A chronic obstructive pulmonary disease (COPD) project was initiated at 18 primary care clinical practices located in rural areas of northeastern Maine to improve the diagnosis and treatment of patients with COPD through the adoption of evidence-based and best practice clinical guidelines for care management. Clinical guidelines based on the Global Initiative for Chronic Obstructive Lung Disease (GOLD) were implemented by the practices using the Institute for Healthcare Improvement Breakthrough Series learning session model. Practice barriers and patient barriers were identified through focus groups and were then addressed at the learning sessions and through direct contact with the practices. To evaluate the improvements that were a result of the project, changes in clinical practice and patient care were measured pre and post initiative. The greatest improvements in COPD patient care were in the areas of smoking cessation counseling, annual influenza vaccinations, discussion of self-management goals, and diet/exercise counseling. Participants reported that the collaborative nature of the project allowed for mutual learning, provided teams with support to identify and overcome barriers, and fostered teamwork to find solutions to shared problems.

Discussions of the delivery of mental health care in rural areas tend to focus on system-level issues, including parity, historic barriers between physical and mental health systems, the growing role of managed care, the traditional separation of funding streams, and the shortage of qualified mental health providers willing to practice in rural areas. Although these public policy issues deserve attention, they are not particularly amenable to local solutions. In these system-level discussions, the needs of rural consumers and providers are often overlooked, and attention is diverted from the development of local-level solutions to the problems of rural mental health delivery systems.In this chapter, we suggest an alternative perspective, that of the public health model, to inform the discussion of delivering mental health services in rural areas. Within the context of the public health model, we take a broad view of mental health services that includes both a mental health orientation and a mental illness orientation. We describe the de facto rural mental health system, discuss the populations served by the existing systems and their service needs, identify access issues and barriers for these populations, and provide a series of tools with which stakeholders can begin to analyze their local delivery system. By doing so, stakeholders will develop a context for understanding how the various components of the system fit together. These tools will enable stakeholders to identify the multiple points of access within their community, to categorize those access points according to a logical framework, and to identify the clinical roles and functions of the various providers, agencies, and organizations that constitute their local mental health system. Within this context, we suggest opportunities to improve and integrate existing components of local mental health delivery systems in rural areas to better meet the needs of the people served by them. Elements of the Public Health ApproachPublic health focuses on the diagnosis, treatment, and etiology of disease; epidemiological surveillance of the health of the population at large; health pro-

The purpose of this study was to determine the prevalence and sex ratio of localized juvenile periodontitis (LJP) cases in a selected Saudi population, to compare these values with different societies, and to correlate the sex ratio with the presence of Actinobacillus actinomycetemcomitans in the afflicted sites. In a retrospective study over a 3‐year period 23 cases of LJP were diagnosed from a group of 5,480 subjects with different forms of periodontal disease. The overall prevalence was 0.42%. The female to male ratio was 1.88:1. The difference in the sex ratio was statistically significant (X = 5.490, P <.05). No statistically significant difference in the sex ratio association regarding the sites afflicted by Actinobacillus actinomycetemcomitans was found. J Periodontol 1994;65:698–701.

Databases were useful for estimating asthma burden and identifying service needs as well as high-risk groups. They were less useful in estimating severity or in identifying environmental risks.

In this population-based study of asthma in the State of Maine, the authors investigated how often asthma symptoms were exacerbated in the workplace. Participants from 5 hospital service areas in Maine completed a telephone questionnaire. Of 474 adult participants (18-65 yr of age) employed during the preceding year and for whom information on occupation and industry was available, 64 (13.5%) were identified with current asthma, including 28 (5.9%) with current physician-diagnosed asthma and 36 (7.6%) who met criteria for symptoms consistent with asthma. Jobs were identified a priori as "high-risk" or "low-risk" for asthma. Of the 64 asthma cases, 16 (25%) reported that their coughing or wheezing worsened at work. Among the symptom-based cases, the percentage with workplace exacerbation of asthma was elevated for high-risk jobs (7/14 = 50%) vs. low-risk jobs (3/22 = 13.6%) (p = 0.03). No similar elevation was observed for individuals with current physician-diagnosed asthma, which might have resulted, in part, from a healthy worker effect.