Although health disparities are commonly addressed in preclinical didactic curricula, direct patient care activities with affected communities are more limited.
To address this problem, health professional students designed a preclinical service-learning curriculum on hepatitis B viral (HBV) infection, a major health disparity affecting the Asian/Pacific Islander (API) population, integrating lectures, skills training, and direct patient care at student-run clinics.
An urban health professions campus.
Medical and other health professional students at University of California, San Francisco, organized a preclinical didactic and experiential elective, and established two monthly clinics offering HBV screening, vaccination, and education to the community.
Between 2004 and 2009, 477 students enrolled in the student-led HBV curriculum. Since the clinics’ inception in 2007, 804 patients have been screened for chronic HBV; 87% were API immigrants, 63% had limited English proficiency, and 46% were uninsured. Serologically, 10% were found to be chronic HBV carriers, 44% were susceptible to HBV, and 46% were immune.
Our student-led didactic and experiential elective can serve as an interprofessional curricular model for learning about specific health disparities while providing important services to the local community.
medical education-undergraduate; underserved populations; medical education-curriculum development/evaluation; disparities; community based interventions; student-run clinic
Community coalitions are increasingly recognized as important strategies for addressing health disparities. By providing the opportunity to pool resources, they provide a means to develop and sustain innovative approaches to affect community health.
This article describes the challenges and lessons learned in building the Asian American Hepatitis B Program (AAHBP) coalition to conduct a community-based participatory research (CBPR) initiative to address hepatitis B (HBV) among New York City Asian-American communities.
Using the stages of coalition development as a framework, a comprehensive assessment of the process of developing and implementing the AAHBP coalition is presented.
Findings highlight the importance of developing a sound infrastructure and set of processes to foster a greater sense of ownership, shared vision, and investment in the program.
Grassroots community organizing and campus–community partnerships can be successfully leveraged to address and prevent a significant health disparity in an underserved and diverse community.
Asian Americans; community-based participatory research; community health services; healthcare disparities; hepatitis B
Although chronic hepatitis B (CHB) affects approximately 2 million United States residents, there is no systematic screening of at-risk individuals, and most remain unaware of their hepatitis B virus (HBV) infection. Unmonitored and untreated, CHB results in a 25–30% risk of death from liver cancer and/or cirrhosis, inflicting an increasing healthcare burden in high-prevalence regions. Despite high prevalence in immigrant Asians and Pacific Islanders, among whom CHB is a leading cause of death, community and healthcare provider awareness remains low. Because safe and effective vaccines and effective antiviral treatments exist, there is an urgent need for integrated programmes that identify, follow and treat people with existing CHB, while vaccinating the susceptible. We describe an extant San Francisco programme that integrates culturally targeted, population-based, HBV screening, vaccination or reassurance, management and research. After screening over 3000 at-risk individuals, we here review our operational and practical experience and describe a simple, rationally designed model that could be successfully used to greatly improve the current approach to hepatitis B while ultimately reducing the related healthcare costs, especially in the high-risk populations, which are currently underserved.
Asians and Pacific Islanders; at-risk populations; cancer surveillance; chronic hepatitis B; culturally targeted screening; disease surveillance; hepatitis B virus; hepatocellular carcinoma; high-risk populations; screening; vaccination
This study investigated effects of San Francisco’s Treatment on Demand Initiative, which was designed to increase substance abuse treatment capacity, on the host treatment system. Secondary data on substance abuse treatment admissions, from 1995 through 2000, were obtained from the Department of Public Health, Community Substance Abuse Services, San Francisco, California. Data on 73,988 admissions were retained and grouped by week of admission. Time series analysis was used to assess the effects of time and treatment on demand (independent variables) on weekly number of admissions, sociodemographic characteristics and types of treatment received (dependent variables). As a function of treatment on demand, the number of weekly new admissions significantly increased. Standard outpatient treatment and comprehensive care admissions constituted greater proportions of admissions after treatment on demand. Persons with a primary heroin, cocaine or alcohol problem constituted greater proportions of admissions, and first-time treatment clients constituted a smaller proportion of admissions. Findings suggest that a capacity expansion initiative can increase system wide admissions and redistribute admissions among modalities towards more comprehensive care treatments.
substance abuse treatment; time series analysis; treatment on demand
Bridge building work in the US is primarily local and voluntary, involving professionals at individual agencies and organizations (public and private) who work towards specific goals. However, federal mandates intended to reduce nursing home admissions and increase access to home and community based services through new model collaboration programs are hastening this work.
Description of policy practice
Successful short-term ‘grassroots’ coalitions advocating for specific health insurance benefits and program funding for poor older adults and people with disabilities are common in all regions, but rarely build permanent bridges across networks. Voluntary cross-network collaborations, such as the Partners III program in Virginia (1993–1996), successfully established regionally specific long-term alliances. Nationally, the federal government is pilot testing 140 Ageing and Disability Resource Centres (ADRC’s) to facilitate permanent cross-network collaboration through coordination of consumer information and referrals across service systems. Financial and technical assistance is provided ADRC’s; interim results are positive.
Sustainment of cross-network bridges is a priority.
Voluntary cross-network collaborations are difficult to sustain long-term and are dependent on interest, leadership, perceived professional need, and funding support. Federal intervention and commitment to bridge historical service network ‘silos’ may create institutional change that fosters greater cross-network collaboration.
ageing; disability; service network; collaboration; long-term care; independent living
Most California prisoners experience discontinuity of health care upon return to the community. In January 2006, physicians working with community organizations and representatives of the San Francisco Department of Public Health's safety-net health system opened the Transitions Clinic (TC) to provide transitional and primary care as well as case management for prisoners returning to San Francisco. This article provides a complete description of TC, including an illustrative case, and reports information about the recently released individuals who participated in the program.
From January 2006 to October 2007, TC saw 185 patients with chronic medical conditions. TC patients are socially and economically disenfranchised; 86% belong to ethnic minority groups and 38% are homeless. Eighty-nine percent of patients did not have a primary care provider prior to their incarceration. Preliminary findings demonstrate that a community-based model of care tailored to this disenfranchised population successfully engages them in seeking health care.
Community prevention coalitions are a common strategy to mobilize stakeholders to implement tested and effective prevention programs to promote adolescent health and well-being. This paper examines the sustainability of Communities That Care (CTC) coalitions approximately 20 months after study support for the intervention ended.
The Community Youth Development Study (CYDS) is a community-randomized trial of the CTC prevention system. Using data from 2007 and 2009 coalition leader interviews, this study reports changes in coalition activities from a period of study support for CTC (2007) to 20 months following the end of study support for CTC (2009), measured by the extent to which coalitions continued to meet specific benchmarks.
Twenty months after study support for CTC implementation ended, 11 of 12 CTC coalitions in the CYDS still existed. The 11 remaining coalitions continued to report significantly higher scores on the benchmarks of phases 2 through 5 of the CTC system than did prevention coalitions in the control communities. At the 20-month follow-up, two-thirds of the CTC coalitions reported having a paid staff person.
This study found that the CTC coalitions maintained a relatively high level of implementation fidelity to the CTC system 20 months after the study support for the intervention ended. However, the downward trend in some of the measured benchmarks indicates that continued high-quality training and technical assistance may be important to ensure that CTC coalitions maintain a science-based approach to prevention, and continue to achieve public health impacts on adolescent health and behavior outcomes.
prevention; prevention science; Communities That Care; macro practice; community practice; evidence-based practice; social work; coalition; community research
The poor health status of black Americans was a widely recognized fact during the first third of the twentieth century. Excess mortality in black communities was frequently linked to the infectious disease tuberculosis, which was particularly menacing in densely populated urban settings. As health authorities in large cities struggled to keep pace with the needs of citizens, private charities worked to launch community-oriented attacks against the deadly disease. In 1914 a novel experiment to address excess mortality among blacks was launched in Philadelphia. The success of the health promotion campaign initiated by the Henry Phipps Institute and the Whittier Centre, two private charitable associations, has been attributed primarily to the presence of black clinicians, in particular public health nurse Elizabeth Tyler. This study suggests that community health efforts also rest on partnerships between like-minded organizations and coalition building.
Local coalitions combine the knowledge, expertise, and resources of many individuals and organizations to improve community health. This article describes data from 11 rural cancer coalitions in Pennsylvania and New York collected through a model-based data system.
The coalition data collection system was adapted from a conceptual model designed to monitor the activities and impact of cardiovascular disease coalitions. Community Coalition Action Theory was used during implementation and validation of the data system. Primary components of the data system were organizational capacity, process, and outcome/impact.
From 2002 to 2004, the 11 coalitions conducted 1369 initiatives, including 1147 (83.8%) interventions and 222 (16.2%) development activities. Among interventions, 776 (56.7%) were outreach only, 158 (11.5%) education only, 117 (8.5%) outreach and education, and 96 (7.0%) screening. Differences in the distribution of initiatives by coalition, cancer site, and target audience were statistically significant (P < .05). The majority of interventions focused on colorectal (37.0%) and breast (32.9%) cancer. Target groups included women (71.3%), rural residents (32.6%), survivors (21.8%), and low-income (21.8%) individuals. Although not statistically significant, an observed 3-year trend was shown for decreased outreach interventiions and increased education and screening interventions. In total, 1951 of 3981 individuals who were offered a cancer screening (49%) completed screening, and 15 sustainable community changes were documented.
This study reports the initiatives and impact of 11 rural community cancer coalitions over a 3-year period. This study estimates the mix of development activities and community interventions, against which this coalition network and others may be compared.
Purpose: To describe the results of efforts to recruit Asian Americans into longitudinal research on cognitive decline in aging. Design and
Methods: Recruitment strategies include clinics for assessment of cognitive impairment at the University of California, San Francisco campus and San Francisco’s Chinatown, lectures to local health care providers and community members, participation in community events, and publications in mass media. Results: Over 200 Chinese patients were evaluated in our outreach clinic. Many were primarily Chinese speaking with low levels of education. One hundred and twenty-five participants enrolled, and annual follow-up has been 88%. Among enrollees, 36% were recruited from our clinical service; 30% via word of mouth; and the rest from community lectures and events, flyers, and mass media. Participants who enrolled were relatively highly educated, tended to be interested in learning about their cognitive abilities, and were supportive of the goals of research. Implications: Despite the significant cultural and linguistic barriers, Chinese Americans can be successfully recruited into longitudinal studies of aging and cognitive impairment. Clinical services are a critical component of such an effort, and low education and other factors that may be associated with it are clear barriers to research participation.
Alzheimer’s disease; Asian and Pacific Rim Older Adults; Attitudes and perceptions toward aging/aged; Cognition; Cross-cultural studies; Dementia; Ethics (research, practice, policy, individual choices)
The incidence of colorectal cancer in portions of rural Appalachia is higher than in much of the United States. To reduce this disparity, cancer-control strategies could be adapted to and implemented in rural Appalachian communities. The objectives of this pilot study were to develop and test community-based participatory research methods to examine whether cancer coalitions in Appalachia could effectively disseminate print materials from a national media campaign intended to promote colorectal cancer awareness to their rural communities.
This pilot study used a two-arm intervention design with random selection of 450 community organizations from nine counties with cancer coalitions (the coalition arm) and 450 organizations from nine matched counties without a cancer coalition (the noncoalition arm) in northern Appalachia. The primary outcome measures were participation by and interest of community organizations in dissemination of materials from Screen for Life:
National Colorectal Cancer Action Campaign, a national campaign to promote colorectal cancer education and screening. The data were collected with prestudy and poststudy surveys.
One-hundred thirty (29%) organizations participated in the coalition arm, and 38 (8%) participated in the noncoalition arm (P < .001). Within the coalition arm, 86 of the 119 (66%) organizations that responded to the question about influence reported being influenced to participate by the local coalition. Initial interest in dissemination was high in each of the study arms but remained higher throughout the study in the coalition arm than the noncoalition arm.
Community cancer coalitions can increase the local dissemination of material from a national media campaign in rural Appalachia. Continued development and study of methods for coalitions to translate and implement cancer-control strategies at a local level in Appalachia is warranted.
Health Promotion may involve assessing the community and assisting in the formation of coalitions that empower a community to reduce health risks.
To describe an intervention lead by a doctor of chiropractic to reduce exposure to environmental tobacco smoke in one rural southeast Alabama town.
A coalition influenced the city council to modify an existing ordinance governing smoking in public places. As a secondary goal, the coalition hoped to use the local media to significantly increase public awareness of the dangers of ETS through positive press coverage of their efforts and general media advocacy. City councilmen and the local media were involved in the coalition to use a political process to change the ordinance. Ten months after initiating the project, the existing ordinance was modified.
Doctors of chiropractic involved as health advocates were able to change the local ordinance pertaining to indoor smoking.
Chiropractic; Health Promotion; Health Education; Tobacco Smoke Pollution
Smoke-free restaurant ordinance campaigns were conducted in 15 Wisconsin cities during 1992 through 2002. Community and health coalition organizational characteristics varied with each campaign; nine campaigns were successful in enacting ordinances, and six campaigns failed.
Data on community and coalition characteristics were analyzed. Community characteristics included adjusted gross income, percentage of Democratic voters in recent elections, and county smoking prevalence. Coalition characteristics included the number of supporters identified, leadership experience, level of print news media coverage, and editorial position of local newspaper.
Successful campaigns were more likely to have leadership with high levels of political experience; eight of nine successful campaigns had leadership with high levels of experience, and two of six unsuccessful campaigns had leadership with high levels of experience. Every successful campaign had high levels of newspaper coverage and strong editorial support. None of the unsuccessful campaigns had high levels of news coverage or strong editorial support.
Characteristics controlled or influenced by coalitions are associated with successful outcomes. Community characteristics were not associated with outcomes. These results should assist communities planning to implement smoke-free ordinances or other health policy campaigns.
Lung cancer is the leading cause of cancer death among US Asian/Pacific Islander (API) and Latina women, despite low smoking prevalence. This study examined survival patterns following non-small cell lung cancer in a population-based sample of lung cancer cases from the San Francisco Bay Area Lung Cancer Study (SFBALCS).
Women diagnosed with lung cancer from 1998–2003 and 2005–2008 and identified through the Greater Bay Area Cancer Registry were telephone-screened for eligibility for the SFBALCS. The screener data were linked to the cancer registry data to determine follow-up. This analysis included 187 non-Hispanic White, 23 US-born Latina, 32 foreign-born Latina, 30 US-born API, and 190 foreign-born API never smokers diagnosed with lung cancer and followed through 2008.
All-cause survival was poorer among APIs (hazard ratio (HR) and 95% confidence interval (CI) = 1.7 (1.0–2.8) among US-born APIs; 1.2 (0.9–1.5) among foreign-born APIs), and Latinas (HR (95% CI) = 2.1 (1.2–3.6) among US-born Latinas; 1.4 (0.9–2.3) among foreign-born Latinas), relative to non-Hispanic Whites. These survival differences were not explained by differences in selected sociodemographic or clinical factors.
Further research should focus on factors such as cultural behaviors, access to or attitudes toward health care, and genetic variations, as possible explanations for these striking racial/ethnic differences.
Latina and API female never smokers diagnosed with lung cancer were up to two-times more likely to die than non-Hispanic Whites, highlighting the need for additional research to identify the underlying reasons for the disparities, as well as heightened clinical awareness.
lung cancer survival; Asian; Latina; Hispanic; never smokers; nativity
The large number of Southeast Asian, Hispanic, and Portuguese immigrants in Rhode Island face formidable language and cultural barriers in gaining access to the health care that they need. As the funding for refugee-specific programs diminishes, the focus is on programs that encourage self-sufficiency, assist in gaining access to mainstream health care, and involve a collaboration among service agencies and the communities they serve. On behalf of a coalition of health care and community agencies, Women and Infants Hospital of Rhode Island received a private foundation grant to produce nine multilingual videotapes that would educate immigrants and refugees about health issues specific to them and help them access the health care system. The project was structured to maximize the involvement of the various communities and to "empower" community members in working with mainstream service agencies. Coalition and other community members provided input into topic selection, script content, and presentation methods for the videotapes that would be culturally appropriate. During the 2-year project, nine videotapes were produced with narration in seven languages. Copies of the videotapes were distributed free of charge to coalition members.
Increasingly, HIV prevention efforts must focus on altering features of the social and physical environment to reduce risks associated with HIV acquisition and transmission. Community coalitions provide a vehicle for bringing about sustainable structural changes. This article shares lessons and key strategies regarding how three community coalitions located in Miami and Tampa, Florida, and San Juan, Puerto Rico engaged their respective communities in bringing about structural changes affecting policies, practices and programs related to HIV prevention for 12–24-year-olds. Outcomes of this work include increased access to HIV testing and counseling in the juvenile correctional system (Miami), increased monitoring of sexual abuse between young women and older men within public housing, and support services to deter age discordant relationships (Tampa) and increased access to community-based HIV testing (San Juan).
Previous research has reported a lack of regular cancer screening among Chinese Americans. The overall objectives of this study were to use a mail survey of primary care physicians who served Chinese Americans in San Francisco to investigate: a) the attitudes, beliefs, and practices regarding breast, cervical, and colon cancer screening and b) factors influencing the use of these cancer screening tests. The sampling frame for our mail survey consisted of: a) primary care physicians affiliated with the Chinese Community Health Plan and b) primary care physicians with a Chinese surname listed in the Yellow Pages of the 1995 San Francisco Telephone Directory. A 5-minute, self-administered questionnaire was developed and mailed to 80 physicians, and 51 primary care physicians completed the survey. A majority reported performing regular clinical breast examinations (84%) and teaching their patients to do self-breast examinations (84%). However, the rate of performing Pap smears was only 61% and the rate of ordering annual mammograms for patients aged 50 and older was 63%. The rates of ordering annual fecal occult blood testing and sigmoidoscopy at regular intervals of three to five years among patients aged 50 and older were 69% and 20%, respectively. Barriers (patient-specific, provider-specific, and practice logistics) to using cancer screening tests were identified. The data presented in this study provide a basis for developing interventions to increase performance of regular cancer screening among primary care physicians serving Chinese Americans. Cancer screening rates may be improved by targeting the barriers to screening identified among these physicians. Strategies to help physicians overcome these barriers are discussed.
Community-based coalitions are commonly formed to plan and to carry out public health interventions. The literature includes evaluations of coalition structure, composition, and functioning; evaluations of community-level changes achieved through coalition activities; and the association between coalition characteristics and various indicators of success. Little information is available on the comparative advantage or “added value” of conducting public health interventions through coalitions as opposed to less structured collaborative mechanisms. This paper describes a qualitative, iterative process carried out with site representatives of the Controlling Asthma in American Cities Project (CAACP) to identify outcomes directly attributable to coalitions. The process yielded 2 complementary sets of results. The first were criteria that articulated and limited the concept of “added value of coalitions”. The criteria included consensus definitions, an organizing figure, a logic model, and inclusion/exclusion criteria. The second set of results identified site-specific activities that met the definitional criteria and were, by agreement, examples of CAACP coalitions’ added value. Beyond the specific findings relevant to the added value of coalitions in this project, the use of a social ecological model to identify the components of added value and the placement of those components within a logic model specific to coalitions should provide useful tools for those planning and assessing coalition-based projects.
Electronic supplementary material
The online version of this article (doi:10.1007/s11524-010-9520-y) contains supplementary material, which is available to authorized users.
Asthma; Coalitions; Community interventions; Socio-ecological model of influence
Training adolescents as student researchers is a strategy that can improve the delivery of care at school-based health centers (SBHCs) and significantly shift school health policies impacting students. From 2003 to 2006, the University of California, San Francisco, in partnership with Youth In Focus, implemented a participatory student research project to enhance the existing evaluation of the Alameda County SBHC Coalition and its participating clinic members, and to help develop and implement school health policies. Providing opportunities and training that enabled youth to identify and research the health needs of their peers, as well as advocate for improvements in SBHCs based on their research findings, represents an exciting youth development strategy. This article describes the role the youth played, how their adult partners supported their work, and the impact that their efforts had on the SBHCs and school health programming and policies in the areas of condom accessibility and mental health services.
As several studies have shown an association between periodontal disease and chronic kidney disease (CKD), regular dental care may be an important strategy for reducing the burden of CKD. Access to dental care may be limited in the US public health system.
In this retrospective cohort study of 6,498 adult patients with (n = 2,235) and without (n = 4,263) CKD and at least 12 months of follow-up within the San Francisco Department of Public Health Community Health Network clinical databases, we examined the likelihood of having a dental visit within the observation period (2005-2010) using Cox proportional hazards models. To determine whether dental visits reflected a uniform approach to preventive service use in this setting, we similarly examined the likelihood of having an eye visit among those with diabetes, for whom regular retinopathy screening is recommended. We defined CKD status by average estimated glomerular filtration rate based on two or more creatinine measurements ≥ 3 months apart (no CKD, ≥ 60 ml/min/1.73 m2; CKD, < 60 ml/min/1.73 m2).
Only 11.0% and 17.4% of patients with and without CKD, respectively, had at least one dental visit. Those with CKD had a 25% lower likelihood of having a dental visit [HR = 0.75, 95% CI (0.64-0.88)] than those without CKD after adjustment for confounders. Among the subgroup of patients with diabetes, 11.8% vs. 17.2% of those with and without CKD had a dental visit, while 58.8% vs. 57.8% had an eye visit.
Dental visits, but not eye visits, in a US public healthcare setting are extremely low, particularly among patients with CKD. Given the emerging association between oral health and CKD, addressing factors that impede dental access may be important for reducing the disparate burden of CKD in this population.
To address disproportionately high rates of diabetes morbidity and mortality in some of Chicago's medically underserved minority neighborhoods, a group of community residents, medical and social service providers, and a local university founded the Chicago Southeast Diabetes Community Action Coalition, a Centers for Disease Control and Prevention REACH 2010 Initiative. A community-based participatory action research model guided coalition activities from conceptualization through implementation. Capacity building activities included training on: diabetes, coalition building, research methods, and action planning. Other activities sought to increase coalition members' understanding of the social causes and potential solutions for health disparities related to diabetes. Trained coalition members conducted epidemiologic analyses, focus groups, a telephone survey, and a community inventory. All coalition members participated in decisions. The participatory process led to increased awareness of the complexities of diabetes in the community and to a state of readiness for social action. Data documented disparities in diabetes. The participatory action research approach (a) encouraged key stakeholders outside of the health care sector to participate (e.g., business sector, church groups); (b) permitted an examination of the sociopolitical context affecting the health of the community; (c) provided an opportunity to focus on preventing the onset of diabetes and its complications; (d) increased understanding of the importance of community research in catalyzing social action aimed at community and systems change and change among change agents.
Literature reviews have identified recruitment as the single most challenging obstacle in conducting pediatric trials. This paper describes a paradigm shift in recruitment design, developed from experience with grassroots campaigns through the DRINK study (Decreasing the Rates of Illness in Kids). The objective of this study was to explain a new method for recruiting in clinical trials based on lessons learned from grassroots political campaigning.
Methods and findings:
The study described is a randomized controlled trial of 638 3–6 year olds from the Washington, DC Area. The design involved a comparison between new recruiting approaches modeled after grassroots campaigns and traditional techniques. Traditional techniques for the purpose of this paper are defined by the use of physician referral, mass media such as radio and television advertisements, along with posters in public places like the subway. Grassroots approaches alternatively developed and utilized community contacts and employed targeted small market media community. The main outcome measures were the percentage of budget used and the number of eligible participants recruited.
The results showed that the grassroots recruitment approach saved 30% of the budget, recruited 638 kids in 4 months and retained over 90% for the 90 day trial. New techniques need further exploration as community studies are stressed.
RCT; recruitment; grassroots
Populations at highest risk for HIV infection face multiple barriers to HIV testing. To facilitate HIV testing procedures, the San Francisco General Hospital Medical Center eliminated required written patient consent for HIV testing in its medical settings in May 2006. To describe the change in HIV testing rates in different hospital settings and populations after the change in HIV testing policy in the SFDH medical center, we performed an observational study using interrupted time series analysis.
Data from all patients aged 18 years and older seen from January 2003 through June 2007 at the San Francisco Department of Public Health (SFDPH) medical care system were included in the analysis. The monthly HIV testing rate per 1000 hadpatient-visits was calculated for the overall population and stratified by hospital setting, age, sex, race/ethnicity, homelessness status, insurance status and primary language.
By June 2007, the average monthly rate of HIV tests per 1000 patient-visits increased 4.38 (CI, 2.17–6.60, p<0.001) over the number predicted if the policy change had not occurred (representing a 44% increase). The monthly average number of new positive HIV tests increased from 8.9 (CI, 6.3–11.5) to 14.9 (CI, 10.6–19.2, p<0.001), representing a 67% increase. Although increases in HIV testing were seen in all populations, populations at highest risk for HIV infection, particularly men, the homeless, and the uninsured experienced the highest increases in monthly HIV testing rates after the policy change.
The elimination of the requirement for written consent in May 2006 was associated with a significant and sustained increase in HIV testing rates and HIV case detection in the SFDPH medical center. Populations facing the higher barriers to HIV testing had the highest increases in HIV testing rates and case detection in response to the policy change.
Hypothesis. Smaller and lower-volume hospitals can attain surgical outcomes similar to high-volume centers if they incorporate the expertise and health care pathways of high-volume centers. Setting. The academic tertiary care center, Moffit-Long Hospital (ML); the community-based Mount Zion Hospital (ZION); the San Francisco County General Hospital (SFGH); and the Veterans Affairs Medical Center of San Francisco (VAMC). Patients. 369 patients who underwent pancreaticoduodenectomy between October 1989 and June 2003 at the University of California, San Francisco (UCSF) affiliated hospitals. Interventions. Pancreaticoduodenectomy. Design. Retrospective chart review. To correct for the potentially confounding effect of small case volumes and event rates, data for SFGH, VAMC, and ZION was combined (Small Volume Hospital Group; SVHG) and compared against data for ML.
Main Outcome Measures. Complication rates; three-year and five-year survival rates. Results. The average patient age and health, as determined by ASA score, were similar between ML and the SVHG. The postoperative complication rate did not differ significantly between ML and the SVGH (58.8% versus 63.1%). Patients that experienced a complication averaged 2.5 complications in both groups. The perioperative mortality rate was 4% for patients undergoing pancreaticoduodenectomy at either ML or the SVGH. Although the 3-year survival rate for patients with adenocarcinoma of the pancreas was nearly twice as high at ML (31.2% versus 18.3% at SVHG), there was no significant difference in the 5-year survival rates (19% at ML versus 18.3% at SVHG). Conclusions. Low-volume hospitals can achieve similar outcomes to high-volume tertiary care centers provided they import the expertise and care pathways necessary for improved results.
Safety-net settings across the country have grappled with providing adequate access to specialty care services. San Francisco General Hospital and Trauma Center, serving as the city's primary safety-net hospital, has also had to struggle with the same issue. With Healthy San Francisco, the City and County of San Francisco's Universal Healthcare mandate, the increased demand for specialty care services has placed a further strain on the system. With the recent passage of California Proposition 1D, infrastructural funds are now set aside to assist in connecting major hospitals with primary care clinics in remote areas all over the state of California, using telemedicine. Based on a selected sample of key informant interviews with local staff physicians, this study provides further insight into the current process of e-referral which uses electronic communication for making referrals to specialty care. It also identifies key services for telemedicine in primary and specialty care settings within the San Francisco public health system. This study concludes with proposals for a framework that seek to increase collaboration between the referring primary care physician and specialist, to prioritize institution of these key services for telemedicine.