What Does Patient-Centered Communication Look Like?: Linguistic Markers of Provider Compassionate Care and Shared Decision-Making and Their Impacts on Patient Outcomes.

Patient-centered communication promotes positive patient outcomes. This study examines the linguistic markers of two key dimensions of patient-centered communication (i.e., provider compassionate care and shared decision-making) and their mediating effects on patient perceived quality of and affective responses to the provider's treatment recommendations. Transcripts (N = 343) of provider talk from provider-patient interactions in medical visits for upper respiratory infection symptoms where patients were not prescribed with antibiotics were analyzed with the Linguistic Inquiry and Word Count (LIWC) dictionary. Results showed that providers' use of affiliation words positively predicted patients' perceptions of their providers' compassionate care. Providers' use of insight words negatively predicted patients' perceptions of provider shared decision-making. Meanwhile, providers' use of first-person singular pronouns, causation and differentiation words, and clout words were positively related to perceived provider shared decision-making. Patient perceived compassionate care and shared decision-making further increased patients' positive affect toward and perceived quality of non-antibiotic treatment recommendations. These perceptions also reduced their negative affect toward the recommendations. Implications of the findings are discussed with regard to patient-centered communication in relation to the promotion of antibiotic stewardship.

Antibiotic stewardship with upper respiratory tract infection patients at student health centers: Providers' communication experiences and strategies.

BACKGROUND: Effective provider-patient communication can improve antibiotic stewardship in primary care, but providers find it challenging to discuss antibiotics with patients. This study, focused on college student health centers, examines patients' tactics for obtaining antibiotics for upper respiratory tract infections and providers' communication strategies for improving patient understanding and reducing demand. METHODS: Health care providers (N = 103) employed at student health centers on large and primarily residential college campuses in the U.S. completed an online survey. RESULTS: Providers perceived patients as wanting antibiotics in approximately 50% of upper respiratory tract infection visits and noted multiple patient tactics to obtain them, including reports of prior prescribing, suggested diagnoses, and direct requests. Providers used multiple strategies to manage patient demand, including explanation of the diagnosis, antibiotic utility and risks, and treatment plan. DISCUSSION: This study extends prior research indicating that patients exercise a range of influence tactics to obtain antibiotics, and thereby create discomfort for providers. The study also elucidates providers' efforts to counter these influence tactics and steward antibiotics by educating patients. CONCLUSIONS: Additional research is needed to specify the most effective ways for providers to respond to patients' influence tactics, including the best approaches to explaining diagnosis, treatment, and antibiotic resistance.

Mental Health and Its Predictors during the Early Months of the COVID-19 Pandemic Experience in the United States.

To date, there has been relatively little published research on the mental health impacts of COVID-19 for the general public at the beginning of the U.S.' experience of the pandemic, or the factors associated with stress, anxiety, depression, and post-traumatic growth during this time. The current study provides a longitudinal examination of the predictors of self-reported stress, anxiety, depression, and post-traumatic growth for U.S. residents between April and May, 2020, including the influence of demographic, psychosocial, and behavioral factors on these outcomes. The findings indicate that, generally, the early months of the U.S. COVID-19 experience were characterized by a modest negative impact on mental health. Younger adults, people with pre-existing health conditions, and those experiencing greater perceived risk, higher levels of rumination, higher levels of co-rumination, greater social strain, or less social support reported worse mental health. Positive mental health was associated with the adoption of coping strategies, especially those that were forward-looking, and with greater adherence to national health-protection guidelines. The findings are discussed with regard to the current status of health-protective measures and mental health in the U.S., especially as these impact future management of the on-going pandemic.

Targeting Perceptions of Risk from Injudicious Antibiotic Use: An Application of the Risk Information Seeking and Processing Model.

Enhancing knowledge about antibiotic-associated risks is key to reducing injudicious antibiotic use and slowing antibiotic resistance. Using the Risk Information Seeking and Processing (RISP) model, the study identified predictors of individuals' seeking and avoidance of information about antibiotic risks and tested the effectiveness of exposure to a RISP-informed video intervention against exposure to a CDC-produced video and a control group. In a national sample (N = 1000), risk judgment led to greater negative affect toward risks of antibiotics and lower positive affect toward antibiotic usefulness. In turn, positive and negative affect shaped information insufficiency, which interacted with perceived information gathering capacity to influence risk information seeking and avoidance. In addition, informational subjective norms and affective responses directly shaped individuals' information behavior. Results showed that relative to the control group, participants viewing the RISP-informed video had greater risk judgment, perceived current knowledge about antibiotic risks, perceived information gathering capacity, and informational subjective norms, as well as lower levels of positive affect toward antibiotics. The RISP-informed video and CDC-produced video performed equivalently well. Implications of the findings for the design of antibiotic stewardship messages are discussed.

Factors associated with antibiotic prescribing for acute bronchitis at a university health center.

BACKGROUND: Antibiotics are not indicated for treating acute bronchitis cases, yet up to 70% of adult acute bronchitis medical visits in the USA result in an antibiotic prescription. Reducing unnecessary antibiotic prescribing for acute bronchitis is a key antibiotic stewardship goal set forth by the Centers for Disease Control and Prevention. Understanding what factors influence prescribing for bronchitis cases can inform antimicrobial stewardship initiatives. The goal of this study was to identify factors associated with antibiotic prescribing at a high-volume student health center at a large US university. The Pennsylvania State University Health Services offers on-campus medical care to a population of over 40,000 students and receives over 50,000 visits every year. METHODS: We conducted a retrospective chart review of acute bronchitis visits for the 2015-2016 academic year and used a multivariate logistic regression analysis to identify variables associated with antibiotic prescribing. RESULTS: Findings during lung exams increased the likelihood of an antibiotic prescription (rales OR 13.95, 95% CI 3.31-80.73; rhonchi OR 5.50, 95% CI 3.08-10.00; percussion abnormality OR 13.02, 95% CI 4.00-50.09). Individual clinicians had dramatically different rates of prescribing (OR range 0.03-12.3). Male patients were more likely than female patients to be prescribed antibiotics (OR 1.68, 95% CI 1.17-2.41). Patients who reported longer duration since the onset of symptoms were slightly more likely to receive prescriptions (OR 1.04 per day, 95% CI 1.03-1.06), as were patients who reported worsening symptoms (OR 1.78, 95% CI 1.03-3.10). Visits with diagnoses or symptoms associated with viral infections or allergies were less likely to result in prescriptions (upper respiratory tract infection (URI) diagnosis OR 0.33, 95% CI 0.18-0.58; sneezing OR 0.39, 95% CI 0.17-0.86; vomiting OR 0.31, 95% CI 0.10-0.83). An exam finding of anterior cervical lymphadenopathy was associated with antibiotic prescribing (tender OR 3.85, 95% CI 1.70-8.83; general OR 2.63, 95% CI 1.25-5.54). CONCLUSIONS: Suspicious findings during lung examinations (rales, rhonchi, percussion abnormality) and individual healthcare providers were important factors influencing antibiotic prescribing rates for acute bronchitis visits. Patient gender, worsening symptoms, duration of illness, symptoms associated with viral infections or allergies, and anterior cervical lymphadenopathy also influenced prescribing rates.

Decreasing the Peril of Antimicrobial Resistance Through Enhanced Health Literacy in Outpatient Settings: An Underrecognized Approach to Advance Antimicrobial Stewardship.

Globally, antimicrobial resistance (AMR) is a serious problem causing 700,000 deaths annually. By 2050, AMR is expected to cause approximately 10 million deaths globally each year if allowed to increase at the present rate. Many individuals have limited knowledge regarding appropriate antibiotic use and AMR. Most antibiotic use occurs in the outpatient setting, with approximately 30% of antibiotics prescribed deemed unnecessary. Antimicrobial stewardship (AMS) is a means to reduce inappropriate antibiotic use and AMR. While existing AMS efforts generally focus on the inpatient setting, a significant gap is present in the outpatient setting. A common theme across various national action plans to reduce AMR is the need for education and awareness. The importance of communicating information in a manner easily comprehended by the patient in addition to productive clinician-patient dialogue cannot be overestimated. Enhancing the public's and patients' AMS health literacy is an underrecognized approach to help address AMR. We describe Four Core Elements of Enhancing AMS Health Literacy in the Outpatient Setting, utilizing the Centers for Disease Control and Prevention's framework: (1) leadership commitment, (2) intervention/action, (3) tracking/reporting, and (4) education/expertise. We call upon leaders in outpatient settings to embrace this approach to curb inappropriate antimicrobial use.

Diagnostic Accuracy, Prescription Behavior, and Watchful Waiting Efficacy for Pediatric Acute Otitis Media.

Current guidelines recommend "watchful waiting" (WW) as an alternative to immediate antibiotic treatment. Continued high rates of antibiotic use suggest that WW may be underutilized. We conducted a retrospective chart review of 474 pediatric acute otitis media (AOM) cases at a clinic in central Pennsylvania. We assessed physical examination findings, diagnostic behavior, WW utilization, prescription writing, and filling in cases of pediatric AOM to evaluate the underutilization of WW. We evaluate diagnostic consistency with published guidelines and rates of antibiotic prescription resulting from misdiagnosis. We report WW instructions and compliance, and prescription filling behaviors. Fifty percent of AOM diagnoses in this sample were not supported by physical examination findings. The majority of these AOM diagnoses received antibiotic prescriptions, suggesting that unsupported diagnoses translated to injudicious prescribing. WW instructions corresponded to 57% fewer filled prescriptions and longer fill delay. We discuss the implications and recommendations to improve antibiotic stewardship.

Social Network, Surgeon, and Media Influence on the Decision to Undergo Contralateral Prophylactic Mastectomy.

OBJECTIVES: The rate of contralateral prophylactic mastectomy (CPM) has risen sharply in the past decade. The current study was designed to examine social network, surgeon, and media influence on patients' CPM decision-making, examining not only who influenced the decision, and to what extent, but also the type of influence exerted. METHODS: Patients (N=113) who underwent CPM at 4 Indiana University-affiliated hospitals between 2008 and 2012 completed structured telephone interviews in 2013. Questions addressed the involvement and influence of the social network (family, friends, and nonsurgeon health professionals), surgeon, and media on the CPM decision. RESULTS: Spouses, children, family, friends, and health professionals were reported as exerting a meaningful degree of influence on patients' decisions, largely in ways that were positive or neutral toward CPM. Most surgeons were regarded as providing options rather than encouraging or discouraging CPM. Media influence was present, but limited. CONCLUSIONS: Patients who choose CPM do so with influence and support from members of their social networks. Reversing the increasing choice of CPM will require educating these influential others, which can be accomplished by encouraging patients to include them in clinical consultations, and by providing patients with educational materials that can be shared with their social networks. Surgeons need to be perceived as having an opinion, specifically that CPM should be reserved for those patients for whom it is medically indicated.

Campaign Preparation for Complex Initiatives: A Person-Centered Approach to Audience Segmentation of Parents' Antibiotic Stewardship.

The evolution of antibiotic resistance is outpacing the speed at which new antibiotics will reach the marketplace. To slow the rate of resistance, people need to engage in antibiotic stewardship, which includes acts to prevent the spread of bacteria and judicious use of antibiotics to treat infections. This study identified the patterns and predictors of antibiotic stewardship behaviors of parents (N = 516) related to their children. The latent class analysis revealed three profiles of parental stewardship, labeled Stewards, Requesters, and Non-Stewards. The findings implied different campaign goals: to encourage Stewards to follow through on their intentions, to encourage Requesters to stop asking providers for antibiotics when their children have ear infections, and to influence Non-Stewards to accept medical advice when an antibiotic is not indicated and to dispose of leftover antibiotics. The covariate analysis provided theoretical insight into the strategies to pursue in campaigns targeting these three groups. For example, parents who perceived antibiotic-resistant infections as less serious health conditions, felt less worry when thinking about their child getting an antibiotic-resistant infection, and had stronger misattributions of antibiotics' efficacy to treat multiple symptoms were more likely to be Requesters and Non-Stewards, instead of Stewards.

Toward Reduction in Antibiotic Use for Pediatric Otitis Media: Predicting Parental Compliance with "Watchful Waiting" Advice.

"Watchful waiting" (WW) can reduce unnecessary antibiotic use in the treatment of pediatric otitis media (ear infection), but the utility of the strategy is impaired by underutilization and noncompliance. Guided by advice response theory (ART), the current study examines how parental compliance with WW and trust in the prescribing physician is predicted by evaluative and affective responses to the advice. Parents (N = 134) of at least one child aged 5 years or younger completed questionnaires that assessed responses to WW advice they received for their youngest child. Perceptions of the advantage from and capacity to undertake WW, the child's level of pain, and the tact (autonomy-granting politeness) of the health care provider predicted compliance and provider trust both directly and indirectly, through advice quality and negative affect. The study suggests modifications to ART that will extend its scope and provides practical guidance for health care providers seeking to improve parent compliance with WW advice.

Motivations for contralateral prophylactic mastectomy as a function of socioeconomic status.

BACKGROUND: Despite no demonstrated survival advantage for women at average risk of breast cancer, rates of contralateral prophylactic mastectomy (CPM) continue to increase. Research reveals women with higher socioeconomic status (SES) are more likely to select CPM. This study examines how indicators of SES, age, and disease severity affect CPM motivations. METHODS: Patients (N = 113) who underwent CPM at four Indiana University affiliated hospitals completed telephone interviews in 2013. Participants answered questions about 11 CPM motivations and provided demographic information. Responses to motivation items were factor analyzed, resulting in 4 motivational factors: reducing long-term risk, symmetry, avoiding future medical visits, and avoiding treatments. RESULTS: Across demographic differences, reducing long-term risk was the strongest CPM motivation. Lower income predicted stronger motivation to reduce long-term risk and avoid treatment. Older participants were more motivated to avoid treatment; younger and more-educated patients were more concerned about symmetry. Greater severity of diagnosis predicted avoiding treatments. CONCLUSIONS: Reducing long-term risk is the primary motivation across groups, but there are also notable differences as a function of age, education, income, and disease severity. To stop the trend of increasing CPM, physicians must tailor patient counseling to address motivations that are consistent across patient populations and those that vary between populations.

Watchful Waiting for Cases of Pediatric Otitis Media: Modeling Parental Response to Physician Advice.

Watchful waiting (WW) can reduce unnecessary antibiotic use in the treatment of pediatric otitis media (ear infection), but its utility is impaired by underutilization and noncompliance. Guided by advice response theory, the current study proposes advantage and capacity as factors that predict how caregivers evaluate and respond affectively to WW. Parents (N = 373) of at least 1 child age 5 years or younger completed questionnaires that assessed responses to hypothetical WW advice for their youngest child. Perceptions of advantage from WW and the capacity to monitor and manage symptoms predicted advice quality, physician trust, and future compliance both directly and indirectly through negative affect. The findings suggest the elaboration of advice response theory to include more aspects of advice content evaluation (e.g., advantage) and the influence of negative affect. The study also provides practical guidance for physicians seeking to improve caregiver reception of WW advice.

Motivations, concerns, and experiences of women who donate normal breast tissue.

BACKGROUND: The Susan G. Komen for the Cure Tissue Bank at the IU Simon Cancer Center (KTB) was established in 2007 with funding from Susan G. Komen for the Cure to provide scientists with a resource for normal breast tissue. To date, nearly 3,500 women have donated their healthy breast tissue to the bank, but little is known about their perspectives. This study was designed to examine their motivations, concerns, and experiences. METHODS: We conducted brief interviews with donors (n = 221) to investigate their donation-related motivations, concerns, and experiences. Donor responses were coded and quantitatively analyzed (descriptive statistics and χ(2)). RESULTS: The most frequent motivation to donate (48% of donors) was personal connection to a breast cancer patient/survivor. A majority of donors (60%) were unconcerned about donation before the event; reported concerns included pain, fear, and dislike of surgical procedures. The most frequent positive experiences were minimal pain and positive behavior by KTB staff and volunteers. A majority of donors (61%) reported no negative experience, but reported negative experiences included the biopsy machine and anesthetic. Younger donors (ages 18-24) reported more concerns and negative experiences than older donors (25+). CONCLUSIONS: Donors of healthy breast tissue are motivated by survivor connections and the ability to help by donating. Their concerns and experiences are relatively positive and consistent with undergoing a minor surgical procedure. Younger donors have more concerns and negative experiences. IMPACT: Findings from this study can inform recruitment campaigns and donation procedures for banking of healthy tissue.

Perceptions of supportive behavior by young adults with bipolar disorder.

Bipolar disorder is a mental illness with a significant negative impact on quality of life. People with bipolar disorder benefit when family and friends provide social support, but quantity and quality of support are often lacking. We present an exploration of the types of behaviors from support network members that young adults (ages 18 to 30) with bipolar disorder perceived as helpful in coping with the illness. We conducted semistructured ethnographic interviews with young adults (N = 30) with bipolar disorder and analyzed them using qualitative coding methods. We found that young adults with bipolar disorder considered a wide variety of emotion-focused and instrumental behaviors helpful, with some behaviors tailored to the unique characteristics of the illness. These findings also indicate the types of behavior support providers might use to help network members cope with bipolar disorder, and the research needed to better understand social support in the context of chronic mental illness.

After 9/11: goal disruption, emotional support, and psychological health in a lower exposure sample.

The terrorist attacks of 9/11 were traumatic even for Americans who were not directly victimized or in the geographic vicinity. This study examined whether emotional support received through interaction with others buffered the association between terrorism-related stress and psychological health (depression, anxiety, and physical symptoms) for individuals with lower exposure to the attacks. Five hundred eleven college students from an eastern university completed measures of goal disruption (stress) from terrorism, received emotional support, and psychological health in the first 2 weeks of December 2001. The results indicate that received emotional support moderated the relationship between goal disruption and depression and somatic symptoms. These findings suggest that the provision of emotional support should be understood as a fundamental communication skill relevant to recovery from disaster events.