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At least 397 records · Page 22Linked to original sources
PubMed2004

Beta-blocker therapy for heart failure outside the clinical trial setting: findings of a community-based registry.

BACKGROUND: beta-Blockers reduce morbidity and mortality rates in heart failure (HF) clinical trials, but it is unknown whether these findings persist in the community setting. METHODS: A registry was created to survey tolerability and outcomes during initiation and 1-year follow-up of beta-blocker treatment with carvedilol in patients with HF treated by cardiologists (CARD) and primary care physicians (PCP) in the community. RESULTS: A total 4280 patients were enrolled (3121 by 259 CARD, 1159 by 129 PCP). Patient age averaged 67 +/- 13 years; 35% were women and 12% were black. The left ventricular ejection fraction averaged 31 +/- 12; New York Heart Association class was II-III in 86% and IV in 3%. Patients of PCP had higher left ventricular ejection fraction, were older, and more frequently were female, black, diabetic, hypertensive, and in New York Heart Association class III/IV. Minimal difficulty titrating carvedilol was noted by >80% of CARD and PCP. Significantly more CARD-treated patients reached carvedilol doses of 25 mg twice daily (49% vs 27%). Kaplan-Meier all-cause mortality rate was 8.5% at 1 year and did not differ between CARD-treated and PCP-treated patients (8.2% vs 9.3%, P =.254). At least one HF hospitalization occurred in 11% of patients during follow-up, compared with 28% in the preceding year. CONCLUSIONS: Community-based physicians use carvedilol with success approaching that of clinical trials. Overall mortality rates and HF hospitalizations were in the same low range as in clinical trials. Thus, it appears that results of clinical trials with carvedilol for HF can be translated to the community setting.

Adrenergic beta-Antagonists↗
PubMed2006

Treatment of elderly breast cancer patients in a community hospital setting.

HYPOTHESIS: Elderly breast cancer patients are underdiagnosed and undertreated in a community hospital setting. DESIGN: Retrospective study of tumor registry patients. SETTING: Community hospital. PATIENTS: A total of 354 breast cancer patients aged 70 years or older diagnosed between 1992 and 2002 were identified from the tumor registry. The data for 3 prospectively chosen age subgroups (aged 70-74, 75-79, and > or =80 years) were subsequently analyzed. MAIN OUTCOME MEASURES: Data were collected regarding the method of detection of cancer, tumor characteristics and staging, type of treatment, and patient comorbidities. Comparisons between age subgroups were made using a likelihood ratio chi2 test. RESULTS: Forty-six percent of all patients presented with palpable breast cancer. Mammography was frequently used as an adjunct to the physical examination but was helpful in detecting occult disease in only 54% of all patients and 38% of patients older than 80 years. Although more than 70% of patients were considered stage I or II, complete pathologic staging was only performed in 64% of patients. Approximately 50% of patients were treated with breast-conservation surgery; however, adjuvant radiation therapy was omitted in 55% of these patients. Additionally, only 29% of patients with positive lymph nodes received chemotherapy, and 67% patients who were estrogen receptor-positive received adjuvant hormonal therapy. CONCLUSIONS: Older breast cancer patients are more likely to be diagnosed and staged clinically. Mammography is underused as a screening modality. While breast-conservation surgery was performed in about half of the patients, adjuvant radiation, chemotherapy, and hormonal therapies were frequently excluded.

Age Factors↗
PubMed1996

Intra-aortic balloon pumping in the community hospital setting.

A community-hospital IABP program provides potentially lifesaving treatment for patients with lethal cardiac problems. Similar to the rapidly growing number of other community hospitals with IABP programs, Landmark Hospital in Rhode Island has successfully implemented this modality of cardiac care, once limited to tertiary care facilities. Although the challenges the community hospital faces when establishing an IABP program and maintaining clinical competency are unique, IABP in the community hospital is a proven treatment modality that decreases mortality rates.

Female↗
PubMedDate not supplied

Decision-making phenomena described by expert nurses working in urban community health settings.

Decision making by expert community health nurses was explored using qualitative research methods. Each subject described a crucial incident, a clinical situation where their independent decision making made a positive difference in a client's outcome. Subjects were given instructions to record a crucial incident in writing. After completing each written incident, subjects were asked five interview questions related to the incident. Subject's verbal responses to questions were audiotaped. Content analysis methods were used to analyze data. Findings suggest that decision making in clinical practice in both a rational and intuitive process. Themes emergent from data describing decision making included the following: focus, type, and purpose of the decision making; characteristics of the decision maker; sequencing of events; data collection methods; facilitators and barriers to decision making; and nursing roles in the decision-making process. Conclusions of the study include recommendations for continued research of decision making using qualitative methods allowing flexibility necessary to explore phenomena representing the essence of nursing practice. A clearer understanding of decision making is essential now and in the next century as nurses increase independent practice roles in community health settings.

Community Health Nursing↗
PubMed1995

Comparison of activities and attitudes of baccalaureate level and entry-level doctor of pharmacy graduates of the University of Illinois at Chicago.

OBJECTIVE: To determine whether (1) differences exist between BSPharm and PharmD pharmacists in practice site selection, activities, attitudes; and (2) differences in activities and attitudes exist unique between BS and PharmD pharmacists in hospital settings and in community settings. DESIGN: A survey was designed and sent through the mail. SETTING: The BSPharm graduating classes of 1985 and 1986 the PharmD graduating classes of 1988-1990 from the University of Illinois at Chicago. PARTICIPANTS: Usable responses were received from 65% (n = 159) of the BSPharm cohort and 54% (n = 176) of the PharmD cohort. MAIN OUTCOMES: The outcomes under study were: (1) the choice of practice setting of the first job and the current job; (2) percent of time spent in 4 broad categories of pharmacists' activities: prescription processing, clinical activities, management, and educating; (3) levels of intrinsic and extrinsic job satisfaction; and (4) levels of professional commitment. RESULTS: Chi-square results indicated that more BS pharmacists were practicing in community settings than were PharmD pharmacists. Multivariate analysis of variance results indicated that PharmD pharmacists were spending significantly more time in clinical and educating activities, and less time in prescription processing, controlling for any effect associated with age. PharmDs were significantly more committed to the profession and had higher levels of intrinsic job satisfaction. Analysis of data on 122 hospital pharmacists showed that PharmDs were spending significantly more time on educating activities and less time in processing prescriptions than BSPharm pharmacists, and that they were more intrinsically satisfied. No differences were found between BSPharm pharmacists and PharmD pharmacists in community settings. CONCLUSIONS: The results of this study suggest that the additional clinical education in PharmD programs may have a role in developing pharmacists with greater professional commitment and job satisfaction.

Adult↗
PubMed1992

Exporting a successful influenza vaccination program from a teaching hospital to a community outpatient setting.

PURPOSE: To assess whether we could export a successful multifaceted influenza vaccination program from an academic medical center to a community setting. DESIGN: Pre/post study using concurrent control groups. SETTING: Clinics in a staff model Health Maintenance Organization (HMO). One urban and one suburban clinic were chosen as intervention clinics, while two similar clinics were selected as control clinics. PATIENTS: All patients aged 65 and over enrolled in the four clinics. INTERVENTIONS: An informational mailing to patients, a standing-order policy allowing nurses to administer vaccine, a vaccination reminder on daily appointment lists, and availability of walk-in visits for vaccination. Patients in the control clinics received usual care. MEASUREMENTS: Vaccination rates were determined using a validated postcard survey of 150 randomly selected patients at each clinic both at baseline (1988-89) and after the intervention (1989-90). RESULTS: The baseline vaccination rates ranged from 51.4% to 74.6%, with nearly all vaccinations taking place at the HMO. In one intervention clinic, the vaccination rate improved from 56.4% to 72.3%, P = 0.01. In the other, the baseline rate was 74.6% and did not change significantly after the intervention. There was no change in the vaccination rate in the control clinics after the intervention period. CONCLUSIONS: An influenza vaccination program that combines several organizational interventions may be successfully exported from an academic to a community setting and may serve as a useful model for others.

Aged↗
PubMed1991

Risks and benefits of laparoscopic cholecystectomy in the community hospital setting.

Laparoscopic cholecystectomy has rapidly become more popular than open cholecystectomy. To further evaluate the safety and efficacy of laparoscopic cholecystectomy in the community setting, the first 190 patients to undergo the procedure in Saginaw, Michigan were studied. There were 159 females and 31 males. The mean age was 47.8 years. All patients had symptoms consistent with biliary tract disease and most had gallstones proven by preoperative ultrasound. The mean operative time was 84 minutes but decreased from 161 minutes the first month of the study to 74 minutes by the seventh month. Eighty-seven percent of patients were tolerating a regular diet by postoperative day 1. Ninety-six percent of patients were requiring only oral pain medications by postoperative day 1. Seventy percent of patients were discharged by postoperative day one while 91% were discharged by postoperative day 2. Six patients were converted to open cholecystectomy due to acute inflammation, significant bleeding or extensive adhesions. There were no deaths and the morbidity rate was 9.5%. The most significant complication was postoperative bile leak which occurred in two patients. Patients returned to work a mean of 16.1 days following surgery and to their normal daily activities at home a mean of 12.9 days postoperatively. This study of the first 190 laparoscopic cholecystectomies in Saginaw affirms the safety and feasibility of this procedure in the community setting in selected patients.

Biliary Tract Diseases↗
PubMed2006

Guiding the transition of nursing practise from an inpatient to a community-care setting: a Saudi Arabian experience.

The purpose of this paper is to provide an overview of the Transitional Practise Model, which was used as the educational learning program to guide the transition of two Saudi nurses from an acute inpatient environment into a community setting. This model was informed by Benner's "novice to expert" concept and is grounded in experiential learning and critical thinking. The aim was to enhance knowledge and skills by providing opportunities for learning in order to make an effective transition from an acute inpatient environment into community nursing. The model was effective in guiding and bridging the gap for nurses to undertake a transition from a hospital inpatient environment into a community setting. The use of preceptors was invaluable in providing an understanding of the nature of professional practise through learning opportunities, mentoring, and support.

Attitude of Health Personnel↗
PubMedDate not supplied

Availability of and attitudes toward resources on alternative medicine products in the community pharmacy setting.

OBJECTIVE: To examine the availability of resources on dietary supplements in the community pharmacy setting and to assess the attitudes of community pharmacists toward these resources. DESIGN: Cross-sectional study. SETTING: Community pharmacies in New York and New Jersey that serve as experiential sites for senior student pharmacists at the Arnold & Marie Schwartz College of Pharmacy and Health Sciences, Long Island University. PARTICIPANTS: Preceptors or full-time pharmacists. INTERVENTION: Mailed survey. MAIN OUTCOME MEASURES: Frequency of use, availability of, and pharmacists' satisfaction with resources on alternative medicines, defined in the survey as any product including herbal remedies, vitamins, minerals, and natural products that may be purchased at a health food store, pharmacy, supermarket, alternative medicine store/magazine for the purpose of self-treatment. RESULTS: A total of 64 pharmacists characterized their frequency of use of resources on alternative medicines while formulating responses to questions as: never (n = 5; 7.8%), seldom (n = 31; 48.4%), often (n = 24; 37.5%), or always (n = 4; 6.3%). A total of 30 different resources were available to 40 respondents. The most commonly available resources were the PDR for Herbal Medicines (42.5%), The Review of Natural Products (20.0%), and the Web site of the National Center for Complementary and Alternative Medicine (12.5%). Of 54 respondents, 4 (7.1%) reported being completely dissatisfied with the available resources; 17 (31.5%) were somewhat dissatisfied; 25 (46.3%) were somewhat satisfied; and 8 (14.8%) were completely satisfied with the resources available to them. Topics the pharmacists most commonly wanted to see improved included safety (72.7%), interactions (70.9%), and uses (69.1%). CONCLUSION: Community pharmacists do not use information resources on alternative medicine products frequently, and many are not satisfied with the resources available to them.

Attitude of Health Personnel↗
PubMed2006

Evaluation of residency training in the delivery of culturally effective care.

OBJECTIVE: To augment resident training in the delivery of culturally effective care in order to improve clinician capacity to effectively care for patients from diverse backgrounds. METHODS: Residents from the Naval Medical Center San Diego and the University of California San Diego participated in experiential learning and service activities. Programme evaluation assessed aspects of the delivery of culturally effective care in community settings. A community-based participatory approach to engaging residents in the delivery of culturally effective care and evaluation of the effectiveness of this approach are described. RESULTS: A significant pre-post rotation increase was noted in residents' self-perceived ability to identify culture-related issues that may impact on the patient's view of illness (P<0.001) and ability to address a culture-related issue (P<0.001). Community evaluations rated residents positively on behaviours that reflected communication skills and professionalism, but less positively on knowledge about communities. CONCLUSIONS: The authors conclude that resident exposure to the block rotation curriculum contributes to improved knowledge of the skills necessary to provide culturally effective care in diverse community settings.

Adult↗
PubMed1996

Predictive properties of serum-prostate-specific antigen testing in a community-based setting.

BACKGROUND: Most studies that have described the sensitivity and specificity of prostate-specific antigen (PSA) as a screening test have been conducted in urology practice settings or in media-based screening programs. The control patients from these settings may have a higher prevalence of urologic disorders that increase serum PSA levels than that of the general population in which screening efforts might take place, leading to biased estimates of sensitivity and specificity. OBJECTIVE: To determine the sensitivity and specificity of serum PSA levels for the early detection of prostate cancer in a population-based setting. PATIENTS AND METHODS: This population-based case-control study was conducted in Olmsted County, Minnesota, where the Rochester Epidemiology Project could identify all incident cases of prostate cancer through passive surveillance of medical care provided to local residents. Case patients were all 177 men (age range, 50-79 years) who were newly diagnosed as having prostate cancer from 1990 through 1992 and had a prediagnostic serum PSA determination (90% of all incident cases). Control patients were randomly selected from the Olmsted County population and had undergone a clinical examination to exclude prostate cancer. RESULTS: The median (25th and 75th percentiles) of serum PSA levels was 9.4 ng/mL (5.4 and 18.6 ng/mL, respectively) for case patients and 1.2 ng/mL (0.7 and 2.1 ng/mL, respectively) for control patients (P < .001). When sensitivity was plotted against 1-specificity, the area under the receiver operating characteristic curve was 0.94 (SE, 0.01). The predictive power declined somewhat with age, with areas under the curve of 0.96, 0.94, and 0.90 for men in their 50s, 60s, and 70s, respectively. When cases were restricted to the 155 men with clinically localized disease, the area under the curve was essentially unchanged (0.94; SE, 0.01) and still much greater than the estimates of 0.75 that were reported from urology practice- and media-based settings. CONCLUSIONS: In a community-based setting, serum PSA levels provide better discrimination between men with and without clinically localized prostate cancer than has been observed in studies that were conducted in urologic practices. These results suggest that previous decision analyses may have underestimated the predictive value of PSA for the detection of prostate cancer in a primary care or community-wide screening program.

Age Factors↗
PubMed2004

Considerations in planning a newborn developmental care program in a community hospital setting.

The effectiveness of developmental care has primarily been evaluated in large tertiary neonatal intensive care units (NICUs) and has shown some promise in enhancing the developmental outcomes of premature newborns cared for in these settings. These interventions have never been prospectively evaluated outside of tertiary care settings. This article attempts to define and critically review developmental care. The differences between large teaching hospital NICUs and smaller community hospital units are highlighted. An overview of developmental care strategies is provided, along with considerations and resources available to support the implementation of developmental care in the community setting.

Hospital Planning↗
PubMedDate not supplied

Impact of spiral computed tomography on the diagnosis of pulmonary embolism in a community hospital setting.

BACKGROUND: While the optimal role of spiral CT angiography (CTA) in the diagnosis of pulmonary embolism (PE) remains controversial, this technology is already being widely utilized in the community setting. OBJECTIVES: To assess the impact CTA has had on angiography utilization rates and the overall diagnostic rate of PE. METHODS: All patients evaluated for PE during a 4-year period were studied. PE was defined as either a high-probability V/Q scan, a positive conventional angiogram, or a CTA with emboli in the segmental or larger pulmonary vessels. Diagnostic rates of PE per 1,000 hospital admissions were determined and analyzed for time periods before and after the introduction of CTA. CT reports were compared with their concurrent chest radiograph (CXR) reports and additional findings that were not apparent on CXR were abstracted. RESULTS: The diagnostic rate of PE per 1,000 hospital admissions was 1.8 prior to the introduction of CTA and increased to 2.8 per 1,000 admissions after the introduction of CTA (p < 0.0001). Total costs for diagnostic testing per PE diagnosis made went from US 2,518 dollars to US 2,572 dollars. While the number of PE diagnosed by V/Q scan remained constant, the number of PE diagnosed by conventional angiography decreased while the number diagnosed by CTA increased. In patients with intermediate probability V/Q scan results, the percentage of patients receiving subsequent angiography (conventional or CTA) increased from 17 to 26% (p = 0.043). When conventional angiography was performed, CT imaging of the chest still had to be ordered for other reasons 38% of the time. Additional information was obtained in 78% of cases when CTA was performed. CONCLUSIONS: Increased utilization of CTA was associated with an increase in angiography utilization rates and diagnostic rates of PE, was cost effective, and often provided additional, useful, and unanticipated diagnostic information.

Angiography↗
PubMed2006

Interventions for tobacco cessation in the dental setting.

BACKGROUND: Tobacco use has significant adverse effects on oral health. Oral health professionals in the dental office or community setting have a unique opportunity to increase tobacco abstinence rates among tobacco users. OBJECTIVES: This review assesses the effectiveness of interventions for tobacco cessation offered to cigarette smokers and smokeless tobacco users in the dental office or community setting. SEARCH STRATEGY: We searched the Cochrane Tobacco Addiction group Specialized Register (CENTRAL), MEDLINE (1966-2004), EMBASE (1988-2004), CINAHL (1982-2004), Healthstar (1975-2004), ERIC (1967-2004), PsycINFO (1984-2004), National Technical Information Service database (NTIS, 1964-2004), Dissertation Abstracts Online (1861-2004), Database of Abstract of Reviews of Effectiveness (DARE, 1995-2004), and Web of Science (1993-2004). SELECTION CRITERIA: We included randomized and pseudo-randomized clinical trials assessing tobacco cessation interventions conducted by oral health professionals in the dental office or community setting with at least six months of follow up. DATA COLLECTION AND ANALYSIS: Two authors independently reviewed abstracts for potential inclusion and abstracted data from included trials. Disagreements were resolved by consensus. MAIN RESULTS: Six clinical trials met the criteria for inclusion in this review. Included studies assessed the efficacy of interventions in the dental office or a school community setting. All studies assessed the efficacy of interventions for smokeless tobacco users, one of which included cigarettes smokers. All studies employed behavioural interventions and only one offered pharmacotherapy as an interventional component. All studies included an oral examination component. Pooling of the studies suggested that interventions conducted by oral health professionals increase tobacco abstinence rates (odds ratio [OR] 1.44; 95% confidence interval [CI]: 1.16 to 1.78) at 12 months or longer. Heterogeneity was evident (I(2) = 75%) and could not be adequately explained through subgroup or sensitivity analyses. AUTHORS' CONCLUSIONS: Available evidence suggests that behavioural interventions for tobacco use conducted by oral health professionals incorporating an oral examination component in the dental office and community setting may increase tobacco abstinence rates among smokeless tobacco users. Differences between the studies limit the ability to make conclusive recommendations regarding the intervention components that should be incorporated into clinical practice.

Counseling↗
PubMed2005

A pilot study of antibiotic cycling in the community hospital setting.

OBJECTIVE: To assess the feasibility of a quarterly antibiotic cycling program at two community hospitals and to evaluate its safety and impact on antibiotic use, expenditures, and resistance. DESIGN: Nonrandomized, longitudinal cohort study. SETTING: Two community hospitals, one teaching and one non-teaching. PATIENTS: Adult medical and surgical inpatients requiring empiric antibiotic therapy. INTERVENTION: We developed and implemented a treatment protocol for the empiric therapy of common infections. Between July 2000 and June 2002, antibiotics were cycled quarterly; quinolones, beta-lactam-inhibitor combinations, and cephalosporins were used. Protocol adherence, adverse drug events, nosocomial infections, antibiotic use and expenditures, resistance among clinical isolates, and length of stay were assessed during eight quarters. RESULTS: Physicians adhered to the protocol for more than 96% of 2,494 eligible patients. No increases in nosocomial infections or adverse drug events were attributed to the cycling protocol. Antibiotic acquisition costs increased 31%; there was a 14.7% increase in antibiotic use. Length of stay declined by 1 day. Quarterly variability in the prevalence of vancomycin-resistant enterococci and ceftazidime resistance among combined gram-negative organisms were noted. CONCLUSIONS: Implementation of an antibiotic cycling program is feasible in a community hospital setting. No adverse safety concerns were identified. Antibiotic cycling was more expensive, partly due to an increase in antibiotic use to optimize initial empiric therapy. Quarterly antibiogram patterns suggested that antibiotic cycling may have impacted resistance, although the small number of isolates precluded statistical analysis. Further assessment of this approach is necessary to determine its relationship to antimicrobial resistance.

Adult↗
PubMedDate not supplied

Patient-guided counseling in the community pharmacy setting.

OBJECTIVE: To test a new prescription counseling method termed "patient-guided counseling" (PGC) in community pharmacies. DESIGN: Post-test experimental design in which subjects were randomized to three groups. SETTING: Six community pharmacies (three chain and three independent). PATIENTS: Patients presenting new prescriptions. INTERVENTIONS: Patients were randomly assigned to one of three comparison groups. The PGC group was given a written prompt instructing them to write any questions they wished to ask about their prescription or their medical condition. The pharmacist then incorporated these questions into the subsequent verbal counseling. A second group was given a written prompt encouraging them to ask the pharmacist questions. This was followed by customary verbal counseling. A third group served as the control. No prompts were provided, but the pharmacist did provide customary verbal counseling. MAIN OUTCOME MEASURES: Patients' demographics, recall of medication information, and satisfaction with counseling. Patients were contacted by telephone 5 days after the start of drug therapy to measure compliance. Pharmacists rated their satisfaction with the information communicated and with their interactions with patients. RESULTS: Compared with customary verbal counseling, the PGC method was associated with more supplemental questions asked by the patient. Compared with the other two methods, PGC was associated with greater pharmacist satisfaction with the information communicated and slightly longer counseling sessions. No significant differences were found for patients' overall satisfaction with counseling, recall of information, and compliance. CONCLUSION: In the community pharmacy setting, PGC fosters patient participation in medication counseling, a necessary element for the provision of pharmaceutical care.

Community Pharmacy Services↗
PubMed2004

Understanding the environmental issues in diabetes self-management education research: a reexamination of 8 studies in community-based settings.

Eight studies included in a recent systematic review of the efficacy of diabetes self-management education were qualitatively reexamined to determine the presence of theoretical frameworks, methods used to ensure cultural appropriateness, and the quality of the instrument. Theoretical frameworks that help to explain complex pathways that produce health outcomes were lacking; culture indices were not incorporated into diabetes self-management education; and the instruments used to measure outcomes were inadequate. We provide recommendations to improve research on diabetes self-management education in community settings through use of a contextual framework that encourages targeting multiple levels of influence--individual, family, organizational, community, and policy.

Community Health Services↗