In a community pharmacy section programme at the FIP congress in Vienna on August 31, participants attended an all-day programme on assessing the quality of various information sources, including internet sources. They also learnt how to integrate “evidence” with advanced clinical judgment to make pharmacotherapeutic decisions for individual patients
Mr Ross Holland (dean, Australian College of Pharmacy Practice), explained that the theme of the session was based around evidence. “Evidence based medicine is the buzz-phrase of the times and we ignore it at out peril.” Although the concept was not new and could be traced back to the mid 19th century in Europe, there were many factors that had catalysed a renewed interest, for example, the staggering growth of medical literature and the increasing complexity of health care.
NHS philosophy
He defined evidence-based medicine as “the conscientious, explicit and
judicious use of current best evidence in making decisions about the care of
patients,” as reported in the British Medical Journal by Sackett et al
in 1996. He told the audience that “evidence-based practice now underpinned
the whole NHS philosophy in the UK”.
The rapid expansion and availability of information had impacted on both practitioners
and consumers. Busy practitioners did not have time to read and assess the literature
and this had led to two developments: meta-analysis databases (Cochrane) and
clinical practice guidelines. Consumers, however, received masses of unfiltered
and confusing information (increasingly from direct-to-consumer advertising,
which reportedly exceeded $1bn) and were often not in a position to evaluate
the quality of this information. Promotion of non-prescription products often
led to suspect claims and this infinite public access to health information
might be a system out of control.
Mr Holland stated that pharmacists had to be able to interpret information to
protect the public from errors of understanding and judgment, and it was no
longer acceptable to refer requests for information to physicians. “The
role of the pharmacist in the future will change from providers of information
to interpreters of information,” he concluded.
Later in the session, Mr Holland asked if providing health care information
really was easy. “Every time a medication problem arises we simply have
to refer to the literature and find out what the evidence base says we should
do.” He reminded participants, however, that good doctors “use both
the best available external evidence and individual clinical expertise”
and that “external evidence alone may be inapplicable or inappropriate
for an individual patient”. It was important not to replace individual
clinical expertise with external clinical evidence and the integration of both
was important for clinical decision making.
He warned against slavishly applying guidelines to all patients and emphasised
that clinical guidelines should also be complemented by assessing the individual
patient factors when making clinical decisions. Most clinical trial evidence
related to highly selected patients with clear-cut indications and no co-morbidity
or co-treatment. Most real-life patients might have other conditions as well
that also required medication. Therefore, clinical trials were not helpful when
trying to assess benefits and risks of individual patient treatment.
Patients’ values and concerns were also becoming important factors in the
treatment decision-making process. There was often a discrepancy in the patient’s
perceptions of risk and benefit and the physician’s perception of the same,
and the increasing role of the patient in therapeutic decision-making made this
trade-off more complicated than before.
Fine-tuning
This should not mean that the patient was not provided with the information.
What was more important was to ensure that evidence was used properly and to
question the values of the policy or “best practice” decision-makers
and to be aware of the values driving the evidence-based medicine agenda. Pharmacists,
therefore, had to fine tune their problem-solving skills in order to apply their
knowledge and clinical judgment to these problems both for health professionals
and for patients.