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.

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.

Effectiveness of group consensus activity in improving appropriateness of care for the management of adult asthmatic patients in the ambulatory care unit

BACKGROUND: Asthma still remains a major cause of chronic morbidity and mortality in the world. Hence it is important that quality care is given to these patients at any given time. Several methods are explored to further improve physician performance particularly residents-in-training, thus this study was conceptualized. OBJECTIVE: This study was done to determine whether a workshop allowing residents to set criteria based on a clinical practice guideline improved the appropriateness of care given to adult asthmatic patients in exacerbation as measured by chart audit. METHODS: The setting was the Ambulatory Care Unit of the Philippine General Hospital with the first year residents of the Department of Family and Community Medicine for the year 2007 as subjects. This is a "before-and-after" study. The comparison of the difference before and after workshop percentage appropriateness of care in terms of five criteria was the main outcome. RESULTS: The mean age of the first year residents was 31.57 + 4.502 years. Four were males and ten females. Mean year graduated from medical school was 5.5 + 4.47. From the five criteria, two of them: history taking (93.9%) and assessment (100%) were already above the set standard of 80% prior to the workshop. After the workshop, the percentage appropriateness of care in terms of history taking and assessment was maintained above the set standard. At baseline, three of the five criteria: physical examination (78.8%), treatment (51.5%) and follow-up/health education (66.7%) were noted below the set standard. The three improved after the workshop: only physical examination was significant (from 78.8% to 100%, p value = 0.006), treatment improved but still below the set standard (from 51.5% to 60.6%) while follow up/health education (from 66.7% to 81.8%) was slightly above set standard. CONCLUSION: Workshop allowing the residents to have their own set of criteria based on a clinical practice guideline as an intervention for quality improvement is an effective tool in improving appropriateness of care in terms of physical examination. However, there seemed to have a need for repeated measures to further attain acceptable levels of appropriateness of care.