PEBM in a resource-limited country
17 June 2019
Practising Evidence-Based Medicine in a Resource-limited country: let's start at the very beginning
Critical care outcomes in Kenya are poor, with mortality rates of over 50% in public hospital Intensive Care Units (ICUs). Outcomes in well-resourced private hospital ICUs are a lot better on the other hand, but these facilities are often incredibly expensive and out of the reach of the common man.
Although the causes of these poor outcomes are multi-factorial, the lack of locally-derived data to create applicable guidelines for our resource-limited facilities may be one contributory factor. Many of the guidelines we are asked to follow are based on research that doesn’t apply to our setting. While the paucity of local data means we cannot dismiss these guidelines altogether, we often do not examine them sufficiently enough to identify what works where and why. There is, therefore, an urgent need to identify evidence-based interventions that lower mortality in resource-limited critical care facilities in Kenya.
Having worked both in Kenya and the UK, and in the public and private sectors in Kenya, I have always wondered how much of what is done in critical care is essential to high quality care: what can safely be discarded to make critical care affordable while still guaranteeing a reasonably good outcome. The requirement for specialist interventions for time-critical emergencies for instance is often not feasible in many Kenyan facilities, leading to diagnostic delays, delayed interventions, and possibly, poor outcomes. Hypotensive patients in urgent need of echocardiographic evaluation, for example, are referred to cardiologists for this service, many of whom may not be readily available, as we have only 50 cardiologists for a population of nearly 50 million. My research is therefore based on evaluating the option to train non-cardiologists in Kenya to perform a basic form of echocardiography called Focused Cardiac Ultrasound (FoCUS) to a high standard, and to explore the impact such training would have on critical care outcomes in our resource-limited facilities. To lay the groundwork for my research, I have been planning a systematic review to evaluate the diagnostic accuracy of a variety of FoCUS protocols when performed by non-cardiologists for non-traumatic hypotension. I have also embarked on a journey to become accredited in basic echocardiography, both for my own practice as an intensivist, as well as to gain further insights into FoCUS. Recently, the Africa-Oxford Initiative awarded me a grant to support my travel as I begin to explore this area of research. My first stop when I received this funding was the Papworth Focused Intensive Care (FICE) course on the 7th June, followed thereafter by a meeting with my FICE mentor at the John Radcliffe Hospital, under whose guidance I will perform supervised scans for FICE accreditation.
And on a rainy, summer day in Oxford, I met with my supervisors to discuss my progress to date, and to plan a review of the resource implications for cardiac care in Kenya…
Wangari Waweru-Siika is Assistant Professor at the Aga Khan University, Nairobi and studying for a DPhil in Evidence-Based Healthcare
Wangari Waweru-Siika received funding support from The Africa Oxford Initiative (AfOx). AfOx is a cross-university platform for academic and research collaborations between the University of Oxford and African researchers and institutions.