RCHC Community Project Abstracts

Back to subject search page or search by preceptor site Screening for Chlamydia Trachomatis Project Date: 10/12/2009 Chlamydia is the most common sexually transmitted bacterial infection in the U.S. with particularly deleterious consequences for women. Alicia Hills, communicable disease nurse and educator at the Department of Public Health in Baker County, has been tracking the rise in Chlamydia positivity throughout Baker County since 2007. Data from DHS in Oregon demonstrates an increase in the incidence of Chlamydia in Baker County overall from 2003 to the present. The rise in positivity may be attributed to greater access to female providers since 2003, an increased risk for false-positive tests due to the lower prevalence of Chlamydia in Baker County as compared to the average for Oregon state, and easier screening methods implemented by clinicians in the area. A universal Chlamydia screening protocol was discussed and implemented at the Eastern Oregon Medical Association and the Baker County Public Health Clinic. In addition, educational pamphlets from DHS discussing sexually transmitted infections will now be offered to patients being screened for Chlamydia. Emergency room physicians agreed to encourage at-risk patients to be tested at the Public Health Clinic. A powerpoint presentation used to educate adolescents and young adults in Baker County about sexually transmitted infections was revised and updated. Providing Successful Comprehensive Outpatient Health Care Project Date: 10/12/2009 With increasing information about the evidence-based benefits of preventive measures, and as the number of recommended vaccines, screening labs and exams, and behavioral and lifestyle screening expands, the daily workload for a family physician also increases. Heightened demands on the crucial face time we have with patients mean we need to find a way to complete all the tasks and meet all the goals of a clinic visit while maximizing our time, energy, and resources. One of the most significant things I witnessed during my rotation was the efforts of the office staff to keep up with expectations and workload. I chose to help the Scappoose clinic develop a more efficient way to implement screening tools without having patients fall through the cracks. In my research, I came across an approach for quality improvement that involves multiple steps. The steps involve understanding the current workflow, identifying the goals, coming up with ways to make changes that will help meet the goals, and developing ways to measure improvements. Late-Life Depression and Psychosocial Factors: Clinical Screening Tools and Social Services for Older Adults in Junction City, Oregon. Project Date: 10/12/2009 Depression in common among older adults in the United States. Contributing factors to depression include biological, psychosocial, and environmental elements. Bereavement, caregiver strain, social isolation, financial strain, and physical disability are among the many psychosocial factors that contribute to the development of depression. Depression among older patients is important not only because it compromises quality of life for patients and their families and undermines the ability to maintain health and independent living, but also because it is an independent risk factor for mortality. While the development of pharmacologic agents for the treatment of depression have made significant impact on quality of life for many individuals, the continued importance of screening for and addressing psychosocial issues cannot be overstated. The goal of this project was to screen older patients in the Junction City area for depression, explore the psychosocial context in which depression exists, and educate health care professionals on the community resources available to address issues such as financial strain and social isolation. The Patient Health Questionnaire 2 was used to screen for depression and a student-designed questionnaire was used to screen for social isolation, community involvement, and daily activities. These two questionnaires, combined with brief patient interviews, revealed some correlation between depression and social isolation. To address issues of late-life depression and the underutilization of social services in the Junction City area, a notebook was developed for use by health care professionals at the Junction City Medical Clinic that included 1) a series of clinical tools for screening for depression, dementia, and activities of daily living; 2) a series of journal articles on the role of psychosocial factors in depression; 3) a questionnaire for use in screening for social isolation and obstacles related to community involvement; 4) information related to enrollment in Medicare through the Senior Health Insurance Benefits Assistance program, the Oregon Prescription Drug Program, and social services available through the Senior & Disabled Services office in Junction City; and 5) an article on house calls. 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. Exploring the decrease in the percentage of women receiving pap tests at the Warm Springs Health and Wellness Center--reasons why and strategies for improvement Project Date: 8/3/2009 According to the Government Performance Results Act (GPRA) report, the percentage of women age 21-64 receiving pap smears at the Warm Springs clinic has steadily decreased from 74.1% at baseline in 2000 to 58.3% in the past year. The current goal for the clinic is 90%, and the goal of this project is to determine what has contributed to the decrease in pap test rates and what can be done to increase the percentage of women receiving these exams. First a survey was distributed to the health care providers at the clinic to explore reasons for the decrease in pap tests and to gauge community awareness. Based on the responses given, an educational pamphlet was put together for patients including information about pap tests, HPV, and how to prevent cervical cancer. Rapid Influenza Testing in the Cottage Grove Community Hospital Project Date: 8/3/2009 The goal of this project is to determine the number of positive and negative cases of influenza that have been detected with the QuickVue rapid influenza test at the Cottage Grove Community Hospital (CGCH) between 7/9/09- 8/25/09. CGCH encompasses an emergency department, medical ward, and outpatient clinics in Cottage Grove, a community of 18,000 in the southern part of Lane County, Oregon. The first screening test used by CGCH in the workup of acute influenza is the QuickVue Influenza test, which detects influenza A and B antigens directly from a patient’s nasal sample. The basic demographics of the patient population tested at CGCH during the study period is outlined, and the most common symptoms of patients presenting with influenza are identified. The sensitivity and specificity of the QuickVue test is discussed along with the prevalence of influenza (specifically the novel H1N1 influenza A virus) in the region. Screening for Dementia in the Primary Care Setting: Experiences at the North Bend Medical Center, Coos Bay, OR Project Date: 6/29/2009 Background: Dementia has emerged as a large and growing health care problem but it is often not diagnosed until later in the disease progression. Early diagnosis has the potential to minimize the burden on patients, family and caregivers; however, no randomized trial has evaluated the efficacy of dementia screening in primary care. Introduction: The purpose of this project was to determine whether a brief screening for dementia in this particular type of primary care setting would identify patients with some memory or cognitive impairment that required further neurocognitive testing. Another purpose of this project was to identify barriers to screening for dementia in this setting. Methods: In order to accomplish these goals, all patients over 70 years old without particular memory concerns were screened for dementia during a two-week period at one Internal Medicine Clinic at North Bend Medical Center in Coos Bay, OR. Also, a survey of Family and Internal Medicine physicians at NBMC was conducted to identify their perceptions of undiagnosed dementia in the community and to determine what prevents them from routinely screening their patients. Results: 20% of the patients screened had an abnormal Mini-Cog screening and 30% had an abnormal MMSE screening. 83% of physicians felt that many of their patients might have undiagnosed dementia. 80% cited a lack of time as the principal factor preventing them from screening. Only 20% frequently used the Mini-Cog for screening. Discussion: The fact that these patients were discovered is information that can be used to explore the issue of whether or not screening asymptomatic elderly individuals in this setting would actually be beneficial in detecting previously undiagnosed dementia. Some of the barriers that physicians identified to screening could potentially be resolved. The Frequency and Types of Dermatological Diagnoses in a Rural Primary Care Practice in Klamath Falls, Oregon Project Date: 6/29/2009 Dermatological disease is frequently encountered in the primary care setting. Some studies show that up to 36.5% of patients who presented to their primary care physician (PCP) had at least one skin problem. The current literature regarding dermatological disease in primary care has mainly been done in urban areas, and little data exists regarding the frequency of dermatological diseases seen by PCPs in rural areas. The goal of this project was to determine the frequency and types of distinct dermatological diagnoses in a family practice in Klamath Falls, Oregon, from July 2006 through July 2009, in order to establish a baseline of data regarding dermatological disease in a rural primary care setting. A total of 437 unique dermatological cases were seen by the PCP during the three year interval, amounting to 2.7% of total patient visits. The diagnosis of actinic keratosis was most common (18.1%) and is attributed to the high amounts of sun exposure in many of the area's occupations and popular outdoor activities. These results will be used to inform rural primary care practices and direct continuing medical education. Due to the high number of sun-related diagnoses, a sun safety poster from the American Academy of Dermatology was chosen and offered to be placed in exam rooms as an educational tool for patients. Current use and capacity for colorectal screening by colonoscopy in Grant County, Oregon Project Date: 3/16/2009 Colorectal cancer incidence and death is largely preventable by screening. Colonoscopy is a particularly compelling screening modality for frontier communities, but capacity may not exist in all these communities to increase screening via colonoscopy given limited access to resources and physicians. A study was conducted in the frontier communities of Grant County, Oregon to determine existing colonoscopy uptake rakes and screening capacity. Access to Health Care in Rural Communities Project Date: 2/9/2009 Access to health care in rural communities has long been recognized as a public health concern and much effort has been expended to study and remedy the problems with access to healthcare in these areas. In our study we examine access to healthcare, and quality of health care for health care providers in four communities in the mid-Willamette Valley in Oregon. All MD’s, DO’s, NP’s, and PA’s in the communities of Stayton, Sublimity, Aumsville, and Mill City OR were surveyed anonymously about their access to healthcare and whether they receive the screenings recommended by the US Preventative Services Task Force (USPSTF). Twenty seven providers where surveyed and 21 responded. Of these, 75% had a personal PCP, but less than half have had a physical exam in the last 2 years and 3 had never had a physical exam. Only 62% of USPSTF screenings were complete for this group and over half of these were self screenings. Preventative Health and Health Maintenance Information for Patients in Monmouth, Oregon: Helping the Patient Help Him(Her)self Project Date: 9/8/2008 Total Health Community Clinic (THCC) primarily serves low income, uninsured or underinsured, individuals. They tend to lack continuity of care and comprehensive care, and often have office visits solely to address acute health issues. Consequently, it is difficult for the health care providers to effectively educate patients on preventative health and health maintenance topics and perform health screening. To facilitate patient knowledge, increase compliance with recommended health screening, and expedite office visits; I created age specific information sheets for patients that outline recommended ways to stay healthy and when specific health screening tests should be performed. Ideally, these will empower the patient to take a more active role in assuring that all of their health care needs are met. Only YOU Can Prevent Colorectal Cancer The Prevalence of Colorectal Cancer Screening at Philomath Family Medicine Project Date: 9/8/2008 Colorectal cancer (CRC) is the third most common type of cancer and the second most common cancer killer in the United States. As a result, an effort is being made to emphasize screening for colorectal cancer to find it before it starts. The methods that are now recommended that can detect pre-cancerous lesions are colonoscopy and flexible sigmoidoscopy with fecal occult blood testing (FOBT), and only FOBT. I was concerned that in a smaller town such as Philomath, OR that these new recommendations may not be in practice. Through my observation of physicians in the practice I was at I saw that indeed these guidelines are in practice. I also did a chart review to get a feel for how many people have been screened for colorectal cancer and if so which methods they used. Eighty patients ages 50 and older were investigated via chart review or direct questioning and it was found that 68 had been screened for CRC and 12 of them had not. The most common method chosen for CRC screening was colonoscopy. Patients who had not been screened were contacted and asked if they would be willing to state the reason they had not been screened for colorectal cancer. Reasons included cost, lack of insurance coverage, lack of doctor visits, lack of discussion with physician, or simply they have not wished to be screened. A brochure explaining the importance of CRC screening and the methods available for screening was sent to patients who had not been screened. Addressing Low Rates of Colorectal Cancer Screening in a Rural Community Project Date: 9/8/2008 Colorectal Cancer is one of the leading causes of cancer-related deaths in the United States today; however, timely screening with tests such as the fecal occult blood test and colonoscopies has greatly increased the number of cancers found in early, treatable stages, thereby reducing the incidence of late-stage and metastatic lesions as well as overall mortality from this disease. Despite the focus placed on preventative medicine by care providers at Santiam Memorial Hospital (SMH) in Stayton, Oregon, screening rates for colorectal cancer in Marion County (home of Stayton) remain below the national and state rates. Additionally, colorectal cancer incidence and mortality in Marion County are higher than those of the state and nation. In this project, Barriers to screening at SMH were investigated, as well as factors associated with low patient adherence to screening recommendations. Fecal occult blood tests are not regularly employed by all doctors at SMH, with efforts often focused entirely on colonoscopy referrals instead. Several suggestions for ways in which barriers might be overcome were then developed, including increased information for patients by way of videos, pamphlets, etc. and increased use of fecal occult blood testing as a less-invasive means for screening that patients might perceive as less intimidating and less embarrassing. Finally, several strategies to increase patient adherence were suggested, including re-writing patient information at a more understandable level for patients with low health literacy, and possibly organizing community forums in which trusted members of the community (including doctors and patients) can speak about their experiences with screening and with colorectal cancer itself. By increasing patient awareness of the risks of colorectal cancer, increasing patient awareness of the benefits of timely screening, and increasing follow up for patient referrals, Marion County should be able to bring its screening rates higher than the state and national averages, while bringing colorectal cancer-related mortality rates below the state and national averages. Screening for urinary Incontinence in Women > 50 years of age in Warm Springs, OR: An underdiagnosed issue Project Date: 9/8/2008 Urinary incontinence (UI) is a significant health issue with substantial social impact. However, this issue is often unaddressed by health care providers in one of its major populations, older women. The goal of this study is to illustrated the degree to which urinary incontinence in woman ages 50 and up is underdiagnosed in Warm Springs, OR. Warm Springs Health and Wellness Center is an Indian Health Services clinic and the only clinic on the reservation. A sample population of women ages 50 and up coming to the Warm Springs Health and Wellness Center medical offices between September 23 and October 6, 2008, were screened for UI using the previously validated MESA questionnaire for urinary incontinence. Surveys were scored and UI prevalence according to the MESA questionnaire was compared to prevalence according to IHS ICD-9 codes for UI. According to a VGEN search of EHR (electronic health record), Warm Springs Health and Wellness Center only had a 13.0% prevalence of UI women in aforementioned sample population. However, according to the MESA questionnaire at least 58.7% this sample population had some form of UI. Not only is UI unaddressed in this community, but patient knowledge and educational information is lacking. Therefore, the final product of this project is an educational pamphlet on UI. Social gatherings and community is a very important part of this population, hopefully addressing undiagnosed and untreated UI may be improve the quality of some of these women, allowing them to actively participated in community functions and gatherings without fear or embarrassments associated with UI. Colon Cancer Screening in Rural Oregon A Small Case-Series for Reedsport, OR. Project Date: 4/28/2008 Purpose: To establish demographic data for those undergoing colonoscopies in rural Oregon. To determine whether current screening with colonoscopy is cost-effective for Reedsport, and Dunes Family Practice. Methods: I performed a chart review of 145 cases dated between 01/03/07 and 03/26/08. Records were evaluated for general demographic data. pertinent past medical/surgical/family/smoking history, presenting symptoms, prior and current colonoscopic & pathologic findings. Results: All 145 cases were included in series (83 females, 62 males). Mean age was determined to be 64.83 years. Approx. 25% had prior history of polyps, 3 % with colon cancer previously. 79% had a positive colonoscopy, with 23% having any type of polyp. Of those with polyps, approximately 47% (15 cases) had adenomatous and 6% (2 cases) with malignant findings. Incidence of colon polyps and cancer was calculated to be 22 per 100 individuals per year and 1.4 per 100 individuals per year, respectively. Total life-years gained for cases was calculated to be 20 yrs. Conclusions: Incidence of colon polyps and cancer found to be significantly higher than national and Oregon average. This is likely due to demographic factors including age and prior health status. Current screening with colonoscopy was found to be cost-effective based on general acceptance of screening procedures with cost per life-year gained <$25,000. 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. Improving Screening Rates for Colorectal Cancer on the Warm Springs Indian Reservation: Using Radio and Internet Video to get the message across Project Date: 10/15/2007 On the Warm Springs Reservation in Central Oregon, the Indian Health Services (IHS) is responsible for providing health care to the members of the Confederated Tribes of Warm Springs. The IHS has a set amount of resources; therefore, preventative medicine is an important component of the healthcare system. One preventative measure, screening for diseases, can help lower costs and reduce incidence of diseases. The Warm Springs Health & Wellness Center (WSHWC) has a chronic care initiative that is exploring new ways of improving the screening rate and treatment of disease. One of the diseases being studied is colorectal cancer. As a part of the chronic care initiative, this community project created two new ways of encouraging tribal members to get screened for colorectal cancer. One is a radio ad campaign educating people on the need to be screened was implemented. The second is an animated video that demonstrates how to complete the screening test. Utilization of an electronic medical record to monitor and improve preventive healthcare at Ontario Family Medicine Project Date: 7/2/2007 Preventive healthcare is an integral part of providing primary care. To guide the use of preventive services, the U.S. Preventive Task Force and Center for Disease control have established based recommendations for health screening and vaccinations. Despite strong evidence supporting the importance of preventive healthcare, the rates of providing these services are often less than ideal in the time pressured setting of primary care. However, the use of electronic medical records with health screening features has been shown to dramatically improve service rates. Ontario Family Medicine is currently using PowerMed electronic medical record, but has not been utilizing the Health Screening section of the program. This project aims to take the first steps to utilize an electronic medical record's health screening capability to improve the provision rates of preventive services in a rural primary care setting. Using current Task Force and CDC guidelines a list of core recommendations that fits the adult patient population of Ontario Family Medicine was established. These recommendations were entered into the program, and then cross-linked to orders so that when an order is entered, it will automatically update the patient's Health Screening section. Next the practitioners and clinic staff were trained on how to view the new Health Screening section, and enter orders. Finally the programs ability to generate reports on overall practice screening rates was evaluated. 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. Screening for Depression Project Date: 3/19/2007 Depression is the most common psychiatric disorder making it a very important issue in primary care practices. This project looked at ways to screen for depression in rural primary care offices, the effectiveness of doing so, and what to do with positive screening results. Design began with observation of an internist’s interaction with patients throughout a five week rotation. Literature review and professional contacts were utilized to evaluate the evidence regarding the efficacy of depression screening in primary care and what tools are most useful if it is to be done. The result of this project was the incorporation of two screening questions into the routine ‘rooming procedure,’ with a follow-up questionnaire for positive screens, informing the staff about what to do with a positive screen, and making information about non-pharmacologic community resources readily available. The Role of the Primary Care Provider in Identifying And Treating Postpartum Depression Project Date: 2/12/2007 Postpartum depression (PPD) is a significant public health problem in the US affecting approximately 1 out of 8 women. Antenatal depression can also occur and when present, is a risk factor for PPD. Although the prevention and treatment of PPD (or perinatal depression) is a public health priority, screening for the disorder is not typically standard of care and therefore PPD is often under diagnosed and inadequately treated placing women, infants and families at risk. Because multidisciplinary primary care providers usually have the most mother/child contact, they are in a prime position to screen for depression and identify risk factors that might lead to PPD. Risk factors such as poor partner/family relationships, lower socioeconomic status, unemployment of self/partner and lack of social support are not uncommon in Eugene, Oregon. The purpose of this project was to: 1. Increase the awareness among the PeaceHealth system (PHS) primary care physicians and midwives of the importance of identifying, treating and/or referring cases of PPD. 2. Introduce a validated screening tool for identifying women at risk of developing or suffering from PPD. 3. Provide a referral list for the treatment and support of PPD. 4. Invite clinician participation in the Lane County PPD Consortium, 5. Provide a PPD screening tool for the PeaceHealth Sacred Heart Hospital labor and delivery social workers. Methods: The patient statistics justifying this project came from 2006 and reflect the number of all PHS physicians’ patients who gave birth at the PHSHH. Information was gathered through conversations with PHS physicians, ancillary staff, the Lane County PPD Consortium and several others. An informational packet (IP) was prepared and distributed to individuals involved with the identification, treatment, referral and quality care of patients with PPD. Findings/Results: Last year, the percentage of diagnosed cases of PPD among PHS primary care physicians’ patients who gave birth at PHSHH was .18%. This is far short of the estimated prevalence of 10-20%. Screening for PPD is not standard of care for primary care doctors in the PHS. Many doctors reported they did not have time to use the IP screening tool and there was a general lack of knowledge of the importance of the role of the primary care provider in addressing the problem of PPD. There were no reported cases of PPD diagnosed during the five week clerkship. Access to Abortion Resources in John Day, Oregon Project Date: 8/7/2006 Current abortion trends indicate that the availability of providers is declining in rural areas. In 2000, 78% of all Oregon counties had no abortion provider. As a result, women must travel longer distances, overcome economic barriers and risk exceeding gestational limitations to terminate their pregnancy. John Day, Oregon is no exception to this trend. Six physicians, 1 NP and 1 PA were interviewed regarding how they provide resources to women seeking abortions. Although no providers exist, 87.5% of the health care workers said they would refer women for an abortion if she asked. In the case of rape or incest, 62.5% said they would “always” include termination in their discussion with the patient. In the past year, the 5 referrals that have been made were from the two female providers. Due to concerns over confidentiality and negative repercussion from the community all agreed that a local abortion provider would not be accepted or used effectively. For rural women, the drawbacks of leaving one’s community, including higher risk of exceeding gestational limitations and money, do not appear to outweigh benefit of anonymity. 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. Care of hypertensive patients in John Day, Oregon: Creation of a clinical reminder checklist. Project Date: 2/13/2006 Hypertension is a medical problem seen by every physician, regardless of his or her specific practice or the type of community they practice in. For physicians in rural communities, it is a diagnosis seen daily. The identification and treatment of patients with hypertension is lengthy, somewhat confusing, and frequently changing. In 2003, the National Heart, Lung and Blood Institute (JNC7) created a new treatment algorithm for hypertensive patients. This study attempted to determine whether or not two physicians in a rural family practice clinic in John Day, Oregon were appropriately caring for their patients with hypertension according to the guidelines set forth by the JNC7. The design was a random selection of 20 patients already diagnosed with hypertension, followed by a chart review of these patients. The chart review identified specific areas the physicians were doing well with and a few that they were lacking in. The results of the chart review prompted discussion of the best way to be consistent and complete with the care of every hypertensive patient. It was decided that a checklist with reminders for specific aspects of the physical exam, laboratory tests, lifestyle modifications, and medication review would be created. Two checklists were created including one for the initial diagnosis of hypertension and one for those already diagnosed. These checklists will be placed in the charts of all pertinent patients. It is expected that these checklists will make it easier for the staff and physicians to provide consistent care of their patients with hypertension according to the guidelines set forth in JNC 7. 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. A standardized admission order for COPD exacerbations at Blue Mountain Hospital in John Day, OR Project Date: 4/25/2005 COPD is an extremely common chief complaint in the aging population and an exacerbation of COPD is one of the most common presenting complaints at the Blue Mountain Hospital emergency room in John Day, OR. Physician admission orders can be as diverse as the physicians themselves and may also represent a significant point of confusion for nursing and respiratory therapy staff. This project was designed to produce a COPD exacerbation standardized admission order that incorporates individual physician preferences, proven efficacious therapies, local formulary and logistical restrictions, but also an easy-to-read document to which hospital staff can refer for high-quality patient care. Improving the Infant vision screening program in Baker City, OR Project Date: 1/3/2005 Infant vision screening is an important part of infant care during the first years of life. Early screening and early treatment for infant eye deficits (e.g. strabismus, amblyopia, and retinoblastoma) provides for better long-term vision outcomes and allows for the use of less invasive treatments. Despite the common incidence of infant visual problems, many children are not examined by an eye care professional until after they fail their first visual acuity test in public school at 5-6 years of age. This study attempted to examine the current system in place for infant vision screening in the city of Baker, OR and to explore methods of improving these system. Design elements included quantifying the percentage of Baker infants receiving eye exams in 2004, identifying barriers to care within the existing system, and implementing solutions to overcome these barriers. The data indicated that fewer than 15% of infants in Baker were participating in the existing vision screening program in 2004. The major barriers to care in Baker were identified as poor parental awareness and lack of physician education in regards to the importance of infant vision screening. Solutions to these problems included educating the physicians who were caring for infants about vision screening, convincing these physicians to act as a direct referral source for the infant vision screening program, and providing these physicians with educational handouts about infant vision screening that they could give to their patients. With these additional measures in place, it is expected that a much higher percentage of Baker infants will receive vision screening exams during 2005 in comparison to all previous years. The Use of Flexible Sigmoidoscopy in a Rural Family Medicine Clinic Project Date: 1/3/2005 Colorectal cancer is a largely preventable and yet prevalent cause of mortality in the US. Accordingly, professional organizations with published guidelines for screening recommend that all adults ages 50 or older receive screening for colorectal canter (1). Of the screening options available, colonoscopy is the most sensitive and specific test for detecting colorectal cancer (2). However, in many rural areas there is a shortage or even absence of colonoscopists. In one such town, Philomath, physicians at a family medicine clinic are working to fill this gap in cancer screening. Eligible patients of this clinic are actively encouraged to get screened via yearly fecal occult blood tests and flexible sigmoidoscopies once every five years. The sigmoidoscopies are performed in the clinic by the family physicians. This study assesses patient records of one of the Philomath physician's positive scope findings over the past five years. In evaluating follow-up colonoscopy and polyp biopsy results on these patients, it will be shown that flexible sigmoidoscopy is a useful tool in colon cancer screening. Not only can flexible sigmoidoscopy identify patients with polyps who are at higher risk for developing colrectal cancer, thereby helping to reduce the burden on limited colonoscopy resources, but it may also provide reassurance to those with negative findings. Hepatitis C prevalence rates in West Salem Clinic Homeless versus low-income non-homeless Project Date: 10/18/2004 The hepatitis C virus is a major public health problem and a leading cause of chronic liver disease. In the US, the CDC estimates that there are more than 2.7 million people with ongoing HCV infection. HCV is the leading cause of death from liver disease in the US. Homelessness is an important risk factor for HCV because of the environments ad behaviors associated with homeless communities such as poor hygiene, poor nutrition and high levels of IDU. The goals of the study were to determine the prevalence rates for HCV in the West Salem Clinic populations and to determine how the rates differed between the homeless and the low-income non-homeless. The study also aimed to look at a few of the associated risk factors for HCV such as drug use, alcoholism and STDs. The study showed that the rates of HCV are indeed higher in the homeless than in the low-income non-homeless, as recent literature has indicated. Further research is required to understand the specific associations between various risk factors and the rates of HCV at the West Salem Clinic. The preliminary data indicates a need for further patient education and intervention regarding HCV transmission, especially among the homeless. Colonoscopy awareness and compliance among patients of Strawberry Wilderness Family Clinic in John Day, OR. Project Date: 7/5/2004 Colon cancer screening can be a challenging issue in rural regions. The following study addressed several issues of colorectal screening such as availability, public awareness and compliance with colonoscopy at the Strawberry Wilderness Family Clinic in John Day, Oregon. A questionnaire was designed in order to evaluate compliance with colonoscopy among patients ages 50 and above. Compliance is defined for this study as the percent of patients who followed their doctor’s recommendation to have the colonoscopy procedure. All of the responses to the questionnaires were compiled and analyzed. Moreover, research was done in order to investigate the availability of colonoscopy for the patients in John Day. The overall compliance with the procedure was 76%, however 18% of the patients questioned were unaware of procedure in general. It was determined that the John Day community has a high rate of colonoscopy compliance. This was attributed to the fact that this screening procedure is readily available for patients in this rural community. Chronic Kidney Disease in Coos Bay- Recognition and Referral Project Date: 5/10/2004 Chronic Kidney Disease (CKD) is a rapidly growing problem in the United States that is not readily recognized by primary care physicians, resulting in excessive healthcare costs, failure to ameliorate disease progression, and increased morbidity and mortality in these patients. One possible reason may be that PCPs are only relying on the serum creatinine as a marker for kidney function, rather than the calculated GFR, which is a truer indicator of renal capacity. Coos Bay, Oregon is a community that receives its nephrology care from a group practicing in Eugene, Oregon. This group of nephrologists is markedly concerned about the underrecognition of CKD and the consequences that come along with it. To express their concern, they recently mailed out a letter to all PCPs regarding this issue. This study was designed to demonstrate to the internal medicine physicians at the Bay Clinic in Coos Bay that many patients with CKD are not being recognized and referred, possibly because the physicians are not using the GFR, but rather are relying only on the serum creatinine. To help overcome this obstacle it was coordinated with the laboratory staff at the Bay Clinic to include a calculated GFR with every serum creatinine on lab reports. Finally, a handout containing recommended CKD guidelines was created and distributed to the internists at the Bay Clinic. ADHD vs. Bipolar Affective Disorder: a Comparison of the Two Mental Health Problems in the Pediatric Population of Klamath Falls. Project Date: 5/10/2004 Mental illness is an important medical problem in the pediatric population that affects communities ranging from large metropolitan areas like Portland to small towns such as Klamath Falls. Although the prevalence of attention deficit hyperactivity disorder (ADHD) and bipolar affective disorder (BAD) are significantly different in the pediatric population, they are often confused with one another due to the overlap of common symptoms. Therefore it is important to identify children with these disorders and make an accurate diagnosis to ensure that they receive the proper medical and psychological treatment. Analysis of ICD9 codes from 2003 demonstrated almost 1,000 visits for ADHD and BAD at The Klamath Pediatric Clinic. These numbers were confirmed by my own record keeping during a three week period which showed 16% of all visits were for mental health issues. Given the number of patients with ADHD and BAD, a screening tool was utilized to try to find differences in the presentation of these two illnesses at the time of diagnosis. Results from questionnaires handed out in the clinic showed higher scores by patients with BAD (24 versus 15; p 0.011). In addition, three specific categories including irritability, thought content, and disruptive behavior were significantly higher in children with BAD. The results of this project suggest that mental illnesses, specifically ADHD and BAD are an important healthcare issue at The Klamath Pediatric Clinic and that there may be ways to better screen for and treat these patients. The St. Elizabeth Health Services Annual Blood Draw: The Evidence For and Against the Use of Routine Blood Testing as a Health Screening Tool Project Date: 3/29/2004 Many of the leading causes of death and disability can be prevented given the appropriate interventions. Thus, providing preventive services is a cornerstone of modern day primary care practice. Routine screening examinations and laboratory tests are major mechanisms by which preventive medicine is carried out in practice and should ideally be based upon recommended guidelines developed from the best currently available evidence. The focus of my community project was to research the evidence in support of and against the use of routine blood testing as a health-screening tool for the St. Elizabeth Health Services Health Fair in Baker City, Oregon. I planned to submit my results as well as my recommendations to the governing authorities of this event for further review. As a result of my investigation I found sufficient evidence to support the practice of routine lipid screening for men >35 and women >45 years of age. Insufficient evidence existed to support routine screening of CBC, CMP, TSH, PSA, LDH and Uric acid. Conflicting recommendations existed regarding the practice of fasting glucose screening mainly due to the fact that no clinical trial has been conducted to establish whether systematic screening of asymptomatic individuals for type 2 diabetes improves health outcomes compared with initiating treatment after clinical diagnosis. Sufficient evidence did exist, however, to recommend routine screening of fasting glucose in individuals with hypertension or hyperlipidemia. Given the high prevalence of these comorbidities in the U.S., especially among the population screened at the annual blood draw, routine fasting blood glucose testing may indeed prove to be an effective health screening practice in Baker County despite the lack of current evidence in support of it. Colorectal Cancer, Screening for Prevention: How well is Rural Oregon Doing? Project Date: 3/29/2004 BACKGROUND: Colorectal cancer is the third leading cause of cancer related death in Oregon, and it ranks fourth in incidence with five new diagnoses of invasive colorectal cancer occurring daily. The US Preventive Services Task Force recommends universal screening of men and women age 50 years or older for colorectal cancer. This study sought to evaluate how well physicians in John Day, Oregon were providing screening for their patient population. METHODS: Chart review to determine screening practices was completed with 100 randomly selected charts of current patient age 50 and older. Interviews with physicians in the community were held to identify barriers to screening, and hospital medical records were reviewed to determine if colonoscopy-screening rates had improved since the time when a surgeon performed the procedure rather than family physicians. RESULTS: Of the 100 charts reviewed, 36% of patients had been screened, 26 by colonoscopy, 5 by flexible sigmoidoscopy, and 5 with fecal occult blood testing. Three percent additionally had screening studies either recommended recently or were scheduled for the near future. The number of colonoscopies completed at Blue Mountain Hospital has increased considerably since family physicians have been trained to perform the procedure. There was an average of 13 colonoscopies performed over 3 years while a surgeon alone was performing the procedure compared to 36 completed in 2003 by three family physicians. CONCLUSION: While the number of people being screened for colorectal cancer each year in John Day is increasing, the majority of patients over the age of 50 years have not been screened for colorectal cancer. Barriers identified include inadequate insurance coverage for preventive procedures, lack of time for physicians to discuss the necessity of screening, and patient disinterest for the topic of colon cancer. 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). Breast Cancer Screening of Postmenopausal Women Project Date: 9/29/2003 With the growing percentage of elderly Americans, osteoporosis and its consequent health risks are becoming an increasing public health concern. Routine screening guidelines have been proposed by many health organizations to evaluate the bone density of those at greatest ri9sk of osteoporosis, especially postmenopausal patients receive screening at a rural family medical outpatient clinic in John Day, Oregon. A chart review was performed and found that only 21% of postmenopausal women age 65 and over had been screened while 50% of postmenopausal women between ages 50 and 65 had been screened. Patients who had been screened were more likely to have come in for routine physical exams at which time appropriate screening test were recommended. Of those patients who had not been screened, many visited the clinic onlyfor treatment of acute medical conditionsof for follow up of a focused chronic medical condition. Recommendations for improved screening rates include increasing patient awareness of osteoporosis prevalence and morbidity as well as taking advantage of focused patient visits to recommend bone density screening. 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. Child Abuse: Screening and Prevention Among the Urban Underserved Project Date: 5/5/2003 Every year there are about 3 million cases of suspected child abuse reported to child protective services. 1000-2000 children die each year from child abuse. The risk factors for child abuse are numerous. The number one risk factor associated with child abuse most frequently is poverty. Since the clinic I worked at in SE Portland serves mainly those in poverty, I decided to look at child abuse screening programs within the Portland area. Also, there was a general lack of knowledge concerning community programs among providers at the SE clinic. My job was to spend one day a week with various community programs that exist to screen/prevent child abuse and report my findings so that physicians in the SE clinic may know how to access important resources for at risk children and families. 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. Colorectal Cancer Screening in the Bay Area Project Date: 11/4/2002 Colorectal cancer screening, though effective in the prevention and detection of cancer, continues to be underutilized by the majority of the population in the United States. This study attempted to examine the issue of colorectal cancer screening in Coos Bay, Oregon during a six-week rotation. First, a limited chart review was performed on patients aged 50 to 80 who had undergone either fecal occult blood testing in the past year, flexible sigmoidoscopy in the past five years, or colonoscopy in the past ten years. This determined that 50% of patients whose charts were reviewed were current with colorectal cancer screening. Next, the study included observation of physician approaches to screening as well as discussions about the views of local internists and their patients in regards to colorectal cancer screening. Discussions with patients found that the majority of those that were declining screening were doing so out of embarrassment or fear of discomfort during the screening test. And, though all internists at the Bay Clinic agreed that colorectal cancer screening is important, their time spent discussing this with patients was limited, particularly if patients did not immediately express a high level of interest in screening. Thus, a patient handout was developed that could be used as a resource to educate patients about colorectal cancer screening. Asthma Screening, Health Education and Referral - Community Health Education Coalition Health Fair, Coos County, Oregon Project Date: 9/23/2002 The National Asthma Education and Prevention Program (NAEPP) addressed the growing number and rate of asthma-related hospitalization and emergency room utilization in this country. For example, since 1994, the prevalence rate increased 75%, death rate increased 56%, and hospitalization rate increased 3%. To ensure effective control of the disease, NAEPP highly recommends multidisciplinary approach - education, prevention, social and medical interventions. Most of what is currently known about asthma distribution, utilization of ER, subsequent follow-up with a PCP and prevalence of high-risk population is based on surveys at the national level. Unfortunately, not enough data is available in small counties, such as Coos County, Oregon. To investigate the prevalence of asthma in rural Oregon community, we conducted a prospective screening study on adult population, ages 18 years above. The screening test was conducted as part of the Community Health Education Coalition (CHEC) Coos County Elder's health fair on Oct 12, 2002 in Pony Village Mall and Oct 22, 2002 in Mill's Casino in Coos Bay, Oregon. Exercise For Residents Of Reedsport, Oregon The Importance Of and Opportunities For. Project Date: 8/12/2002 The obesity trend in the United States of America is on the rise. In Oregon, the number of overweight and obese rose from 55% in 1998 to 57% in 2002. Obesity has been proven to be associated with an increased incidence of heart disease, stroke, diabetes, high blood pressure, osteoarthritis, and some cancers. During my rural rotation at Dunes Family Health Clinic as a third year medical student in Reedsport, OR, I calculated the BMI on 53 of the patients I saw in clinic and found that 87.3% of the patients I saw were overweight or obese. Because obesity and lack of exercise are often coexisting conditions, I created a patient pamphlet which includes information on reasons why to exercise regularly, how to start a exercise program, and ideas for exercise in the Reedsport area. A Bright Future for Well-Child Checks in Coos Bay, Oregon: Implementation of National Guidelines and Survey of Parental Satisfaction Project Date: 8/12/2002 Bright Futures is a national child health promotion and disease prevention initiative that provides guidelines for health supervision visits (ie. well-child checks). The purpose of this project was to (1) compare well-child checks performed by pediatricians at NBMC & Bay Clinic in Coos bay, Oregon with Bright Futures guidelines, and (2) conduct a survey among parents regarding their satisfaction with patient education materials received during the visits. Well-child checks at NBMC and Bay Clinic correlate approximately 85% and 75% with Bright Futures guidelines, respectively. The survey completed at NBMC reveals a generally high level of satisfaction with patient education materials. Examination of risk factors for the development of osteoporosis in adolescent girls at the Woodburn Pediatric Clinic. Project Date: 7/1/2002 Osteoporosis is a major health issue in America, affecting 30% to 40% of adults older than 60. Although osteoporosis is most prevalent in the older population, it is now understood that its roots lie with the pediatric population. The failure to achieve an adequate peak bone mass is a significant risk factor for future development of osteoporosis, and this process is almost complete by the onset of adulthood. This study attempts to identify the prevalence of risk factors in 9 to 13 year old girls that may predispose them to the development of osteoporosis. Data was collected by surveying girls regarding their dietary habits, exercise routine, medication use, and family history of osteoporosis. A chart review of well child exams for children of the same age was completed to assess how the Woodburn Pediatric Clinic addresses the issue of bone health. The findings of this study estimate that 60% of female patients in this age range were not consuming the recommended 1300 mg of calcium daily, 50% were not participating in regular weight-bearing exercises, and 33% already had a known family history of osteoporosis. The chart review demonstrated that the Woodburn Pediatric healthcare team is addressing nutrition and exercise in a broad sense, but fail to specifically evaluate and educate patients about the risk of developing osteoporosis. It is recommended that clinicians begin screening girls for inadequate calcium intake and exercise and providing counseling regarding preventing osteoporosis beginning at the 5-year-old well child exam. Heel Ultrasonography for Osteoporosis Screening Project Date: 2/11/2002 Heel ultrasound is a highly acceptable method of identifying patients at risk of osteoporosis. Not only is the heel an appropriate location for measurement, but also ultrasound is an appropriate technique. Both are well supported by the literature. These results are best studied on the Achilles+. If another machine is to be used, the manufacturer should be contacted for further data, as there are likely inadequate published data, based on this review of the literature. If osteopenia or osteoporosis is identified by heel ultrasonography, the patient should be referred for DEXA. Screening For Colorectal Cancer At Health Associates Of Peace Harbor In Florence, Oregon. Project Date: 1/2/2002 Colorectal cancer is a common cause of cancer related death that can often be prevented by routine screening. The aim of this study is to determine the proportion of patients of Family Physicians at Health Associates of Peace Harbor that have been screened for colorectal cancer, as well as to identify potential barriers to colorectal cancer screening specific to this clinic. The electronic medical records of 100 clinic patients over the age of 50 were reviewed for documentation of colorectal cancer screening, and the type of screening was recorded. Additionally, four family practice physicians were interviewed to identify potential barriers to colorectal cancer screening. Of the 100 medical records reviewed, 38 had received some form of screening (16 colonoscopy, 6 fecal occult blood tests, 15 sigmoidoscopy and 1 dual contrast barium enema). The major barriers to colorectal cancer screening identified by physicians were public awareness and acceptance of colorectal cancer screening and time constraints during patient visits. Additionally, all physicians felt that having a "Health Maintenance" section of the medical record would be helpful. The proportion of patients being screened at this clinic was comparable to national survey data showing that 44% have been screened. Specific recommendations to improve colorectal cancer screening rates are to introduce a "Health Maintenance" section of the medical record which documents recommended and performed screening tests for each patient, and to use this database to send patients information about recommended screening tests prior to complete physical exams. Back to subject search page or search by preceptor site