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)

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

8. 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

9. 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

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

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

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

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

14. 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

15. 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

16. 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

17. 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. 1991.

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

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