Transcript Teaching Family Physicians To Be Information Masters

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
Information Mastery:
A Practical Approach to Evidence-Based Care
Taking the Right STEPS to Avoid Fallacies
of Decision-Making
Taking the Right STEPS . . .
“Level 0” Proficiency
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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
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NOT the “Best Information”
Information Mastery Proficiency
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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)
Trends in Prescribing of Alpha-adrenoceptor Blocking Drugs in
General Practice in England
1,400,000
Doxazosin
Prazosin
Terazosin
Others
1,200,000
Items
1,000,000
800,000
600,000
400,000
200,000
0
Mar-04
Dec-03
Sep-03
Jun-03
Mar-03
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Sep-02
Jun-02
Mar-02
Dec-01
Sep-01
Jun-01
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Dec-00
Sep-00
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Dec-99
Sep-99
Copyright PPA 2004
Jun-99
Mar-99
Quarter to
Prescribing of alpha-blockers in the
US following ALLHAT
Stafford RS, et al. JAMA 2004; 291: 54-62
Taking the right “STEPS” when
evaluating new information
S=
T=
Safety
Tolerability
look for “pooled drop-out rates”
E=
Effectiveness -- Studies showing that the new
drug is better than your current choice
•
P=
S=
Subtherapeutic vitamin D doses in all bisphosphonate studies
Price
Simplicity of use
Preskorn SH. Advances in antidepressant therapy: the pharmacologic basis. San Antonio:
Dannemiller Memorial Educational Foundation, 1994
STEPS- Topamax vs Riboflavin
Safety:
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Topamax:
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Serious: acidosis, osteoporosis, anemia, psychosis, suicide,
hepatotoxic, pulmonary embolus
Common: fatigue, memory impairment, anorexia, anxiety,
depression, diarrhea, taste disturbance, insomnia
Riboflavin:
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Bright yellow urine
STEPS- Topamax vs Riboflavin
Tolerability:
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Topamax: 21% drop out rate (NNTH = 5)
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Riboflavin: 3.6% drop out rate (NNTH = 27)
STEPS- Topamax vs Riboflavin
Effectiveness (50% reduction in severity and
occurrence):
Topamax: (NNT = 5) (immediate response)
Riboflavin: (NNT = 3) (two months to respond)
STEPS- Topamax vs Riboflavin
Price (one month)
 Topamax (generic): $40-50
 Riboflavin: $6 – $10
Simplicity:
 Topamax: twice daily
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Riboflavin: once daily
Randomized
Analyzed on an intention to treat basis
Individuals assessing outcomes were blind to treatment
STEP- Clinical Example
Should SSRIs be the drug of first choice for the
treatment of depression?
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Anderson IM, Tomenson BM. Treatment discontinuation with
SSRIs compared with tricyclic antidepressants: A metaanalysis. BMJ 1995;310:1433-8.
62 RCTs, double-blind comparing efficacy and tolerability
Results
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Efficacy: HAM-D: Favored Tricyclics
Tolerability: Favored SSRIs
• Drop-out rates nearly equal, 30.8% vs 33.4%
• NNTH 10 vs 9
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What about safety?
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Price: Large difference, but need to consider
total cost of care
• Suicide rates equal
Information Mastery
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Rely on PR for data, not decisions
Look for “Patient-Oriented Evidence that
Matters”, the reasons to choose one drug over
another
• STEPS
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Take responsibility for validity
Take active approach, teach PR your needs
The “Appeals Process”
Correct
Correct
+
Information
Reasoning
Correct
Conclusion
See: Johnson RH, Blair JA. Logical Self-Defense. 2nd ed. Toronto:
McGraw-Hill Ryerson Limited. 1991.
Appeals – Rational/Non Rational
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Rational: All relevant information, true
facts, sound reasoning connecting facts
to conclusion
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Non-rational: Fallacy of Logic
Fallacies of Logic
Appeal to authority
 Bandwagon effect
 Red herring
 Appeal to pity
 Appeal to curiosity
 Error of omission
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