P23S02: Transient ischemic attack (replace a drug
combination)
Bottom line: Information on Transient Ischemic
Attack (TIA) was used to
modify the management of a patient (replace the combination aspirin/clopidrogel
by clopidrogel alone). It contributed to increase patient knowledge, and to
avoid inappropriate treatment.
Level 1 outcome (situational relevance): On December 23,
2008, P23 did a search at work, with their
supervisor, and during an encounter with a patient. P23 retrieved two
information hits about Transient Ischemic
Attack (TIA) outside the examination room, discussed with the supervisor, and came back in the room. The reported
search objective was: to address a clinical question. The patient [a man between seventy five and eighty years old] had the TIA a few
years ago. [
] And after the TIA,
Neurology was consulted and they suggested starting both Aspirin and Plavix
[Clopidrogel] for his treatment. [
] So he [the patient] started the treatment, he was doing well and then
he decided to stop Plavix by himself because of some issues with constipation. [
] So [when I saw] this patient, I
realized that this happened in the last few years and I was wondering if he
should go back to the combination of Aspirin and Plavix. [
] My search was mainly based on this, would it be
better to start only Plavix, or [the combination
of] Aspirin and Plavix, thinking that he is almost eighty. He is an elderly person and [I wanted] [
] to see what would be the best choice for him. According to P23,
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 practice improvement and learning, P23 stated: For this particular
patient [my practice will
be improved because] the main plan at the beginning was to do Aspirin and Plavix, as
recommended by Neurology. But [I have learned
that] the evidence shows that Plavix is as good as [the combination of] Aspirin and Plavix
[so] we can probably
just go with Plavix alone.
Retrieved information hits:
1) e-Therapeutics+ (CIRT): Therapeutics Tab TIA Prevention
of ischemic stroke Pharmacologic
choices Antiplatelet agents (P23S02H01)
2) e-Therapeutics+ (CIRT):
Therapeutics Tab TIA Prevention of ischemic stroke Highlight (P23S02H02)
Level 3 outcome
(information use): Information on TIA was retrieved, and used to better understand a
specific issue with respect to the management of the patient, and to modify the
management of a patient (information used as presented in e-Therapeutics+).
When P23 saw this patient, the patient was only on aspirin because he stopped
the treatment with clopidrogel: P23 stopped aspirin, and re-prescribed
clopidrogel. We decided to change the
treatment for this patient. So I went back to the room, and talked to the
patient. [I wanted] to choose the right management. [
] The Neurology
consult done a few years ago, [
] suggested that the
patient should receive both medications Aspirin and Plavix, but based on the
highlight, [
] the risk of
bleeding receiving both is increased compared to Plavix alone, without being
more effective. So thats why we said we should go only with Plavix, not with
the combination.
Level 4 outcome (patient health): Regarding
patient health, P23 reported that the information contributed to increase
patient knowledge, and to avoid inappropriate treatment. We discussed a lot on this subject and I also explained to the patient
what are the risks and benefits of this therapy. They seemed more comfortable
with restarting the medication [
] [because] practically its
not necessary to give him two drugs. One drug is enough.
Levels of outcome of information-seeking
|
Situational relevance |
Positive cognitive
impact |
Information use |
Patient health |
|
Address a clinical question |
Practice improved Learned something Motivated to learn Confirmed Reassured |
Manage differently Understand issue |
Avoid Patient knowledge |