Experiences in the Philippines: Adapting the essential ... filetreadmill test fibersigmoidoscopy...
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9/12/2011 1 Experiences in the Philippines: Adapting the essential newborn care guidelines LEONILA F. DANS, MD MS University of the Philippines-Manila OUTLINE 1. HOW WE PLANNED TO DO CPGs 2. WHAT ACTUALLY HAPPENED: LESSONS LEARNED IN 3 CASE STUDIES 3. WHERE WE ARE AT PRESENT: ADAPTING THE ESSENTIAL NEWBORN CARE GUIDELINES
Transcript of Experiences in the Philippines: Adapting the essential ... filetreadmill test fibersigmoidoscopy...
9/12/2011
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Experiences in the Philippines: Adapting the essential
newborn care guidelines
LEONILA F. DANS, MD MSUniversity of the Philippines-Manila
OUTLINE
1. HOW WE PLANNED TO DO CPGs
2. WHAT ACTUALLY HAPPENED: LESSONS LEARNED IN 3 CASE STUDIES
3. WHERE WE ARE AT PRESENT: ADAPTING THE ESSENTIAL NEWBORN CARE GUIDELINES
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GUIDELINE DEVELOPMENT METHODOLOGY(PHILIPPINE GUIDELINES ON HYPERTENSION, DYSLIPIDEMIA,
ANGINA, STROKE, PERIODIC HEALTH EXAMINATIONS)
EVIDENCE BASED DRAFT
PUBLIC FORUM
NOMINAL GROUP TECHNIQUE
MODIFIED DELPHI TECHNIQUE
DISSEMINATION
CASE STUDY #1
PHILIPPINE GUIDELINES FOR
MANAGEMENT OF ANGINA
(1996)
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• Multi-sectoral panel• Formal consensus method• Graded level of evidence and strength
of recommendations
PROCESS
PROBLEMS
• Lack of dissemination plan• Lack of political will
1. Use of the following drugs remains debatable because ofmethodologic problems within trials, or conflicting results betweentrials:
a. Dipyridamole (Grade B)b. Fish Oil (Grade B)c. Trimetazidine (Grade B)
Guideline Statement
Angered Response of Educational Influential:
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LESSON LEARNED:
Resolve conflicts of interests -both individual and institutional.
CASE STUDY #2
PHILIPPINE GUIDELINES ON
PERIODIC HEALTH EXAMINATIONS
(2000)
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• Cost range: $100-600• 10% of all medical admissions• Total Cost: $ 1.5M
Note: minimum daily wage $4
COSTS OF EXECUTIVE CHECK-UPS (n=6214) IN 9 METRO MANILA HOSPITALS
1996
• Involved 101 organizations• Graded level of evidence
and strength of recommendations
PROCESS
• FUNDING• DISSEMINATION
PROBLEMS
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“Not just run-of-the-mill healthy,
the President is in top shape, after
his executive check-up…”
“President Ramos is in excellent
health… but he needs a change of
glasses... ”
ANNUAL PHYSICAL CHECK-UP
RESTING ECG TREADMILL TEST FIBERSIGMOIDOSCOPY ULTRASOUND-LIVER ULTRASOUND-GB ULTRASOUND-PROSTATE ULTRASOUND-KIDNEY ULTRASOUND-TRANSVAG CHEST XRAY UPPER GI SERIES MAMMOGRAPHY*
URINALYSIS STOOL EXAM COMPLETE BLOOD COUNT BLOOD UREA NITROGEN CREATININE FASTING SUGAR URIC ACID TOTAL CHOLESTEROL* HDL* LDL TRIGLYCERIDES LIVER FUNCTION (5)AntiHCVHEPATITIS BsAgAntiHBc
Package B (OUTPATIENT)
• Optional: WHOLE BODY PET SCAN
COST: male $550
female $650
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LESSON LEARNED:
CPG uptake needs multi-level support.
CASE STUDY #3
PHILIPPINE NEWBORN
SCREENING GUIDELINES
(2000)
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Newborn Screening
not done at birth
Positive for Congenital
Hypothyroidism
No physical signs at birth
Not treated immediately
14-year old retarded boy
Newborn Screening
done at birth
Positive for Congenital
Hypothyroidism
Treated immediately
Normal 7-year old girl
PROBLEMS:
• Lack of information
• Lack of infrastructure
• Lack of funds
• Lack of policies
STRENGTH:
Strong Advocate: Filipino geneticist
INCLEN KM+ CPG Steps
Philippine Newborn Screening
1: Prioritize
2: Track Evid Accessed relevant databases
3: Validity Appraised Evidence Summaries
4. Applicability Biologic, Socio-Economic Issues
(Prevalence and Health Eco Eval )
5: Equity
6: Policy Advocacy: Incorporated in CPGs ,
Passed a NBS Law
7: Implement’n Involved DOH, PhilHealth
8: Evaluation Screened: 39% babies, 1M
PhilHealth coverage - 90%
?
?
448 CONFIRMED CASES
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LESSON LEARNED:
Guidelines should be put in the context of the socio-economic situation.
WHERE WE ARE AT PRESENT?
ADAPTING THE ESSENTIAL
NEWBORN CARE GUIDELINES
(2008)
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1988 1993 1998 2003 2008
Under Five MR
Neonatal MR
<5 year old and Neonatal MortalityNational Demographic and Health Survey
/1000 live births
Potentially harmful NB care practices (N = 481)
Sobel, H et al. Acta Pediatrica 2010
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PROCESS:
• DOH- WHO-UNICEF initiative
• Evidence-based
• GRADE approach
• Expert and stakeholder panel review
• Pre-planned Dissemination and Evaluation Strategies
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Department of Health EINC Campaign
Hospital Reform Agenda
Network of Centers of Excellence
Curriculum Changes
Social Marketing Campaign
CHALLENGES
1. Inertia of traditional experts
2. Competing piecemeal approaches (ex . NB Screening program)
3. Wider coverage, rapid scale-up
4. Need for operational research
5. Changing political landscapes
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WHERE ARE WE NOW?
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Summary
1. Resolve conflicts of interests, both individual and institutional.
2. CPG uptake needs multi-level support.
3. Guidelines should be put in the context of the socio-economic situation.
4. Adapt guidelines, not just adopt, and share the experience.
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"I have not failed. I've just found 10,000 ways that won't work.“
~ Thomas Alva Edison
