Health benefit utilization and out-of-pocket expenses in outpatient care and hospitalizations: Baseline surveys of three primary care sites in the Philippines

Background@#The Philippine Primary Care Studies (PPCS) is a network of pilot studies that developed, implemented, and tested strategies to strengthen primary care in the country. These pilot studies were implemented in an urban, rural, and remote setting. The aim is to use the findings to guide the policies of the national health insurance program (PhilHealth), the main payor for individualized healthcare services in the country.@*Objective@#The objective of this report is to compare baseline outpatient benefit utilization, hospitalization, and health spending, including out-of-pocket (OOP) expenses, in three health settings (urban, rural, and remote). These findings were used to contextualize strategies to strengthen primary care in these three settings.@*Methods@#Cross-sectional surveys were carried out using an interviewer-assisted questionnaire on a random sample of families in the urban site, and a stratified random sample of households in the rural and remote sites. The questionnaire asked for out-patient and hospitalization utilization and spending, including the OOP expenses. @*Results@#A total of 787 families/households were sampled across the three sites. For outpatient benefits, utilization was low in all sites. The remote site had the lowest utilization at only 15%. Unexpectedly, the average annual OOP expenses for outpatient consults in the remote site was PhP 571.92/per capita. This is 40% higher than expenses shouldered by families in the rural area, but similar with the urban site. For hospital benefits, utilization was lowest in the remote site (55.7%) compared to 75.0% and 78.1% for the urban and rural sites, respectively. OOP expenses per year were highest in the remote site at PhP 2204.44 per capita, probably because of delay in access to healthcare and consequently more severe conditions. Surprisingly, annual expenses per year for families in the rural sites (PhP 672.03 per capita) were less than half of what families in the urban sites spent (PhP 1783.38 per capita). @*Conclusions@#Compared to families in the urban site and households in the rural sites, households in remote areas have higher disease rates and consequently, increased need for outpatient and inpatient health services. When they do get sick, access to care is more difficult. This leads to lower rates of benefit utilization and higher out-of-pocket expenses. Thus, provision of “equal” benefits can inadvertently lead to “inequitable” healthcare, pushing disadvantaged populations into a greater disadvantage. These results imply that health benefits need to be allocated according to need. Families in poorer and more remote areas may require greater subsidies.

Philippine guidelines on periodic health examination: Pediatric immunization

Executive Summary@#This Clinical Practice Guideline for the Periodic Health Examination (Pediatric Immunization) is an output from the joint undertaking of the Department of Health and National Institutes of Health-Institute of Clinical Epidemiology. This clinical practice guideline is a systematic synthesis of scientific evidence on immunization for the prevention of human papilloma virus (HPV) infection, influenza, typhoid fever, Japanese encephalitis, poliomyelitis, meningococcal infection, and Hepatitis A in the pediatric population. The CPG provides nine (9) recommendations on prioritized questions regarding the relevant vaccines for preventing these seven (7) diseases. Recommendations are based on the appraisal of the best available evidence on each of the eight identified clinical questions. The CPG is intended to be used by general practitioners and specialists in the primary care setting, policy makers, employers and administrators, allied health practitioners and even patients. The guideline development process followed the widely accepted Grading of Recommendations, Assessment, Development, and Evaluation or the GRADE approach including GRADE Adolopment, a systematic process of adapting evidence summaries and the GRADE Evidence to Decision (EtD) framework. 1,2 It includes 1) identification of critical questions and critical outcomes, 2) retrieval of current evidence, 3) assessment and synthesis of the evidence base for these critical questions, 4) formulation of draft recommendations, 5) convening of a multi-sectoral stakeholder panel to discuss values and preferences and assess the strength of the recommendations, and 6) planning for dissemination, implementation, impact evaluation and updating. The recommendations in this CPG shall hold and will be updated after 3 years or when new evidence arise.

Technical capacity mapping for clinical practice guideline development in the Philippines

@#<p style="text-align: justify;"><strong>Background.</strong> A 2017 situational analysis assessing Clinical Practice Guidelines (CPG) development in the Philippines revealed CPGs of inconsistent quality. In response, the Department of Health (DOH)-Philippine Health Insurance Corporation Manual for CPG Development was developed to outline the standardized steps of the CPG development process. To implement this, technically qualified institutions and individuals should be commissioned.</p><p style="text-align: justify;"><strong>Objective.</strong> To identify qualified institutions and individuals and map out their technical skills and potential for capacit building in CPG development</p><p style="text-align: justify;"><strong>Methods.</strong> Mixed methods were used in this cross-sectional study. A snowballing method identified specific institutions and individuals. Self-administered surveys and key informant interviews were conducted to determine competence, strengths, and gaps in the development of CPGs.</p><p style="text-align: justify;"><strong>Results.</strong> A total of 74 individuals from 45 institutions with competencies in CPG development were identified. Of the 45 institutions, 72% were non-clinical, with roughly half working on formal research. Of the 74 individuals, 96% possessed relevant knowledge and skills and 85% already provided training on CPG development topics. Around half of the respondents have been part of a CPG development task force. Only about half were able to incorporate social concepts of equity, and only one-third had experience in managing conflicts of interest.</p><p style="text-align: justify;"><strong>Conclusion.</strong> Qualified institutions and individuals identified in this capacity mapping can be tapped in future CPG development in the country. Incorporation of social concepts and management of conflicts of interest still need to be ensured.</p>

Assessing the impact of a physician resiliency and wellness program to physician burnout levels in a pediatric department of a tertiary hospital: A pilot study of the I-CARE program

@#<p><strong>Background:</strong> Physician burnout is a growing problem worldwide. Several interventions aimed at lowering burnout rates among physicians have been implemented. To date, there is no established structured program to combat burnout in the Philippine General Hospital. This study evaluated the effectiveness of the I-CARE program, a physician resilience and wellness program which adapted the different components of the international programs for the Philippine setting.</p><p><strong>Objective:</strong> To evaluate the effectiveness of the I-CARE program in reducing medical residents' burnout level.</p><p><strong>Methods:</strong> After key components of the I-CARE program were identified, the program was implemented in 2 phases. The first phase involved training of consultants to hone their facilitation skills. The second phase was a before-and-after study of the I-CARE program. The participants' burnout level was measured before and after the program using the Maslach Burnout Inventory.</p><p><strong>Results:</strong> The I-CARE program was implemented in the Department of Pediatrics from March to August 2020. There was no significant change in the overall burnout levels of 59 pediatric residents after the I-CARE implementation (p=0.32). This may be due to several challenges encountered during the implementation, such as time constraints, the increased workload caused by the COVID-19 pandemic, and the lack of physical meetings due to the restrictions of the pandemic. However, the feedback of the administrators, facilitators and residents was generally positive. All the interviewed participants recommended the continuation of the I-CARE program in the Department of Pediatrics.</p><p><strong>Conclusion:</strong> The I-CARE program shows potential in promoting mental health and emotional wellness among physicians in training.</p>

Delayed-type hypersensitivity reaction to glargine and biphasic isophane human insulin in a Filipino patient with type 2 diabetes mellitus: A practical approach to diagnosis and management

Insulin hypersensitivity reactions are rare, but cause significant complexity in the care of patients with diabetes mellitus. A 54-year-old Filipino male with type 2 diabetes mellitus and multiple co-morbidities developed delayed-type hypersensitivity reactions to biphasic isophane human insulin and glargine. Despite good glycemic control on oral hypoglycemic agents, his endocrinologist foresaw the need for future insulin therapy, particularly one basal and one short-acting insulin. Targeted skin tests demonstrated protamine allergy and negative reactions to regular insulin and detemir. Close coordination of care among endocrinologists, allergists, patients and patients' family is needed to optimize glucose control, prevent complications, and minimize the risk of future hypersensitivity reactions.Key Words: drug hypersensitivity, insulin, diabetes mellitus

Should sanitation tents be used for prevention of COVID-19 transmission?

Key Findings@#There is currently no evidence to support the use of sanitation tents in the prevention of COVID-19 transmission. • Sanitation tents or disinfection tents have been installed in various areas of the Philippines as a measure to decontaminate individuals and prevent COVID-19 transmission. • The commonly used disinfectant in these tents is diluted household bleach. Others propose to use alcohol or diluted povidone iodine to decontaminate individuals in the tent. • Bleach is an irritant to mucous membranes and loses its antimicrobial effect over time or when exposed to heat and sunlight. • Alcohol is flammable and also causes irritation to mucous membranes. • Povidone iodine may cause skin irritation, chemical pneumonitis when inhaled, and acute kidney injury when systemically absorbed. • There are no completed or ongoing studies on the use of sanitation tents for the prevention of COVID-19 transmission. • To date, there are no guidelines that recommend the use of sanitation tents for prevention of COVID-19 transmission. • The World Health Organization explicitly recommends against spraying alcohol or chlorine all over a person's body due to adverse health effects and the lack of inhibitory activity against viruses that have already entered the body. • The Centers for Disease Control and Prevention note that most environmental protection agency-registered household disinfectants are effective against COVID-19. However, these products are approved for use only on surfaces and not on humans. • The Department of Health guidelines recommend the avoidance of spraying or misting for COVID-19 due to lack of evidence of its efficacy.

What is the second sedative agent to add to Dexmedetomidine for sedation of COVID-19 patients?

Key Findings@#At present, there are no studies that evaluate the efficacy or safety of dexmedetomidine with another sedative agent among coronavirus disease 2019 (COVID-19) patients. Possible adverse events should be carefully considered in the choice of an add-on sedative agent. • Adequate sedation is important among ventilated COVID-19 patients. Dexmedetomidine is an alpha2-adrenergic receptor agonist that produces sedation, analgesia and anxiolysis. It preserves respiratory function even when given in high doses; thus, it is commonly used for COVID-19 patients. • Due to the high cost of dexmedetomidine, a common clinical practice is to use dexmedetomidine in combination with other sedatives. • Co-administration of dexmedetomidine with other sedatives has an additive effect. Possible adverse effects of combination treatment include hypotension, bradycardia, and delirium. • There are no completed or ongoing clinical trials that evaluate the efficacy or safety of dexmedetomidine with another sedative agent among COVID-19 patients. • Currently, there are no guidelines that specifically mention the recommended add-on sedative agent to dexmedetomidine for sedation of COVID-19 patients. • The World Health Organization recommends light sedation and minimizing continuous or intermittent sedation among suspected COVID-19 patients with severe acute respiratory infection. • Consensus statements for mechanically ventilated COVID-19 patients recommend using dexmedetomidine, lidocaine or opioids during extubation to minimize coughing. • Clinical practice guidelines for sedation among critically ill, mechanically ventilated adult patients recommend the use of propofol or dexmedetomidine over benzodiazepines due to decreased time to extubation, duration of stay in the intensive care unit, and incidence of delirium.

Should virgin coconut oil be used in the adjunctive treatment of COVID-19?

Key Findings@#There is currently no evidence to support the use of virgin coconut oil in the adjunctive treatment of COVID-19. • Virgin coconut oil is naturally extracted from fresh coconut kernel and is rich in medium chain triglycerides, with lauric acid as the predominant fatty acid. • Virgin coconut oil is currently explored as an adjunctive treatment for patients with COVID-19 due to its antiviral and immunomodulatory properties. • In vitro studies show that lauric acid or its derivative exert inhibitory activities against viruses with similar structure to coronavirus (enveloped ssRNA virus) such as Junin virus, vesicular stomatitis virus, human immunodeficiency virus type 1 (HIV-1), and Semliki Forest virus. • Animal studies demonstrate antiviral activity of monolaurin, the pharmacologically active metabolite of lauric acid, on avian influenza virus and Simean immunodeficiency virus, which are both enveloped ssRNA viruses. • Clinical trials among patients with HIV report that virgin coconut oil can increase CD4+ T lymphocyte counts and reduce viral load. • In vitro and animal studies demonstrate anti-inflammatory properties of virgin coconut oil. • At present, there are no studies that investigate the effectiveness of virgin coconut oil in the adjunctive treatment of COVID-19 infection. • There is currently one ongoing clinical trial in the Philippines evaluating the use of virgin coconut oil in the adjunctive treatment of COVID-19. • Nausea, vomiting, mild diarrhea, and abdominal pain have been reported, but no serious adverse events have been identified with the use of virgin coconut oil. • To date, there are no guidelines that mention virgin coconut oil as an option for the adjunctive treatment of COVID-19.