Effectiveness of health education interventions directed to patient, family, community on Chronic Obstructive Pulmonary Disease in family and community practice: A meta-analysis

Background@#Chronic obstructive pulmonary disease (COPD) is one of the contributors to the burden of non-communicable disease. Health education is a key component in COPD management. Effective health education interventions directed to patient, family and community are necessary to prevent exacerbations, emergency room visits, hospitalizations and improve quality of life for patients with COPD. The general objective of the study was to determine effectiveness of health education interventions directed to patient, family and community. Specifically, to determine the effect on the number of acute exacerbations, COPD related emergency room visits and hospitalizations, improvement in the quality of life and patient satisfaction.@*Methods@#This study only included comparative clinical trials randomized or non- randomized, parallel or cross-over clinical trial design, cohort study involving humans as the participants. It also includes published studies in peer reviewed journals of PubMed, clinical trials registered Cochrane Central Register of Controlled Trials, and the grey literature. There were no foreign language studies included relevant to this review. The non-comparative clinical trials, outcomes research or real-world data, animal experiments, reviews and case reports were excluded. The study population of reviewed literature has an established diagnosis of Chronic Obstructive Pulmonary Disease based on the Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria for diagnosis of COPD. Studies involving COPD patients who have other co morbidities were also included. The patients with COPD in the study were similar to patients consulting in family and community medicine practice clinics in the Philippines. Data synthesis was done separately for each type of intervention, i.e., patient directed, family directed, community directed health education intervention on Chronic Obstructive Pulmonary Disease. Quantitative analysis was only possible for studies reporting similar outcomes and units of measures such as number of COPD-related hospitalizations and emergency room visits for health education intervention directed to patient and improvement in the quality-of-life scores for health education intervention directed to family and community. Narrative synthesis was done when it was not feasible to include studies to do pooled analysis due to any of the following reasons such as different outcomes and when outcomes not reported as means with standard deviation. The Review Manager 5 software was used in the analysis of the data. Sensitivity analysis was done by restricting the analysis to published studies and with low risk of bias.@*Results@#A total of ten studies were included. Health education interventions directed to patient has no benefit in decreasing the number of COPD related emergency room visits (1.84, 95% CI 0.94,2.74) and insufficient evidence to decrease the number of COPD related hospitalizations (4.33,95%CI-4.69,13.34). Health education intervention directed to family have insufficient evidence to improve the quality of life among patients with COPD (0.35,95% CI -0.49,1.19). Community directed health education intervention have significantly improved the quality of life among patients with COPD (-1.95,95% CI -3.37, -0.53).The studies had low risk for bias in terms of random sequence generation, allocation concealment and blinding of outcome assessment except for one study that was a non-randomized trial (Tabari et al, 2018). The highest risk for bias across the studies was the non-blinding of the participants. The withdrawals or dropouts in one study exceeded 20%. Three studies reported non possibility of blinding the assessor (Marques et al 2015, Nguyen et al 2019, Tabari et al 2018). Furthermore, five studies (Gallefos, 2004, Hernandez et al 2015, Tabari et al 2018, Van Wetering et al 2010, Marques et al, 2015) did not report the use of intention to treat analysis@*Discussion@#Effective health education interventions directed to patient, family and community in conjunction with standard of care may decrease exacerbations, hospitalizations, emergency visits, better quality of life and patient satisfaction. The studies included for this review were heath education interventions solely directed to patient, to family and to community and not a combination of the interventions directed to patient and family, or patient and community, or patient and family and community. Overall, health education interventions are integrated in a patient centered family focused community-oriented care for COPD. Health education is just one of the components of the integrated care on COPD. Better control of COPD is likely due to the combined effects of the different care components. Hence, there is a need for more randomized controlled trials on health education interventions directed to patient and family. Inclusion of COPD related hospitalizations, emergency room visits, acute exacerbations as outcome measures in health education interventions directed to patient, family and community is useful to provide evidence in effectiveness of the intervention. The authors declare no financial or funding involvement in the development and implementation of this study. This protocol was registered with Research Grants Administration Office (RGAO) with Registration No. RGAO-2020-1276, Research Implementation Development Office (RIDO) and to the Research Committee of the Philippine Academy of Family Physicians. The study was given Certification of Exemption from Ethical Review by the University of the Philippines Research Ethics Board (UPMREB CODE: UPMREB 2020-783-EX

Keeping up with COVID-19: A review for family physicians

Background@#Coronavirus disease 2019 (COVID-19) was first identified in Wuhan, China in December 2019. This has rapidly spread worldwide, causing a pandemic. The Philippines ranks 3rd in Southeast Asia with more than 15,000 confirmed cases, and a case fatality rate of 6.01%, close to the global average of 6.33%.@*Objective and Methods@#This review aims to provide Family and Community Physicians the latest updates on epidemiology, pathogenesis, clinical manifestations, diagnosis, treatment options, and prognosis of COVID-19. Online literature search was done with WHO and DOH websites prioritized for epidemiologic data, and MEDLINE for the most recent and relevant journal articles.@*Pathogenesis@#SARS-CoV-2, the etiologic agent of COVID-19, is an enveloped, positive sense single-stranded RNA virus which triggers immune-mediated responses responsible for most of the clinical manifestations of the disease. Angiotensin Converting Enzyme 2 appears to play a critical role in viral entry and disease severity.@*Clinical Manifestations@#There have been reports of asymptomatic cases. Majority have mild illness, with common symptoms of fever, cough, headache and fatigue. Those who progress to the critical stage of the disease present with Severe Acute Respiratory Syndrome, sepsis or Multiple Organ Dysfunction.@*Diagnostic Evaluation@#The definitive diagnosis of SARS-CoV-2 requires an analysis of respiratory specimens collected through oropharyngeal and nasopharyngeal swabs. The reverse transcriptase-polymerase chain reaction (RT-PCR) is considered the confirmatory test. Serological rapid detection test (RDT) for SARS-CoV-2 IgM and IgG may be done, but as an adjunct only because antibodies appear later in the course of disease. Imaging studies and other tests are used to monitor the severity of the condition, but not for diagnosis.@*Treatment and Prognosis@#Supportive therapy is the cornerstone of management. Currently, there is no FDA-approved drug or agent specifically for the treatment of COVID-19. Drugs being investigated for treatment are those that are currently used for other viral infections or indicated for other conditions. A vaccine is yet to be developed. Old age, the presence of comorbidities such as hypertension, diabetes, cardiovascular and lung diseases, and smoking history are risk factors that lead to severe complications and death.@*Conclusion@#COVID-19 has caused a global public health crisis. In the Philippines, cases are still on the rise. Majority of cases are mild. More severe and fatal disease is associated with old age and the presence of comorbidities. Definitive diagnosis is through RT-PCR. Supportive therapy is the cornerstone of management. The search continues for a proven, effective drug for treatment and vaccine for prevention of COVID-19.