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 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”

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)

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 = 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

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

STEPS- Topamax vs Riboflavin Tolerability: Topamax: 21% drop out rate (NNTH = 5) 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 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? Anderson IM, Tomenson BM. Treatment discontinuation with SSRIs compared with tricyclic antidepressants: A meta- analysis. BMJ 1995;310: RCTs, double-blind comparing efficacy and tolerability

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

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

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

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

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