OBSTACLES TO EVIDENCE BASED MEDICINE in DEVELOPING COUNTRIES

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OBSTACLES TO EVIDENCE BASED MEDICINE in
DEVELOPING COUNTRIES
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CASE STUDY 1 MANAGEMENT OF ACUTE MYOCARDIAL
INFARCTION and CORONARY DISEASE
3
n/N

1992
22/147
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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.
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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
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CASE STUDY 3 PERIODIC HEALTH EXAMINATIONS
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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
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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
Hospital 8
19,672
668
3.40
58
Hospital 9
18,212
0.32
Overall
192,026
6,714
3.5
Dans et al, 1997
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CASE STUDY 4 INTRA-OPERATIVE MONITORING
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Surgeries
IOM
HOSPITAL 1
65
18.5
HOSPITAL 2
12.9
155
HOSPITAL 3
10.5
190
4.9
HOSPITAL 4
142
HOSPITAL 5
13.4
157
HOSPITAL 6
410
2.6
TOTAL
1119
8.1
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INTRA-OPERATIVE MONITORING DETERMINANTS
1. GLOBAL RISK
2. HOSPITAL of ADMISSION
3. ABILITY TO PAY
Dans et al, Phil J Int Med 96
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OBSTACLES TO EVIDENCE BASED MEDICINE
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THE FIRST OBSTACLE - EXPERTS
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Odds Ratio (Log Scale)
0.5
1.0
2.0
1960
1965
1970
1975
1980
1985
1990
Favors Tx
Favors Ctrl
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(No Transcript)
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THE SECOND OBSTACLE - PHARMACEUTICAL INDUSTRY
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SOURCES OF THE PROBLEM

• Pharmaceutical Enticements
• Pharmaceutical CME
• Pharmaceutical Research

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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
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THE THIRD OBSTACLE - PHYSICIANs
SELF-INTERESTS
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SOURCES OF THE PROBLEM
1. FEE-SPLITTING
2. SELF-REFERRAL
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Dr. Mianne Silvestre
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SMILE! THATLL BE 500 PESOS!
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PLAN OF ACTION
1. EXPERTS
INVOLVE IN PROCESS
2. COMPANIES
SELF-REGULATION
3. MDs SELF-INTEREST
SELF-REGULATION
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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
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THINK BIG !
start small.
ACT NOW