Transcript Learning about medicines:

Learning about
medicines:
needs a framework
Andrew Herxheimer
24.5.02
CA seminar: Patient Information
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We need information to decide
whether to use a medicine or not
 if yes, which to choose
 how to use it, for how long
 what to look out for while using it
 whether some event is connected with
the medicine
 whether and how to change the dose or
stop
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The information may not be enough
to enable us to decide – because
we don’t know enough about the
problem we want to treat
 or we can’t easily apply it to our own
circumstances
 or we lack experience & confidence

So we need to discuss it
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In deciding what to prescribe a doctor
has to consider
 the
disease or problem
 the treatment
 the individual to be treated
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Half the job is having the information,
the other half, knowing what to do with it:
judgments must be made.
They involve facts and values
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Weighing up benefits and harms
can be complicated because
 the natural course of a disease varies
 an expected benefit matters more to
some people than to others
 disadvantages of treatment, including
possible harms, worry some more than
others
 everyone has personal preferences
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Organising the information on a medicine:
Key questions
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What type of medicine is it?
Does it cure, relieve symptoms, prevent a
problem, or help to maintain normal function?
What are its benefits and disadvantages?
How does it get to where it acts?
How & how fast is it eliminated?
The bigger the dose, the bigger the effects?
How do people differ in sensitivity to it?
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An example
High blood pressure needing drug treatment
Ranking what’s on the menu:
Effectiveness
Safety
Quality & completeness of information
Convenience
Patient’s preference
Cost
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Three types of drug to consider:
(1) a diuretic
(2) a beta-blocker
(3) an ACE inhibitor

Each helps to prevent stroke and heart attack
 Each is safe – except (1) in gout,
(2) in asthma, (3) in kidney disease
 Their side effects are mostly acceptable
 A lot is known about all three, none are new
 All are convenient to use
 (1) and (2) cost less than (3)
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Let’s look at atenolol, a beta-blocker
Benefits v. disadvantages
+ atenolol reduces high BP, helps
prevent angina, stroke, heart attack
– can worsen asthma, cause tiredness,
cold hands & feet
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Atenolol –2
How does it get to where it acts?
It acts on the heart and reaches it via the
blood
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Atenolol – 3
How and how fast is it eliminated?
It’s excreted in the urine
A dose acts for 8 to 24 hours
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Atenolol – 4
The bigger the dose, the bigger the
effect?
Treatment can start with 25mg/day or
even less
The dose can if necessary be increased
to 50 or even 100mg/day
But higher doses also cause side effects
more often and more intensely
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Atenolol – 5
Differences in individual sensitivity
Most elderly or thin people need only
small doses
Women may need smaller doses than
men
Black people are less sensitive
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Concordance:
achieving shared goals in medicine use
To achieve shared goals,
professionals and patients need to
understand each other,
and to understand how the other thinks.
Doctors must not only inform, but listen
and explain.
‘Doctor’ originally meant ‘teacher’.
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But crash courses in consultations
cannot do very much
There’s far too much else to take in
 Patients are often anxious or tense
 Time is short
 Learning/ teaching is rarely on the
agenda for either patient or doctor
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So how should we shape the future
of patient information?
1. Information can only be well used by people with
adequate ‘information receptors’. That means they
have to understand the relevant concepts.
2. Ideally they should learn the rudiments of critical
appraisal: to be able to assess the relevance, validity
& reliability of information.
3. Sources of reliable health information – on diseases,
treatments, nutrition, etc must be identifiable as such.
4. Written information should be tested on samples of
real patients, to check that most can use it effectively
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1. Basic concepts about medicines
should be taught in schools
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They straddle biology, domestic science and
social science, and are easy to grasp
 They provide broader perspectives than
‘drug education’, which shouldn’t be separate
 They are easy and interesting to illustrate
from everyday experience
and lend themselves to simple projects
 The students can be encouraged and helped
to teach older family members – as happens
in many developing countries
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2. Critical appraisal workshops for
patients/ consumers/ health service users
can enable more people
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to contribute their experience & views to
research agendas
ethics committees
health service management
independent self-help groups
 to recognise misinformation & manipulation
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3. Identifying reliable and helpful
information
Accreditation of information sources
nationally & internationally: kitemarks?
 Transparent official endorsement of
trustworthy information, eg using the
DISCERN criteria
 Links to National electronic Library of
Health (NeLH)
 Internet sites are a special problem
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4. Written information should be tested
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Until now most information is produced by
professionals who decide what information
patients/ consumers need, and not tested.
 We must involve consumers in the design of
the information, and test leaflets, etc, on
samples of the patients for whom they are
intended, and improve the material until at
least 80% of people can understand and use
it effectively.
 This has been pioneered in Australia
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Pharmaceutical promotion:
The truth,
the half-truth,
and nothing like the truth
Direct-to-consumer advertising of
prescription medicines, as in the US,
spreads misinformation, distorts health
care, does not improve health, &
increases costs
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Last but far from least: professionals
must learn from patients and carers
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Ask them what they think of the treatment
… how they use it
Listen to their experiences – eg DIPEx
(Database of Individual Patients’ Experiences
of illness)
Enable patients to report adverse events
directly to regulatory authorities & companies
Help patients to learn from the experiences of
others
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DIPEx website
Analysis of a broad range of people’s
narrative descriptions of their experience
Linked to evidence-based information about
treatments, resources, support groups
Overlapping information needs - presented
for patients, family, teachers, students, health
professionals, policy makers, researchers
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Welcome to DIPEx
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DIPEx database : Narratives
• summaries of main themes from
interviews
• illustrated with video, audio and
written clips from the interviews –
people telling their stories
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DIPEx database : Evidence
• descriptions of the condition,
prevalence, prevention
• information about treatments,
including evidence of effects
• questions and answers
• All indexed and searchable
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DIPEx studies now
Complete on website: hypertension,
prostate cancer, breast cancer, colorectal
cancer
Current: cervical screening, cervical cancer,
testis cancer, carers of people with
dementia
Planned for 2002/03: epilepsy, rheumatoid
arthritis, smoking cessation, malignant
melanoma, lung cancer
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