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Considerations for altering therapy & Summary

Considerations for altering therapy & Summary
So again let’s go back and look at what the goal guideline said from 2014. Now I only should read to you the first part. But let’s look at what happened to have listed after though the evidence B. It says although there are insufficient data to provide firm conclusions concerning the optimal duration of corticosteroid therapy of acute exacerbations of COPD but yet they felt the need to change their guidelines to include this new information. So, remember of the things that I say you should really consider when altering therapy. So greater safety. Do I feel that the safety was greater in giving a five-day course compared to a 14-day course and I would say no. Steroid burst it’s gonna be very similar.
For we’re talking about longer duration that might be the case. Greater effectiveness. Well with all the limitations in the trial, I really don’t know if they found greater effectiveness especially since the primary outcome wasn’t the preferred one that the guidelines recommended. Lower cost. Well I’m not for sure in all countries but I would imagine that a five-day course of corticosteroids is probably not that much different from a 14-day course and it’s not increasing hospital days because the patients were discharged on these oral medications and it didn’t affect their current hospital stay. Greater convenience. While they’re taking a shorter therapy that might possibly be. but I still think since it’s a short burst that wouldn’t be that much different .
So what about in context with the current CGPs. Well since the quality of that trial was so poor, my personal conclusion would be that I don’t think it’s worth switching a patient from 14 to 5 day considering that may not be more efficacious and we’re looking at hospital readmission rates. So I think I would still want to go with the 14 days but that’s not what the guideline recommended. So let’s look at a case again to maybe look at some more of this information and how to evaluate practice guidelines. So let’s say you’re given giving a neuroscience presentation to the nursing staff, you need to talk about prevention of stroke prophylaxis.
So you google stroke guideline primary prevention and you get a PDF link to this citation. So let’s see if you can look at a couple of questions. Stop the tape. And then I’ll come back and give you the answers to these. What type of EBM is the citation listed in the case? And you can go back and review the slides for the different types. And then list the five questions a clinician should ask to help confirm or doubt this as the correct CPG. So answer the questions as best as you can for this excerpt and then we’ll come back and regroup and answer these two questions together.
So what are the other type of CPGs there’s consensus statements from in executive summaries there’s updates to CGPs and there’s position or summary statements to be able to determine what it is. So for 2, is it endorsed by US or National Organization? Yes it appears to be. Is a correct disease State provide treatment recommendations? Well from the information I gave you that’s a little bit difficult to determine. Is it the full CPG? Well it’s 52 pages so I’d hope it would be but you need to gather a little bit more information Is it up to date? Well probably not. Since it’s 2006 and actually the newest is 2014. So again googling doesn’t always get you the most current one.
Was it free to access? Well you really can’t determine stuff from a citation but yes it was free to access. Alright let’s continue. So here let’s look at a little excerpt that provided some great evidence and see if you could determine the meaning of them. So you can see I gave you an excerpt there was a recommendation that each patient should have an assessment of his or her stroke risk Class one level of evidence A the use of a risk assessment tools such as an FSP should be considered as these tools can help identify patients who could benefit from therapeutic interventions and who may not be treated on the basis of any one risk factor and this one was class two level of evidence B.
So stop to the tape for a moment and see if you can discern what these what these class and levels mean and then we’ll start start and I’ll provide the answers to you. So you can see from the table that they provided in their guideline, what they consider to be class one. So again this is fairly similar to what we had but it’s a little bit different. And then they had not only class but level. So they could put different things together. So class one level A looks like it’s the highest possible recommendation. that could possibly need to be made that had the most evidence.
So you can remember the next one was class 2A level B which looks like it’s a benefit versus risk again that it’s not clear as to whether that should be done in every patient. Something that they also did which you can see I had in some of mine but they have this is the full list and I know you really can’t see what’s there because it’s way too much on a slide. But you can see on the bottom it does what I did. It has wording recommendation based on which level or class they had.
So should is recommended is indicated those types of things to help you as the reader to be able to provide recommendations consistent with what they had in their guideline. So you can see here class one level A highest rating benefit clearly outweighs the risk sufficient evidence for multiple randomized control trials or meta-analysis phrases should recommend it is indicated is useful effective beneficial So to me I find that highly helpful for the reader to be able to then make recommendations based of what this is. And then as a mission class 2A level B a little bit less sure of whether that should be used or not.
They say benefit does outweigh risk but I again I would have to look at the studies that are associated with that. they say there is some conflicting evidence and some phrases you might want to use is reasonable can be useful effective beneficial is probably recommended or indicated. So hopefully now that we’ve gone over the different components what is a practice guideline what isn’t how you find them how you evaluate them you have a better understanding of the strengths and limitations of clinical practice guidelines. And as dr. Brown said it’s really going to limit your practice if you’re just going to memorize them and not be able to evaluate them.
So you need to evaluate clinical practice guidelines just like you do studies. You develop your own search strategy to help you to locate them. And then you’re going to want to maintain Electric library, electronic library for those that you commonly use because you might need to refer back to them in certain situations. If you have a different patient population that you’re looking at. You need to be somewhat familiar with the grade level system but then you’re going to want to make sure that you look at each practice guideline to see how they differ for each one. To make sure you’re providing the right recommendation and you also again want to develop your own approach for evaluating them.
Again you need to pull articles you’re going to have to look at the relevance and you’re going to have to go back and do all the stuff that we talked about with literature evaluation to be able to be sure that you’re providing the right information and the relevance and validity of the practice guideline that you’re providing will provide optimal patient care.

Prof. Mary Ferrill demonstrates how to evaluate CPGs with a case study and summarizes this week in this video.

To begin with, we still have some considerations for altering therapy, including greater safety, greater effectiveness, and greater patient convenience.

Furthermore, we are given a case and asked to answer the question: what type of EBM is the citation listed in the case?

Besides, please list the 5 questions a clinician should ask to help confirm or doubt this as the correct CPG.

To make sure you have learnt something from this week, please pause this video, review the previous slides for types, and write down answers on your own.

Finally, we hope you have a better understanding of the strengths and limitations of CPGs, and develop your own approach for evaluating CPGs after completing this lesson.

This is the end of this week. If you have any question or thoughts, please share them below.

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Evidence-Based Medicine in Clinical Pharmacy Practice

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