Modified Systemic Modified Systemic Approach to Answering Approach to Answering

QuestionsQuestions

Dr. Angie Eaton-MaxwellDr. Angie Eaton-Maxwell

Pharm 631Pharm 631

September 4, 2008September 4, 2008

ObjectivesObjectives

At the end of this lecture, the student should be At the end of this lecture, the student should be able to:able to:Determine pertinent information when presented Determine pertinent information when presented with at drug information questionwith at drug information questionCategorize the ultimate question and develop an Categorize the ultimate question and develop an efficient strategyefficient strategyFormulate a response appropriate for the Formulate a response appropriate for the sophistication of the requestorsophistication of the requestorIdentify the categories f drug information that are Identify the categories f drug information that are appropriate for follow-upappropriate for follow-up

Systematic Approach (1975)Systematic Approach (1975)

Five stepsFive steps

Step I: Classification of the requestStep I: Classification of the request

Step II: Obtaining background informationStep II: Obtaining background information

Step III: Systematic SearchStep III: Systematic Search

Step IV: ResponseStep IV: Response

Step V: Reclassification Step V: Reclassification

Modified Approach (1987)Modified Approach (1987)

Step I: Secure demographics of requestorStep I: Secure demographics of requestor

Step II: Obtain background informationStep II: Obtain background information

Step III: Determine and categorize ultimate Step III: Determine and categorize ultimate questionquestion

Step IV: Develop strategy and conduct researchStep IV: Develop strategy and conduct research

Step V: Perform evaluation, analysis, and Step V: Perform evaluation, analysis, and synthesissynthesis

Step VI: Formulate and provide responseStep VI: Formulate and provide response

Step VII: Conduct follow-up and documentationStep VII: Conduct follow-up and documentation

Modified ApproachModified Approach

Approach can be used in other settings Approach can be used in other settings outside of the DI outside of the DI

Community pharmacyCommunity pharmacy

Pharmaceutical industryPharmaceutical industry

Institutional pharmacy managementInstitutional pharmacy management

General application in professional General application in professional consultationconsultation

Requestor Demographics Requestor Demographics

1st step1st step

Listen closely to caller to determine level Listen closely to caller to determine level of sophistication and knowledgeof sophistication and knowledge

Determine the requestor’s position, Determine the requestor’s position, training, and anticipated knowledgetraining, and anticipated knowledge

Identify method of delivery of response Identify method of delivery of response (e.g. fax, mail, verbal, and written)(e.g. fax, mail, verbal, and written)

Background QuestionsBackground Questions

Essential step for formulating effective Essential step for formulating effective responsesresponses

Usually the most difficult stepUsually the most difficult step

Why is this person asking this question?Why is this person asking this question?

Always ask if the request is concerning a Always ask if the request is concerning a specific patient’s conditionspecific patient’s condition

Background question inquiry and reply Background question inquiry and reply should be a dialogue should be a dialogue

Background QuestionsBackground Questions

Always ask the requestor how they have Always ask the requestor how they have research the answer.research the answer.

This will avoid duplication of informationThis will avoid duplication of information

Keep in mind that some individuals do not Keep in mind that some individuals do not know how to correctly use all resourcesknow how to correctly use all resources

Intermediaries Intermediaries

Medical studentsMedical students

NursesNurses

PharmacistsPharmacists

Administrative AssistantsAdministrative Assistants

Work with them or bypass themWork with them or bypass them

General QuestionsGeneral Questions

NameNameLocation/pager #Location/pager #AffiliationAffiliationResources already consultedResources already consultedPatient specific or academicPatient specific or academicPatient’s diagnosis, other medications, and Patient’s diagnosis, other medications, and pertinent medical informationpertinent medical informationUrgency of the requestUrgency of the requestSee Appendix 2-3 for specific questionsSee Appendix 2-3 for specific questions

Ultimate Question/Categorization of Ultimate Question/Categorization of QuestionQuestion

Obtaining adequate background information will easily Obtaining adequate background information will easily identify the ultimate questionidentify the ultimate questionMay be the same as the original questionMay be the same as the original question

Example Original Question:Example Original Question:How do I get thalidomide?How do I get thalidomide?

Ultimate QuestionUltimate QuestionWhat are third line therapeutic recommendations for this What are third line therapeutic recommendations for this patient?patient?

Once the ultimate question has been confirmed then categorize Once the ultimate question has been confirmed then categorize the questionthe question

Useful in the development of the search strategyUseful in the development of the search strategy Useful in determining the necessary resourcesUseful in determining the necessary resources

Categorization of QuestionCategorization of Question

AvailabilityAvailability

IdentificationIdentification

General Product General Product InformationInformation

Laws/Policy & Laws/Policy & Procedure/P&TProcedure/P&T

CostCost

Foreign/InvestigationalForeign/Investigational

Compatibility/Stability/Compatibility/Stability/Administration RateAdministration Rate

Drug InteractionsDrug Interactions

PharmaceuticsPharmaceutics

PharmacokineticsPharmacokinetics

Therapy EvaluationTherapy Evaluation

DosageDosage

Adverse EffectsAdverse Effects

Poisoning/ToxicologyPoisoning/Toxicology

TeratogenicityTeratogenicity

LactationLactation

Search StrategySearch Strategy

Depending on the categorization of the Depending on the categorization of the question (e.g. Adverse Effect)question (e.g. Adverse Effect)

Prioritize the resourcesPrioritize the resources Ease of accessEase of access Degree of comfortDegree of comfort

Data Evaluation, Analysis, and Data Evaluation, Analysis, and SynthesisSynthesis

Information obtained must be objectively Information obtained must be objectively critiqued critiqued

Literature Evaluation and Statistical Literature Evaluation and Statistical AnalysisAnalysis

Formulation and Provision of Formulation and Provision of ResponseResponse

Unethical to misrepresent the resultsUnethical to misrepresent the resultsInform the requestor when one course of action Inform the requestor when one course of action is more desirableis more desirableMust present conflicting dataMust present conflicting dataMust be delivered within an appropriate time Must be delivered within an appropriate time frameframeMust be delivered with an appropriate level of Must be delivered with an appropriate level of sophisticationsophisticationResponder must be prepared for additional Responder must be prepared for additional questionsquestions

Format for Logical Argument in Format for Logical Argument in Response FormulationResponse Formulation

Step I:Step I: Present the competing viewpoints Present the competing viewpoints and considerationsand considerationsStep II: State the assessment of the literature or Step II: State the assessment of the literature or information reviewed and claim the superior information reviewed and claim the superior viewpointviewpointStep III: Succinctly refute the major strengths Step III: Succinctly refute the major strengths and present weaknesses of the inferior viewpointand present weaknesses of the inferior viewpointStep IV: Defend the major weaknesses and Step IV: Defend the major weaknesses and promote the strengths of the superior viewpointpromote the strengths of the superior viewpointStep V: Reiterate the final assessment in Step V: Reiterate the final assessment in support of the superior viewpoint.support of the superior viewpoint.

Follow-Up, Follow-Through, and Follow-Up, Follow-Through, and DocumentationDocumentation

Follow-UpFollow-Up

Process of verifying the appropriateness, Process of verifying the appropriateness, correctness and completeness of a correctness and completeness of a responseresponse

Good businessGood business

Patient specific requests Patient specific requests

““Soft” dataSoft” data

Follow-Through Follow-Through

Process of readdressing a request based Process of readdressing a request based on the availability of new dataon the availability of new data

Provide updates when new literature Provide updates when new literature becomes availablebecomes available

DocumentationDocumentation

Reduces the liability Reduces the liability

Promotes the development of continuous Promotes the development of continuous serviceservice

DI Form or extensive review and DI Form or extensive review and summation of all processes completedsummation of all processes completed

Ultimate question, resources searched, Ultimate question, resources searched, the response and follow-up.the response and follow-up.

Formulating Effective Responses and Formulating Effective Responses and Recommendations: A Structured ApproachRecommendations: A Structured Approach

Desired Characteristics of a ResponseDesired Characteristics of a ResponseTimelyTimelyCurrentCurrentAccurateAccurateCompleteCompleteConciseConciseWell ReferencedWell ReferencedClear and logicalClear and logicalObjective and balancedObjective and balancedFree of bias or flawsFree of bias or flawsApplicable and appropriate for specific circumstancesApplicable and appropriate for specific circumstancesAnswers important related questionsAnswers important related questionsAddresses specific management of patients and situationsAddresses specific management of patients and situations

Response Response

Restatement of the request Restatement of the request

Begin with introduction of the problem, Begin with introduction of the problem, issues, and circumstancesissues, and circumstances

Introduce the topic and systematically Introduce the topic and systematically present specific findingspresent specific findings

Pertinent background informationPertinent background information

Conclusions and recommendationsConclusions and recommendations

ReferencesReferences

Sample CaseSample Case

Can ranitidine cause thrombocytopenia?Can ranitidine cause thrombocytopenia?

Develop an approachDevelop an approach Requestor informationRequestor information Patient informationPatient information

PMHPMH

SHSH

Current MedicationsCurrent Medications

AllergiesAllergies

LabsLabs

Sample CaseSample Case

Restate the questionRestate the question

Dear ____,Dear ____,

Thank you for inquiry concerning the use of Thank you for inquiry concerning the use of ranitidine as a potential cause of ranitidine as a potential cause of thrombocytopenia.thrombocytopenia.

- If it is drug specific remember to use registered If it is drug specific remember to use registered or trademarks with brand namesor trademarks with brand names

- BonivaBoniva®® or ™ or ™

Sample CaseSample Case

A review of …. Indicates that ____ has/has not A review of …. Indicates that ____ has/has not been reported as a cause of thrombocytopenia. been reported as a cause of thrombocytopenia. However, there are reports that show that ____ However, there are reports that show that ____ has been infrequently associated with has been infrequently associated with thrombocytopenia.thrombocytopenia. Sum up the findingsSum up the findings Discuss the prevalenceDiscuss the prevalence OnsetOnset D/C ?D/C ?

Sample CaseSample Case

Analysis and SynthesisAnalysis and Synthesis Although these factors have been reported in Although these factors have been reported in

other cases, the most likely cause of other cases, the most likely cause of thromobocytopenia for this patient is _____.thromobocytopenia for this patient is _____.

Response and RecommendationResponse and Recommendation Continue regimenContinue regimen D/C particular drugsD/C particular drugs Change dosageChange dosage

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