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This paper describes an ethnographically-oriented participant-observation study conducted during the annual Crow Fair, held in south central Montana. Data collected included audio-recorded interviews with participants, participant observations, photographic and video recordings. Narrative interviews were transcribed and analyzed using the constant comparison method. Multiple data sources improved the veracity of this study through triangulation, and four themes emerged from the data: commercialization, alcohol abuse, spirituality, and community. The researchers discuss these themes and their conclusions regarding the "selling" of Native American culture as a form of cultural transmission. Theme analysis revealed the researchers recognized that the principal researcher had changed his view of the Crow Fair as being frivolous to having a deeper purpose and meaning to participants.

Purpose: To evaluate the feasibility of translating the Diabetes Prevention Program (DPP) lifestyle intervention into practice in a rural community. Methods: In 2008, the Montana Diabetes Control Program worked collaboratively with Holy Rosary Healthcare to implement an adapted group-based DPP lifestyle intervention. Adults at high risk for diabetes and cardiovascular disease were recruited and enrolled (N = 101). Participants set targets to reduce fat intake and increase physical activity ([greater than or equal to]150 mins/week) in order to achieve a 7% weight loss goal. Findings: Eighty-three percent (n = 84) of participants completed the 16-session core program and 65 (64%) participated in 1 or more after-core sessions. Of those completing the core program, the mean participation was 14.4 [plus or minus] 1.6 and 3.9 [plus or minus] 1.6 sessions during the core and after core, respectively. Sixty-five percent of participants met the 150-min-per-week physical activity goal during the core program. Sixty-two percent achieved the 7% weight loss goal and 78% achieved at least a 5% weight loss during the core program. The average weight loss per participant was 7.5 kg (range, 0 to 19.7 kg), which was 7.5% of initial body weight. At the last recorded weight in the after core, 52% of participants had met the 7% weight loss goal and 66% had achieved at least a 5% weight loss. Conclusion: Our findings suggest that it is feasible to implement a group-based DPP in a rural community and achieve weight loss and physical goals that are comparable to those achieved in the DPP.

Purpose: To assess stroke knowledge and practice among frontier and urban emergency medical services (EMS) providers and to evaluate the need for additional prehospital stroke training opportunities in Montana. Methods: In 2006, a telephone survey of a representative sample of EMS providers was conducted in Montana. Respondents were stratified into 2 groups: those working in urban and frontier counties. Findings: Compared to EMS providers from urban counties, those from frontier counties were significantly more likely to be older (mean age 44.7 vs 40.1 years), have fewer personnel working in their service (mean 17.7 vs 28.6), to be located farther away from a computed tomography scan (CT scan) (mean 41.3 vs 17.6 miles), and to be volunteers (84% vs 49%). They were also less likely to have a stroke protocol (58% vs 66%) and use a stroke screening tool (36% vs 47%) than their urban counterparts. There were no significant differences between frontier and urban EMS respondents' ability to correctly identify 4 or more stroke warning signs (58% vs 61%), 4 or more stroke risk factors (46% vs 43%), or the 3-hour recombinant tissue plasminogen activator (rt-PA) treatment window (56% vs 57%). Approximately two thirds of respondents from urban and frontier counties believed they had adequate stroke knowledge, but 90% indicated they were interested in additional stroke-related training. Conclusions: Although stroke knowledge did not differ between urban and frontier groups, stroke screens and stroke protocols were less likely to be used in the frontier areas. Training opportunities and the implementation of stroke protocols and screening tools are needed for EMS providers, particularly in frontier counties.

Context: Rapid diagnosis and treatment of ischemic stroke can lead to improved patient outcomes. Hospitals in rural and frontier counties, however, face unique challenges in providing diagnostic and treatment services for acute stroke. Purpose: The aim of this study was to assess the availability of key diagnostic technology and programs for acute stroke evaluation and treatment in Montana and northern Wyoming. Methods: In 2004, hospital medical directors or their designees were mailed a survey about the availability of diagnostic technology, programs, and personnel for acute stroke care. Findings: Fifty-eight of 67 (87%) hospitals responded to the survey. Seventy-nine percent (46/58) of responding hospitals were located in frontier counties, with an average bed size of 18 (11 SD). Of the hospitals in frontier counties, 44% reported emergency medical services prehospital stroke identification programs, 39% had 24-hour computed tomography capability, 44% had an emergency department stroke protocol, and 61% had a recombinant tissue plasminogen activator protocol. Thirty percent of hospitals in frontier counties reported that they met 6-10 of the criteria established by the Brain Attack Coalition to improve acute stroke care compared to 67% of hospitals in the nonfrontier counties. Conclusion: A stroke network model could enhance care and improve outcomes for stroke victims in frontier counties.

Improved preventive care and clinical outcomes among patients with diabetes can reduce complications and costs; however, diabetes care continues to be suboptimal. Few studies have described effective strategies for improving care among rural populations with diabetes. In 2000, the Park County Diabetes Project and the Montana Diabetes Control Program collaboratively implemented a countywide effort, which included health systems interventions and coordinated diabetes education, to improve the quality of diabetes care. Clinical data from the diabetes registries in 2 primary care practices, in addition to baseline and follow-up telephone surveys, were used to evaluate improvements in care, outcomes, education, and barriers to self-management. In the cohort of patients, the proportion receiving the following services increased significantly from 2000 to 2003: annual foot examination (43% to 58%), influenza (30% to 53%), and pneumoccocal immunizations (39% to 70%). The median hemoglobin A1c values decreased significantly from baseline to follow-up (7.2% to 6.8%). Mean systolic and diastolic blood pressure decreased significantly over the 2 time periods (139 mmHg to 135 mmHg, and 78 mmHg to 75 mmHg, respectively). Significant decreases were also observed in barriers to self-management, including lack of knowledge (decrease from 12% to 5%), difficulties making lifestyle changes (36% to 27%), cost of monitors and test strips (25% to 16%), cost of medications (37% to 24%), and diabetes education (22% to 4%). Findings suggest that system changes in primary care practices and the implementation of accessible diabetes education can improve care and reduce barriers for rural patients with diabetes.

Objectives To compare participation, self-monitoring behaviors, and weight loss outcomes in older and younger participants in an adapted Diabetes Prevention Program (DPP) lifestyle intervention. Design Pre- and postevaluation of outcomes in participants enrolled in the Montana Cardiovascular Disease ( CVD) and DPP lifestyle intervention from 2008 through 2012. Setting Community. Participants Adults at high risk for CVD and type 2 diabetes mellitus (N = 3,804). Measurements Number of core (16 weekly sessions) and postcore (6 monthly sessions) intervention sessions attended, weekly self-monitoring of fat intake and minutes of physical activity, weight loss outcomes and achievement of the weight loss goal, and improvements in CVD-related risk factors. Results Participants aged 65 and older were significantly more likely to attend more intervention sessions, self-monitor their fat intake, and achieve the physical activity and weight loss goals than those younger than 65. Older and younger participants experienced significant improvements in CVD-related risk factors. Conclusion Older adults at high risk of CVD and diabetes mellitus participating in an adapted DPP lifestyle intervention had higher participation and self-monitoring rates than younger participants, were more likely to achieve physical activity and weight loss goals, and achieved similar CVD risk reduction. [ABSTRACT FROM AUTHOR]

Background. Prudent antibiotic prescribing practices are essential to limiting antibiotic resistance. Objective. To assess the trend in percentage of office visits for acute respiratory infections (ARIs) linked with an antibiotic prescription. Methods. Retrospective analysis of Montana Medicaid billing claims data for each year, 1999 to 2010, was done. Participants included continuously enrolled children aged ≤14 years. Primary outcomes were ARI-related office visits and filled antibiotic prescriptions within 10 days of the office visit. Results. Of the 873 244 office visits identified, 116 962 (13%) had an ARI as the primary diagnosis. Among ARI-related office visits, 64 250 (55%) were linked with an antibiotic prescription. From 1999 to 2010, the odds of ARI-related visits being linked with an antibiotic prescription did not change (odds ratio = 1.00; 95% confidence interval = 0.995-1.002). Conclusions. The percentage of ARI-related visits linked with an antibiotic prescription did not decrease from 1999 to 2010. Further efforts are needed to reduce antibiotic treatment for ARIs. [ABSTRACT FROM PUBLISHER]

The article focuses on a study which examined the potential of a state-generated recall letter to boost vaccination coverage among children in Montana. 47% of children enrolled in Montana Medicaid were eligible for study participation. Results of the study showed that 32% of children whose parents received the letters had completed the vaccination series. The study recommends further investigation on the limited effectiveness of the recall letter in improving vaccination coverage.

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Abstract: Developments and improvements of remedial technologies are needed to effectively manage arsenic contamination in groundwater at hazardous waste sites. In June 2005, a 9.1 m long, 14 m deep, and 1.8 to 2.4 m wide (in the direction of groundwater flow) pilot-scale permeable reactive barrier (PRB) was installed at a former lead smelting facility, located near Helena, Montana (USA). The reactive barrier was designed to treat groundwater contaminated with moderately high concentrations of both As(III) and As(V). The reactive barrier was installed over a 3-day period using bio-polymer slurry methods and modified excavating equipment for deep trenching. The reactive medium was composed entirely of granular iron which was selected based on long-term laboratory column experiments. A monitoring network of approximately 40 groundwater sampling points was installed in July 2005. Monitoring results indicate arsenic concentrations >25 mg L−1 in wells located hydraulically upgradient of the PRB. Of 80 groundwater samples collected from the pilot-PRB, 11 samples exceeded 0.50 mg As L−1; 62 samples had concentrations of arsenic at or below 0.50 mg L−1; and, 24 samples were at or below the maximum contaminant level (MCL) for arsenic of 0.01 mg L−1. After 2 years of operation, monitoring points located within 1 m of the downgradient edge of the PRB showed significant decreases in arsenic concentrations at depth intervals impacted by the emplaced zerovalent iron. This study indicates that zerovalent iron can be effectively used to treat groundwater contaminated with arsenic given appropriate groundwater geochemistry and hydrology. The study also further demonstrates the shortcomings of hanging-wall designs. Detailed subsurface characterization data that capture geochemical and hydrogeologic variability, including a flux-based analysis, are needed for successful applications of PRB technology for arsenic remediation. [Copyright &y& Elsevier]

Abstract: Aims: To assess attitudes, barriers and practices of clinicians in assessing and treating cardiometabolic risk in overweight adults. Methods: In 2006, primary care physicians and mid-level practitioners in Montana were surveyed (N =430). Results: Most primary care clinicians (95%) recognized the clinical benefit of weight loss, but many cited patient motivation (87%), lack of support services (61%), and lack of time (58%) as barriers. Over 80% identified obesity, hypertension, abnormal lipids, history of gestational diabetes, and family history as indications for diabetes screening. Most clinicians used fasting glucose (89%), random glucose (58%), and A1c (42%) as initial screens for diabetes. To confirm the diagnosis, the majority of respondents used A1c testing (80%) or fasting glucose (64%). Approximately one-quarter used the diagnosis pre-diabetes (26%), but just over half (52%) used alternative diagnoses of glucose intolerance. Sixty-five percent used the diagnosis of metabolic syndrome. Of those using metabolic syndrome, mid-level practitioners were more likely than physicians to assess waist circumference (49% vs. 63%). Conclusions: Despite citing significant barriers, clinicians routinely assessed cardiometabolic risk with diabetes screening, but relatively few reported using the diagnosis pre-diabetes. Metabolic syndrome was used commonly to diagnose overweight adults at risk for diabetes and cardiovascular disease. [Copyright &y& Elsevier]

Objective: The paper provides an overview of a strategy to increase utilization of online bibliographic databases by public health workers. Methods: A web-based survey of professional staff in the Montana Department of Public Health and Human Services was conducted to assess their use of and interest in training in online bibliographic databases. Based on the findings from the assessment, the department, in collaboration with the state university, provided brief ninety-minute training sessions for interested staff on the use of PubMed. Results: Seventy of 115 (61%) of staff completed the survey. Only 39% of staff reported using an online bibliographic database to conduct a literature search in the past year, and only 10% (n=7) reported having ever received any training in their use. Perceived proficiency with the use of PubMed was higher upon completion of the brief training. The majority of training participants (n=27) indicated that they were very likely to use PubMed in the next year to search the literature. Conclusions: A collaboratively designed training can increase public health workers' proficiency in and intentions of using online bibliographic databases. [ABSTRACT FROM AUTHOR]

Objectives: The purpose of this study was to assess trends in diabetes in pregnancy in American Indian and whites mothers in Montana and North Dakota. Methods: Montana and North Dakota birth records were utilized to assess trends in any diabetes in pregnancy in American Indians and whites from 1989 to 2000. Results: From 1989 through 2000, there were 133,991 and 102,232 births in Montana and North Dakota, respectively. The majority of mothers were American Indian (11%) or white (87%). The rate of any diabetes in pregnancy increased significantly in Montana Indian (3.1–4.1%, p = 0.04) and white mothers (1.8–2.6%, p < 0.001) from 1989–1991 to 1998–2000. The rate also increased significantly in white North Dakota mothers (1.6–3.2%, p < 0.001), but the increase in rate for Indian mothers in North Dakota did not reach statistical significance (3.8–4.8%, p=0.06) during this time period. In each time period, Montana and North Dakota Indian mothers were more likely than white mothers to have any diabetes in pregnancy. Conclusions: The rate of diabetes in pregnancy has increased in American Indian and white mothers. Thus public health programs are now facing an increasing number of women with a history of GDM at future risk of type 2 diabetes and an increasing number of offspring of diabetic pregnancies at risk for becoming overweight and developing type 2 diabetes at a young age. [ABSTRACT FROM AUTHOR]

Compares the prevalence of cigarette smoking and smoking cessation between American Indians and non-Indians living on or near Montana's reservations. Background of some clinical guidelines for smoking cessation; Information on cardiovascular disease caused by smoking; Rates of addictive smoking.

Focuses on the pneumococcal immunizations among people with diabetes. Coverage level of immunizations; Effectiveness of immunizations; Increase in the proportion of patients with a pneumococcal immunization.

Focuses on the results of a survey on the perceptions of Montana residents of the risk and prevention of type 2 diabetes. Subjects; Analyses of the results.

Background Unintentional death due to prescription drug-related poisoning has been a growing problem nationally. Some sub-populations have been shown to be at higher risk than others. Methods In 2014, we matched death records to Medicaid eligibility files to determine enrollment status at the time of unintentional death from prescription opioid poisoning from 2003 to 2012 in Montana. Medicaid prescription claims for decedents were used to assess prescribing patterns and time between refills. Results The age-adjusted mortality rate per 100,000 from opioid poisoning for adults aged 18–64 years and enrolled in Medicaid at the time of death was eight times higher than the rate for non-Medicaid Montana adults (38.2 [95% CI (30.7–45.7)] vs. 4.7 [95% CI (4.1–5.3)]). Twenty-eight percent of unintentional poisoning deaths during this time frame were among Medicaid members. Only 33% of the Medicaid decedents had a claim for an opioid prescription during the month before their death. Conclusion Our findings suggest that more needs to be done to address prescription opioid use in Montana. Adults enrolled in Medicaid continue to be at high risk for prescription opioid unintentional poisoning deaths. Data on prescribing practices suggest that there are opportunities to intervene and provide education on use of opioid medications for Medicaid members and prescribing providers. [ABSTRACT FROM AUTHOR]

Objectives: Previous studies suggested that the cancer incidence rates in American Indians and Alaska Natives were lower than in other groups. The objective of this study was to compare the cancer incidence rates in American Indians and whites in Montana. Methods: Age-adjusted 6-year cancer incidence rates were calculated for American-Indian and white men and women in Montana to allow comparison of rates in 1991–1996 to those in 1997–2002. Results: The age-adjusted rates for American-Indian men were significantly higher than those for white men for all cancer sites (755 ± 74 [95% confidence interval] per 100,000 vs 544 ± 9 per 100,000), lung cancer (167 ± 35 per 100,000 vs 83 ± 4 per 100,000), and colorectal cancer (115 ± 29 per 100,000 vs 61 ± 4 per 100,000) from 1997 to 2002. The adjusted rates for American-Indian women were significantly higher than those for white women for all cancer sites (526 ± 47 per 100,000 vs 412 ± 8 per 100,000) and lung cancer (120 ± 24 per 100,000 vs 56 ± 3 per 100,000) during this same time period. There was a significant increase in the age-adjusted rates for all cancer sites among white men and women but not for American-Indian men or women between 1991–1996 and 1997–2002. Conclusions: There is a significant disparity in the cancer incidence rates between American Indians and whites in Montana. Regional or state-level surveillance data will be needed to describe the changing patterns of cancer incidence in many native communities in the United States. [Copyright &y& Elsevier]

: BackgroundCardiovascular disease (CVD) and diabetes are prevalent and of major concern for American-Indian communities in the United States. Health professional counseling is effective in increasing patient awareness and inducing lifestyle modification. The objective of this study was to compare the prevalence of CVD, modifiable risk factors and counseling for smoking cessation, physical activity, and a healthy diet in adult American Indians with and without diabetes.: MethodsA random sample of adult American Indians living on or near the seven Montana reservations was interviewed through an adapted Behavioral Risk Factor Surveillance System telephone survey in 1999 (N=1000) and 2001 (N=1006).: ResultsRespondents with diabetes, compared to those without, had a significantly higher prevalence of CVD (27% vs 8%); overweight (89% vs 71%); high blood pressure (57% vs 24%); and high cholesterol (44% vs 22%). There were no differences for insufficient physical activity (60% vs 51%) or smoking (34% vs 41%) after adjustment for age, gender, and survey year. Respondents with diabetes, compared to respondents without diabetes, were significantly more likely to report health professional counseling for smoking cessation (83% vs 58%); physical activity (73% vs 37%); and reduced fat consumption (57% vs 24%).: ConclusionsThe prevalence of modifiable CVD risk factors was alarmingly high among adult American Indians with and without diabetes. Strategies to increase health professional counseling for healthy diet and smoking cessation are needed. [Copyright &y& Elsevier]

Advancements in molecular genetics have revealed that hybridization may be common among plants, animals, and fungi, playing a role in evolutionary dynamics and speciation. While hybridization has been well-documented in pathogenic fungi, the effects of these processes on speciation in fungal lineages with different life histories and ecological niches are largely unexplored. Here we investigated the potential influence of hybridization on the emergence of morphologically and reproductively distinct asexual lichens. We focused on vagrant forms (growing obligately unattached to substrates) within a clade of rock-dwelling, sexually reproducing species in the Rhizoplaca melanophthalma (Lecanoraceae, Ascomycota) species complex. We used phylogenomic data from both mitochondrial and nuclear genomes to infer evolutionary relationships and potential patterns of introgression. We observed multiple instances of discordance between the mitochondrial and nuclear trees, including the clade comprising the asexual vagrant species R. arbuscula, R. haydenii, R. idahoensis, and a closely related rock-dwelling lineage. Despite well-supported phylogenies, we recovered strong evidence of a reticulated evolutionary history using a network approach that incorporates both incomplete lineage sorting and hybridization. These data suggest that the rock-dwelling western North American subalpine endemic R. shushanii is potentially the result of a hybrid speciation event, and introgression may have also played a role in other taxa, including vagrant species R. arbuscula, R. haydenii and R. idahoensis. We discuss the potential roles of hybridization in terms of generating asexuality and novel morphological traits in lichens. Furthermore, our results highlight the need for additional study of reticulate phylogenies when investigating species boundaries and evolutionary history, even in cases with well-supported topologies inferred from genome-scale data.

Objectives To evaluate lifestyle change outcomes among women with and without a history of gestational diabetes mellitus (GDM) enrolled in the Montana Diabetes Prevention Program (DPP). Methods Participation, self-monitoring behavior, weight loss, and cardiometabolic risk reduction were compared among 5091 women at high-risk for type 2 diabetes, with and without a history of GDM, enrolled in the Montana DPP between 2008 and 2015. Results Women with a history of GDM (6% of enrolled women, n = 283) were significantly younger than women without GDM. No significant differences in participation, self-monitoring fat intake, achievement of the physical activity goal, or weight loss were found among women with and without a history of GDM. Overall, women lost an average of 5.0 kg (± 6.5), and 45 and 29% of women achieved 5 and 7% weight loss, respectively. Both groups lost significant and comparable amounts of weight. After adjusting for age and other factors, no differences were found in achievement of ≥ 5% weight loss (AOR 0.84; 95% CI 0.61-1.16) or the ≥ 7% weight loss goal (AOR 1.04; 95% CI 0.73-1.47) among women with and without a history of GDM. Conclusions for Practice Our findings suggest that women with and without a history of GDM successfully participate in and achieve significant weight loss in the DPP. Health care providers should identify and refer women with risk factors for type 2 diabetes, including a history of GDM, to a DPP within their community.

The Centers for Disease Control and Prevention, State and Local Health Departments, and other organizations in the USA are working to increase population access to the Diabetes Prevention Program (DPP) lifestyle intervention. Delivering the DPP through telehealth videoconference may increase access to this intervention, particularly in rural communities. The purpose of this study was to compare participation, monitoring of diet and physical activity, and weight loss in participants receiving the intervention on-site and those participating virtually through telehealth. Beginning in 2008, Holy Rosary Healthcare collaborated with the Montana Department of Public Health and Human Services to provide the DPP to participants on-site in one community and simultaneously through telehealth to participants in multiple other communities. From 2008 through 2015, 894 participants were enrolled in the program (29% at telehealth sites). The mean age of participants was 51.7 years and 84% were female. Overall, participants attended 14.4, 3.9, and 15.0 weekly core, post-core, and total sessions, respectively. There were no statistically significant differences in number of intervention sessions attended by the telehealth or on-site participants. There were no statistically significant differences in the mean weight loss or reduction in BMI between the telehealth and the on-site groups. There also were no statistically significant differences in the percentage of telehealth or on-site participants who achieved ≥5% weight loss (56 vs. 57%) or the 7% weight loss goal (38 vs. 41%). Our findings suggest that participants receiving the DPP through telehealth have similar rates of participation and achieve similar weight loss as participants attending the program on-site.

Benefis Medical Group, in Great Falls, Montana, improved identification and treatment of hypertension through multifaceted interventions. The interventions included adopting policies for collection of vital signs, enhancing system-level reporting capability, tracking patients for the registry, and conducting patient outreach activities. From baseline to follow-up (December 2012 through September 2013), the percentage of patients with a documented blood pressure increased from 67% to 80%, the percentage diagnosed with hypertension increased from 16% to 36%, and the percentage with blood pressure control increased from 41% to 64%. Benefis Medical Group plans to sustain the successful evidence-based strategies that were adopted.

Objective: The purpose of this study was to assess if group size is associated with weight loss outcomes among participants in an adapted diabetes prevention program., Methods: Adults at high-risk (N=841) for CVD and diabetes were enrolled in the lifestyle intervention in 2011. Multiple logistic regression analyses were used to identify if group size (smaller group<16 participants; larger group ≥16 participants) was independently associated with weight loss outcomes among participants., Results: In the bivariate analyses, participants in the smaller groups compared to those in the larger groups were significantly more likely to have a higher baseline body mass index, to attend fewer intervention sessions, and less likely to self-monitor their fat intake for ≥14 weeks, and to have lost less weight during the core intervention (5.1 kg [SD 4.7] versus 5.8 kg [4.5]). However, analysis adjusting for age, sex, baseline BMI, achievement of the physical activity goal, number of weeks self-monitoring fat intake, and group size, found only two factors to be independently associated with achievement of the 7% weight loss goal: frequency of self-monitoring of fat intake and achievement of the physical activity goal., Conclusions: Our findings indicate that intensive lifestyle intervention goals can be achieved as effectively with large or small groups., (Copyright © 2014 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.)

Introduction: National initiatives to improve the recognition of heart attack and stroke warning signs have encouraged symptomatic people to seek early treatment, but few have shown significant effects in rural American Indian (AI) communities., Methods: During 2009 and 2010, the Montana Cardiovascular Health Program, in collaboration with 2 tribal health departments, developed and conducted culturally specific public awareness campaigns for signs and symptoms of heart attack and stroke via local media. Telephone surveys were conducted before and after each campaign to evaluate the effectiveness of the campaigns., Results: Knowledge of 3 or more heart attack warning signs and symptoms increased significantly on 1 reservation from 35% at baseline to 47% postcampaign. On the second reservation, recognition of 2 or more stroke signs and symptoms increased from 62% at baseline to 75% postcampaign, and the level of awareness remained at 73% approximately 4 months after the high-intensity campaign advertisements ended. Intent to call 9-1-1 did not increase in the heart attack campaign but did improve in the stroke campaign for specific symptoms. Recall of media campaigns on both reservations increased significantly from baseline to postcampaign for both media outlets (ie, radio and newspaper)., Conclusion: Carefully designed, culturally specific campaigns may help eliminate disparities in the recognition of heart attack and stroke warning signs in AI communities.

Background: Coxiella burnetii is an endemic bacterial pathogen in the United States and the causative agent of Q fever. Two outbreaks of Q fever occurred in Montana during 2011, which led to the issuance of a health alert urging clinicians to test patients with Q fever-compatible illnesses for C. burnetii infection., Methods: We retrospectively evaluated the medical records of patients hospitalized for fever, pneumonia, chest pain, and viral infection of unknown etiologies during the two Q fever outbreaks and following the health alert., Results: A total of 103 patients were included in the analysis. Clinicians assessed<1% of patients suffering illnesses compatible with Q fever for known risk factors or C. burnetii infection. Only 1 patient had Q fever excluded as a diagnosis., Conclusion: Clinicians should assess for Q fever risk factors and consider the diagnosis in patients hospitalized with Q fever-compatible illnesses when the etiology of illness is unknown. Work is warranted to evaluate the effectiveness of current healthcare alert practices for zoonotic diseases.

Introduction: Most US studies on asthma prevalence have been conducted in urban areas, and few have assessed the prevalence of asthma among residents of rural areas versus urban areas. The objective of this study was to compare the prevalence of asthma among adults living in metropolitan versus nonmetropolitan counties in Montana., Methods: We analyzed data from 6,846 adult Montanans who completed the Behavioral Risk Factor Surveillance System survey in 2008. We used Rural-Urban Continuum Codes to categorize respondents' county of residence as metropolitan (Metro), nonmetropolitan and adjacent to a metropolitan county (NMA), and nonmetropolitan and nonadjacent to a metropolitan county (NMNA). We compared the prevalence of current self-reported asthma among respondents in the 3 areas, overall and by selected characteristics, and conducted multivariable logistic regression analyses to identify factors independently associated with current self-reported asthma., Results: No differences in the prevalence of self-reported asthma were found between residents of Metro and NMA or NMNA counties, overall or by age, sex, race, years of education, health insurance status, annual household income, or body mass index. Respondents aged 65 years or older (adjusted odds ratio [AOR], 0.7; 95% confidence interval [CI], 0.5-0.9) and men (AOR, 0.6; 95% CI, 0.5-0.8) were less likely to report current asthma than younger respondents and women, respectively. Obese respondents were more likely (AOR, 1.9; 95% CI, 1.4-2.7) to report asthma than were respondents who were not obese. Metropolitan county of residence was not independently associated with self-reported current asthma., Conclusion: The prevalence of self-reported current asthma is similar in metropolitan and nonmetropolitan counties in Montana, but other sociodemographic differences exist. Our findings highlight the need to conduct regional and state surveillance of asthma to understand the demographic risk factors associated with it and to determine the potential geographic variation of asthma prevalence in the United States.

Aims: To assess the factors associated with achieving the 7% weight loss goal among participants enrolled in an adapted Diabetes Prevention Program (DPP)., Methods: Adults at high-risk (N=989) for CVD and diabetes were enrolled in the lifestyle intervention. Multiple logistic regression analyses were used to identify factors associated with achieving the weight loss goal., Results: Overall 37% of participants achieved the weight loss goal. Participants who were older, male, had a lower baseline BMI, self-monitored their fat and caloric intake more frequently, and who achieved higher levels of physical activity were more likely to achieve the weight loss goal compared to participants without these characteristics. In multivariate analyses more frequent self-monitoring of fat and caloric intake and higher levels of weekly physical activity were the only factors independently associated with participant achievement of the weight loss goal., Conclusions: In a real-world translation of the DPP lifestyle intervention participants who achieved the weight loss goal were more likely to have monitored their dietary intake frequently and increased their physical activity markedly both in a dose-response relationship. Our findings highlight the importance of supporting participants in lifestyle interventions to initiate and maintain dietary self-monitoring and increased levels of physical activity., (Copyright © 2010 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.)

Objective: The purpose of this study was to assess the capacity of diabetes self-management education (DSME) programs in urban and rural counties to provide services to patients with diagnosed diabetes, lifestyle services to persons at high risk for developing diabetes, and to assess the potential barriers to providing diabetes prevention services., Methods: In 2009, the Montana Department of Public Health and Human Services conducted an Internet-based survey of all DSME programs in Montana., Results: Thirty of the 39 (77%) DSME programs completed the survey. Seventy-seven percent of the urban programs and 50% of the rural programs reported a capacity to provide DSME to additional patients with diagnosed diabetes. More than 70% of the urban and the rural programs currently provide lifestyle services to patients with abnormal glucose tolerance but without diabetes. Eighty-four percent of the urban programs and 60% of the rural programs reported a capacity to provide lifestyle services to additional persons at high risk for diabetes. Eighty-five percent of the urban programs and 58% of the rural programs have already implemented or intend to implement a lifestyle intervention service consistent with the Diabetes Prevention Program. Overall, the most frequently reported barriers to implementing a diabetes prevention services were lack of reimbursement (80%) and the lack of staff to provide the service (60%)., Conclusion: Urban and rural DSME programs in Montana have the capacity to implement both DSME for patients with diagnosed diabetes and diabetes prevention lifestyle services to additional people at high risk for diabetes. Reimbursement for diabetes prevention services is critical to ensure program development and implementation.

Background: Rural-urban gaps in stroke care remain challenging in part because of the lack of resources, personnel, and necessary infrastructure., Purpose: The purpose of this study was to assess changes in the acute stroke diagnosis and treatment capacity among rural hospitals before and after implementation of a regionwide stroke initiative., Methods: In 2004, the Montana Cardiovascular Health Program partnered with stroke stakeholders throughout the state and surveyed hospitals in Montana and northern Wyoming to assess the availability of technology, services, and personnel for acute stroke care. The Montana Stroke Initiative (MSI) developed protocols, educational material, and stroke awareness campaigns to address the geographic disparities identified in the survey. From 2004 to 2006, protocols and educational material were made available on a website and distributed to rural and critical-access hospitals throughout the region. Stroke awareness campaigns were completed, and MSI members conducted acute stroke care training of prehospital, nursing, and primary providers throughout the region. A follow-up survey in 2008 assessed changes in the stroke systems of care between 2004 and 2008. Data were analyzed in 2009., Results: There were significant increases in availability of prehospital stroke screens, written emergency department protocols, computed tomographic scanning capability, acute stroke teams, and community stroke awareness programs., Conclusions: A systematic statewide effort to improve stroke care led to improved acute stroke care capabilities in necessary infrastructure in rural facilities and a narrowing of the gap between these facilities and the urban facilities., (Copyright © 2010 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Prompt identification of the warning signs of ischemic stroke is critical to ensure appropriate and timely treatment. We implemented a 20-week public education campaign in one media market to increase community awareness of warning signs for stroke and the need to call 911. Telephone surveys were conducted in adults aged 45 years and older in the intervention county and a comparison county before and after the campaign to evaluate its impact. There was a significant increase in awareness of two or more warning signs for stroke from baseline to follow-up in the intervention county (73%-82%) but not in the comparison county (68%-69%). Respondent awareness of stroke warning signs increased significantly in the intervention county among men (68%-79%) and women (76%-84%) and among respondents aged 45 to 64 years (77%-85%) and respondents aged 65 years and older (67%-78%). There was no significant change in the proportion of respondents indicating they would call 911 if they witnessed someone having a stroke in the intervention county (81%-84%). However, after the campaign, an increased proportion of respondents in the intervention county indicated they would call 911 if they experienced sudden numbness or loss of sensation (50%-56%). Our findings suggest that a high-intensity public education campaign can increase community awareness of the warning signs for stroke and the need to call 911 for specific symptoms., (Copyright (c) 2010 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

Introduction: Telephone counseling through quitlines combined with cessation medication is an effective strategy to support tobacco cessation. This study assessed the characteristics of quitline enrollees selecting varenicline (Chantix) compared with nicotine replacement therapy (NRT) medication and evaluated the cessation outcomes (7-day point prevalence) among these enrollees at 3 and 6 months after program completion., Methods: A retrospective study analyzed demographic, tobacco use history, and abstinence outcome information of participants who enrolled in the Montana Tobacco Quit Line program and selected varenicline (n = 3,116) or NRT (n = 3,697)., Results: Participants selecting varenicline had significantly different demographic characteristics and tobacco use histories compared with enrollees selecting NRT. In the bivariate analyses, the odds of abstinence were greater among persons using varenicline compared with NRT at 3 months (22% and 13%; odds ratio [OR] = 1.85 95% CI 1.50-2.29) and 6 months (17% and 11%; OR = 1.66 95% CI 1.23-2.24). Independently, varenicline use, increasing age, having health insurance, and a greater number of counseling sessions were associated with tobacco use abstinence at 3 months. Only increasing age and a greater number of counseling sessions were independently associated with 6-month abstinence., Discussion: Organizations providing varenicline as part of their quitline services should anticipate that participants selecting this medication have different demographic characteristics and tobacco use histories. The findings suggest that the addition of varenicline enhances 3-month abstinence rates and that the tobacco user's commitment to quit may be the most important predictor of successfully quitting.

Objective: To improve stroke knowledge, identification, and acute care among first responders (FRs) and emergency medical technicians (EMTs) through educational outreach and support., Methods: Beginning in 2006, the Montana Stroke Initiative implemented outreach to FRs and EMTs and emergency medical services (EMS) statewide. Cross-sectional telephone surveys of FRs and EMTs were used to evaluate changes in stroke knowledge and practice in 2006 (n = 988) and 2009 (n = 944), overall and in rural and urban counties., Results: The respondents to the 2009 survey were more likely to report the availability of a stroke protocol in their service (69% vs. 61%, p = 0.001), training in the use of a stroke screening tool (62% vs. 42%, p < 0.001), use of a stroke screening tool (62% vs. 40%, p < 0.001), and an adequate level of knowledge about stroke (81% vs. 66%, p < 0.001) compared with the respondents to the 2006 survey. Significant improvements in each of these areas were achieved for both rural and urban FRs and EMTs., Conclusions: Educational outreach to FRs and EMTs was associated with marked improvement in selected components of the EMS system of stroke care.

Purpose: The purpose of this study was to evaluate the feasibility of translating the Diabetes Prevention Program (DPP) lifestyle intervention into practice in the general community., Methods: In 2008, the Montana Diabetes Control Program, working collaboratively with 4 health care facilities, implemented an adapted group-based DPP lifestyle intervention. Adults at high risk for diabetes and cardiovascular disease were recruited and enrolled (n = 355). Eighty-three percent (n = 295) of participants completed the 16-session program. Participants set targets to reduce fat intake and increase physical activity (>or=150 minutes per week) to achieve a weight loss goal of 7%., Results: Seventy percent of participants achieved the physical activity goal of >or=150 minutes per week. There was a significant decrease among participants' weight from baseline (mean +/- SD, 99.3 +/- 19.7 kg) to week 16 (92.6 +/- 18.8 kg; mean difference, 6.7 +/- 4.0 kg, P < .001). Forty-five percent of the participants achieved the 7% weight loss goal, and 67% achieved at least 5% weight loss. Participants who were 60 years of age and older, had a diagnosis of hypertension, met their physical activity goal of >or=150 minutes per week, and those more frequently monitoring their fat intake were more likely to meet the 7% weight loss goal compared with participants without these characteristics., Conclusion: The findings suggest that it is feasible to recruit and retain high-risk participants and achieve weight loss and physical goals in a group setting that are comparable with those achieved in the DPP.

Problem: Enforced primary seatbelt laws can reduce morbidity and mortality associated with motor-vehicle crashes. Constituent support is an important factor associated with legislator voting behavior toward injury prevention laws. Little is known about attitudes toward a primary seat belt law among adults in rural states without a primary seat belt law., Methods: Data from the Behavioral Risk Factor Surveillance System (BRFSS) survey, a telephone survey of a representative sample of adults in Montana, were used to assess attitudes toward a primary seat belt law., Results: Sixty-one percent of respondents supported a primary seat belt law. Using multiple logistic regression analyses, women (AOR 1.87; 95% CI 1.49-2.36), persons aged 65 years and older (1.45; 1.06-1.96), American Indians (2.71; 1.55-4.75), those with health insurance (1.51; 1.07-2.14), and those who reported always wearing their seat belt (4.05; 3.14-5.21) were more likely to support a primary seat belt law than respondents without these characteristics., Conclusions: The majority of adults in a rural state support a primary seat belt law.

Background: Though racial disparities in asthma prevalence are well documented, little is known about the burden of asthma in American Indians compared to whites in the United States., Objectives: To compare the prevalence of asthma among American Indian and white adults 18 years of age and older in Montana., Methods: We used Behavioral Risk Factor Surveillance System (BRFSS) data representative of the Montana population from 2001 to 2006., Results: Using multiple logistic regression analysis, American Indian race was not independently associated with increased asthma prevalence (OR 1.05, 95% CI 0.83-1.33). Obesity, lower household income and lower educational attainment, factors disproportionately affecting American Indians in Montana, were independently associated with increased asthma prevalence., Conclusions: Regional and national surveillance is needed to comprehensively document asthma prevalence in American Indians and other underrepresented minorities in the United States.

Purpose: Diabetes self-management education (DSME) is an integral component of diabetes care; however, skilled educators and recognized programs are not uniformly available in rural communities., Methods: To increase access to quality DSME, the Montana Diabetes Control Program and the Montana chapter of the American Association of Diabetes Educators developed a mentoring program with 3 levels: basic, intermediate, and advanced. All participants were assisted by a volunteer certified diabetes educator (CDE) mentor. In addition, the program provided technical support for recognition through the American Diabetes Association and the Indian Health Service., Results: From 2000 to 2005, 90 individuals participated; 76% were nurses and 21% dietitians. Twenty-seven of the 90 enrollees (30%) completed their structured option, and 13 achieved CDE certification. Most provided services in frontier counties (66%). Statewide, the number of CDEs in Montana increased 46% from 52 in 2000 to 76 in 2005. Twenty-five of the 30 facilities that received technical assistance achieved recognition. Statewide, the number of recognized education programs increased from 2 in 2000 to 22 in 2005. Twelve (55%) of these programs were located in frontier counties., Conclusions: Mentoring and technical support is an effective method to increase personnel skills for DSME and to increase access to quality education programs in rural areas.

Objectives: The objective of this study was to identify factors associated with perceived risk for cardiovascular disease (CVD) among older American Indians., Design: In 2003, a telephone survey was conducted in American Indians aged > or = 45 years who lived on or near the seven reservations in Montana. Respondents were asked about their history of CVD and selected risk factors and their perceived risk for CVD. The prevalence of CVD and risk factors among men and women aged > or = 45 years (N = 516) was high: CVD (26% and 15%), diabetes (24% and 26%), high blood pressure (48% and 46%), high cholesterol (34% and 40%), smoking (28% and 33%), and obesity (37% vs 46%). Men with a history of CVD (87% vs 46%), high blood pressure (70% vs 44%), high cholesterol (71% vs 53%), and obesity (67% vs 52%) were more likely to report being at risk for heart disease compared to men without these conditions. Women with a history of CVD (98% vs 58%), diabetes (74% vs 60%), high blood pressure (73% vs 56%), high cholesterol (72% vs 60%), and obesity (74% vs 55%) were more likely to report being at risk for heart disease compared to women without these conditions. Neither men nor women associated smoking with their own risk for heart disease., Conclusions: The prevalence of CVD risk factors was high in this population, and most people recognized the risks associated with the modifiable CVD risk factors. However, neither men nor women who smoked reported being at risk for heart disease more frequently than nonsmokers.

Objective: To assess trends in diabetes screening among American Indian adults and identify opportunities to extend blood glucose screening to those at risk for undiagnosed diabetes and prediabetes., Methods: In 1999, 2001, and 2003, approximately 1,000 American Indian adults aged 18 years and older living on or near the seven reservations in Montana were interviewed through telephone surveys., Results: Of respondents without diagnosed diabetes, the proportion who recalled blood glucose screening for diabetes within the past 3 years increased from 68 percent in 1999 to 78 percent in 2003. Between 1999 and 2003, screening increased among men (64%-75%), women (71%-80%), those aged 18-44 years (64%-72%), and those aged 45 years and older (76%-84%). Factors independently associated with screening included age more than 45 years, family history of diabetes, and a history of high cholesterol. Current smokers were less likely to report screening compared to nonsmokers. Gender, obesity, and a history of high blood pressure were not associated with screening., Conclusions: Although self-reported diabetes screening increased over a 5-year period among Indians in Montana, additional groups who could benefit from screening include younger and obese individuals, and those with hypertension.

Background: Disparities in stroke and heart disease have been well defined in many populations in the United States. Relatively few studies, however, have assessed current disparities in cardiovascular disease in American Indian populations and compared trends with other regions of the United States., Methods and Results: Using mortality data, age-adjusted all-cause, heart disease, and stroke mortality rates (per 100,000) were calculated for American Indians and whites from 1991 to 1995 and 1996 to 2000. The all-cause mortality rate was strikingly higher for American Indians than for whites. For example, during 1996 to 2000, the all-cause mortality rate for American Indians (1317, +/-61) was more than half again greater than that for whites (831, +/-8). Heart disease mortality declined significantly in whites (237 to 216 per 100,000) in Montana over the past decade and declined, although not significantly, in American Indians (326 to 283 per 100,000). Stroke mortality also declined significantly in whites (64 to 60 per 100,000) but not in American Indians (80 to 81 per 100,000) during this time period. The proportion of deaths before age 65 years for heart disease and stroke was considerably higher in Indian men (45% and 36%) and Indian women (29% and 28%) compared with white men (21% and 11%) and white women (8% and 7%)., Conclusions: The disparity in heart disease and stroke mortality exists between American Indians and whites in Montana. Regional or state-level surveillance data will be needed to describe the changing patterns of heart disease and stroke mortality and cardiovascular risk factors in many native communities in the United States and Canada.

Introduction: Diabetes care is a challenge in rural areas where primary care practices are faced with limited resources, few clinical information systems, and relative isolation from education programs and diabetes centers with multispecialty teams. This report describes an effective field-based approach to support improved care for patients with diabetes in primary care practices in rural states., Methods: A collaborative effort between diabetes prevention and control programs in Montana and Wyoming and the University of North Dakota was established to provide support to rural primary care practices for improvement in diabetes care. Field teams from each state diabetes program approached primary care practices. After assessment and orientation of office staff, a computer-based registry was established in each practice. Baseline data were collected in 1997 in Montana and in 1998 in Wyoming; follow-up occurred on July 31, 2004. Health department staff provided ongoing technical support for implementing and evaluating quality-improvement interventions., Results: Forty primary care practices, providing care to more than 7000 patients with diabetes, participated in this quality-improvement effort at follow-up. Of the 37 primary care practices participating in the quality-improvement program for 6 or more months at follow-up, there were significant improvements in Montana in rates of hemoglobin A1c testing, blood glucose control, low-density lipoprotein cholesterol testing, foot and dilated retinal examinations, and pneumococcal vaccinations, and there were significant improvements in pneumococcal vaccinations in Wyoming., Conclusion: A field-based approach in which individual practices maintain and use their own registries for both clinical care and quality improvement with ongoing support is a sustainable and an effective strategy for improving diabetes care for rural populations.

Background: Persons who perceive their risk for stroke accurately may be more likely to engage in prevention practices to reduce their risk., Methods: In 2004, 800 adults aged 45 years and older in two counties participated in a telephone survey to assess their perceived risk for stroke and their history of stroke risk factors., Results: Overall, 39% of respondents perceived themselves to be at risk for having a stroke. In the multivariate analyses, younger age, current smoking, and a history of diabetes, high blood pressure, high cholesterol, heart disease, and stroke/TIA were independently associated with perceived risk for stroke. Respondents with atrial fibrillation were no more likely to report being at risk for stroke compared to respondents without atrial fibrillation. Perceived risk for stroke increased as the number of risk factors increased. However, 46% of respondents with three or more risk factors did not perceive themselves to be at risk., Conclusions: Many adults with multiple risk factors do not perceive themselves to be at risk for stroke. Clinical and public health efforts are needed to increase awareness of the risk for stroke.

Introduction: Rapid identification and treatment of ischemic stroke can lead to improved patient outcomes. Public education campaigns in selected communities have helped to increase knowledge about stroke, but most data represent large metropolitan centers working with academic institutions. Much less is known about knowledge of stroke among residents in rural communities., Methods: In 2004, 800 adults aged 45 years and older from two Montana counties participated in a telephone survey using unaided questions to assess awareness of stroke warning signs and risk factors. The survey also asked respondents if they had a history of atrial fibrillation, diabetes, high blood pressure, high cholesterol, smoking, heart disease, or stroke., Results: More than 70% of survey participants were able to correctly report two or more warning signs for stroke: numbness on any side of the face/body (45%) and speech difficulties (38%) were reported most frequently. More than 45% were able to correctly report two or more stroke risk factors: smoking (50%) and high blood pressure (44%) were reported most frequently. Respondents aged 45 to 64 years (odds ratio [OR] 2.44; 95% confidence interval [CI], 1.78-3.46), women (OR 2.02; 95% CI, 1.46-2.80), those with 12 or more years of education (OR 1.96; 95% CI, 1.08-3.56), and those with high cholesterol (OR 1.68; 95% CI, 1.17-2.42) were more likely to correctly identify two or more warning signs compared with respondents without these characteristics. Women (OR 1.48; 95% CI, 1.07-2.05) and respondents aged 45 to 64 years (OR 1.35; 95% CI, 1.01-1.81) were also more likely to correctly identify two or more stroke risk factors compared with men and older respondents., Conclusion: Residents of two rural counties were generally aware of stroke warning signs, but their knowledge of stroke risk factors was limited.

Background: Cardiovascular disease (CVD) is the leading cause of death among American Indians. The objective of this study was to assess trends in CVD and CVD risk factors among American Indians in Montana., Methods: In 1999 and 2003, 1000 American Indian adults aged > or =18 years living on or near the seven reservations in Montana were interviewed each year using an adapted Behavior Risk Factor Surveillance System survey., Results: During the 5-year period from 1999 to 2003, the prevalence of CVD risk factors increased significantly: diabetes (12% to 16%), high blood pressure (26% to 34%), high cholesterol (23% to 30%), and obesity (34% to 39%). The percentage reporting current smoking was stable and remained high (38% to 36%). After adjusting for age and gender, the increases in high blood pressure, high cholesterol, and obesity remained significant. The percentage reporting two or more CVD risk factors increased significantly overall, among men and women, and among older and younger respondents during the 5-year time period., Conclusions: The prevalence of CVD risk factors among American Indian adults in Montana is high, and for many of the risk factors, has increased significantly over a 5-year period.

The prevalence of diabetes is two- to threefold higher in American Indians in Montana compared with the non-Indian population. High rates of diabetes have also been described in Canadian aboriginal populations closely related to the tribes in Montana. Diabetes in pregnancy has increased among Indian mothers and high-birth-weight babies are increasingly likely to be born to Indian mothers with diabetes in pregnancy. Over 70% of the incident cases of diabetes in youth less than 20 years of age on the reservations have the clinical characteristics of type 2 diabetes. Cardiovascular disease mortality rates are high among Indians in Montana, and the prevalence of smoking in the Indian populations of Montana and the neighboring tribes in Canada is remarkably high. Indians in Montana are more likely than non-Indians of similar age to believe that diabetes is preventable and to recall advice about diabetes risk.

Objectives: To estimate the prevalence and incidence of type 2 diabetes among American Indian youth., Study Design: Medical records were reviewed annually for all patients with diabetes who were <20 years of age at 6 Indian Health Service facilities in Montana and Wyoming. All cases < or =5 years of age or weight per age < or =10th percentile at diagnosis or with islet cell antibodies were considered as probable type 1. Among the remaining cases, probable type 2 diabetes was defined when a child had one or more of the following characteristics: weight per age > or =95th percentile or acanthosis nigricans at diagnosis, elevated C-peptide or insulin, family history of type 2 diabetes; treatment with oral agents with or without insulin or no hypoglycemic therapy after 1 year of follow-up., Results: From 1999 to 2001, 53% of prevalent cases and 70% of incident cases were categorized as probable type 2 diabetes. The average annual prevalence of probable type 1 and type 2 diabetes was 0.7 and 1.3 per 1000. The average annual incidence rates for probable type 1, and type 2 diabetes were 5.8, 23.3 per 100,000., Conclusions: The incidence of probable type 2 diabetes was approximately 4 times higher than type 1 diabetes among American Indian youth in Montana and Wyoming

Context: Vaccine-preventable diseases among adults are major contributing causes of morbidity and mortality in the United States. However, adult immunizations continue to be underutilized in both urban and rural areas., Purpose: To evaluate the effectiveness of a community-wide education campaign and mailed reminders promoting pneumococcal immunizations to rural Medicare beneficiaries., Methods: We implemented a community-wide education campaign, and mailed reminders were sent to Medicare beneficiaries in 1 media market in Montana to increase pneumococcal immunizations. In a second distinct media market, mailed reminders only were sent to beneficiaries., Findings: The proportion of respondents aged 65 years and older aware of pneumococcal immunizations increased significantly from baseline to follow-up among respondents both in the education-plus-reminder (63% to 78%, P = 0.04) and the reminder-only (64% to 74%, P = 0.05) markets. Overall from 1998 to 1999, there was a 3.7-percentage-point increase in pneumococcal immunization claims for Medicare beneficiaries in the education-plus-reminder market and a 1.5-percentage-point increase in the reminder-only market. Medicare beneficiaries sent reminders in the education-plus-reminder market compared to those in the reminder-only market were more likely to have a claim for pneumococcal immunization in 1999 (odds ratio 1.18, 95% confidence interval 1.08 to 1.28). The results suggest that these quality improvement strategies (community education plus reminders and reminders alone) modestly increased pneumococcal immunization awareness and pneumococcal immunization among rural adults. Mailed reminder exposure was associated with an increased prevalence of pneumococcal immunizations between 1998 and 1999 and was augmented somewhat by the education campaign.

Background: Testing for microalbuminuria is recommended to detect early kidney damage in patients with diabetes or other diseases. However, few studies have examined laboratory practices for microalbuminuria testing in the general community., Methods: In 2002, all laboratories in Montana and reference laboratories used by Montana laboratories for microalbuminuria measurement were surveyed by mail to ascertain if they provided testing for microalbuminuria, specific tests performed, and units and cutoff values used to report microalbuminuria results., Results: One hundred three of 126 laboratories (82%) responded to the survey. Overall, 79% of laboratories offered quantitative testing for microalbuminuria, either on site or through a reference laboratory. Twenty-five laboratories (24%) surveyed provided quantitative testing for microalbuminuria on site. Only 14 of 23 laboratories offering albumin-creatinine ratios on site reported results in units and cutoff values consistent with current recommendations. Fewer laboratories provided 24-hour (6 of 17 laboratories) or other timed (2 of 7 laboratories) testing, and many of these laboratories did not report results using recommended units and cutoff values. Overall, only 11 of 25 laboratories (44%) with on-site testing reported microalbuminuria values from 1 or more types of specimens exclusively using recommended units and cutoff values., Conclusion: Quantitative testing for microalbuminuria is not offered universally, and results often are reported in units and cutoff values that differ from current clinical recommendations.