Understanding antibiotic overprescribing in China: A conversation analysis approach

Claiming or abdicating medical authority: Treatment recommendation actions, doctor-patient relationship, and antibiotic overprescription in Chinese paediatrics

Antibiotic overprescription in China has long been considered a problem on the supply side, linked to the financial incentives of physicians. Based on the conversation analysis of 187 video-recorded naturally occurring medical consultations in Chinese paediatric primary care settings, this study finds that the driving force behind the problem of antibiotic overprescription in China has changed. Physicians use a low-authority communication style to recommend treatment, displaying a low level of medical authority and a willingness to accommodate caregivers' preferences in antibiotic prescribing decisions. The problem is now attributed to physician-caregiver interaction, doctor-patient relationship and the antibiotic-saturated prescribing culture. Practice implications involve deepening the understanding of the evolving nature of the antibiotic overprescription problem in China, building trust between physicians and patients/caregivers in order to facilitate the physicians' role as the gatekeeper of antibiotics and providing training programmes to help physicians develop effective communication skills.

Behind the Scenes: A Qualitative Investigation of Interviewers' Performance in EQ-5D Valuation Studies

BACKGROUND

The EuroQol Valuation Technology (EQ-VT) protocol is currently employed by the valuation studies of the EQ family of instruments worldwide. To date, all the evidence in support of the quality control (QC) originates from quantitative indicators.

OBJECTIVE

We aimed to explore interviewers' conversational patterns in EQ-VT interviews, beyond quantitative QC indicators, and to provide a preliminary exploration of how the interaction between interviewer and respondent impacts data quality.

METHODS

Two researchers transcribed and independently coded 24 video-recorded interviews from the Italian EQ-5D-5L valuation study, adopting the conversational analysis framework. The analysis identified positive and negative 'patterns' of conversational practice. These were categorized into themes and sub-themes and were used to score a random sample of 42 video-recorded interviews conducted at different time points by seven interviewers.

RESULTS

The conversational analysis identified 20 positive and 14 negative interview patterns, which were grouped into two main themes (i.e., task execution and communication skills). Positive items included appending questions that stimulated respondents' engagement, providing different explanations for an unclear aspect, supporting the participant with useful information for completing the tasks, and increasing the interview's coherence by confirming the respondent answers. Negative patterns included moving forward in the exercise without making sure that the respondent understood, trying to force an answer from the respondent, speaking too fast, and providing incomplete or incorrect explanations of the task. Most interviewers exhibited a moderate increase in positive patterns or a decrease in negative patterns over time. A certain degree of consistency between the quantitative QC results and the qualitative scoring deriving from the interviewer-respondent interaction was observed, with the best and worst performers of the qualitative scoring showing good and bad scores on key QC items, respectively.

CONCLUSIONS

The identified positive and negative patterns may be useful to inform the training material of EQ-VT studies worldwide and complement the existing QC process.

Communication in Primary Healthcare: A State-of-the-Art Literature Review of Conversation-Analytic Research

We report the first state-of-the-art review of conversation-analytic (CA) research on communication in primary healthcare. We conducted a systematic search across multiple bibliographic databases and specialist sources and employed backward and forward citation tracking. We included 177 empirical studies spanning four decades of research and 16 different countries/health systems, with data in 17 languages. The majority of studies originated in United States and United Kingdom and focused on medical visits between physicians and adult patients. We generated three broad research themes in order to synthesize the study findings: managing agendas, managing participation, and managing authority. We characterize the state-of-the-art for each theme, illustrating the progression of the work and making comparisons across different languages and health systems, where possible. We consider practical applications of the findings, reflect on the state of current knowledge, and suggest some directions for future research. Data reported are in multiple languages.

Companions' contributions to information gathering in Chinese outpatient clinical interaction

Patients are commonly accompanied to visit clinicians in Chinese outpatient clinics. Although there has been extensive research on the roles of companions in asymmetric interactions within medical settings, there is a paucity of conversation analytic studies that examine the active participation and contributions of companions on an equal footing in medical consultations. How companions on an equal footing participate and contribute in Chinese outpatient clinical consultations remains under-explored. By employing video recordings of three-party consultations in the Chinese orthopaedic outpatient clinic as the data and adopting conversation analysis as the method, this study investigated how companions participated in and contributed to the information-gathering activity and how their contributions were interactionally negotiated and managed by clinicians and adult patients over sequences of interaction. We showed that companions negotiated epistemic rights in reporting and repairing the information about medical problems in the patients' epistemic domain and displayed different levels of encroachment on patients' epistemic rights by endorsing patients' responses, repairing the information in patients' responses, and offering information directly to clinicians. Companions also exerted deontic authority and shaped the trajectory of the consultations by hindering or facilitating the progressivity of the interaction. We argued that companions' contributions to the information-gathering activity might reflect the family-centred model of the doctor-patient relationship in the Chinese orthopaedic outpatient clinic. Clinicians are suggested to open up opportunities for companions' participation and contributions while respecting patients' rights, especially when there is a collision of knowledge claims between patients and their companions.

Companion responses to diagnosis in Chinese outpatient clinical interaction

Patients regularly attend clinical consultations with companions in Chinese outpatient clinics. Despite companions' significant influence on clinical consultations, how companions respond to diagnosis and their contributions to the activity of diagnosis in Chinese outpatient clinical interaction remain under-researched. The present study, by adopting the method of conversation analysis, investigated clinicians' diagnostic deliveries and companions' subsequent responses in Chinese outpatient clinical interaction. The data for this study consisted of 79 video recordings of clinical consultations in the Chinese orthopedic outpatient clinic, approximately lasting 12 h and involving three male clinicians, 79 patients (37 male/42 female), and 91 companions (51 male/40 female). Three basic categories of companion responses to diagnosis were identified: minimal verbal responses, embodied responses, and extended responses. It was demonstrated that these distinct responses allowed companions to challenge clinicians' medical authority in the activity of diagnosis by delivering their own diagnostic judgments, resisting clinicians' diagnoses, and orienting to clinicians' accounts for their diagnostic statements and reasoning, thus displaying companion agency in the Chinese outpatient clinical decision-making and indicating a transition from a paternalistic model to a family-centered model of the doctor-patient relationship in the Chinese orthopedic outpatient interaction. This study furthers current knowledge of companion involvement across healthcare contexts and contributes to raising clinicians' awareness of the significance of companions' contributions in Chinese outpatient clinical interaction.

Characteristic analysis of bio-oil from penicillin fermentation residue by catalytic pyrolysis

The hazardous waste penicillin fermentation residue (PR) is a huge hazard to the environment. The bio-oil produced by the pyrolysis of the penicillin fermentation residue has the potential to become a biofuel in the future. This paper studied the pyrolysis characteristics of PR at 400°C ∼700°C. According to the weight loss and weight loss rate of PR, the whole process of pyrolysis can be divided into three stages for analysis: dehydration and volatilization, initial pyrolysis, and pyrolytic char formation. The experimental results showed that the yield of the liquid phase is the highest (33.11%) at 600°C. GC-MS analysis results showed that high temperature is beneficial to reduce the generation of oxygenated hydrocarbons (73%∼31%) and the yield of nitrogenous compounds gradually increased (19%∼43%); the yield of hydrocarbons was low in 400°C∼600°C pyrolysis (2%∼5%) but significantly increased around 700°C (22%). In the temperature range of 400°C to 700°C, the proportion of C5-C13 in bio-oil gradually increased (26%-64%), and the proportion of C14-C22 gradually decreased (47%-16%). The catalyst can increase the proportion of hydrocarbons in the bio-oil component. And the Fe₂O₃/HZSM-5 mixed catalyst has a significant reduction effect on oxygen-containing hydrocarbons and nitrogen-containing compounds.

Patient expectations do matter - Experimental evidence on antibiotic prescribing decisions among hospital-based physicians

BACKGROUND

The global public health crisis of antibiotic resistance is being driven in part by over prescription of antibiotics. We aimed to assess the relative weight of patient expectations, clinical uncertainty, and past behaviour on hospital-based physicians' antibiotic prescribing decisions.

METHODS

A discrete choice experiment was administered among hospital-based physicians in Tuscany, Italy. Respondents were asked to choose in which of two clinical scenarios they would be more likely to prescribe antibiotics, with the two cases differing in levels of clinical uncertainty, patient expectations, and the physician's past behaviour. We fitted a conditional logistic regression.

RESULTS

Respondents included 1,436 hospital-based physicians. Results show that the odds of prescribing antibiotics decrease when a patient requests it (OR=0.80, 95%CI [0.72,0.89]) and increase when the physician has prescribed antibiotics to a patient under similar circumstances previously (OR=1.15, 95%CI [1.03,1.27]). We found no significant effect of clinical uncertainty on the odds of prescribing antibiotics (OR=0.96, 95%CI [0.87, 1.07]).

CONCLUSIONS

We show that patient expectation has a significant negative association with antibiotic prescribing among hospital-based physicians. Our findings speak to the importance of cultural context in shaping the physician's disposition when confronted with patient expectations. We suggest shared decision-making to improve prudent prescribing without compromising on patient satisfaction.

Weighing patient attributes in antibiotic prescribing for upper respiratory tract infections: A discrete choice experiment on primary care physicians in Hubei Province, China

Objectives

This study aimed to determine how primary care physicians weigh intervenable patient attributes in their decisions of antibiotic prescribing for upper respiratory tract infections (URTIs).

Methods

A discrete choice experiment (DCE) was conducted on 386 primary care physicians selected through a stratified cluster sampling strategy in Hubei province, China. The patient attributes tested in the DCE were identified through semi-structured interviews with 13 primary care physicians, while the choice scenarios were determined by a D-efficient design with a zero prior parameter value. Conditional logit models (CL) and mixed logit models (MXL) were established to determine the preference of the study participants in antibiotic prescribing for URTI patients with various attributes. Relative importance (RI) was calculated to reflect the influence of each attribute.

Results

In addition to age and duration of symptoms, the interventionable patient attributes were also considered by the primary care physicians in their antibiotic prescribing decisions. They preferred to prescribe antibiotics for URTI patients with difficulties to schedule a follow-up appointment (p < 0.001) and for those without a clear indication of refusal to antibiotics (p < 0.001). Patient request for antibiotics had an RI ranging from 15.2 to 16.3%, compared with 5.1-5.4% for easiness of follow-up appointment. The influence of these two interventionable patient attributes was most profound in the antibiotic prescribing decisions for patients aged between 60 and 75 years as indicated by their interaction effects with age (β = 0.69 for request for antibiotics, p < 0.01; β = -1.2 for easiness of follow-up, p < 0.001).

Conclusion

Reducing patient pressure and improving accessibility and continuity of care may help primary care physicians make rational antibiotic prescribing decisions for URTIs.

Pre-Visit Use of Non-Prescribed Antibiotics among Child Patients in China: Prevalence, Predictors, and Association with Physicians’ Prescribing of Antibiotics at Medical Visits

Antibiotic resistance is one of the most serious global public health crises. Inappropriate use of antibiotics is an important contributor. Using a cross-sectional survey, we recruited 3056 caregivers from 21 provinces in China to complete a questionnaire pertaining to their most recent medical visits for children’s acute respiratory tract infection (ARTI) symptoms in October 2013. The findings show that the prevalence of caregivers giving children non-prescribed antibiotics before their medical visit was as high as 38%. Caring for an older child and having lower educational attainment increased the likelihood of self-medication with antibiotics; among Chinese residential areas, caregivers living in tier 2 urban districts were most likely to administer non-prescribed antibiotics before their visit. Physicians’ prescribing of antibiotics was significantly associated with caregivers’ self-reported pre-visit use of non-prescribed antibiotics. Misuse should be addressed by regulating the sale of antibiotics and improving communication at medical consultations.

Making Conversation Analysis Accessible: A Conceptual Guide for Health Services Researchers

The quality of healthcare communication can impact both experiences and outcomes. We highlight aspects of communication that can be systematically examined using Conversation Analysis (CA) and provide guidance about how researchers can incorporate CA into healthcare studies. CA is a qualitative method for studying naturally occurring communication by analyzing recurrent, systematic practices of verbal and nonverbal behavior. CA involves examining audio- or video-recorded conversations and their transcriptions to identify practices speakers use to communicate and interpret behavior. We explain what distinguishes CA from other methods that study communication and highlight three accessible CA approaches that researchers can use in their research design, analysis, or implementation of communication interventions. Specifically, these approaches focus on how talk is produced (specific words, framing, and syntax), by whom, and when it occurs in the conversation. These approaches can be leveraged to generate hypotheses and to identify patterns of behavior that inform empirically driven communication interventions.

OUP accepted manuscript

In order to design appropriate antimicrobial stewardship (AMS) programmes, it is crucial to understand challenges to tackling antibiotic resistance (AMR) specific to each healthcare setting. Antibiotic prescribing in primary care accounts for most prescriptions with a significant proportion considered clinically inappropriate. Qualitative research has a long history in social sciences, but its value and contribution are still contested in medical journals including in the AMR/AMS field. However, through its focus on understanding, meaning making and explaining, qualitative research can offer insights in how to improve AMS efforts in primary care. This paper provides an overview of unique considerations, contributions and challenges related to using qualitative research in AMS to help the AMS community new to qualitative research to utilize its potential most fully. First, we discuss specific considerations for AMS in relation to the stages of conducting a qualitative study, including identifying a research question and choosing a suitable methodology; sampling appropriate participants; planning a recruitment strategy; choosing a method of data collection; and conducting data analysis. These are illustrated with examples of qualitative AMS studies in primary care. Second, we highlight the importance of patient and public involvement throughout all stages of the project and ensuring quality in qualitative AMS research. Finally, drawing on these considerations, we make a further case for the value and contribution of qualitative methodologies in AMS/AMR research while outlining future directions for both AMS and qualitative research, including the need for studies with diverse actors; interdisciplinary collaborations; and complex decisions on methodologies and timelines.

Dueling in the clinic: When patients and providers disagree about healthcare recommendations

We begin by considering the evolving nature of the physician-patient relationship. Research shows that physicians have retained significant authority as health professionals but not to the extent that they had in the golden age of doctoring. Instead, as patient centered care movements gained momentum, patients became empowered through policies and parallel consumer social movements. Patient-centered care advocates envisioned an active patient who would ask questions and voice preferences and concerns but would remain rational and thus make choices that remained in line with standard of care practices. Instead, we discuss research on patient communication with clinicians that has documented an unexpected form of patient participation: patients sometimes advocate for treatments that are not necessarily good for them and sometimes resist recommendations that are the current standard of care. We review the varied ways in which these engaged patients influence diagnoses and treatment/care outcomes. Finally, we introduce the eight papers that comprise this special section of Social Science and Medicine on dueling in the clinic.

Negative stance towards treatment in psychosocial assessments: The role of personalised recommendations in promoting acceptance

People presenting to the emergency department with self-harm or thoughts of suicide undergo a psychosocial assessment involving recommendations for e.g. contact with other practitioners, charity helplines or coping strategies. In these assessments, patients frequently adopt a negative stance towards potential recommendations. Analysing 35 video-recorded liaison psychiatry psychosocial assessments from an emergency department in England (2018-2019), we ask how these practitioners transform this negative stance into acceptance. We show that practitioners use three steps to anticipate and address negative stance (1) asking questions about the patient's experience/understanding that help the patient to articulate a negative stance (e.g., "what do you think about that"); (2) accepting or validating the reasons underlying the negative stance (e.g., "that's a very real fear and thought to have"); and (3) showing the patient that their reasons were incorporated in the recommendation (e.g., "it's telephone support if you're a bit more uncomfortable with face to face"). These steps personalise the recommendation based on the patient's specific experiences and understanding. When practitioners followed all three of these steps, the patient moved from a negative stance to acceptance in 84% of cases. When practitioners made a recommendation but did not follow all three steps, the patient moved from a negative stance to acceptance in only 14% of cases. It is not the case that each communication practice works on its own to promote patient acceptance, rather Steps 1 and 2 build on each other sequentially to develop and demonstrate shared understanding of the patient's negative stance. In this way, acceptance and validation play an indispensable role in addressing a patient's concerns about treatment.

Going shopping or consulting in medical visits: Caregivers' roles in pediatric antibiotic prescribing in China

Antimicrobial Resistance (AMR) is one of the gravest global public health crises today. Over-prescription in clinical settings is a primary driver. Despite its magnitude and scale, the problem of antibiotic over-prescription in China has not been understood adequately nor addressed effectively. Based on a corpus of 183 video-recorded medical conversations in the Chinese pediatric setting, we show that patient caregivers frequently challenge the physician's medical authority by resisting treatment recommendations, displaying a high level of entitlement to influence the treatment decision. As a result, even when the physicians do not recommend antibiotics based on their professional judgment, they prescribe in response to caregiver pressure. We argue that the relatively low level of medical authority is a significant contributor to the problem. Under this consumerist model of doctor-patient relationship, antibiotics are oriented to by the caregivers as a negotiable commodity and physicians are unable to fulfill their role as gatekeepers. Educational campaigns are needed to promote rational use of antibiotics among patients and caregivers, and serious efforts are called for to protect physicians' professional authority in China.