Lecture Notes

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Types of Drug info requests:

  • Verbal consults (phone, voicemail)

  • Written (email, mail, fax, text, electronic)

  • Personal interactions

Importance of written DI responses:

  • mech for communicating info

  • written back up to verbal response

  • documentation (prof responsibility, position justification, legal issues)

Evidence-based practice:

  • best available evidence

  • clinical expertise

  • patient pref

Five A’s of EBP

  • Ask an answerable question

    • Obtain request info

    • obtain requestor demographics

    • obtain background

    • determine EBP question

  • Acquire the best evidence

    • define search criteria

    • define search strat

  • Appraise the evidence

    • evaluate the studies found

    • evaluate the info

  • Apply the evidence

    • synthesize the info

    • apply results to patients

  • Assess the results

    • determine the final rec

    • document final answer

Documenting DI Request

  • EBP allows organized, structured process for providing responses the DI inquiries

  • intake or documentation form often used to facilitate

  • benefits:

    • ensures sufficient background info and patient data obtained

    • helps to guide pharmacist in providing complete response

    • avoids oversimplification of DI question

  • disadvantages:

    • may not apply in all situations

    • could disrupt the natural flow of info

Question and background

  1. write down what requestor is asking

  2. obtain background info (if applicable)

    1. patient-specific, academic, personal?

    2. what resources has requestor already consulted?

    3. why is question being asked?

    4. how will the info provided by used?

      1. treating patient? deposition for lawsuit?

    5. how has the problem/situation been managed to date?

    6. are there alternative options that should be explored?

Importance of Background

  • arrive at real question

  • understand needs

  • provide responses that addresses needs

  • avoid vague/general response

  • anticipate additional questions/concerns

Tips:

  • good communication skills: respect, correct grammar, appropriate terms

  • always restate questions

  • ensure enough info gathered so question “why is requestor asking for this info” can be answered

  • call requestor back if additional info is necessary after the initial encounter with the requestor

Requestor Info

  • name/contact

  • appropriate mode of communication for response

  • when response needed

  • assess requestor’s background knowledge and familiarity with the topic

Patient Info

  • gender

  • age

  • height/weight

  • race

  • allergies

  • PMH

  • SH

  • meds (prescriptions, OTC, Herbal)

  • Relevant physical findings (symptoms, vitals)

  • relevant lab and procedure data

Requestor presented problem

  • write down what requestor ask

  • write down other info gained when inquired further

Treatment

  • what is the standard treatment for the problem?

  • how is the patient treating the issue?

PICO

  • Patient/Population/Problem

  • Intervention

  • Comparison

  • Outcomes

Initial EBP question

  • requestor may miss or omit details in original request or requestor may phrase question in indirect or disorganized manner

  • pharmacist needs to identify true need

Structuring EBP question options:

  1. In POPULATION, what is the effect of INTERVENTION on OUTCOME compared with COMPARISON?

  2. In POPULATION, does the use of INTERVENTION reduce the future risk of OUTCOME compared with COMPARISON?

Categorizing question

  • what is underlying topic of question?

    • adverse event, product info, pharmacokinetics, etc

  • often multiple categories

  • helps with search strategies


Evidence Evaluation: (2/11)

  • Evidence based practice:

    • best available evidence

    • clinical expertise

    • patient preference: take best guidelines and clinical expertise that your patient will comply with

Literature Types:

  1. Primary: direct access to data

  2. Secondary: abstracting of indexing search engines, facilitate location of primary and tertiary literature

  3. Tertiary lit: indirect access to data, author interpretation of the literature

When answering a DI question, what literature do we search?

  1. tertiary

  2. practice guidelines

  3. systematic reviews/meta-analyses

    1. bigger sample size

  4. primary literature

    1. back up information that you have

    2. may be part of systematic review

What questions can be answered with tertiary sources?

  • what is apixban’s place in the management of atrial fibrillation?

  • what is the dosing of xarelto for atrial fibrillation

  • how should the dose of eliquis be adjusted for decreased renal function?

  • how long should treatment be continued with xarelto for atrial fibrillation?

  • what is the level of evidence for the use of eliquis in atrial fibrillation?

Use of AI

  • where is AI getting the information?

    • ask it to provide sources

    • double check information: make sure references are not hallucinated (make something up)

  • report use of AI

    • debate about it, but bc not provided by human, it is not cited

Levels of evidence:

  • do not mean that weaker levels are not good sources of information, just not as strong

  • strongest: clinical practice guidelines/health technology assessments, then systematic review meta-analysis

Are all RCTs better than a cohort study?

  • a well-designed cohort study might provide better evidence than a poorly executed randomized controlled trial

    • may be poorly designed

  • a lower-level article may be better evidence than a higher level one


Practice Guidelines

  • check authorship and affiliations

    • reputable guidelines usually associated with non-profit organizations

    • some guidelines sponsored by drug companies (probably biased toward drug that company produces)

  • funding source

  • date of publication

    • takes a long time to complete, very costly (many experts gather together), may not reconvene very often

    • ex. stemi guidelines: from 2013

    • sometimes do focused updates

    • some update annually (diabetes)

  • methodology of development

    • how was literature searched, how was literature chosen, how did they grade level of evidence

  • level of evidence for recommendations


Systematic Review vs Meta-Analysis

  • Systematic review:

    • authors collect evidence from previously conducted studies and summarize it

    • NO statistics performed

  • Meta Analysis:

    • authors collect evidence from previously conducted studies and summarize

    • statistics performed

    • “study of studies”

Advantages and Disadvantages of Systematgic Reviews and Meta-Analyses

  • advantages:

    • comprehensive

    • increased precision of effect

      • larger sample size

    • enhance statistical power

  • disadvantages:

    • quality of studies included

      • low quality studies may yield inappropriate conclusions

    • publication bias

      • overstimulation of treatment effects

    • confounding factors

    • incomplete reporting

Primary Literature:

  • randomized controlled trial

The Life Cycle of Scientific Information

  • start at original research

  • write up and rewrite results

  • submit for publication

  • peer review, likely sent back to rewrite (or rejected entirely)

Peer Review:

  • ”a process by which something proposed (as research or publication) is evaluated by a group of experts in the appropriate field”

  • Not everything in a journal is peer-reviewed

    • original research will be peer-reviewed

      • systematic reviews and meta analyses will be reviewed

    • editorials, opinions, etc will not be reviewed

Evaluating a journal’s reputability

  1. recognized as a scholarly publication

  2. transparent publication process

  3. respected within discipline

Is it indexed in medline?