Arriving at no: Patient pressure to prescribe antibiotics and physicians' responses

High-Stakes Treatment Negotiations Gone Awry: The Importance of Interactions for Understanding Treatment Advocacy and Patient Resistance

Doctors (and sociologists) have a long history of struggling to understand why patients seek medical help yet resist treatment recommendations. Explanations for resistance have pointed to macrostructural changes, such as the rise of the engaged patient or decline of physician authority. Rather than assuming that concepts such as resistance, authority, or engagement are exogenous phenomena transmitted via conversational conduits, we examine how they are dynamically co-constituted interactionally. Using conversation analysis to analyze a videotaped interaction of an oncology patient resisting the treatment recommendation even though she might die without treatment, we show how sustained resistance manifests in and through her doctor's actions. This paradox, in which the doctor can both recommend life-prolonging care and condition resistance to it, has broad relevance beyond cancer treatment; it also can help us to understand other doctor-patient decisional conflicts, for instance, medication nonadherence, delaying emergent care, and vaccine refusal.

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.

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.

Decision making on antimicrobial use: Cat and dog owners' knowledge and preferences for veterinary communication

BACKGROUND

Veterinarians' understanding of cat and dog owners' perceptions about antimicrobial use will enhance their ability to communicate with clients to uphold antimicrobial stewardship guidelines.

METHODS

A total of 571 cat and dog owners were surveyed via an online platform to understand their antimicrobial knowledge and preferences for veterinary communication in antimicrobial use decision making. Data were analysed descriptively and inferentially to determine relationships between variables.

RESULTS

Cat and dog owners' backgrounds had an impact their antimicrobial knowledge. Women, individuals with a university degree, those with a health/science background and those identifying as white had a higher level of knowledge of antibiotics and antibiotic resistance. Owners' trust in veterinarians positively impacts adherence to recommendations. Where there was a strong preference for one type of messaging regarding antimicrobial use and stewardship, the owner's background was not predictive of a difference in response.

LIMITATIONS

The study population was mostly white, which reflects the US population and the reported distribution of pet owners who own dogs and cats. Respondents may have been susceptible to recall bias and/or social desirability bias.

CONCLUSION

Veterinarians should tailor their communication to meet clients' level of knowledge and rely on competent communication to enhance understanding and facilitate adherence to antimicrobial stewardship guidelines.

Decreases and Pronounced Geographic Variability in Antibiotic Prescribing in Medicaid

Antibiotic resistance is a persistent and growing concern. Our objective was to analyze antibiotic prescribing in the United States (US) in the Medical Expenditure Panel System (MEPS) and to Medicaid patients. We obtained MEPS prescriptions for eight antibiotics from 2013 to 2020. We extracted prescribing rates per 1000 Medicaid enrollees for two years, 2018 and 2019, for four broad-spectrum (azithromycin, ciprofloxacin, levofloxacin, and moxifloxacin) and four narrow-spectrum (amoxicillin, cephalexin, doxycycline, and trimethoprim-sulfamethoxazole) antibiotics. Antibiotic prescriptions in MEPS decreased from 2013 to 2020 by 38.7%, with a larger decline for the broad (-53.7%) than narrow (-23.5%) spectrum antibiotics. Antibiotic prescriptions in Medicaid decreased by 6.7%. Amoxicillin was the predominant antibiotic, followed by azithromycin, cephalexin, trimethoprim-sulfamethoxazole, doxycycline, ciprofloxacin, levofloxacin, and moxifloxacin. Substantial geographic variation in prescribing existed, with a 2.8-fold difference between the highest (Kentucky = 855/1000) and lowest (Oregon = 299) states. The South prescribed 52.2% more antibiotics (580/1000) than the West (381/1000). There were significant correlations across states (r = 0.81 for azithromycin and amoxicillin). This study identified sizable disparities by geography in the prescribing rates of eight antibiotics with over three-fold state-level differences. Areas with high prescribing rates, particularly for outpatients, may benefit from stewardship programs to reduce potentially unnecessary prescribing.

Beyond the patient-doctor dyad: Examining "other" patient engagement in Traditional Chinese Medicine consultations

This paper explores the unique phenomenon of "other" patient participation in Traditional Chinese Medicine (TCM). Specifically, it focuses on cases where doctors enlist the help of bystanders to address patient resistance and advance their medical agendas. By analyzing video-recorded practitioner-patient interactions in TCM hospitals, this study uncovers the various roles that third parties can assume during these medical interactions. The research identifies three distinct forms of "other" patient participation: the "other" patient as an illness-free individual providing a contrasting case, the "other" patient as a lay witness to the patient's clinical manifestations, and the "other" patient as a recovered fellow patient demonstrating treatment effectiveness. The findings of this study contribute to existing research on patient resistance and triadic medical interactions, offering insights into the dynamics and implications of third-party involvement in medical consultations.

Invoking Uncertainty: Parents' Accounts for Intrusions on Medical Authority in Pediatric Neurology

In pediatric medical visits, parents may assume the role of co-caregiver with clinicians. At times, parents challenge physicians' authority to determine diagnoses and treatments for their children. The present study uses conversation analysis to examine parents' accounts for their intrusions on medical authority in a corpus of 35 video-recorded pediatric neurology visits for overnight video-electroencephalogram monitoring. I show how parents can exploit their legitimate role as carers to challenge medical authority. Through invoking uncertainty in contexts where they have somehow challenged medical authority, parents can account for their conduct in ways that elide direct conflict with physicians and thereby minimize damage to the physician-family partnership.

Factors Associated with Geographical Variability of Antimicrobial Use in Japan

INTRODUCTION

Evidence regarding the factors affecting the geographical variation of antimicrobial use (AMU) is relatively scarce. This study aimed to evaluate factors potentially associated with geographical variability of AMU per day per 1000 habitants in the 47 prefectures of Japan.

METHODS

This is an observational ecological study using the Japanese national database in 2019. The outcome was the defined daily doses per 1000 inhabitants per day by prefecture. Multivariable negative binomial regression analysis was conducted using patient- and physician-level variables.

RESULTS

The study included 605,391,054 defined daily doses of AMU in 2019 from the 47 prefectures. In the multivariable negative binomial regression analyses for the outcome of total AMU, the proportion of female individuals (adjusted rate ratio [aRR] 1.04 [1.01-1.08] per 1% increase, p = 0.021), the proportion of upper secondary graduates going to further education (aRR 1.01 [1.00-1.01] per 1% increase, p = 0.005), and the annual number of diagnoses related to upper respiratory infections (URIs) per 1000 inhabitants per day (aRR 1.21 [1.10-1.34], p < 0.001) were significantly correlated with total AMU.

CONCLUSIONS

In this ecological study, the variability of total AMU by Japanese prefecture was associated with the proportion of female individuals, education level, and the number of URI diagnoses per population. The results suggest the potential need for additional stewardship efforts to reduce unnecessary antimicrobial prescriptions for URI.

Evaluating the long-term portrayal of antibiotic resistance in major U.S. newspapers

BACKGROUND

Popular media play a critical role in informing the public about antibiotic resistance, which has remained a health concern for over seven decades. Media attention increases the notoriety of antibiotic resistance and shapes the public's perception of its severity, causes, and solutions. Therefore, it is critical the media accurately portray scientific knowledge that may shape personal and policy responses to antibiotic resistance.

METHODS

We analyzed articles from two major U.S. newspapers, The New York Times and Los Angeles Times, from 1940 to 2019 to assess trends in sentiment and lexicon surrounding antibiotic and antimicrobial resistance.

RESULTS

We observed a gradual increase in the number of relevant articles about resistance, although far fewer than other topics with comparable mortality rates. We found a consistently threatening portrayal of antibiotic resistance as a crisis, reflected in the usage of terms such as "superbug" to refer to some pathogens. Governmental agencies responsible for determining antibiotic usage policies were infrequently mentioned in articles. Blame for resistance was almost exclusively attributed to inappropriate antibiotic use, mainly in animals, rather than appropriate uses of antibiotics.

CONCLUSIONS

Collectively, our results provide insights into how popular media can more accurately inform the public about antibiotic resistance. Potential changes include increasing news coverage, avoiding fear-mongering, and adequately conveying the multiple uses of antibiotics that can potentiate resistance.

Addressing Consumer Misconceptions on Antibiotic Use and Resistance in the Context of Sore Throat: Learnings from Social Media Listening

A misunderstanding of the mechanism of action and bacterial targets of antibiotics by consumers may drive inappropriate antibiotic use and antimicrobial resistance (AMR). Tackling AMR requires an in-depth understanding of consumer beliefs and misconceptions. We explored consumer conversations on a number of social media platforms on antibiotic use and AMR in the context of sore throat and how coronavirus disease 2019 (COVID-19) affected online conversations between 1 January 2018 and 25 November 2021 across eight countries. Five distinct consumer groups were identified (antibiotic-preserving peer educators, antibiotic-cautious consumers, medication-resistant antibiotic opponents, believers in the strength of antibiotics, determined pro-antibiotic consumers) with a wide spectrum of beliefs around antibiotics in sore throat. Many opinions were based upon misconceptions, the most prominent of which was that antibiotics are strong medications that can treat all types of sore throat. COVID-19 had a multifaceted effect on the sore throat and AMR conversation. Sore throat triggered anxiety as consumers feared it may be a COVID-19 symptom while engagement in conversations around antibiotics for COVID-19 increased. Finally, consumers sought multiple routes to access antibiotics, such as directly from the pharmacy or by attempting to persuade physicians to prescribe. Knowledge obtained from this study could be used to develop focused approaches to dispel consumer misconceptions and mitigate AMR.

Antibiotic utilization pattern in treatment of acute diarrheal diseases: the case of Hiwot Fana Specialized University Hospital, Harar, Ethiopia

BACKGROUND

The vast majority of acute diarrheal diseases are self-limiting and do not require treatment on a regular basis. Empirical antibiotics should only be used to treat dysenteric and invasive bacterial diarrhea. Antibiotic misuse in the treatment of acute diarrhea is widespread in clinical practice worldwide. Hence, the purpose of this study was to examine the pattern of antibiotic use for the acute diarrheal diseases at Hiwot Fana Specialized University Hospital, Harar, Ethiopia.

METHODS

A retrospective, institution-based cross-sectional study was conducted to investigate the antibiotic utilization pattern for the treatment of acute diarrheal diseases from September 1 to September 30, 2022. Data were obtained retrospectively from patient cards treated for diarrheal disorders from August 1, 2021 to August 31, 2022, using standardized questionnaires, and the analysis was performed using IBM SPSS Statistics version 27.

RESULTS

Among 332 patients in present study, 271 (81.63%) of them received nine different types of antibiotics, with the most commonly prescribed drugs were Cotrimoxazole (30.26%), Ciprofloxacin (19.19%), and Azithromycin (17.71%). Based on the presence of blood in the stools, 14.76% of the cases were invasive bacterial in nature. Antibiotics were prescribed about 2.55 times more frequently to patients under the age of 12 than to subjects 65 and older (AOR 2.55, 95% CI 1.45-3.87). Patients who received three or more medications were 2.77 times more likely to be prescribed antibiotics (AOR 2.77, 95% CI 1.84-7.56). For every unit increase in the number of drugs prescribed, the odds of prescribing antibiotics increased by 2.44 units (COR 2.44; 95% CI 2.06-4.32).

CONCLUSIONS

The current study found that antibiotics were overused in both adults and children with acute diarrheal diseases at Hiwot Fana Specialized University Hospital. The number of antibiotics prescribed was significantly associated with the patient's age and the number of medications prescribed. To reduce antibiotic overuse, health professionals have to follow the national standard treatment guidelines.

Exploring medical and veterinary student perceptions and communication preferences related to antimicrobial resistance in Ontario, Canada using qualitative methods

BACKGROUND

Antimicrobial resistance (AMR) threatens our ability to treat and prevent infectious diseases worldwide. A significant driver of AMR is antimicrobial use (AMU) in human and veterinary medicine. Therefore, education and awareness of AMR among antimicrobial prescribers is critical. Human and animal health professionals play important roles in the AMR issue, both as contributors to the emergence of AMR, and as potential developers and implementers of effective solutions. Studies have shown that engaging stakeholders prior to developing communication materials can increase relevance, awareness, and dissemination of research findings and communication materials. As future antimicrobial prescribers, medical and veterinary students' perspectives on AMR, as well as their preferences for future communication materials, are important. The first objective of this study was to explore medical and veterinary student perceptions and understanding of factors associated with emergence and spread of AMR. The second objective was to identify key messages, knowledge translation and transfer (KTT) methods, and dissemination strategies for communication of AMR information to these groups.

METHODS

Beginning in November 2018, focus groups were conducted with medical and veterinary students in Ontario, Canada. A semi-structured format, using standardized open-ended questions and follow-up probing questions was followed. Thematic analysis was used to identify and analyze patterns within the data.

RESULTS

Analyses showed that students believed AMR to be an important global issue and identified AMU in food-producing animals and human medicine as the main drivers of AMR. Students also highlighted the need to address society's reliance on antimicrobials and the importance of collaboration between different sectors to effectively reduce the emergence and transmission of AMR. When assessing different communication materials, students felt that although infographics provide easily digestible information, other KTT materials such as fact sheets are better at providing more information without overwhelming the target audiences (e.g., professional or general public).

CONCLUSION

Overall, the study participants felt that AMR is an important issue and emphasized the need to develop different KTT tools for different audiences. This research will help inform the development of future communication materials, and support development of AMR-KTT tools tailored to the needs of different student and professional groups.

It's about the patients: Practical antibiotic stewardship in outpatient settings in the United States

Antibiotic-resistant pathogens cause over 35,000 preventable deaths in the United States every year, and multiple strategies could decrease morbidity and mortality. As antibiotic stewardship requirements are being deployed for the outpatient setting, community providers are facing systematic challenges in implementing stewardship programs. Given that the vast majority of antibiotics are prescribed in the outpatient setting, there are endless opportunities to make a smart and informed choice when prescribing and to move the needle on antibiotic stewardship. Antibiotic stewardship in the community, or "smart prescribing" as we suggest, should factor in antibiotic efficacy, safety, local resistance rates, and overall cost, in addition to patient-specific factors and disease presentation, to arrive at an appropriate therapy. Here, we discuss some of the challenges, such as patient/parent pressure to prescribe, lack of data or resources for implementation, and a disconnect between guidelines and real-world practice, among others. We have assembled an easy-to-use best practice guide for providers in the outpatient setting who lack the time or resources to develop a plan or consult lengthy guidelines. We provide specific suggestions for antibiotic prescribing that align real-world clinical practice with best practices for antibiotic stewardship for two of the most common bacterial infections seen in the outpatient setting: community-acquired pneumonia and skin and soft-tissue infection. In addition, we discuss many ways that community providers, payors, and regulatory bodies can make antibiotic stewardship easier to implement and more streamlined in the outpatient setting.

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.

Managing Patient Pressure to Prescribe Antibiotics in the Clinic

Acute respiratory tract infections (ARTIs) are typically viral; however, in the USA, approximately one-third of adults and 52% of children with ARTIs receive an antibiotic, making antibiotic prescribing for ARTIs a major contributor to the problem of inappropriate prescribing. Relying on a synthesis of work across pediatric and adult primary care, this article shows some of the main ways that patients and parents pressure physicians for antibiotics, whether intentionally or unintentionally, and how physicians combat that pressure. All data are from video recordings of community-based clinical encounters allowing us to see what is happening "on the ground." Strategies that physicians actually use are documented; however, untutored physicians do not rely on these reliably or strategically, leaving substantial room for the deployment of a three-pronged communication strategy that can reduce patient pressure and inappropriate antibiotic prescribing.