In healthcare, there is a world of clinical knowledge that students and practitioners alike need to retain and apply to help patients arrive at better outcomes. Thanks to 21st-century advances in technology, this clinical information has never been more accessible. Online drug information compendia, consistently updated clinical practice guidelines, and primary literature like clinical trial data are all examples of convenient and attainable clinical information right at your fingertips.
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One of the most important concepts to understand as a student pharmacist is that the key to success in your classes, rotations, and work experiences is actually not necessarily what you know, but how you know. Of course, as future healthcare providers we’re trained with the expectation that a certain level of clinical and pharmacotherapy-related information must be ingrained in our minds. However, it’s equally important to realize that you don’t need to know absolutely everything in your textbooks. In fact, it’s not expected. It’s certainly much more responsible when healthcare professionals take time and effort toward compiling good research to support clinical recommendations, regardless of whether we know all the answers at the top of our heads.
Our education as student pharmacists lets us discern quality clinical data and reliable drug information resources from others that may not be up to par, but still available to the general public. It’s truly our responsibility to ensure that we cite credible resources and relay accurate scientific information back to our patients.
This reference guide walks through some of the fundamentals of evidence-based practice and drug information resources, and is intended to be a helpful resource for students in case conferences, on rotations at IPPEs and APPEs, and in real-life situations after graduation.
Evidence-based practice and why it matters
Evidence-based practice can be described as “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.” This method ensures that clinical decisions are rooted in features including the best research evidence and personal clinical expertise, as well as patient values and preferences. The five steps to evidence-based practice in pharmacy are as follows:
Convert clinically important information into answerable questions. This could be information related to diagnosis, prognosis, therapy, and other healthcare issues. Using the information given, create a patient-focused, searchable, clinical question.
Access the best evidence to answer these questions. Conduct a search of the tertiary, secondary, and/or primary literature. Refer to notes and academic resources from previous pharmacy school courses.
Appraise your results critically. Evaluate evidence for quality and usefulness. Just because there is published data online doesn’t mean it contains the best or appropriate evidence for the clinical question at hand or in general.
Apply results to your patients. Implement your findings for your patients according to their specific conditions or details, like age and weight, allergies, costs, current medications, level of liver and kidney function, and so on.
Assess your process. Take time to assess how you gathered information and arrived at a decision for an intervention. Feel free to reformulate your process as you gain more experience.
Classification of information sources
To make the best decisions for patients, it’s important to be able to know exactly where to look to find sources that will effectively answer your clinical questions. Classification of information sources fall into three different categories: primary, secondary, and tertiary.
Primary sources consist of original content and can include things like clinical research studies, scientific experiments, journal articles, conference papers, dissertations, and patents. Clinical research studies classified as a primary source typically will report original quantitative and/or qualitative data.
Secondary sources analyze and interpret research results and typically synthesize findings from multiple primary resources. These sources index or abstract the primary literature, and therefore best function to direct the user to the original primary literature. Some examples of secondary sources may include Embase, PubMed, clinical practice guidelines, meta analyses, and systematic review articles.
Tertiary sources include summarized information from both primary and secondary sources, and typically condense this information into a more digestible format. Some examples of tertiary resources include textbooks, drug compendia like Lexicomp or Micromedex, package inserts, websites like the CDC or ClinicalTrials.gov, and other online databases.
Depending on the situation, students should think critically to assess which sources to check when posed with a question from a preceptor regarding drug information and clinical decision-making. More often than not, consulting drug compendia like Lexicomp, Micromedex, or UpToDate would be the first choice for their ease of use, comprehensiveness, and time efficiency. Drug compendia offer many features like drug identification, drug interaction checkers, IV compatibility, and patient counseling and education, among others.
Below is a table that compares and contrasts compendia like Lexicomp, Micromedex, and UpToDate.
| Features | Lexicomp | Micromedex | UpToDate |
|---|---|---|---|
| FDA indications & off-label uses | ✓ | ✓ | ✓ |
| Hepatic and renal dosing adjustments | ✓ | ✓ | ✓ |
| Adverse reactions and side effects | ✓ | ✓ | ✓ |
| Drug-drug interaction checker | ✓ | ✓ | ✓ |
| IV compatibility | ✓ | ✓ | ✖️ No direct IV compatibility checker, just peer-reviewed articles. |
| Pill identifier | ✓ Drug ID | ✓ Indentidex | ✖️ |
| Clinical practice guideline references | ✓ | ✓ | ✓ |
| Special populations | ✓ Includes pediatric, neonatal, geriatric, pregnancy / lactation | ✓ Includes pediatric, geriatric, pregnancy / lactation | No clear, concise, and direct assessment of dosage adjustments according to special populations. Must individually search “drug name” + desired population” and read through peer-reviewed articles. |
| Drug pricing | ✓ General | ✓ Includes Red Book, which lists medications by maker, NDC number, form, strength, package size, and more | ✓ General |
| Patient counseling | ✓ Includes printable patient education leafleft | ✓ Includes printable patient education handout | ✖️ |
| Other features | Briggs’ Drugs in Pregnancy and Lactation Natural products AHFS DI (Adult and pediatric) Pharmaco- genomics Facts and comparisons |
NeoFax on neonatal drugs Martindale on international drugs Drug comparison table tool Red Book online Alternative medicine |
Topics by specialty Practice Changing UpDates |
Clinical practice guidelines
According to the Institute of Medicine, clinical practice guidelines, known as CPGs, are systematically developed statements to assist practitioner and patient decisions about appropriate healthcare for specific clinical circumstances. Different organizations publish guidelines according to disease states and areas of practice like cardiology, gastroenterology, neurology, oncology, and more. These guidelines are developed to include recommendations that are based on evidence from rigorous systematic reviews and synthesis of the published literature.
Instead of a one-size-fits-all approach to patient care, clinical practice guidelines serve to enhance clinician and patient decision-making by critically appraising the scientific evidence, risks, and benefits behind clinical recommendations. In this sense, supplementing decision-making with guidelines allows for clinical decisions to be made in accordance with individual patient considerations.
Examples of CPGs include:
Clinical Guideline for the Evaluation and Management of Chronic Insomnia in Adults (PubMed)
Nonpharmacologic and Pharmacologic Therapies for Osteoarthritis of the Hand, Hip, and Knee (American College of Rheumatology)
AACE Medical Guidelines for Clinical Practice for Diagnosis and Treatment of Menopause 2011 (Endocrine Practice)
Practice Guidelines for Chronic Pain Management (Anesthesiology)
Supplemental drug information sources
Nonpharmacologic treatment: Natural Medicines is the gold standard for information on dietary and herbal supplements and natural products such as amica, ginkgo biloba, valerian root, and more. This compendia discusses safety, effectiveness, pharmacokinetics/mechanism of action, drug interactions, and adverse effects. In addition, there are printable patient education handouts that will make it easier to counsel patients on these natural products as pharmacists.
Geriatric population: The American Geriatrics Society has published the 2019 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. The goal of the AGS Beers Criteria is to improve medication selection, educate clinicians and patients, reduce adverse drug events, and serve as a tool for evaluating quality of care, cost, and patterns of drug use of older adults.
Pharmacogenomics: A great resource to turn to when wanting to learn more about pharmacogenomic biomarkers associated with medications is the Clinical Pharmacogenetics Implementation Consortium Guidelines. In addition, the FDA’s Center for Drug Evaluation and Research has a website that includes a table pairing current medications on the market with their respective pharmacogenomic biomarker pairs, along with actions to be taken based on the biomarker information. By accessing this information, we would be better equipped to assess and prevent serious genetically linked adverse events from occurring in our patients.
Sources matter
As student pharmacists in the midst of preparation into our roles as medication experts in the healthcare industry, it is critical to have a solid foundation for evidence-based practice and an accessible tool belt for drug information resources. Though there are endless sources of knowledge online, streamlining searches with drug information compendia, peer-reviewed primary literature, and clinical practice guidelines can be a much more effective and efficient way to apply findings and help optimize treatment for patients.
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