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.

Effectiveness of blood pressure monitoring card on pharmacoadherence and hypertension control: A randomized controlled trial

Background: Blood pressure (BP) monitoring was identified to have a direct relationship with adherence and BP control. Measurement of blood pressure (BP) at home or out-of-clinic can accomplish several of the advantages of ambulatory BP monitoring. Furthermore, regular measurement of BP may increase awareness of the condition and may lead to behavioral changes needed in the management of hyepertension such as DASH diet, smoking cessation, limited alcohol intake and regular exercise. It may also increase compliance with antihypertensive therapy and reduce the number of visits required for the diagnosis and treatment of hypertension. Objective: To determine the effect of provision of BP monitoring card on improving patient's adherence to medication and control of BP among hypertensive patients of PGH-Family Medicine Clinic. Design, Setting, and Participants: An open, randomized controlled trial based on a Chronic Care Model. The trial was conducted at the Philippine General Hospital-Family Medicine Clinic enrolling 102 participants aged 30-70 years with uncontrolled essential hypertension based on JNC VII classification. Participants were recruited from December 2008 to March 2009 and were followed up for 6 months. Intervention participants were assigned and randomized to usual care (control group) and usual care plus BP card (intervention group). Patients were instructed to do BP measurements at least twice a week for the whole duration of study. Outcome Measures: The primary outcome measures were the percentage of patients with controlled BP ( 0.05). Comparison of clinical profile, associated risk factors in hypertension, behaviors related to hypertension, and presence of co-morbid conditions and target-organ damage, factors affecting blood pressure monitoring and pharmacoadherence exhibited similar results (P value> 0.05). Mean SBP and DBP for study population was also similar 158.3 (18.46) and 159.76 (16.51) mmHg; and 93.86 (8.27) and 94.15 (7.74) mmHg for control and intervention groups, respectively. Compared with patients receiving usual care, the proportion of patients adherent to the prescribed regimen was higher in the group with usual care plus BP card in all clinic visits [29(70.7%) 30(73.2%) 32(78.0%)]. The difference was statistically significant on the 6th month of follow-up (P value =: 0.02). A greater proportion of patients had controlled BP in the intervention group [24(54.5%) vs 32(78.0%)] after six months. The intervention group had a lower systolic and diastolic SP than the control group [SBP 135.68 (11.74), 129.15 (9.02) DBP 82.73 (5.55), 78.90 (5.914)] and this was statistically significant with a P value of 0.01 for both measurements. Conclusions: A new model of patient-centered care that uses BP card can improve BP monitoring, and this may lead to behavioral change particularly adherence to medication and improve SP control in patients with hypertension. This very simple and cost-effective model proved to be effective and the same intervention could be used to improve the care of large numbers of patients with uncontrolled hypertension and the provision of SP monitoring cards to all hypertensive patients could be included in the standard care.