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BackgroundOne-third of outpatient antibiotic prescriptions for pediatric acute respiratory tract infections (ARTIs) are inappropriate. We evaluated a distance learning program's effectiveness for reducing outpatient antibiotic prescribing for ARTI visits.MethodsIn this stepped-wedge clinical trial run from November 2015 to June 2018, we randomly assigned 19 pediatric practices belonging to the Pediatric Research in Office Settings Network or the NorthShore University HealthSystem to 4 wedges. Visits for acute otitis media, bronchitis, pharyngitis, sinusitis, and upper respiratory infection for children 6 months to

ObjectiveSoliciting patients' complete agendas of concerns (aka. 'agenda setting') can improve patients' health outcomes and satisfaction, and physicians' time management. We assess the distribution, content, and effectiveness of physicians' post-chief-complaint, agenda-setting questions.MethodsWe coded videotapes/transcripts of 407 primary-, acute-care visits between adults and 85 general-practice physicians operating in 46 community-based clinics in two states representing urban and rural care. Measures are the incidence of physicians' questions, their linguistic format, position within visits, likelihood of being responded to, and the nature of such responses.ResultsPhysicians' questions designed to solicit concerns additional to chief concerns occurred in only 32% of visits (p

In the more than 1 billion primary-care visits each year in the United States, the majority of patients bring more than one distinct concern, yet many leave with "unmet" concerns (i.e., ones not addressed during visits). Unmet concerns have potentially negative consequences for patients' health, and may pose utilization-based financial burdens to health care systems if patients return to deal with such concerns. One solution to the problem of unmet concerns is the communication skill known as up-front agenda setting, where physicians (after soliciting patients' chief concerns) continue to solicit patients' concerns to "exhaustion" with questions such as "Are there some other issues you'd like to address?" Although this skill is trainable and efficacious, it is not yet a panacea. This article uses conversation analysis to demonstrate that patients understand up-front agenda-setting questions in ways that hamper their effectiveness. Specifically, we demonstrate that up-front agenda-setting questions are understood as making relevant "new problems" (i.e., concerns that are either totally new or "new since last visit," and in need of diagnosis), and consequently bias answers away from "non-new problems" (i.e., issues related to previously diagnosed concerns, including much of chronic care). Suggestions are made for why this might be so, and for improving up-front agenda setting. Data are 144 videotapes of community-based, acute, primary-care, outpatient visits collected in the United States between adult patients and 20 family-practice physicians.

ObjectivesWe investigated how provider vaccine communication behaviors influence parental vaccination acceptance and visit experience.MethodsIn a cross-sectional observational study, we videotaped provider-parent vaccine discussions (n = 111). We coded visits for the format providers used for initiating the vaccine discussion (participatory vs presumptive), parental verbal resistance to vaccines after provider initiation (yes vs no), and provider pursuit of recommendations in the face of parental resistance (pursuit vs mitigated or no pursuit). Main outcomes were parental verbal acceptance of recommended vaccines at visit's end (all vs ≥ 1 refusal) and parental visit experience (highly vs lower rated).ResultsIn multivariable models, participatory (vs presumptive) initiation formats were associated with decreased odds of accepting all vaccines at visit's end (adjusted odds ratio [AOR] = 0.04; 95% confidence interval [CI] = 0.01, 0.15) and increased odds of a highly rated visit experience (AOR = 17.3; 95% CI = 1.5, 200.3).ConclusionsIn the context of 2 general communication formats used by providers to initiate vaccine discussions, there appears to be an inverse relationship between parental acceptance of vaccines and visit experience. Further exploration of this inverse relationship in longitudinal studies is needed.

PurposeThis study examined relationships between provider communication practices, antibiotic prescribing, and parent care ratings during pediatric visits for acute respiratory tract infection (ARTI).MethodsA cross-sectional study was conducted of 1,285 pediatric visits motivated by ARTI symptoms. Children were seen by 1 of 28 pediatric providers representing 10 practices in Seattle, Washington, between December 2007 and April 2009. Providers completed post-visit surveys reporting on children's presenting symptoms, physical examination findings, assigned diagnoses, and treatments prescribed. Parents completed post-visit surveys reporting on provider communication practices and care ratings for the visit. Multivariate analyses identified key predictors of prescribing antibiotics for ARTI and of parent visit ratings.ResultsSuggesting actions parents could take to reduce their child's symptoms (providing positive treatment recommendations) was associated with decreased risk of antibiotic prescribing whether done alone or in combination with negative treatment recommendations (ruling out the need for antibiotics) [adjusted risk ratio (aRR) 0.48; 95% CI, 0.24-0.95; and aRR 0.15; 95% CI, 0.06-0.40, respectively]. Parents receiving combined positive and negative treatment recommendations were more likely to give the highest possible visit rating (aRR 1.16; 95% CI, 1.01-1.34).ConclusionCombined use of positive and negative treatment recommendations may reduce the risk of antibiotic prescribing for children with viral ARTIs and at the same time improve visit ratings. With the growing threat of antibiotic resistance at the community and individual level, these communication techniques may assist frontline providers in helping to address this pervasive public health problem.

ObjectiveTo characterize provider-parent vaccine communication and determine the influence of specific provider communication practices on parent resistance to vaccine recommendations.MethodsWe conducted a cross-sectional observational study in which we videotaped provider-parent vaccine discussions during health supervision visits. Parents of children aged 1 to 19 months old were screened by using the Parent Attitudes about Childhood Vaccines survey. We oversampled vaccine-hesitant parents (VHPs), defined as a score ≥50. We developed a coding scheme of 15 communication practices and applied it to all visits. We used multivariate logistic regression to explore the association between provider communication practices and parent resistance to vaccines, controlling for parental hesitancy status and demographic and visit characteristics.ResultsWe analyzed 111 vaccine discussions involving 16 providers from 9 practices; 50% included VHPs. Most providers (74%) initiated vaccine recommendations with presumptive (e.g., "Well, we have to do some shots") rather than participatory (e.g., "What do you want to do about shots?") formats. Among parents who voiced resistance to provider initiation (41%), significantly more were VHPs than non-VHPs. Parents had significantly higher odds of resisting vaccine recommendations if the provider used a participatory rather than a presumptive initiation format (adjusted odds ratio: 17.5; 95% confidence interval: 1.2-253.5). When parents resisted, 50% of providers pursued their original recommendations (e.g., "He really needs these shots"), and 47% of initially resistant parents subsequently accepted recommendations when they did.ConclusionsHow providers initiate and pursue vaccine recommendations is associated with parental vaccine acceptance.

This JAMA Insights in the Communicating Medicine series explores how differences in word choice can affect both visit interactions and visit outcomes in patient encounters. [ABSTRACT FROM AUTHOR]

This article is a conversation-analytic examination of situations where one speaker responds to another in a way that publicly exposes that the two speakers hold an incompatible position on a same matter, and in a way that claims that the respondent holds epistemic authority over the matter. These types of responsive actions (i.e., counterinformings) solicit accepting or rejecting responses, and normally include information (e.g., an explanation) that facilitates the other speaker's ability to reconcile the speakers' positional incompatibility. Withholding such information from a counterinforming can be an interactional control tactic. This article focuses on these types of withholding counterinformings and their management by the other speaker. Specifically, this article describes an interactional practice used to solicit reconciliatory information.

Extending Jefferson's analysis of the limited utility of turn-constructional-unit (TCU)-initial particles in managing overlapping talk, this article limits itself to a similar turn-taking context/position in which current speakers bring TCUs to places of possible completion when it is relevant for next speakers to take a turn of talk. This article examines situations in which current speakers continue to audibly inhale in the transition space, arguing that inhalations (a) are pre-beginning actions; (b) bestow a weaker right to speak next than does talk; (c) are not accountable for obscuring next speakers' talk (if it eventuates); (d) allow for beginning TCUs while monitoring for next speakers' talk, thereby allowing inhalers to proceed contingently based on next speakers' unfolding conduct; and (e) are used to mitigate the systemic turn-taking troubles of "no person speaking at a time" and "more than one person speaking at a time." Data are videotapes of mundane, dyadic, American English conversation. [ABSTRACT FROM AUTHOR]

This investigation assesses interobserver agreement on conversation analytic (CA) transcription. Four professional CA transcribers spent a maximum of 3 hours transcribing 2.5 minutes of a previously unknown, naturally occurring, mundane telephone call. Researchers unitized transcripts into words, sounds, silences, inbreaths, outbreaths, and laugh tokens, and then coded each of 1,827 units on as many as 15 transcription dimensions. Agreement was assessed using Cohen's kappa for nominal level data: Speaker designation, unit sequencing, semantics, orthography, cutoff, and plosiveness reached the level of "substantial" agreement (90% or greater accuracy). Pitch, overlap, doubt, and smile voice reached the level of "moderate" agreement (80-89% accuracy), while pace, sound stretch, underline/amplitude, and intonation fell below acceptability except when examined post hoc as presence versus absence of the feature. Silence lengths, examined as ratio-level data, were reliable at the "acceptable" level (alpha greater than .70) among those using a counting method (as opposed to stopwatch or other mechanical means). We make recommendations for transcription training.

Examines how physicians and patients interactionally accomplish the transition from the activity of history taking to that of physical examination. Finds implications for: the theoretic relationship between verbal and nonverbal behavior in social meaning; what it means to explain transitions and reduce patients' uncertainty; the organization of physician-patient interaction; and the relationship and interface between macro- and microconceptualizations of context. (SG)