1. OBSTACLES TO EVIDENCE BASED MEDICINE in DEVELOPING COUNTRIES

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

3. 1992 n/N% 22/14715% 1993 35/104 35% 199480/17047% 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. CALCIUM ANTAGONISTS ACE INHIBITORS BETA-BLOCKERS DIURETICS 62% 31% 17% 11% USE of ANTI-HYPERTENSIVES Sison et al, Phil J Cardiol ‘97 n = 10,748

7. CASE STUDY #3 PERIODIC HEALTH EXAMINATIONS

8. EXECUTIVE CHECK-UP 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 PLAN C (2 NIGHTS)

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

10. CASE STUDY #4 INTRA-OPERATIVE MONITORING

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

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

13. OBSTACLES TO EVIDENCE BASED MEDICINE

14. THE FIRST OBSTACLE - “EXPERTS”

15. 1960 1965 1970 1975 1980 1985 1990 2304 5647 6 850 8 1239 9 1451 11 1686 12 1986 14 8412 158745 p=NS 0.51.02.0 Odds Ratio (Log Scale) Favors TxFavors Ctrl RoutineSpecoficRare/NeverExperimental Not Mentioned 174 4 2 1 4 4 5 3 4 5 1 7 3 8 4 2 8 6 5 2 9 3 1 4 2 1 1 1 6 1 1 2 2 1 1 2 3 3

17. THE SECOND OBSTACLE - PHARMACEUTICAL INDUSTRY

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

19. 0 20 40 60 80 100 120 140 03691215182124273033363942 FORMULARY 1ST COURSE 2ND COURSEINVITATION RX UNITS 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. 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