s Evidence Based Medicines+Evidence Based Care and the Exercise of Clinical Judgement = Evidence Based Practice | I2P: Information to Pharmacists - Archive
Publication Date 01/07/2014         Volume. 6 No. 6   
Information to Pharmacists


From the desk of the editor

Welcome to the July 2014 homepage edition of i2P (Information to Pharmacists) E-Magazine.
At the commencement of 2014 i2P focused on the need for the entire profession of pharmacy and its associated industry supports to undergo a renewal and regeneration.
We are now half-way through this year and it is quite apparent that pharmacy leaders do not yet have a cohesive and clear sense of direction.
Maybe the new initiative by Woolworths to deliver clinical service through young pharmacists and nurses may sharpen their focus.
If not, community pharmacy can look forward to losing a substantial and profitable market share of the clinical services market.
Who would you blame when that happens?
But I have to admit there is some effort, even though the results are but meagre.
In this edition of i2P we focus on the need for research about community pharmacy, the lack of activity from practicing pharmacists and when some research is delivered, a disconnect appears in its interpretation and implementation.

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News Flash

Newsflash Updates for July 2014

Newsflash Updates

Regular weekly updates that supplement the regular monthly homepage edition of i2P. 
Access and click on the title links that are illustrated

Comments: 1

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Feature Contribution

Woolworths Pharmacy - Getting One Stage Closer

Neil Johnston

It started with “tablet” computers deployed on shelves inside the retailer Coles, specifically to provide information to consumers relating to pain management and the sale of strong analgesics.
This development was reported in i2P under the title Coles Pharmacy Expansion and the Arid PGA Landscape”
In that article we reported that qualified information was a missing link that had come out of Coles market research as the reason to why it had not succeeded in dominating the pain market.
Of course, Woolworths was working on the same problem at the same time and had come up with a better solution - real people with good information.

Comments: 5

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Intensive Exposition without crossing over with a supermarket

Fiona Sartoretto Verna AIAPP

Editor's Note: The understanding of a pharmacy's presentation through the research that goes into the design of fixtures and fittings that highlight displays, is a never-ending component of pharmacy marketing.
Over the past decade, Australian pharmacy shop presentations have fallen behind in standards of excellence.
It does not take rocket science - you just have to open your eyes.
Recently, our two major supermarkets, Woolworths and Coles, have entered into the field of drug and condition information provision - right into the heartland of Australian Pharmacy.

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The sure way to drive business away

Gerald Quigley

I attended the Pregnancy, Baby and Children’s Expo in Brisbane recently.
What an eye and ear opening event that was!
Young Mums, mature Mums, partners of all ages, grandparents and friends……...many asking about health issues and seeking reassurances that they were doing the right thing.

Comments: 1

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‘Marketing Based Medicine’ – how bad is it?

Baz Bardoe

It should be the scandal of the century.
It potentially affects the health of almost everyone.
Healthcare providers and consumers alike should be up in arms. But apart from coverage in a few credible news sources the problem of ‘Marketing Based Medicine,’ as psychiatrist Dr Peter Parry terms it, hasn’t as yet generated the kind of universal outrage one might expect.

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Community Pharmacy Research - Are You Involved?

Mark Coleman

Government funding is always scarce and restricted.
If you are ever going to be a recipient of government funds you will need to fortify any application with evidence.
From a government perspective, this minimises risk.
I must admit that while I see evidence of research projects being managed by the PGA, I rarely see community pharmacists individually and actively engaged in the type of research that would further their own aims and objectives (and survival).

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Organisational Amnesia and the Lack of a Curator Inhibits Cultural Progress

Neil Johnston

Most of us leave a tremendous impact on pharmacies we work for (as proprietors, managers, contractors or employees)—in ways we’re not even aware of.
But organisational memories are often all too short, and without a central way to record that impact and capture the knowledge and individual contributions, they become lost to time.
It is ironic that technology has provided us with phenomenal tools for communication and connection, but much of it has also sped up our work lives and made knowledge and memory at work much more ephemeral.

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Academics on the payroll: the advertising you don't see

Staff Writer

This article was first published in The Conversation and was written by Wendy Lipworth, University of Sydney and Ian Kerridge, University of Sydney
In the endless drive to get people’s attention, advertising is going ‘native’, creeping in to places formerly reserved for editorial content. In this Native Advertising series we find out what it looks like, if readers can tell the difference, and more importantly, whether they care.
i2P has republished the article as it supports our own independent and ongoing investigations on how drug companies are involved in marketing-based medicine rather than evidence-based medicine.

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I’ve been thinking about admitting wrong.

Mark Neuenschwander

Editor's Note: This is an early article by Mark Neuenschwander we have republished after the soul-searching surrounding a recent Australian dispensing error involving methotrexate.
Hmm. There’s more than one way you could take that, huh? Like Someday when I get around to it (I’m not sure) I may admit that I was wrong about something. Actually, I’ve been thinking about the concept of admitting wrong. So don’t get your hopes up. No juicy confessions this month except that I wish it were easier for me to admit when I have been wrong or made a mistake.
Brian Goldman, an ER physician from Toronto, is host of the award-winning White Coat, Black Art on CBC Radio and slated to deliver the keynote at The unSUMMIT for Bedside Barcoding in Anaheim this May. His TED lecture, entitled, “Doctors make mistakes. Can we talk about it?” had already been viewed by 386,072 others before I watched it last week.

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Dispensing errors – a ripple effect of damage

Kay Dunkley - BPharm, Grad Dip Hosp Pharm, Grad Dip Health Admin, MPS, MSHPA

Most readers will be aware of recent publicity relating to dispensing errors and in particular to deaths caused by methotrexate being incorrectly packed in dose administration aids.
The Pharmacy Board of Australia (PBA), in its Communique of 13 June 2014, described a methotrexate packing error leading to the death of a patient and noted “extra vigilance is required to be exercised by pharmacists with these drugs”.
This same case was reported by A Current Affair (ACA) in its program on Friday 20 June

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Take a vacation from your vocation

Harvey Mackay

Have you ever had one of those days when all you could think was, “Gosh, do I need a vacation.”
Of course you have – because all work and no play aren’t good for anyone.
A vacation doesn’t have to be two weeks on a tropical island, or even a long weekend at the beach. 
A vacation just means taking a break from your everyday activities. 
A change of pace. 
It doesn’t matter where.
Everyone needs a vacation to rejuvenate mentally and physically. 
But did you also know that you can help boost our economy by taking some days off? 
Call it your personal stimulus package.

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Explainer: what is peer review?

Staff Writer

This article was first published in the Conversation. It caught our eye because "peer review" it is one of the standards for evidence-based medicines that has also been corrupted by global pharma.
The article is republished by i2P as part of its ongoing investigation into scientific fraud and was writtenby Andre Spicer, City University London and Thomas Roulet, University of Oxford
We’ve all heard the phrase “peer review” as giving credence to research and scholarly papers, but what does it actually mean?
How does it work?
Peer review is one of the gold standards of science. It’s a process where scientists (“peers”) evaluate the quality of other scientists' work. By doing this, they aim to ensure the work is rigorous, coherent, uses past research and adds to what we already knew.
Most scientific journals, conferences and grant applications have some sort of peer review system. In most cases it is “double blind” peer review. This means evaluators do not know the author(s), and the author(s) do not know the identity of the evaluators.
The intention behind this system is to ensure evaluation is not biased.
The more prestigious the journal, conference, or grant, the more demanding will be the review process, and the more likely the rejection. This prestige is why these papers tend to be more read and more cited.

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Dentists from the dark side?

Loretta Marron OAM BSc

While dining out with an elderly friend, I noticed that he kept his false tooth plate in his shirt pocket. He had recently had seven amalgam-filled teeth removed, because he believed that their toxins were making him sick; but his new plate was uncomfortable. He had been treated by an 'holistic dentist'. Claiming to offer a "safe and healthier alternative" to conventional dentistry, are they committed to our overall health and wellbeing or are they promoting unjustified fear, unnecessarily extracting teeth and wasting our money?

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Planning for Profit in 2015 – Your key to Business Success

Chris Foster

We are now entering a new financial year and it’s a great time to reflect on last year and highlight those things that went well and those that may have impacted negatively in the pursuit of your goals.
It's also a great to spend some time re-evaluating your personal and business short, medium and long term goals in the light of events over the last year.
The achievement of your goals will in many cases be dependent on setting and aspiring to specific financial targets. It's important that recognise that many of your personal goals will require you to generate sufficient business profits to fund those aspirations

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ReWalk™ Personal Exoskeleton System Cleared by FDA for Home Use

Staff Writer

Exoskeleton leader ReWalk Robotics announced today that the U.S. Food and Drug Administration has cleared the company’s ReWalk Personal System for use at home and in the community.
ReWalk is a wearable robotic exoskeleton that provides powered hip and knee motion to enable individuals with Spinal Cord Injury (SCI) to stand upright and walk.
ReWalk, the only exoskeleton with FDA clearance via clinical studies and extensive performance testing for personal use, is now available throughout the United States.

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Attracting and Retaining Great People

Barry Urquhart

Welcome to the new financial year in Australia.
For many in business the past year has been described as a challenging period.
Adjectives are a key feature of the English language.  In the business lexicon their use can be, and often is evocative and stimulate creative images.  But they can also contribute to inexact, emotional perceptions.
Throughout the financial pages of newspapers and business magazines adjectives abound.
References to “hot” money draw attention and comment.  The recent wave of funds from Chinese investors, keen to remove their wealth from the jurisdiction and control of government regulations is creating a potential property bubble in Australia.

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Updating Your Values - Extending Your Culture

Neil Johnston

Pharmacy culture is dormant.
Being comprised of values, unless each value is continually addressed, updated or deleted, entire organisations can stagnate (or entire professions such as the pharmacy profession).
Good values offer a strong sense of security, knowing that if you operate within the boundaries of your values, you will succeed in your endeavours.

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Evidence-based medicine is broken. Why we need data and technology to fix it

Staff Writer

The following article is reprinted from The Conversation and forms up part of our library collection on evidence-based medicines.
At i2P we also believe that the current model of evidence is so fractured it will never be able to be repaired.
All that can happen is that health professionals should independently test and verify through their own investigations what evidence exists to prescribe a medicine of any potency.
Health professionals that have patients (such as pharmacists) are ideally placed to observe and record the efficacy for medicines.
All else should confine their criticisms to their evidence of the actual evidence published.
If there are holes in it then share that evidence with the rest of the world.
Otherwise, do not be in such a hurry to criticise professions that have good experience and judgement to make a good choice on behalf of their patients, simply because good evidence has not caught up with reality.

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Laropiprant is the Bad One; Niacin is/was/will always be the Good One

Staff Writer

Orthomolecular Medicine News Service, July 25, 2014
Laropiprant is the Bad One; Niacin is/was/will always be the Good One
by W. Todd Penberthy, PhD

(OMNS July 25, 2014) Niacin has been used for over 60 years in tens of thousands of patients with tremendously favorable therapeutic benefit (Carlson 2005).
In the first-person NY Times best seller, "8 Weeks to a Cure for Cholesterol," the author describes his journey from being a walking heart attack time bomb to a becoming a healthy individual.
He hails high-dose niacin as the one treatment that did more to correct his poor lipid profile than any other (Kowalski 2001).

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Culture Drive & Pharmacy Renewal

Neil Johnston

Deep within all of us we have a core set of values and beliefs that create the standards of behaviour that we align with when we set a particular direction in life.
Directions may change many times over a lifetime, but with life experiences and maturity values may increase in number or gain greater depth.
All of this is embraced under one word – “culture”.
When a business is born it will only develop if it has a sound culture, and the values that comprise that culture are initially inherent in the business founder.
A sound business culture equates to a successful business and that success is often expressed in the term “goodwill” which can be eventually translated to a dollar value.

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ReWalk™ Personal Exoskeleton System Cleared by FDA for Home Use

Staff Writer

Exoskeleton leader ReWalk Robotics announced today that the U.S. Food and Drug Administration has cleared the company’s ReWalk Personal System for use at home and in the community.
ReWalk is a wearable robotic exoskeleton that provides powered hip and knee motion to enable individuals with Spinal Cord Injury (SCI) to stand upright and walk.
ReWalk, the only exoskeleton with FDA clearance via clinical studies and extensive performance testing for personal use, is now available throughout the United States.

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Pharmacy 2014 - Pharmacy Management Conference

Neil Johnston

The brave new world of health and wellness is not the enemy of Pharmacy, it is its champion.
Australian futurist, Morris Miselowski, one of the world's leading business visionaries, will present the Opening Keynote address on Pharmacy's Future in the new Health and Wellness Landscape at 2.00pm on Wednesday July 30.
Morris believes the key to better health care could already be in your pocket, with doctors soon set to prescribe iPhone apps, instead of pills.
Technology will revolutionise the health industry - a paradigm shift from healthcare to personal wellness.
Health and wellness applications on smartphones are already big news, and are dramatically changing the way we manage our personal health and everyday wellness.

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Generation and Application of Community Pharmacy Research

Neil Johnston

Editor’s Note: We have had a number of articles in this issue relating to pharmacy research.
The PGA has conducted a number of research initiatives over the years, including one recently reported in Pharmacy News that resulted from an analysis of the QCPP Patient Questionnaire.
Pharmacy Guild president, George Tambassis, appears to have authored the article following, and there also appears to be a disconnect between the survey report and its target audience illustrated by one of the respondent comments published.
I have asked Mark Coleman to follow through, elaborate and comment:

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Evidence Based Medicines+Evidence Based Care and the Exercise of Clinical Judgement = Evidence Based Practice

Neil Johnston

articles by this author...

Neil Johnston is a pharmacist who trained as a management consultant. He was the first consultant to service the pharmacy profession and commenced practice as a full time consultant in 1972, specialising in community pharmacy management, pharmacy systems, preventive medicine and the marketing of professional services. He has owned, or part-owned a total of six pharmacies during his career, and for a decade spent time both as a clinical pharmacist and Chief Pharmacist in the public hospital system. He has been editor of i2P since 2000.

When the chorus of protest went up from a range of industry and professional critics in respect of the recent PGA/Blackmore’s alliance, the pressure generated was sufficient to cause its abandonment.
Not so much as a response to what had actually happened (because nothing much had been piloted or implemented), but in terms of what was perceived as to what could actually happen.
Perception (without evidence) was everything!
There were two primary perceptions:
(i) That the clinical evidence surrounding the publicised process was thought too weak to sustain credibility.
(ii) That the profit motive negated any professionalism. The perception was that all patients on particular drugs were going to be “up-sold” to a nutritional product that they may not  derive any health benefit from.

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Most pharmacists adopt and identify with the principle originally espoused by George W Merck:
"We try never to forget that medicine is for the people.
It is not for the profits.
The profits follow..."

But there is difficulty in gathering information for evidenced-based medicines (more so in the complementary field) to support pharmacists in a daily evidence-based practice environment.
But even the evaluation of orthodox medicines' evidence is sometimes difficult to assess without some form of recognised and independent rating of that evidence.
And this is the area that pharmacists must be transparently be seen to be applying – also the area that the leaders of pharmacy must immediately set about to organise and eliminate any deficiencies that currently exist.
They must also promote and claim the fact that pharmacists are the experts in evidence-based medicine providing an evidence-based care combined with sound clinical judgement, to deliver evidence-based practice.
Linda Bryant, an i2P writer from New Zealand, attended a recent conference around this very topic, and has written an article in the October edition titled “From Patient Care to Data Care” .
What follows is a very pertinent extract:

“It was felt that the concept of evidence based medicine, has to a large degree, been hi-jacked so that the important role of clinical judgment is minimised. 
No one suggested that evidence-based medicine should be ignored or discarded, but rather that evidence-based care should support individualised patient care.
Practitioners need to move from having information to having understanding to having the wisdom and capacity to exercise their clinical judgment.
An expert generally has the same knowledge as the relative novice, but the expert thinks differently, problem solving complex issues with abstract thinking - thinking outside the textbook box, and adding in-depth knowledge and understanding to the decision making process.
Pharmacists in particular need to take note of this as many pharmacists acknowledge the patient’s disease and then utilise ‘guidelines’ as an end point without greater thought as to the patient’s many other facets – medical and non-medical. 
We are seeing 94 year old people with severe cognitive impairment being treated with statins following a TIA because ‘that’s what we do for people with TIA’.
We see people who smoke 1 or 2 cigarettes a day receiving 14 mg Nicotine replacement patches “because we want to make it easy for people to stop smoking” – even though they do not have a serious nicotine addiction and who would likely be more responsive to a more personalised intervention. In these scenarios there is obviously not a lot of thinking going on.” 

Being treated with statins following a TIA is remarkably similar process to the proposed PGA/Blackmore’s alliance concept of adding a nutritional supplement to a prescription item; because there was a possibility the drug caused a specific nutrient depletion.
Both sides of the divide obviously have to do a bit more thinking on the subject.

Evidence-based medicine (EBM) is the process of applying the best available evidence derived by scientific method to clinical decisions involving patient care.
The whole process is probably best titled “evidence-based practice”  (EBP) where assessments are made in respect of all evidence gathered on behalf of a patient, the risks and the benefits of the treatment (or the lack of treatment) and diagnostic tests.
The elements of EBP (that form up in the title to this article) must always be present in total and also be in balance according to individual patient need, and will therefore differ from patient to patient.
I am tired of hearing criticism of pharmacists based on EBM only, particularly when there is not even a single practical database of quality evidence for pharmacists to draw from.
The quality of the evidence can range from meta-analyses and systematic reviews of double-blind, placebo-controlled clinical trials as the gold standard all the way down to conventional wisdom (anecdotal).

There is currently a call for the TGA to structure a searchable database for sponsor data for orthodox medicines and also one separately for complementary medicines with all listings properly evaluated.
This would be a good starting point and is backed by the recent Australian National Audit Office report titled, 

“Therapeutic Goods Regulation: Complementary Medicines” (Para 43):

“It would enhance transparency and help inform both consumers and healthcare professionals if the TGA were to place the summary of evidence it collects from sponsors, as received, on its website — with a clear indication of whether it had been assessed or evaluated by the TGA.”

Health professionals endeavour to carry out investigations to provide evidence supporting or rejecting the use of specific interventions.
Pressure toward EBP in pharmacy has also come from consumer groups plus some public and private health insurance providers.
Sometimes the insurers refuse coverage of practices lacking in systematic evidence of usefulness.

But there is one very important process missing from the TGA database of evidence and that is an easily interpreted star-rating (or similar) by an agency that is competent to rate the evidence.
Looking at evidence in a different setting (Criminal Law in the UK) there is a basic reference in Wikipedia that states:

England and Wales

“Blackstone's Criminal Practice states that:

The best evidence rule, which was used in the 18th and early 19th centuries as an exclusionary principle, i.e. to prevent the admission of certain evidence, where better evidence was available, is now all but defunct.

Lord Denning MR has stated:

The old rule, that a party must produce the best evidence that the nature of the case will allow, and that any less good evidence is to be excluded, has gone by the board long ago.
The only remaining instance of it is that, if an original document is available on one’s hands, one must produce it; that one cannot give secondary evidence by producing a copy.

Nowadays we do not confine ourselves to the best evidence. We admit all relevant evidence.

The goodness or badness of it goes only to weight, and not to admissibility.”

There is probably a parallel here compared to medical evidence that would be gathered by a pharmacist practitioner.
Criminal law has evolved to include all evidence as being admissible-just different weightings for each class of evidence being applied.
My feeling is that the most vocal and strident of critics of pharmacists usually make claims that no evidence or weak (anecdotal) evidence has been relied on and that the only evidence they will observe is the gold standard version (double blind crossover placebo version)
How weak or strong the evidence relied upon is generally assessed by the critic, suffering from the same failings as others.
If other evidence exists, is it available in an accessible format from a reliable source?

The practicality of the traditional pharmacy environment must be considered – one not generally set up in an office format and not too private.
Also one where traditionally there is no separate professional income to offset any costs in providing a clinical stream of activity.
Health consumers seem to be expecting a pharmacy clinical stream with all the trappings, and some will pay for it.
If it is a valuable clinical service, government will pay on behalf of taxpayers.
Clinical pharmacists have definitely been held back in this regard and it does relate to a pharmacy business model that has developed in isolation from any professional input – one of the reasons the Blackmore’s/PGA alliance was doomed to fail.

Now we see the PSA starting to divorce some of its activities from the PGA, probably triggered by recent events.
In a press release dated 11 October 2011 it was announced:

“The NSW Branch of the Pharmaceutical Society of Australia has decided not to renew its agreement with the Pharmacy Guild to jointly present the annual Pharmacy Expo.

NSW Branch President of the PSA, Professor Charlie Benrimoj, said the agreement was due for renewal with the Pharmacy Guild NSW but PSA believed the proposed NSW Pharmacy Guild approach to the clinical program was not in the best interests of pharmacists or the public they serve.

“We believe the original concept of a PSA Clinical Expo is still very valid, and should include a close integration of the education program with the exhibiting companies. For instance, pharmaceutical companies could have experts available to discuss their products, and the optimal use of those products, with pharmacists,” Professor Benrimoj said.

“Although we were keen to work collaboratively with the NSW Pharmacy Guild regrettably, in our view the new format proposed by the Pharmacy Guild would potentially undervalue clinical presentations and their critical importance in helping to improve the wellbeing of Australians.”

This is probably a good move and will allow the PSA to spread its wings outside of the shadow cast by the PGA.
But divorce can never be absolute because clinical services need a pharmacy infrastructure to support them. And pharmacies need professional services as part of their “core business”.
What should now happen is that the PGA should ask the PSA what sort of support structures they might need in community pharmacies and encourage tailor-made environments to suit.
That would be the ideal partnership and would allow for the development of individually developed and funded clinical practices, owned by clinical pharmacists and sub-contracted to pharmacies.

Moving on to a national ratings agency concept for medicines evidence (orthodox and complementary), I looked to borrow the concept developed by the financial markets. I was surprised that the ratings concept had been a fairly recent development.
Wikipedia says:

“A Nationally Recognized Statistical Rating Organization (NRSRO) is a credit rating agency (CRA) that issues credit ratings that the U.S. Securities and Exchange Commission (SEC) permits other financial firms to use for certain regulatory purposes. Originally, seven rating agencies were recognized as NRSROs, a number that dwindled as a result of mergers to six by the mid-1990s[1] and then to three by 2003.[2] As of April 2011, ten organizations were designated as NRSROs.[3]

Ratings by NRSROs are used for a variety of regulatory purposes in the United States. In addition to net capital requirements (described in more detail below), the SEC permits certain bond issuers to use a shorter prospectus form when issuing bonds if the issuer is older, has issued bonds before, and has a credit rating above a certain level. SEC regulations also require that money market funds (mutual funds that mimic the safety and liquidity of a bank savings deposit, but without Federal Deposit Insurance Corporation insurance) comprise only securities with a very high rating from an NRSRO.
Likewise, insurance regulators use credit ratings from NRSROs to ascertain the strength of the reserves held by insurance companies.”

I’ll stop at that point but if readers are interested to learn more, follow this link

Ratings organisations rate the strength of major businesses and even the national economies of various nations.
The following ratings index is used by Standard and Poor’s, a major international ratings agency. As you will note the rating can be varied to indicate subtle strengths and weaknesses

Investment Grade Rating:

An obligor rated 'AAA' has extremely strong capacity to meet its financial commitments. 'AAA' is the highest issuer credit rating assigned by Standard & Poor's.

An obligor rated 'AA' has very strong capacity to meet its financial commitments. It differs from the highest-rated obligors only to a small degree. Includes:

AA+: equivalent to Moody's Aa1 (high quality, with very low credit risk, but susceptibility to long-term risks appears somewhat greater)

AA: equivalent to Aa2

AA-: equivalent to Aa3

An obligor rated 'A' has strong capacity to meet its financial commitments but is somewhat more susceptible to the adverse effects of changes in circumstances and economic conditions than obligors in higher-rated categories.

A+: equivalent to A1

A: equivalent to A2

An obligor rated 'BBB' has adequate capacity to meet its financial commitments. However, adverse economic conditions or changing circumstances are more likely to lead to a weakened capacity of the obligor to meet its financial commitments.

Depending on the ratings agency they use variations on the theme, but each grading is represented by a simple code so that others can gauge the strength of the organisation bestowed with such a rating.
This is a system that needs to be applied to drugs and other forms of clinical practice applications so practitioners, such as pharmacists, can quickly grasp and evaluate any product recommendation on behalf of their patient.

One such system has been developed in the US by the US Preventive Services Task Force.
Again, from Wikipedia:

“Systems to stratify evidence by quality have been developed, such as this one by the U.S. Preventive Services Task Force for ranking evidence about the effectiveness of treatments or screening:

Level I: Evidence obtained from at least one properly designed randomized controlled trial.

Level II-1: Evidence obtained from well-designed controlled trials without randomization.

Level II-2: Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one centre or research group.

Level II-3: Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled trials might also be regarded as this type of evidence.

Level III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.”

So there is a framework already established that health practitioners could borrow from and build on to develop a ratings system with an Australian flavour, that could be managed by some respected and trusted agency.
This would allow clinical pharmacists (and all other health practitioners) to move beyond what they are capable of at the present time.
The system would allow confidence to build and avoid some of the criticisms that are made by generally uninformed people – because their access to good evidence is also restricted and their version is always offered in an opportunistic manner.
They, and clinical pharmacists, should simply get on with the job of developing what should have been available years ago, and start building mutually respectful practices through an ongoing discussion relating to evidence-based medicine and evidence-based care, relative to being able to exercise sound clinical judgement.

                        "People don't care how much you know

                          until they know how much you care".

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