Drug Information Questions

• Pharmacists must be experts in answering drug information questions from patients, healthcare providers, or based on clinical problems.
• Clarifying drug therapy questions helps address the patient’s underlying issue efficiently.

Importance of Asking the Right Question

• While many drug therapy questions have an answer, ensuring the correct question is being answered is crucial.
• A clearly understood and defined drug information question is essential.
• A framework can be used to illustrate the question clearly.
• Databases help identify literature for addressing the question.
• Formulating effective responses is important before considering evidence-based medicine (EBM).
• Ensuring an answerable question is not always straightforward.
• Getting to the right question requires as much skill as providing the right answer.
• Defining the problem (question) correctly is crucial before seeking solutions.

Examples of Questions and the Need for Clarification

• Questions such as "What is the best treatment for diabetes?" are too general and broadly stated.
• The meaning of "effective" needs to be understood in questions such as, "Is there evidence that vitamin B12 supplements are effective?".
• Questions can come from various sources, and the underlying concern needs to be understood.
• The person asking may not know what they want to know until further discussion, especially regarding potential drug interactions.
• One should not passively accept a question as posed, but ensure complete understanding.

The Importance of Probing Questions and Clarifying Ambiguous Terms

• It is essential to ask questions about a question posed.
• Examples of probing questions include: "Why do you ask about this?"
• Ask questions about the definition of ambiguous terms and understanding what you don't know about the question.
• Repeating the question back in one's own words ensures understanding.
• Clarifying ambiguous terms and avoiding misunderstandings is essential.
• The goal is to understand exactly what the other person is thinking so that your response can be relevant and appropriate.

The Pharmacist as a Detective

• Pharmacists need to be good detectives when addressing drug information questions.
• Questions may not come directly from the person who originally has the question.
• Clarifying questions are necessary even when the intermediary doesn't know the real question.
• Failure to clarify can lead to wasting time on a wrong or incomplete response and not providing a timely response.

General Questions vs. Specific Patient Cases

• Questions asked in general terms likely pertain to a specific patient case.
• Understanding the patient's situation provides more context for framing the answerable question to address their clinical needs.

Example: Vitamin B12 Supplement Effectiveness

• The terms "efficacy" and "effective" have different meanings.
• Reading only the abstract to answer a question is generally inappropriate; the entire article should be read.
• Answering based solely on the abstract's conclusion would be inadequate if the physician was interested in healthy elderly adults.
• This highlights the importance of asking questions about questions to save time and provide clinically relevant answers specific to the patient's needs.

The PICO Framework

• The PICO framework helps formulate and clarify drug information questions, making them answerable and specific.
• PICO is an acronym representing components of a question (Patient Population/Problem, Intervention/Exposure/Test, Comparison/Control, Outcome of Interest).
• Sometimes a T (Time) is added, making it PICOT.
• Patient Population/Problem identifies who the question is about.
• Intervention/Exposure/Test specifies the treatment, exposure, or diagnostic test being considered.
• Comparison/Control is what the intervention is being compared to (placebo, standard of care, another intervention).
• Outcome of Interest defines what you want to happen as a result of the intervention.
• Time specifies when the outcome of interest should be observed.
• More PICO/PICOT elements in the question make it easier to find relevant literature.

Formulating Questions Using the PICO Template

• Strive to formulate drug information questions using the template: "In X patient population, what is the effect of X intervention compared to say Y comparison group on Z outcome within X timeframe, if you would".

Applying PICO to the Vitamin B12 Question

• The population of interest (P) was unclear, leading to the use of a study on children, which was incorrect.
• The intervention (I), vitamin B12 supplements, could be more specific regarding dose, administration route, and dosage regimen.
• The comparator (C) was inferred as "do nothing" or placebo, but this wasn't explicitly stated.
• The outcome (O), "effective," is vague and needs clarification.
• The time (T) component was not initially considered.
• Using the PICO framework helps identify missing information and guide clarification.
• An example of PICO elements for the Vitamin B12 question includes:
  • P: Healthy elderly adults aged 70 years or older with no prior diagnosis of vitamin B12 deficiency.
  • I: Oral cyanocobalamin 1000 mcg daily.
  • C: Placebo control.
  • O: Improvement in energy levels as measured by a validated fatigue scale at baseline and after 3 months.
  • T: 3 months.
• The question in PICO format allows a well-designed literature search strategy to be implemented.

Applying PICO to "What is the best treatment for diabetes?"

• Dialogue is necessary to clarify all PICO components because the question is too broad and vague..
• A potential PICO-formatted question could be: "In adult patients with type 2 diabetes (P), what is the effect of metformin as first-line therapy (I) compared to sulfonylureas as first-line therapy (C) on the reduction in risk of heart attacks, strokes, and peripheral artery disease (O)?".
• The timeframe (T) for assessing the outcome might not be initially specified but should be considered when reviewing the evidence.

Applying PICO to "Is an ACE inhibitor alone better than a diuretic alone?"

• Each PICO component should be clarified through conversation.
• The intervention (I) and comparator (C) are clarified (ACE inhibitor alone vs. diuretic alone).
• The patient population (P), outcome (O), and possibly time (T) still need clarification.
• The word "better" is ambiguous and needs to be defined in terms of a clear outcome measure.
• Ambiguous words like "improve" or "help" are not specific enough for the outcome of interest.

The Importance of Clarifying the Outcome of Interest

• Clarifying the outcome of interest with the person asking the question is crucial for building an effective and efficient search strategy for relevant evidence.

Benefits of Using the PICO Framework

• A structured approach like PICO guarantees a better outcome in finding relevant literature.
• Using the PICO framework as the basis for answering drug information questions produced more relevant literature citations than using the original question alone.

Steps for Providing an Effective Response: Clarifying the Question

• Focusing on clarifying the question requires the PICO framework to obtain all key information needed for an accurate response.
• Steps for gathering information to clarify P, I, C, O, or T are mentioned:
  • Assemble and organize patient information
  • Gather information about relevant disease state
  • Collect medication information
  • Obtain pertinent background information
  • Indentify other relevant factor and special circumstances

Factors to Consider When Clarifying PICO Components

• As a question is evaluated and PICO components are clarified, the following should be considered:
  • Demographics: Age, gender, race, ethnicity.
  • Disease state/Condition: Specific diagnosis, comorbidities.
  • Medication history: Current medications, allergies, past adverse events.
  • Other therapies: Non-pharmacological treatments.
  • Severity of condition: Mild, moderate, severe.
  • Duration of condition: Acute, chronic.
  • Prior treatment failures: What has been tried before.
  • Patient preferences: Values and beliefs.

Additional Tips: Questions to Ask Yourself

• Consider these questions when clarifying and a drug information:
  • Does the question pertain to a specific patient?
  • If so, what are the relevant patient demographics and medical history?
  • What is the desired outcome?
  • What are the interventions or comparators of interest?
  • Is there a timeframe of interest for the outcome?
  • What is the urgency of the request?
  • What is the context of the question?
  • What resources might be helpful to consult?
  • How should the response be communicated?
  • What is the level of detail required in the response?

Addressing Questions About Specific Patients

• Many questions will be about a specific patient case.
• Answers should be as specific as possible to that patient.
• The goal is often to solve a clinical problem for a specific patient.
• Accessing the patient's medical record (EHR) can provide helpful lab data and other information for formulating a response.

Characteristics of Effective Responses

• After formulating a PICO question, acquiring evidence, and appraising the literature, one is ready to write a response.
• Characteristics of more effective responses include:
  • Accurate
  • Up-to-date
  • Complete
  • Concise
  • Clear
  • Well-referenced
  • Timely
  • Free of bias (objective and balanced)
  • Applicable to the specific question or patient
  • Organized and logical
  • Addresses all components of the question
• Timeliness is crucial, especially in urgent situations like hospitalized patients.
• Effective responses must be free of bias, both your own and potential biases in the literature.

Formatting Your Response and Communication

• Understanding the optimal way to communicate your answer is important.
• Different clinicians have different preferences for communication (phone call, text, fax, chart note, contacting their team).
• Learning the clinician's preferences ensures the response is received effectively.

HIPAA Considerations and References

• Be mindful of HIPAA considerations and avoid disclosing protected health information (PHI) inappropriately depending on the communication method.
• Always use appropriate references and citations, even when communicating with patients, to allow assessment of the evidence used.

Follow Up and Assessment

• Following up on the application of evidence is crucial.
• Following up with the clinician or checking the EHR assesses the results of one's response.
• Follow-up allows for reevaluation of the initial response and modification if needed due to changes in the patient's condition or new evidence.

Drug Information Intake Form

• A drug information intake form is used, which includes:
  • The question as originally asked.
  • Space to reformulate the question in PICO format.
  • Space for other pertinent information.
  • The response to the question.
  • Literature references.

Summary and Key Takeaways

• Clarifying the question before attempting to answer is fundamental.
• The PICO framework structures the understanding of the question.
• The patient’s specific needs and context should be focused on.
• Providing a timely, accurate, and well-referenced response is essential.