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OBSTACLES TO EVIDENCE BASED MEDICINE in DEVELOPING COUNTRIES

OBSTACLES TO EVIDENCE BASED MEDICINE in DEVELOPING COUNTRIES. CASE STUDY #1 MANAGEMENT OF ACUTE MYOCARDIAL INFARCTION and CORONARY DISEASE. 35/104. 35%. 1993. 1994. 80/170. 47%. n/N. %. 1992. 22/147. 15%. USE OF UNCONVENTIONAL DRUGS FOR ACUTE MI.

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OBSTACLES TO EVIDENCE BASED MEDICINE in DEVELOPING COUNTRIES

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  1. OBSTACLES TO EVIDENCE BASED MEDICINE in DEVELOPING COUNTRIES

  2. CASE STUDY #1 MANAGEMENT OF ACUTE MYOCARDIAL INFARCTION and CORONARY DISEASE

  3. 35/104 35% 1993 1994 80/170 47% n/N % 1992 22/147 15% USE OF UNCONVENTIONAL DRUGS FOR ACUTE MI

  4. CASE STUDY #2 MANAGEMENT OF HYPERTENSION

  5. The fifth report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC V); Arch Intern Med, 1993. Evidence-based Guidelines on the Control of Hypertension in the Philippines - Phil J Cardiol, 1996.

  6. USE of ANTI-HYPERTENSIVES n = 10,748 CALCIUM ANTAGONISTS 62% ACE INHIBITORS 31% BETA-BLOCKERS 17% DIURETICS 11% Sison et al, Phil J Cardiol ‘97

  7. CASE STUDY #3 PERIODIC HEALTH EXAMINATIONS

  8. EXECUTIVE CHECK-UP PLAN C (2 NIGHTS) URINALYSIS FECALYSIS HEMOGLOBIN WHITE CELL COUNT PLATELETS BLOOD UREA NITROGEN CREATININE HBsAg RAPID PLASMA REAGIN ELECTROCARDIOGRAM STRESS TEST PROCTOSIGMOIDOSCOPY PAPs SMEAR ULTRASOUND-HBT ULTRASOUND-PROSTATE ULTRASOUND-KIDNEY CHEST XRAY UPPER GI SERIES BARIUM ENEMA MAMMOGRAPHY IVP(OPTIONAL, 10% DISC) T3/T4 ( “ ) FASTING SUGAR URIC ACID TOTAL CHOLESTEROL HDL-CHOLESTEROL LDL-CHOLESTEROL TRIGLYCERIDES SGOT, SGPT, DB, IB, TB ALKALINE PHOS

  9. PERIODIC HEALTH EXAMINATIONS Total Adm ECUs % Hospital 1 11,504 4 0.03% 5.15% Hospital 2 35,917 1,851 Hospital 3 13,127 208 1.58% Hospital 4 9641 102 1.06% 5.50% Hospital 5 42,690 2,348 Hospital 6 15,554 1,097 7.05% Hospital 7 25,709 378 1.47% 3.40% Hospital 8 19,672 668 58 Hospital 9 18,212 0.32% Overall 192,026 6,714 3.5% Dans et al, 1997

  10. CASE STUDY #4 INTRA-OPERATIVE MONITORING

  11. Surgeries IOM HOSPITAL 1 65 18.5% HOSPITAL 2 12.9% 155 10.5% HOSPITAL 3 190 4.9% HOSPITAL 4 142 HOSPITAL 5 13.4% 157 HOSPITAL 6 410 2.6% TOTAL 1119 8.1%

  12. INTRA-OPERATIVE MONITORING: DETERMINANTS 1. GLOBAL RISK 2. HOSPITAL of ADMISSION 3. ABILITY TO PAY Dans et al, Phil J Int Med ‘96

  13. OBSTACLES TO EVIDENCE BASED MEDICINE

  14. THE FIRST OBSTACLE - “EXPERTS”

  15. Routine Specofic Rare/Never Experimental Not Mentioned 2 304 17 4 5 647 4 1 6 850 8 1239 2 7 1 1 9 1451 3 1686 11 8 2 1986 12 1 2 4 4 2 1 1 4 8 1 8412 14 5 6 2 5 3 3 p=NS 15 8745 2 4 1 3 5 9 4 6 1 3 2 1 Odds Ratio (Log Scale) 0.5 1.0 2.0 1960 1965 1970 1975 1980 1985 1990 Favors Tx Favors Ctrl

  16. Odds Ratio (Log Scale) 0.5 1.0 2.0 23 1 1960 Routine Specofic Rare/Never Experimental Not Mentioned 65 2 143 3 1965 4 316 21 1970 7 1783 5 p < 0.01 10 2544 11 2651 1 10 1975 15 3311 1 2 17 3929 22 5452 2 8 23 5767 1980 7 8 p < 0.001 27 6125 1 12 30 6346 1985 33 6571 1 8 4 p < 0.0001 43 21059 54 22051 1 7 3 65 47185 1990 67 47531 5 2 2 1 67 48154 15 8 6 6 1 Favors Tx Favors Ctrl

  17. THE SECOND OBSTACLE - PHARMACEUTICAL INDUSTRY

  18. SOURCES OF THE PROBLEM • Pharmaceutical Enticements • Pharmaceutical CME • Pharmaceutical Research

  19. 1ST COURSE INVITATION 2ND COURSE FORMULARY 140 120 RX UNITS 100 80 60 40 20 0 0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 MONTHS

  20. THE THIRD OBSTACLE - PHYSICIAN’s SELF-INTERESTS

  21. SOURCES OF THE PROBLEM 1. FEE-SPLITTING 2. SELF-REFERRAL

  22. Dr. Mianne Silvestre

  23. MD Laboratories, Inc. SMILE! THAT’LL BE 500 PESOS!

  24. PLAN OF ACTION 1. EXPERTS INVOLVE IN PROCESS 2. COMPANIES SELF-REGULATION 3. MD’s SELF-INTEREST SELF-REGULATION

  25. Though some scientists, particularly the older and more experienced ones, may resist indefinitely, most of them can be reached in one way or another. Conversions will occur a few at a time until, after the last holdouts have died, the whole profession will again be practicing under a single, but now different, paradigm. - Thomas Kuhn, 1962

  26. THINK BIG ! start small. ACT NOW

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