Information Mastery: A Practical Approach to Practicing and Teaching EvidenceBased Medicine

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Information MasteryA Practical Approach to
Practicing and Teaching Evidence-Based Medicine

• Course Directors
• Allen Shaughnessy, PharmD
• David Slawson, MD
• Tufts Health Care Institute
• Tufts University School of Medicine
• November 12-14, 2009
• Boston, Massachusetts

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Information Mastery Evidence-Based Medicine in
Everyday Practice
Taking the Right STEPS to avoid Fallacies of
Decision-Making
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Taking the Right STEPS . . .
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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 drugsthe importance of who says
  what. Fam Pract 200320 61-8
• NOT the Best Information

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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 (lt1)
• Level 3 Create original research (primary) or
  systematic reviews (secondary)

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

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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

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STEPS- Topamax vs Riboflavin

• Tolerability
• Topamax 21 drop out rate (NNTH 5)
• Riboflavin 3.6 drop out rate (NNTH 27)

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STEPS- Topamax vs Riboflavin

• Effectiveness (50 reduction in severity and
  occurrence)
• Topamax (NNT 5) (immediate response)
• Riboflavin (NNT 3) (two months to respond)

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STEPS- Topamax vs Riboflavin

• Price (one month)
• Topamax (generic) 275
• Riboflavin 6 10.
• Simplicity
• Topamax twice daily
• Riboflavin once daily

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Randomized
Analyzed on an intention to treat basis
Individuals assessing outcomes were blind to
treatment
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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
  19953101433-8.
• 62 RCTs, double-blind comparing efficacy and
  tolerability

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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

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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

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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.
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Appeals Rational/Non Rational

• Rational All relevant information, true facts,
  sound reasoning connecting facts to conclusion
• Non-rational Fallacy of Logic

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Fallacies of Logic

• Appeal to authority
• Bandwagon effect
• Red herring
• Appeal to pity
• Appeal to curiosity
• Error of omission

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