Vantage Point Laboratory Without Walls
I S the 2lst century approaches, the gauge of a unilrrsity's greatness will increasingly include how ff well that institution combines research excellence with outreach progmms. The University of North I lCarolina at Chapel Hill already blends both. Not only can UNC-CH count itself as one of the nation's leading academic and research centers, it also can list many community outreach programs at its several professional schools, institrtes and centers. In this issue of Endavors the University recognizes a program designed specifically to cross the university'<ommunity bridge namely, the North Carolina Area
Health Education Centers (AHEC) Program. Utilizing both state funds and community resources, the North Carolina AHEC Program is the larsest and the best supported of the nations 30 or so AHEC projects. The North Carolina AHEC consists of nine area AHECs that function as minirmpuses in health science: Area L AHEC, Charlotte AHEC, Eastern AHEC, Fayettwille AHEC, Greensboro AHEC, Mountain AHEC, Northwest AHEC, Wake AHEC and
Wilmington AHEC. The AHEC Program improves the distribution of needed health professionals in all of North Carolinas 100 counties. It helps practitioners stay uptodate with the latest medical advances while assuring that North Carolinians have access t0 the best qualify health care. Furthermorq AHEC is now on the thrqshold of creating a statewide laboratory for biomedical, clinical and health services research-a iaboratorv without walls. The AHEC Program, based in the School of Medicine, enjoys a rich and active partnership with the UNC Schools of Dentistry Nursing, Pharmacy and Public Health as well as with the academic health science centers at Bowman Gray Hospital, Duke University and East Carolina University, Beyond these relationships, however, AHEC's successes come from its community
I
,tr
.=
partners-community practitioners, community hospitals, public health departments, mental health centen, nursing homes, home health agencies, other university campuses, community colleges/ technical institutes and public schools.
ln all these underlakings, AHEC's role in student education is well lmown, but bgvond these activities, AHEC is a maior pro vider of continuing education for health practitioners in North Carolina. The figures for acarlemic year 1989-90 are illustrative: More than 127,000 health professionals from each of the state's 100 counties participated in 4,935 prolessionaltredit programs conducted in 80 of the state's counties. A hallmark 0f the AHEC Program has been the placement of full-tine faculty in the nine AHECs of Nofth Carolina. These faculty are responsible not only for student rotations and residency training, but also for continuing education. AHECs also coordinate the preceptor roles of community practitioners who wish to participate in the teaching program. Specifically, AHEC supports more than 150 full-time medical faculty away from Chapel Hill. [n addition, there are. more than 100 full-time faculty in pharmacy, nursing, public health, dentistry allied health and mental health. With the support of 23 full-time health sciences librarians based in communities from Boone and Ashe-ville tc Greenville and Wilmington and with the help of thousands of community practitioners who voluntarily teach students. AHEC provides the network for ucellence in offcampus education
::
and training. This full-time faculty and staff developed an infrastructure that allows AHEC's statmide classroom to become a statewide laboratory AIIEC not only helps bring scholars to the community but it helps bring the community with its problems and community-based findings to scholars in their classrooms and research labontories. Dozens of these joint \entures are glimpsed in this special issue of Endeavors. Jusl as it does fcrr the University, the commitment to this tvpe of scholarship keeps the AHEC Program alive and up{otheminute. I am pleased to recognize the facully whose work is featured in this issue of Endeavors.
-/1 9 u e4* d
Eugene S. Mayer, M.D.
C Y ), lv\af-0
Associate Dean and Director North Carolina AHEC program uNC-CH School of Medicine
Foreword
A Lifetime Practice challenges in the n NE 0f the greatest "professions is equip students t lneaftn<are \.f for a lifetime of professional practice.
The great trends dwelopment of
t"o
those
and data access as well as information transfer
now make nar technologies available in offices and clinia that were traditionatly only found in academic medical centers. To be most effective, educational programs for health care providers
can be wasteful at best, and hollow, sren destructirre at wont. 0n the other hand, education
of professional
health care include the
nologies that are generally more dispersible than of past decades. Capabilities for information
To
take up this challenge a relationship must be forged betr,veen education and practice, because neither is sufficient alone. 0n the one hand, uninformed by the realities of practicg education
dominated by considerations
in
prerrentive and therapeutic tech-
must offer substantial experience in these dispersible technologies of medical practice Having
prac-
tice becomes training rather than education, and the profession itself evolves into a discipline in which uneducated graduates are only able to
pioneered
in the dwelopment of
AHECs, North
Carolina already offers these important dimen-
apply empirical skills. The North Carolina Area Health Education Centers (AHEC) Program has been a national and world pioneer in dareloping community-based
sions of health care education. The North Carolina AHEC Program
educational programs for almost alt types of
state, thus strenghening and refreshing the educational programs t0 assure health care
link
universities, through medical schools, to the fields of health care practice in the communities of the
health care providers. With strong support from North Carolinas governors and its legislature, AHEC is built on the invohtment of community hospitals in medical education as fashioned by the late Dean Reece Berryhill and Dean and
personnel of the highest competence and com-
mitment. At the same time, AHEC linl$ this states practicing health care communities
a hundred years ago-have
to
the
states medical schools and universities in ways that assure practicing communities information
Chancellor Emeritus Christopher Fordham. AHEC
Germany more than
has had orceptional leadership-Mr. Glenn Wilson, the first director, and Dr. Eugene Mayer, the director for the past 13 years. Under their
over the past 25 years developed ways for
sources and support the recruitment
medical education and university hospital-based
care providers throughout the communities of
medical practice to interact outside the university with the larger world of hospital-based clinical
North Carolina.
is not only rooted in communities from one end of the state to the other, but also offers a medical university without walls guidance, AHEC now
practice
ln
in
other
&r/6"",tr-**^
states, clinical medical education has been, in
highest quality.
part, dispersed from the academic medical centers into community hospitals, clinics and
Stuart Bondurant, M.D.
doctors' offices.
Dean School of Medicine
Organized programs
of instruction in this
clinia-a
coun-
model pioneered in
health
many states, community-based medical
schools hare been formed de novq and
that provides an educational experience of the
try's hospitals and
of
Foreword
An 0ngoing Partnership fnHE University of North Carolina at Chapel I Hltt is a great institution not only because I of its tongi,ity-tfre Unirersity is approaching
Under the able leadership of Dr. Eugene Mayer and nine area directors, AHEC has broad-
ened its involvement to include projects funded by the General ksembly to address nursing work force needs and training needs in the community mental health qmtem. In recent pars, AHEC
a third century of service to the people of North Carolina-but also because the University and the state hale participated in an historic and ongoing partnership to define the needs of North Carolina and to obtain the necessary resources to address those needs. One of the most salient exampla of the benefits of this partnership is the North
activities hare anticipated state and national
health care agendas by focusing on such critical issues as aging, health promotion and disease prevention, health care service management education, AIDS, and the education and employment of allied health professionals. The articles in this issue of Endavors ofler a sample of the many ways in which the Universitys AHEC Program benefits the citizens of North Carolina. The integration of the teaching,
Carolina Area Health Education Centers (AHEC) Program.
Beginning
with a 1946 state commission
recommendation that an expanded UNC-CH School of Medicine be "integrated effectively and
a statewide network of hospitals and heatth centersl' the concept became a reality with a federal contract to the School of Medicine continuously with
in
1972
to establish three regional Area
research and service components of these activ-
ities is kry to AHEC's success, as are the mutually beneficial and positire relationships that enist between Unirarsity faculty and local health care practitioners. The North Carolina AHEC
Health
Education Centers. In 1974 the UNC Board of Governors recommended erpansion of this pro gram, and by 1975 all of the present nine AHECs were
in
in
Program has become
operation. The foresight shown
establishing the nation's first public university
was again wident as North Carolina became one state of only a few to assume responsibility for a major portion of its AHEC budget. In recent years, local communities have also become active participants and currently provide funding for a
significant portion of regional AHEC
retention, geographic and specialty distribution, and quality of health care professionals and sup port personnel. with special attention given to increased minority repruentation.
in
The Division of Health Affairs' participation the AHEC is extensive, and includes faculty
a standard of excellence for
others throughout the nation. A,s UNC-CH engages in a planning process that may set its course for the decade the AHEC Program also demonstrates how careful aftention to the needs
of the statg high quality education
institutions can be combined to achieve a farsighted and purposeful fulfillment
For almost two decades, the mission of the AHEC Program has been to collaborate with teaching and service institutions throughout North Carolina in providing education and training to meet health manpower needs, and to work with other programs and agencies in the planning and
and students from the Schools of Dentistry Medicine, Nursing, Pharmacy and Public Health. Activities in the regional AHECs include training for health professions students, medical and dental resident training, specialty consultation clinia, library and information services, educational media services, continuing education offerings for
delivery of community health care services. AHEC initiatives have worked to improve the
health professions practitioners and offrampus
H. Garland Hershey, D.D.S.
degree programs.
Vice Chancellor
budgets.
programs,
collaborative research and cooperation with other
University's mission.
for Halth Affairs
ol
the
End Endeavorc
FOREWORDS
Research and Graduate Education at the University
of North Carolina ai Chapel Hill
I
Fall l99l
A Lifetime
Practice
by
Stuart Bondurant
Volume IX, Number I
2
Endeavorc is a rnagazine published thrce times a
I
the 0ffice of Research Services at the Unirersity of North Carolina at Chapel Hill. Each issue of fndeancrs describes only a fevt of the many research proiects undertaken by faculty and students of lhe University.
year
Requests for permission
4
An Ongoing Partnership by H. Garland Hershey
Carolina 0pinion North Carolinians and Health
by Thad L. Beyle
t0 reprint material,
readers' comments and requesls for extra copies should be sent to Editor, Emleawn Olfice of
5
Research Services, CB# 4100, 300 Bynum Hall,
The University of North &rolina at Chapel Hill,
Walking the High Wire Bringing Pharmacodynamics to the Bedside
Chapel Hill, NC 27599-4100 (919/966-5625).
by Scott Lowry
Chancellor: Paul Hardin
Interim ProvosL William F. Little ksociate Provost and Dean of Research: Mary Sue Coleman
7
Heal Yourselves Health Care for the People and by the People
by Lisa Blansett
Director, Office of Research Services: Robert P. Lowman
ll
Mvisory Boud for ORS Publications: Philip Cafl
lftnndh
Coleman
An Ounce of Prevention Reducing lnfant Mortality
in
New Hanover County
by Scott Lowry
Katherine High Douglas Kelly Carol Reuss
t2
Ex 0fficio:
Mary Sue Colenan
AHEC Spotlight Cutting the
Robert P Lowman Brenda Powell
Fat
Dental Drills
Editor-in4hief: Tom K. Scott Managing Editor: Brenda Powell Assistant Editors: Lisa Blansett
Calling All Nurses
Dottie Horn Scott Lowry
by
Lisa Blansett
Photognpher: Will 0wens Design: UNC Design Services
FAHEC Responds to AIDS
@ tSSt Uy the Uni,renity of North Carolina at Chapel Hill in the United States. All rights reserrcd. No part of this publication may be repmduced
Extending the Cutting Edge
without the consent of the University of North Carolina at Chapel Hill.
A Specialist for All
Seasons
by Dottie Horn
As Ye Sow. .
16
.
AHEC Research Support Bears Fruit
by Scott Lowry
18
Antibody Building Developing a Hib Meningitis
Vaccine
by Dottie Horn Cover lllustration: 56
x 46
Pavel Tchelitchew. Anatonical Painting. c.1945. oil on canvas inches. Collection of Whitney Museum of American Art, New York. Cift
of Lincoln Kirstein 62.26. Photography by Jerry L. Thompson, Amenia,
N.Y
Cover: Area Health Education Centers (AHECs) reach throughout the corpus of North Carolina.
Garolina Opinion
f 1'OW people perceive their health may be H fts best indicator oi health and chances I ltor longer lite. Recenr studies have tbund
North Carolinians and Health This colunn futures information from the Carolina Poll conducted by the UNCTH School of Journalism and Mass Communication and the lnstitute for Research in Social Science.
by fhad
that how healthy an individual feels is one of the best gauges of how long he or she will live. So, how healthy do North Carolinians feel? This past March, the Carolina Poll, con' ducted by the School of Journalism and Mass Communication and the lnstitute lor Research in
or poor?" As indicated in
of five North Carolinians feel they are in excellent or good health. table, four out
in fair or poor health. Nevertheless,
that
(10)
96
4
(42)
90
l0
45-64
(33)
74
26
65+
05)
58
42
p5) (34
59
41
82
r8
(27)
90
10
(17)
96
4
<$i0,000
02)
63
JI
$10-$20,000
(15)
74
26
$20-$30,000
(24)
90
l0
$30-$40,000 $40,000+
(20)
87
13
(30)
95
5
Metropolitan area
(sl)
87
Non-metro area
(4s)
/5
Mountains Piedmont
(8)
85
(60)
84
l5 l6
Coastal Plain
(34
75
25
White
(8t)
83
\t
Non-white
0e)
71
29
very
(34)
87
l3
Pretty
60
79
2t
Not too
(10)
65
35
very
(48)
83
Pretty
(46)
8I
Not too
(6)
63
Household Income:
a
college degree feeling well. Similarly, those with the lowest incomes are far more likely to report feeling in fair or poor
Residence
health than are those at the upper end of the income scale. At the very highest income levels
in
Reridence
almost weryone reports good to excellent health. North Carolinians who live in non-metropolitan areas are twice as likely to report poorer health as those living in metropolitan areas, and those who live in the coastal plain region are slightly
or
school
Some college College grad
The poll also found that the more education an individual has the more likely he or she is t0 report feeling well. In North Carolina this ranges from three out of five feeling in excellent
mountains
19%
Educationr
excellent.
to feel well than those living in
Poor
25-44
High school
less likely
Fair or
18-24
(than high
or good health among those with less than a high school education to nearly everyone with
Good 000%) 81%
Age:
the
threefifths of those over 65 say their health is
or
fxcellent
Nor{h Garolina
nearly
good
is:
or
As might be expected, older North Carolinians are more likely than younger ones to report they are
Beyle
Question: Taken all together, horu would you say things are these dap-would you say yqur own health, in general,
Social Sciencq asked 509 adult North Carolinians: "Would you say your own health, in general, is excellent, good, fair
t.
in
NC:
l3 q(
NC:
Race:
the
Piedmont.
Happy with life:
African-American and other non-white North Carolinians are slightly less likely t0 report a good health status than whites. Finally, those reporting that they are happy with their life overall and have a happy family
Happy family life:
life are much more likely t0 report being healthy, too. Although no causal relationships are suggested here, these responses do fit together as part of an individual's total view of themselves which in turn may translate into an overall
These findings are based on telephone interuiws
wilh 509 North Carolinians age l8 or older, conducted March, l99l in Social Sciencr, UNC"CH. The margin of enor is
Journalism and Mass Communicalion and lhe Institute for Research
17
l9
I the School of +/- 4 percenl
for the t0lal sample, but is larger for comparison benreen groups.
healthy perspective.
The In$itute for Research in Social Science collects and maintains one of the oldest and large$ archives of computer-readable data in the United States. The collection includes the Louis Harris Data Center (the national repository for approximately 900 public opinion polls collected
since 1963); Roper Centers lnternational Survey Library Association (public opinion data); and the N.C. State Data Center (census data).
Beyle
is a UNCCH Professor of Political
These public opinion items and many more are included in a computerized index which allows researchers to locate informatron
Science
of
interest by word search.
Walkingthe High Wire Bringing Pharmacodynamia to the Bedside by Scott Lowry
alking into the office of the Greensboro AHEC's Pharmacy Education Division Director in the Moses H. Cone Memorial Hospital suggests entering a beehive. Intense activity reigns in this cramped cell, where
=
apparent chaos somehow coalesces into coherent activity. The room fairly buzzes with energy. The source of this henetic activity is Director Peter Gal. fuo years after earning his Doctor of Pharmacy at the State University of New York at Buffalo, he joined the Greensboro AHEC and the UNC-CH School
of
Pharmacy,
excited by Moses Cone Hospital's national reputation as a center for clinical pharmacy. It is easy to believe that he has not paused for breath since, as projects engage him across the hospital. "Pediatrics, neonatology and family
medicine-those are the people I've worked most closely withl' he recounts. "There was a time when I did more with the [Department of] Medicine, but I've gotten s0 busy with s0 many other things that I've had to cut down. I used to do an asthma clinic and an epilepsy clinic. I don't do those things any more because I just don't have timel' In the past dozen years, his work has focused more sharply on the clinical pharmacist's role in helping hospitalized infants and children. "There's very little literature about drug [treatment of] neonates, so it was a wide-open fieldl' Gal explains.
"lt's ideal for
research because we monitor so intensely that
once we developed a system that collected the information while we were doing routine care, we could get the research information without doing anything differentl' fuo of the techniques Gal uses in his search to learn how pharmacy can best help these youngest of patients are pharmacokinetics and pharmacodynamics. In his words, "pharmacokinetics is the mathematical modeling of what the body is doing to the drug-how the body is absorbing, distributing and eliminating itl' Local hospitals a few years ago would ask pharmacokinetic experts like Gal to help them
Peter Gal and Yvonne Brown, R&D chemist, examine a printout from the high-performance liquid chroma tography analyzer behind them, which shows the drug concentrations
in patients'blood.
establish drug dosing programs, but sophisticated computer programs available today allow hos-
a matching of the drug level to the drug effect so that we can simulate what's going to happen
pitals to do much of the work themselves. That works well for Gal, who now uses kinetics primarily as an element of pharmacodynamics. "Dynamics is what's dear to my heart right nowl' he confides.
pharmacologicallyi'
"Pharmacodynamicsl' Gal continues, "is a dual modeling system overlapping the two systems of pharmacokinetics and pharmacology. For each drug, there are known pharmacological effects. With dynamics [we] look at the amount [of the drug] in the blood and use the mathematical modeling [of kinetics t0 find] how much is likely to be in the blood at different
times and parallel that to the pharmacologic effects of the drug at different levels. [t creates
From its beginning in the late i960s, most pharmacodynamic modeling has been carried out at highly abstract mathematical levels using sophisticated computer programs. Gal's research brings the technique down to earth by trading in large computers for professional experience
and moving from the laboratory to the clinic. "Most pharmacodynamic modeling is used to gain a population sense of what will happen with drug and effect. There are probably very few people who do bedside pharmacodynamic practice. One of the nice offshoots 0f this is that I'm proving that it's valuable in the clinical environment, that it's not just a research tooli'
Asked to pick his most interesting research project, Gal settles on his work with indomethacin, a non-steroidal anti-inflammatory agent. He was drawn to it, he remembers, "because unlike other drugs where people have a preconceived idea of what the safe and effective concentrations are, there was no such pre-
you have to do this with pharmacodynamic modeling; it just can't work without thatl' The system's effectiveness is not confined
conceived notion. [n fact, it was thought that the drug levels did not correlate with drug effect. We proved that drug levels did correlate with effect, and we also proved that with this
[then in the pharmacy residency program at the hospitall and I showed that by dosing heparin pharmacodynamically in patients who had venous thrombosis flike the phlebitis which
combined modeling [of pharmacodynamics] we could improve [patient] response rate and cut
afflicted former president Nixon] we could cut their
down toxicity by a lotl' The findings have directly benefited patients at Moses Cone Hospital. A number of premature infants have been spared chest surgery as a direct result of the indomethacin study. In patent ductus arteriosus, a blood vessel between the aorta and the pulmonary artery fails to close before birth, allowing blood to return
directly to the lungs without circulating through the rest of the body, resulting in fluid overload of the lungs and multiple secondary toxicities.
If
treatment with indomethacin cannot close
the vessel, then a neonatal cardiovascular surgeon must tie it off. But the drug treatment is complicated because a delicate balance must be maintained: too low a level oi indomethacin means the ductus will not close, but severe kidney toxicity occurs at a level just a half step beyond. Worsening matters is the wide variation among infants in response to conventional dosing procedures, resulting in a disappointingly high failure rate. Because Moses Cone Hospital has no neonatal-cardiovascular surgery center, the sur-
gery option involves the additional dangers of transporting very sick babies to centers at other hospitals. Avoiding this risk provided strong incentive to try the highly individualized pharmacodynamic model. Study results were striking. While nearly half of those babies treated with conventional dosing guidelines failed to respond, permanent closure was achieved in more than 95 percent of those treated using bloodlevel
monitoring and pharmacodynamic information. Furthermore, none of the babies undergoing the experimental treatment showed symptoms of renal toxicity, while 60 percent of those receiving conventional dosing did. The study resulted in something more
important than the article in the Journal of Perinatology: better patient care in the hospital because of a new standard of practice. "That to me is the most important issuej' Gal says. "Using this system, we've only had one 0r two kids not respond after about 65 cases, an outstanding response rate for this drug, and we've
only had minimal toxicity, while most centers experience quite a lot of kidney toxicity. But
to indomethacin treatment of patent
ductus
arteriosus. "What we've done with indomethacin, we'ye also done with [the anticoagulant] heparinl' Gal reports. 'A few years ago, Jay Groce
hospital stay by two and one-half days, and we resolved their leg pain a day earlier. A study showed that subsequent pulmonary embolus
[blood clotting
in the lungs] was much
less
if you optimize
dosing within the first 24 hours; using this pharmacodynamic approach, we were optimizing doses within 12 hoursl' [severe]
tific breakthroughs that affect medicine 20 years from now, but for that 20 years, while we use these therapies [developed in the clinic], we actually are in a better position [to help patientsli' To Gal, an a(vantage of clinical research is that it can be carried out with modest resources. "[t's just a matter of convincing physicians to analyze their practicel' he says. "With routine clinical practice, important research information can be obtained if people are attentive and consistent, if they can follow a protocol closely. lt doesn't require research per se to do that protocol. [[t's a matter of asking] 'lf I lust change this little thing, will I improve the outcome?' It improves patient care because we try to fix what we see as problems, and things
like our heparin study can wind up being services that pharmacy departments can applyl'
Gal believes this dynamic approach could improve the effectiveness of many pharmaceutical treatment programs. The key is the clinical pharmacist's discretion. "People are looking at
There are also advantages for the researchers,
[dosing] like there's some restrictive set of numbers, that you should keep the blood [drug] level between these numbersl' he admonishes. "['m saying there's a risk/benefit percentage instead, and that you weigh the risk and you weigh the benefit, and you monitor intensively. For some patients you push [drug level] very high and for others you keep it very lowknowing the level, you can target your effects more precisely. [t's very individualized]' It is the human factor that makes pharmacodynamics work at the bedside. "Clinical medicine does not fit as perfectly into computers as one would likel' explains Gal. "For example, the physiologies are always changing in the premature baby, and in my experience with [computer] programs for pharmacodynamics there hasn't been flexibility for the programs to [adjust to] what's actually happening physiologically. When I'm doing this freehand, the built-in flexibility is my judgmenti' Though such research presently has little impact on his own practice, Gal admires those who are carrying out pharmacodynamic modeling with sophisticated computers and abstract math. He sees their work complementing the clinical research carried out by researchers like himself, much as the type of research performed at university hospitals complements that done in community hospitals like Moses Cone. "I think in the long term, the type of research done in the universities has the greater impact, but community practice sees the common problems that are truly medicine, so from an immediate clinical standpoint we're able to research common problems that affect a greater population. Certainly we're not going to study the thines done at universities that make scien-
this because it continues to intellectually stimuIate them. They see opportunity for growth and
who might worry about stagnating in a community practice after leaving the academic setting.
"0ur
neonatologists are excited about doing
developmenti'
Despite the apparent isolation oi being out in the AHEC regions instead of on campus, Gal could not imagine a more fruitful job. Like a bee fertilizing the flowers of the fields while collecting nectar to make its honey, he is able t0 promote cross-pollination among various
in the medical field while working at his own practice. This opportunity t0 serve as messenger between clinical pharmacists and physicians, between faculty working with scientific aspects of medicine and clinicians working areas
with practical aspects, between university and community-this is what really excites Gal about his work. It is also what AHEC is all about. 'As much as I en.joy research, my favorite thing is clinical practice. I can do both here, and AHEC is the perfect system for that. Without that stimulus, that interest in research, we would stagnate, and if we stagnate, we won't be much value to either the University or the communityl'
I
HeaI Yourselves Health Care for the People and by the People by Ltsa Blancett
I\ I I
octors used to make house calls, especially in rural areas where folks iuo could not get t0 medical care.'Those days seem to be all but Ll'ou"r. Doctors to'day have lots of people and fancy equipment. It just would not be feasible to run things the old-fashioned way. Or would it? The residents of Madison County, a rural area on North Carolinas border with Tennessee, are getting some old-fashioned care, without losing the benefits
of the latest medical technology. The Mountain Area Health Education Program (MAHEC), in concert with the Hot Springs Health Program, and funded by the W.K. Kellogg Foundation of Battle Creek, Michigan, has created a unique Community Oriented Primary Care (C0PC) project that blends the best of two centuries. "Philosophically, one of the best things about C0PC is that it comes back to the old, nineteenth-century idea that good medicine is ultimately social and economicl' says Tom Plaut, a professor
of sociology at Mars Hill College who directs the Community
Needs
Assessment and lntervention component of the COPC project. The community
itself has taught the medical profession how to update the housecall. Instead
of waiting for patients t0 come to them, health care workers are going to the people, working with them to improve their health.
"lt is the humdrum, day-in, dayout, everyday work that is the real satisfaction of the practice of medicine; the million and a half patients a man has seen on his
daily visits lver a forty-year period
of
weekdays and Sundays that
make up his life.. ." Madison County sits in the Appalachian Mountains. Its peals and valleys,
hills and hollows, creeks and rivers form distinctive and diverse communities. 0f North Carolinas one hundred counties, Madison ranks 88th in population density-only 38 people live in the average square mile. In 1980, the county ranked 98th in per capita income, with the average falling in the $7,000 range.
Lying in some of this country's most beautiful landscapes, Madison County has a long history-Europeans were settled there by the 1790s. "Our community is hyper-sensitive to the stereotypical image of the Appalachian people, the povertyl'says Gary Lewis, the Hot Springs Health Program's executive director. The COPC board members know that their project would
not have been very easy, 0r very successful, if UNC doctors had come in and said to the people, We know what you need better than you do. The people in Madison County would not have put up with that. [n fact, according to Lewis, a few people tried that years ago. At needs-assessment meetings, community representatives revealed their discomfort with intrusive
North Carolina Collection University of N.C. Library at Chapel Hill (circa 1930)
E.iI
D
E,
surveys that required individual interviews and surveys-they would rather
avoid personal questions. Moreover, the benefits of such surveys are delayed for years while legislation is formulated. But the people who provided the data may not learn of or directly benefit from the survey results. The project proposal was thus coordinated by community and agency representatives
with the assistance of Lewis, Plaut, epidemiologist and
COPC project director Dr. Suzanne Landis, community liaison Jerry Plemmons,
and project coordinator June Tlevor, as well as Dr. Richard Olson, Dr. Marianna Daly and Dr. Harry Summerland. What they found was not really so new-they went to the people themselves to find out their health concerns. First, because team members brought different backgrounds, perspectives and goals to the project, the group had to work out exactly how they were going to proceed. "The interdisciplinary nature of the original research design caused tremendous tension in the group-healthy tensionl' remembers Plaut. "Epidemiologists and cultural anthropologists have very
different methods and purposes when it comes t0 data. Each is sensitive to certain aspects, such as what information you're after and how you go after itl' The community provided many of those answers. But the team had to find out how the community works. "When you work in rural societ/'says Plaut, "you're talking about informal relationships, networks. We had to plug into that network systeml' Simply asking the Board of Elections was not going t0 be enough-the BOE had official lines, the ones bureau-
crats drew with little attention to the informal communities that make up rural life. Madison County is really a collection of neighborhoods, what sociologists call "kinship communitiesl' After understanding these close-knit entities, focus groups were formed. "The focus group was a way t0 engage people in the process of deciding what care was best and most needed in a way that was not threatening or alienatingl' says Tlevor. "The members of the focus groups shared their opinions and got feedback from us-they felt they had a vested interest in the projecti' One of the things the focus groups said loudly was that long surveys were not going to work. Landis said, "But that's what epidemiologists do!" To which the focus group countered, "Not
in Madison Countyl" But hard data was still necessary for the project. The team asked the focus group a series of qualitative questions which concentrated on what the
A
o n.s group perceived as the major health care concerns, what caused the health problems, where and why the serious barriers to health care existed, and
whom do residents call for help and advice. These questions were presented to the focus groups in a narrative form and presented informally to further avoid the stigma of survey 0r questionnaire.
To make such qualitative data into useful quantitative data, the team coded the various responses, i.e. each illness mentioned was given a separate letter, and then the number of times each letter was mentioned was tabulated. Overall, the 41 focus groups mentioned 230 different illnesses. The codes were then ranked, indicating the greatest areas of concern and interest. After the data tabulation, the team went back to community advisory boards to check the answers with them. These agency and community representatives agreed with the findings. Moreover, when the team asked area doctors for their responses to this data, by and large they said, Yes, these are the problems we see most often. "We found our people very well informedl' says Lewis. "l think our physicians were surprised; in fact, we were all surprisedl' The gathered data enters an ongoing database project, headed by Lewis. "We're most excited by the database that's being builtl' says Lewis. "We've got the hard, objective data that the'bench' scientists will get excited about, but we also have the kind of data that sociologists wantl' Lewis sees the database as synthesizing the two points of vieq giving everyone a much fuller picture of the county and its needs. But the hard and soft data are not even the whole picture. "lts the gray area that everyone knows has an impact on healthi' says Lewis. "We know, for example, that there's an association between health and poverty, but it has nothing to do with whether people have money in their back pocket that causes
them to get sick. The impact comes in terms of their sociocultural outlook on the use of medical care, and the availability of that care to theml' The next step involves developing the system's research capability. Correlating data so physicians can see where the problems lie, will go a Iong way to improving health care and access to it. The community thus defined its own problems. The team did not stop there, however, and asked the focus groups to help devise solutions and interventions, and the groups agreed to take responsibility for many of the interventions themselves. From this information three interventions have
'l , .when they were being born,
when they were dying, watching them die, watching them get well !
=
'. F
when they were
ill,
has always
absorbed me."
ilD
EAY
'l . .The actual calling on people,
at all times and under all conditions, the coming to grips with the intinate conditions of their lives. . ." 'r{,'diilr
rrl:,11:'
'.* ,t'-/
;'
'&.,,ll
@..
I
I
E .a F
already been implemented. These interventions have given researchers an opportunity to work in the area of applied research, though all team members shy away from characterizing their work as being in any way experimental, or referring to the county as a laboratory. And for good reason-laboratories are staffed by professional technicians and doctors; the interventions per-
children answered their own survey, the process of examining teeth and placing sealants began. Dentists and hygienists descended on the schools, working on the auditorium stage, in the chemistry lab-anywhere they could fit. ln two years, the team will restudy the children to see ifthe sealants have
in Madison County truly belong to the people. In fall of 1990, Madison County Health Department gave free influenza
says Landis, may help get legislation passed to make dental sealants available
formed
shots to the elderly, one of the problem areas cited in focus-group sessions. The immunization program accomplished two tasks: not only did the project give the elderly free shots, but it also asked them questions about their overall health and if and where they sought health care. "The overall goali' says Trevor, "was to reach senior citizens not receiving regular health carel' To reach these citizens, the program was administered at numerous sites-at the Madison County Health Department as well as at all county nutrition program meal sites, churches and volunteer fire departments. Community volunteers helped with pub[cizing the campaign, obtaining consent for the shots and administering a brref survey. The survey found, however, that most of the participants had received flu shots in the past and had a regular physician. The findings show, then, the happy circumstance of a health care system that is indeed functioning well. In the future the C0PC project hopes to target more isolated senior citizens through outreach programs. While data was being gathered on other health areas, preventative dental care for children had been identified as a long-standing Madison County problem. Existing data proved that Madison County school children suffered from lots of cavities or dental caries. The program designed a dental sealant project for all second graders, to be carried out at their schools. "Dental health is one particular aspect of public health that particularly lends itself to activities performed on a large number of people-one such example is water fluoridationl' says Landis. To get baseline information on how children and parents cared for their teeth, the team created a knowledge, attitude and practice survev (KAP survey). While some parents were given this survey at parent-teacher
meetings, many received them at home. A surprisingly high percentage, 90 percent, responded. "The teachers were very motivated to help us,' says Trevor. "One teacher got every single
childi' Several weeks after the
helped cut down on the number of cavities these children get. This information,
to children throughout the state. 'We will see how the collaboration among agencies works, how much it all costs, and whether these children have better oral health at the end of two years. We're hoping that this information can be used t0 support legislation so that we will have public health dentists involved in providing sealants at the schoolsl' says Landis. 0f all the projects implemented thus far, the team is most proud of the Laurel Parent-Team project as it incorporates all the goals 0f
community-oriented health care. "lt evolved completely as a result of the communitv advisory board-lack of preventive care for children was identified as a major problem in the focus group encounters we held in the countyl'says Landis. The team did not have to search long for a place to work-the Laurel School PTA was very interested in doing an intervention involving children. "Parent-Team's goals are to improve use of pediatric preventive services. especially routine visits to the doctor, especially those that would normally provide anticipatory guidance on normal childhood development, potential injuries and immunization compliancel' says Landis, In working with the Laurel PIA, several strategies for accomplishing these tasks were discussed. The best possibility relied on "natural helpers,'or those people in the community that others routinely turned to for help and advice. There was some skepticism as to whether such a plan would work. "The issue of how effective are natural helpers, or lay health advisers, has been raised time and again as a concern in our and other programsl' Landis says. "Do these volunteers then become overzealous and try to treat things that should be referred to a qualified professional?" The researchers decided that it was more a theoretical problem than a real one. Here was a very small area, with a limited number of people. "lt would be local, verv locall' says Landis, "there would be more accountability of the Parent-Team members so that thev would not try to diagnose and treat illnesses. The team's goal involved monthly visits to parents of newborns
E.il
l0
to provide support and linkage to services as well as give new parents a resource guide to those services and a safety kit which included a smoke alarm, among other things. The lay health advisers for the Parent-Team proiect jumped right in, making the project their own from the start. The first thing they changed was the consent form. "The women who participated had to sign consent formsthe usual complicated, institutional formsl' says Plaut. "The advisers in Laurel looked at the form and said,'Nobody is going to sign this thingl" So they changed it. "They were brilliantl' says Tlevor, "They said, 'Why don't
you make this into a brochure so it looks friendly?"' So the consent form is now a singlepage, three-part brochure. "0ne part says here's what we do, one says here's what we expect of you. The third asks, do you agree? What could be more simple?" asls Plaut. This piece of work has caused a stir in similar programs across the
nation. "When we were in Washington for a Kellogg conference, this was one of the pieces of literature that everyone wanted to see. Everyone has the same problem with lengthy, complicated formsl' says Lewis. The ParentTeam lay health advisers have taken hold of so many aspects of the project, that it really is their project: from the questions they ask when they visit new parents to the items in the care kit and the guide to services. "The very last session I worked with theml' says Thvor, "l could just feel that this project was theirs nowl' The COPC research team hopes to see this kind of success in many of their projects, and to be able to share those successes with community-based health care systems throughout the country. "l think it's fairly unusual to find a community where you have such a dialogue between community members and the health care systeml' says Landis. 0r, as Plaut puts it: "We take the community seriously; most people don'ti'
I
I .g F
"l lost mryelf in the very properties of their minds: for the moment
at least
I actually became
them,
whoever they should be, so that when
I detached myself from
them at the end of a half-hour of intense concentration over some illness which was affecting them,
it
was as though
I
were reawaken-
ing from a sleep."
lllustmtion by Ellen Hill
Quotalions from William Carlos Williams, Iie Doctot Stoiles, 1938 by William Carlos Williams. Reprinted by permission New
O
Directions Publishing Corporation.
An Ounce of Prevention Reducing Infant Mofiality
in New Hanover County
by Scott Lowry
he statistics are remorseless: the most recent figures from the State Center for Health Statistics in Raleigh show that in 1989, 1,170 newborns in North Carolina died during their first year. That works out t0 an infant mortality rate of 11.5 deaths per 1,000 births. worse than in any other state except Georgia. Preliminary figures for 1990 indicate the possiblrty of some improvement, but continue to place North Carolina among the worst in the nation. The statistics may not care, but many people who work with statistics do. One of them rs Deborah Covington, a research specialist with the Wilmington AHEC at New Hanover Regional Medical Center who is evaluating local projects aimed at reducing the infant mortality rate. Covington points out that because Iow birthweight is directly linked with infant mortality, bv decreasing the number of low-birthweight and very-low-birthweight births (newborn babies weighing less than 5.5 and 3.3 pounds, respectively), we can reduce both infant morbidity (disease) and infant mortality (death). Not only
rvill this benefit individuals and families, she continues, but it will reduce the cost of infant
effect on others. "We found that the program worked well to reduce low-birthweight births among white womenl' she explains, "but it did
not seem to have an effect on reducing lowbirthweight births among black women, who generally are at greater risk for premature births than whites. However, when we examined the data more closely, we found that black women were much less likely [than without the programl to have a very-low-birthweight birth. Very-low-birthweight babies tend to have the highest rates of mortality, so delaying [these] births to even low-birthweight status both decreases mortality and morbidity and reduces the cost of infant carel' But the data did not produce good news for adolescent mothers, Covington says: "Teenagers enrolled in the proQram still had a very hieh
$,
ffi
ffi ff @'
proportion of low-birthweight births (14 percent compared to nine percent for women 20 years and
older)l' With pregnant adolescents accounting for about one-sixth of births in North Carolina, Covington's findings spurred New Hanover County
Health Department t0 obtain a March of Dimes grant to implement a project in November 1989 called "Teens in TYansition through Educationi' The project's three objectives are to reduce low-
and very-low-birthweight births, to reduce rapid repeat pregnancies and to improve parenting skills of participants. If the project meets its three objectives, it will help the state's efforts to reduce the death rate among infants. "lt's an incredibly important proiect, and the preliminary data seem to indicate that its workingl' says Covington excitedly. "We certainly hope it's workingi'
t
lbrying the ruturc ofTeenagrMothcs: Rcducirtg
l{ca'at
ltccrtancic'
i- |Elt::.'i,li::r,.it'l'
:':f:rr',.|
care and the drain on hospital nursery resources.
Since joining the Wilmington AHEC in
a local evaluation 0f the North Carolina Prematurity Prevention 1986, Covington has directed
Program. This statewide prevention effort, established in January 1985, requires all participating local health departments working with hospitals providinq prenatal care to take three steps to reduce premature (and hence low-birthweight) births: identify those obstetric patients at high risk for preterm labor; teach all obstetric patients good habits for nutrition
and health as well as the signs, symptoms and ways t0 prevent preterm labor. and train hos-
pital staff in preterm delivery prevention, Covington's research exposed some problems
in the program: while effective in
reducing
low-birthweight births for part of the population, it has little effect on some segments and no
Ir thc area served by the \\:ilminr{ton A[]EC. Delrorah Covinqton and Research Assistant M. Paiqe (lhurchill urrrk to reduce inlant deaths thnrLrqh prograns like Teens in Transition throLrqh Education.'
t
12
AHEG Spotlights by Lisa Blaneett
Cutting the Fat
and teaching tools, the other relied on information
Dental Drills
provided by the National Cholesterol Education program, a lecture that Levin calls "didacticl'
the '70s, new acquaintances might have asked, ''What's your sign?" But in ihe
1'n
! I
health conscious 90s, the question may well become "What's your cholesterol level?" For better 0r worse commercial television has been the primary source of the layperson's understanding of the relationship between a low-fat diet and health. ln fact, the chances are relatively high that unless we are quite overweight, we will not even bother to check with our physician to learn healthy eating habits. But we should. And Drs. Mina Levin, Robert Grossman, Suzanne Pletcher and Arthur Evans are researching
methods through the Faculty Development Pro gram t0 make sure physicians feel competent advising patients about good diet. "Very little nutrition counseling is taught in medical schoolsl' says Levin. In fact, the first part of the study asked residents in seven clinics in the South and one in Pennsylvania
when and if they had received such training. 0nly one-third of physicians had been trained in dietary counseling skills during medical school, and less than one-half during residency. "They knew about high cholesterol and who should be tested and treatedl' says Levin, "but they didn't know their dietary facts awfully welll' While the residents said they felt deficient in their skills, they were, on the whole, also convinced that it was a doctor's responsibility to provide dietary
counseling to people with high cholesterol levels. But while more than 80 percent of the residents in the survey said that such counseling was a high priority, less than one{hird felt prepared to counsel and even fewer felt their counseling would have an impact. 'There's a big gap between what they think they should
be doing and what they think they can actually accomplishl' says Levin. But Levin's team did not just determine that residents feel underqualified when it came to advising patients about cholesterol: the team formulated a new teaching method and tested it against older accepted methods. "The questionnaire confirmed that we had to teach them ways t0 counsel that would make them feel effectivel' says Levin.
At health centers
through-
out the Southeastern United States, and one center
in
Pennsylvania. participating faculty gave
two different lectures to a total of 154 resident physicians. One lecture used the new techniques
Half the residents attended the new-style lecture; half the old. Each of the two groups of residents was divided again in two. One group's patients had a cholesterol reading available to the physician;
one did not. This gave the researchers a total of four groups for comparison. The new techniques tested included teach. ing residents how to assess their patients' diet. "As it turns out, nobody really understands the 30 percent [fat-in-your-diet guidelines], or how [to calculate the] ounces of fat you eat 0n a daily basisl' says Levin. So using a tool called MEDICS: Meat, Egg products, Dairy products, Invisible fats, Cooking fats and Snack foods, physicians are able to ask their patients questions that are easily answered: "How many eggs do you eat in a week? What do you cook with, lard, margerine, oil?" Based on these answers, according to Levin, doctors can make
more pertinent suggestions. "[0nce] you see what the patient's habits are, then you can contract with the patient to change one or two behaviors until the next visit,' says Levin. The physicians are taught to watch lor possible barriers to change. "Patients [might] sa,v, 'l can't afford this kind of food;' or, 'My family won't
shop for this;' or, 'What do I do when I eat out?"' says Levin. The residents are also taught relapse counseling, that is, what to tell patients when they slip back intO Old habits. After the physicians worked with patients, the researchers reviewed charts to see how residents documented what went on during clinic visits. The research team also asked patients for their ideas on how the program had worked; this data is still being analyzed. The residents who were in the group that received the new lecture and training tools felt more prepared to counsel, and more confident in their counseling skills. "They reported more use of behavior modification methods and gave their patients educational materials more oftenl' says Levin. 0verall cholesterol levels did not, however, change significantly.
"l
think if
we
had done that, it really would have been a remarkable outcomel' she says. The more doctors learn, the better they will be able to help patients lower their cholesterol levels and thus change their
lives.
I
here is more to your dentist than just that intimidating instrument aimed at your mouth. Beyond the years of educa tion that taught the dentist and her assistants how to wield those instruments, if she lives in North Carolina, your dentist has the opportunity to continually enhance and further her education. Darlene Sams, Dental Director at the Wake AHEC, and a team of researchers, have been studying ways to ensure your dentist and her stafi have all the education they could possibly want. "We've formed a partnership with UNC-CH, East Carolina University and Duke University's medical centers and with the local Dentai Aux-
iliary societies to offer continuing education. We want to be able to network resources better and increase collaborative effortsl' says Sams. A recent research project, called the Dental Office Techniques survey, asked all North Carolina dentists, hygienists and assistants to characterize their office environment, job satisfaction, career goals, as well as office management techniques. "There is a high turnover rate in dental jobsl' says Sams. "We wanted to find out where the problems were in the office, and then build courses around the needsl' While the data is still being comprled and matched, Sams believes that the survey will
yield data "that will help us meet the needs of the profession for several yearsl'This sort 0f data has not been compiled anywhere else in the nation. "The American Dental Association is looking at our survey,' says Sams, "with an eye toward using it nationwidel' 0ther dental topics have given rise to continuing education courses offered by the Dental Education program. The controversy over the use of mercury amalgams for fillings is an example. While some healthqre professionals advise patients
to have mercury amalgams removed to alleviate the symptoms of multiple sclerosis or other problems, others consider purely anecdotal the evidence that would support this treatment. The program has also taught the latest in aseptic techniques t0 ensure that infectious diseases such as HIV or the common cold cannot be transferred
from practitioner to patient or patient to practitioner. "[The programs] really depend on the local needs]' says Sams, "and are in cooperation with all the local dental organizationsl'
I
l3
aHEG
spottigh"
ff AHEC Spotlisht Illustrali0ns by Ellen Hill
became [state] legislationl' says Helen Brinson, chair 0f the AHEC Nurses Council Recruitment and Retention Committee. Funding provided by the legislation included allocations for recruitment, retentions, a scholars program, as well as grants and loans. AHEC has worked hard to make sure that money is well used, and has created several programs to help recruit and retain nurses. The first piece of work was to change the image of nurses and their work place. "We've talked with public school teachers and counselors. They did not have the correct information about nursing, about salaries, about expanded [roles], settings, and flexible hoursl' says Brenson. Most thought that nurses made
about $14,000 dollars a year. The average starting salary for a hospital registered nurse in eastern North Carolina ranges from $21,000 to 27,000. Moreover, while educators did see nurses as contributing significantly to society, they did not see nurses as professionally educated.
Calling All Nurses
ost people think of Florence Nightingale as the patron saint of nursing. The profession, of course, has come a very long way since then, but going where there is a need remains an essential part of the profession.
The nursing shortage in North Carolina, and much of the rest of the nation, however, has made this commitment more difficult to fulfill. Advances in technology have contributed much to the need for educated and skilled nurses. Many think of nurses as being low-paid, overworked, with an education they picked up in a few weeks of technical training. Each is a misconception. Though invalid, such popular beliefs add up to a nursing shortage as college-age men and women
seek other, ostensibly higher-paying, more prestigious jobs.
In
1987 data began
to show a veritable
crisis in nursing recruitment. Between 1983 and 1987, enrollment in nursing programs for registered nurses dropped 22 percent, while enrollment in programs for practical nurses declined 45 percent. AHEC reacted immediately by forming a task force to respond. "The North Carolina AHEC program was instrumental in accomplishing a great deal of what eventually
"They were not aware that many nurses had masters degrees and doctoratesl' says Brinson. Educators failed to direct students with math and science talents toward nursing, sending them instead toward other professions where teachers felt the students could make more money. Most teachers also believed that nurses worked primarily in hospitals. While this is true, there are many other roles for nurses,
according to Brinson. "There are health depart-
ment and school health nurses; nurses can work in mental health, wellness programs, cardiac rehabilitation programs; there are nurse entrepreneurs, educators, counselors, consultants and many other areas into which nurses can
easily fitl' she says. Beyond working with high school teachers and counselors on these issues, AHEC has sponsored several other projects. "We've [created]
experiential recruitment programs, including a program where students shadow working nurses [in their environment]l' says Brinson. AHEC has also sponsored summer camps and lectures to civic groups to help recruit nurses, and developed 29 new clinical sites so nurses can
practice. Many minority groups and males have been approached to whet their interest in the field. "We're stereotypically a female professionl' laments Brinson. "We are still about 95 percent femalei'To help retain nurses, a selfstudy refresher course has been devised, giving nurses who have inactive licenses or who have been out of the profession for as many as five years a chance to reenter. More than 10,000 junior and high school students, as well as nurse aides, and adult civic groups have received information about nursing. AHEC wants a nurse, one
to make sure that when you
will be there for you.
I
need
AHEG Spotlights by Dottie Horn
FAHEC Responds
to AIDS
fessionals such as firefighters and police officers who are first on the scene in an emergency. As they often provide the initial health care to
hen the N.C. Assembly passed a law requiring AIDS education in public junior high and high schools beginning in 1987, Fayetteville and surrounding counties turned to the Fayetteville Area Health Education Center (FAHEC). While performing AHEC's primary mission of educating health professionals, Dr. Charles Ellenbogen, Director of Internal Medicine at FAHEC, leads AHEC in this new direction as well. In 1987, most health care providers did not have sufficient expertise to provide AIDS education, so Ellenbogen gave talks to area high school students. He now trains schoolteachdrs
to provide AIDS education
them-
selves. "Over the last seven years, as the AIDS
willing to give an educational talk at a school or a local civic organization. "But, now you come t0 AIDS, and the doctors in the com-
emergency victims, first responders are at risk
munity don't feel comfortable talking about it.
for HIV infection, and North Carolina law requires that they learn how to protect themselves. [n addition to speaking to groups of first responders, Ellenbogen developed a manual for them that includes protective strategies and statistics on risk. Cumberland County, in the
They're worried, for example, that if they talk about AIDS that they're going to get identified as an AIDS doctorl' Some physicians fear that, if this happens, patients will stop seeing them,
FAHEC area, paid
is readily available in the scientific press, AIDS
to have 350 copies of the manual printed for distribution to its firstresponder employees. Ellenbogen also responds
t0 requests from other community organizations and speaks several times a month to such groups as the PTA, community college classes and professional and church groups.
The community's need for expert informa-
tion is coupled with a need for emotional
though this would not necessarily happen, says Ellenbogen. Although information about AIDS is so emotion-laden that physicians are frightened about learning, says Ellenbogen. "You have got to have time, interest, and courage to accumulate information about AIDSI' In addition to the emotional content,
AIDS-which is many different diseases and problems requiring separate treatments-is medically complex. Because of both factors, physicians caring for AIDS patients may be intimidated. Ellenbogen realized there was a need for a manual after numerous physicians
in the FAHEC area called for a consultation: "[ would get a phone call from a doctor who would say, 'l have a patient, and ['m pretty sure it's AIDS, and I want you to accept the patient in transferl I'd say, 'Fine, I'd be more than willing to do that, but only after we talk about
it,
because chances are good
you'll
be
of it yourselfl [And] at least half the time, once we'd talked about it, the abie to take care
physician realized, 'l can handle this, I can do Ellenbogen soon realized: "There wasn't a huge number of questions that came up. There were maybe 10 or 15 basic issuesl' Ellenbogen's pocket-size manual addresses clinical, psychosocial and legal issues associated with the treatment of AIDS and the protection of
it here."'
health care providers. Designed for bedside 0r emergency r00m use, the outline format of Ellenbogen's manual allows the physician to quickly determine which drug and what dosage to use. The text also serves as a curriculum Dr. Charles Ellenbogen of the Fayetteville AHEC developed a manual for rescue workers at risk for AIDS.
problem has become more pervasive, increased interaction with the public has become a more accepted part 0f the AHEC operationl' says
support. Says Ellenbogen, "AIDS is inherently marked by bigotry, prejudice and discomfort. How many diseases have there been in which
Ellenbogen.
the state legislature had to specifically state, 'No, doctor, you may not test for this without getting the patient's consentl There aren't any othersl' With most diseases, says Ellenbogen, any community doctor would be qualified and
The school system, however, proved only one of many community groups seeking information about AIDS. Law enforcement agencies wanted him to speak
to "first respondersl'
pro-
in AIDS for
the
family medicine residents at the Cape Fear Valley Medical Center in Fayetteville. Five hundred copies of the first edition, printed in January 1990, have been distributed-many free of charge to physicians and hospitals in FAHEC counties; an updated second edition became available
in January
1991.
This demand for Ellenbogen's manuals shows that FAHEC not only serves AHEC's traditional clientele, but breaks new ground in serving
community education needs as
well.
I
t5
aHEc spotligh"
m A Specialist for AII
Seasons
Extending the Cutting Edge
amily medicine is a speciality whose residents are trained to treat everything from a broken leg to heart disease. Nevertheless, when it comes to serious health problems, such as heart failure, shock and stroke, many laypersons as well as doctors think that physicians specializing in internal medicine do a better job. Dr. Marjorie Bowman disputes this notion. As professor and chair 0f the Depart-
ment of Family and Community Medicine at the Bowman Gray School of Medicine, Bowman helps train Northwest AHEC s family practice residents. Along with Dr. Patricia McGann, assistant professor in the same department, Bowman found that family physicians provide care similar in outcome and less expensive than that provided by internists, physicians who specialize in internal medicine. Bowman and McGann used the MedisGroups database, specifically designed
for studying the
quality of medical care. They selected data from 30 hospitals, balanced by geographic region, size and profit or non-profit status. From each hospital, the researchers obtained an abstracted record for each inpatient over the age of 65 who had one of l0 major problems such as heart failure, shock or stroke and was the patient of either a family practitioner 0r an internist. Bowman and McGann obtained abstracts from 10,353 admissions to internists and 5,473 admissions to family practitioners. Each abstract contains a series of medical observations, called key clinical findings, such as
the oxygen level in the blood, x+ay findings and blood pressure readings. Based on these key clinical findings, the MedisGroups system assigns each patient an admission severity score. The abstracts also contain information about the patient's outcome, during their hospital stay, noting either the patient's key clinical findings
at discharge or the patient's death. AIter grouping patients by their admission-severity rate, the researchers compare within each group the percentage of family physicians and the percentage
oI internists whose patients died. The
death
rate was slightly, though not significantly, higher for the patients of family physicians. Also,
within each severity group, Bowman and McGann compare the percentage of family physicians and the percentage of inlernists whose patients had a poor outcome. Poor outcome means that the
I clinician working in a rural community f! health center, for reasons of time, funds I land proximity, often has limited access to
patient either dies or has key clinical findings at discharge which indicate serious disease. Again, no significant difference between family physicians and internists was found. The mortality rate may be higher in patients of family physicians, says Bowman, because family physicians' patients were older and sig-
nificantly sicker at admission. Although family physicians' patients were only about half a year older on average, studies show that, in patients over 65, the odds of dying increase by 2 percent to 5 percent with each year of age. While there was no significant difference
in the outcome of the two specialties'
care,
their costs did differ significantly. Comparing only charges billed by the hospital, Bowman and McGann found that care provided by internists
on average cost 2 percent more. While many physicians already consider treatment by family doctors cost effective, Bowman says, they only had reports from health maintenance organizations to substantiate their impressions. Bowman's work is one of the first studies to show this relationship, namely, that family physicians not only provide effective care, but provide it cost effectively.
I
continuing education programs. As a result, clinicians may feel unsupported and ill-equipped to use their field's cutting-edge insights. ln a cost- and time-effective way, Catherine Tedder, Director of Mental Health Education and Special Projects for Area L AHEC, lessens the professional isolation of mental health practitioners in the largely rural, five-county area surrounding Rocky Mount. Various North Carolina medical school or university faculty fly at least once a month to each of the three mental health centers of Area L t0 present three-hour continuing education sessions. Bringing faculty to the mental health centers, says Tedder, saves not only the staffs limited
training and travel allowances, but their time: "The therapists don't have to travel away from the center; they can be on calll'This arrangement also allows the staff to receive more individual attention than is possible at a conference. Tedder custom-designs each center's topics after assessing
therapists' needs. Between five and 20 therapists attend each session, allowing participants to
talk specilically about individual concerns. While sharing information and skills is the primary goal of this arrangement, support is a significant ancillary benefit. Therapists certainly benefit, but so do faculty members, who often carry back to the university information about cases
of special interest. The cutting edge extends in both directions. I
E,AYO
16
As Ye Sow. o
o
AHEC Research Support Bars Fruit by Scott Lowry
single organization. One solution used by AHEC is to help promising projects throughout the University, projects receiving
have a lump. Even if you do breast self-exams, you still need to have a mammogram and an exam by a physician each yearl' He reports that while the percentage of at-risk women
documentation project. Initiated a dozen years ago by Peter Curtis, professor of family medicine, with Jacqueline Resnick (now with the Department of Maternal and Child Health), the
most of their funding from traditional grant bit of support that AHEC can provide, such as seed money or expertise, helps researchers and the community many
receiving mammograms has increased over the past decade from 15 percent each year to about 35 percent, that is still far short of the national goal of 80 percent.
project was a response to the reluctance of other medical disciplines t0 accept the new field of family medicine.
times over.
The four-year project found some answers about why participation is so disappointing. With the cost of a mammogram as low as $50 and insurance more willing than ever to pay, few women cited cost as a major factor. Instead, lack of information among women and physicians was found to be a primary obstacle.
o one can do it alt alone-nor can
a
sources. The extra
Cultivating Awareness of Breast Cancer "Without the assistance of the AHEC people
in Greenville and Wilmington, this research simply couldn't have been donel' says Russell Harris about the New Hanover Breast Cancer Screening Program. An assistant professor in
the School of Medicine, he is a member of a UNC research team funded by the National Cancer Institute (NCI) which joins AHEC researchers, other physicians and community
members
in those two regions. The team inves-
tigates why women who would most benefit from screening exams and mammography all too often fail to get them. "Breast cancer is a terrible disease in this country;' Harris explains. "More than 40,000 women a year die of it. We think the high
in the United States probably results from something in the lifestyle, and yet incidence rate
it
has been very hard t0 tease apart exactly what that is. What we do know is that we have become very good at finding breast cancer early, when it's curable. Research has indicated that we could cure at least 30 percent of women
now dying of breast cancer. We're talking about more than 10,000 lives a yearl' But to save these lives, women must recognize the increasing importance of screening for breast cancer as they get older. "lf you're
of 50 in American society right now and a woman, then you are at risk for breast cancerl'warns Harris. "You need to go
Researchers therefore developed
a pilot program
in New Hanover County to get the word out to both groups. Education for the medical community, media campaigns, social events, speakers and special events were all part of the multifaceted campaign. One special event, Breast
Cancer Screening Week in May 1990, resulted in over 400 extra screenings among women of
the target age group. The NCI provided the funding for this success story, yet Harris credits AHEC with making it possible. "Unlike most states, in North Carolina the University and the community unite and say, 'This is a problem we want to solve together. We have the same interests, s0 let's think about how we can study this and learn from itl The AHEC people have a foot in both camps, so they can speak to both sides and help us work together. Their communities will thank Jorge Gonzales of the Wilmington AHEC and Donald Lannin of the East Carolina School of Medicine (who works with AHEC) because they will have actually contributed to the communities' healthl'
Seed Money
for Reprogramming
above the age
in and
have the screening even
if you don't
AHEC has also helped the medical school's Department of Family Medicine with some of its research programs, such as the resident
Eleanor Bentz, current project director, reports that the specialty of family medicine was born only two decades ago to fill a gap in the provision of primary care. Studies initiated by the federal government and the American Medical Association in the mid-1960s, she says, "found that many people, especially in rural
to medical care. Congress to this need in 1971 by passing the
areas, had no access responded
Health Manpower Bill which funded family practice residency training programs throughout the country. These programs provide family practice residents with three years of additional training beyond the M.D., so they have a lot more experience in more areas than the old general practitioner had after one year of internshipi' When the first graduates of UNC s Department began setting up practices in 1974, they discovered that their fledgling discipline was facing concerted resistance from established specialties throughout the country. Many specialists serving on hospital privileges boards felt threatened and were arbitrarily denying those in family medicine the right to admit patients to the hospital and to treat them there. "The boards were saying, 'We have no evidence
that you know how to perform this kind of procedure or that kind of procedurel " remembers Curtis, "so we needed to create a system t0 give our residents the facts about their experience,
to show that they'd done 60 or 70 deliveries or things like thati' Curtis and Resnick joined with Duke University's Samuel Warburton to study methods 0f residency documentation throughout the United States. This research resulted in a book reporting
o.R
N.D.E
their findings and in development of a documentttion program run on the University's mainframe computer. The department soon became a documentation clearinghouse for four family practice residency programs in the state,
but the project eventually began to stagger under the weight of its success. The mainframe was archaic; the mass of data each year absorbed
too many hours of work; communications with the other schools delayed processing. So Curtis requested a special grant from AHEC in 1987 to redesign the system for use on personal computers. Intrigued by the potential of such documentation for all medical specialties, AHEC provided the funds that allowed Curtis and Bentz to analyze eight years of data, determine what was necessary to get hospital privileges and streamline the program for PCs. Compared to the other documentation systems available, Curtis points out that this system is very easy to use, allowing users great freedom. "We were able to decentralize; each residency now runs its own systeml' he continues. "We've been able to use the feedback to change the educational experience, t0 get the
right kinds of teaching, to adjust the curriculum. It's also a quality control issue; it allows our residents to justify their skill to get privileges. There have been inquiries from other departments in the medical school wanting to use the system, and with its simplicity, it could be adapted for their usel'All this from a research prolect begun a decade ago to overcome suspicion about the newcomer. "lt's now a part of residency training herel' Curtis reflects, "and accepted as suchl'
f,elp with the Information f,arvest When Carl Bose was faced in 1987 with a failing program in the Department of Pediatrics, he came up with a new idea to improve infant hospital care in North Carolina. The existing program, sponsored by the North Carolina Department of Health and Human Services (HHS), now the Department of Environment, Health and National Resources, sought to track scarce empty beds in the state's 1l neonatal intensive care units (NICUs) so that il one hospital had more critical infant patients than space, it could defer the request for the transfer of a new patient t0 a unit with an available bed. But all hospitals were frequently at capacity or not reporting empty beds to the computerized system for fear
s
So the associate professor in the Department's Division of Neonatal-Perinatal Medicine convinced HHS to redirect the funds t0 a new system to develop a database describing every instance of hospitalization
in these
NlCUs.
"l
had this idea that the state might benefit in the aggregate and each might benefit individually from this computerized collectionl' Bose explains. "lndividually, there is a tremendous need for review of data within each unit for a variety of reasons: for reports, lor quality assurance,
for documenting level of service, to
identify the flow of patients, to review your resources and how you are using them. [0n a statewide level,] we can focus health care planning better by examining data like this. [For example,] we found that there's a tremendous flow of neonatal patients out of the Northeastern part of the state into the Piedmont area because they can't get care therel' The database also provides raw material and background for research. The information gathered has been used in state efforts to prevent premature births, and could also contribute to its endeavors
to better understand birth
defects.
The four-year history of the program has not been without problems. "l began as a novice in developing the program, and I made a few mistakes in planningi' Bose remembers. "[But] Deborah Covington in the Wilmington AHEC was extremely helpful and had some good suggestionsl' Getting the project underway in 11 different NICUs was also difficult. Some had computers and experience to use them, but in most locations Bose had to provide virtually a complete starter package. 0nce again, AHEC was able to lend a hand, providing transportation for distribution of equipment and software. "We would have had a tough time doing it without thatl' he smiles. The main problem is finding the resources to collect and record the data at each location. "With 11 different centers across the state and
a salaried person at every center, you're talking about a quarter of a million dollars a yearl' says Bose. "We don't have that kind of money, so it's a matter of convincing [the hospitals] that there is an advantage for them. Most of
The North Carolina AHEC has helped deliver com. munity benefits ranging from public education programs to medical education documentation projects to databases describing neonatal intensive care.
The loss is more than that represented by their percentage of North Carolinas neonatal ICU cases. "For 1989, we had a full year of data for every admission to every NICU in the state.
lt
was a descriptor of
all such patients, which
really cannot be matched anyr,vhere in the countryi' Such a complete network can provide the full picture essential to both state policymaking and to research. "The '90s are the era of datal' concludes Bose. "People
who have data are going to
be
the ones with power. Health care planning will not be done properly unless we understand what the issues are, and we cannot do that without precise informationl' Recognizing the critical importance of collecting, analyzing and sharing the latest in medical information, the North Carolina AHEC reaps the greatest medical benefits by cultivating a wide variety of University projects throughout the state.
I
the people who are really using the program see the value, so they've identified some sort of resource, even if it's come out of their own pocketsi' Bose's greatest disappointment is that two centers stopped participating two years ago.
that their own facilities would be overwhelmed. Illustration by Scott Lowry and
Be[y P Llo(
!...<n't';:;:1:;:i:;:;:;:;:i:iii!i:i:;:;:;:;:;:;:;:;:
l8
Antibody Building Developing a Hib Meningitis Vaccine
by Dottie f,orn _a
E
=
1| n infection of the meninges, the memA brun., that envelop the Srain and spinal fl.oro. menrngl.s cause. 0y rne naem.philus influenzae type b (Hib) bacteria affects as many as 15,000 children every year in the United States, most of them infants between 6 and 15 months of age. Although Hib meningitis can be successfully treated with antibiotics, 25 percent t0 35 percent of those cured of the infection have complications such as deafness, mental retardation and seizure disorder. Because these complications are severe, scientists have worked for decades to develop vaccines against
the Hib bacteria. These efforts have paid olf: last year, two Hib vaccines-the Hib-TITER and Ped Vax Hib-were licensed by the Food and Drug Administration. Dr. James C. Parke, Chair of the Department of Pediatrics at the Charlotte AHEC, joined in 1989 by Dr. Davrd Rupar, Pediatric Infectious Disease Specialist at the Charlotte AHEC, has been a part of this more than 20-year effort to create vaccines for infants against the Hib bacteria. Although the availability of other Hib vaccines means his work has been scaled down, Parke continues in a project likely to result in licensure of another Hib vaccine, called the Hib-TT. Although the Hib bacteria causes infections other than meningitis, including bloodstream infection, 60 percent of Hib infections are meningitis. Because meningitis is more prevalent and its complications are more severe, preventing this disease has been the main goal of Parke and Rupar's research. Preventative efforts have focused on vaccination, which typically involves, says Rupar, injection 0f part 0f the capsule of the disease-causing organism. In response to the capsule, a person produces antibody, which fights off infection from that particular bacteria. Parke first studied a vaccine, developed by pediatricians John B. Robbins and Rachel Schneerson at the National lnstitute of Child Health and Human Development (NICHD), formed from the capsule of the Hib bacteria. Between
March 1974 and March 1976, Parke vaccinated
lw
Eil
D
oRS
Also following immunization, Parke tested antibody levels in the blood, as well as the blood's bactericidal, or bacteria-killing, power. "You take the patient's serum and put in the
Hib bacterial' says Rupar, "to see how well the Hib survives in that serum, and to see if the serum kills it. Then you see how many times you can dilute the serum and still have it killl'
A bacteriologic study tests whether the antibody kills the bacteria, or, in other words, whether the antibody is worth having. Parke's pilot study showed that the vaccine does produce antibody, and that the antibody does kill the Hib bacteria. However, one factor could complicate the success of the Hib-TT vaccine-maternal antibody. "During pregnancyl' says Parke, "the
infant receives antibody through the placenta. Different babies receive different levels, which disappear in varying periods of time, by about 2 months to 3r/l monthsl' Whether this maternal antibody suppresses the infant's production of Parents at 37 community sites. including physicrans'offices and health department clinics, agreed infants participate in Dr. James Parke's study
to have their
approximately 8,000 children, ranging in age from 2 months to 5 years. Following immunization, he measured antibody levels in the
study to see whether the vaccine was safe in infants and whether it produced sufficient antibody against the Hib bacteria. He vaccinated 77
infants' blood. He also followed the infants to if they developed Hib disease. This study showed, says Parke, that the vaccine did not prevent meningitis, but for patients 2 years or
infants with a series of shots given at ages 5, 7 and l8 months. To study the vaccine's safety, Parke had parents reCord, after each
see
older a single injection provided some protection. The infants did not produce sufficient antibody, says Rupar, because the capsule
of the
3,
injection, their child's temperature and their own observations of the injection site. As no serious reactions were reported, Parke deemed the vaccine safe.
his or her own antibody in response t0 a vaccine needs further clarification. To $udy this question, Parke draws blood from the infants before the initial immunization at 2 months. Parke can thus gauge how much antibody the infant has received from its mother. Based on these levels, he divides infants into those with "high" and "low" antibody levels. The difference between the two groups' antibody levels is statistically significant. He then studies the two groups' response to vaccination with the Hib-TT vaccine. Following the first two injections, the antibody levels of the "high" group were about one-half those of the "low" group. After the
Hib bacteria, and thus the vaccine, was made
up of a complex sugar called a polysaccharide. The infant's immune system, particularly the T cells, only gradually becomes responsive to sugars as the infant ages, says Parke. The T cells are the memory cells, "the part that remembers the rnvading substance from the last time, is ready and knows how to respond to itl' says Rupar. When you inject infants with a sugar, "you may get a little bit of a response,
but it drops off, and a couple of months later, it's like you never saw it before. And, you don't respond as well to begin with to a sugari'
After Parke's study, scientists worked to produce a more effective vaccine. Because they knew that proteins are "the best substance to induce an immune response in infantsl' re-
a protein to the sugar capsule of the Hib bacteria. "By combining searchers chemically attached
a sugar with a protein, you get a protein-like
it still works aqainst the capsule. It's tricking the immune system reallyl' says response. But, Rupar.
After Robbins and Schneerson developed new vaccine, the Hib:IT, Parke did a pilot
a
Hib meningitis, which mostly affects infants. can often have severe complications. Because the infant immune system differs from that found in adults, researchers sought a vaccine effective in this age group.
DE
20
vo if you give a HibiIITER vaccine after somebody has gotten the Hib:lT vaccine 0r one of the other brands of vaccine? Do they add to each other or not? That's another question we're consideringi' The researchers plan to finish immunizing yOu get a booster effect
all infants by December
1991. Happily, licensed
vaccines are already helping to prevent men' ingitis. Parke's early research contributed to the development of those vaccines, and his current project with Rupar may yield another licensed vaccine against the Hib bacteria. Parke is particularly pivud that, since the initial project in 1974, community pediatricians have played a large part in his research. "[ have 30 physicians' offices and six health
department clinics participating in the studyl' says Parke. At each site, the physician or health department's staff gives patients the information, gets the paperwork done and gives the injections. By taking research to patients, not only are projects able to expand in scope, but they also meet AHEC's goal to reach out lo the
A parent comforts her baby after an injection. After going home, she will make recordings of the child's
community. Says Parke, "[t's what everybody
temperature and observe the iniection site.
would like to do in clinical researchl'
final immunization, however, the "high" group had higher antibody levels than the "low" group. Like most of the research on the topic, says Rupar, their data show no evidence that high levels of maternal antibody decrease an infant's response to the Hib:fT vaccine. Although they learned from the pilot study that the HibTT vaccine produced antibody that kitled the Hib bacteria, Rupar says this data is only a proxy for a test of the vaccine's efficacy. To document a vaccine's effectiveness, a scientist must show that, compared to subiects given placebos, vaccinated subiects develop signifi-
cantly fewer cases of disease. In September 1989, in collaboration with the NICHD, Parke undertook this sort of efficacy trial. He hoped
to enroll 10,000 infants.
0n 0ctober 4, 1990,
however, another
vaccine against the Hib bacteria was licensed by the Food and Drug Administration. This vaccine, the Hib:llTER, is also composed of
a
infants who received the Hib-TT vaccine can either stay with the investigational vaccine or switch to the licensed vaccine. Rupar says he initially doubted that parents would have their infant stay with the investigational vaccine. However, he says, "they've overwhelmingly wanted to stay with the Hib:ITl' Rupar speculates that parents feel part of the study: "Parents understand that the study has potential importance and they want t0 stay with it. They know that the vaccine was well tolerated by their child. Since it's coming heavily through their private physicians, I think
they trust their doctorsl' Before the initial immunization, and each time an infant comes in for his or her next vaccine, the researchers draw blood and measure the amount of antibody the infant has produced. Says Rupar, "lf our vaccine gets an equivalent antibody response to the approved vaccine, then we will assume it to be of ap-
sugar capsule attached to a protein, but one attached to a different protein. Licensure of the Hib-TITER vaccine meant that Parke's project had to be modified: "Once
proximately equal efficacyi' ln addition, says Rupar, they are comparing the two vaccines to see which one gets the quickest antibody
you have a licensed productl' says Parke, "it's no longer ethical to use a placebo in an efficacy trihll' tn addition, as an effective vaccine is now available for use with infants, the need for the study is no longer as urgent. For these reasons, Parke's study has been scaled down and modified. Only the 2,000 infants enrolled prior to licensure of the HibTITER vaccine will continue in the study. Those infants who had received placebos will now receive the Hib:llTER vaccine. Those
in this
response. Bacteriologic tests
will not be
done
study, says Rupar, because the antibody's
killing power was demonstrated in the pilot study.
The modified study has also created a new population of interest: those infants who, having received the HibjIT vaccine, switch over to the licensed vaccine. Says Rupar: "We're getting blood samples from them to see what happens in the real world. When someone moves, they may go from one place that uses one vaccine to another place that uses another vaccine. Do
!
The research in progress discussed in this article is supporled in full by $657,185 from the National Institute 0f Child Health and Human Development.
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Photo by
\flill
Owens