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PubMed2003

Health status, service use, and costs among veterans receiving outreach services in jail or community settings.

OBJECTIVE: This study compared client characteristics, service use, and health care costs of two groups of veterans who were contacted by outreach workers: a group of veterans who were contacted while incarcerated at the Los Angeles jail and a group of homeless veterans who were contacted in community settings. METHODS: Between May 1, 1997, and October 1, 1999, a total of 1,676 veterans who were in jail and 6,560 community homeless veterans were assessed through a structured intake procedure that documented their demographic, clinical, and social adjustment characteristics. Data on the use and costs of health services during the year after outreach contact were obtained from national databases of the Department of Veterans Affairs (VA). Chi square and t tests were used for statistical comparisons. RESULTS: The veterans who were contacted in jail obtained higher scores on several measures of social stability (marital status and homelessness status) but had higher rates of unemployment. They had fewer medical problems but higher levels of psychiatric and substance use problems, although the rate of current substance use was lower among these veterans than among the community homeless veterans. One-year service access for the jailed veterans was half that of the community homeless veterans. No differences were observed in the intensity of use of mental health services among those who used services, but the jailed outreach clients used fewer residential, medical, and surgical services. Total health care expenditures for the veterans who received outreach contact in jail were $2,318 less, or 30 percent less, than for those who were contacted through community outreach. CONCLUSIONS: Specialized outreach services appear to be modestly effective in linking veterans who become incarcerated with VA health care services. Although it is clinically challenging to link this group with services, the fact that the rate of current substance use is lower during incarceration may provide a window of opportunity for developing linkages between inmates and community rehabilitative services.

Community Mental Health Services↗
PubMed2002

BRCA1/2 genetic testing in the community setting.

PURPOSE: BRCA1/2 genetic testing has been commercially available in the United States since 1996. Most published reports described BRCA1/2 testing as research studies at large academic centers, but less is known about testing in the community. This study evaluates the process and early outcomes of BRCA1/2 genetic testing as a clinical service in the community setting. METHODS: Surveys were mailed to women in the United States whose health care providers ordered BRCA1/2 genetic testing from Myriad Genetic Laboratories from August 1998 through July 2000. Women tested at 149 large academic centers were excluded. Main outcome measures were demographic characteristics, recall of and satisfaction with the genetic testing process, and likelihood of pursuing cancer prevention strategies. RESULTS: Among the 646 respondents, 414 (64%) had a personal history of cancer and 505 (78%) had at least one first-degree relative with breast and/or ovarian cancer. Most subjects (82%) recalled discussions of informed consent before testing (median time, 30 minutes). Genetic results were conveyed during an office visit (57%), by telephone (39%), or by mail (3%). More than 75% of respondents were "very satisfied with the counseling received." Cancer-free subjects with a germline mutation were more likely to consider prevention strategies after receiving the genetic results. CONCLUSION: Virtually all respondents had a personal and/or family history of breast/ovarian cancer. Although pretest and posttest communications were not standardized, overall satisfaction with clinical breast cancer genetic testing was high. Additional follow-up will provide data on future cancer prevention practices and cancer incidence.

Adult↗
PubMed1988

Aneurysm surgery in a community setting.

A 15-year surgical experience of 34 aneurysms in private practice is reported. There was 1 death secondary to postoperative arterial spasm, and 3 patients sustained neurological injury. The remaining patients were normal or neurologically stable or improved. Although intracranial aneurysm surgery in a community setting differs from such surgery in a university setting, it seems that similar results can be obtained despite the more limited number of cases encountered.

Adult↗
PubMedDate not supplied

Preventing dental disease for people with special needs: the need for practical preventive protocols for use in community settings.

People with disabilities have more dental disease, more missing teeth, and more difficulty receiving dental care than other members of the general population. Because of the deinstitutionalization movement during the later 20th century, many formerly institutionalized people now reside in community settings, which lack oral health services. Even individuals who were not institutionalized have barriers to oral health services. These realities underscore the importance of preventing dental disease in people with special needs by establishing preventive dental disease protocols.

Adolescent↗
PubMed1985

The Lifestyle Satisfaction Scale (LSS): assessing individuals' satisfaction with residence, community setting, and associated services.

Satisfaction of mentally retarded persons with their quality of life is an important outcome measure of deinstitutionalization. The Lifestyle Satisfaction Scale (LSS) was developed to assess mentally retarded persons' satisfaction with their residence and its community setting and associated services. An acquiescence subscale makes it possible to correct satisfaction scores for acquiescence bias. Empirical data indicate that this experimental version of the LSS has internally consistent subscales and good test-retest and interrater reliabilities.

Adult↗
PubMed2004

Image guided I125 prostate brachytherapy with Hybrid Interactive Mick technique in the community setting: How does it compare?

The aim of this study is to evaluate the target coverage, procedural techniques, and merits of Hybrid Interactive Mick (HIM) I125 transperineal permanent implantation (TPPI) of the prostate performed with 10 urologists in a community hospital. Detailed day 0 post-implant dosimetric evaluations of TPPI procedures were performed on 333 consecutive monotherapy patients treated between September 2000 and November 2003 at a single institution. All patients underwent TPPI with HIM. Pelvic and CXR films were obtained for a manual seed count at day 0 and again > day 90 on 175 patients. The HIM-prostate brachytherapy performed in a community hospital provided median D(90), V100, and V150 values of 157Gy, 94%, and 42.3%, respectively. 18% of patients had seed migration to the lungs while 2% had seed migration to the bladder. Only 7 patients (4%) had 2 or more seeds migrate to the lungs. Procedure times average 38 minutes and number of needles used averaged 18. The post-implant urinary retention rate was 2.1% Use of HIM-prostate brachytherapy in the community setting with multiple urologists reproducibly maintained excellent and consistent dosimetric coverage. Procedure times and number of needles used were minimized, and with careful attention to image-guided technique, seed migration to bladder and lung was also minimized.

Aged↗
PubMedDate not supplied

Long-term outcomes after breast conservation therapy for early stage breast cancer in a community setting.

We, as a large community practice, retrospectively reviewed our experience in treating early stage breast cancer to determine rates of breast-conserving therapy (BCT), disease outcomes after such treatment, and risk factors for local recurrence. A hospital tumor registry was used to identify breast cancer cases diagnosed between 1987 and 2003. Rates of BCT and radiotherapy were examined using primary treatment data. For subsequent disease outcomes analyses, cases were limited to only those treated between 1987 and 1994 to allow for adequate follow-up. For the subset of 521 T1-2N0 patients treated with BCT, we calculated crude rates of first failure at 8 years, with outcomes classified as local failure (LF), distant or regional node failure (DNF), dead without failure (DWF), or alive without failure (AWF). Polychotomous logistic regression was done to assess the influence of age at diagnosis, tumor grade, total radiation dose to the tumor bed, and use of systemic therapy. From 1987 to 2003, rates of BCT went from 69% to 89% and the rate of radiation after breast-conserving surgery was 90%. For the subset of 521 T1-2N0 patients treated with BCT who had at least 8 years of follow-up, median age was 58 years, 15% had grade 1 tumors, 83% had T1 tumors, 4.6% had positive margins, 83% got a total radiation dose >or=60 Gy to the tumor bed, and 51% had systemic therapy. At 8 years, 7% of patients had LF, 8% DNF, 10% were DWF, and 75% were AWF. Patient age (p = 0.076), tumor grade (p = 0.056), use of systemic therapy (p = 0.077), and radiation dose (p = 0.127) had borderline significant effects on the risk of LF versus AWF. The majority of patients in this community were treated with BCT and most received radiotherapy. Local control was excellent and comparable to that seen in large academic centers.

Adult↗
PubMed1976

Medication maintenance of mentally ill patients by a pharmacist in a community setting.

The use of a community pharmacy as a facility for medication maintenance services usually provided by a mental health center was evaluated. The project pharmacist was affiliated with the community mental health center, the community pharmacy facility was borrowed for purposes of this study. Records and prepackaged medication were transported by the pharmacy-clinic. Medication histories were taken and maintained by the pharmacist. Problems such as medication noncompliance, drug side effects, drug interactions and minor alterations in the patients mental status were handled by the pharmacist. Telephone consultations with a psychiatrist were also available. Twenty-two patients were involved in the study over an eight-month period. The evaluation consisted of a patient acceptance questionnaire and a retrospective chart review analyzing the clinical response of patients. Data suggest that selected stabilized psychiatric patients can be safely maintained in the community pharmacy. A carefully structured program and a pharmacist with special competencies are felt to be prerequisites for this type of service.

Attitude↗
PubMed2003

Choroidal osteoma: observations from a community setting.

PURPOSE: To determine the characteristics of choroidal osteoma arising from a previously unreported patient population and to document new observations in this condition. DESIGN: Retrospective, observational case series. PARTICIPANTS: Eleven consecutive patients seen from 1986 through 2002 with choroidal osteoma from one community-based retina practice. INTERVENTION: Laser ablation of subretinal neovascularization in two cases and focal laser treatment of retinal pigment epithelial leaks in one case. METHODS: Photographs, fluorescein and indocyanine green angiograms, and clinical records were analyzed. MAIN OUTCOME MEASURES: Demographic variables, visual acuity, complications of laser treatment, growth of lesions, and associated funduscopic changes. RESULTS: Choroidal osteoma from a community setting is more frequently asymptomatic (5/11 cases; 45%) than in previously reported university series, is usually initially misdiagnosed, and is not rare. Light-intensity focal laser photocoagulation for serous retinal detachment unaccompanied by subretinal neovascularization can resolve fluid (1/11 cases; 9%). Laser ablation of secondary subretinal neovascularization stimulates rapid choroidal osteoma vascular remodeling (2/11 cases; 18%) and can cause retina-osteoma venous and arterial anastomoses (1/11 cases; 9%). Spontaneous choroidal hemorrhage unaccompanied by subretinal neovascularization can occur with confinement to the osteoma borders (1/11 cases; 9%). Association of choroidal osteoma with retinitis pigmentosa is reported. CONCLUSIONS: These data on choroidal osteoma natural history and treatment help clinicians managing these lesions. In the community, a higher index of suspicion for choroidal osteoma is warranted.

Adolescent↗
PubMed1987

Community health projects as part of a core clinical clerkship: teaching research skills in a community setting.

Although medical student research has been advocated as a valuable learning experience and specific programs have been developed to offer research opportunities, only a minority of students have participated in these programs. We report a student research program that is integrated into a required six week clinical clerkship in Community Health, thus ensuring that all students participate in a research project. The program offers the additional advantage that research projects are student initiated and executed. Although the limited time frame usually results in pilot or exploratory studies, the program introduces students to all facets of a research project within a community setting and promotes independent learning. The program has been well received by students and may stimulate further research interests in some students.

Clinical Clerkship↗
PubMed1991

Appropriate diets for the rehabilitation of malnourished children in the community setting.

The treatment of severe PEM includes--as appropriate in individual patients--fluid and electrolyte therapy, antimicrobial drugs, dietary management, and social and behavioral counseling. Except in the case of severe anorexia or life-threatening infections or dehydration, nutritional rehabilitation can be completed in the community setting, using centrally-processed or locally-prepared food mixtures and, when necessary, supplemental vitamins, minerals, and trace elements. Energy intakes should be maximized to promote rapid recovery, and protein: energy ratios must be increased according to the expected rate of weight gain. Nutrient: energy densities should meet or exceed the RDAs. Cultural and economic factors must be considered in the formulation of mixed diets, and organoleptic characteristics of the enhanced recipe(s) must be appropriate for young children. Selected issues concerning implementation of a community-based rehabilitation program are discussed.

Child↗
PubMed2003

Reducing the risk of alcohol-exposed pregnancies: a study of a motivational intervention in community settings.

OBJECTIVES: To test the feasibility and impact of a motivational intervention in reducing drinking and/or increasing effective contraception in women who are at risk for an alcohol-exposed pregnancy. METHODS: A multisite single-arm pilot study was conducted in 6 community settings in 3 large cities. A total of 2384 women were screened for eligibility; 230 were eligible on the basis of their alcohol use and lack of contraception. Of the eligible women, 190 consented and were enrolled, and 143 (75.3%) completed the 6-month follow-up. The intervention consisted of 4 manual-guided motivational counseling sessions delivered by mental health clinicians and 1 contraceptive counseling session delivered by a family planning clinician. Outcome measures include intervention completion rates, alcohol use (frequency, quantity, and bingeing), contraceptive use and effectiveness, and risk for alcohol-exposed pregnancy. RESULTS: Among women who completed the 6-month follow-up, 68.5% were no longer at risk of having an alcohol-exposed pregnancy; 12.6% of women who completed the program reduced drinking only; 23.1% used effective contraception only; and 32.9% reported both. Results were consistent across the 6 diverse high-risk settings. CONCLUSIONS: This study provides evidence that providing 4 sessions of motivational interviewing plus a contraception counseling session is feasible and strongly suggests that this intervention can decrease the risk of alcohol-exposed pregnancy in women in high-risk settings. Additional investigation in a randomized controlled trial is warranted.

Adolescent↗
PubMed1998

Teams in a community setting: the AUHS experience.

The Pennsylvania Local Interdisciplinary Team was created to develop and implement an innovative model for the education of students from multiple disciplines and institutions in the theory and practice of quality improvement. The lead poisoning prevention project is presented as an example of the work of an interdisciplinary student team in a community setting in Philadelphia.

Clinical Clerkship↗
PubMed2005

Robotic radical prostatectomy in the community setting--the learning curve and beyond: initial 200 cases.

PURPOSE: The introduction of robotic assistance has the potential to improve surgical outcomes and reduce the steep learning curve associated with conventional laparoscopic radical prostatectomy. We report on our experience with robotic radical prostatectomy in the community setting. MATERIALS AND METHODS: A total of 200 patients underwent robotic radical prostatectomy during 18 months. Prospective data collection included a quality of life (Expanded Prostate Cancer Index Composite) questionnaire, basic demographics, prostate specific antigen (PSA), clinical stage and Gleason grade. Operative outcome measures included operative time, estimated blood loss and complications. Postoperative outcome measures included hospital stay, catheter time, pathology, PSA and return of continence. RESULTS: Average operative time was 141 minutes with an estimated blood loss of 75 cc. The intraoperative complication rate was 1% with no mortality, reexploration or transfusion. Of the patients 95% were discharged home on postoperative day 1 (1 to 3) with hematocrit averaging 34.5 (range 25 to 45). The average difference in preoperative and postoperative hematocrit was 3 points (range -2 to 15). Average catheter time was 7.2 days (range 5 to 15). The positive margin rate was 10.5% for the entire series, 5.7% for T2 tumors, 28.5% (T3a), 20% (T3b) and 33% (T4a). Of the patients 95% had undetectable PSA (less than 0.1 ng/ml) at average followup of 9.7 months. Continence at 1, 3, 6, 9 and 12 months was 47%, 78%, 89%, 92% and 98%, respectively. CONCLUSIONS: Our initial experience with robotic radical prostatectomy is promising. The learning curve was approximately 20 to 25 cases. With a structured methodical approach we were able to implement robotics safely and effectively into our community practice with minimal patient morbidity, and good oncological and functional outcomes.

Adult↗
PubMed2006

How can experience in clinical and community settings contribute to early medical education? A BEME systematic review.

REVIEW DATE: Review period January 1992-December 2001. Final analysis July 2004-January 2005. BACKGROUND AND REVIEW CONTEXT: There has been no rigorous systematic review of the outcomes of early exposure to clinical and community settings in medical education. OBJECTIVES OF REVIEW: Identify published empirical evidence of the effects of early experience in medical education, analyse it, and synthesize conclusions from it. Identify the strengths and limitations of the research effort to date, and identify objectives for future research. SEARCH STRATEGY: Ovid search of: BEI, ERIC, Medline, CINAHL and EMBASE Additional electronic searches of: Psychinfo, Timelit, EBM reviews, SIGLE, and the Cochrane databases. Hand-searches of:Medical Education, Medical Teacher, Academic Medicine, Teaching and Learning in Medicine, Advances in Health Sciences Education, Journal of Educational Psychology. CRITERIA DEFINITIONS EXPERIENCE: Authentic (real as opposed to simulated) human contact in a social or clinical context that enhances learning of health, illness and/or disease, and the role of the health professional. Early: What would traditionally have been regarded as the preclinical phase, usually the first 2 years. Inclusions: All empirical studies (verifiable, observational data) of early experience in the basic education of health professionals, whatever their design or methodology, including papers not in English. Evidence from other health care professions that could be applied to medicine was included. EXCLUSIONS: Not empirical; not early; post-basic; simulated rather than 'authentic' experience. DATA COLLECTION: Careful validation of selection processes. Coding by two reviewers onto an extensively modified version of the standard BEME coding sheet. Accumulation into an Access database. Secondary coding and synthesis of an interpretation. HEADLINE RESULTS: A total of 73 studies met the selection criteria and yielded 277 educational outcomes; 116 of those outcomes (from 38 studies) were rated strong and important enough to include in a narrative synthesis of results; 76% of those outcomes were from descriptive studies and 24% from comparative studies. Early experience motivated and satisfied students of the health professions and helped them acclimatize to clinical environments, develop professionally, interact with patients with more confidence and less stress, develop self-reflection and appraisal skill, and develop a professional identity. It strengthened their learning and made it more real and relevant to clinical practice. It helped students learn about the structure and function of the healthcare system, and about preventive care and the role of health professionals. It supported the learning of both biomedical and behavioural/social sciences and helped students acquire communication and basic clinical skills. There were outcomes for beneficiaries other than students, including teachers, patients, populations, organizations and specialties. Early experience increased recruitment to primary care/rural medical practice, though mainly in US studies which introduced it for that specific purpose as part of a complex intervention. CONCLUSIONS: Early experience helps medical students socialize to their chosen profession. It helps them acquire a range of subject matter and makes their learning more real and relevant. It has potential benefits for other stakeholders, notably teachers and patients. It can influence career choices.

Attitude of Health Personnel↗
PubMed1992

Comparison of partial and modified radical mastectomy in the community setting--"10 years later".

Conservative surgery followed by postoperative radiation is considered equivalent to a modified radical mastectomy (MRM) for the treatment of early breast cancer. It cannot be assumed that results from selected academic centres are equivalent to those obtained in the general community setting, because there may be differences in patient selection or surgical or radiotherapy techniques that may adversely affect outcome. A quality-control study of women who were seen at the British Columbia Cancer Agency and were treated by partial mastectomy (PM) was begun in 1983. Eighty-four women who underwent conservative surgery between January 1979 and November 1982 and were referred to the British Columbia Cancer Agency were matched with 84 women who underwent MRM. The mean follow-up was 10.5 years. At 10 years disease-free survival in both groups was 63%. Survival overall for the PM group was 72.6% and for the MRM group was 69%. The survival rate decreased with increasing size of the tumour and increasing number of nodes. In women with lymph-node involvement there was a survival advantage for those treated by PM and radiation compared with those treated by MRM. The woman's age at diagnosis did not affect these findings. Recurrence and complication rates were similar in both groups, and treatment was considered equivalent.

Adult↗
PubMed2004

Complementary and alternative therapy use at end-of-life in community settings.

OBJECTIVE: To investigate the prevalence of complementary and alternative medicine (CAM) use by an end-of- life population. DESIGN: Random selection of death certificates used to locate family caregivers who were interviewed by telephone 2-5 months following decedents' deaths. PARTICIPANTS: Decedent subjects died of natural causes in community settings. Family caregivers were very involved in the care and decision making for decedents during their terminal illness. MEASURE: Family caregivers reported on whether decedents had used CAM, type of modality, and motivation for use. RESULTS: CAM use by decedents was reported by 53.7% of family caregivers. Decedents who had used CAM were more likely to be younger, to have college degrees and higher household incomes, and to have used one or more life-sustaining treatment. The most frequent reason the decedents had used CAM was for symptom relief. CONCLUSIONS: As baby boomers age, bringing their CAM familiarity and previous practices into the end-of-life phase, clinicians will need to be aware that CAM use for symptom control is likely to be prevalent.

Aged↗