P20S06: Renal insufficiency
Bottom line: Information on renal
insufficiency was used to justify the
management of the patient (stop a medication). There were no information-related patient health outcomes.
Level 1 outcome (situational relevance): On December 1, 2008, P20 did a search at work, by themselves, before the encounter with the patient (following an encounter with the physician). They retrieved two information hits about
renal insufficiency. The reported search objectives were: to address a clinical question, to
share information with a patient, to exchange information with another health
professional, and to plan, manage or coordinate tasks with this health professional. “The physician asked me to review the
patient’s [a woman in her late sixties] medications. […][He, the
physician, had] got lab work back [for this
patient] with an elevated creatinine. [He] asked me to
assess her renal function and to make sure her medications were being used
safely. […] For drugs that are renally cleared, I would have considered reducing the dose
or stopping the drug.[...]The clinical question was “are the [patient’s] medications safe in renal insufficiency”? […] Then, I went
back to the doctor with my therapeutic interventions. Then, I called the
patient to go over the changes. […] I followed up and looked at her bone density
and how severe her osteoporosis and her risk of fracture is, and determine that
she still needed to be treated for her osteoporosis.” According to P20, e-Therapeutics+ was the only source for information,
and the found information was relevant.
Level 2 outcome (cognitive impact): Two hits were associated with a report of positive cognitive impact (see table). Regarding
confirmation, reassurance and reminder, P20 stated: “It just reassures me, and it confirms I’m
doing the right thing. If I look up Alendronate and in my head I knew it was
renal eliminated, […] it’s just confirming the facts that it is. […][I also] remembered
that you can’t use it [Fosamax], with renal insufficiency and basically, I
was confirming something I already knew. [...] It’s hard to remember 3000 drugs in your head.”
Retrieved
information hits:
1) e-Therapeutics+ (CIRT): Therapeutics Tab – Keyword: Dosage adjustment and renal impairment – Table 2 (P20S06H01)
2) e-Therapeutics+ (CIRT): eCPS Tab – Monograph –
Keyword: Fosamax [biphosphonate] – Dosage (P20S06H02)
Level 3 outcome
(information use): Information on the renal insufficiency was retrieved,
and used to justify the management of the patient (information used as
presented in e-Therapeutics+). “We stopped the drug based on the
information. [...] I spoke to the physician first, got the physician’s ok on my
recommendations. And then, I phoned the patient. [However,] the person was borderline [in terms of
renal impairment]. And so I guess I didn’t do the right thing necessarily. [...] Stopping the bisphosphonate for two weeks
is not going to harm the patient, whereas if her renal insufficiency was more
severe, it would have harmed the patient to stay on the drug. So I think we
were just being prudent.”
Level 4 outcome (patient health): Patient health
outcomes were unknown (no follow-up yet). “We didn’t really do the wrong thing but we
didn’t do the right thing either. It was just taking precaution and being
careful. [...] I don’t know if her renal function changed
because it’s so recent [case] and it’s a chronic renal insufficiency. [...] We
are going to do a new creatinine clearance before deciding whether to restart
the bisphosphonate or not.”
Levels of outcome of information-seeking
|
Situational relevance |
Positive cognitive
impact |
Information use |
Patient health |
|
Address a clinical question Share information Exchange information Manage patient care |
Reminded something Motivated to learn Confirmed Reassured |
Justify choice |
No outcome |