P28S04: Refractory high
blood pressure
Bottom line: Information on high blood pressure was used to justify the management of a
patient (increase dose of an anti-hypertensive
medication). It contributed to avoid inappropriate procedures, and to prevent
health deterioration.
Level 1 outcome (situational relevance): On December 9, 2008, P28 did a search at work, and during an encounter
with a patient. The patient was present while P28 was doing the search, and P28
showed her an information hit. P28 retrieved two information hits about an angiotensin-converting
enzyme (ACE) inhibitor, candesartan cilexetil (Atacand). The reported search objectives were: to address a
clinical question, and to exchange information with another health
professional. “She [the patient, a
woman in her seventies] had come in for a routine check-up. On the
check-up I had noticed that she had been high with regards to her blood
pressure for the last 1 or 2 visits. So I looked at what medications she was on
and she was on Atacand, so I decided that I would increase the dose of the ACE
inhibitor, before introducing a new agent to try and control her hypertension.
My clinical question was how much to increase her dose by, and also the side
effects that she could experience. […] Usually, […] I see the patient and then I go present my
patient to a physician [supervisor] who’s watching me on a camera. So I used
this information also to speak with that physician regarding why I chose to
increase the Atacand versus add another agent.” According to P28, e-Therapeutics+ was in agreement with and more
relevant than the information from another health professional (supervisor) and
from another electronic resource (Up-to-Date). “The physician didn’t remember the exact
dosing recommendations for Atacand for hypertension, and what increment to
increase by. […] With respect to the dosages, Up-To-Date I
find, doesn’t give a lot of dosage specific recommendations.”
Level 2 outcome (cognitive impact): The second hit was associated with a report of positive
cognitive impact (see table). Regarding practice improvement and learning,
P28 stated: “I learned what increment
Atacand should be increased by. […] I
know the denominations that Atacand comes in now, and so I wouldn’t necessarily
have to look that up the next time that I want to increase someone [who
is on Atacand].”
Retrieved
information hits:
1) e-Therapeutics+ (CIRT): eCPS Tab – Keyword: Atacand – Side
effects – Table 5 (P28S04H01)
2) e-Therapeutics+ (CIRT): eCPSTab – Keyword: Atacand – Dosage in hypertension (P28S04H02
Level 3 outcome
(information use): Information on Atacand was retrieved, and used to maintain
(be more certain about) the medication, and to
justify the management of the patient (information
used as presented in e-Therapeutics+). “I ended up increasing the
dose of Atacand. […] We
actually [gave] her
16 mg and an 8 mg, because she was so old. I didn’t want to increase her from
16 to 32 all the way.”
Level 4 outcome (patient health):
Regarding patient health, P28 reported that the information contributed to
avoid inappropriate procedures, and to prevent health deterioration. “ [The
plan] was just avoiding to use another pill, or try to
increase this pill first, before actually going onto another medication. […] So
obviously, [I was hoping to help her]
control the risks of stroke, heart disease, etc, to […]
improve her health in the long run. [Did you have a follow-up?] Yeah yeah, I, I saw her,
and her blood pressure was more improved.”
Levels of outcome of information-seeking
|
Situational relevance |
Positive cognitive
impact |
Information use |
Patient health |
|
Address a clinical question Exchange information |
Practice improved Learned something Reminded something Confirmed Reassured |
Justify choice Be more certain |
Prevent Avoid |