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PubMed1997

Patterns of hypnotic drug prescription in Italy. A two-week community survey.

BACKGROUND: In Italy a number of studies have been published on psychotropic drug use in general practice and community settings. However, the present study is the first Italian study to focus on hypnotic drug prescriptions in a large community sample. METHOD: Data were collected from 145 of the total of 404 pharmacies of five large cities in north-eastern Italy. All consecutive patients presenting a prescription for a hypnotic drug were interviewed by the pharmacists during a two-week period. RESULTS: The pharmacists interviewed 7/44 consecutive patients. The highest prevalence of prescriptions for hypnotic drugs was found in the elderly and in women. The majority (96%) of prescriptions were for benzodiazepines, with lorazepam and triazolam accounting for 50%. Short-acting and ultra-short-acting benzodiazepines were more frequently prescribed for sleep induction by general practitioners (GPs) than by psychiatrists and other physicians. Frequently the benzodiazepine used as a hypnotic was also prescribed for day time sedation. Approximately 72% of subjects reported they had been taking the prescribed drug for one year or more. CONCLUSIONS: In Italy benzodiazepines are the most frequently prescribed drugs for sleep induction; as they are widely prescribed for elderly people by GPs often for long periods of time, educational programmes and guidelines on the rational use of benzodiazepines in general practice are needed.

Adult↗

PubMedDate not supplied

Medication error reporting by community pharmacists in Vermont.

OBJECTIVE: To document community pharmacists' awareness and use of the United States Pharmacopeia Medication Errors Reporting (USP MER) program. DESIGN: Telephone survey. SETTING: Community pharmacies in Vermont. PARTICIPANTS: One self-identified community pharmacist from each community pharmacy. INTERVENTION: Each operating community pharmacy in Vermont was contacted by telephone between June 2002 and February 2003. The first individual to self-identify himself or herself as a pharmacist was asked to participate. The telephone surveys were conducted using a standard script. MAIN OUTCOME MEASURE: Survey responses to questions about awareness and use of USP MER. RESULTS: A pharmacist was contacted in 98% (122/124) of all operating community pharmacies in Vermont. Nine (7%) pharmacists refused to participate, leaving 113 pharmacists who responded to the survey. Although more than one half of all respondents (70/113; 62%) had heard of USP MER, less than one quarter (24/113; 21%) had ever submitted a report. Significantly more pharmacists employed by independent pharmacies had submitted a report, compared with pharmacists from other pharmacy types (chain, supermarket, mass merchandiser; P = .03). Submitting reports through a corporate hierarchy or to a corporate program was the reason most frequently cited by pharmacists for not submitting reports directly to USP MER (37%). Whether corporate reports were forwarded to USP MER is unknown. CONCLUSION: The majority of Vermont community pharmacists were aware of USP MER. However, use was low. Barriers to reporting to a common system such as USP MER may differ depending on pharmacy type. Further research to document the barriers to submitting reports is warranted.

Adverse Drug Reaction Reporting Systems↗

PubMed2005

Impact of the Medicare prescription drug benefit on home- and community-based services waiver programs.

"Dual eligibles" is the term for the 6.4 million low-income, elderly, and disabled Americans who are enrolled in both Medicare and Medicaid. With home-and community-based services waivers allowed under Section 1915(c) of the Social Security Act, many of these individuals are able to live in a home or community setting, thereby avoiding institutionalization. Surveying Maryland's 3,180 dual eligibles who are enrolled in home-and community-based waiver programs, the author finds that the end-of-2005 transfer of prescription drug coverage from Medicaid to Medicare under the Medicare Modernization Act of 2003 could put these beneficiaries in jeopardy. Maryland's experience is likely to be typical of what other states will face. The author recommends a number of federal policy remedies, among them allowing 90-day prescriptions, using open or shared formularies, and lengthening the enrollment period.

Aged↗

PubMed2006

A survey of school dental screening practise in community dental services of England and Wales in 2003.

OBJECTIVE: To describe the school dental screening process in Community Dental Services across England and Wales. BASIC RESEARCH DESIGN: Cross-sectional study using a postal questionnaire. CLINICAL SETTING: Community Dental Services. PARTICIPANTS: Clinical Directors of Community Dental Services in England and Wales. MAIN OUTCOME MEASURES: Respondents answers about the objectives of school dental screening, criteria used for referring a child, methods of informing parents of screening results, and methods used to confirm subsequent dental attendance. RESULTS: The response rate for this study was 92.1%. Respondents identified dental registration (75.2%) and attendance at a dentist (82.9%) as objectives of school dental screening. Less than one third (29.5%) saw the activity as having a preventive role. Caries in the primary and secondary dentitions and soft tissue lesions were reported as key criteria for referral. Methods of follow-up of screened positive children differed and were often inadequate; approximately one third of respondents used a letter carried home by the child that did not allow parents to inform the CDS of action taken. Half of the respondents routinely collected data on the number of screened positive children who subsequently visit a dentist. CONCLUSIONS: School dental screening is delivered in a similar fashion throughout England and Wales but methods of informing parents of a positive screen and follow-up mechanisms for children with positive screens vary. Most school dental screening programmes do not collect sufficient data to evaluate the impact of their programmes on children's oral health.

Child↗

PubMed1987

An attitudinal assessment of faculty practice plans.

An awareness of potential conflict between medical schools and private practice prompted an attitudinal assessment of faculty practice plans (FPPs). A representative sample of eight medical school FPPs in seven different communities was selected for study. For each FPP, a sample of health care leaders, stratified at different levels of administrative responsibility, was selected from academic medical centers and from community settings. Topics for FPP assessment were chosen for their relevance to physician and lay administrators involved with academic and community practice. Questions were answered on a yes-no basis and were graded by intensity of response. Although only two of the questions revealed statistical disparity on a simple yes-no basis, the intensity of response differed significantly in eight of the 14 questions asked. This study gives consideration to the strategic implications of FPPs for universities, medical schools, and organized medicine.

Administrative Personnel↗

PubMed1996

Recruitment and enrollment for Project HeartBeat! Achieving the goals of minority inclusion.

OBJECTIVE: The inclusion of women and minorities in health research supported by the National Institutes of Health (NIH) has received increasing attention since the adoption of related guidelines by NIH in 1990. Investigators in population-based and clinical research may need to identify and recruit research participants from community settings in which little is known by investigators of the dynamics and day-to-day needs of the community. This was the case at the start of Project HeartBeat!, an intensive longitudinal study of the development of cardiovascular risk factors against the background of growth and maturation. This paper identifies those elements found essential when recruiting and enrolling minority participants for Project HeartBeat! METHODS: No prior experience had existed in the community from which the majority of Black participants were recruited to the Project. Therefore, recruitment methods were based on previous experience of the investigators as well as on the published reports of others. RESULTS: Immediate costs were substantially greater than projected, and the recruitment period was two years rather than one-a circumstance with longer-term implications as well. However, with the support of a community-based advisory committee, the school district, and a local recruitment staff, the recruitment goal was obtained. CONCLUSIONS: Recruitment and enrollment of minority participants can be especially challenging; however, many of those challenges are common to any target population. Elements that need to be adequately addressed include the researchers' involvement with the community in which the participants live, a tracking system to assess recruitment efforts, flexibility in the methods of recruitment, and adequate resources in time, money and personnel.

Adolescent↗

PubMed1998

Orientation to community in a family practice residency program.

BACKGROUND: Family practice residencies are expected to include opportunities for trainees to learn about population-based approaches to health care delivery. METHODS: To prepare them for community projects later in training, first-year residents were introduced to a community-oriented primary care (COPC) curriculum by an interdisciplinary team with representatives from public health and academic family medicine. During their mid-year orientation month, the residents spent three afternoons in community settings, each year focusing on a different public health issue. The residents spent the first afternoon discussing principles of community medicine, the COPC model, and planning community interviews. The second afternoon, they interviewed in the community. The residents reported and evaluated on the third afternoon. RESULTS: During the 3 years described, most residents participated with enthusiasm, later reporting increased awareness and use of community resources. However, months after the third experience, a comparison of clinic records before and after the orientation showed no difference in the residents' inclusion of the health issue studied in managing their patients, although social workers and other non-physician faculty team members reported that residents consulted them more frequently following the community orientation. CONCLUSIONS: It is important to provide residents with an efficiently designed and attractive community orientation early in training. An interdisciplinary team should plan and coordinate their experiences, but all faculty should role model good community behavior. Although the 1996 residents described behavioral changes following this brief orientation, this was not documented by a chart review.

Adolescent↗

PubMed2003

Factors in creating sustainable intersectoral community mobilization for prevention of heart and lung disease.

This paper describes factors facilitating and working against successful community mobilization in the implementation of an integrated prevention programme for cardiovascular disease and lung cancer in four community settings in Québec, Canada. Implementation evaluation data from several sources showed that over the 3-year period, mobilization was partly achieved in all four communities, although the degree of success varied. The data support those of previous studies showing that several factors are key to effective intersectoral community mobilization: (i) involvement of concerned and influential community members with a commitment to shared goals and a visible community focus; (ii) formation of multi-organization systems among appropriate organizations, recognizing their strengths, resources and competencies, and preserving both their autonomy and interdependence with an appreciation of divergent perspectives; (iii) development of decision-making mechanisms through the setting up of formal structural arrangements to facilitate decisions with clear leadership; (iv) clear definition of objectives, tasks, roles and responsibilities; and (v) official support and legitimization from participating agencies, government authorities, and organizations with adequate resources devoted to partnership building. This study also replicated a number of barriers to the creation of sustainable intersectoral community mobilization, notably the potentially destructive role of power conflicts among the key institutional partners.

Cardiovascular Diseases↗

PubMed2002

Pharmacokinetics of ciprofloxacin as a tool to optimise dosage schedules in community patients.

OBJECTIVE: To evaluate the dosage regimens of ciprofloxacin prescribed for outpatients by applying the principles of antibacterial therapy. DESIGN: Retrospective analysis of prescription and demographic data. SETTING: Community pharmacy in Valladolid, Spain. PATIENTS: Fifty male and female patients aged 18-93 years and with bodyweight 41-95kg. METHODS: Prescribed dosage regimen, age, weight, height, type of infection, comorbidity and coadministered drugs were recorded for each patient. Plasma concentration curves were simulated from literature values of the pharmacokinetic parameters of the drug and the age and weight of the patients. Urine concentrations were estimated from simulated plasma concentrations, literature values of renal clearance and an average urinary flow rate of 2 L/day. The potential efficacy of the prescribed treatment was evaluated from the ratio of the simulated peak plasma concentration (C(max)) to the literature value of the minimum inhibitory concentration (MIC) for the bacterium most probably responsible for the infection (C(max) /MIC). The ratio of area under the plasma concentration-time curve over 24 hours to MIC (AUC24 /MIC) was also estimated for non-urinary infections. RESULTS: Demographic variables such as age or bodyweight do not seem to be taken in consideration when ciprofloxacin is prescribed, at least in the patients considered here, leading to wide interindividual variability in plasma concentrations. This may not be relevant for urinary infections, since ciprofloxacin concentrates in the urine, leading to high Cmax /MIC ratios in all patients. Simulated plasma concentration-time curves revealed consistent underdosing for systemic infections in young patients over 60kg, for whom the plasma concentrations achieved led to Cmax /MIC and AUC24 /MIC ratios lower than those associated with clinical efficacy and minimal spread of bacterial resistance. CONCLUSIONS: The standard regimen of ciprofloxacin 250mg every 12 hours prescribed for urinary infections may not be the best choice, since a more convenient regimen of 500mg once daily leads to a higher Cmax /MIC ratio, which is associated with a more significant postantibiotic effect and higher efficacy of fluoroquinolones. For non-urinary infections, the age and weight of patients should be taken into account to achieve optimum plasma concentrations.

Adolescent↗

PubMed1977

Improving out-patient care through participation: the Newark experiment in staff and patient involvement.

Several studies have confirmed that well-organized health services and vital health information are critical in insuring that consumers utilize health services and practice preventive health habits adequately. Inaccessibility actively discourages the consumer while the lack of on-going health education activities limits his ability to practice life-promoting health habits. Recent work of the Health Education Project (HEP) at the College of Medicine and Dentistry of New Jersey in Newark, has demonstrated tangible ways of eliminating some of the barriers that limit consumers in receiving health services in an out-patient setting. Redesigning the health services in ways that reflect consumer and provider needs and involving the staff and consumers in this process has been a dominant aim of the project which has resulted in the elimination of unnecessary laboratory work, improved coordination of human resources, and increased staff and patient morale. Health education activities are now integrated into the clinic routines as a result of structural changes in outpatient procedures. The work of HEP has been focused on multi-racial, inner-city health problems. Nonetheless, its findings in terms of how to deal with organizational aspects of delivering health services and ways to develop comprehensive health education activities should be of use to health providers and consumers in many other settings. The second part of the paper deals with special aspect of the project, namely, the development of low-cost, community oriented videotapes which are used regularly both in the outpatient department and in various community settings as a teaching tool for providing consumers with critical health information. Tailored to specific teaching objectives and interwoven into health education discussion groups, the videotapes use recognizable local settings and residents to stress the relevance and importance of controlling and taking charge of one's health care. Among the outcomes of the use of these videotapes have been increased demands by consumers for physician continuity, information concerning medication and laboratory tests, and, in general, more information about how to stay healthy.

Appointments and Schedules↗

PubMed1998

Secondary donation of frozen embryos is more common after pregnancy initiation with donated eggs than after in vitro fertilization-embryo transfer and gamete intrafallopian transfer.

OBJECTIVE: To determine the availability of donated cryopreserved embryos. DESIGN: Retrospective review. SETTING: Community hospital-based donor oocyte program. PATIENT(S): Eighty-nine consecutive infertile couples and women who had 94 sets of embryos cryopreserved after pregnancy initiation with unfertilized donated eggs between January 1, 1991 and December 31, 1996. INTERVENTION(S): Cryopreservation of fertilized ova or cleaving embryos. MAIN OUTCOME MEASURE(S): Disposition of frozen embryos as of June 1, 1997. RESULT(S): Of the 94 sets of frozen embryos, 52 (55.3%) were thawed into the original recipient. At an average of 30 months since the treatment cycle, 26 (27.7%) sets of embryos remain in storage. Of the 16 sets of embryos not thawed for transfer, 11 sets (11.7%) were donated and 5 sets (5.3%) were destroyed. The fraction of spare embryos donated was much higher after pregnancy initiation with unfertilized donated eggs than after IVF-ET and GIFT (68.8% versus 19.1%, respectively). CONCLUSION(S): Couples and women who did not use their frozen embryos after pregnancy initiation with unfertilized donated eggs were twice as likely to donate them as to have them destroyed. Secondary donation of cryopreserved embryos was much more common after pregnancy initiation with unfertilized donated eggs than after standard IVF-ET and GIFT.

Adult↗

PubMed2002

[Prevalence and risk factors for pressure ulcers].

OBJECTIVES: To study prevalence of pressure ulcers among functionally impaired patients in the community and evaluate risk factors associated with the development of pressure ulcers in these patients.Design. Cross-sectional, observational study. SETTING: Community dwellers served by the Primary Health Care Area of Rincón de la Victoria in Málaga.Participants. All patients included in the < > (n=178). METHODS: A questionnaire was developed to ascertain demographic and health characteristics. Risk factors were evaluated with the Modified Norton Scale. The outcome variable of interest was presence or absence of pressure ulcers, their location and grade. The denominator used for the calculation of the prevalence was the total of evaluated patients. Results. Prevalence of pressure ulcers in our Basic Health Area was 12.9%. The most important sociodemographic characteristic associated with the presence of pressure ulcers in these patients was the educational attainment of the caregiver. Health varaibles of the patient were also associated with the risk of developing ulcers. CONCLUSIONS: Results indicate the need of diagnostic protocols with standardised instruments and prevention plans to reduce pressure ulcers in the community. Longitudinal studies are needed to evaluate interventions in this area.

Adult↗

PubMed1996

Educational issues in preparing community health nurses to use nursing diagnosis with population groups.

Recently there has been increased interest in the use of nursing diagnosis by community health nurses who work with population groups in community settings. The purpose of this article is to discuss educational issues important in the preparation of undergraduate students and practising community health nurses in the use of nursing diagnosis with population groups. The educational issues discussed emerged from the findings of a preliminary survey of undergraduate students and community health nurses and were related to: differences in the learning requirements of novice and expert practitioners; common errors in the use of nursing diagnosis; and the perceived benefits and barriers in using nursing diagnosis. There is a need to develop an educational strategy to address these concerns for both undergraduate students and community health nurses.

Clinical Competence↗

PubMed1998

Team midwifery: the views and job satisfaction of midwives.

OBJECTIVE: As part of an evaluation of a team midwifery scheme we assessed the satisfaction of community and hospital midwives and their views about working practices and care provided. DESIGN: Survey of complete enumeration of community midwives (most working in teams) and hospital midwives providing antenatal, intrapartum and postnatal care to a population of women. SETTING: Community and district general hospital, in the UK. MEASUREMENTS: Socio-demographic data about midwives, ratings on Likert-type scales of job satisfaction, quality of care variables, relationships with other professionals and women; Glasgow Midwifery Process Questionnaire. FINDINGS: 80 out of 92 midwives (87%) responded. Community midwives were younger, more recently qualified, employed on lower grades, less likely to be married and have children than hospital midwives. The Glasgow Midwifery Process Questionnaire revealed that midwives, particularly hospital midwives, had low morale. Community midwives were more likely to report that their job was satisfying, offered a variety of work, enabled them to use skills and knowledge fully, and offered opportunities for professional development. Hospital midwives were more likely to report following strict guidelines. Community midwives, however, disliked the long on call and unsociable hours, and reported disruption to family/social life. Forty-one per cent of hospital midwives (12) and 28% of community midwives (14) reported regularly working beyond their shift. Whilst midwives thought that team midwifery was, in theory, a good idea, in practice it was not working well because of the size of teams and caseload. About half the community midwives felt that teams had detrimentally affected the quality and continuity of care. CONCLUSIONS: Whilst team midwifery aims to improve continuity of maternity care, in this instance, it does not appear to achieve this aim. Many midwives reported it had adversely affected care. Team midwifery is a source of disillusionment for midwives, since the continuity of carer ideal is unachievable in a system based on teams of seven or more. Attendance at the delivery may be a luxury provided at the expense of antenatal and postnatal continuity. IMPLICATIONS: Midwives recommended remedial measures: reducing team sizes, reducing caseloads, ensuring teams were fully staffed, reducing 'on call' and labour ward hours. It remains to be seen whether these will have the desired effects on continuity of care.

Adult↗

PubMed2006

A population-based family study of DSM-III generalized anxiety disorder.

BACKGROUND: A recent meta-analysis provides evidence that generalized anxiety disorder (GAD) is familial. However, two of the key studies relied on subjects who were self-selected or recruited from the clinic setting, thereby limiting generalizability. METHOD: We conducted a family study of GAD in which probands and controls came from a community sample originally enrolled in a prevalence study in Edmonton, Canada. One hundred and sixty probands, 764 controls and 2386 first-degree relatives (FDRs) were interviewed using the Diagnostic Interview Schedule (DIS); lifetime diagnoses were made according to DSM-III criteria without exclusions. Logistic regression analysis was performed with GAD (in a proband) as the 'exposure', and GAD in an FDR as the 'outcome'. Several analytic strategies were used to control for potential confounding by major depressive disorder (MDD) and several anxiety disorders (panic disorder, phobic disorders, obsessive-compulsive disorder, and post-traumatic stress disorder). RESULTS: The odds ratios for the association between GAD in a proband and GAD in an FDR were in the range 1.4-1.8 when the entire FDR sample was analysed, and in the range 2.1-2.8 when we restricted to FDRs who were children of probands and controls. CONCLUSION: In the community setting, GAD exhibits mild to moderate familial aggregation.

Anxiety Disorders↗

PubMed2002

Fall events among people with stroke living in the community: circumstances of falls and characteristics of fallers.

OBJECTIVES: To describe the frequency and circumstances of falls among a community sample of people with stroke and to compare characteristics of fallers and nonfallers. DESIGN: Cross-sectional, observational study. SETTING: Community. PARTICIPANTS: Forty-one community-dwelling people with stroke (26 men, 15 women; mean age, 69.7 +/- 11.6y), of which 23 had right-hemisphere infarction, 16 left-hemisphere infarction, and 2 had a brainstem lesion. Time since onset of stroke ranged from 3 to 288 months (mean, 50mo). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Standardized tests were used to measure mobility, upper limb function, activities of daily living (ADL ability), and mood. Information about fall events was collected by using a questionnaire. RESULTS: Twenty-one participants (50%) were classed as fallers, of whom 10 had fallen repeatedly. No significant differences were found between fallers and nonfallers on any of the measures used. However, those who had 2 or more falls (n = 10) had significantly reduced arm function (P = .018) and ADL ability (P = .010), compared with those who had not fallen or experienced near falls (n = 5). Loss of balance, misjudgment, and foot dragging during walking, turning, and sit to stand were reported by fallers as the suspected causes and activities leading to falls. CONCLUSIONS: The high risk of falling among people with stroke was evident in this community-based sample. Repeat fallers had greater mobility deficits and significantly reduced arm function and ADL ability than those who did not report any instability.

Accidental Falls↗

PubMed2001

Interprofessional collaboration: a stakeholder approach to evaluation of voluntary participation in community partnerships.

A major goal of community coalitions is to engage the community in large-scale systems change. This paper examines how five interprofessional partnerships in South Africa involved their local communities as well as a variety of voluntary agencies in the long-term planning and delivery of health care. The obstacles and difficulties encountered by the volunteers who participate in the partnerships are highlighted. The paper compares the views of 427 participants from four stakeholders: the community health workers; the projects' core staff; 'solo' community members; and representatives of voluntary agencies, community-based agencies and non-governmental organisations. This article considers the benefits and costs of participation as well as satisfaction, ownership, representation, contributions, and commitment. The findings suggest that while the stakeholders value their partnerships, some of the costs associated with their participation may affect their satisfaction and commitment. The challenges of working in partnerships with volunteers in a community setting are discussed and strategies for addressing them are considered. The implications for coalition functioning and the lessons for future community involvement in the planning of local health services by way of interprofessional partnerships are also addressed.

Adult↗

PubMed2001

Survey of nonoccupational HIV postexposure prophylaxis in hospital emergency departments.

BACKGROUND: Nonoccupational HIV postexposure prophylaxis (nPEP) is being used in community settings, but little is known about practice patterns. This study examined the status of nPEP in Massachusetts emergency departments (EDs), community sites where nPEP is most likely to be practiced. METHODS: In June 1998, a mailed survey was sent to identified medical directors of the 78 hospital EDs statewide; 66 (85%) responded. RESULTS: Overall, 52% reported having patient requests for nPEP within the prior year. 15% (10 of 66) had established written nPEP protocols; 33% (22 of 66) indicated their protocols were informal and not written. Twenty-five EDs could estimate the number of nPEP patients assessed; their mean estimate was 31 for the prior year (standard deviation [SD], 19.9) and 34% of the patients overall had nPEP recommended. Most (81%) of the hospitals with written or unwritten protocols recommended the use of three-drug antiretroviral regimens, which included two nucleoside analogues and a protease inhibitor; 41% approved more than one nPEP regimen. CONCLUSIONS: A demand for nPEP is occurring in hospital EDs. The diversity of practice patterns suggests the need for evidence-based practice guidelines.

Anti-HIV Agents↗