Family medicine in the academic and community settings.
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Community Health Services↗
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Introducing an in-patient treatment for alcohol detoxification into a community setting.
Alcohol detoxification in the UK is not standardized and treatment is usually determined by local policies. Drug regimens are often predetermined and unrelated to the extent and duration of dependence, recent consumption, or previous withdrawal symptoms. Diazepam loading shortens the detoxification period and avoids the indiscriminate use of medication. It has been shown to be effective as an in-patient treatment. This paper examines the feasibility of introducing diazepam loading in a community setting, and discusses the implications that this would have for clinical practice.
Absenteeism↗
Interventions to improve the management of diabetes mellitus in primary care, outpatient and community settings.
BACKGROUND: Diabetes is a common chronic disease that is increasingly managed in primary care. Different systems have been proposed to manage diabetes care. OBJECTIVES: To assess the effects of different interventions, targeted at health professionals or the structure in which they deliver care, on the management of patients with diabetes in primary care, outpatient and community settings. SEARCH STRATEGY: We searched the Cochrane Effective Practice and Organisation of Care Group specialised register, the Cochrane Controlled Trials Register (Issue 4 1999), MEDLINE (1966-1999), EMBASE (1980-1999), Cinahl (1982-1999), and reference lists of articles. SELECTION CRITERIA: Randomised trials (RCTs), controlled clinical trials (CCTs), controlled before and after studies (CBAs) and interrupted time series (ITS) analyses of professional, financial and organisational strategies aimed at improving care for people with Type 1 or Type 2 diabetes. The participants were health care professionals, including physicians, nurses and pharmacists. The outcomes included objectively measured health professional performance or patient outcomes, and self-report measures with known validity and reliability. DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted data and assessed study quality. MAIN RESULTS: Forty-one studies were included involving more than 200 practices and 48,000 patients. Twenty-seven studies were RCTs, 12 were CBAs, and two were ITS. The studies were heterogeneous in terms of interventions, participants, settings and outcomes. The methodological quality of the studies was often poor. In all studies the intervention strategy was multifaceted. In 12 studies the interventions were targeted at health professionals, in nine they were targeted at the organisation of care, and 20 studies targeted both. In 15 studies patient education was added to the professional and organisational interventions. A combination of professional interventions improved process outcomes. The effect on patient outcomes remained less clear as these were rarely assessed. Arrangements for follow-up (organisational intervention) also showed a favourable effect on process outcomes. Multiple interventions in which patient education was added or in which the role of the nurse was enhanced also reported favourable effects on patients' health outcomes. REVIEWER'S CONCLUSIONS: Multifaceted professional interventions can enhance the performance of health professionals in managing patients with diabetes. Organisational interventions that improve regular prompted recall and review of patients (central computerised tracking systems or nurses who regularly contact the patient) can also improve diabetes management. The addition of patient-oriented interventions can lead to improved patient health outcomes. Nurses can play an important role in patient-oriented interventions, through patient education or facilitating adherence to treatment.
Ambulatory Care↗
Open-label, observational study of the effects of risperidone on the behavioral and psychological symptoms of dementia and caregiver stress in the community setting.
BACKGROUND: Behavioral disturbances and psychological symptoms of dementia--such as agitation, aggression, and psychosis--compromise patients' quality of life and daily functioning as well as contribute to caregiver burden and the decision to institutionalize the relative with the disease. OBJECTIVE: The goal of this study was to examine the effects of risperidone on noncognitive symptoms and caregiver burden in the community setting. The tolerability of risperidone was also assessed. METHODS: This was an observational, open-label, multicenter study. Dementia patients with behavioral and psychological symptoms received risperidone for 3 months. At 1 and 3 months, physicians rated symptoms on the Neuropsychiatric Inventory (NPI) and the Clinical Global Impression of Severity (CGI-S) scale. Caregivers rated their distress in relation to individual NPI items using the NPI Caregiver Distress (NPI-D) scale. Outcome variables were analyzed using Friedman and Wilcoxon tests. RESULTS: A total of 263 patients (mean age, 77.5 years) received a mean (SD) risperidone dose of 1.4 (0.7) mg/d at 1 month and 1.5 (0.8) mg/d at 3 months. The total NPI score (mean [SEM]) decreased from 33.7 (1.91) at baseline to 11.9 (0.98) at month 3 (P < 0.01), and the NPI-D score decreased from 22.5 (1.02) at baseline to 9.0 (0.64) at month 3 (P < 0.01). Agitation/aggression and sleep disturbances were the most improved symptoms and caused the largest decrease in caregiver burden. Improvements were also noted on the CGI-S scale (from 4.0 at baseline to 3.4 at month 3; P < 0.01). Extrapyramidal symptoms decreased significantly (P < 0.05) over the course of the study. CONCLUSIONS: In this study of community-based patients with dementia, risperidone significantly improved behavioral and psychological symptoms and, as a result, also reduced caregiver burden. Risperidone was well tolerated in this elderly population, particularly with regard to extrapyramidal symptoms.
Aged↗
Financing pediatric education in community settings.
Increasingly, hospital-based pediatric outpatient departments are recognized as settings that attempt to combine two critical, but not always compatible, mandates: (1) education of medical students and pediatric residents in outpatient pediatrics, and (2) service, often with inadequate resources, to a socially highrisk population with a disproportionately high prevalence of social, family, and psychological dysfunction. Coexistence of these two mandates has raised a number of concerns, because pediatric ambulatory care education and training have historically been based almost exclusively in a hospital setting. Trainees often get a false impression of the types of problems they will be dealing with in pediatric primary care and of how an efficient pediatric practice is managed. In addition, they often are supervised by full-time faculty who have little if any experience in community settings and who practice only part time or not at all. These problems have led to a widespread desire to train pediatric residents outside the hospital, in settings that more closely approximate the places in which they will practice in the future. Residency programs that address this issue also provide residents with the opportunity to be trained by seasoned practitioners whose primary professional responsibility is the outpatient care of children. To date, little has been written about the cost or the financing of such educational efforts. This article summarizes what is known about the costs. We also attempt to specify the costs that should be anticipated for the various components and steps involved in devising and implementing pediatric community-based educational programs and to describe potential sources of funding for such programs.
Costs and Cost Analysis↗
The diagnostic value of troponin T testing in the community setting.
BACKGROUND: Many patients presenting with chest pain to their family physician are referred to the emergency room, in part, due to lack of accurate objective diagnostic tools. This study aimed to assess the diagnostic value of bedside troponin T kit testing in patients presenting with chest pain to their family physician. DESIGN: Prospective, multi-center study. METHODS: Consecutive subjects with chest pain were recruited from 44 community clinics in Jerusalem. Following clinical assessment by the family physician, qualitative troponin kit testing was performed. Patients with a negative clinical assessment and negative troponin kit were sent home and all others were referred to the emergency room. The final diagnosis at the time of hospital discharge was recorded and telephone follow up was performed after 60 days. Positive predictive value, negative predictive value, sensitivity and specificity of troponin kit for myocardial infarction diagnosis and of family physician for hospitalization, were assessed. RESULTS: Of 392 patients enrolled, 349 (89%) were included in the final analysis. The prevalence of myocardial infarction was 1.7%. The positive and negative predictive values of the troponin kit for myocardial infarction diagnosis were 100% and 99.7%, respectively. The positive and negative predictive values of the family physician's assessment to predict hospitalization were 41.4% and 94.1%, respectively. CONCLUSIONS: Troponin kit testing is an important tool to assist the family physician in the assessment of patients with chest pain in the community setting. Troponin kit testing may identify otherwise undiagnosed cases of myocardial infarctions, and reduce unnecessary referrals to the emergency room.
Ambulatory Care↗
Maintaining performance of autistic clients in community settings with delayed contingencies.
To facilitate the classroom and workshop integration of three autistic clients, we examined the feasibility of teaching them to respond appropriately without the continual presence of specially trained treatment providers. Within a multiple baseline design, a 4-step treatment process was implemented to promote durable responsive performance. Results indicated that the therapist could be removed from the treatment environment and that appropriate behavior could be successfully maintained in community settings with only infrequent and delayed contingencies.
Adolescent↗
Investigating the potential for students to provide dental services in community settings.
Some dental educational institutions in North America have incorporated community-oriented programs into their curriculum. The purpose of this study was to investigate the potential for the clinical placement of Ontario's dental and dental hygiene students in community-based settings. Key informant interviews were used to collect data. The study group consisted of 15 key informants from 9 potential placement sites and 4 educational institutions in Toronto and London, Ontario. The textual data were analyzed qualitatively to identify important issues regarding a clinical placement program. Results showed that there is strong support for the placement of students in community-based clinics; however, the degree to which health centres can accommodate students varies. The majority would not set any limit on the types of dental services that students could provide as long as the services were within the students' competencies. Funding was identified as a barrier to the implementation of such a program, with most of the organizations not able to contribute financially. None would be able to provide sufficient supervision without additional funding. These results indicate that a clinical placement program would be a welcome addition to the training of dental and dental hygiene students, but that external funding for supervision and operational expenses must be available before a program can be instituted.
Administrative Personnel↗
On the front line: practice satisfactions and challenges experienced by dietetics and nutrition professionals working in community settings in New York State.
The goal of this study was to understand dietetics and nutrition professionals' experiences of their practice roles. Qualitative interviews using a grounded theory design covered practitioners' perceptions of their professional roles, role enactment, and practice context. Twenty-four dietetics and nutrition practitioners varying in their work settings, length of professional experience, education, and community type were recruited through professional contacts in New York State. Interview transcripts were analyzed using the constant comparative method of qualitative data analysis. An ecological model of practice in context emerged in which participants described daily practice satisfactions and challenges arising out of interactions among their personal characteristics, client characteristics, the work setting, and the food and nutrition and health care systems. Practice satisfactions related to positive interactions and measurable outcomes of work with clients and coworkers, recognition for expert and helper roles, and involvement in disease prevention. Practice challenges centered on others' misunderstandings of the dietary change process, assessment of practice outcomes, others' respect for expertise, keeping up-to-date, client and coworker expectations, isolation from peers, and the food environment. An ecological model of dietetics and nutrition practice as experienced in community settings draws attention to the need to address challenges in the multiple contexts that frame that practice.
Adult↗
The learning career in the community setting: a phenomenological study of a Project 2000 placement.
The findings of one element of an English National Board-funded research study conducted in two phases between 1989 and 1992 are discussed. The study examined one aspect of the new Project 2000 courses introduced in 13 'demonstration districts' in England in the autumn of 1989. During Phase 2 of the study (1991-1992). 14 district nursing sisters and 12 of the students they supervised were interviewed. Data were re-transcribed and interpreted in 1993; the interpretation was based on a phenomenological paradigm which focused on the subjective perceptions of students and supervisors. Participants identified 'learning', as it took place in the community setting, as a sequential process, which is referred to here as the 'learning career'. Using terminology adopted by participants themselves; the authors identify the stages of the 'learning career' as:'encountering reality'; 'having a go' 'gaining confidence'; 'thinking through and understanding'; 'developing ideas'; 'being independent'; and 'being assessed'. Supervisors could ease their students' passage through this complex and anxiety-provoking sequence of events in a number of ways. They could demonstrate their practice and provide opportunities for students to gain experience for themselves; they could teach their students about nursing, and enable them to reflect on their own practice; and they could also monitor and assess their students' work.
Community Health Nursing↗
Cardiology or primary care for heart failure in the community setting: process of care and clinical outcomes.
STUDY OBJECTIVES: Severity of illness, treatment choices, and clinical outcomes may vary with physician training. This study was performed to determine whether such differences exist among patients with congestive heart failure (CHF) treated by cardiologists and by noncardiologists in the community hospital setting. DESIGN: Prospective cohort study. SETTING: Ten acute-care community hospitals. PATIENTS, MEASUREMENTS, AND RESULTS: Two thousand four hundred fifty-four patients with CHF were identified and followed up for 6 months after hospital discharge. Patients who were not treated by a cardiologist (group I; n = 977) were compared with patients whose attending physician was a cardiologist (group II; n = 419) and patients who received consultative care from a cardiologist (group III; n = 1,058). When compared with group I patients, group II patients were more likely to receive the recommended diagnostic tests and treatment strategies, although some of these differences could be explained by variations in the case mix. Group II patients had higher hospital charges, but lower CHF readmission rates and better postdischarge quality-of-life measures. No differences in adjusted mortality rates were observed. CONCLUSIONS: In the community-hospital setting, the clinical practices of cardiologists are more compatible with published treatment guidelines than the clinical practices of other physicians. The benefits of cardiology specialty care include lower CHF readmission rates and better postdischarge quality-of-life measures, rather than lower mortality rates, fewer hospital charges, or shorter length of stay.
Aged↗
Feasibility of implementing the Strong for Life program in community settings.
PURPOSE: We describe the results of the dissemination of an efficacious, home-based exercise program called Strong for Life as it was implemented in a nationwide, volunteer caregiving program called Faith in Action, including training of volunteers who implemented the program, recruitment of older adult participants, exercise adherence, and attitudes and perceptions of program staff and participants. DESIGN AND METHODS: Frail, homebound older adults (N = 105) were recruited from 10 Faith in Action sites to participate in the Strong for Life exercise program. Volunteer trainers (n = 103) were trained by physical therapists to assist the older adults with the program. Surveys were conducted with older adults, volunteer trainers, and Faith in Action sites at baseline and after the older adults had been engaged in the program for 4 months. RESULTS: Satisfaction with program components was very high: At follow-up, 100% of volunteers and 98.6% of older adults rated the program positively. Participants reported engaging in exercise on average 2.2 times per week, with 53% of the participants exercising at least 2 to 4 times per week. Participants also had significant improvements in the Short Form-20 social functioning scale. There were no serious adverse events reported. IMPLICATIONS: Dissemination of the Strong for Life program in a community setting using trained lay volunteers was feasible, acceptable, and safe. Existing volunteer caregiving organizations such as Faith in Action offer a feasible and safe means of disseminating late-life exercise programs to the frail older population.
Aged↗
Exercise and blood pressure: applying findings from the laboratory to the community setting.
1. During the 1980s, there was growing epidemiological evidence that aerobic training lowered blood pressure (BP). Early intervention studies had not always supported this conclusion. Such studies were limited by methodological shortcomings. Few studies had used normotensive individuals or women alone. 2. Exercise training is an attractive lifestyle strategy in the prevention of hypertension. In our studies in men, vigorous intensity cycling did not lower resting BP. 3. Vigorous exercise reduces day time ambulatory BP and, in combination with calorie restriction, had a synergist effect to reduce night-time and 24 h BP. 4. Exercise is a positive and effective adjunct to other lifestyle measures in the prevention of hypertension. Adherence to either supervised or unsupervised moderate-intensity exercise is sufficient to reduce BP in the short and long term. 5. Further studies need to be performed to evaluate the clinical significance and mechanisms for the increase in resting BP observed in older women. 6. Older individuals with hypertension should be monitored when taking up a swimming programme. 7. Exercise induced changes in BP seen in the laboratory are also observed in the community setting.
Alcohol Drinking↗
Use of integrated, general education, and community settings as primary contexts for skill instruction for students with severe, multiple disabilities.
Four students with severe, multiple disabilities learned to use four to five new skills at critical moments within age-appropriate activities. Instruction was provided only at moments critical to the continuation of the activities when natural cues and consequences delineated the need for the target behaviors. This method of intervention was combined with a more traditional package of antecedent prompt-fade procedures and, in a few instances, time delay. The purpose of the study was to analyze the effects of instruction given only at natural critical moments on the acquisition of basic sensory, motor, social, and communication behaviors. A multiple baseline design across skills within separate activities for four participants was employed. Fifteen of 17 skills were acquired to criterion. In addition, "learning to learn" effects occurred within each activity as instruction of new target behaviors was introduced. The outcomes are important for the participant population because they document the effect of integrated educational models for teaching the most basic skills. Discussion of the motivation provided by activity routines in general education and community settings, as well as interpretation of data when participants have the most severe disabilities, is presented.
Behavior Therapy↗
Risk of deep vein thrombosis and pulmonary embolism after acute infection in a community setting.
BACKGROUND: Acute infection increases the risk of arterial cardiovascular events, but effects on venous thromboembolic disease are less well established. Our aim was to investigate whether acute infections transiently increase the risk of venous thromboembolism. METHODS: We used the self-controlled case-series method to study the risk of first deep vein thrombosis (DVT) (n=7278) and first pulmonary embolism (PE) (n=3755) after acute respiratory and urinary tract infections. Data were obtained from records from general practices who had registered patients with the UK's Health Improvement Network database between 1987 and 2004. FINDINGS: The risks of DVT and PE were significantly raised, and were highest in the first two weeks, after urinary tract infection. The incidence ratio for DVT was 2.10 (95% CI 1.56-2.82), and that for PE 2.11 (1.38-3.23). The risk gradually fell over the subsequent months, returning to the baseline value after 1 year. The risk of DVT was also higher after respiratory tract infection, but possible diagnostic misclassification precluded a reliable estimate of the risk of PE after respiratory infection. INTERPRETATION: Acute infections are associated with a transient increased risk of venous thromboembolic events in a community setting. Our results confirm that infection should be added to the list of precipitants for venous thromboembolism, and suggest a causal relation.
Acute Disease↗
A comparison of the oral health of persons with and without chronic mental illness in community settings.
Severe dental disease has been reported for patients receiving psychiatric treatment. This study compared the oral status of noninstitutionalized adults with chronic mental illness with a similar group without such history, and evaluated relative risk factors, for example, xerostomia, diet, hygiene, and poverty. A sample of 37 subjects with chronic mental illness (CMI) and 29 control subjects without mental illness were assessed for dental, medical and social history; head, neck, and oral soft tissue pathology; salivary flow; DMFS, gingivitis, loss of periodontal attachment, plaque, and calculus. The groups were equivalent in socio-economic level, education, dental history, and home care. All subjects with CMI received psychotropic medications (mean of 3.8 drugs for 10.3 years). The CMI group had significantly higher incidence in the following variables: self-reported dry mouth; consumption of carbonated beverages (P less than .001); mucosal, lip, and tongue lesions (P less than .01); coronal smooth surface caries (P less than .001); severity of plaque (P less than .001) and calculus (P less than .01); and salivary flow (P less than .05). No significant differences were evident in the M and F components of DMFS, in gingivitis or loss of attachment. The results indicate significant increases in risk factors and increased oral pathosis in persons with mental illness who live in community settings compared with a control group that showed dental neglect.
Adolescent↗
Development of a passive sampler to measure personal exposure to gaseous PAHs in community settings.
A sensitive, simple, and cost-effective passive sampling methodology was developed to quantify personal exposure to gaseous polycyclic aromatic hydrocarbons (PAHs). A Fan-Lioy passive PAH sampler (FL-PPS) is constructed from 320 sections of 1-cm long SPB-5 GC columns (0.75-mm i.d. and 7-microm film thickness), similar to a mini-honeycomb denuder. Given the unique feature of the GC column stationary phase, gaseous PAHs are collected on the inner surfaces of the columns by molecular diffusion and thermally desorbed to GC/MS for analysis. The sampling rates of FL-PPS were determined in the laboratory using a controlled test atmosphere containing eight PAHs for a range of face velocity, temperature, relative humidity, PAH concentration, and sampling duration. The sampling rate (mean, %RSD, cm3/min) was 26.7 (21%) for acenaphthylene, 37.6 (25%) for acenaphthene, 56.2 (13%) for fluorene, 49.1 (25%) for phenanthrene, 62.7 (22%) for anthracene, 65.4 (24%) for fluoranthene, and 64.4 (18%) for pyrene over a sampling duration of 8-48 h. The sampling rate for naphthalene was approximately 14.1 (12%) cm3/min over a sampling period of 8 h but decreased along with an increase of sampling time. The effects of temperature, humidity, face velocity, and PAH concentration on the sampling rate were not significant for all the compounds tested. A reasonable agreement (<30%) was obtained for most compounds measured by FL-PPS and a conventional active PAH sampling method colocated side-by-side in the field, but a sampling time of 24 h or longer was required for detection of less abundant PAHs in community settings.
Air Pollutants↗
Obtaining and providing health information in the community pharmacy setting.
Community pharmacists are a valuable information resource for patients and other healthcare providers. The advent of new information technology, most notably the Internet, coupled with the rapid availability of new healthcare information, has fueled this demand. Pharmacy students must receive training that enables them to meet this need. Community advanced pharmacy practice experiences (APPEs) provide an excellent opportunity for students to develop and master drug information skills in a real-world setting. Preceptors must ensure that students are familiar with drug information resources and can efficiently identify the most useful resource for a given topic. Students must also be trained to assess the quality of resources and use this information to effectively respond to drug or health information inquiries. This article will discuss key aspects of providing drug information in the community pharmacy setting and can serve as a guide and resource for APPE preceptors.
Community Pharmacy Services↗