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PubMed2002

Unprotected carotid artery stenting compared to carotid endarterectomy in a community setting.

PURPOSE: To evaluate the feasibility and safety of carotid artery stenting (CAS) performed by a dedicated multidisciplinary team in a community hospital. METHODS: Forty-nine patients (30 men; mean age 74.3 +/- 7.4 years, range 51-88) with 14 symptomatic and 35 asymptomatic >50% carotid stenoses were enrolled into the study and treated with self-expanding stents without cerebral protection. The patients were evaluated at 30 days for death, neurological sequelae, and length of stay. A contemporaneous group of 140 patients (80 men; mean age 72.3 +/- 7.7 years, range 43-89) undergoing carotid endarterectomy (CEA) was used for comparison of the outcome measures. Owing to crossover of failed CAS patients to the CEA group, the data were analyzed according to intention-to-treat and treatment-received. RESULTS: The only difference in baseline characteristics between the treatment and control groups was the greater frequency of bilateral disease in the CEA group (p=0.009). The CAS procedures were successful in 47 (96.0%) patients; 2 access failures were converted to endarterectomy, and 1 access-site pseudoaneurysm was treated surgically. There were no deaths or myocardial infarctions in either group. In the CAS group, there were no major and only 2 (4.1%) minor strokes compared to 4 (2.9%) major and 4 (2.9%) minor strokes in the CEA group (p>0.05). Median LOS was significantly lower in the CAS group (p<0.0001). CONCLUSIONS: Careful case selection and multidisciplinary collaboration facilitate the safe performance of carotid stenting in a community setting with acceptable early results.

Adult↗

PubMed1996

Efficacy of preconception care of diabetic women in a community setting.

OBJECTIVE: To determine the impact of informal preconception care of diabetic women on first-trimester glycemia control in a community setting. STUDY DESIGN: Forty-five women with pregestational diabetes underwent a standardized interview regarding their preconception care prior to the index pregnancy. Patients under 14 weeks' gestation had their glycosylated hemoglobin measured; it was used as an index of first-trimester glycemic control. Variables related to glycemic control were analyzed with reference to glycosylated hemoglobin results. RESULTS: Despite a high incidence of counseling and frequent preconception visits, the mean first-trimester glycosylated hemoglobin (+/- SD) was high (10.7 +/- 2.0), and the majority of pregnancies were unplanned. CONCLUSION: Informal and noncentralized preconception care was not effective in preventing first-trimester hyperglycemia in this group of diabetic women. A high rate of unplanned pregnancy and lack of structured preconception care were prevalent and possibly etiologic.

Adult↗

PubMed2001

Outcome survey of early intensive behavioral intervention for young children with autism in a community setting.

This article presents findings from an outcome survey of the effects of early intensive behavioral intervention (EIBI) for young children with autism in a community setting. Results from both individual case reviews and parent questionnaires are presented, with the data failing to support any instances of'recovery' while still yielding a high degree of parental satisfaction with the treatment. Moreover, a follow-up inquiry into the type of services each child was receiving in his or her post-EIBI setting documents continued dependence on extensive educational and related developmental services, suggesting that the promise of future treatment sparing did not materialize. Limitations of the survey in evaluating community-based EIBI services are discussed along with the need for further research designed to document the effectiveness of services provided to young children with ASD in the community.

Autistic Disorder↗

PubMed2006

Diarrhea in American infants and young children in the community setting: incidence, clinical presentation and microbiology.

OBJECTIVE: The characteristics and microbiology of the full spectrum of pediatric diarrhea occurring in the U.S. community setting are not well-understood. METHODS: Six-month prospective cohort study of 604 healthy 6- to 36-month-old children recruited by the Slone Center Office-based Research Network. RESULTS: The incidence of parent-defined diarrhea was 2.2 episodes per person-year. The median duration of diarrhea was 2 days with a median of 6 stools per episode. Outpatient visits and hospitalization were prompted by 9.7 and 0.3% of episodes, respectively. The most common microorganisms identified in healthy baseline stools were atypical enteropathogenic Escherichia coli (12.2%), enteroaggregative Escherichia coli (3.7%), Clostridium difficile (3.5%) and Clostridium perfringens (2.9%), and each of these was no more common in diarrhea stools. In contrast, all of the viruses analyzed were more prevalent in diarrhea specimens than in baseline specimens: enteric adenovirus (5.7% diarrhea versus 1.4% baseline), rotavirus (5.2% versus 1.4%), astrovirus (3.5% versus 1.4%), Sapporo-like virus (3.0% versus 0.8%) and norovirus (1.9% versus 0.8%). A likely pathogen was detected in 20.6% of diarrhea specimens. Vomiting and > or =16 stools in an episode were predictive of isolating a pathogen from the stool, each with a relative risk of approximately 2. CONCLUSIONS: Healthy young children in this study experienced more than 2 cases of diarrhea per person-year, but most were brief and do not require medical attention. Although most diarrhea-associated pathogens were viruses, no likely pathogen was found in almost 80% of cases; possible etiologies for these cases include currently unknown gastrointestinal infections, nongastrointestinal illnesses and dietary/environmental factors.

Adenoviruses, Human↗

PubMed2003

Early postoperative mortality following total hip arthroplasty in a community setting: a single surgeon experience.

The senior author performed 4967 total hip arthroplasties, 4164 primary and 803 revision, between 1970 and 1996 in a community setting. All charts were evaluated for postoperative death including in-house, 30, 60, and 90 days following the procedure. 1.0 per cent of patients (42) died following a primary procedure and 0.87 per cent (7) died following a revision procedure within 3 months of surgery. The number of in-house deaths were 26 (0.52 per cent), including 21 in the primary group (0.5 per cent) and 5 in the revision group (0.62 per cent). In both the primary and revision situation and independent of co-morbidities, age greater than 70 years was significantly associated with increased risk for post-operative mortality (p<0.0001), with 0.44% mortality in patients aged 70 years or younger (0.51 per cent primary and 0.00 per cent revision), and 1.45 per cent mortality in patients greater than 70 years of age (1.38 per cent primary and 1.86 per cent revision). This experience of a single surgeon with a high volume community practice performing both primary and revision total hip arthroplasty, documents a low but significant incidence of postoperative death in the first 3 months following total hip arthroplasty (0.98 per cent).

Aged↗

PubMedDate not supplied

Prevalence of bacterial vaginosis in a community setting and role of the pap smear in its detection.

OBJECTIVE: To study the revalence of bacterial vaginosis (BV) in symptomatic and asymptomatic women in a community setting, to assess the validiy of the Pap smear in the detection of BV and to determine the sensitivity and specificity of clinical criteria for the diagnosis of BV. STUDY DESIGN: Gram staining was performed on vaginal secretions collected from 301 women to determine the prevalence of BV. Each smear was assigned a score on the basis of the bacterial morphotypes identified. The bacterial pattern was also studied on 270 adequate, Pap-stained cervical smears and compared with the gold standard, the morphotypes on gram stain, to derive the validity of the Pap smear in diagnosing BV. Also each clinical criterion defined for diagnosis of BV was independently evaluated to determine their sensitivity and specificity. RESULTS: The overall prevalence of BV was 41.5% in the study subjects using Amsel's and Nugent's criteria. The Pap smear was 78.3% sensitive and 86.9% specific in detection of BV. Among the clinical criteria, the presence of clue cells on wet mounts was both highly sensitive (76.7%) and specific (92.4%) for diagnosing BV, while a positive whiff test had a specificity of 86.9% with sensitivity of 33.9%. Vaginal pH > 4.5 was sensitive (88.3%) but less specific (58.6%). The presence of a thin, homogeneous discharge clinging to vaginal mucosa had low sensitivity (56.3%) and specificity (48.9%). In this study, BV was prevalent in both symptomatic and asymptomatic women. The routine Pap smear was able to detect BV in the majority of women. Its utility can be greater in asymptomatic women, in whom this infection may go undetected otherwise, resulting in future complications related to reproductive health. Among Amsel's clinical criteria, the most sensitive and specific was the presence of clue cells in wet mounts. They can be detected easily by laboratory staff with little training in primary health care seting

Adolescent↗

PubMed2003

[The application of Chinese health questionnaire for mental disorder screening in community settings in mainland China].

OBJECTIVE: To examine the applicability of Chinese Health Questionnaire (Taiwan version) (CHQ) originated from General Health Questionnaire (GHQ) for mental disorder screening in community settings in mainland China. METHODS: A pilot study was conducted in Hangzhou (n = 377). Three thousand seven hundred and seven subjects were recruited from four cities to validate the results of the pilot study. Validation of the Screening Questionnaire was analyzed, using Relative Operating Characteristic (ROC) method. RESULTS: Cronbach's alpha coefficients were calculated to be 0.79 for the 12-items and 0.89 for 30-items to CHQ version in the first sample, and 0.74 in the second sample (12-items). Four factors were extracted from the CHQ-30, including somatic symptoms, anxiety and worry, social dysfunction, poor family relationship, and depression. CHQ-12 could be explained by a single factor in both samples. The areas under ROC were 0.80 (95% CI: 0.70 - 0.89) for 12 items and 0.72 (95% CI: 0.62 - 0.82) for 30 items. The sensitivities of CHQ-12 and CHQ-30 were found to be 76.9% and 71.8%, and the specificities were 73.8% and 67.9% with Kappa value 0.44 (P = 0.00) and 0.38 (P = 0.00), respectively. The estimated rates of mental disorder were 18.13% (95% CI: 14.16 - 22.10) by CHQ-12, and 22.80% (95% CI: 18.19 - 27.11) by CHQ-30 in the first sample and the rates were 21.72% (95% CI: 20.39 - 23.05) by CHQ-12 in the second sample. CONCLUSION: CHQ, especially CHQ-12 through slight language modification, could be used for epidemiological studies and on community health care to screen for mental disorder in the mainland of China.

Adult↗

PubMed1997

Diabetes management: improving care in HMO and community settings.

Developing an effective, quality-driven disease management program for the treatment of patients with diabetes has become essential for MCOs, which cover the majority of American individuals suffering from this condition. At Cedars-Sinai Medical Center in Los Angeles, the Diabetes Managed Care Program was developed and implemented in an effort to provide a model for similar diabetes management initiatives in both managed health care plans and community settings.

California↗

PubMedDate not supplied

Practical protocols for the prevention of dental disease in community settings for people with special needs: the protocols.

People with special needs have more dental disease and more missing teeth than the general population. They also have reduced access to oral health diagnostic, preventive, interceptive and treatment services. If services are available, they can be complicated and costly. It is critical to prevent dental diseases in these individuals. This article presents a set of practical protocols for preventing dental disease in people with special needs. These protocols are designed to be used in community settings outside of a dental office.

Anti-Infective Agents, Local↗

PubMedDate not supplied

Characteristics of pharmacies and pharmacists associated with the provision of cognitive services in the community setting.

OBJECTIVE: To determine the influence of payment, pharmacy setting characteristics, pharmacist demographics, practice setting, and attitudinal characteristics on whether cognitive services (CS) were performed by pharmacists, and the volume of CS performed. DESIGN: Prospective randomized trial. Community pharmacies were randomized to a documentation-and-payment group (study group) and a documentation-only group (control). Participating pharmacies and pharmacists were surveyed by mail, and responses were linked to a documented CS database. SETTING: Community pharmacies serving ambulatory Medicaid patients in the state of Washington, excluding health maintenance organization pharmacies and pharmacies predominantly serving long-term care residents. PARTICIPANTS: 200 community pharmacies and their pharmacists (110 study, 90 control) participating in the Washington State Cognitive Activities and Reimbursement Effectiveness (CARE) Project. INTERVENTION: Payment for CS. All participants documented CS. Study group pharmacies billed Medicaid for services performed in identifying and resolving drug therapy-related problems. MAIN OUTCOME MEASURE: Documentation of CS. RESULTS: Documentation of CS was more likely if the pharmacist was an owner or manager, if documentation was not perceived as burdensome, and if the pharmacy had a low ratio of prescription to total sales. Higher documentation rates were associated with study group status, lower pharmacy prescription volume as a percentage of total sales, and a higher percentage of prescriptions billed to Medicaid. Among pharmacists, two setting variables--medical center location and rural location--were associated with higher documentation rates. CONCLUSION: Performance of CS was strongly affected by payment and other situational factors, including practice setting and volume of prescriptions dispensed. Pharmacies and pharmacists were also more likely to perform CS if the target patient population represented a relatively large percentage of that pharmacy's patient clientele.

Medicaid↗

PubMed2001

Comorbid conditions in patients with erectile dysfunction in a community setting.

The objective of this study was to assess the prevalence of chronic comorbidities and the use of concomitant medications in men diagnosed with erectile dysfunction (ED) in a community setting, using a large integrated database. All patients who experienced an episode of ED during a two-month period were identified from the database. Comorbid conditions were determined through outpatient management claims and prescription claims for concomitant conditions were also assessed during the study period.

Chronic Disease↗

PubMed1996

Pattern of utilization of rifabutin for prophylaxis of Mycobacterium avium complex among patients with advanced human immunodeficiency virus disease in a community setting.

OBJECTIVE: To characterize the pattern of utilization, effectiveness, and safety profile of rifabutin for Mycobacterium avium complex (MAC) prophylaxis among individuals with advanced human immunodeficiency virus disease in a community setting. METHODS: Individuals who, while registered in the provincial drug distribution program, had at least one CD4 count below 100 cells/mm3 for the period 1 May 1993 to 31 March 1994 were included. MAC diagnoses were identified through a record linkage with the mycobacterial reference laboratory of the Provincial Centre for Disease Control. In order to determine the occurrence of adverse events, a survey was sent in March 1994 to the 98 primary care physicians prescribing rifabutin prophylaxis in the province. We achieved 100% response rate to the survey. RESULTS: During the study period 515 patients in our drug treatment program were eligible to receive MAC prophylaxis. Of these, 340 (66%) were being prescribed rifabutin as recommended by current guidelines. Rifabutin prophylaxis use was significantly associated with use of antiretroviral therapy. The product limit estimate of the cumulative incidence of MAC at 10 months was 13.0% among those receiving rifabutin prophylaxis. Diagnosis of MAC was significantly associated with a lower baseline CD4 count (cumulative incidence 7.1% and 18.1% for CD4 > or = 50 and < 50 cells/mm3, respectively, P = 0.01). A total of four cases of uveitis, eight cases of pseudo-jaundice, and five cases of arthralgia in 16 patients were identified by our survey. CONCLUSION: Our data demonstrates that rifabutin prophylaxis of MAC is being used by approximately 66% of eligible individuals. Rifabutin use was associated with antiretroviral use, which may reflect individuals' attitudes towards medications. Our intention-to-treat analysis, with a 10 month cumulative MAC incidence of 13.0% among those receiving rifabutin prophylaxis, is in keeping with break-through rates previously reported in the context of clinical trials. Our results also support previous observations that the risk of MAC infection greatly increases at CD4 counts < 50 cells/mm3. Rifabutin prophylaxis was generally well-tolerated in our program.

AIDS-Related Opportunistic Infections↗

PubMed1992

The dependency-support script in institutions: generalization to community settings.

This study tested the generalizability of the dependency-support script, a behavioral system describing and explaining dependent behaviors of the institutionalized elderly. A comparative study with 22 community-dwelling elderly was conducted, which identified typical interaction patterns between the elderly and family members or home health nurses. The dominant interaction pattern in the community setting, too, was the dependency-support script. In addition, however, a significant social response to independent self-care behavior was observed, which created a highly ambivalent response contingency. Independent behaviors were followed about twice as often by an incongruent (dependence-supportive) than by a congruent (independence-supportive) response. Expectations of incompetence and of the helping role are offered as explanations.

Activities of Daily Living↗

PubMedDate not supplied

Practical protocols for the prevention of dental disease in community settings for people with special needs: preface.

This issue of Special Care in Dentistry presents protocols that were designed during a conference, Practical Protocols for the Prevention of Dental Disease in Community Settings for People with Special Needs, which was held at the University of the Pacific School of Dentistry on February 1, 2002. After each expert reviewed and reported on one area of the literature, which included risk assessment; chlorhexidine mouth rinses; xylitol chewing gum; topical fluoride and fluoride varnish applications; and methods to control or treat periodontal disease, practical protocols were developed. Next, a strategy of implementation and dissemination will be designed using nurses, case managers, social workers, caregivers, and others to encourage people with special needs to use these protocols. A plan will also be implemented to increase social and health care provider awareness about these interventions through professional publications and educational opportunities. The goal is to reduce dental disease in special needs populations and thereby decrease the need for difficult and costly treatment.

Clinical Protocols↗

PubMed1996

Rapid HbA1c testing in a community setting.

OBJECTIVE: To determine whether the DCA 2000 analyzer provides valid and reliable HbA1c results when used under field conditions and operated by nonmedical personnel. This study was part of a community diabetes education program, the Native American Diabetes Project, in which HbA1c was measured as an indicator of average glycemic control. RESEARCH DESIGN AND METHODS: Two study samples were taken, the first in the spring of 1994 and the second in the spring of 1995. Seven community members in 1994 and six new community members in 1995 were trained over 2 days, using standard protocol, to operate the DCA 2000 HbA1c analyzer and to collect two capillary blood samples from participants in the Native American Diabetes Project. Duplicate DCA 2000 HbA1c measurements performed by the community workers were compared with measurements from a high-performance liquid chromatography (HPLC) system. Validity and reliability measures were calculated. RESULTS: Of the participants, 43 were studied in 1994 and 14 in 1995. Comparison of the mean DCA 2000 results with those of HPLC showed high validity, with the absolute relative difference between the mean DCA 2000 and the external reference of HPLC (magnitude of mean DCA 2000-HPLC magnitude of /HPLC) as 4.0 and 2.0% for 1994 and 1995, respectively. The Pearson correlation coefficients (r) between these two measures were 0.968 and 0.996 for 1994 and 1995, respectively. While the 1994 data appeared to have less validity for values > 10%, they included only one value with a 60-min warm-up of the DCA analyzer. The 1995 data, all collected after a 60-min warm-up, had good correlation throughout the range of values. The within-run reliability was excellent, with an intraclass correlation coefficient of reliability of 0.959 and 0.975 for paired samples, for 1994 and 1995 respectively. The mean coefficient of variation for these paired measures was 3.0% in 1994 and 2.8% in 1995. Both validity and reliability were improved by changing the warm-up period of the DCA 2000 analyzer from 5 to 60 min. All correlation coefficients were statistically significant (P < 0.0001). CONCLUSIONS: The DCA 2000 gave valid and reliable HbA1c results when operated in a community setting by nonmedical personnel. Extending the warm-up period of the device to 60 min slightly improved the validity and reliability of the test.

Blood Chemical Analysis↗

PubMed1998

Validity of the medical outcomes study depression screener in family practice training centers and community settings.

BACKGROUND AND OBJECTIVES: Screening inventories that identify primary care patients suffering from depression should be brief, correlate with depression diagnoses, and be evaluated in populations with whom the inventories will be used. METHODS: A total of 566 patients from a medical school training center and 457 patients from six community family practice offices completed the Medical Outcomes Study (MOS) depression screener and a questionnaire reporting demographic information and health habits. All subjects scoring above the recommended screener cut-off, and a random sample of those scoring below, were interviewed with the Diagnostic Interview Schedule (DIS). RESULTS: A total of 195 subjects from the training center and 147 from the community sample were called and administered the DIS. About 33% of the training center and 25% of the community sample scored above the cutoff. Of those above the cutoff and administered the DIS, 23% of the training center and 10% of the community sample were diagnosed with either major depression or dysthymia. CONCLUSIONS: The MOS screener was an effective method of identifying depressed subjects in the training center and community settings. However, because of the relatively low prevalence of depression in these settings, a relatively high number are falsely screened positive. Identifying these patients as having subthreshold depressive symptoms and the necessity/efficacy of treatment is controversial, as is the use of screening instruments. The simplified MOS scoring strategy and template used in this study would probably increase its usefulness in the primary care setting.

Chi-Square Distribution↗

PubMed2001

Interventions to improve the management of diabetes in primary care, outpatient, and community settings: a systematic review.

OBJECTIVE: To review the effectiveness of interventions targeted at health care professionals and/or the structure of care in order to improve the management of diabetes in primary care, outpatient, and community settings. RESEARCH DESIGN AND METHODS: A systematic review of controlled trials evaluating the effectiveness of interventions targeted at health care professionals and aimed at improving the process of care or patient outcomes for patients with diabetes was performed. Standard search methods of the Cochrane Effective Practice and Organization of Care Group were used. RESULTS: A total of 41 studies met the inclusion criteria. The studies identified were heterogeneous in terms of interventions, participants, settings, and reported outcomes. In all studies, the interventions were multifaceted. The interventions were targeted at health care professionals only in 12 studies, at the organization of care only in 9 studies, and at both in 20 studies. Complex professional interventions improved the process of care, but the effect on patient outcomes remained less clear because such outcomes were rarely assessed. Organizational interventions that facilitated the structured and regular review of patients also showed a favorable effect on process measures. Complex interventions in which patient education was added and/or the role of a nurse was enhanced led to improvements in patient outcomes as well as the process of care. CONCLUSIONS: Multifaceted professional interventions and organizational interventions that facilitate structured and regular review of patients were effective in improving the process of care. The addition of patient education to these interventions and the enhancement of the role of nurses in diabetes care led to improvements in patient outcomes and the process of care.

Ambulatory Care↗

PubMed2002

An open-label study to evaluate the safety, tolerability and efficacy of rivastigmine in patients with mild to moderate probable Alzheimer's disease in the community setting.

BACKGROUND: Long-term safety and efficacy of Exelon (rivastigmine) was evaluated in a multi-center open-label study of 62 patients with probable mild to moderate Alzheimer's disease living in community setting. MATERIAL/METHODS: The patients started treatment with 1.5 mg bid (3 mg/day) Exelon and were scheduled to receive doses of 1.5 mg bid Exelon escalating on a biweekly basis. The patients were maintained on the highest tolerated dose within the assigned dose range 1.5-6.0 mg bid (3-12 mg/day) for the rest of the study. Evaluations were scheduled at biweekly intervals for the first 8 weeks and subsequently at study weeks 12, 18 and 26. Effects of Exelon on cognition were evaluated using the mini-mental state examination (MMSE) and selected items of Alzheimer's disease assessment scale (ADAS-cog) and the staging of the disease was measured using the global deterioration scale (GDS). Safety was monitored by physical examinations, vital signs, laboratory tests, ECG recording and by the assessment of adverse events. RESULTS: 55 patients completed the study (89%). Patients treated for 26 weeks showed the mean MMSE, ADAS-cog and GDS scores close to baseline values (p=NS) with no improvement and no deterioration. Exelon was generally well tolerated with 11% of patients withdrawing due to adverse events. The most frequently reported adverse events related to the gastrointestinal tract. CONCLUSIONS: In conclusion, the study data indicate that treatment with Exelon is safe, generally well tolerated and inhibits the progression of cognitive decline in patients with mild to moderate Alzheimer's disease over 26 weeks of treatment.

Aged↗