Users' Guides to the Medical Literature
Guyatt G, Rennie D, Meade MO, Cook DJ
Part B Therapy
Chapter 11.5. Qualitative Research
Mita Giacomini, Deborah J. Cook
Clinical Scenario
Topics Discussed:
inappropriate drug prescribing, pharmacology, geriatric, polypharmacy, qualitative observation, qualitative research
Excerpt:
"After a grand rounds presentation by a visiting speaker on polypharmacy
in the elderly, you reflect on a patient under your care, a 77-year-old
woman with chronic obstructive pulmonary disease (COPD), hypertension,
and mild renal insufficiency who presented with community-acquired
pneumonia. After 6 days of antibiotic treatment, she developed Clostridium
difficile colitis. During rounds yesterday, the intern
suggested that the antibiotic therapy contributed to the development
of colitis. You pointed out that the proton-pump inhibitor the patient
had taken for more than a year, and which you continued in hospital,
increased her risk of developing both the original pneumonia1 and
the hospital-acquired C difficile infection.2 The
day she was admitted, you remember charging the intern with finding
out why she had been taking a proton-pump inhibitor. The intern
discovered that the drug was started 1 year ago, during an intensive
care unit admission for an exacerbation of her COPD that required
mechanical ventilation. The clinicians responsible for the patient's
care administered the proton-pump inhibitor, instead of the more
appropriate histamine-2 receptor antagonist, to prevent stress ulceration.
Furthermore, there was no documentation in the chart about why the
proton-pump inhibitor was subsequently continued. The patient remembers
receiving a prescription for this new drug when she was discharged
from the hospital but does not recall a conversation about why...."
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