Clinical pathways for the management of hypertension in family and community practice

BACKGROUND: Hypertension is a major risk factor for cardiovascular disease. The prevalence of hypertension in the Western Pacific Region is 37% of adults older than 24, while in the Philippines it is 25% of adults 21 years old and above. Several guidelines have been developed for the management of hypertension. All these guidelines have recommendations for assessment and treatment.OBJECTIVES: The overall objective of the development and implementation of this clinical pathway is to improve outcomes of patients with hypertension seen in family and community practice.METHODS: The PAFP Clinical Pathways Group reviewed published medical literature to identify, summarize, and operationalize the clinical content of diagnostics, interventions and clinical indicators or outcomes to develop an evidence-based clinical pathway in family medicine practice. The group developed a time-related representation of recommendations on patient care processes, in terms of history and physical examination, laboratory tests, pharmacologic and non-pharmacologic interventions as well as social and community strategies to treat hypertension and prevent complications.RECOMMENDATIONS: Recommendations were made based on the number of visits. During the first visit, all adult patients consulting at the clinic should be screened for hypertension with appropriate BP measurement. A thorough history focusing on symptoms, family history using genogram, smoking and other lifestyle and co-existing chronic disease and a thorough physical examination focusing on the weight/BMI, waist/hip ration, funduscopy, neurological, cardiac, renal and peripheral arteries should be done. For the laboratory, request for 12-lead ECG, urinalysis, FBS, creatinine, serum K and lipid profile to determine co-morbidities and baseline values. If the patient is already diagnosed hypertensive, start/continue medications with either or a combination of thiazide-type diuretic, calcium channel blockers, angiotensin-converting enzyme inhibitors and angiotensin receptor blocker depending on co-morbidities or side effects. But if there is a need for further confirmation, no medication is warranted. Educate the patient about hypertension, risk factors and complications. If medications were prescribed, explain the dose, frequency, intended effect, possible side effects and importance of medication adherence. Lifestyle modifications focusing on weight control, exercise and smoking cessation should be advised. During the first first visit is expected that the patient is aware of the diagnosis of hypertension, its risks factors and complications to encourage compliance.IMPLEMENTATION: Education, training and audit are recommended strategies to implement the clinical pathway.

Clinical pathways for the management of dyspepsia in family and community practice

BACKGROUND: Dyspepsia is any chronic or recurrent discomfort in the epigastric area described as bloatedness, fullness, gnawing or burning continuously or intermittently for at least 2 weeks. About 40% of the adult population may suffer from dyspeptic symptoms but most of them are un-investigated because only about 2% consult their physician.OBJECTIVE: The general objective of this clinical pathway is to improve outcomes of patients with dyspepsia in family and community practiceMETHOD: The PAFP Clinical Pathways Group reviewed the previous Clinical Practice Guideline for the Treatment of Dyspepsia in Family Practice, a local guideline developed by the Family Medicine Research Group and adopted as policy statement by the Philippine Health Insurance Corporation. The reviewers then developed a time-related representation of recommendations on patient care processes, in terms of history and physical examination, laboratory tests, pharmacologic and non-pharmacologic interventions as well as social and community strategies to treat hypertension and prevent complications.RECOMMENDATION: All patients with gastrointestinal pain or discomfort should have a detailed history focusing on weight loss, hematemesis, hemetochezia, melena, dysphagia, odynophagia, vomiting, NSAID intake, alcohol intake, smoking, frequent medical complaints, depression, anxiety, personal or family history of gastrointestinal disease using family genogram. Physical examination findings provide minimal information but should be done to rule out an organic pathology and to look for alarm clinical features like anemia, abdominal tenderness or mass, jaundice, melena etc. If the patient is with history of previous dyspepsia treatment, more than 45 years old or long-term use of NSAID, the physician may request for non-invasive H. pylori test. Upper abdominal ultrasound, liver function test, pancreatic amylase may be done if organic problem is considered. Start therapeutic trial of prokinetic treatment for 1-2 weeks or proton-pump inhibitor depending on the symptoms. Fixed drug combination may be used if symptoms are undifferentiated. The patient should be educated about upper gastrointestinal disorders and dyspepsia, risk factors and complications. If medications were prescribed, explain the dose, frequency, intended effect, possible side effects and importance of medication adherence. Lifestyle modifications focusing on low fat meals, weight reduction, avoidance of alcohol intake and smoking cessation, eating way before bedtime, elevated head while sleeping, etc. may also be done. Recommendations were also made on subsequent visits.IMPLEMENTATION: Quality improvement strategy is recommended for implementation of this pathway. This will involve pre- and post-intervention data collection using records review. Intervention strategies may be feedback, group consensus or incentive mechanisms.

The Family Medicine Integrated Clinical Pathways Project (FM ICliP): Methods of development and implementation

Continuing care in family and community medicine is a dynamic process that requires regular patient assessments and adjustments of treatment strategies as the patient goes through the wellness and disease process. Family and community physicians need to be aware of any changes in the patient's clinical condition and re-assess therapeutic interventions when such changes occur. The use of clinical pathways can optimize the management of patients with a given disorder in our setting. The overall goal of the project is to improve the quality of health care in Philippine family and community medicine practice.Clinical pathway is defined as a "tool to guide family and community medicine practitioners to implement evidence- based care and holistic interventions to specific group of patients and populations within a specific timeframe adjusted for acceptable variations that may be due to patient and practice setting characteristics designed to achieve optimum health outcome for the patient and community and efficient use of health care resources." In this definition, holistic interventions refer to interventions directed to the individual patient within the context of the family and community. In this context the PAFP Clinical Pathways Project will be developed to promote and implement the clinical pathways in family and community medicine. The PAFP Clinical Pathways Project will be implemented by a group who will review published medical literature to identify, summarize and operationalize the clinical content of diagnostics, interventions and clinical indicators or outcomes to develop an evidence-based clinical pathway in family medicine practice. The group will also identify processes and indicators to measure the effect of implementation of clinical pathways. Linear time-related representations of patient care processes, in terms of assessments, pharmacologic and non-pharmacologic interventions as well as social and community strategies to prevent complications and maintain wellness will be developed. The clinical pathways will be disseminated to the general PAFP membership and other stakeholders for consensus development. We hope that with this process, family and community medicine practitioners will be dedicated to a common goal and overcome organizational, personal, and professional perspectives barriers to the implementation of the clinical pathway.The implementation of the clinical pathways to be adopted by the PAFP will include a nation-wide dissemination, education, quality improvement initiatives and feedback. Dissemination will be in a form of publication in the Family Filipino Physician Journal, conference presentations and focused group discussions. Quality improvement activities will be in a form of patient record reviews, audit and feedback. Audit standards will be the assessment and intervention recommendations in the clinical pathway. Variations will be discussed in focused group meeting and feedback sessions. The clinical pathways recommendations may also be revised if the variations are justified. Quality improvement activities will also be used to identify barriers in the implementation of clinical pathway. An electronic medical information system may also be used to facilitate the implementation.To monitor the implementation of clinical pathways the PAFP need to select, define and use outcomes and impact to monitor the success of implementation. Outcomes and impact will be at the practice level and the organizational level. Practice level can be a simple count of family and community medicine practice using and applying the clinical pathways. Patient outcomes will also be measured based on quality improvement reports. Organizational outcomes can be activities of the PAFP devoted to the promotion, development, dissemination and implementation of clinical pathways.

Prostate disease correlation on demographics and clinical findings among national annual prostatic digital rectal examination campaign participants

OBJECTIVE: National prostatic digital rectal examination (DRE) advocated by the Philippine Urological Association (PUA) started 2 decades ago in the advent of prostate specific antigen (PSA) screening. It is an effective campaign in promoting prostate health awareness among Filipinos. The aim of this research was to describe and correlate the demographics, clinical profile and prostatic physical findings examined by urologists in over 60 centers in the country.METHODS: This study was an analytical cross-sectional study involving the participants of the 2013-2015 National DRE campaign. The data were retrieved from the PUA secretariat using a convenience-sampling method on completed forms. The data were correlated using a non-parametric measure of statistical dependence between two variables.RESULTS: The total number of participants was continuously rising [n=978 (2013), n=2052 (2017) and n=2792 (2015)] having 60-70% newly diagnosed cases annually. Participants were mostly on their 6th decade of life, mostly employed, married and an educational attainment of secondary level. The most predominant symptom was nocturia followed by frequency, incomplete emptying and weak stream. The usual prostate size was between 21-30 grams mostly with doughy consistency, nodular and tender. The mean age of having clinically benign prostate enlargement was noted to be consistent at the age of 61 while that of a prostate cancer suspect ranged from 63-69 years old.CONCLUSION: Filipinos have similar predominant signs and symptoms of prostate disease as compared to Malays, Chinese and Indians. Clinical findings of prostate diseases correlated well with age, prostate size and consistency.

New strategies in the management of GERD and dyspepsia

The internationally accepted definition of dyspepsia is "chronic or recurrent pain or discomfort centered on the upper abdomen."Gastro-esophageal reflux disease on the other hand is defined as the presence of risks of physical complications of gastroesophageal reflux, or the experience of clinically significant impairment of health-related well being (quality of life) due to reflux related symptoms. Several theories have been proposed regarding the etiology of these disorders, including acid exposure, visceral hypersensitivity, impaired fundal accommodation, delayed gastric emptying, and H. pylori infection. There seems to be a significant overlap of pathophysiological disorders between dyspepsia and GERD. The diagnosis of dyspepsia is challenging. The use of self administered questionnaires in routine clinical care has been questioned by other authors as studies showed that the rate of recognition of heartburn differed between questionnaires. Endoscopy is the preferred procedure to detect lesions in the upper gastrointestinal tract. However, experts suggest empiric treatment over prompt endoscopy because of cost and limited availability of endoscope facilities. After a diagnosis of dyspepsia or GERD, the primary care physician can choose between the following strategies: symptom-guided empirical treatment, direct referral for endoscopy, non-invasive testing for H pylori and subjecting the H pylori positive patients to endoscopy ("test-and-scope"), and. non-invasive testing for H pylori and treatment of the infection in H pylori positive patients ("test-and-treat"). While the role of H pylori in peptic ulcer has been clearly established, its role in dyspepsia is still being debated. A recent meta-analysis suggested that there is a small benefit of about 10% over placebo. Considering the pathophysiology as acid reflux and dysfunctional motility as being the main problem, the combination of a prokinetic like domperidone and a PPI like pantoprazole may offer improved response to empiric treatment. Starting the patient on high potency drugs or combination treatment (step-down approach) is therefore a new strategy that has potential impact to improve response. Potential advantages of the step-down approach include faster healing, maximum symptom relief and a more rapid improvement in the patient's quality of life. Adherence to treatment is also an issue for a chronic and relapsing illness like dyspepsia and GERD. Adherence to prescribed self-administered medication is low in patients with chronic conditions. It is estimated to average only 50%. Fixed dose and sustained release formulations are designed to decrease the number of pills to be taken and the frequency of dosing Le. simplifying the treatment regimen thereby improving adherence. Dyspepsia is a multi-factorial syndrome. Abnormalities include disturbances of GI motor and sensory function as well as specific psychological disorders including depression and anxiety. An intensive medical treatment targeting GI abnormalities with psychological interventions will result to better long-term improvement of symptoms.

Assessment of primary care orientation of the residency training programs under PAFP using the PCAT provider survey

Background: A primary care-based health care system has the potential to make the health system more efficient. The high hospitalization rate for diseases that can be treated in an outpatient setting in areas where there is low access to primary care physicians leads to higher cost of care. Objective: This study was conducted to determine the primary care orientation of the different family and community medicine training programs in Manila. Methods: This was a self-administered questionnaire survey using the primary care assessment tool provider survey (PCAT-PS) conducted on resident physicians undergoing training in family medicine in the different hospitals in Manila. Based on the PCAT scoring, we used a cut-off score of 3.5 as the desirable level of orientation. Results: A total of 24 residents from 8 hospitals responded to the questionnaire. A significant percentage of patients are being seen in their clinic over a period of 1-4 years. Majority of the patients they see are those aged 20 years old or more. Of all the 9 domains, the programs had very good scores in coordination of care, information system, family-centeredness and cultural competence. However, improvement is needed for services that are available, services being provided, ongoing care and community orientation. In terms of the overall primary care score for the core indicators, the training programs in family medicine did not reach the target mean score of 3.5. However, when the other domains were added the overall mean primary care score with the expanded domains had a mean of 3.55. This suggests that the current training programs in the Manila are strong in their family-centeredness and their cultural competence. Conclusion: In conclusion, our training programs may be improved to be more primary care oriented. We need to be patient-centered by asking our patients and determine what health service they need and want. Then we need to train our residents in providing these services, with greater exposure to outpatient rotations and community clinics.

Clinical practice guideline for the diagnosis and treatment of degenerative osteoarthritis

A review of the non-pharmacologic madalities was done by Puett 1994. Of the 7 cited modalities, exercise was found to be the most beneficial. Acupuncture and health education were not found to be effective. Ettinger, et al, in 1997 studied 439 patients aged 60 and above. He found that aerobic and resistance exercise were found most beneficial among patients with advancing age.

Impact of chart reminder flyers on the delivery of coronary primary preventive care in a randomized controlled trial

OBJECTIVE: To evaluate the effectiveness of chart reminder flyers in increasing the appropriateness of coronary primary preventive care. DESIGN: Randomized controlled trial. SETTING: A university-based clinic in the period January-June, 2000. PATIENTS: 120 charts randomly selected from 256 patients in the intervention group were considered. Another 120 randomly chosen from 295 patients were selected for the control. These subjects were those who consulted from January-June 2000 at the university clinic. INTERVENTIONS: Each clinic day was randomized to be either "with reminder flyer day" or "without reminder flyer day." On "with reminder flyer days", a one-page flyer that contained a letter of reminder for physicians to perform coronary primary preventive care was placed on the charts of all patients consulting at the clinic. The reminder flyer was detached from the chart right after each consultation. On "without reminder flyers days", no intervention was done. At the end of the trial, 120 charts from each group were randomly selected for auditing for appropriateness of coronary primary preventive care. RESULTS: The proportions of charts that recorded appropriate history taking, physical examination and pharmacological and non-pharmacological interventions were all significantly greater in the intervention group than in the control group (p values 0.001, 0.005 and 0.0001). When coronary primary prevention was taken as a whole, the proportion of charts that reflected appropriate care was significantly greater in the intervention group than in the control group (25 percent vs. 5 percent, p 0.001). Reminder flyers reduced the relative risk of not being given appropriate coronary prevention to 0.79 (p, 0.001). MAIN OUTCOME MEASURES: Proportion of charts that documented appropriate primary coronary preventive care in the intervention and controlled groups were compared using the test for equality of proportions. The changes in appropriateness of the preventive care from baseline for each group was taken and compared. CONCLUSION: The proportion of charts that recorded appropriate coronary primary preventive care was significantly higher in the reminder flyer group.