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Learning about medicines:. needs a framework Andrew Herxheimer. 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 - PowerPoint PPT Presentation
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24.5.02 CA seminar: Patient Information 1
Learning about medicines:
needs a framework
Andrew Herxheimer
24.5.02 CA seminar: Patient Information 2
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
24.5.02 CA seminar: Patient Information 3
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
24.5.02 CA seminar: Patient Information 4
In deciding what to prescribe a doctor has to consider
the disease or problemthe treatmentthe individual to be treated
24.5.02 CA seminar: Patient Information 5
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
24.5.02 CA seminar: Patient Information 6
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
24.5.02 CA seminar: Patient Information 7
Organising the information on a medicine: Key questions
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?
24.5.02 CA seminar: Patient Information 8
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
24.5.02 CA seminar: Patient Information 9
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)
24.5.02 CA seminar: Patient Information 10
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
24.5.02 CA seminar: Patient Information 11
Atenolol –2
How does it get to where it acts?
It acts on the heart and reaches it via the blood
24.5.02 CA seminar: Patient Information 12
Atenolol – 3
How and how fast is it eliminated?
It’s excreted in the urine
A dose acts for 8 to 24 hours
24.5.02 CA seminar: Patient Information 13
Atenolol – 4
The bigger the dose, the bigger the effect?
Treatment can start with 25mg/day oreven less
The dose can if necessary be increased to 50 or even 100mg/dayBut higher doses also cause side effects
more often and more intensely
24.5.02 CA seminar: Patient Information 14
Atenolol – 5
Differences in individual sensitivity
Most elderly or thin people need only small dosesWomen may need smaller doses than menBlack people are less sensitive
24.5.02 CA seminar: Patient Information 15
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’.
24.5.02 CA seminar: Patient Information 16
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
24.5.02 CA seminar: Patient Information 17
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
24.5.02 CA seminar: Patient Information 18
1. Basic concepts about medicines should be taught in schools 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
24.5.02 CA seminar: Patient Information 19
2. Critical appraisal workshops for patients/ consumers/ health service users can enable more people
to contribute their experience & views to
research agendas
ethics committees
health service management
independent self-help groups to recognise misinformation & manipulation
24.5.02 CA seminar: Patient Information 20
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
24.5.02 CA seminar: Patient Information 21
4. Written information should be tested
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
24.5.02 CA seminar: Patient Information 22
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
24.5.02 CA seminar: Patient Information 23
Last but far from least: professionals must learn from patients and carers 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
24.5.02 CA seminar: Patient Information 24
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
24.5.02 CA seminar: Patient Information 25
Welcome to DIPEx
24.5.02 CA seminar: Patient Information 26
DIPEx database : Narratives
• summaries of main themes from interviews
• illustrated with video, audio and written clips from the interviews – people telling their stories
24.5.02 CA seminar: Patient Information 27
DIPEx database : Evidence
• descriptions of the condition, prevalence, prevention
• information about treatments, including evidence of effects
• questions and answers
• All indexed and searchable
24.5.02 CA seminar: Patient Information 28
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