (CHD) is the single leading cause of death in the United States. Mortality from CHD and overall incidence of CHD has been declining since the 1960’s. This trend has not been as significant in African Americans, Hispanic Americans, American Indians, individuals of lower socioeconomic status, and rural populations. Differing trends in heart disease have been observed within different sub-populations in Oregon. The purpose of this study was to compare trends in heart disease in the most urban area of Oregon, Multnomah County, to heart disease trends in a rural region, Klamath County. Methods and Results: Yearly, age adjusted heart disease death rate, coronary heart disease (CHD) death rate, myocardial infarction death rate, and risk factor data, including data on smoking, obesity, physical activity, diabetes, and cholesterol awareness data for Klamath and Multnomah counties was analyzed. Trends in heart disease mortality from 1995 to 2005 were compared. Heart disease death rates were found to be consistently been higher in Klamath County than in Multnomah County. Hispanics and Native Americans residing in Klamath County had significantly higher mortality rates from cardiac disease. There was a decreasing trend in heart disease mortality and myocardial infarction mortality in Multnomah County from 1995-2005 that was not apparent in Klamath County. Prevalence of major risk factors such as smoking and obesity was also found to be significantly higher in Klamath County. Conclusion: Klamath County exhibits several disparities related to recent trends in heart disease. Primary prevention programs with improved outreach that are more specifically targeted towards those living in rural areas need to be established. Better access to health care is necessary in rural Oregon. Physician shortages must be addressed to improve both preventive and specialized care. Obesity in Scappoose, Oregon: Developing a patient handout about the benefits of a Mediterranean Diet Project Date: 9/8/2008 Obesity and weight-related diseases (hypertension, diabetes mellitus, and hypercholesterolemia) are major medical problems in the United States. This study was initiated to design an educational handout to assist patients in making beneficial nutritional changes to combat these diseases. The study consisted of an observational period to assess patients’ needs, difficulties, and constraints during this process, as well a period of research and development to create a pamphlet to best address these requirements. During the latter phase, strong research was found proving that the Mediterranean Diet was beneficial in addressing these diseases. The final period of the study consisted of a distribution phase to share the new material with the patients and gauge the impact of the handout. More research needs to be done regarding how the pamphlet influenced the patients, and would reveal specific strengths and weaknesses. n=1 or n=1 x 10? An Individual Perspective on Population-based Healthcare: A Case Study Project Date: 6/30/2008 In the United States, cardiovascular disease (CVD) affects 80.7 million (37.l%) individuals, is responsible for 869 thousand deaths per year, and generates an estimated $448.5 billion in annual economic costs. There are an ever increasing number of large epidemiologic studies, trials, and meta-analyses dealing with primary and secondary prevention of cardiovascular disease and its complications. New management and treatment guidelines are constantly generated and old ones discarded, updated, or revised, but the burden of CVD continues to increase. Oregon Health Division vital statistics show that Malheur County, location of my Rural and Community Health Clerkship, has a significantly higher than average death rate due to cardiovascular disease. The goals of this inquiry are twofold: one, to develop an understanding of Community Oriented Primary Care (COPC) within the context of a disease that is as relevant to populations in Malheur County as it is those in places like Orange County or Miami-Dade County and two, to evaluate some of the strengths and weaknesses of population-based perspectives like COPC on clinical outcomes for individual patients or the economics of healthcare. Educational Tools to Promote HealthY Patient Behavior Project Date: 4/28/2008 Diabetes and hyperlipidemia are now well established risk factors for cardiovascular disease that are quite poorly controlled in our country. Each of these medical conditions drain the health and financial reserves of all of our communities. Grants Pass, is an economically challenged community located in Josephine County Oregon. High rates of cardiovascular disease and chronic medical conditions in this city serve to only worsen the already poor socioeconomic state of this city. The Wellspring Family Practice Grants Pass clinic is composed of a high proportion of patients with diabetes and hyperlipidemia. Unfortunately, the patients lack a sophisticated understanding of how these disease processes lead to harm in their lives. Furthermore, many individuals were frustrated with the lack of success of lifestyle intervention and were skeptical that improved diet and exercise would improve outcomes in their community. The results of this study confirmed that increased exercise, improved diet and tight glucose control were all correlated with better health outcomes in this population. The findings appear to support the applicability of well established cardiovascular risk factors in this community and thus provide an additional powerful set of educational tools to promote health patient behavior. Recent Onset Cardio-pulmonary Disease in Three Fiberglass Plant Workers in Hines, Oregon Project Date: 3/17/2008 In 2007-2008 High Desert Medical Clinic in Burns, Oregon saw 3 patients who presented with acute-onset respiratory and cardiovascular illness after working with fiberglass at the Monaco Coach Corporation’s plant in neighboring Hines, Oregon. Purpose of the study: (1) identify what substances are used in fiberglass manufacturing that may cause cardio-pulmonary disease, (2) evaluate methods of protection used by the Monaco plant against occupational exposure to these substances, (3) consider ways in which the local medical community and plant management can improve public health regarding the occupational hazards associated with fiberglass manufacturing. Conclusions: (1) the Monaco plant has a thorough exposure protection policy that exceeds the requirements set by law or insurer, (2) although styrene is the principal toxin used in fiberglass manufacturing that is measured by regulatory bodies, there are other agents, such as fire retardant filler, phthylates, and fiberglass dust particles, that may be associated with respiratory and cardiovascular illness in plant workers. Assessing the Current Methods for Managing Hyperlipidemia and Their Effectiveness Project Date: 3/17/2008 Chronic disease management is a large part of primary care and it can have a big impact on the heath of a population. Hyperlipidemia is one of the more common chronic diseases seen in primary care and it is a major risk factor for cardiovascular disease and stroke. Coronary heart disease is the leading cause of death in this country. Studies have shown that optimal management of patients with hyperlipidemia is essential to decreasing the risk of cardiovascular disease. The goal of this study was to assess the current methods for managing hyperlipidemia in one rural family practice clinic and their effectiveness. The design was observation of clinical practices, interviews with clinic providers and random chart reviews of twenty-five patients with previously diagnosed hyperlipidemia. The findings indicated that lipid levels were fairly well controlled with the current strategies. Areas for improvement included regular patient follow up and management of coexisting cardiovascular risk factors. A standardized form was created to be both a clinical checklist as well as a tool for documentation. It is expected that this document will help improve overall management and facilitate simple and comprehensive documentation. Cardiovascular Risk Reduction in Hood River, OR: Availability without Access Project Date: 2/11/2008 Although preventable, heart disease remains the number one cause of death in the United States. This study sought to examine cardiovascular risk reduction in an internal medicine clinic in Hood River, OR. Methods included observation of clinic practices, interviews with health care providers, and analysis of inpatient admissions for 2007. Patient education for cardiovascular disease in the clinic included brief, informal counseling performed during the visit and focused on risks that were identified through the patient’s history, physical examination, and laboratory evaluation. No handouts for patients were in use to augment this education or encourage lifestyle modification. A comprehensive cardiovascular risk reduction program was available but expensive, minimizing its utilization. The ultimate goal of this project was to create an efficient and educational patient handout aimed at increasing awareness of modifiable cardiovascular risk factors, encouraging lifestyle modifications, increasing patient-physician dialogue, and highlighting free or insurance-reimbursed programs available in the area. Which Bay Patients are on Vytorin and What Do They Know About The ENHANCE Trial? Project Date: 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. Cardiac Arrest: Changing Resuscitation Guidelines to Increase Participation, Improve Survival Rates and Extend Community Resources Project Date: 8/6/2007 Each year, several hundred thousand Americans die as a result of cardiac arrest despite several decades' worth of training in cardiopulmonary resuscitation. Widespread confusion about when and how to implement resuscitation protocols, distaste for certain aspects of the procedure, and declining confidence in its potential for success contribute to a lack of bystander participation and resultant strain on local emergency resources. A handout has been prepared to reflect current research on the subject and provide an opportunity for further discussion. Small steps such as this may help to reintroduce the topic of cardiac resuscitation to the lay public, particularly if new guidelines are easier to understand and implement. "Exercise by Prescription" Project Date: 3/19/2007 A routine of exercise and physical activity has been shown to decrease morbidity in patients suffering from things such as heart disease, cerebrovascular disease, hypertension and osteoporosis. Physical Inactivity however has been correlated with many external factors beyond the patients’ control. This study attempts to identify key barriers to physical activity in a rural population, specifically among the elderly. The design was the questioning of patients over 50 who came to Klamath Family Practice, and the Merle West Medical Center in Klamath Falls Oregon. Each patient who was being seen as a follow up for hypertension, Diabetes, or was having a complete physical exam was questioned on the primary reason that they did not perform a routine form of physical activity and or exercise. 2 different focus groups of 10 and 12 senior citizens at Klamath Senior Center & Center for Aging were also questioned about the same issue. This study found that the major barriers included weather in Klamath, safety and motivation along with other barriers. Whereas there was a great deal of emphasis on the importance of physical activity, the barriers to those activities were not being addressed by physicians and/or residents. In fact it was rare that a consultation was held at all to discuss physical activity for many patients who would obviously benefit. Therefore my intervention sought to decrease the burden of those same barriers in an effort to motivate the patients to seek out the recommended amount of physical activity set forth by “Healthy People 2010.” This included but was not limited to, making trail maps for walking and jogging, convincing local fitness centers and rentals shops to give discounts to patients mentioning “exercise by prescription” from their doctor. Such a sheet of information and incentives give the physicians in office, something to have in hand in order to have a worthwhile discussion about exercise with patients and to hopefully further impact preventive care in Klamath Falls. Eastern Oregon Medical Associates Weighs In: Assessment of the prevalence of overweight and obese patients in a rural community health clinic and provider education about screening, prevention, and treatment of obesity. Project Date: 2/12/2007 The obesity epidemic in the United States is well known to primary care providers. Obesity is a contributing factor to patients acquiring diabetes, hypertension, coronary artery disease, arthritis, certain cancers, and other diseases. Lowering an overweight or obese patient’s weight by just 10% can decreased their cardiac risk factors and can increase their quality of life.1 Primary care clinics are the cornerstone of prevention, screening, and treatment of obesity but according to providers at Eastern Oregon Medical Associates (EOMA), advice on healthy eating and exercise often falls on deaf ears. Physicians at this rural health clinic feel that they have an overwhelming number of overweight and obese patients but are unaware of the most effective ways of counseling these patients about weight loss. They were also eager to learn of any new treatment options. This project aimed to determine just what the rates of overweight and obese adult patients were in the clinic and to educate the providers on the most recent research and recommendations on screening, prevention, and treatment. EOMA uses an electronic medical record system that automatically calculates BMI with each patient visit. To determine the prevalence of overweight and obesity, data was collected for all patients 15 years and older who had a BMI of greater than 24 by using the EMR system’s search function. Data was categorized by overweight (BMI>24 but <30) and obese (BMI>/=30) and then further categorized into gender and age. It was found that EOMA has a prevalence of 12.6% overweight patients and 13.5% obese patients; much lower than the national prevalence. Research using several different methods (Medline database search, Cochrane database search, and use of NIH and CDC data) was used to find the most current information and recommendations on screening, prevention, and treatment of obesity. This information was compiled into a report that included the clinic data and was presented to all providers at EOMA. 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. Project Date: 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. Heart Disease and Diabetes Handout for Kids Project Date: 1/1/2007 Heart disease and Diabetes are two of the most common diseases now present in the U.S. In the National Health Survey of 2004, the percent of non-institutionalized adults with diagnosed heart disease was 11.5 and the number of annual deaths was 654,092. In 2004, heart disease was responsible for 1/3 of all deaths. Diabetes is also of epidemic proportions. Approximately 7.2 million people have Type II Diabetes in the U.S.(actually diagnosed). According to the National Diabetes Statistics fact sheet, (NIDDK of 2003) approximately 1 in 17 or 5.88% or 16 million people in USA have diagnosed and undiagnosed diabetes. Diabetes is the nation's seventh leading killer and contributed to about 187,800 deaths in 1995 Two known risk factors for these diseases include smoking and obesity. Despite this, the incidence of obesity in adults and children continues to rise, and smoking has increased in young adolescents. For these reasons, we feel it is extremely important to begin educating young children about heart disease and diabetes, and give them basic tools to avoid these diseases. To accomplish this in the rural family practice setting, a children's book was created which outlines the basics of these diseases and encourages healthy eating, exercise and not smoking as three methods to help prevent heart disease and diabetes. The book will be used in the office setting as a tool to open up conversation and learning opportunities around these issues. In addition, a one-page handout summarizing the above will be given to the patients to take home as a reminder of what they learned. This is the beginning of an early education regarding the importance of lifestyle choices in the future health of our nation. When are Thrombolytics Indicated? Project Date: 1/1/2007 The issue of when and when not to use thrombolytics in rural community hospitals continues to exist. This issue is propagated by an increase in the use of percutaneous intervention in urban areas as well as the increasing frequency of immediate inter-hospital transfer to PCI capable institutions in the case of ST-Elevation Myocardial Infarction. This change in the standard of care in urban settings has caused a perceived lack of need for extensive education in the use of thrombolytics and a resulting deficiency in training at urban care centers. This alteration then disturbs health care administration at rural community sites due to consults from care centers where thrombolytics are rarely used. The use of protocols in community hospitals addressing the proper use of thrombolytic medications when indicated may prevent the under use of this live saving treatment. Effectiveness of hypertension management in Astoria, OR. Project Date: 10/16/2006 Hypertension (HTN) incidence and prevalence continues to increase across the country, with a higher disease burden found in some rural areas. In fact, it was the most frequent diagnosis recorded for all routine health checks (4.1%) in the US, and in a small Family Practice clinic in Astoria, OR, HTN was the reason for 6.1% of visits per day. However, recent studies show only 20-30% of those with HTN have optimally controlled blood pressures (BP). I researched current recommendations for successful management of HTN in the literature, and used this information to investigate the effectiveness of HTN management in this small Family Practice clinic in Astoria, OR. A flowsheet was created to focus on these guidelines and a chart review of 35 patients was done using this tool. Data was collected, including weight, BMI, BP, risk factors/secondary causes, PE and labs done, medications, and expected follow-up. Results showed that these two Family Practitioners did an outstanding job of overall BP management, with almost ¾ of their patients at or below their goal BP, and timely lab follow-up. Areas of improvement include stricter use of recommended medications for specific co-morbidities, consistently including fundoscopic exam as part of the PE, and ordering EKGs. This information can be used as a background for future HTN management in this clinic, with utilization of the flowsheet to aide in the improvements discussed. Medical Management of Chest Pain in John Day, Oregon: Development of a Standing Order Form. Project Date: 9/11/2006 I was able to create a standard admission form that is clear in its wording, directs physicians and nurses towards up-to-date diagnostic testing and treatment strategies. Based on my interviews with the physicians, nurses, and ancillary healthcare professionals practicing at the Blue Mountain Hospital, this form will be useful and used by the physicians there. This has the potential to positively impact not only physicians and staff at Blue Mountain Hospital, but also its patients as studies have shown that effective standardized orders lead to more consistent and higher quality care. As chest pain is one of the most common diagnoses in hospitals across the nation, my form has the potential to make a sizable impact in the John Day and Grant County community. Weight loss interventions in Astoria, OR: development of a patient resource guide to connect patients with weight loss resources in the community. Project Date: 8/7/2006 With over 60% of Americans classified as overweight or obese, a significant portion of our population continues to share an elevated risk for obesity related conditions such as diabetes, hypertension, coronary artery disease, arthritis and sleep apnea. Through this project, I hoped to identify ways in which physicians could support their patients who are trying to lose weight. Exploring this question involved observing how my preceptor in Astoria discussed weight loss with her patients. I then created a list of simple, cost effective ways a family physician could support weight loss among a patient population. An interview was conducted with my preceptor and her practice partner to learn how willing they would be to implement various weight loss interventions. I spent one morning at Curves, a chain fitness center that offers circuit training and is attended mostly by women. Willing participants were interviewed regarding weight loss and how doctors could support weight loss efforts. Interviewees were also asked to evaluate how helpful it would be if their doctors implemented various specific weight loss interventions. Of the many interventions suggested, patients and doctors were most excited about the availability of a booklet that presented information on local resources for weight management. Therefore, the project culminated in the creation of "Health Knocks: A Resource Guide to Weight Management in Astoria, OR". This tool will help physicians to connect patients with weight loss resources n the community. Hyperlipidemia in John Day, OR: An Assessment of Follow-Up and Management Project Date: 7/3/2006 BACKGROUND: Although mortality from heart disease has steadily declined since 1980, it still remains the leading cause of death in the United States and the second leading cause of death in Oregon. Of the 685,089 deaths caused by heart disease in the US, 70% were due to ischemic heart disease. Correlation between certain risk factors and premature coronary heart disease (CHD) has been markedly established, and about 80-85% of individuals with CHD possess one or more of the four conventional risk factors: cigarette smoking, diabetes, hyperlipidemia, and hypertension. Current data suggests that optimal control of hyperlipidemia with appropriate follow-up can significantly reduce an individual’s risk for cardiovascular events, and proper management in patients with CHD can significantly decrease cardiovascular events, cardiovascular mortality, and overall mortality. OBJECTIVE: To assess whether or not the stated goal of six-month cholesterol screenings for previously identified hyperlipidemic patients is being met; and to determine if treatment plans accomplish the desired goal of lowering cholesterol. METHODS: A random chart review of patients with hyperlipidemia in Dr. Holland’s practice was performed. CONCLUSIONS: Because there was a significant decrease in total cholesterol, LDL, and triglyceride levels in patients with hyperlipidemia, therapeutic management of this disease in Dr. Holland’s clinic is adequate. However, there was an overall decrease in HDL, which is less than desirable. Also, the stated desired goal of six-month follow-ups for hyperlipidemic patients is not being met but implementing a patient reminder system could increase follow-up. The metabolic syndrome in Coos County, Or: Causative factors, and issues for treatment. Project Date: 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. Helmet Use in Klamath Falls Project Date: 3/20/2006 Safety helmet use within the pediatric population continues to be an important part of preventive health. The bicycle is associated with more childhood injuries than any other consumer product except the automobile with head injuries accounting for the majority of bicycle-related deaths and hospital admissions. There are many factors that contribute to the use of safety helmets including access to obtaining a helmet, education regarding appropriate use of helmets, as well as many compliance issues. This study attempted to examine the percentage of children without access to a safety helmet and questioned what particular barriers to helmet ownership exist within the Klamath Pediatric Clinic population. The design included a seven question survey including age and sex of the child, whether the child owned a safety helmet and asked how often the child wore the helmet during bicycling, skateboarding/roller blading, and skiing/snowboarding. The survey was initially given to all parents who came to the pediatric clinic with children 3-18 years old. When this proved to be of low yield, parents were questioned verbally in the waiting area of the clinic, using the same questionnaire as a guide. ASSET: Acute ST Segment Elevation Taskforce Awareness in Grants Pass, Oregon Project Date: 3/20/2006 Heart disease is the number one cause of mortality in Grants Pass, Oregon. Through recent studies, it is clear that Percutaneous Coronary Intervention is the best treatment option for a patient suffering from a myocardial infarction. The Acute ST Segment Elevation Taskforce, serving Grants Pass, was implemented in order to reduce infarct time between recognition of symptoms and therapy. Unfortunately, many patients are not aware of this program and are transporting themselves to the local hospital, one without treatment capabilities. With community education and awareness through direct patient contact, local newspaper articles, posters, and other media, patients were educated about the program. Such education resulted in an increased willingness to use the program and decrease morbidity and mortality. Oral Anticoagulation Management at Madras Medical Group in Madras, Oregon Project Date: 3/20/2006 Maintaining anticoagulated patients within an INR of 2.0-3.0 has been shown to reduce bleeding events without increasing rates of the thromboembolic events for which anticoagulation was being administered. Madras Medical Group of Madras, Oregon recently changed their warfarin administration system to that outlined in Ebell (2005). This project examined the charts of all 103 patients receiving anticoagulation services for a six-month period before and a six-month period after the change. The mean number of INR checks per patient during both six-month periods was 3.9 Before the change 44.3% of INRs were within the therapeutic range, while 48.4% were within range after the change. The number of bleeding events was the same before and after the change. Three thromboembolic events occured after the change. Use of a new flow sheet would provide easy access to important information for the group. Use of a point of care meter could make INR testing more accessible to patients and could result in more frequent testing and a greater time in therapeutic range. Chronic Disease Management in Grant County Project Date: 3/20/2006 Problem: Almost half of all Americans have a chronic disease which may lead to extensive morbidity and mortality. Traditionally, diseases such diabetes mellitus (DM), hypercholesterolemia, and asthma are managed on a reactive, acute need basis. Pro-active physician-patient management of these three diseases reduces disease morbidity and mortality. The Grant County Public Health Department is writing a grant for $60,000 to try to improve Grant County’s health care of these diseases. To write and effective grant proposal, the department needs to learn what PCPs in the community are currently doing to manage the diseases and to propose ideas for improvement. Methods: An interview survey was conducted with all of the eight PCPs in Grant County about their current management of DM, hypercholesterolemia, and asthma. They were also asked what challenges they had managing each of these diseases, and what suggestions they had to improve the management of these diseases. Findings: Most PCPs actively monitored DM, many monitored hypercholesterolemia, and only one actively monitored asthma. Poor patient motivation and understanding as well as computer and time limitations were viewed as the largest challenges. Group education classes, such as the group diabetic dietitian class, were viewed as the most helpful resource. In addition, the majority of PCPs think a tickler file would be helpful. Conclusion: Grant County PCPs are currently using a variety of methods to manage DM, hypercholesterolemia, and asthma. All of expressed a desire for improve disease management, mentioning several clinical and community suggestions. Care of hypertensive patients in John Day, Oregon: Creation of a clinical reminder checklist. Project Date: 2/13/2006 Hypertension is a medical problem seen by every physician, regardless of his or her specific practice or the type of community they practice in. For physicians in rural communities, it is a diagnosis seen daily. The identification and treatment of patients with hypertension is lengthy, somewhat confusing, and frequently changing. In 2003, the National Heart, Lung and Blood Institute (JNC7) created a new treatment algorithm for hypertensive patients. This study attempted to determine whether or not two physicians in a rural family practice clinic in John Day, Oregon were appropriately caring for their patients with hypertension according to the guidelines set forth by the JNC7. The design was a random selection of 20 patients already diagnosed with hypertension, followed by a chart review of these patients. The chart review identified specific areas the physicians were doing well with and a few that they were lacking in. The results of the chart review prompted discussion of the best way to be consistent and complete with the care of every hypertensive patient. It was decided that a checklist with reminders for specific aspects of the physical exam, laboratory tests, lifestyle modifications, and medication review would be created. Two checklists were created including one for the initial diagnosis of hypertension and one for those already diagnosed. These checklists will be placed in the charts of all pertinent patients. It is expected that these checklists will make it easier for the staff and physicians to provide consistent care of their patients with hypertension according to the guidelines set forth in JNC 7. Stroke Disease in Klamath Falls: Public Awareness of Symptoms and Risk Factors Project Date: 2/13/2006 Cerebrovascular accidents are serious medical events that are responsible for significant morbidity and mortality in the United States. In the case of thrombotic or embolic strokes, early intervention with thrombolytic therapy often leads to improved outcomes. However, early intervention often depends upon patient and public awareness of stroke symptoms and understanding of the need to seek medical attention promptly. This study attempted to determine knowledge of stroke disease and risk factors of residents of Klamath Falls, Oregon. This was accomplished by a voluntary, written survey of outpatients at the Klamath Family Practice Center (KFPC). The survey was designed to determine patient knowledge of stroke causes, symptoms, and risk factors, as well as patients’ individual risk factors for stroke and the distance they live from the local hospital emergency room. Analysis of survey responses showed deficiencies in patient knowledge of causes of stroke (57% sensitivity, 86% specificity), risk factors of stroke disease (57% sensitivity, 86% specificity), and symptoms of a stroke (67% sensitivity, 81% specificity). Additionally, there was little or no correlation between individual patients’ risk factors and their knowledge of stroke disease and its symptoms. Based on the results of the survey, efforts were made to improve public awareness of stroke symptoms and risk factors. Cholesterol Education in Grant County Project Date: 1/2/2006 The Strawberry Mountain Wilderness Family Medicine Clinic sees a large number of senior citizens and middle aged patients, many whom have hyperlipidemia. The goal of this project was to create several handouts that address common questions patients have about cholesterol. These handouts discuss what cholesterol is and where it comes from along with the different types of cholesterol. They present guidelines from the NCEP so patients can compare their lab results with recommended levels. They provide methods of lowering cholesterol including diet, exercise and medication. Finally, they will include a summary table of different kinds of fat and how each type affects cholesterol. As part of this project, individuals who participated took a small quiz before and after going over the handouts with the medical student. This quiz was designed as a teaching aid and to help evaluate the effectiveness of the handouts. Nine individuals completed the quiz. Participants preformed moderately better on the post-quiz. Participants reported that they had a better understanding of cholesterol after going-over the information and felt they could share information with their friends and family members. The cholesterol education handouts will stay in the clinic for future use by practitioners. Effectiveness of Type 2 Diabetes management in Astoria, Oregon Project Date: 10/17/2005 The management of type 2 diabetes represents a unique challenge for Oregon’s rural practitioners. Death rates among diabetic patients in Oregon have steadily increased, with much of the disease burden resting in rural communities. In Clatsop County, the death rate from diabetes is staggeringly high, at 40.8 per 100,000 people – a rate almost double the national average. In attempt to address this issue, I investigated the management of type 2 diabetes mellitus at a small, private family medicine clinic in Astoria, Oregon. A chart review was performed of fifty patients with the diagnosis of type 2 diabetes, with a focus on three components of diabetic care: 1) glycemic control, as measured by HbA1C, 2) cardiovascular risk management, and 3) the assessment, prevention, and treatment of diabetic complications, specifically retinopathy and nephropathy. The results of the review revealed several areas of possible improvement in diabetic monitoring, in addition to highlighting the importance of medical therapy with aspirin, ACE inhibitors, and lipid-lowering agents. Several barriers to optimal diabetic management were identified, with the primary impediment being patient non-adherence to diabetic treatment and follow-up regimens. This data should serve as a background for future endeavors in the clinic, with the eventual goal of developing a better tracking system for diabetes management. Hypercholesterolemia and hypertriglyceridemia in Grant County, Oregon Project Date: 10/17/2005 Hyperlipidemia is well-established as an important risk factor in the development of heart disease. Estimates of the prevalence of hyperlipidemia in the US are approximately 1 in 3. Discussions with Grant County physicians and the Grant County Health Department family nurse practitioner indicated that the health care community was unaware of the prevalence of hyperlipidemia in their patient population. Lab data from the annual Health Fair sponsored by the Grant County Health Department, Blue Mountain Hospital and the US Forest Service was reviewed, and individuals with hypercholesterolemia and hypertriglyceridemia were identified. 620 blood draws were recorded, approximately 10% of the population of Grant County. 47% of participants demonstrated elevated cholesterol levels and 27% had elevated triglycerides. These results suggest that hyperlipidemia is a grave health concern in Grant County. A comprehensive educational patient handout addressing screening, prevention and treatment was developed for distribution at the next annual health fair and at the Grant County Health Department. Suggestions for future possible research projects related to this topic are included. Lifestyle Modifications to Prevent and Treat Hypertension in Reedsport, Oregon. Project Date: 9/12/2005 Hypertension is epidemic in developed countries today. In United States, 50 million adults, or approximately 25%, have hypertension (defined as blood pressure > 140/90 mm Hg) and/or use anti-hypertensive medications1. More than half of all adults aged 60 years or older have hypertension2. As Reedsport and its surrounding communities contain large proportion of elderly population, many patients at the Dunes Family Health Care (DFHC) have hypertension and its complications. Thus, hypertension is an important and common health problem treated at DFHC. The purpose of this project is to increase public awareness of hypertension by creating an informative pamphlet. The results from a survey indicate that participants place lifestyle changes, mainly diet and exercise, as best methods to prevent and treat hypertension over anti-hypertensive medications, even though almost half of participants are currently taking anti-hypertensive medications. Thus, lifestyle changes in regards to diet and exercise are emphasized in the pamphlet, with main focus on Dietary Approaches to Stop Hypertension (DASH) diet as well as community resources available to Reedsport residents to make exercise and dietary changes to lower and maintain healthy blood pressure. The Metabolic Syndrome in Coos Bay Project Date: 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. ASSET: An Effort to Improve Outcomes for Acute MI Patients in Rural Southwestern Oregon and Northern California Project Date: 4/25/2005 With the increasing numbers of patients with coronary artery disease in this country spanning from metropolitan cities to rural communities, there is a growing population of patients at risk for acute myocardial infarction. Successful treatment of acute myocardial infarctions requires adequate and prompt identification and transfer to a facility for definitive treatment. The most effective treatment for ST elevated myocardial infarctions (STEMI) is percutaneous coronary intervention (PCI). Rapid PCI is the treatment of choice to minimize morbidity and mortality from STEMI. Unfortunately, time is heart muscle in the event of a heart attack. In rural communities, local hospital evaluation, transport to the nearest cath lab many miles away, and activation of the cardiac care team leads to a delay of 2 hours or more. The ASSET program developed by Dr. Brian Gross in Medford, Or has attempted to minimize the time delays and get cardiac patients in rural communities to definitive catheter treatment in a timely fashion. The program involves local rural community hospitals and their ambulance services as well as a group of on call interventional cardiologists in Medford to serve a nearly 50 mile radius around the Medford area. The protocol allows for first responders to identify STEMI patients in the field and bypass the nearest local hospital to transport the patient to a pre-alerted cardiac intervention team in Medford. The outcome was a decrease in the morbidity and mortality associated with time delays accrued in the rural setting and to make rural Oregon the “safest place to have a heart attack”. Hyperlipidemia in Grant County: Is the Public aware of the dangers of elevated cholesterol levels? Project Date: 4/25/2005 The cardiovascular risks associated with hyperlipidemia have been well established through multiple studies. The public’s understanding of this issue, however, has lagged behind scientific discovery, and failure to make appropriate life style changes may unnecessarily lead to an early demise. A recent article published by the Center for Disease Control and Prevention (CDC) showed that too few Americans have their serum cholesterol checked as recommended by the National Cholesterol Education Program (NCEP). My objectives in this project were to first identify the prevalence of hyperlipidemia in Grant County, Oregon and then conduct an informative discussion with the public regarding cholesterol physiology. Using a computer generated list, I was able to identity 282 adults who receive care at the Strawberry Mountain Wilderness Clinic in John Day, Oregon who carry the diagnosis of hyperlipidemia. Based on this number, the calculated prevalence of hyperlipidemia within this cohort was 6.7%, far short of the national average of 24%. Following this discovery, I held a 45-minute PowerPoint discussion in an attempt to enhance the public awareness of the dangers associated with hyperlipidemia and presented potential solutions to this problem. My interactions with the group lead me to the conclusion that the public’s knowledge regarding cholesterol health is insufficient, though a more thorough investigation is needed to substantiate this hypothesis. Furthermore, I believe that with more physician-directed discussions, the public will take a more active role in screening and reduction of hyperlipidemia. Reported Stroke Mortality in Harney County: the perceived need for additional stroke education Project Date: 2/7/2005 Cerebrovascular accident "Stroke" is one of the leading causes of Morbidity and mortality in the US. Unfortunately, Oregon stands out as a state with a disproportionate stroke-related burden of morbidity and mortality. As Harney County is one of the most rural counties in the state, the goal of this project was to use rough analysis of mortality data for the county and state to make assessments of relative stroke burden compared to stroke. What was revealed from the analysis was a significantly decreased level of stroke-related deaths reported for the county, than the state. Assuming that Harney County is not significantly healthier than the state at large, the disparity in reporting is hypothesized to be due to a relative lower level of stroke awareness and education, which may lead to lower frequency of presentation to available health system. Therefore, a newspaper article/public service announcement was written and information cards posted in the clinic in an effort to further educate the community to the signs, symptoms and risk factors associated with stroke. Thus, the intended long term outcome from this project developed into further education of the Harney County community regarding recognizing stroke and minimizing risk factors. Hypertension in Baker City, Oregon: Treatment, Awareness, Compliance, and Lifestyle Project Date: 10/18/2004 Hypertension is a major risk factor for many cardiovascular diseases, renal disease, and retinopathy. Hypertension is implicated in 800,000 deaths per year in the United States, and is highly prevalent in the portion of the American population over 60 years of age. A study of patients’ knowledge of hypertension was conducted in Baker City, Oregon in October and November 2004. Patients diagnosed with hypertension were interviewed regarding their awareness, compliance, and lifestyle choices related to hypertension. Interviewed patients are moderately aware of their condition, are compliant with physician recommendations, and have altered their lifestyles to reduce hypertension-related health problems. Summary statistics suggest that interviewed patients had similar levels of compliance compared to those reported in the literature. In most cases, the physician’s response to elevated patient blood pressure was to adjust medication dosages. High Cholesterol: A simple means of patient education Project Date: 9/13/2004 High cholesterol is known to play a major role in heart disease and is one of the more common health care issues Americans face. This study attempts to identify the effectiveness of cholesterol screening and the accuracy of information given to patients at St. Elizabeth Hospital and Eastern Oregon Medical Associates Family Practice Clinic in Baker City, OR. Physician interaction with patients who either have high cholesterol or risk factors for coronary heart disease were observed during a 5 week rotation in Baker City. The annual Health Fair is the primary resource outside of the physician’s office that patients can get their cholesterol, as well as several other health issues, screened for health maintenance. The director of this program was contacted for information regarding the number of patients that use the health fair and what health information was given to patients regarding the different health conditions they were being screened for. Although there seems to be a mechanism for roughly identifying those with high total cholesterol, there did not seem to be an effective method of identifying and educating patients who would benefit, based on their individual cholesterol values, family history and other health issues, from preventative steps to help them avoid high cholesterol and heart disease in the future. The endpoint of this study was the creation of a patient handout to be used in the clinic to explain the basics of cholesterol and its role in heart disease, as well as helping the patient understand that cholesterol and heart disease goals are developed in regards to the specific patient. In addition, the handout incorporates the latest updates to cholesterol management by the NCEP, is formatted in a brief and simple document, and encourages patients to develop a regular dialogue with their health care provider about how to maintain healthy cholesterol levels. Assessing and enhancing women's awareness of heart disease in the Coos Bay area. Project Date: 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. Medical Management of Heart Failure in John Day, Oregon: Implementation New Practice Guidelines. Project Date: 11/10/2003 Heart failure is a major health concern in the United States. Nationally, over twnty perxent of hospital admissions are for heart failure. More than two-thirds of patients diagnosed with heart failure are treated by primary care physicians. This is certainly the xase in John Day, Oregon, where there are few spexialists present on a regular basis. As the population ages and life-ecpectancy of other cardiac diseases increases, heart failure will become even more of a public health concern. In the past several years, many studies have been published and new guidelines have been put forth for the management of heart failure. Optimal medical management of heart failure and improvement patient education can reduce thenumber of hospitalizations. This study aimed to determine if new treatment recommendations were being put into practice by local family practitioners in John Day. A pre-printed admission order form for heart failure and a discharge checklist with patient education materials were developed to help implement the current treatment guidelines. Rate versus Rhythm Control and Rates of Stroke in the Treatment of Patients with Non-Rheumatic Atrial Fibrillation in Baker County, Oregon Project Date: 9/29/2003 Atrial fibrillation is the most common clinical cardiac arrhythmia1. Traditionally, rhythm control has been the standard of care for atrial fibrillation, though recent randomized controlled trials maintain the equivalence of rate and rhythm control in the treatment of AF. The manner of treatment, either with rate or rhythm control along as well as anticoagulation, was reviewed for the last 30 AF patients admitted to the St. Elizabeth Hospital in Baker County, Oregon. 78% of patients included in the study were treated with single agent or combination therapy aimed at reducing ventricular rate by AV nodal blockade. 22% were treated with antiarrhythmic medication. Interestingly, 85% of those treated for rhythm control had previously failed rate control therapy. 36% of all patients included for analysis were taking warfarin for anticoagulation. 52% of all patients had a history of anticoagulation, though 31% of these had to discontinue warfarin secondary to complications of hemorrhage. The prevalence of stroke in the history of the patients in this study was 15%. Though all of these patients were in the rate control group, none of them were on warfarin anticoagulation at the time of stroke. Though in contrast to the findings of major studies evaluating rate versus rhythm control, only the patients in the rate control group had a history of stroke and also were the only ones to experience side effects that necessitated the change from one treatment modality to another. Although the small sample size and incomplete patient records in this study may have affected the results, it appears that rate control is the preferred treatment modality of Baker County physicians. Cardiovascular Rehabilitation in Coos Bay: Does Program Compliance Effect Hospital Readmission Rates? Project Date: 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. The Potential Benefit of Electronic Medical Records In the Management of Chronic Illness: A Case Study of Coronary Heart Disease and Depression in Lebanon, Oregon. Project Date: 3/24/2003 In recent years electronic medical records (EMR) have become an increasingly important part of documenting and providing medical care. In addition to saving money, reducing errors, and improving documentation, EMRs can potentially improve patient health by allowing physicians to better monitor patient progress and increase information access to patient populations. This report was designed use a patient population in Lebanon, Oregon as a case study to gain an understanding of how EMR could affect the care provided for a chronic medical condition. The paper charts of 62 admissions (97% of the total) coded for acute myocardial infarction at Lebanon Community hospital for the year 2002 were selected as markers for coronary heart disease (CHD). These were reviewed to determine the prevalence of a comorbid diagnosis of major depression or medical treatment of depression. Depression is a major risk factor for increased severity and mortality in cardiac events, therefore managing depression can have a significant impact on patient outcomes. This study found that 15-19% of patients hospitalized with an acute myocardial infarction were either diagnosed or being treated for depression. However due to systemic barriers it was difficult to efficiently assess patients’ long- term history and to evaluate whether depression in these patients was successfully being treated. This was because information was often missing from charts, hospital and outpatient records were not integrated and documentation was often incomplete. The Samaritan Health System that provides care in Lebanon is part of a network of five hospitals and 21 outpatient clinics. This system would likely receive more benefit from an EMR through greater efficiency and better quality control and decision-making support than the initial cost of installation, training and conversion of old records Time to Acute Myocardial Infarction Diagnosis and Reperfusion Therapy in Baker City, Oregon versus National Average Project Date: 12/30/2002 Objective - Acute myocardial infarction (AMI) is the largest cause of morbidity and mortality within the United States. Reperfusion therapy, which consists of thrombolysis and/or percutaneous transluminal coronary angioplasty (PTCA), is the cornerstone of contemporary AMI therapy. The benefits of both modalities are greatest when given within two hours of symptom onset. One might expect the time from emergency department (ED) presentation to thrombolysis would be shorter at St. Elizabeth Hospital, a rural hospital in Baker City, Oregon, when compared to a national, urban average. Conversely, it may be assumed that time from ED presentation to PTCA will be longer in Baker City than in large, urban institutions. This project compares time to 1st ECG, thrombolysis, and PTCA in patients with AMI presenting to St. Elizabeth Hospital from 1/01 to 9/02 versus a national, urban average. Methods - The average urban time from presentation to 1st ECG, thrombolysis, and PTCA was obtained from the National Registry of Myocardial Infarction 2 study. Average time to first ECG, thrombolysis, and minimum time to PTCA for nineteen patients presenting to St. Elizabeth Hospital with AMI was determined by chart review. Results - Time from presentation to 1st ECG and thrombolysis was found to be four and six minutes earlier in Baker City than the national average, respectively. Time to PTCA was considerably longer, 386 minutes, for patients presenting at St. Elizabeth Hospital. Discussion - While shorter at St. Elizabeth, the difference in time to thrombolysis is not significant enough to impact patient outcome relative to the national average. However, the time to PTCA was appreciably different, with patients in Baker City having to wait over three hours longer than patients in an urban environment. This time difference is composed of an observation period following thrombolysis and transfer time to St. Alphonsus Hospital. This project focused on treatment delay and its impact on time to reperfusion therapy in rural versus urban communities. Future projects might determine if patients in Baker City wait longer to seek medical attention than their urban counterparts, thus delaying the administration of thrombolytics. Recognition of cardiac risk factors among Hispanic patients of the West Salem Clinic. Project Date: 3/25/2002 This study sought to assess the major independent modifiable risk factors for coronary artery disease among the Spanish-speaking patients of the West Salem Clinic and to compare and contrast the results with these patients' self-assessments of their personal risk for the disease. The design is a self-assessment survey of 32 consecutive Spanish-speaking patients of the clinic and a review of their charts both attempting to assess cardiac risk factors including smoking, hypertension, hyperlipidemia, glucose intolerance, physical hypoactivity, and excessive body weight. Twenty patients' surveys and chart data were compared. Overall patients slightly underestimated their risk for CHD. Greatest discrepancy was found in the body mass category: 90% were overweight, including 80% who were obese wheras only 60% indicated that they were overweight. Among other findings, 85% did not know their cholesterol level and 80% never spoke with their health care provider about cholesterol; 50% did not know their ideal body weight; and 80% never spoke with their provider about their risk for diabetes. The report further provides some recommendations for patient education on these issues. Follow-up Frequency of Benign Hypertension at BAC Project Date: 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. Assessment Of The Signs And Symptoms Of Acute Myocardial Infarction Of The Elderly In The Emergency Setting In Reedsport, Oregon. Project Date: 1/2/2002 The purpose of this study was to examine elderly patients who presented to the emergency department (ED) in Reedsport, Oregon for symptoms of acute myocardial infarction (AMI). The objective was to determine what diagnoses were ultimately found for these persons, and then to determine if the presenting signs and symptoms of the elderly with a discharge diagnosis of myocardial infarction (MI) were representative of the national average. The ultimate goal was to determine whether the elderly with AMI are being underdiagnosed in Reedsport, and, if so, can improvements be made to diagnose them? A case review was done of approximately one year's prior time of all persons greater than 70 years of age presenting to the emergency room (ER) with symptoms of AMI. These cases were reviewed for chief complaint, associated symptoms, electrocardiogram (ECG), cardiac markers (Troponin-I, CK-MB, and myoglobin), and other various findings. It was found that 9% of subjects selected were ultimately diagnosed with an AMI. 35% had other cardiac problems (13% related to angina and 22% related to non-ischemic etiologies), and 56% had diagnoses unrelated to cardiac origin. The ECGs, cardiac marker findings, and other studies are described. It is thought that due to limitations in specificity and sensitivity of the ECG and cardiac markers, but moreover, the prevalence of atypical presentations of AMI in the elderly, that it is possible that a number of MIs in the elderly are not being diagnosed in Reedsport. Recommendations for improvement are given. Atrial Fibrillation and Stroke Prevention at Dunes Family Health Care (Reedsport, Oregon). Project Date: 11/5/2001 OBJECTIVE: This study sought to examine the approach of five physicians in a small, rural family practice clinic in Reedsport, Oregon in regards to preventing ischemic stroke in patients with nonvalvular atrial fibrilllation. This study also attempted to determine what effects the application of three current risk stratification models would have upon therapy indications for the patients in this practice. METHODS: There were two components to this study, (1) a chart review to determine the risk factors of and treatment for patients with recurrent paroxysmal and persistent nonvalvular atrial fibrillation and (2) a written survey of the provider's approach to anti-thrombotic therapy in patients with atrial fibrillation. The providers' practices were compared to current national guidelines for anti-thrombotic therapy in AF patients. RESULTS: There was found to be a high rate of anti-thrombotic therapy among patients with AF, even among those patients at low risk for stoke. The application of three models of risk-stratification resulting in very different results, the fractions of the cohort classified as low-risk varying from 7% to 37%. Finally, not all providers used risk-stratification for patients with atrial fibrillation, and when used, there is much variation in the use of risk factors by physicians in the decision whether to anticoagulate. CONCLUSIONS: Patients at Dunes Family Health Care have excellent rates of anticoagulation and anti-thrombotic therapy. Though the reasons for anticoagulation cannot be assessed, whether patient preference or physician advise, patients at low-risk for stroke may be better served by less aggressive therapy. Finally, when used, the providers studied had limited use of risk-stratification and may do well do incorporate more identifiable factors in the stratification of their patients. Evaluation of Acute Stroke Treatment in Reedsport, OR: A look at thrombolytic therapy in this rural setting. Project Date: 5/6/2002 Unlike some of the rural settings in Oregon, Lower Umpqua Hospital in Reedsport currently does not have a protocol for thrombolytic use in acute stroke. The goal of this project was to evaluate standard acute stroke treatment in Reedsport and the surrounding rural communities, then to assess what it would entail to incorporate thrombolytic therapy into the hospital’s stroke treatment. The evaluation for the project involved many components, including: 1) assessment of local stroke epidemiology, 2) assessing Reedsport physician support of acute stroke therapy, 3) assessing patient recognition and response to signs and symptoms of stroke, and their current utilization of EMS services, 4) analyzing the hospital and EMS needs for providing acute stroke treatment, and 5) questioning physicians from areas that provide thrombolytics for acute stroke. The report will address various aspects of providing acute stroke treatment in a rural setting vs. an urban setting. The findings in this report are meant to be informational and do not suggest whether acute stroke thrombolysis should or should not be integrated in the Reedsport ER protocol. The report does, however, provide a basic set of guidelines for helping establish acute stroke treatment in Reedsport should they decide to pursue this. Establishment of a Coumadin Clinic in Philomath, Oregon. Project Date: 11/5/2001 Warfarin is a commonly prescribed anticoagulant medication with a narrow therapeutic range. Patients on chronic warfarin therapy must have frequent blood tests to monitor the effects of the medication. Traditional warfarin monitoring requires a monthly venipuncture and a follow-up phone call from the physician to make medication adjustments. Anticoagulation clinics (Coumadin clinics) are increasing in popularity and provide instant blood test results and dosage adjustments with a drop of blood out of the fingertip. Philomath Family Medicine manages the anticoagulation for 45 patients on chronic warfarin therapy and will be opening a Coumadin clinic in January, 2002. The majority of patients surveyed indicate that they are interested in utilizing the services of a Coumadin clinic. The Detection and Treatment of Depression in Post-Myocardial Infarction Patients in Baker County, Oregon Project Date: 9/24/2001 Depression is common in patients recovering from a myocardial infarction. Approximately 1 in 6 patients with MI experience major depression and even greater numbers experience significant depressive symptoms following the event. Post-MI depression is an independent risk factor for angina, ventricular arrhythmias, future myocardial infarctions, and mortality following MI. However, given the acuity of the event, depression may often be under-recognized while diligently managing the patient's acute medical care. This study was designed to ascertain the detection rates of post-MI depression in an internal medicine clinic in Baker City and subsequent treatment practices and mortality. This study compared the prevalence of depressed post-MI patients in this Baker clinic to that of multiple national studies in which patients were comprehensively screened for depression following MI. National post-MI screening revealed a prevalence of depression between 16-23%. The documented Baker rates of depression following MI were 14.6% over the last three years, and 7.7% during the past year. However, the Baker general patient population had a lifetime prevalence of depression of 16%, comparable to the national average of 15%, indicating that depression in the post-MI patient population may not be recognized at the same rate. Regarding treatment of depression in patients at risk for MI, several studies suggest that the use of Tricyclic antidepressants is contraindicated, as they may potentiate a Class 1A antiarrhythmic effect leading to increased risk of mortality. In its place, selective serotonin reuptake inhibitors are now being recommended as first-line treatment for post-MI patients not only due to decreased cardiac side effects compared to older antidepressants, but also due to its inhibition of platelet activation. In the Baker City clinic, all documented depressed post-MI patients were treated pharmacologically. One third of the patients were treated with an SSRI alone, another third were treated simultaneously with an SSRI and a tricyclic (usually for another simultaneous condition such as chronic pain), and the last third were treated with antidepressants from other classes. Despite the use of TCAs in some of these patients, none of the depressed patients suffered mortality or a recurrent MI in the last 3 years. Although post-MI patients are being successfully detected and treated for depression, an improvement can be made in identifying more at risk patients and reconsidering the use of TCAs in this population. 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