BACKGROUND AND OBJECTIVE

Due to their academic load, medical students are highly susceptible to stress. Stress is one of the factors that can alter sleep quality which may consequently affect the cognitive performance of medical students. There has been a lack of published local literature that looks into the association between stress and sleep quality, especially during the COVID-19 pandemic. With this, the general objective of this study is to determine the effect of stress on the sleep quality of medical students from the University of the Philippines Manila - College of Medicine (UPCM).

A cross-sectional study was conducted using a stratified random sample of 273 males and females of Learning Unit (LU) III (1st year) to VII (5th year) medical students from a college of medicine based in the Philippines, UPCM, during the second semester of the academic year 2021-2022. A self-administered questionnaire was distributed to assess sleep quality using the Pittsburgh Sleep Quality Index (PSQI), and stress level using the Kessler Psychological Distress Scale (K10). Kruskal-Wallis was used to test statistical differences between stress scores and the sleep quality of students from different year levels. Spearman's Rho was used to determine the correlation between stress and sleep, and a binary logistic regression was employed to study the association of stress with sleep while accounting for confounding variables namely caffeine intake, year level, daytime nap, duty hours, clinical rotation, sex, and age.

A high prevalence of stress (79.71%) and poor sleep quality (59.73%) among LU III to LU VII UPCM students were found, with a statistically positive correlation (⍴=0.44) 95CI [0.33-0.55] (p-value < 0.001). Both the stress scores and sleep quality indices were not statistically significantly different across LUs. Gathered data and interpreted results showed that medical students suffering from stress are more likely to have poor sleep quality, which can lead to low academic performance and high susceptibility to chronic diseases, compared to those medical students with low levels of stress. Only being an LU IV [OR=1.38 95CI (0.036-4.625)] and LU V [OR=2.13 95CI (0.296-6.936)] student had increased odds of having poor sleep quality compared to LU III students. Caffeine intake, daytime nap, duty hours, clinical rotation, sex, and age were not associated with poor sleep quality.

This study documents a statistically significant association between stress and poor sleep quality among LU III to LU VII UPCM students. A larger study covering multiple medical schools in the Philippines may be of merit for future investigations to generate nationwide data. Additional recommendations include: a) conducting a cross-sectional or a longitudinal study to detect changes in the characteristics of the population, b) observing the differences in the contributing factors at multiple points throughout the year, c) investigating the effect of dwelling set-up on sleep quality may also be investigated and d) determining if sleep quality affects the level of perceived stress of medical students.

Objective. The study evaluates the clinical profile of patients who underwent coronary artery bypass graft surgery (CABG) under the Philippine Health Insurance Corporation (Philhealth) Z Benefit Package (PZBP), as well as time intervals between PZBP screening, approval, and timing of surgery. Methods. A review of medical records was done to collect data on time intervals between the screening process and Philhealth approval in CABG patients under PZBP. The clinical profile and surgical outcomes of patients were also evaluated. Results. Sixty-three patients were included from March 2017 to December 2018. Most patients were under 61-70 years old. Hypertension was the most commonly observed comorbidity. Time intervals were analyzed including identification for surgery to eligibility screening (2–217 days, median 25 days), Philhealth approval (8–266 days, median 20 days), and surgery (9-403 days, median 33 days). Postoperative atrial fibrillation was seen in 22.58%. The most commonly observed complication prolonging hospitalization was pneumonia. Conclusion. This is the first local study which evaluated the timelines of PZBP. Results may be use as basis of follow up study in the future for identification of an acceptable timeline intervals. Several modifiable factors affecting time intervals were identified for further improvement of healthcare services. The leading cause of increase length in hospitalization were HAP and AF.
Coronary Artery Disease ; Vascular Diseases ; Vascular Surgical Procedures ; National Health Programs

BACKGROUND: Acute coronary syndrome (ACS) is a leading cause of admission and mortality in a tertiary care hospital in the Philippines. The significant burden of the disease necessitates that evidence-based care set by international and local guidelines be met to improve service delivery and quality of care (QOC). Institution-specific QOC studies showed gaps between guideline recommendations and compliance. Development and utilization of a clinical pathway are among the identified strategies to improve compliance. It is also crucial for implementation of standard-of-care set specific to a hospital setting based on its needs and resources. METHODS: This is a descriptive research on the development of a clinical pathway for ACS appropriate for the emergency room setting of a tertiary care hospital from March 2021 to August 2022. Local QOC studies and evidence behind the latest international guideline recommendations on the management of ACS were reviewed to create the interim ACS Pathway. Two-level content validation of the interim pathway was done: internal validation with the consultants and fellows of the Division of Cardiovascular Medicine and external validation through focused group discussions with different hospital units and stakeholders to assess applicability and feasibility based on the resources of the setting, identify hindrances, and propose solutions in its implementation. RESULTS: An evidence-based clinical pathway for ACS that encompasses identification and management of ST-segment elevation myocardial infarction and non–ST-segment elevation acute coronary syndrome with judicious use of locally available and feasible resources applicable for local emergency room hospital setting was created. CONCLUSION Review of local QOC studies and interdepartmental collaboration are necessary components in developing institution-specific clinical pathway for ACS.
Acute Coronary Syndrome ; Critical Pathways ; Quality of Health Care

BACKGROUND

Coronary artery disease is the leading cause of death in the Philippines and can present as acute coronary syndrome. Hospitalization for ACS has epidemiologic and economic burden. In fact, last 2017, there were 1.52% or 152 admissions for every 10,000 hospitalized patients for medical conditions in PhilHealth-accredited hospitals locally. However, coronary angioplasty was performed in only less than 1% of these cases mainly because of its cost and the out-of-pocket expense that the treatment entail, when primary percutaneous intervention has been proven to be effective in reducing mortality in STEMI and early invasive intervention performed during index hospitalization for NSTEMI is likewise recommended. Moreover, there is a big disparity between the current case rates for ACS for medical therapy alone and for invasive intervention compared to the actual ACS hospitalization cost.

1) To propose revisions to the current PhilHealth case rates for acute coronary syndrome (ACS); and 2) To determine the budget impact of the proposed ACS case rates.

The Philippine Heart Association with the assistance of a technical working group undertook the study. A panel of experts composed of general and invasive cardiologists from Luzon, Visayas, and Mindanao was formed. The ACS hospitalization costs based on the recent study by Mendoza were presented and discussed during the focus group discussions with the panelists. Issues pertinent to their localities that may affect the costs were discussed. The proposed revised costs on the particular ACS conditions and therapeutic regimens were then voted and agreed upon. A budget impact analysis of the proposed case rates was then performed.

The proposed case rates for ACS ranged from Php 80,000 (for low risk unstable angina given medical treatment) to Php 530,000 (for ST-elevation myocardial infarction initially given a thrombolytic agent then underwent PCI which necessitated the use of three stents). The budget impact analysis showed that the proposed ACS rates would require an additional PHP 1.5 billion to 2.3 billion during the first year of a 3- versus 5-year implementation period, respectively. The period of implementation will be affected by budgetary constraints as well as the availability of cardiac catheterization facilities in the country.

The proposed revised PhilHealth hospitalization coverage for ACS is more reflective or realistic of the ACS hospitalization costs in contrast with the current PhilHealth case rates. The corresponding budget impact analysis of these proposed case rates showed that PHP 7.6 billion is needed for full implementation. However, given the budget constraints, the percentage of the total costs for the first and subsequent years of implementation may be modified.

BACKGROUND

Hospitalization for acute coronary syndrome (ACS) has epidemiologic and economic burden. The coverage for hospitalization in the local setting is much less than the actual costs. Many patients do not consent to or avail of the optimal and timely management because of financial challenges.

The paper aimed to propose revised PhilHealth case rates/packages for ACS, namely: 1) unstable angina (UA), 2) non-ST-elevation myocardial infarction (NSTEMI), and 3) STelevation myocardial infarction (STEMI).

A consensus panel was organized to provide inputs such as cost and other matters pertaining to the revision of the PhilHealth ACS case rates/packages. The results of the cost of hospitalization of the different ACS conditions derived from a study on hospitalization cost for ACS were presented to the panel. Several focused group discussions were held afterward for propositioning new case rates through votation and by nominal group technique, using the costs from the study as the bases of rate adjustment.

Final costs agreed upon by the consensus panel for medical management alone for UA, NSTEMI, and STEMI were adjusted or amended in increments of Php 20,000, (80,000, 100,000, and 120,000, respectively). Thrombolysis of a patient admitted for STEMI increased the cost to Php 140,000. An additional cost of Php 150,000 was added on top of the cost for medical management and coronary angiogram for NSTE- ACS for PCI with use of a single stent. For STEMI, the same category had an additional cost of Php 180,000. For each additional stent used for all clinical scenarios undergoing PCI, Php 65,000 was added, to cover up to a total of 3 stents.

Based on the consensus process with Philippine Heart Association ACS panelists, the cost proposed ranges from 80,000 pesos to 530,000 pesos depending on the clinical scenarios.

OBJECTIVE

This study aimed to determine the budget impact of the proposed revised PhilHealth case rate packages for acute coronary syndrome (ACS).

This budget impact analysis used the static approach or cost calculator modeling method. The prevalence of hospitalization for coronary artery disease in all PhilHealth-accredited hospitals in the country in 2017 and the data from the ACS registry project of the Philippine Heart Association were used in this study. The study multiplied the present PhilHealth coverage with the number of ACS hospitalization claims to come up with the total cost of ACS hospitalization in the next three years with the assumptions that the eligible population and the ACS PhilHealth case rates will remain constant for these years. The future ACS hospitalization costs were also determined if the proposed case rates were used rather than the current PhilHealth case rates. The cost of re-admissions was considered as savings in hospitalization cost (due to prevention of admissions if the appropriate interventions were given) and were deducted from the future total cost of ACS hospitalizations.

The annual total ACS hospitalization cost using the current case rates was Php 1,134,683,000. Using the proposed case rates, the total hospitalization costs over five years was Php 2,653,019,000 in the first year (proposed case rates implemented to only 20% of the ACS patients) and increased to Php 8,726,364,000 by year 5 (full implementation of the proposed case rates or to 100% of ACS patients). This resulted in a lower incremental cost in the first year of implementation compared with a less gradual implementation over 3 years. The total incremental costs would amount to PHP7.6 billion for full implementation.

The study provided the budget impact of the proposed revised ACS case rates. The incremental cost is relatively huge, however the benefits of providing coverage of guidelinedirected therapy including invasive strategies for ACS must be considered.