Andy Gray andy@healthlink.org.za and Candy Day candy@healthlink.org.za
If there is one acronym which keeps rearing its head in pharmacy circles at the moment it’s PTC – no, not the Post and Telecommunications Company but the Pharmacy and Therapeutics Committee. While at present this organism is spoken of more commonly in the larger public sector hospital arena, its application promises to be far wider. Each district and each facility will soon have a local equivalent. The equally prevalent formulary committees in private sector hospitals and in managed care operations serve a very similar purpose. Imagine for a moment that you are the brave pharmacist on one of these committees, and are expected to contribute your knowledge and expertise to the development of local policies for the use of medicines in your practice site. The item on the agenda today is paediatric asthma – the question: whether to actively promote the use of inhaled steroids in children. Since this is an enlightened practice setting, you have at least been provided with one basic tool – Internet access. But right now you feel like the tourist at the Hampton Court Maze – you can see the entrance, but not the way to go from there. Is the Internet going to help or hinder you in providing input to the PTC?
Starting from the premise that "local is lekker", let’s see what the most trusted childrens’ hospital can do: the Red Cross Outpatient Protocols are available on the Net, and the asthma guidelines can be found at http://www.uct.ac.za/depts/chu/acasthma.txt
But, you also know that the PTC Chairperson is not one to blindly follow where others have been, and will want something more recent, preferably backed up with some quality literature. Somehow you also know that the world’s medical literature is sure to be full of articles on asthma – but will they help answer the question? So, the next step is a quick Medline search (at http://www.ncbi.nlm.nih.gov/PubMed ). Somewhere along the line you have heard about review articles, and hope those might be of more use than single research papers. Searching for "asthma AND reviews" brings you the hoped-for result. Calpin C, et al. J Allerg Clin Immunol 1997; 100(4): 452-457. Effectiveness of prophylactic inhaled steroids in childhood asthma: a systematic review of the literature. But does it answer the question – the abstract is peppered with references to "overall weighted relative improvement" in percentage terms, with 95% confidence intervals. Maths IB seems a long way off. Can you present this data with confidence?
Back to the Net for help. McMaster University, the American College of Physicians and the British Medical Journal come to the rescue with some "how to" guides:
Each of these is part of a series of articles on how to use the literature to find the evidence to support changes in practice – the very essence of the role of the pharmacist in bringing to the PTC the ammunition needed to make decisions. More can be found in the very long list of Internet resources collected by the School of Health and Related Research at Sheffield University at http://www.shef.ac.uk/uni/academic/R-Z/scharr/ir/netting.html
Oxford University produces a wonderfully witty series on evidence-based medicine in the form of a series of bullet points, called Bandolier. An expert reading of the review article you found (at http://www.jr2.ox.ac.uk/bandolier/band48/b48-3.htm ) supports your understanding of the final statement: "prophylactic inhaled steroids are effective, compared with placebo, in improving both clinical and laboratory outcomes in childhood asthma".
Anticipating the next question to be raised at the PTC, you check on the efficacy of practice guidelines (CPGs) in changing clinical outcomes. Medline again supplies the ammunition, a systematic review (that term again) published by Worrall G, et al. CMAJ 1997; 156(12): 1705-1712 concluded that "there is very little evidence that the use of CPGs improves patient outcome in primary medical care, but most studies published have used older guidelines and methods, which may have been insensitive to small changes in outcomes. Research is needed to determine whether the newer, evidence-based CPGs have an effect on patient outcomes". Now what was that the Council said about research being a core competency for all pharmacists? Perhaps this is a chance to really make a difference – how about measuring the effects of producing and implementing a local practice guideline?
And was the Internet a help or a hindrance? With a bit of practice and a few pointers, the mass of information residing on the Net can be harnessed for local application, and help the pharmacist make a meaningful impact on deliberations at Pharmacy and Therapeutics Committees. And that is Pharmaceutical Care practised at a population level.
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