Organizational culture influences health care workers' influenza immunization behavior.

BACKGROUND AND OBJECTIVES: Low rates of influenza immunization among health care workers (HCWs) pose a potential health risk to patients in primary care practices. Despite previous educational efforts and programs to reduce financial barriers, HCW influenza immunization rates remain low. Variation in practice-level organizational culture may affect immunization rates. To explore this relationship, we examined organizational cultures and HCWs' influenza immunization behaviors in three family medicine practices. METHODS: We used a multi-method comparative case study. A field researcher used participant observation, in-depth interviews, and key informant interviews to collect data in each practice in November-December 2003. A diverse team used grounded theory to analyze text data. RESULTS: Organizational culture varied among practices and differing HCW immunization rates were observed. The most structured and business-like practice achieved immunization of all HCWs, while the other two practices exhibited greater variation in HCW immunization rates. Physicians in the practices characterized as chaotic/disorganized or divided were immunized at higher rates than other members of the practices. CONCLUSIONS: In these practices, organizational culture was associated with varying rates of influenza immunization for HCWs, especially among nonphysicians. Addressing elements of organizational culture such as beliefs regarding influenza immunization and office policies may facilitate the immunization of all staff members.

Complementary and alternative medicine in US family medicine practices: a pilot qualitative study.

CONTEXT: The growth of complementary and alternative medicine (CAM) has led some family medicine practices to include CAM. Acupuncture or herbal medicine, for example, may be offered at such practices. When a practice incorporates both CAM and conventional treatments, its goals and values may differ from those found in traditional primary care. Little is known about the development of these integrated practices, which may be expected to become more widespread. OBJECTIVE: To identify some of the concepts and challenges shaping family medicine practices that incorporate CAM. DESIGN: Comparative case study. METHOD: Multi-method assessment process including participant observation, key informant interviews, semi-structured depth interviews, and observation of patient-provider encounters. SETTING: Four family medicine/CAM practices in the mid-Atlantic region of the United States. RESULTS: Key themes that influence these practices' organization include dimensions of health, the selection of therapies used, the practices' approach to evidence, their perspective on the amount of time spent with patients, and their adaptations to financial concerns. Each practice emphasized long patient visits. In each, physicians had expertise that enabled them to draw on both conventional medicine and CAM. CONCLUSION: Successful incorporation of CAM modalities within a family medicine framework requires adaptation not only at the practice level but also by individual physicians.

Influenza immunization disparities in primary care offices--a comparative case study.

Without insight into the primary care environment, further improvements in influenza immunization rates are unlikely. We conducted a comparative case study of family medicine offices during the 2003 influenza immunization season. Practice 1 (P1) served an urban African American population, practice 2 (P2) served a suburban non-minority population, practice 3 (P3) served an urban Hispanic population. Influenza immunization rates among patients age 65 years and older in P1, P2, and P3 were 32%, 33%, and 67% by medical chart. Rates were highest in P3, where medical staff supported vaccination, promoted communication with patients and staff, and made use of systems to identify eligible patients. Characteristics that appear to affect influenza immunization in the primary care environment include the presence of a practice champion, issues of communication and collaboration, and the use of systems approaches. These data support the need for investigation of how these factors affect population level disparities.

A program for managing weight gain associated with atypical antipsychotics.

This study assessed the efficacy of a weight control program for patients taking atypical antipsychotics. Thirty-one patients with schizophrenia or schizoaffective disorder participated in a 12-week weight control program that incorporated nutrition, exercise, and behavioral interventions. Changes in patients' weight and in body mass index (BMI) were recorded and compared with those of 15 patients in a control group. The intervention group had a mean weight loss of 2.7 kg (six pounds) and a mean reduction of.98 BMI points, compared with a mean weight gain of 2.9 kg (6.4 pounds) and a mean gain of 1.2 BMI points in the control group. These data suggest that the intervention was effective in this group of patients. Professionals treating persons who are taking atypical antipsychotics should encourage them to engage in weight control activities.

Assessing diversity and quality in primary care through the multimethod assessment process (MAP).

The U.S. health care system serves a diverse population, often resulting in significant disparities in delivery and quality of care. Nevertheless, most quality improvement efforts fail to systematically assess diversity and associated disparities. This article describes application of the multimethod assessment process (MAP) for understanding disparities in relation to diversity, cultural competence, and quality improvement in clinical practice. MAP is an innovative quality improvement methodology that integrates quantitative and qualitative techniques and produces a system level understanding of organizations to guide quality improvement interventions. A demonstration project in a primary care practice illustrates the utility of MAP for assessing diversity.

A multimethod study of needs for physician assessment: implications for education and regulation.

INTRODUCTION: Deficiencies in physician competence play an important role in medical errors and poor-quality health care. National trends toward implementation of continuous assessment of physicians hold potential for significant impact on patient care because minor deficiencies can be identified before patient safety is threatened. However, the availability of assessment methods and the quality of existing tools vary, and a better understanding of the types of deficiencies seen in physicians is required to prioritize the development and enhancement of assessment and remediation methods. METHODS: Surveys of physicians and licensing authorities and analysis of the Federation of State Medical Boards (FSMB) Board Action Data Bank were used to collect information describing the nature and types of problems seen in practicing physicians. Focus groups, depth interviews with key professional stakeholders, and state medical board site visits provided additional information about deficiencies in physician competence. RESULTS: Quantitative and qualitative analyses identified (1) communication skills as a priority target for assessment approaches that also should focus on professional behaviors, knowledge, clinical judgment, and health-care quality; and (2) differences between regulatory approaches of licensing and certifying bodies contribute to a culture that limits effective self-assessment and continuous quality improvement. System problems impacting physician performance emerged as an important theme in the qualitative analysis. DISCUSSION: Considering alternative perspectives from the regulatory, education, and practice communities helps to define assessment priorities for physicians, facilitating development of a coherent and defensible approach to assessment and continuing professional development that promises to provide a more comprehensive solution to problems of health-care quality in the United States.

Chasteberry.

For centuries, chasteberry has been used to treat many hormone-related gynecologic conditions. The current literature supports the use of chasteberry for cyclical breast discomfort and premenstrual syndrome; data on its use for menstrual irregularities and fertility disorders are weak. Its traditional use as a galactagogue (i.e., a substance that enhances breast milk production) is not well supported in the literature and should be discouraged. There are no clinical data to support the use of chasteberry for reducing sexual desire, which has been a traditional application. Chasteberry is well tolerated; reported adverse effects are minor and may include gastrointestinal complaints, dizziness, and dry mouth. No herb-drug interactions have been reported, but caution is advised for its concomitant use with dopamine agonists or antagonists. Optimal standardization and dosing recommendations await clarification in clinical studies.

Herbs, menopause, and dialysis.

Women with chronic kidney disease (CKD) are at increased risk for menstrual disorders, early menopause, and osteoporosis, and rarely discuss gynecologic and reproductive issues with their nephrologist. Various complementary and alternative medicine (CAM) products are of interest to women with end-stage renal disease (ESRD) who have these disorders. However, very little is known about the specifics of using herbal medicines in patients on chronic dialysis, resulting in numerous problems when patients and providers try to ascertain the safety and efficacy of these products. This article reviews evidence regarding the safety and efficacy of black cohosh, ginseng, chastetree, dong quai, evening primrose oil, soy products, and the so-called natural hormones. Pharmacologic parameters important to evaluating the quality of botanical products are discussed, along with recommendations and information resources.