RCHC Community Project Abstracts

Back to subject search page or search by preceptor site Childhood Obesity: A review of literature to support development of a community intervention Project Date: 10/12/2009 besity is one of the leading health concerns in the developed world. Being overweight and obese as an adult has consequences of type II diabetes, cardiovascular disease, hyperlipidemia, and exacerbates other health conditions such as arthritis. Obesity is growing not only in the adult population but also the pediatric population. More than 16% of children are obese or overweight currently, a 4-fold increase in the last 30 years. These numbers are larger in underserved and minority populations. The Community Health Improvement Partnership (CHIP) in Madras, OR has initiated a number of programs in the schools and community to fight obesity. There is interest in focusing on pregnant women and parents of young children to change behavior before it becomes habit. Background research was needed to identify which groups to target and how to have to most meaningful impact at a reasonable cost for the community. A review of the literature showed 1) the early in life the intervention, the more successful, 2) Interventions should aim at decreasing sedentary activity and unhealthy food choices 3) Anticipatory guidance and reinforcement of breast feeding, delaying introduction of solids and parental nutrition knowledge building are effective tools in preventing obesity. Physical activity group visit at the McClaine Street Clinic in Silverton, Oregon Project Date: 10/12/2009 Currently, in the United States, obesity is a growing problem with many related health concerns, the small town of Silverton, OR is not exempt from this problem and many of those who reside there are overweight. One of the health concerns related to obesity is Type II DM, this project attempted to identify some of those who are at risk of developing or who already have Type II DM, and get them involved in some type of physical activity. This was done through a group patient visit with a didactic session on exercise, followed by a 1 mile walk for physical activity, and ending with individual meetings to discuss their personal action plan for physical activity. Participants were selected based not only on their Type II DM risk factors but also if they were sedentary. Diabetic foot ulcers Project Date: 8/3/2009 The idea behind this project was to create a informative patient friendly handout with regard to diabetic foot ulcers. Diabetic foot ulcers are a common potential long term complication of diabetes. In the Mid Valley Medical Plaza about 2% of diabetic patients have this particular diagnosis. However currently there isn't a easy to understand, accessible resource to teach patients about diabetic ulcers. The goal of my project was to create a handout that would fulfill these requirements. A handout was created that was composed of 3 sections: what diabetic foot ulcers are and how they form, how to prevent ulcers and how to manage ulcers. Inactivated Influenza Vaccine Rate and Implications in Diabetic Patients in John Day, Oregon Project Date: 4/27/2009 Flu vaccination is an important preventative focus of diabetic care. Deaths and hospitalization from influenza are uncommon among the general population. However, diabetes puts people at higher risk for severe flu illnesses, secondary complications and death. Given the high prevalence of diabetes and the development of the diabetic questionnaire in John Day in November 2008, I would like to use this opportunity to understand whether the influenza vaccination rate is improving with the utilization of the questionnaire. The project is designed as a retrospective study for the inactivated influenza vaccination status on diabetic patients seen for the last two years in Blue Mountain Hospital, Strawberry Wilderness Community Clinic. A total of 307 diabetic patients were selected for the study. The result shows the rate of influenza vaccination increased from 30% in 2007 to 38% in 2008. Uncontrolled Diabetes in the Hispanic Community of Hood River, Oregon: Identifying Barriers to Good Diabetic Control Project Date: 10/13/2008 It is a well known fact that diabetes is one of the leading chronic diseases in our country today. However, it is not well known why some minorities have a higher risk to acquire this disorder. Compared with Caucasians, blacks have a 60 percent higher risk of developing diabetes, and Hispanics have a 90 percent increased risk. These numbers are astonishing. Now let us narrow our focus to the Hispanic group. Why is it that Hispanics are at higher risk? And why do they have higher rates of uncontrolled diabetes and less continuity of care for their diabetes in general? These are some of the questions that this brief study will attempt to answer. It will focus more on some of the barriers and problems faced by diabetic patients that receive their health care at La Clinica del Carino in Hood River, Oregon. 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. Community Diabetes Education: Development of a patient handout for Madras's Diabetic Workshop Project Date: 9/8/2008 Diabetes has become an epidemic in the United States with over 7.8% of the population affected. Jefferson County is not immune to this phenomenon and Madras Medical Group (MMG) has a large population of diabetic patients. Although no cure to diabetes is currently available, much can be done to prevent complications, improve quality of life and manage the disease through patient education and vigilant care. This project will provide educational information on how diabetes is managed in the primary care setting and what patients can do to minimize complications of diabetes. This information will be presented in the form of an informational pamphlet and a power point presentation to the Madras community at a local diabetes workshop. The content of the pamphlet was a representation of most frequently asked information in the primary care setting based on observations of patient-physician interaction in the office. Information was gathered from clinic staff and online diabetes resources in order to create the educational materials to represent MMG at the workshop. The workshop was set up to introduce diabetic resources to the community and provide information to diabetic and pre-diabetic patients, their families, and those with risk factors for diabetes about the disease. Enhancing Diabetes Care Project Date: 6/30/2008 Diabetes mellitus type II is nearing epidemic numbers in the United States, straining our healthcare delivery system. A complicated disease to manage, diabetes poses a particular problem for rural hospitals and providers who may lack the resources or continuity available to urban patients. Blue Mountain Hospital in John Day, Oregon has addressed the problem of complicated inpatient management, in part, by creating standardized admission and discharge orders for complicated problems. This project aimed to enhance diabetes care at BMH by adding admission and discharge order sets that any provider may use to streamline admission and improve the hospital course. In addition, patient education materials were found and provided. Due to low patient volume, the orders have not yet been used, but received positive feedback from practitioners, hospital staff, and the director of nursing services. Diabetes Education Among the Local Hispanic Population Project Date: 4/28/2008 The goal of my project was patient education in regards to diabetes. I focused on explanation of the disease, who is at risk for the disease, and what steps can be taken to prevent development of diabetes. My target audience was the Hispanic population that lives in the surrounding areas of Portland, therefore I made a brochure in Spanish explaining the things mentioned above. Educating and Empowering Patients and Physicians to Reduce Diabetes-Associated Morbidity in Eugene, Oregon Project Date: 4/28/2008 Diabetes is an epidemic in the United States. Successful management of A1C, LDL, weight, and blood pressure reduces diabetes associated mortality and morbidity. Patients and physicians have ever-increasing expectations to reach established target goals, many times without complete success. Reaching targets requires a partnership between the patient and physician; patient responsibility, motivation, and investment in their personal health care can have tremendous impact in outcomes. Educational and motivational barriers can be overcome through the use of a patient-specific visual risk assessment profile that demonstrates the direct influence patient actions today have on future risk of complications including heart attack, stroke, kidney failure, foot problems, and eye problems. The American Diabetes Association’s online Personal Health Decisions (ADA’s PHD) risk profile can be used by physicians and patients together in order to successfully move toward established targets, reducing morbidity. Specifically, integration of the PHD into the existing PeaceHealth Diabetes Wellness Assessment Program (DWAP) could increase successful management of physician and patient management of diabetic targets within the PeaceHealth system in Eugene, Oregon. 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. Screening for Depression in the Elderly in the Primary Care Setting: Piloting the Use of a Two-Item Questionnaire in Florence, OR Project Date: 4/28/2008 Depression is a major health issue among the elderly, with approximately 10% of adults aged 65 or older suffering from clinically significant depression. This problem is particularly relevant to Florence, OR, which has a large and growing retirement community. A major obstacle to addressing this issue in the primary care setting is that of efficiently screening for depression in a geriatric population with many co-morbidities that can confuse or overshadow mental health issues, and limited time to administer screening tests. Currently, elderly patients at the Florence family practice are only screened for depression at certain visits, such as annual diabetic exams. This project piloted the use of the two-item Patient Health Questionnaire 2 (PHQ-2) among all elderly patients visiting their family practice doctor in Florence, OR as a brief, efficient means of identifying depression in this population. The screening questions were verbally asked of patients age 65 or older, and the questionnaire results were analyzed to determine both total rate of positive screens and the number of these that were previously undiagnosed as depressed. The results of this pilot use indicate that incorporating the PHQ-2 into regular screening of elderly patients visiting the clinic could substantially improve detection of depression in this demographic. A better way to manage Diabetes in Eugene, Oregon: The DWAP Project Date: 10/15/2007 The prevalence of Diabetes Mellitus in the United States has been rapidly increasing in the past seventeen years. The complications of poorly managed diabetic care can be disastrous for patients, their families, and society as a whole. PeaceHealth Medical Group of Eugene, Oregon has instituted a Diabetes Wellness Assessment Program (DWAP) in order to maximize diabetes management and avoid these complications. The DWAP program follows the American Diabetes Association’s guidelines of care, and includes comprehensive visits, modifying behaviors, and data reporting in order to improve care for patients with diabetes. Since its inception three years ago, the DWAP program has shown widespread improvement in the way physicians and clinics manage this chronic and potentially debilitating condition. Pahe’yoo Meals of the Wadatika (Three Meals of the Burns Paiute Tribe) Project Date: 9/10/2007 Significant morbidity and mortality can be avoided in chronic disease states such as Hypertension, Diabetes, and health complications from obesity with simple lifestyle modifications such as a healthy diet and increased exercise. Many studies have emphasized this. By using surrogate markers such as blood pressure as a measure of cardiovascular disease and Hemoglobin A1C as a measure of diabetes control, doctors can monitor the progression of disease in a population. However, the doctors in Harney County often lament the poor health and poor treatment plan compliance among their Native American patient population, based on measurements of those surrogate markers. Barriers must clearly exist to patient compliance among the stated population. These can include mistrust of the medical community, inability to pay for services and medications, misunderstanding of treatment principles, and what types of foods constitute a healthy diet. How do you gain the trust of a patient population to help them to modify their current diet in a way that is beneficial in terms of health goals, but is also feasible, financially and culturally for them? What can be done to increase compliance and decrease the disease burden among Native Americans? While I cannot attempt to answer these huge questions in a lifetime of medicine, I can ask a smaller question which lead patient and provider in the right direction. What are the current dietary habits of the population in question, i.e., the Burns Paiute Tribe? Community Based Diabetic Retinopathy Screening: Non-mydriatic Imaging and Telemedicine Project Date: 9/10/2007 Diabetic retinopathy ranks as the leading cause of preventable blindness in the United States. Early detection and treatment can preserve vision, yet a fraction (~25%) of those at the highest risk receive annual screening for diabetic retinopathy. A new process that combines non-mydriatic retinal imaging with telemedicine at the primary care level promises to change this discrepancy. Within ten years of widespread implementation, Australia now screens most of its populace annually. Comparable success in being reported in this country where the strategy is gaining acceptance. Virginia Garcia Memorial Health Center now annually screens ~55% of its diabetic registry after it teamed up two years ago with Pacific University's School of Optometry for remote retinal reading. The feasibility of setting up an analogous program at the WSC was investigated here. Barriers were identified to avoid pitfalls in process set-up to allow smooth integration of retinal image capture within a scheduled diabetic visit. Funds from a CareOregon grant will be used to purchase a non-mydriatic camera. With the aim of preventing blindness due to retinopathy, the goal is increase annual eye exam screening among the WSC diabetic registry from 37% to >70%, a national standard set by the Diabetes Disparities Collaborative. Diabetes Education Handout Project Date: 8/6/2007 The number of people with Type 2 Diabetes is increasing in the United States. It is a major contributor to overall morbidity and mortality in the Untied States and in Astoria Oregon. There was an average of 41.8 deaths per year (17.5% of all deaths) caused by diabetes between 2000 and 2004 in the Astoria service area1. Following diabetes management guidelines can help decrease the associated morbidity and mortality of type 2 diabetes2.This study attempted to identify information that would be helpful in educating patients about newly diagnosed diabetes and compiling the information into a one page handout. A family doctor in Astoria was observed counseling newly diagnosed diabetics. Educational material for diabetics was reviewed. A handout for patients with diabetes was the end product. How Rural Practice Diabetes Management Meets Medicare's 2007 Physician Quality Reporting Initiative And Other Measures Of Clinical Quality Project Date: 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. Putting the brakes on diabetes in Eugene, Oregon by putting the facts in a patient's hands: Development of a handout incorporating diabetes risk assessment and prevention strategies. Project Date: 7/2/2007 Diabetes Mellitus has grown into one of the nation's largest health concerns for the new millennium. Because of its insidious effects on the arteries of many organs, diabetes has a significant morbidity and mortality. The cost of treating diabetes also has a significant impact on healthcare and the economy. Dr. Larry Hirons, a family physician in downtown Eugene, Oregon, has watched many of his patients develop diabetes. He is always counseling his patients concerning weight loss and exercise, but would like a more specific tool to help patients realize their risk for developing diabetes, why they do not want to become diabetic, and how they can avoid diabetes. The prevalence of obesity in patients presenting to Dr. Hirons was observed, as well as his interaction with patients motivating them to lose weight and avoid becoming diabetic. A literature search was performed to identify a tool for diabetes risk assessment as well as studies showing effective risk reduction strategies. A handout was designed using the information from the literature search and the effectiveness of this handout was assessed by patient and physician interviews. Treatment of the prediabetic patient in a primary care practice. Study of the current practices of managing prediabetic patients in Philomath, OR Project Date: 4/30/2007 Diabetes is a serious medical condition affecting 20.8 million children and adults in the United States, or 7% of the population. The diagnosis of diabetes has far reaching consequences including adverse effects on a patient’s kidneys, heart, eyes and nerves. There is growing evidence that a pre-diabetic states exists before the development of diabetes and that individuals in this state have the opportunity to prevent the disease through lifestyle changes in their diet and exercise regimens. The purpose of this project is to identify the prevalence of a population at high risk for diabetes, to assess current methods of diabetes prevention through interviews with family practice doctors and to develop effective patient education materials, which will help to teach patients methods to modify their risk for developing the disease. Education will be focused on lifestyle modifications with the goal of preventing the development of type 2 diabetes. Future projects may assess the effectiveness of these materials by long term follow up of the identified patient population and their propensity for developing diabetes. "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. No More Excuses Project Date: 3/19/2007 Type II Diabetes and Obesity are increasing in incidence at an alarming rate. It has been well established that diet and exercise is the treatment of choice for obesity and type II diabetes. This study attempted to identify the effectiveness of treating and managing type II diabetics with diet and exercise. The design was to document each diabetic patient seen over a 5-week period, the date they were diagnosed with diabetes, their BMI and HbA1C at diagnosis and their current BMI and HbA1C as well as the medications used to treat their diabetes. When able, patients were questioned as to reasons why they chose to not exercise. These values were put into a chart from which came the results: How many patients have managed to successfully treat his or her diabetes with diet and exercise alone. Finally, a pamphlet was made to help aid providers in educating patients on the benefits of increasing physical activity through little effort on behalf of the patient. The perioperative evaluation of the diabetic patient in Grants Pass, OR: A patient guide for long-term disease management Project Date: 3/19/2007 Diabetic patients remain amongst the more vulnerable and complicated surgical candidates. Experts agree that the most effective measure taken to minimize peri-operative morbidity is maintaining long-term glycemic control. During a family medicine clerkship in Grants Pass, Oregon, it was noted that both patients and providers felt that improving patient awareness regarding diabetes management is key in achieving the optimal glycemic control. Given the complexity and scarcity of local diabetes educational resources, a summarized guideline was designed in the form of a patient hand-out to enhance peri-operative cooperation amongst patients and their various health care providers. Based on the request of local family doctors, a portion of this hand-out was dedicated to dietary instructions and risk factor modifications that can serve as a supplement to in-office discussions between the physician and the patient. 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. 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. Diabetes Mellitus and Obesity in Eugene, OR: An Assessment of the Epidemic and Development of Treatment Recommendations. Project Date: 9/11/2006 Diabetes is a growing epidemic worldwide. In the U.S. diabetes is the sixth leading cause of death and affects 18.2 million Americans currently, with an estimated 5.2 million who have not yet been diagnosed. Importantly, overweight and obesity are the main modifiable risk factors for type 2 diabetes. The goal of this community project was: 1) to assess the nature of the problem of diabetes and its relationship to obesity at Barger Family Medicine Clinic, 2) to develop a guideline based on an extensive literature review in the management of diabetes and obesity and 3) to develop a hand-out and nutritional food guide for patients with diabetes. 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. Diabetic Retinopathy Screening at the West Salem Clinic Project Date: 7/3/2006 Diabetes mellitus is a common disease in the United States with an unfortunate catalog of debilitating complications. One of these complications, retinopathy, is the main cause of blindness in our working population. While blood sugar control is the primary method of preventing and treating all diabetic complications, including retinopathy, specific treatment is available for retinopathy and vision preservation. This project focused on the ways that a rural and underserved community identifies diabetic patients with retinopathy, and investigated one means of improving the screening rate. Non-dilated eye exams, performed in the primary care office, using a retina camera and a remote retina specialist evaluating the retina images, is an effective way of bringing the screening to the people. Published reports and a local farm-worker clinic using this model were investigated. Purchasing a camera and initiating a screening program is a promising opportunity. If enough of those screened have insurance to pay for the exam, the clinic can afford to screen those patients who are uninsured. Further investigation is required to identify an accessible and affordable option for treatment for those are found to have a positive screen for retinopathy. Medication Compliance in a Small Subpopulation of Elderly Patients in the Illinois Valley Project Date: 5/1/2006 As patients age, their risk of developing chronic conditions such as hypertension, diabetes, and hyperlipidemia increases. These illnesses are manageable by taking medications, but eventually patients may find themselves taking multiple prescriptions which may actually make it difficult to treat their illnesses if they are unable to comply. One reason for this is that as people age they may have increasing difficulty remembering things and may not be able to keep track of many drugs. In a rural setting other factors such as low incomes and long distances may also play a part in medication noncompliance. The family practice clinic in Cave Junction, Oregon consists of almost 2,400 patients; 26% are over the age of 65 and several of them have multiple chronic conditions. The goal of this project was to determine whether there are barriers to compliance with taking medications in this rural community and to identify solutions to resolve them. Ten home visits and eight phone interviews were conducted to determine which systems patients use in remembering to take multiple drugs. Most patients had lists and/or pillboxes to help them remember and were taking everything as prescribed. It was therefore concluded that medication compliance in this small subpopulation of elderly patients is better than expected and that they are not currently plagued by barriers to compliance. Even though these patients are able to get their prescriptions filled now, however, they are worried about rising costs. Many of them are of low income and therefore struggle to pay for their medicines. Patients with Medicare Part D are particularly unhappy because they pay more now than they paid before it was implemented this year. Rising costs and the new prescription drug coverage plan may represent future barriers to compliance for these patients. Surveying the diabetic patients at OHSU Scappoose Family Health Clinic: general characterization of the diabetic cohort and their interest in diabetes educational sessions. Project Date: 3/20/2006 Lying within the St. Helens service area, Scappoose is a town with a population of 5,480 where diabetes is the 6th leading cause of death by disease5. With its impending expansion of both location and medical personnel, the OHSU Scappoose Family Health clinic is poised “to expand the scope of services we provide [and] to dedicate more resources to patient education programs,” states Dr. B. Rugge, the Scappoose Medical Director. Among the patient education programs under development are diabetes education sessions in small groups. This project assists in targeting diabetes education sessions for adult patients of the Scappoose clinic. By creating and disseminating a survey to incoming diabetic patients at Scappoose during a 2.5 week period, the intention of this project was to better characterize the diabetic population and their concerns about their disease and its complications. 28 completed surveys yielded a 14% representation of the estimated total diabetic cohort. Generally, the results of the survey portrayed a population with the average age of 59 and average duration of diagnosis at 11 years. While 86% whom monitor blood glucose levels, the majority of them (32%) had cbg between 126-150. 64% of those surveyed were interested in attending education sessions. Finally, the top three most interesting diabetes related topics were nutrition, blindness and weight loss. Further specifics are found in the report below. Future considerations would include continuing the survey such that the majority of cohort will have an opportunity to complete the survey, and discovering deterrents to attendance in order to maximize participation. 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. Evaluation of Diabetes Mellitus Management in John Day, Oregon: Are current standards of care being implemented? Project Date: 2/13/2006 Diabetes Mellitus is a major medical problem in the United States, affecting 6% of the population. Due to the morbidity and mortality associated with diabetes, standards of care have been designed to help reduce complications of the illness. As part of maintaining its status as an Oregon Federally Certified Rural Health Center, the Strawberry Wilderness Community Clinic (SWCC) is required to perform yearly chart reviews. The purpose of this project was to develop a chart review form for diabetes screening and treatment based on established diabetes guidelines. This form was then used in a chart review of thirty patients, ten from three physicians, to assess if SWCC is currently implementing these guidelines in its practice. Results of the review demonstrated that physicians are meeting guidelines for HbA1c measurement, use of ACE inhibitors, reviewing self monitored blood glucose readings, and checking creatinine annually. Areas of improvement were found to be screening for dyslipidemia and microalbuminuria. The biggest deficits in care were found to be in ensuring that patients received yearly dilated eye exams, visual foot inspection at each visit, comprehensive foot exams annually, and using aspirin therapy in patients > 40 years of age. These results can be used by the SWCC to help design methods to improve deficits in diabetes management and therefore reduce morbidity associated with the disease in their community. 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. Ontario Health Initiative for Children Project Date: 1/2/2006 The prevalence of childhood obesity has more than tripled in the past 2 decades. As this number continues to rise, it is imperative that children become more educated about how they can live healthier lifestyles. The CDC indicates that the rise in obesity within the US is primarily due to poor nutritional intake and decreased physical activity levels.(5) This project focuses on educating the Ontario community and specifically the 4th grade classes at Alameda Elementary about how to balance good nutrition with daily physical activity. In accord with the CDC recommendations about health education and clinical experience, a poster was created to convey straightforward, attainable goals relevant to all age groups. This medium was chosen to create a publicly displayed message visible throughout the community: at the Treasure Valley Pediatrics clinic, Alameda Elementary, the upcoming Ontario health fair. Hopefully, this will help increase awareness about the importance of nutrition and physical activity in Ontario and lead to a healthier, more active youth. Diabetes management in John Day, Oregon: a summary of objective measures of diabetes care and the impact of an appointment reminder system on HbA1c testing frequency Project Date: 1/2/2006 BACKGROUND: The prevalence of type II diabetes is growing nationwide, a trend that includes both urban and rural areas. Intensive diabetes management is a cooperative process between patients and their health care providers: providers have an opportunity to help their patients intervene in an otherwise progressive disease by prescribing medications to improve glycemic control, blood pressure, and cholesterol, screening for complications, and encouraging appropriate lifestyle modifications. Rural settings have the unique challenge of meeting the needs of their patients and complying with complex documentation requirements without the benefits of extra staff or record systems dedicated to diabetes care. OBJECTIVE: The goals of this project were to summarize current objective measures of diabetes care in Dr. Holland’s practice in John Day, OR, assess the management of diabetes before and after the implementation of an appointment reminder system started in July 2003, and create a record system that the nursing staff can use to help improve the documentation of diabetes care. METHODS: A chart review of all patients with diabetes in Dr. Holland’s practice was performed. RESULTS: The chart review identified an average HbA1c of 7.5, blood pressure of 140/74, total cholesterol of 161, triglycerides of 169, HDL of 35, and LDL of 91. The implementation of the appointment reminder system on July 2003 improved the frequency of HbA1c testing. Finally, a database was generated to aid in identifying patients due for an appointment and in documenting vitals, exam findings, and lab values. CONCLUSIONS: Objective measures of diabetes control in Dr. Holland’s practice have been described, and strengths and areas for improvement were identified. Dr. Holland and the nursing staff plan to use the database generated as part of this chart review to aid in reminding patients about their appointments and in documenting diabetes care. 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. Obesity Associated Type II Diabetes Mellitus In Scappoose, OR, Adolescents: Awareness May Lead Early Diagnosis and/or Prevention Project Date: 10/17/2005 As in adults, the numbers of overweight and obese children and adolescents have tripled over the past thirty years. As a result, the incidence of type-II diabetes, conventionally known as “adult onset diabetes”, in childhood has risen 10 fold. Obesity and its related co-morbidities represent a major proportion of family practice office visits. Indeed, during my time in the Scappoose clinic the majority of the adolescents seen were either overweight or obese. The aim of this study was to determine, using provider interviews and information available for the prevalence of obesity at Scappoose High School, OR, if adolescents are at high risk of developing type II diabetes (DMII), and if so, what are the rates of diagnosis and factors which may limit the process. Adolescents of Scappoose, OR, in accordance to national trends, were found to be at risk of developing DMII but have low rates of diagnosis, raising a concern for the awareness of overweight and obese adolescent patients and their parents. Finally, using the information learned from the study a new patient handout was made, aimed at increasing patient/parent awareness of obesity and DMII, to improve prevention, detection, and long-term outcomes. Diabetes Mellitus Community Awareness Project Date: 8/8/2005 There are over 18.2 million people in the United States with Diabetes Mellitus. Only 13 million or so of which have been diagnosed. This leaves about 1/3rd with untreated Diabetes. Diabetes itself is the fifth leading cause of death, and a vast contributor to increased morbidity in the form of “heart disease, blindness, kidney failure, extremity amputations, and other chronic diseases. ” The cost of DM to the health care economy is enormous, with over 92 billion per year in direct costs, and an additional 40 billion in indirect costs. Per capita, more than twice the amount of health care dollars are spent on someone with DM than someone without. Various methods are proposed to help eliminate or reduce these problems through better access to preventative care, more widespread diagnosis, more intensive disease management, and through the advent of new medical technologies. The possible results of this project seem pretty intangible. The articles will be going in the paper starting this week and going for the next four weeks. Best case scenario: some people that were previously untreated, like the patient I saw in clinic, will decide to talk to their doctor about their symptoms. Further expansion of this project could include additional articles on Diabetes, to measuring the effect of these articles by comparing rates of DM diagnosis before and after the articles, or by supplying newly diagnosed diabetics with questionnaires about why they came to the doctor. In addition, further outreach could be undertaken, such as ads on the local radio station, or a booth at the County Fair (the first week of Sep). Also, many other health topics are not popularly known, so additional education could be undertaken through the weekly column in the local paper. Diabetes Management in Reedsport, Oregon, Is It Under Control? Project Date: 8/8/2005 Rural communities such as Reedsport, Oregon lack the majority of specialists that are present in urban communities. Because of this, most chronic diseases are cared for solely by the family physician. This project addresses the chronic care of diabetes in the Reedsport. This is done through chart reviews and a questionnaire of the physicians at the Dunes Family Health Care Clinic. It addresses the question of how diabetes is currently being managed in Reedsport, Oregon and suggests areas of improvement for increased quality of care in diabetic management. Awareness of Diabetic Foot Complications in Baker City, OR Project Date: 8/8/2005 Diabetic foot complications are associated with significant morbidity and mortality. Patient education has been shown to decrease diabetic foot complications. Therefore, the purpose of this study was to assess patient education in a rural community. The level of education in Baker City diabetics was found to be low compared to other studies. Complications reported among diabetics were also low, suggesting that the lower level of education has not adversely affected this population. However, the complication rates could be reduced and education was shown to have a positive effect on reducing complications. Additionally, annual foot exams, podiatry referrals and medication management were lacking, and could be improved with education. Thus, a patient education brochure regarding diabetic foot care would be appropriate. 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. Are Group Visits for Patients with Type II Diabetes a Feasible Option in John Day? Project Date: 7/4/2005 The potential morbidity and mortality associated with poorly controlled Type II diabetes mellitus makes patient education a particularly important undertaking in treating this chronic condition. Group visits have been shown to improve HgbAlc and cholesterol levels in patients with diabetes, as well as overall patient and physician satisfaction with care of chronic illnesses. The primary purpose of this study was twofold: to determine whether group visits were a feasible option for the residents of John Day and if so, to put together the necessary information that would facilitate easy implementation of group visits by Dr. Robert Holland. Methods: 1) a focus group was held among select patients with type II diabetes; 2) an interview was conducted with the registered dietitian (RD) to determine whether interdisciplinary support for such visits existed. 3) A review of the literature was conducted for structural and curricular development of a group visit. Results: 30% (4/12) of those invited to the focus group attended. All who attended were eager to participate in group visits. The resulting projected number of Dr. Holland's patients who would be interested in group visits is between 21-32 patients, a sufficient number to make the endeavor worthwhile from a business standpoint. Interdisciplinary support (RD) is available. Conclusions: Group visits are a feasible option in John Day, in terms of interest and from a business perspective. A packet of information for the clinic was compiled that should facilitate this endeavor. Diabetes Education in Scappoose, OR: Assessing diabetic education through the development of a patient questionnaire and educational handout Project Date: 3/21/2005 Diabetes is a very common disease in the U.S. and is growing in prevalence by the day. It is a major cause of morbidity and mortality and one of every ten healthcare dollars are spent on diabetes and its related complications.1 Since diabetics themselves are the one’s responsible for the prevention of long-term complications, they must be properly educated on the basic etiology of their disease and it’s management. This study attempts to assess the overall education on pertinent facts about diabetes in both the diabetic and non-diabetic population in Scappoose, OR, and then to educate patients on important concepts and common misperceptions of diabetes management. Overall, this study found that diabetics in general were not more knowledgeable about their disease than the non-diabetic population. In fact, the general population seemed to be more knowledgeable about the etiology, prevention and treatment of diabetes and the diabetic population sampled. Utilization of Eye Care Services by Patients of Scappoose, Oregon Project Date: 2/7/2005 Blindness and visual impairment currently affects over 3 million Americans and this number is growing. Visual impairment and blindness are easily prevented in many circumstances through timely eye screening and treatment. Rural populations are traditionally limited in availability of specialized care. The aim of this project is to determine patterns of utilization of eye care services in the rural town of Scappoose. To achieve this goal, patients were surveyed during a 2 week period regarding their risk factors, utilization of eye care services, and vision coverage. Seventy-three patients completed the survey. All of the patients were over 18, with a mean age of 46.57 years. Nineteen patients reported having existing eye disease that included age related macular degeneration, glaucoma, and multiple sclerosis. Seventeen patients reported a history of diabetes, 35 % of these patients had not received a comprehensive eye exam in the past 2 years. The most common reasons given for failing to seek eye care were lack of vision insurance and lack of tangible vision problems. Based on the findings of this survey, an informational brochure was produced for patients. This brochure focused on: 1. Highlighting current screening recommendations, 2. Educating patients regarding common eye disorders, and 3. Providing uninsured patients with resources to obtain vision coverage. This brochure was made available to patients in the clinic waiting room. The four primary care providers at Scappoose were also provided with copies of a recent review article tailored to PCP’s that highlights the recommended role of PCP’s in preventing blindness and visual impairment. Informal discussions were held with each provider to highlight the findings from this project and emphasize their role in vision screening. Working toward a Community based education approach for Diabetes management and prevention of complications in John Day, Oregon Project Date: 2/7/2005 Diabetes is a disease that is approaching epidemic proportions in the US. It is a disease with high morbidity and mortality due in large part to its complications. Intensive therapy has been shown to be important in the prevention and control of diabetes. Community - based education is one modality of treatment that has been shown to work to prevent development of, and reduce complications of diabetes. In this study I surveyed 68 diabetes treatment and management where patients had questions. The results of this survey show a high interest in small group-based education for diabetes. Issues that many diabetics had questions about included nutrition, medications, need for specialist exams, and blood testing. These topics could be covered in group-based education and supplemented with a brochure/handout. The results of this survey and production of this handout may be useful building blocks to establish community-based or small-group education in John Day, Oregon. Diabetes Mellitus is a common disease. Project Date: 2/7/2005 Diabetes mellitus is a common disease that is seen by a family practitioner on a daily basis. Aggressive glycemic control and preventive monitoring have been shown to help prevent end-organ damage. Many patients in the West Salem Clinic have not had a dilated eye exam in the last year. A chart review of these patients was conducted to identify areas of improved compliance. Several areas were identified including lack of data entry, lack of referral tracking, and lack of referrals. The area of most influence is with having providers use the diabetic logs that have already been provided. Lack of insurance is a minor problem and several solutions are discussed. A Diabetic Management Flowsheet for patients of Primary Care Physicians Based Upon Current Guidelines. Project Date: 1/3/2005 The management of the patient with Diabetes in the primary care environment is both a great challenge as well as a great opportunity for substantial prevention of serious sequella associated with poor control of blood glucose both over the short and long term. Many guidelines are recommended, and the burden of meeting these care guidelines falls squarely upon the primary care physician, and in rural communities the family physician is the first line of management, with more complicated cases being managed by an endocrinologist where geographically possible. The population targeted in this project is limited to those with diabetes being seen by Dr. Dan Gleffe, a family physician in Grants Pass for the past 18 years, but is intended to be usable by any primary care physician desiring to closely and systematically monitor recommended health guidelines of diabetics. Current management guidelines and recommendations were obtained and compiled onto a one-page table format in the attempt to standardize diabetic management and assist the primary care physician in attaining recommended goals. General Guidelines for Preventing Childhood Obesity, and a Closer Look at Progressive Resistance Training as a Therapy for Diabetic (Type II) Patients with Co-morbid Obesity Project Date: 7/5/2004 Obesity in adolescents and children is a growing trend across the US. It is not an isolated phenomenon but is a co-morbid condition and even a causal factor for many other pathologic processes. Among the Native Americans, there is an extremely high prevalence of obesity and diabetes mellitus II. In Burns, there are efforts to make obesity more visible on the health awareness billboard. This will be a continuation of the project started by Alison Bahr, a former medical student in Burns. This project will provide two handouts. One handout will outline the guidelines for the prevention of childhood obesity, and will be made available for the Logician digital system at the clinic. The other handout will discuss options in physical activity as an adjunctive treatment of obese diabetic patients, and will be submitted to the Burns Times-Herald for public awareness. Lack of Health Care benefits Project Date: 3/29/2004 In the past 6 weeks I have been very fortunate to work with Dr. Lance Loberg, Medical Director for NW Human Services community clinics. Because of the comprehensive care provided through this agency, I had the unique opportunity to see patients at the West Salem Clinic, Total Health in Monmouth and H.O.A.P. Mental Health clinic for the homeless and underserved. The experience of being immersed in the lives of such diverse populations enabled me to learn their different interests and life dreams as well as their common fears and frustrations. In a short time, it became frightingly apparent to me how many members of the Salem communty were living with diabetes and felt like they were fighting against more barriers than they could handle. With the decline in health care benefits and services, most patients had lot their mental health and prescription coverage. This left them using unavailable financial resources to provide for medical care and medications. Combined with the current unemployment rate and the increase in costs of living, many hard working people found it necessary to choose between their health and the basic welfare of their family. Community Resources for Patients with Diabetes Requiring Yearly Eye Exam Project Date: 1/5/2004 The West Salem Clinic is found actively engaged in implementing the Diabetes Collaborative II by applying the Chronic Care Model. Last year’s significant gains in improving the proportion of patients with HbA1c less than 8%, LDL-C less than 130mg/dl, and increased empowerment of self-management goals for patients with diabetes has given a new outlook in terms of dealing with chronic diseases such as diabetes. The Chronic Care Model, through its extensive integration of clinical information systems, self-management support, delivery system design, community resources and policies, health care organization, and decision support, has been monumental in achieving these tremendous advances in the care of patients with chronic diseases. As part of my community project, I explored community resources in the Salem area particularly in regards to eye clinics that provide charitable care and/or discounted fees for a yearly eye exam of uninsured patients with diabetes. I also attempted to do a survey on how the uninsured patients of the West Salem Clinic are fairing with regards to their recommended annual screening eye exam. As the result, I was able to find close to twenty eye clinics that offer or are willing to offer assistance for patients who do not have the resources to get an eye exam on their own. However, the part of my project that deals with the survey was not successful since I was able to contact only 3 out of 14 registered uninsured patients from WSC database. Most of the patients had either moved away or did not leave their contact information when they left the Mission (a temporary shelter that houses homeless individuals in the Salem area). Knowledge and epidemiology of diabetic risk factors among The Baker City high school population Project Date: 11/10/2003 Adult onset diabetes and the devastating sequela that result there from are not only occurring in greater prevalence in this country, but are also occurring younger. After making the disturbing diagnosis of adult onset diabetes in a 28 year old patient and observing her remarkable ignorance of the disease and its consequences, the question was asked, "how much does the younger generation know about diabetes and how many of them are currenly at risk for developing adult onset diabetes"? This study was designed to assess the current knowledge of diabetes among the high school aged students in Baker City Oregon, whether they appreciate the effects of the disease, its preventablitiy and treatments, to educate them as to the seriousness of the disease, and finally, to determine the prevalence of diabetic risk factors among them. The study was conducted with the participation of 4 high school health classes (3sophomore classes and 1 junior) and was seperated into three major parts: a 10 question test consisting of baskic but pertinent diabetic questions, a 30 minute lecture following the test, and the collection of fasting sugar levels, blood pressures and abdominal cirumferences to ascertain the prevalence of certain risk factors. In addition, both high school health teachers were present during the lectures and received the nexessary materials and instruction to present an updated lecture to their classes in the future. The goals of this project closely mirror the three segments to which it was administered namely, to determine if a need exists in Baker City to better educate high school students of the effexts and precalence of adult onset diabetes ( as indicated by either a gross ignorance of the disease, a high prevalence of risk factors, or both), and to equip those students, as well as their health teachers, with the information to help aid themselves and others in the prevention of diabetes. Early intervention to prevent diabetes in Lebanon, Oregon: development of a patient education pamphlet on insulin resistance syndrome for clinical use Project Date: 11/10/2003 Insulin resistance syndrome (IRS) has been established as the predictor for diabetes1. The prevalence of insulin resistance in the U.S. is estimated at 70-80 million. Without intervention or treatment, patients with this disease will progress to impaired glucose tolerance or overt diabetes within 10 years2. Primary care physicians are currently actively identifying patients whom they suspect to have insulin resistance or at risk for pre-diabetes so that aggressive lifestyle modification can be used to prevent the progression from insulin resistance to overt diabetes in these patients. In Lebanon, Oregon, family physicians are diagnosing many patients with insulin resistance syndrome or pre-diabetes. As a result of the complexity of this disease, patients often fail to understand their disease and its implication on their health or the goal of the treatment; therefore, they often become noncompliant with treatment plans (diet, exercise and hypoglycemic agent such as Metformin). Patients diagnosed with this syndrome are asymptomatic and are less motivated to change their lifestyle than patients with other diseases such as myocardial infarction. Newly diagnosed patients are initially educated with slides on the topic of insulin resistance at their doctor's office in the Mid-Valley Medical Group. These educational slides are provided by the Endocrine Society as a patient education aid3, 4. However, patients remain unsure and confused about their diagnoses of IRS and require subsequent reinforcement during follow-up visits, pre-diabetic classes and discussion with registered dietitians. During the first week of my rural rotation, I had to explain to many patients at the Mid-Valley Medical Group practice what insulin resistance is by using diagrams and hand drawings. I quickly realized the need for a patient educational pamphlet on insulin resistance syndrome. This patient pamphlet would also serve as a resource for pre-diabetic patients and introduce them to the pre-diabetes classes offered by Samaritan Lebanon Community Hospital (SLCH). This pamphlet was put into clinical use during the last week of my rotation in Lebanon and was very well accepted by patients and physicians. Diabetes Management Guidelines in Lebanon. Project Date: 8/18/2003 My rural rotation took place in Lebanon, Oregon. During my five weeks there, I encountered several patients with poorly controlled diabetes. Therefore, the goal of my community project was to increase the awareness and the knowledge level of patients with diabetes. I created an informational sheet that physicians could give to patients with diabetes. This informational sheet covered the definition, prevention, treatment, complications, prevalence, diagnosis, online resources, and risk factors of diabetes. The point here was to increase patient’s knowledge in order to empower them against their disease. Hopefully, with this knowledge base, patients could take an active role in controlling their diabetes and preventing complications. Care Of The Type 2 Diabetic in John Day, OR Project Date: 7/7/2003 Type 2 diabetes mellitus (DM) continues to progress to epidemic status in America today. It is an illness that requires both diligent and coordinated care of a gifted team of medical professionals. In a rural community the responsibility of care coordination, as well as other roles usually filled by consultants, lies in the hands of the primary care physician. A two physician, private practice clinic in John Day, Oregon, was the site of a quality assessment project that both examined and attempted to improve the consistency and quality of diabetic care. A system modeled after the pap and physical reminder cards was implemented with a trial of fifteen patients. Investigating the diabetic population of Florence, Oregon. Project Date: 8/18/2003 As people age their risk of developing diabetes mellitus type II increases. Florence is a growing retirement community with a large population of individuals with diabetes. The long-term complications of diabetes can be very devastating to an individual. A survey of 18 diabetic patients was conducting to evaluate their knowledge about diabetes. This will show us if the education that they are receiving is effective and if they are retaining the knowledge. The patients will also rank their knowledge and this will be compared with the number of questions that they get correct on the survey to assess true knowledge vs. perceived knowledge. The survey showed that the perceived knowledge vs. true knowledge did not correlate well. The regression line for this data was 0.0392. Many participants did not know the complications of diabetes, the function of insulin, or what their blood sugar should be in the morning. The patients seemed to be losing a lot of the knowledge that they learned during their diabetes education classes. Integrating refreshing education courses could be beneficial to these patients. Diabetic Disparity: The Educational Divide Between Hispanic and Caucasian Diabetic Patients Project Date: 7/7/2003 Diabetes is highly prevalent chronic disease that affects Hispanics more often than Caucasians. Its prognosis can be significantly improved with proper education. Unfortunately diabetic Hispanics have historically been under-educated on their disease. Hispanic diabetic educational status was evaluated in a Salem, Oregon non-profit clinic to determine whether this historical discrepancy existed in this population. No statistically significant educational deficit was found between Hispanic and Caucasian populations, however it is suggested that further analysis be performed and more Spanish-language material be made available for patients. Does Diabetes Play Fair in Coos County? An Attempt to Even the Playing Field. Project Date: 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. Diabetes: Low Diabetic Follow-Up Rate in Florence, Oregon Project Date: 3/24/2003 Having noted a low percentage of annual diabetic follow-up in Dr. Dodson’s practice (59% of 46 patients reported as not coming in for over a year), especially compared to other doctors in the same clinic, Dr. Dodson and I posed the question, “why aren’t his diabetic patients coming back to the clinic to be seen for their annual diabetic visit (termed DWAP--diabetic wellness assessment program--exam by this clinic)?” For my Florence, Oregon community project, I isolated Dr. Dodson’s diabetic patients, especially the ones noted by the diabetic counselor that hadn’t been seen for their DWAPs in over a year. I did a chart review on all of his diabetic patients and a phone interview with each of those without an annual DWAP regarding their reasons for failing to be seen. Surprisingly, I found that most of his patients actually had been seen by him for a DWAP in the last year, are currently seen by an endocrinologist for their diabetes, or are no longer under Dr. Dodson’s care. 3 patients he had performed equivalent testing for without equivalent documentation; 4 patients’ tardiness was due to inadequate clinic follow-up scheduling during an organizational transitional period, now resolved. The rest (only 5) had individual mitigating life circumstances. Only 1 patient seemed to truly be uninterested in aggressive follow-up, quite contrary to what we had expected. Therefore, the vast majority of Dr. Dodson’s patients have more than adequate diabetic follow-up, reflecting both his and Peacehealth’s commitment to diabetic health. Diabetes Mellitus at Klamath Family Practice Evaluating the Amount of Medical Care Given and Improving Analysis of Blood Glucose Self-Monitoring. Project Date: 3/24/2003 Diabetes Mellitus is significant national, state, and local problem. At Klamath Family Practice management of diabetes mellitus involves diabetic self-monitoring of blood glucose. The goals of the community project were therefore twofold. One goal was to quantify the amount of care at Klamath Family Practice dedicated to patients with diabetes mellitus. The second goal was to evaluate and improve diabetic self-monitoring of blood glucose by instituting a system for downloading patients’ glucose meter readings into a software program, which could save and graph readings for provider analysis and diabetic management. The community project showed that approximately 19.6% of patients seen per day at Klamath Family Practice have diabetes mellitus. Evaluation of diabetic self-monitoring at Klamath Family Practice revealed that 34.1% of patients already owned Accu-checkÒ meters, 27.3% had OneTouchÒ meters, 22.7% had GlucometerÒ meters, and 15.9% did not know which brand of meter they owned, had another brand, or owned no meter. Equipment for downloading readings from the three most common brands of meters owned by patients was evaluated. LifeScan, the maker of OneTouchÒ meters, supplied meters capable of data transfer and the computer equipment necessary to download patient readings. However, other OneTouchÒ meters exist that use less expensive test strips and from which data can also be downloaded in the clinic, and this information will be made available to patients. Klamath Family Practice may also choose to offer data downloading for Accu-checkÒ and GlucometerÒ meters. The Screening and Control of Hypertension Among Diabetics by Family Practitioners in Rural John Day, Oregon. Project Date: 3/24/2003 Hypertension in diabetic patients leads to multiple and severe complications. In 2002, the American Diabetes Association recommended that blood pressure in diabetics be maintained below 130/80 with an optimal goal of 120/80. But studies indicate that only 11-25% of diabetics with hypertension are effectively managed to meet the ADA standards. Via a chart review of 83 diabetics, this study provides an assessment of screening for and control of hypertension among diabetics in rural John Day, Oregon. Four primary aspects of care were evaluated including the prevalence of hypertension among the patients, the adequacy of screening, the adequacy of starting treatment, and the efficacy of the treatment. Additionally, a comparison between the two clinic physicians was executed in an attempt to identify any variations in practice measures. Results indicate that 21.6% of definitively hypertensive diabetics in John Day, Oregon are effectively screened and managed. However, this success rate drops to 18.6% if patients with borderline hypertension are included in the study pool. Both of these values suggest that the efficacy of hypertension screening and management in rural Oregon proves comparable to the national standard. Interestingly, the comparison of physician practice profiles reveals differing tolerances with respect to meeting ADA recommendations suggesting individual variation. It appears that these discrepancies stem from differences in training depending on when the physician was trained and what the management criteria for hypertension in diabetics were at that time. To educate physicians about current guidelines and to facilitate the ease of patient monitoring, a Diabetic Flow Sheet was created to be included in the charts of diabetics. The hope is that this will improve the screening and management of hypertension in John Day to a level that far exceeds the national average. Discovering Diabetes Education in Klamath County: Diabetes CareLink Project Date: 11/4/2002 Problem: 16 million people in the United States are estimated to have diabetes. Diabetes is a chronic disease and therefore requires time, money, and education. The Task Force on Community Preventive Services (Task Force) found that diabetes self-management education (DSME) provided in the community setting resulted in improved glycemic control and recommended that DSME take place in community gathering places for adults with type 2 diabetes. According to the Oregon Public Health Department, of the 705 deaths in Oregon from diabetes in 1995, 4% occurred in Klamath Falls. People with diabetes in Klamath Falls would greatly benefit from better glycemic control and hence from DSME. Population: The population studied were residents of Klamath County of all ages with type 2 diabetes. Methods: I interviewed the diabetes educator of Diabetes CareLink, a DSME program in Klamath Falls, and several participants. I also attended a community diabetes education seminar, conducted a survey, and attended a local diabetes support group. Findings: Survey results showed increased understanding of diabetes among participants of Diabetes CareLink. Diabetes CareLink meets the Task Force’s criteria of a DSME by providing group or individual classes. Discussion: Diabetes CareLink is a good example of a DSME that is working in a rural community. Type 2 Diabetes Mellitus in Florence, Oregon. The Cost of Disease Management Project Date: 12/30/2002 Diabetes Mellitus is a disease marked by several pathophysiologic consequences including hyperglycemia and eventual end organ disease secondary to altered physiological states. Type 2 Diabetes (DM2) is manifest by insulin resistance leading to eventual impairment of insulin secretion by the pancreas and increased glucose production via gluconeogensis in the liver. The prevalence of DM 2 is rising in the US and is expected to continue to rise rapidly due to the occurrence of obesity and reduced activity levels. Oral hypoglycemic drugs are a major line of therapy in the treatment of DM 2. Many people diagnosed with this health challenge in Florence, Oregon are part of a population that might have limited assistance accessing drug therapies due to the limitations of traditional Medicare coverage. As many patients must contribute to or are completely responsible for the cost of medication and these drugs reduce long-term complications, the patients encumbered by this disease are in essence buying their long term health. Mexican American attitudes and perspectives regarding Type II Diabetes and its modifiable risk factors. Project Date: 9/23/2002 CONTEXT: Mexican Americans have a genetic predisposition to Type II Diabetes Mellitus, whcih theoretically evolved from a "thrifty gene". In an increasingly obese and sedentary society, the frequency with which Mexican American youth and young adults are acquiring Type II DM is reaching epidemic proportions. OBJECTIVE: To explore cultural-specific attitudes and beliefs pertaining to Type II DM and its modifiable risk factors with the goal of providing valuable information about prevention strategies in a culturally-sensitive manner. DESIGN: A cross-sectional survey of 15 parents of school-aged patients at the Woodburn Pediatric Clinic appearing for routine clinic visits. Specific information about respondents included age, country of birth, and linguistic capabilities. Children's ages, weights (kg), and heights (meters) were recorded. BMI's were calculated using the equation kg/meters squared. Respondents answered 10 short-answer and 5 multiple-choice questions in their language of choice (Spanish and English), which addressed attitudes and beliefs surrounding four major themes: Diabetes, obesity, eating habits, and physical activity. Brief 5-10 minute follow-up interviews conducted by a skilled bilingual investigator provided clarifications of both questions and answers and explored additional commentaries on behalf of respondents. RESULTS: One-third of patients were considered obese (95th percentile or greater for weight) The majority of parents attributed diabetes and obesity to the excessive consumption of foods high in fat and carbohydrates. Only two believed diabetes was due to a "susto" (fright). Parents of obese children were concerned about their children's weight. Most parents felt that it was important to provide a variety of fruits and vegetables to their children and convince them that fruits and vegetables were necessary for good health. Half of the children engaged in sedentary activities (TV, video games, computer) for 3 or more hours per day. Seven of the children engaged in near daily physical activity, however the majority of these had a BMI at or above the 90th percentile. Parents who were active on a daily basis attributed activity to work-related activity (3) or walking 1/2 to 2 miles per day (3). The remaining nine were minimally active or sedentary. Parents encouraged their kids to engage in sports so they can be healthy, but only three were proactive about exercising for health and involving their kids in habitual exercise regimens. CONCLUSIONS: Mexican American parents are appropriately aware of the role of excessive fats and carbohydrates as a risk factor for diabetes. However, there is little awareness about the role of physical activity in diabetes prevention. In general parents do little to encourage their children to exercise, nor do they model physically active lifestyles to their children. Recommendations for cultural-specific approaches to diabetes prevention were provided based on these findin Managing Your Diabetes: A blood glucose diary and educational brochure designed for education, motivation and improved utilization of the 15-minute appointment Project Date: 8/12/2002 Diabetes Mellitus (DM) is a serious and potentially deadly syndrome that affects 6.2% of the United States population. It is also a financial burden. The estimated cost of annual medical care for diabetics (direct costs) is $100 billion. Fortunately, it is also controllable. Through observation of family physicians, nurses, and diabetic patients, at Philomath Family Medical Practice, three issues fundamental to diabetes management were identified: 1) time limitations (15-minutes) of the diabetic appointment 2) education 3) motivation/morale. Both a blood glucose diary and an educational brochure were developed to try and address these three issues. Prevalence of Diabetes Mellitus at the Philomath Family Clinic. Project Date: 8/13/2001 This study sought to determine the prevalence of diabetes at the Philomath Family Medical Clinic, a single-site provider clinic served by five physicians. The design is a chart review of the patient encounters for the year from August 1, 2000, to August 1, 2001. Outcomes were measured by ICD-9 codes reported for patient visits. Out of 5381 patients seen, 240 carried a diagnosis of diabetes. The report compares diabetes prevalence for this population against national and statewide estimates and suggests directions for future lifestyle interventions for this population. Back to subject search page or search by preceptor site