Clinical practice guideline is defined as “statements that include recommendations intended to optimize patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options”. It includes recommendations that are intended to optimize patient care. They are the best source of evidence for busy clinicians and may be the most efficient type of evidence to guide decision making in family practice.
Practice Guideline

Tuberculosis (TB) in Malaysia is rising due to multiple factors and issues related to its management are addressed in the updated evidence-based clinical practice guidelines. Screening for active TB should be considered in high risk groups. Light emitting diode-based fluorescence microscopy and nucleic acid amplification tests are recommended investigations. Health education and standardised 6-month daily antituberculosis (antiTB) regimen are among important elements for successful treatment. Latent TB infection screening should only be performed on high risk individuals. AntiTB regimen offered to HIV-positive adults should be the same as for HIV-negative adults and timing to initiate highly active antiretroviral therapy in patients with TB is based on CD4 count. All patients on antiTB treatment should be monitored to assess their response to treatment and to identify problems associated with it.
Tuberculosis ; Practice Guideline ; HIV

Objective: To determine the rate of the appropriateness of the requested CT and MRI procedures in the Outpatient Department of a tertiary hospital in the Philippines from January to June 2018 using the American College of Radiology Appropriateness Criteria (ACR-AC).

Methods: This retrospective research reviewed outpatient CT and MR imaging requests and cross-referenced with the corresponding ACR-AC guideline available for the written clinical diagnosis.

Results: Four hundred thirty-six (436) (56%) of the 774 retrieved requests were CT scan studies, while the remaining 338 (44%) are MR imaging procedures. Cross-referencing with ACR-AC, the rate of appropriateness across all patients is high at 96.6%, with a 95% confidence interval of 95.0% and 97.6%. The rates were not significantly different between MRI and CT (p-value = 0.4502). Likewise, there was no significant difference in rates of appropriateness for the body parts abdomen, cranial, chest, and spine (p-value = 0.6502).

Conclusion: Although the results were high, relative to the few available international studies, the importance and potential of the ACR-AC cannot be disregarded. The ACR-AC serves as a guide in selecting the appropriate imaging test given a clinical situation. This may equate to better patient management, considering all patient-related factors.

Key Words: diagnostic imaging; reviews, appropriateness; practice guideline

Background. A 2017 situational analysis assessing Clinical Practice Guidelines (CPG) development in the Philippines revealed CPGs of inconsistent quality. In response, the Department of Health (DOH)-Philippine Health Insurance Corporation Manual for CPG Development was developed to outline the standardized steps of the CPG development process. To implement this, technically qualified institutions and individuals should be commissioned.

Objective. To identify qualified institutions and individuals and map out their technical skills and potential for capacit building in CPG development

Methods. Mixed methods were used in this cross-sectional study. A snowballing method identified specific institutions and individuals. Self-administered surveys and key informant interviews were conducted to determine competence, strengths, and gaps in the development of CPGs.

Results. A total of 74 individuals from 45 institutions with competencies in CPG development were identified. Of the 45 institutions, 72% were non-clinical, with roughly half working on formal research. Of the 74 individuals, 96% possessed relevant knowledge and skills and 85% already provided training on CPG development topics. Around half of the respondents have been part of a CPG development task force. Only about half were able to incorporate social concepts of equity, and only one-third had experience in managing conflicts of interest.

Conclusion. Qualified institutions and individuals identified in this capacity mapping can be tapped in future CPG development in the country. Incorporation of social concepts and management of conflicts of interest still need to be ensured.

Cardiovascular disease is a significant cause of morbidity and mortality in patients with diabetes mellitus (DM). According to the IDF Diabetes Atlas 2013, the prevalence of diabetes in Myanmar is 5.7%.(1) Diabetes is recognized as a risk equivalent for coronary heart disease. The lipid profile in patients with type 2 DM is characterized by elevated triglycerides, low high-density lipoprotein cholesterol and raised small dense low-density lipoprotein cholesterol (LDL-C) particles. This is believed to be a key factor in promoting atherosclerosis in these patients. There is ample evidence that aggressive statin therapy reduces cardiovascular end points in patients with DM in both primary and secondary prevention studies. In all persons with DM, current treatment guidelines recommend reduction of LDLC to less than 100 mg/dL, regardless of baseline lipid levels. In very high risk patients with DM and coronary heart disease lowering of LDL-C to less than 70 mg/dL may provide even greater benefits. Treatment for hypertriglyceridaemia is recommended only if TG levels is very high (>500 mg/dL).
Myanmar ; Practice Guideline

Objective: The implementation of guidelines in clinical practice is still facing a lot of obstacles. Although clinical recommendations of dyslipidemia are extant, little is known about how community physicians view guidelines and their implementation. The objective of this study is to assess the acceptance of guideline content and perceived implementation of dyslipidemia guidelines among physicians in Malang, Indonesia. Methodology: Semi-structured validated questionnaires were given to 67 random physicians consisting of general practitioners (GP), internal medicine residents and internists. The questionnaire consisted of 19 questions evaluating four parts: information about access to dyslipidemia training, dyslipidemia guideline-perceived knowledge, level of understanding of dyslipidemia guidelines and application rate of guideline adopted. Evaluation results were scored ordinally and divided into 3 levels; less, enough and good for each part of the questionnaire. Results: 89.2% of samples in the GP group lacked information about dyslipidemia training. The resident group had participated and were involved in dyslipidemia management training (98.3%), followed by the internist group (95.2%). In the GP group, 89.2% never or had less participation in dyslipidemia management training. The GP group (76.2%) also had had poor knowledge in understanding lipid guidelines, in which the least knowledge is known about targets of treatment, non-drug treatment and risk factors. Also, 40.3% of the GP group is still not capable of adopting dyslipidemia guidelines in daily practice. A major barrier was lack of understanding of guidelines (76.3%), followed by failure of adherence to the therapy of patients (12.1%). In the resident group, a major obstacle in the application of the guidelines is education level of the patient (45.5%). In all groups, HMG-CoA Reductase inhibitors are the most commonly used lipid-lowering drugs for treatment of dyslipidemia (98.1% in GP group, 96.3% in resident group, and 97.3% in internist group). Conclusions GPs, as physicians in primary health care system, had poor information and participation in dyslipidemia training, and poor knowledge of dyslipidemia guidelines (AACE, AHA, CCS), as well as understanding and application of the dyslipidemia guidelines (ATP III, PERKENI) to the population, whereas residents and internists had better perception and application of dyslipidemia guidelines.
Dyslipidemias ; Guideline ; Physicians

Diabetes Mellitus (DM) in pregnancy has serious impact on both mother and baby if not optimally managed. The Indonesian Task Force on Reproductive Diseases determined that diabetes in pregnancy represents a priority area in need of updated evidence-based practice guidelines. The aim of the guidelines is to provide the best evidence-based recommendations for diagnostic evaluation and management of diabetes in pregnancy. The following article summarizes the guidelines.
Pregnancy ; Practice Guideline ; Indonesia

Diabetes Mellitus ; Practice Guideline ; Prevalence

BACKGROUND: Despite the availability of clinical guidelines for stroke, variation exists in the management patterns of stroke among neurologists.
OBJECTIVE: To determine the current practice patterns of Filipino adult neurologists in stroke and their adherence to the current clinical guidelines of the Stroke Society of the Philippines (SSP).
METHODS: Cross-sectional survey using a 3-page, 17-item questionnaire reviewed by the Stroke Council of the Philippine Neurological Association (PNA).
RESULTS AND OBSERVATIONS: From November 2013 to July 2014, 136 of 277 (49%) locally practicing board certified adult neurologists of the PNA were surveyed. Some important findings from the survey include: (1) 70% of respondents underestimated the benefit of warfarin in stroke prevention in nonvalvular atrial fibrillation (NVAF); (2) for acute ischemic stroke, although the recommended systolic blood pressure (SBP) threshold is >220 mm Hg, 43% would initiate antihypertensive therapy at SBP >180 mm Hg; (3) for acute primary intracerebral hemorrhage (ICH), 42% would start antihypertensives at SBP >140 mm Hg; (4) despite the absence of guidelines recommending the use of neuroprotectant drugs for acute stroke, 75% and 56% of neurologists have prescribed it to >80% of their patients with infarcts and ICH respectively; (5) 46% of neurologists have not experienced giving thrombolytic therapy to any of their patients with acute ischemic stroke; (6) among patients with clinically stable hemorrhagic strokes, 77% of neurologists would give antithrombotics, while 28% of them would start it 30 days after the onset of stroke; (7) only 21% of respondents have ordered carotid studies as part of their work up in >80% of their patients with ischemic strokes; and (8) 64% of respondents have requested carotid revascularization procedures for patients with significant carotid stenosis, and about 38% of these patients underwent the procedure.
CONCLUSION: The management patterns in stroke remain varied among Filipino neurologists, although the patterns show increasing adherence toward guideline recommendations. The following practices are noted: underestimation of the benefits of oral anticoagulation for stroke prevention among patients with NVAF; use of pharmacologic control of blood pressure below the recommended threshold for acute ischemic stroke; widespread use of neuroprotectant drugs despite lack of definite evidence for its use; low utilization of carotid studies in the work-up of patients with ischemic stroke and the low rate of revascularization procedures in confirmed cases of carotid stenosis; and a relative increase in experience with thrombolysis.

Human ; Physicians, Family ; Practice Guideline