Therapeutic Decision Making and Clinical Practice Guidelines

Grade methodology

• rate quality of evidence

• determine strength of recommendation

• grading of recommendations assessment development and evaluation

Determinants of strength of recommendation

• quality of evidence

• patient values/preferences

• balance between benefits, harms, and burden

• resources/cost

standards for credible guidelines

• transparency

• conflict of interest managed and reported

• well-balanced, multidisciplinary guideline development group

• systematic literature review

• recommendations with underlying reasoning, potential harms/benefits, quality of evidence, contribution of values/experience, level of confidence, strength of rec, and any differences of opinion

• recommendations clearly stated

• external review by relevant stakeholders, public

• provide date of publications/review

• update when new relevant info available

Benefits of guidelines

• improves quality of life, reduces morbidity/mortality

• better consistency of care

• directs future need for research/funding

• provides education to providers

• condenses lit and evidence to usable format

Guideline limitations

• may be outdated/not regularly updated

• different orgs may publish guidelines with conflicting recs

• recs can be cumbersome/unclear

• may not account for complex pts

Pharmacist decision making

• prescriptive (least prevalent)

• consultative

• corrective

• submissive (most prevalent)

Clinical decision making steps

1. identify actual/potential drug problem

2. determine desired outcome

3. evaluate potential therapeutic options

4. create optimal therapeutic regimen

5. identify appropriate monitoring parameters

6. provide patient education if appropriate

priority of clinical decision making

quality of clinical care

Therapeutic decision making steps

1. information gathering

2. clinical reasoning

3. clinical judgement

4. decision

Information Gathering sources

• documented info about pt

• patient interview

• guidelines/literature review

• past experience

Patient information synthesis

• compile pertinent facts

• develop prioritized problem list

• stage each problem according to guidelines

Clinical Reasoning

• evaluate gathered info

• apply to specific pt treatment goals

• create list of viable options to meet tx goals

Clinical judgement

• perform risk/benefit assessment for each treatment options

• create ranked list of management options

Decision

• patient-focused consideration basd on previous clinical judgement

• enact decision with pt/provider