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Information Mastery: A Practical Approach to Evidence-Based Care

Information Mastery: A Practical Approach to Evidence-Based Care. Course Directors: Allen Shaughnessy, PharmD, MMedEd David Slawson, MD Tufts Health Care Institute Tufts University School of Medicine November 10-12, 2011 Boston, Massachusetts.

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Information Mastery: A Practical Approach to Evidence-Based Care

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  1. Information Mastery:A Practical Approach to Evidence-Based Care Course Directors: Allen Shaughnessy, PharmD, MMedEd David Slawson, MD Tufts Health Care Institute Tufts University School of Medicine November 10-12, 2011 Boston, Massachusetts

  2. Information Mastery:A Practical Approach to Evidence-Based Care Taking the Right STEPS to Avoid Fallacies of Decision-Making

  3. Taking the Right STEPS . . .

  4. “Level 0” Proficiency • Three factors influenced most, if not all, of the decision making. • What are they? • Patient request • Pharmaceutical rep recommendation • Local expert-based CME Prosser H, Almond S, Walley T. Influences on GPs' decision to prescribe new drugs—the importance of who says what. Fam Pract 2003;20: 61-8 • NOT the “Best Information”

  5. Information Mastery Proficiency • Level 1: Use the highest quality information to guide clinical decisions (100%) • Level 2: Search, evaluate, and make available specialty specific Level 1 information (<1%) • Level 3: Create original research (primary) or systematic reviews (secondary)

  6. Prescribing of alpha-blockers in the US following ALLHATStafford RS, et al. JAMA 2004; 291: 54-62

  7. Taking the right “STEPS” when evaluating new information S = Safety T = Tolerability look for “pooled drop-out rates” E = Effectiveness -- Studies showing that the new drug is better than your current choice • Subtherapeutic vitamin D doses in all bisphosphonate studies P = Price S = Simplicity of use Preskorn SH. Advances in antidepressant therapy: the pharmacologic basis. San Antonio: Dannemiller Memorial Educational Foundation, 1994

  8. STEPS- Topamax vs Riboflavin Safety: • Topamax: • Serious: acidosis, osteoporosis, anemia, psychosis, suicide, hepatotoxic, pulmonary embolus • Common: fatigue, memory impairment, anorexia, anxiety, depression, diarrhea, taste disturbance, insomnia • Riboflavin: • Bright yellow urine

  9. STEPS- Topamax vs Riboflavin Tolerability: • Topamax: 21% drop out rate (NNTH = 5) • Riboflavin: 3.6% drop out rate (NNTH = 27)

  10. STEPS- Topamax vs Riboflavin Effectiveness (50% reduction in severity and occurrence): Topamax: (NNT = 5) (immediate response) Riboflavin: (NNT = 3) (two months to respond)

  11. STEPS- Topamax vs Riboflavin Price (one month) • Topamax (generic): $40-50 • Riboflavin: $6 – $10 Simplicity: • Topamax: twice daily • Riboflavin: once daily

  12. Randomized Analyzed on an intention to treat basis Individuals assessing outcomes were blind to treatment

  13. STEP- Clinical Example Should SSRIs be the drug of first choice for the treatment of depression? • Anderson IM, Tomenson BM. Treatment discontinuation with SSRIs compared with tricyclic antidepressants: A meta-analysis. BMJ 1995;310:1433-8. • 62 RCTs, double-blind comparing efficacy and tolerability

  14. Results • Efficacy: HAM-D: Favored Tricyclics • Tolerability: Favored SSRIs • Drop-out rates nearly equal, 30.8% vs 33.4% • NNTH 10 vs 9 • What about safety? • Suicide rates equal • Price: Large difference, but need to consider total cost of care

  15. Information Mastery • Rely on PR for data, not decisions • Look for “Patient-Oriented Evidence that Matters”, the reasons to choose one drug over another • STEPS • Take responsibility for validity • Take active approach, teach PR your needs 4

  16. The “Appeals Process” Correct Conclusion Correct Information Correct Reasoning + See: Johnson RH, Blair JA. Logical Self-Defense. 2nd ed. Toronto: McGraw-Hill Ryerson Limited. 1991.

  17. Appeals – Rational/Non Rational • Rational: All relevant information, true facts, sound reasoning connecting facts to conclusion • Non-rational: Fallacy of Logic

  18. Fallacies of Logic • Appeal to authority • Bandwagon effect • Red herring • Appeal to pity • Appeal to curiosity • Error of omission 6

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