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PubMed2006

Early experience of stapled hemorrhoidectomy in a community hospital setting.

BACKGROUND: Stapled hemorrhoidectomy was introduced as a new procedure for the surgical management of hemorrhoidal disease in 1993. We present a cohort longitudinal study performed in a community hospital setting where the short-term outcomes of stapled hemorrhoidectomy were compared with those of conventional hemorrhoidectomy. METHODS: We compared 41 consecutive patients who underwent a conventional open diathermy (Ferguson) hemorrhoidectomy between September 1999 and September 2001 with 40 consecutive patients who underwent a stapled hemorrhoidectomy procedure between September 2001 and June 2004. We analyzed perioperative and postoperative complications, length of hospital stay, patient satisfaction and case costing for both groups. RESULTS: The stapled hemorrhoidectomy group comprised 13 men and 27 women. The open hemorrhoidectomy group comprised 9 men and 32 women. There were no intraoperative complications in either group. In the stapled hemorrhoidectomy group, 3 patients presented with postoperative complications and 3 required admission. In the open hemorrhoidectomy group, 14 patients presented with postoperative complications and 11 required admission. At 2-week follow-up, 35 patients (88%) presented no complaints in the stapled hemorrhoidectomy group, versus 27 (66%) in the open hemorrhoidectomy group. The total cost calculated for the stapled hemorrhoidectomy procedure was dollar 716.38, whereas the total cost of the open hemorrhoidectomy procedure was dollar 760.00. CONCLUSIONS: The stapled hemorrhoidectomy technique is a safe alternative to the traditional open hemorrhoidectomy. It can be performed as an outpatient procedure, is well tolerated by patients and is no more expensive than conventional surgical therapy.

Adult↗
PubMed1990

Coronary angioplasty in emergency treatment of myocardial infarction in a community-hospital setting.

From July 1986 through June 1988, 135 consecutive patients with myocardial infarction, including 23 in cardiogenic shock, were treated with percutaneous transluminal coronary angioplasty in a community-hospital setting. In 109 (81%) of the cases, angioplasty was successful, resulting in brisk anterograde flow and in residual stenosis of less than 50%. The success rate was 88% (99/112) for patients not in cardiogenic shock and 43% (10/23) for those in shock. During the term of hospitalization, clinically evident total reocclusion occurred in 5 (4%) patients not in shock on presentation (2 of these experienced anterior infarction, and 3 inferior infarction); repeat angioplasty was performed successfully in all 5. No clinical reocclusion was detected in the smaller group of patients admitted in shock. Eleven patients (8%) underwent emergency coronary artery bypass grafting following the coronary angioplasty procedure: 4 for failed angioplasty in the infarct-related artery, and the other 7 for severe triple-vessel disease. Hospital mortality was 0.9% (1/112) for patients not in cardiogenic shock and 52% (12/23) for those admitted in shock, for an overall rate of 10% (13/135). Among patients whose balloon angioplasty was successful, hospital mortality was 0% for those not in shock and 30% (3/10) for those in shock. Among patients whose angioplasty failed, however, mortality was 8% (1/13) for those not in shock and 69% (9/13) for those admitted in shock.

Journal Article↗
PubMed1998

Exploring mental health nurses' expectations and experiences of working in the community.

As mental health care is increasingly being provided in community settings, a variety of job opportunities are becoming available to mental health nurses. The extent to which nurses' views and experiences of working in community settings have been explored, however, is limited. This paper reports on newly qualified nurses' plans in relation to taking up work in the community and, for those who thought it likely that they would take up such work, their reasons for doing so. Reasons for working in the community were diverse, and suggested that a range of satisfactions could be expected. The extent to which such expectations become a reality is considered in the light of findings from interviews with 12 nurses who were working in community settings. Satisfactions and difficulties experienced by the 12 nurses are described, and suggestions for tackling some of the difficulties are made.

Attitude of Health Personnel↗
PubMed2002

Diabetes disease management in a community-based setting.

PURPOSE: The medical cost of diabetes in the United States in 1997 was at least $98 billion. This study illustrates the behavioral change and medical-care utilization impact that occurs in a community-based setting of a diabetes disease-management program that is applied to program participants in a health insurance plan's health maintenance organization and preferred provider organization. DESIGN: A historical control comparison of diabetes-management participants. METHODOLOGY: One hundred twenty-seven identified diabetes patients are followed from baseline through 1 year. Differences in behavior are compared at program intake and at a 6-month reassessment. Differences in medical-service utilization are compared in the baseline year and the year subsequent to program enrollment. Poisson multivariate-regression models are estimated for counts of inpatient, emergency department, physician evaluation and management, and facility visits, while also controlling for potential confounders. PRINCIPAL FINDINGS: Behaviors improved between program intake and the 6-month reassessment. From patient reports, the number of participants having a hemoglobin A1c test increased by 44.9 percent (p < .001), and there was a 53.2-percent decrease in symptoms of hyperglycemia (p = .002). From medical claims after program enrollment, a drop occurred during the program year in every dimension of medical-service utilization. Regression results show that in-patient admissions decreased by 391 (p < .001) per 1,000 for each group, while controlling for age, length of membership, and the number of comorbid claims for congestive heart failure. In the analysis of costs that were pre- and post-enrollment, which included disease-management program costs, a 4.34:1 return on investment was calculated. CONCLUSION: The diabetes program provides patients with comprehensive information and counseling relative to practicing self-management of diabetes through a number of integrated program components. This study strongly suggests that the implementation of such a program is associated with positive behavioral change and, thus, with substantial reduction in medical-service utilization. In addition, the intervention resulted in a net decrease in direct medical costs.

Aged↗
PubMed2001

Percutaneous dilatational tracheostomy in a community hospital setting.

BACKGROUND: Over the past 15 years, many large university hospitals have reported their experience with percutaneous dilatational tracheostomy (PDT). The purposes of this study are to evaluate the safety of PDT in a non-university hospital setting and to compare our results with those published in the literature. METHODS: The study was done by retrospective chart review. RESULTS: Over a 6-year period, 300 PDTs were done in two community hospitals in Tyler, Texas. There was one death and 12 complications. Comparison of our results and those reported in five recently published articles in the literature showed no significant difference in mortality rate, pneumothorax, bleeding, paratracheal placement, dislodgement, or cellulitis. There was a trend toward a significantly lower incidence of paratracheal placement using bronchoscopic guidance. CONCLUSION: Bedside PDT with bronchoscopic guidance can be safely done in a community hospital setting.

Adult↗
PubMed2001

Transforming community psychology.

Community psychology has made great strides in including context when understanding people in their environments. While continuing to consider context, we need to expand our conceptualization of the individual in community settings. I propose 3 principles: (1) focus our research on people, not programs; (2) consider multiple dimensions of people's experience; and (3) conceptualize people as agentic and not simply as reactors to the environmental press. I illustrate those principles with research on domestic violence and welfare reform. In doing so, I call attention both to the way in which aspects of people's lives intersect with community settings, and to the embeddedness of people's lives (and community settings) in larger social structures.

Community Mental Health Services↗
PubMed2002

Professional issues for physiotherapists in family-centred and community-based settings.

This paper reports results from a qualitative study of physiotherapists in a community-based and family-centred setting in which a growing awareness of the family-centred approach accompanied the transition from an institutional structure to a predominantly community-based structure. The goal was to gain insight into how a family-centred philosophy was working and to explore the benefits and dilemmas for physiotherapists in such a setting. Semi-structured interviews were conducted with 10 physiotherapists working with children with disabilities. Analysis of the results against a continuum of family control versus physiotherapist control showed that physiotherapists saw their roles as working with the family to discuss shared goals. However, qualitative analyses showed tensions between the policy of family involvement and another influential policy in physiotherapy: evidence-based practice. Further, there were tensions if the desires of the family could not be matched with available resources. The results show benefits and barriers to working in a community-based, family-centred approach. Barriers included practical dilemmas, policy dilemmas, and career dilemmas. This paper argues that, while family-centred practice is supported by the literature and physiotherapists, significant policy and professional issues need to be addressed before such practice can be fully adopted.

Attitude of Health Personnel↗
PubMedDate not supplied

Ability of clinical pharmacists in a community pharmacy setting to manage anticoagulation therapy.

OBJECTIVES: To determine the ability of community pharmacists within an anticoagulation clinic to keep international normalized ratios (INRs) within therapeutic ranges and, secondarily, to determine the incidence of bleeding and thromboembolic events and patient satisfaction. DESIGN: Retrospective observational study. SETTING: Eckerd PatientCARE Network in Eckerd pharmacies in Tampa Bay area of Florida. PATIENTS: 50 patients taking warfarin and having INR determinations for 6 consecutive months. INTERVENTIONS: Clinical pharmacists monitored patients' anticoagulation status using point-of-care analyzers and making dosage changes as needed under a collaborative agreement. Extensive patient education was provided to patients regarding their anticoagulation. Data were collected from the initial visit through the 6 consecutive months. Patients were surveyed to assess their satisfaction with the clinic. MAIN OUTCOME MEASURES: Percentage of INRs within therapeutic range and, secondarily, incidence of bleeding and thromboembolic events and patient satisfaction with the clinic. RESULTS: During the 6 months of initial therapy with warfarin, 243 of 435 (56%) INRs were in desired therapeutic ranges. A total of 15 bleeding episodes were reported, of which 10 were minor and 5 were significant. No thromboembolic events were reported. There was a 22% response rate to the survey, in which all statements were rated as above average to excellent. CONCLUSION: Community pharmacists in an anticoagulation clinic effectively manage anticoagulation therapy, as the results of this clinic are similar to those of clinics managed by pharmacists in other settings.

Aged↗
PubMed2026

Psychiatric mental health nurse practitioner outcomes after completion of a 1-year postgraduate fellowship.

Psychiatric mental health nurse practitioners (PMHNPs) are an essential and growing part of the health care workforce, especially in community settings. To address PMHNPs' increasing presence in community psychiatry, a 1-year postgraduate PMHNP fellowship in community psychiatry was developed with the goals of enhancing clinical competency and employment retention in underserved public sector settings. Data on 5 cohorts and 31 fellows are presented in this article. PMHNP fellows, preceptors, didactics, and clinical sites were evaluated across several time points including baseline and 6 and 12 months. The program has graduated 100% of fellows with largely positive feedback. Fellows reported significant improvements in competency across the domains of 1) assessment and diagnosis, 2) treatment, and 3) professionalism and leadership. These items were substantiated by clinical preceptors' ratings of fellows' clinical skills from 6-month and 12-month time points. Relatedly, clinical sites, preceptors, and didactics were all rated highly by fellows. After the program, 90.3% of graduates remained working in the public sector including correctional settings, community clinics, and safety net hospitals.

Community psychiatry↗
PubMed1998

Underuse of venous thromboembolism prophylaxis for general surgery patients: physician practices in the community hospital setting.

BACKGROUND: Venous thromboembolism is a common complication of surgery. Although surveys of physician self-reported practices have suggested near universal support for routine use of measures to prevent venous thromboembolism, medical record auditing has demonstrated underuse. OBJECTIVE: To assess physician practices of venous thromboembolism prophylaxis in the community hospital setting. METHODS: Retrospective review of the medical records from 20 hospitals in Oklahoma of 419 Medicare patients aged 65 years or older undergoing major abdominothoracic surgery between April 1 and December 31, 1995. Utilization rates of prophylaxis stratified according to patient risk for venous thromboembolism were measured. RESULTS: Prophylaxis measures were implemented for only 160 (38%) of 419 patients studied (95% confidence interval, 33%-43%). There was little variation in the use of prophylaxis based on the risk for venous thromboembolism. Only 97 (39%) of 250 patients (95% confidence interval, 33%-45%) at very high risk received any form of prophylaxis and of these 97, only 64 patients (66%) received appropriate measures (95% confidence interval, 56%-75%). CONCLUSIONS: Despite widely disseminated, evidence-based recommendations, venous thromboembolism prophylaxis is underused in Medicare patients undergoing major abdominothoracic surgery in community hospitals in Oklahoma.

Abdomen↗
PubMed1998

Long term results with breast-conserving therapy for patients with early stage breast carcinoma in a community hospital setting.

BACKGROUND: Prospective randomized trials and retrospective reviews from academic centers have documented the success of breast-conserving therapy (BCT) for patients with early stage breast carcinoma. The authors retrospectively reviewed the outcome of BCT for early stage breast carcinoma to determine the success of BCT at the study institution, a 1000-bed community hospital. METHODS: Between January 1980 and December 1987, 400 cases of Stage I and II breast carcinoma were managed with BCT at the study institution. All patients were treated with an excisional biopsy. The axilla was surgically staged in 383 patients (96%). Postoperative treatment was composed of 45-50 gray (Gy) external beam irradiation to the whole breast and a boost to the tumor bed to at least 60 Gy in all patients. The median follow-up of the 292 surviving patients is 118 months. RESULTS: At last follow-up, there were 37 local recurrences for 5- and 10-year actuarial rates of 4% and 10%, respectively. Clinical, pathologic, and treatment-related factors were analyzed for an association with local recurrence. On univariate analysis, patient age < or = 35 years and positive surgical margins were associated with an increased risk of local recurrence. On multivariate analysis, only patient age < or = 35 years remained significant. The 10-year actuarial regional recurrence rate was 5%. The 10-year actuarial cause specific survival rate was 91% and 69% for Stage I and II patients, respectively. CONCLUSIONS: BCT for patients with early stage breast carcinoma in a community hospital setting produces excellent results comparable to contemporary series reported from academic institutions and multiinstitution trials.

Actuarial Analysis↗
PubMed1999

Genetics education for primary care providers in community health settings.

Patients who are in need of genetic services are often inappropriately managed, in part due to inadequate knowledge of genetic issues among primary health care providers. The purpose of this study was to determine the effect of a genetics education program on the knowledge and attitudes of primary care providers in community health settings. A total of one hundred twenty-one primary care providers who work in Texas Public Health Region VIII participated in an educational program designed to provide basic genetics information. A one-group pretest-posttest design was used to assess knowledge and attitudes of subjects, and comparisons were made pre and post intervention. Pretest assessment revealed less than adequate knowledge about basic genetic principles and relatively positive attitudes among the subjects. Following the program, there were statistically significant increases in both knowledge about genetic conditions (P = .001) and attitudes toward provision of genetic services (P = .001). These results indicate that primary health care providers, motivated to learn complex materials and new skills in order to assist their patients, can do so in a relatively short time period.

Attitude of Health Personnel↗
PubMed1978

The aftermaths of deinstitutionalization: problmes and solutions.

Thousands of mentally handicapped patients released from mental hospitals are now living in a variety of community settings. Services to help them remain in community are often fragmented, uncoordinated and limited. Research and experience have highlighted the services they need. Numerous demonstrations have shown that patients can be successfully maintained in community setting. Coordinated services and fixed responsibility for each individual placed are essential.

Adult↗
PubMedDate not supplied

Facilitating interdisciplinary practice through mobile service provision to the rural older adult.

Reaching the older adult in the rural communities in which they reside is desirable in an effort to support aging in place. The Idaho State University (ISU) Senior HealthMobile is an innovative, interdisciplinary rural health outreach effort designed to meet the needs of the older adult and support healthy aging. Health and wellness support services are provided through mobile interdisciplinary teams involving students and faculty in nursing, physical therapy, occupational therapy, pharmacy, and dietetics, among other disciplines. Students and supervising faculty provide services in the ISU Senior HealthMobile, in the rural senior centers, and in the home, providing a unique opportunity to be a part of the life of the older adult in the rural community setting. Partnerships and collaborative linkages within the community setting support the enhancement of existing services in collaboration with the ISU Senior HealthMobile.

Aged↗