Doc, look at the evidence

New Delhi, Oct. 5: In a large hospital in rural Haryana, doctors have prescribed a 60-year-old man with chronic obstructive pulmonary disease (COPD) a package of exercise, nutrition and oxygen in addition to standard drugs.

Pulmonologist Dhruv Chaudhry at the University College Health Sciences, Rohtak, has introduced lung rehabilitation for COPD patients ---- a treatment package that he and other doctors say hasn't been adopted in India as widely as it should have been.

"Lung rehabilitation has been proven an effective therapy with effects as good as, or better than, standard drug therapy. But it remains hugely under-utilised," said Paul Glasziou, former director of the Centre for Evidence-Based Medicine at Oxford, who is now director of a similar centre at Bond University in Australia.

Glasziou and other doctors say the under-use of lung rehabilitation in managing COPD provides an illustration of the failure of the medical community in India and elsewhere to always practice evidence-based medicine.

"Most of medicine is indeed evidence-based, but sometimes things proven useful aren't offered to patients and things proven useless continue to be prescribed," said Kameshwar Prasad, a neurologist at AIIMS, New Delhi.

Prasad and other advocates of evidence-based medicine are hoping that all doctors would make use of systematic and rigorous reviews of research that establish what works in medicine, what doesn't, and what should not be used at all.

They will begin a three-day conference here tomorrow, inviting medical practitioners, government health policy makers and medical faculty to discuss strategies to promote evidence-based medicine in the country.

Sometimes, the early findings of the benefits of a therapy, for instance, may not hold when applied in large numbers to patients, Prasad said. For nearly three decades, doctors urged post-menopausal women to use long-term hormone replacement therapy (HRT).

The early belief was that it provided protection against strokes and heart attacks. But subsequent research of the outcomes of HRT in large numbers of patients showed that the therapy actually increased the risk of strokes, heart attacks and breast cancer.

Prasad and his colleagues, who examined prescriptions furnished by 250 patients who had come to AIIMS after seeking treatment from other doctors, found that nearly half the patients had been asked to take a so-called neuro-protective drug that has been proven to have no role in protecting against stroke.

Glasziou cites another example of a needless procedure called vertebroplasty in which a glue-like substance is injected into the vertebral bones to treat crush fractures that occur in osteoporosis.

"These vertebroplasty injections have been shown to be no better than sham injections," he said. "But there appear to be clinics in India still offering this."

Glasziou is preparing a handbook on non-drug remedies. A simple head manoeuvre, for instance, might help manage vertigo --- spells of dizziness ---- now routinely treated with drugs.

Sometimes, lack of infrastructure prevents adoption of evidence-based medicine.

"Lung rehabilitation, for instance, demands teamwork. You need a pulmonologist working together with a cardiopulmonary physiotherapist and a nutrition specialist," said Chaudhry. "There's need for great coordination between them."

Similarly, the outcome of strokes can be significantly improved if hospitals establish a dedicated stroke unit, Prasad said. A stroke unit equipped with neurologists, nurses and physiotherapists working together helps patients, he said.

"But India has less than 20 stroke units," Prasad said. "Not enough for our burden of strokes."

The three-day conference will review available evidence from various branches of medicine, seek ways to include evidence-based medicine in the medical curriculum, and identify reliable sources of information for doctors to update themselves.