How can clinical research improve primary care service?

FMS Conference 2013 Kuantan

Content

1.Research enhance clinical practice 2. Clinical scenario TB

We need new and better way to manage new disease and emerging disease - Diagnostic - Treatment - Prevention

Clinical Scenario
64 yr old male Cough > 3 weeks Bloody sputum Losing weight Fever Has been to Indonesia for few times over the last 6 months

Saya sakit apa, Doctor?

Clinical Scenario
ESR > 100 mm/hr Sputum AFB +ve (All 3) CXR

Anda mengidapi batuk kering atau TB, Pakcik.

Clinical Scenario
Macammana buat, sekerang, Dr?

Dr: You need treatment to heal TB and to stop others getting TB from you.

Management of TB
Before anti-TB regimen - 5 drugs for 6 months (Streptomycin(S), Ethambutol(E) ,isoniazid (H),pyrazinamide(Z) ,rifampicin(R) )

Current treatment- 4 drugs- 2 months of HRZE and 4 mths of HR, all oral
How do we make this decision ? Why not single but combination of drugs?

Sir Austin Bradford Hill Epidemiologist & Statistician 1st Randomised Clinical Trial 1948 UK Medical Research Council Effects of aminoglycoside antibiotic Streptomycin on Tuberculosis

Randomisation - By the allocation of the patients to the two groups we want to ensure that these two groups are alike except in treatment this might be done, ., by a random division of the patients; the first ..treatment A, the second being orthodoxly treated and serving as a control, the third being given treatment A, the fourth serving as a control, and so on, no departure from this rule being allowed. (Hill 1937)

Clinical Scenario
What should I do when on treatment? Will I be completely cured?
Dr: You must follow treatment plan. Someone need to sign the book after you take the drugs. There are few side effects of anti-TB such as rash, itch, disturbance with sensation. If you complete the treatment, you will do well and most likely has no recurring of TB.

Clinical Practice Guideline-TB

Prognosis TB is a treatable disease. Without treatment, mortality rate >50%; With treatment, case fatality rate - 4.6% Risk factors for death include increased age, delay in diagnosis , extent of lung involvement on XRay, need for mechanical ventilation, ESRD, diabetes, and immunosuppression Pt must be compliance to treatment Directly Observed Treatment, Short-course(DOTS) ensure success >95%

Prevention and new research areas

Directly Observed Treatment, Shortcourse(DOTS)-prevents emergence of multi-drug resistant TB WHO Stop TB strategy 2006 Patient centred treatment Multi- drug resistant TB TB / HIV With success of DOTS in controlling TB, expanded to NCD i.e. DM, HPT and epilepsy

What else?
Screen his family members/ persons in close contact with him

Prevent further transmission of TB

Clinical research enhance clinical practice

Diagnostic research
Make a diagnosis based on signs and symptoms & investigations

Interventional research
& Prognostic research

Treat the patient based on best evidence Tell patients about their prognosis & how to enhance prognosis

Prevent further spread/ complications Aetiologic research of the disease

Clinical practice is not about prescribing drugs

As healthcare provider, we must - be updated with research findings -use them as evidence to improve our care -do own research if we cant find evidence -gather patient reported outcome measures

Thank you
Any questions?

Thank you contact@crc.gov.my