RCHC Community Project Abstracts

Back to subject search page or search by preceptor site How effective is dyslipidemia screening in the Peace Harbor Family Medicine Clinic? Project Date: 9/7/2009 This study looks at the prevalence of dyslipidemias in a Family Medicine outpatient clinic in Florence, Oregon. The Peace Health electronic health record was used to identify adults 18 and older with at least one dyslipidemia; lower than recommended for HDL, or higher than recommendations for total cholesterol, LDL, or triglycerides. Medication lists were used to identify those receiving treatment, including omega-3 fatty acid supplements, statins, niacin, fibrates, etc versus those with no cholesterol treatment listed. 86.8% of patients in this population were found to have at least dyslipidemia, and 59.3% of these patients were receiving treatment. A patient handout on dyslipidemias, treatment, and the importance of screening was designed from this information. Chronic opiate therapy in the rural setting: special considerations and concerns Project Date: 9/7/2009 Chronic opiate use represents a challenge for rural providers. These patients often have pain with no treatable cause and may be high utilizers of clinical time. In the absence of pain and addiction specialists, it falls to the family doctor to manage these issues. There are many resources available to providers including online pain management recommendations and recently the Oregon Senate recently passed Bill 355 creating a controlled drug database. This project explores the role of this new program in the development of a standardized pain agreement and the management of these patients in the clinic. Medical Marijuana in a Small Town: A Growing Issue Project Date: 9/7/2009 Several states have laws approving the use of marijuana for medical reasons. This requires a special permit and a Doctor’s approval. However, while state government may allow the use of medical marijuana the Federal government still considers it illegal whether for medical use or not. Therefore doctors are wary of discussing or prescribing medical marijuana. Not only do the rules between state and federal government differ, the actual long-term health affects of marijuana is not well understood. For every study that quotes a therapeutic use another shows that long-term use can cause harm. Other studies suggest that marijuana interacts with other medications making it difficult for physicians to know whether the risks of using marijuana outweigh the benefits. Despite these concerns, medical marijuana is being requested by patients more often. This may be more common in certain populations or areas of the state. So not only are the uses of medical marijuana not well understood, the actual number of patients requesting or using medical marijuana is rapidly growing. In my project I will attempt to gain a better understanding of the patients who ask for or use medical marijuana by looking at certain variables such as the reason for requesting medical marijuana, the age, gender and other medications used. An attempt will also be made to estimate the total number of patients with medical marijuana cards in a small southern Oregon rural practice. I also hope to gain more information from clinics that specifically work with patients desiring medical marijuana cards. All this information will be gathered to gain a better, broader understanding of medical marijuana and those who ask for it. Medical Marijuana for Chronic Pain Management at a Mixed Rural/Urban Adult Primary Care Practice: Project Date: 9/7/2009 Following passage of the Oregon Medical Marijuana Act in 1998, medical marijuana has been available to Oregonians with severe pain with the endorsement of their physicians. However, this is a controversial subject involving debates of medical marijuana’s legality and effectiveness for treating chronic pain. While scientific evidence supporting an analgesic benefit of medical marijuana has started to materialize, legal conflict between federal and state statues remains. Complicating this is the unique nature of medical marijuana. It is patient-directed therapy that has standard preparation and consequently, diminished ability to determine dose received. These factors have made it hard for physicians to equate treatment with benefit. While working with Dr. John Allcott at Applegate Medical Associates, a primary care clinic with offices in Veneta and Eugene, OR, a 3 component strategy was derived to monitor the effectiveness of therapy for medical marijuana patients. The components are: 1) determining the level of patient disability through evaluation of patient ability to achieve patient-directed goals addressing social, emotional and physical parameters. 2) Educating patients about possible benefits of medical marijuana, potential adverse reactions, and risks of use. 3) Reviewing patient progress with data obtained from standardized instruments (the PHQ-9 depression screening questionnaire for example) and patient ability to achieve individual goals. The final result was a proposed set of questions to be entered into the EMR and utilized by the clinic staff for medical marijuana patients. 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. Prevalence of Antibiotic Resistant Bacteria Project Date: 4/27/2009 I studied the prevalence of antibiotic resistant bacteria among the population serviced by the laboratories at Silverton Hospital. Antibiotic resistance data for 2009 was obtained for the following species: C. feundii, E aerogenes, E cloacae, E faecalis, E coli, K. oxytoca, K pneumonia, M morganii, P. mirabilis, P. aeruginosa, S marcescens, S aureus, S epidermidis, S. saprophyticus, S. agalactiae. Sensitivity data for the following drugs was available: Amikacin, Ampicillin, Aztreonam, Cefazolin, Ceftazidime, Ceftraxone, Cefuroxime, Ciprofloxacin, Clindamycin, Ertapenem, Erythromycin, Gentamicin, Imipenem/Cilast, Levofloxacin, Nitrofurantoin, Oxacillin, Piperacillin/Tazobactam, Sulfa/Trimethoprim, Tetracycline, Vancomycin. Relevant literature was reviewed including data from national levels and from the greater Portland area. There is data in the literature to suggest that regional antibiograms provide accurate, cost effective information for local providers concerning trends in community-specific resistance trends. Providing sensitivity that is regional and accurate will help to guide empiric therapy of common infections, and can ultimately help to decrease the rate of increase in resistant bacteria. Helping Chronic Pain Patients Improve their Pain and Functioning Project Date: 3/16/2009 Chronic pain is frustrating for patients and physicians alike. It is costly to society in terms of lost productivity and high use of health care resources. Medications are one component of managing pain, but they are most effective when combined with exercise, relaxation, nutrition, and counseling. Like patients with other chronic diseases, those with chronic pain must move from being passive recipients of care to informed, active participants if they are to improve their functioning and quality of life. This project consisted of designing a group visit with an educational didactic session followed by brief individual visits using measurement tools and a standardized progress note to set and evaluate goals, progress, and effectiveness of treatment plans for OHP patients in Silverton, OR. While this project is an attempt to implement a chronic care model with limited resources of a small practice, patients could certainly benefit from a counselor specializing in cognitive behavioral therapy. A Brief Sojourn in the Land of Chronic Pain Medication, as experienced at Scappoose Family Medicine Project Date: 8/4/2008 A recent article in the New York Times detailed the increasing use of methadone for chronic pain in the primary care setting. Often considered by the public as a drug for drug addicts, it is an opioid similar to the prototypical opioid morphine. However, methadone has substantially different pharmacokinetics, and these properties may make the drug dangerous to certain patients. Still, the increase in methadone use continues, likely due to its lower cost relative to other extended-release opioid formulations. Does this pose problems for primary care patients with chronic pain and public benefits such as CareOregon? Does it pose problems for providers who are unaccustomed to or uncomfortable with methadone's pharmacokinetics? Though this short study cannot answer these questions definitively, by considering the patients of OHSU Family Medicine Scappoose, we can learn about chronic pain medications and their use. We also can glean some providers' opinions regarding the prescription of methadone, and the restrictions that they face due to many patients having public benefits. Finally, we may remind ourselves as clinicians that hidden dangers lurk for patients starting methadone, or for those converting to methadone from another opioid. Reviewing the Changeways Program as a treatment for depression in a rural setting Project Date: 6/30/2008 Mental health care treatment options are limited in the Coquille area. The Changeways Depression Program is a psychoeducational group therapy protocol designed to introduce clients to basic psychological self-care concepts. A group of patients with depression went through the 10-week program earlier this year. In this rural project, interviews were used to review the effectiveness of the program from the group members' perspectives. Overall, the group support setting was appreciated by the participants, and the lesson material was well liked, even though all of the group members still suffer from depression and all continue to take antidepressants. It is the conclusion of this project that the Changeways program should continue to be used, with increased recruitment effort and better data collection. Avoiding Unintentional Doping Violations Project Date: 4/28/2008 The problem addressed in this project was the possibility of a volunteer physician at the 2008 Olympic Trials causing an unintentional doping violation in an elite athlete/patient, by unknowingly prescribing a medication containing an agent prohibited by anti-doping regulations. The proposed solution was the creation of a concise educational report, detailing the appropriate prescribing practices for elite competitive athletes, and warning them of the often-prescribed medications which may cause positive drug screen results. This was accomplished by researching the anti-doping policies, practices, and requirements of US Track and Field and the International Olympic Committee, and the US Anti-Doping Agency and World Anti-Doping Agency. Research was also done to determine the medications most likely to cause unintentional doping violations. The result was a concise report, intended to be distributed to the physician volunteers for the Olympic Trials. True assessment of the success of the project would require follow up surveys of the physicians after the conclusion of the competition. Feasibility Study of Vitamin K Supplementation to Treat Patients with Unstable Anticoagulation on Warfarin at the Scappose Family Practice Clinic Project Date: 4/28/2008 The management of warfarin therapy affects a large segment of the aging population and is expensive and time consuming for the patients and clinicians. For many of the patients at the Scappoose Family Practice Clinic, it was a financial hardship to take time off work, find transportation and pay a $20 co-pay each time they needed their Warfarin dose adjusted. This is in addition to the financial and medical devastation such as stroke or hemorrhage that could result from a patient being under or over anticoagulated. The purpose of this community project was to design a study to test the hypothesis that 150mcg of daily Vitamin K could stabilize patients on warfarin in an INR range of 2-3 and reduce the frequency of warfarin dosage adjustments. Phase I consisted of a literature search and then based on previous studies developing inclusion and exclusion criteria which would be used to identify a subset of patients at the Scappose Family Practice Clinic who would be eligible for this study. Once these patients were identified, a retrospective chart review was done collecting data on these patients for the period 11/1/07 - 5/1/08. Phase II will involve giving these patients 150mcg of daily vitamin K and collecting data for 6 months. We will then compare the two data sets. If the results indicate that 150mcg daily vitamin K improves anticoagulation control in patients with unstable INRs, this protocol can then be initiated to the benefit of the patients and the clinic. Mental Health Care Practitioners in Philomath, OR: Difficulties with access and availability. Project Date: 4/28/2008 The supply of both prescribing mental health care providers as well as licensed therapists in rural settings in the United States is a major problem. Subsequently, there is a significant shortage of available providers to see patients in a timely manner. Although many primary care physicians, such as family medicine doctors, are capable of supporting and treating many patients with psychiatric problems, most lack both the time necessary to engage in meaningful therapy as well as the skill set required to manage acute mentally ill patients well. For these reasons this project was developed in order to better characterize the local deficiencies in mental health care services and access as well as to offer a potential solution by generating a viable list of providers in the area that are accepting new patients. A general consensus within the Philomath Family Medicine clinic indicated a shortage of rapid access to prescribing mental health care providers was present and that more providers were needed in the area. A provider list was generated four years earlier through a similar project, although many of the physicians, counselors, and therapists on that list were either no longer in the area, or they were no longer accepting new patients. The primary care physicians felt an updated list of social support structures (public and private), psychiatrists, counselors, and therapists in the area would be of value. Through the use of various resources, a thorough list was created and included such information as a description of the practice with areas of interest/specialization unique to the provider, the current waiting time to be seen, eligibility requirements, and payment structure. Antibiotic resistance data for Lower Umpqua Hospital and the surrounding area for 2007. Project Date: 3/17/2008 Emerging antibiotic resistance of bacteria is a major problem in healthcare. It is a frequent cause of morbidity and mortality in hospitalized patients and is a major financial burden. As resistance patterns increase, newer and more expensive antibiotics must be used. Several strategies have been postulated to prevent these resistance patterns. They include: minimizing inappropriate use of broad spectrum antimicrobials, knowledge of local resistance patterns, prompt initiation of empirical therapy, using proper dosing and dosing regimens, prompt narrowing of antimicrobial therapy, and antimicrobial cycling. To date, antibiotic resistance in rural hospitals has not been well studied. At the Lower Umpqua Hospital (LUH) in Reedsport, OR, due to a low volume of cultures, antibiograms are not routinely done. Thus, to aid the physicians in understanding the local resistance pattern of their hospital, antibiotic resistance data was gathered for LUH between 2007-08, and 2008-present. Additionally, resistance patterns were gathered for the two nearest hospitals: Peace Harbor in Florence, OR and Bay Area Hospital in Coos Bay, OR in order to both compare the different communities and provide further information is aid in antimicrobial prescribing, since the these three hospitals often share patients. This information was presented to the physicians of LUH in order to help in the prescribing of the cheapest, narrow spectrum antibiotics possible for their patients. Generally, the resistance patterns at LUH were better than that of the surrounding hospitals. Zostavax and Hood River, OR: Raising Awareness of the Efficacy, Availability, and Cost of the Herpes Zoster Vaccine Project Date: 10/15/2007 Herpes Zoster and its all too common complication of postherpetic neuralgia is widely recognized by the medical community as having a significant impact on the well being of the general population. Within the first week alone of the Hood River Rural and Community Health Rotation, four separate patients inquired about the nature of herpes zoster and the available vaccine. As the vaccine has only just recently received FDA approval, the public’s knowledge of its efficacy and availability is quite poor. A small community project was formulated to determine the prevalence of herpes zoster and the efficacy, availability, and cost of the herpes zoster vaccine as it relates to the patient population seen by the Providence Hood River Internal Medicine Clinic. Literature searches, brief health practitioner interviews, and development of a simple but informative fact sheet to be given to inquiring patients were the focus of this community project. Use of Vicscosupplementation in Patients Suffering from Osteoarthritis of the Knee: Improving Outcomes for the Patients of Klamath Family Practice Center Project Date: 10/15/2007 Osteoarthritis is a widespread problem, especially among older adults. Due to the pain and immobility associated with the condition its effect on quality of life is often detrimental. The relatively large number of patients seen for osteoarthritis at the Klamath Family Practice Clinic made the relevance of osteoarthritis treatment to the Klamath Falls community quite clear. The rural quality of the community adds a further level of importance, since employment and household responsibilities tend to be physical and dependent upon mobility. Hyaluronic Acid injections are a relatively new form of treatment of osteoarthritis of the knee. They represent a new tool for primary care physicians in helping their patients to overcome the disabling effects of osteoarthritis of the knee. I interviewed a number of patients who had received the Hyaluronic Acid injections and a pair of doctors who have given the injections to their patients to assess the efficacy and subjective value of this therapy. I also reviewed current literature on the therapy. Research showed that the injections are moderately effective in controlling pain and improving mobility, with better duration of effect (up to ~12 months) than current non-surgical therapies. Subjective data showed a large perceived benefit for most patients and doctors utilizing the treatment, with exceptions tending toward patients with more advanced disease. The Use of Herbal and Supplemental Medicine in Coos Bay, Oregon Project Date: 8/6/2007 Many patients have incorporated herbal and supplemental medicines into their health care. There are an unidentified population of patients at the Bay Clinic, who use herbal/supplemental medicine without knowledge of proper usage or the risks. Additionally, there is a general lack of communication between patients and physicians concerning herbal/supplemental medicine usage. This study attempted to define how patients use herbal and supplemental medicine, assess what they know about it, and to facilitate a means to identify supplement users on a daily basis and open a line of conversation between patients and physicians through a brochure. Interviews were conducted with patients of the Bay Clinic who use herbal and supplemental medicine as the main method of investigation. Eighty percent of the patients admitted to supplement usage with the majority using it for long-term health maintenance or chronic health problems. All of the patients felt that supplements were safe and were generally unaware of the possible complications. A pamphlet was created using information gathered from the interviews and literature searches, and it included advice on reading supplement bottle labels, words of caution, interactions and side effects of the more commonly used supplements, and resources for more information. The pamphlets were distributed to the internal medicine faculty at the Bay Clinic and has served as a discussion aid. Communication Between Mental Health and Primary Care in Grants Pass: Screening Templates for Patients on Psychiatric Medications for Healthcare Continuum Project Date: 7/2/2007 Access to healthcare, especially mental health, is more difficult in rural settings, with many more patients continuing their mental health treatment in the care of their primary physician than patients in urban areas would. Beyond the poor access of mental health services, communication between mental health and primary care has been identified as a problem for many years. This lack of communication between mental health and primary care is a significant obstacle to continued patient care. The medical directors of both the Independent Physicians Association and Options for Oregon mental health services were interviewed for their assessment of overall status of, barriers to, and current methods of improving this communication. This project addressed the specific need for primary care monitoring of patients being treated with specific psychiatric medicines. One template was created for second-generation antipsychotics, a high-risk class of drugs that significantly increases these patients’ risks of morbidity and mortality from heart disease and diabetes which include Clozaril, Zyprexa, Seroquel, and Risperdal. Another screening template was created for the drugs Lithium, Depakote, and Trileptal. These two templates were created to provide primary care physicians with pertinent screening information necessary to maintain the health of patients taking these psychiatric medications. Antimicrobial Prophylaxis in the Surgical Patient at the Lower Umpqua Hospital in Reedsport, OR Project Date: 4/30/2007 Postoperative surgical site infection (SSI) is a major source of illness in the surgical patient. According to many experts, the level of bacterial burden is the most significant risk factor in the development of SSI, but modern surgical techniques and the use of prophylactic antimicrobials have reduced this risk. Despite the evidence of effectiveness and the publication of guidelines for antimicrobial prophylaxis to prevent SSIs, substantial inconsistencies exist in the use of prophylactic antimicrobials for patients undergoing surgical procedures. After the literature review, medical records of the patients who had a surgical procedure and were discharged from the Lower Umpqua Hospital from 10/01/2006-03/31/2007 were reviewed. After the data was collected and analyzed, the results from this project were compared to the results obtained by the National Surgical Infection Prevention Project. The Storm of Users: How can physicians actively participate in identifying and treating addiction without falling into the common pitfalls of either ignoring or contributing to this growing problem? Project Date: 3/19/2007 Substance dependency in this country is continuing to grow at epidemic rates. Some estimates indicate that twenty percent of primary care patients are affected by substance use or dependency, with upwards of fifty percent of emergency room visits being related to drugs or alcohol. The overwhelmingness of this problem has left our healthcare system fractured without clear roles for providers. This project attempted to explain how physicians could actively participate in identifying/treating addiction without falling into the common pitfalls of either ignoring the problem or contributing to it. Data was collected through informal interviews of key individuals with some role in substance use/dependency, recover, treatment, prevention, or enforcement. Collaborating data was collected from the Oregon Department of Human Services, National Institute on Alcohol And Alcoholism (NIAAA), and the National Institute on Drug Abuse (NIDA). Results found that the enormity of the problem is paralyzing. The consensus of individuals interviewed was the substance dependency is a growing problem with no signs of slowing in the future. At present due to the lack of a uniform approach, appropriate training, lack of time and resources, physicians are often tempted to ignore the problem or even add to it by careless prescription practices. Proper identification of the problem, education, and treatment with whatever means available (inpatient, outpatient, 12-step, individual, group) is key to future efforts. Breast Cancer Patient Resources in Grant County, Oregon. Project Date: 2/12/2007 Breast cancer is a major medical concern for women in the United States. Women currently are thought to have about a 1 in 7 lifetime risk of developing breast cancer. This means that even a small community such as John Day, Oregon in rural Grant County likely has many women who have dealt or are dealing with a diagnosis of breast cancer. The goal of this study was to attempt to determine if there is a need for breast cancer patient resources in Grant County and if so what resources are currently available to meet this need. Although there is not an oncologist in Grant County or a site for chemotherapy infusion or radiation, there are still likely many breast cancer patients/survivors living in the area who may need support and resources outside of those provided when going out of town for treatment. The design of this study was observation of materials available at health care provider clinics as well as interviews of local health care providers and breast cancer patients and survivors. The final outcome of this project was to develop a database of contacts for local resources as well as to obtain a handout of national resources for the local health care provider offices. Contraception and Family Planning Education in Madras, Oregon Project Date: 1/1/2007 Jefferson County Oregon has the highest teen pregnancy rates in the state, however, it has doctors that are working to decrease that rate. To help them in the pursuit of this I developed a comprehensive patient handout explaining 17 different contraception options available. The handout is designed to allow patients to make the decisions about which contraceptive methods works best for their lifestyle. I attempted to increase contraception education giving a talk to and getting the handouts to be apart of the materials offered at the county birthing and parenting class. The result was a one page double sided handout that was well received by physicians, nurses, and staff at Madras Medical Group. This handout will help Madras health care professionals guide their patients in making contraception decisions. Understanding Chemical Dependency as a Family Illness: Ways to Help in a Rural Primary Care Facility Project Date: 9/11/2006 Misconceptions about drug and alcohol addiction abound in American society. Addiction is a brain disease as shown by neurobiological studies. However, most Americans, even physicians, view it as primarily a moral or personal weakness. Families need to be educated about the causes of addiction, but they also need to understand their roles in helping their loved ones. Resources for addicts are available, but often the effects of chemical dependency on the family system are overlooked. My project’s concrete goals were to educate the staff about addiction, as well as to develop some handouts they can give to families suffering from a loved one’s addiction. Abstract goals were to help families: 1. Understand chemical dependency 2. Accept chemical dependency as a family illness 3. Embrace self-acceptance 4. Commit to a continuing recovery program 5. Identify local resources Medication Compliance in the Elderly Population of Grants Pass Project Date: 5/1/2006 Medication non-compliance is an important issue facing the elderly population because they have the highest prevalence of chronic disease and the largest consumption of medications. Non-compliance is associated with large increases in morbidity, mortality, hospital admissions, and cost to the community and health care system. This study was designed to evaluate and improve the factors contributing to medication non-compliance in the growing elderly population of an internal medicine clinic in Grants Pass, Oregon. Factors were identified using the following methods: extensive review of the literature on medication compliance, surveys of the patients regarding contributing factors, interview with the physician, and identification of resources currently available in the community. Based on the results, a patient handout with a medication log was constructed in order to address these problems and implemented in the internal medicine clinic. Both patients and physicians had a positive response to the handout, however there was not sufficient time to evaluate the effects of the handout/medication log on compliance. Additionally, further work beyond patient education is necessary in order to have the greatest impact on compliance including education of health care professionals and changes within the health care system. Use of Herbal Remedies in Florence, Oregon: Helpful or Harmful? A Patient Handout to aid in discussion of natural supplements. Project Date: 5/1/2006 Over the past twenty years there has been a resurgence in public interest and use of complementary and alternative medicine. Although natural, herbal supplements are pharmacologically active and have the potential to both help and harm the patient. While in Florence I attempted to identify those who are using natural supplements and determine if they had discussed their use with their physician as well their reasons for using the supplement. The design was a chart review of all patients seen by one physician during the month of May to determine who had natural supplements on their medication list and to determine what herbal remedies are used most commonly. Informally, patients that were taking herbal medications were then asked if they were aware of any potential interactions or side effects of the medications and if they felt the medication was effective in treating the condition they expected. Many voiced concerns over not knowing the purity and potency of the herbal supplements they were taking or what recent research shows about the efficacy of the supplement. The purpose of the study was to gather information and design a patient handout that would be targeted appropriately to the patient population at the outpatient clinic to encourage open discussion of natural supplements between a physician and patient, as well as provide a brief synopsis of the most commonly used herbs and recommendations on further reading. 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. 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. Medicare drug plans in Burns, Oregon Project Date: 3/20/2006 In the town of Burns, Oregon, Medicare-eligible patients who had been receiving their medications for free from drug company patient assist programs (PAPs) were informed that most of the drug company assist programs would no longer provide their medications after the Medicare Part D deadline of May 15, 2006. In response to such news, there was much confusion for health care providers and patients. In addition to Medicare Part D, the federal government also instituted a separate subsidy program for the drug plan through Social Security to assist low-income patients. My project looked into all Medicare-eligible patients in the Burns health clinic who had received drug company assist in the past six months to see whether patients were deciding to join a drug plan and to gauge the extent of their knowledge of the additional help through Social Security as more patients on drug company assist would probably qualify for the extra subsidy than the general Medicare patient population. In Burns, there were a total of 163 patients who had received medications from drug company assist programs in the past six months, 116 (71%) of whom were Medicare-eligible. I conducted a phone survey to all the Medicare-eligible, PAPs patients and spoke to 71 patients (61%). Each patient was called at least twice over a course of three days. Management of Chronic Back Pain: Evaluation of the Efficacy of Spinal Surgery Project Date: 8/8/2005 Less than 10% of individuals who experience back pain will develop a chronic back pain syndrome. Of these patients, a fraction will fail all conservative therapies and seek relief through one or more spinal surgeries. There is much controversy regarding the effectiveness of surgery compared to an intense rehabilitation program. During a meeting of the Independent Physician's Association (IPA) of Josephine County, this issue was discussed in relationship to disbursement of state and federal funds to provide coverage for a procedure that has not been shown to have steadfast value in the management of patients with chronic back pain. This project was devised with the ultimate goal of examining the pre- and post-operative functionality and use of prescribed medications of patients undergoing back surgery. A small sample of patients who have undergone one or more back surgeries were selected from a family practice clinic in Grants Pass, Oregon. Their charts were reviewed and documented information on functionality, number of office visits relating to pain, and medication usage were extrapolated. The results of this project were inconclusive as insufficient information was present in the patients charts. Future research could evaluate efficacy of surgical treatment by utilizing IPA databases, contacting and surveying patients, and running analyses on changes in medication utilization. Methamphetamine use in Grant County: Development of a patient handout to increase methamphetamine treatment. Project Date: 8/8/2005 Methamphetamine use continues to be a growing and seriously problem in the United States, with rural areas being affected particularly heavily. This project was designed to increase the use of treatment options by methamphetamines users in Grant County, with the creation of a brochure that is available to patients in the Emergency Room at Blue Mountain Hospital and Grant County Center for Human Development. Before this project, there was a lack of ready information for people who use methamphetamines about their treatment options locally and regionally. The attention grabbing and succinct brochure highlights the reasons why methamphetamine use is harmful, increases insight into the person’s habit, and explains what options are available to help them quit. The handout can be easily altered to accommodate different regions of Oregon and the US, and it is hoped that it will increase the number of people who successfully quit their addiction to methamphetamines. Investigation of the Pneumococcal Vaccination Policy at Holy Rosary Medical Center in Ontario, Oregon Project Date: 4/25/2005 Pneumonia, bacteremia, and meningitis are common clinical manifestation of pneumoccoccal disease caused by streptococcus pneumoniae. Pneumococcal disease causes more death than any other vaccine preventable bacterial disease, and antibiotic resistance, especially against penicillin, has emerged. A vaccine to prevent pneumococcal disease has been available for decades, but is currently underutilized. The ACIP recommends implementing a standing order policy to increase vaccination rates. Holy Rosary Medical Center in Ontario, Oregon developed a vaccination policy that includes a standing order and a screening tool, but vaccination rates have not increased. This study investigated possible obstacles preventing the implementation of the vaccination policy. The three largest obstacles appear to be making sure that copies of the screening tool and preprinted order form are readily available and placed on every chart, educating the staff about the policy, and adequately communicating with the patient's primary care provider. Analysis of drug sample use at OHSU Scappoose Family Practice Clinic Project Date: 8/9/2004 Prescription drug costs are a growing concern for many patients seeking medical care in the United States today. One recent study predicts that drug expenditure growth should continue to outpace the growth in overall health care expenditures and the growth in the U.S. economy. Currently many physicians use free drug samples provided by the pharmaceutical companies to provide medication to their patients. This study attempted to analyze the use and opinions of drug sample resources from three practitioners in a rural OHSU primary care clinic in Scappoose, Oregon. The design was to randomly select 101 instances in which drug samples were given out to patients and analyze as to which physician prescribed the sample, total costs saved for the patient versus local pharmacy costs, and compare with the insurance status of the patient. In addition the three practitioners from the clinic were independently interviewed concerning their views of drug samples to be compared with the actual free sample prescribing habits. The overall objective of this project is to determine if there is any pattern to the prescribing of free drug samples from the clinic and to investigate alternatives available for patients who are not able to afford their prescription drug costs. Treatment of Opiate Addiction in Rural Communities Project Date: 3/29/2004 Background: Opiate abuse is a chronic, relapsing brain disease with significant public health implications. Traditionally, methadone maintenance is the standard of care for this disorder. Methadone maintenance is structured so that, at least initially, patients must present to the clinic every day to receive their dose. The nearest methadone clinic to Lebanon, Oregon is over 30 miles away, which poses a significant barrier to care to those seeking treatment. In addition, physicians in Lebanon recently decided not to implement a methadone maintenance program due to concerns about financial constraints and community perception. The purpose of this study was to determine whether office-based treatment of opiate addiction with a sublingual formulation of buprenorphine and naloxone is a viable alternative to the treatment of opiate addiction for rural communities with limited access to a methadone maintenance program. Methods: A literature review was conducted to determine efficacy of buprenorphine/naloxone in the treatment of opiate addiction. A Medline search of English language articles pertaining to human subjects provided four studies. Results: The studies showed that buprenorphine alone is as efficacious as equivalently dosed methadone. One study showed that, in comparison to placebo, a sublingual formulation of buprenorphine and naloxone is safe and reduces opiate-addicted patients’ cravings when used in a primary care setting. Conclusion: Buprenorphine is a safe and efficacious alternative to methadone for rural communities with limited access to a methadone maintenance program. However, the cost of the medication and restrictions placed on providers limit the potential for this medication. Antibiotic Prescribing Practices in two community settings: Are Physicians in Southern Oregon practicing the judicious use of Antibiotics? Project Date: 1/5/2004 Antibiotic resistance is a public health problem that could potentially affect our ability to treat infections like otitis media, acute sinusitis, acute pharyngitis, and pneumonia. The overuse of antibiotics and the inappropriate use of broad-spectrum antibiotics for acute upper respiratory tract infections contribute to the development of resistant strains of bacteria. The Oregon Department of Human Services reports that Oregon clinicians prescribe antibiotics for URI and pharyngitis at a lower frequency than the national average. However, Oregon physicians prescribe antibiotics more often for bronchitis and acute otitis media. The AWARE (Oregon Alliance Working for Antibiotic Resistance Education) campaign provides educational materials for clinicians and their patients promoting the judicious use of antibiotics in Oregon. In celebration of antibiotic resistance awareness week, January 25-31, 2004 and evaluation of antibiotic prescribing practices in Southern Oregon is performed to determine if, indeed, the message is getting through 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. Methadone Maintenance Therapy: An evaluation of health benefits, cost-effectiveness, social impact. Project Date: 12/30/2002 BACKGROUND: Injection drug use in the United States is a significant cause of morbidity and mortality, increased health care costs, and criminal behavior. While methadone maintenance therapy (MMT) reduces criminality, health care expenditures, and morbidity and mortality among injection drug users and the general population, economic, social and political barriers prevent its universal funding. The purpose of this review was to examine the cost effectiveness, effect on morbidity and mortality, and effect on criminality of MMT in order to help determine whether MMT should be covered by health care plans. METHODS: A literature review was conducted to determine the cost effectiveness of MMT with respect to morbidity and mortality, criminal behavior, and survival as measured by overall survival and quality-adjusted life-years. RESULTS: Among a population of drug users and non-users, methadone maintenance treatment leads to significantly decreased health care costs, decreased morbidity and mortality, and has a cost per quality-adjusted life-years that is well below many other accepted medical interventions. CONCLUSIONS: Methadone maintenance treatment is cost-effective on the basis of commonly accepted criteria for medical interventions. Funding MMT is a cost-effective investment by health care plans that should lead to long term monetary savings and increased quality-adjusted life years among the entire population. The Rising Cost of Medications. What's a physician to do? Project Date: 2/11/2002 This preliminary survey sought to establish whether insurance coverage excluded financial strain due to medication costs among patients at the Cascade Medical Clinics in Redmond, Oregon. The design is a cross-sectional study involving patients 18 years and older who were seen in clinic between March 7,8, and 11th, 2002. A survey which included name, DOB, insurance, type of drug coverage, and whether or not medication costs have ever caused the patient financial strain was distributed to patients in the lobby and returned at the fron desk. During the three-day period, 100 surveys were returned. Fourteen surveys were excluded based on age (less than 18 years old), or missing answers. Of the 76 valid surveys, 66% of patients reported having some form of pharmaceutical coverage. Of the 66%, 42% reported having significant financial strain due to medication costs despite insurance. This report discusses the rising concern of pharmaceutical costs, and what every physician should be doing to help control these costs. Back to subject search page or search by preceptor site