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 practice
METHOD: 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.

Human ; Dyspepsia ; Smoking ; Smoking Cessation ; Hematemesis ; Melena ; Weight Loss ; Deglutition Disorders ; Medication Adherence ; Gastrointestinal Diseases ; Helicobacter Pylori ; Hypertension

Introduction: Prognosis is an issue which most doctors and patients find difficult to discuss. Both patients and physicians find this process distressing as they can be unprepared to receive and give life-altering news. Although clinicians report that they are discussing prognosis, patients and caregivers frequently do not corroborate these reports, creating communication gaps especially in end-of-life situations. Objective: This study determined how attending physicians documented the communication of prognosis on the patients’ records in terms of content, timing, and frequency during the course of hospitalization. Methods: This is a retrospective chart review of 234 terminally-ill patients admitted from January 2020 to March 2020 in five (5) clinical departments of a public tertiary hospital. Discharge summaries and physicians’ daily chart notes were reviewed to identify the major events of each case. Results: Two-thirds of the patients’ records had no documentation of any discussion with patient/family/significant others relating to patients’ worsening condition. The quantitative and qualitative forms of contextual information regarding patient prognosis were infrequently recorded. Notes on conversations of survival rate, probability of treatment response and failure were likewise lacking. However, for the occasional documentation observed, the timing of the communications was appropriate across the disease trajectory and was significantly correlated with all major points of illness deterioration (p<.001). Physician and patient characteristics had no association with the practice of documenting communication prognosis Conclusion Communication prognosis is not a common practice for most physicians. Prognosis was poorly documented on the patients’ charts, which could suggest that either such a communication process did not take place at all or physician education on documentation should be reinforced by an institutional protocol, especially in the care of terminally ill patients.
Terminal illness ; prognosis

Background: Acute tonsillopharyngitis is a common reason for consult in the primary care setting. Although most cases are viral in etiology, more than half of patients with acute tonsillopharyngitis still receive antibiotic therapy for group A beta-hemolytic streptococcal infection. Streptococcal throat infection may lead uncommonly to suppurative complications like peritonsillar abscess and non-suppurative complications like acute rheumatic fever. It is with this consideration that streptococcal throat infection must be distinguished from viral infections. Clinical practice guidelines have focused their efforts on how it can be accurately diagnosed to prevent complications while reducing unnecessary antibiotic prescribing. Objective: This clinical pathway was developed to serve as guidance for family and community medicine practitioners in making clinical decisions regarding the diagnosis and management of acute tonsillophrayngitis. Methods: After defining the scope of the pathway, the PAFP Clinical Pathways Group first identified the key issues in managing patient with acute tonsillopharyngitis. These key issues were then translated to review question. The group then reviewed the published medical literature to identify, summarize, and operationalize the evidence in clinical publication. Databases were first searched for existing clinical practice guidelines from reputable medical organizations. Further search for evidence was also conducted using the terms “tonsillopharyngitis” or “tonsillitis”, “diagnosis” and “treatment”. Evidence was then summarized and its quality assessed using the modified GRADE approach. From the evidence-based summaries, the CPDG then developed general guideline and pathway recommendations which are stated as time-bound tasks of patient-care processes in the management of acute tonsillopharyngitis in family and community practice. The recommendations were then presented to a panel of family and community practitioners in both urban and rural settings, for a consensus agreement on the applicability of the recommendations to family and community practice. Lastly, the final clinical pathway was written and developed to include the recommendations, the clinical pathway tables, and an algorithm. The clinical pathway can be used as a checklist or standards of care. The algorithm can be used to explain the process of care to the patient. Recommendations: This clinical pathway contains updates on recommendations in the 2010 clinical practice guidelines on acute tonsillopharyngitis. Recommendations on the utilization of clinical scoring and rapid antigen tests as basis for deciding on need for antibiotic therapy comprise the major changes from the previously published guidelines. Penicillin remains as the first-line antibiotic therapy for streptococcal throat infection. Implementation Implementation of the clinical pathway will be at the practice and the organizational levels. The pathway may be used as a checklist to guide family medicine specialists or general practitioners in individual clinic and community medicine practice. It may also be used as reference for exams by the training programs and the specialty board. In the commitment to achieve the goal of improving the effectiveness, efficiency and quality of patient care in family and community practice, the clinical pathway may also be implemented through quality improvement activities in the form of patient record reviews, audit and feedback. Audit standards will be the assessment and intervention recommendations in the clinical pathway. Organizational outcomes can be activities of the PAFP devoted to the promotion, development, dissemination and implementation of clinical pathways.
Pharyngitis ; Family Practice

Human ; Male ; Middle Aged ; Abdominal Pain ; diagnosis ; Fibrosis ; Carcinoma, Hepatocellular

BACKGROUND: In the recent years, there appeared to be a rise of herbal products in the market. Thus, it becomes imperative for health practitioners to become knowledgeable on this aspect of complementary medicine. However, data on familiarity with and actual utilization of the 10 DOH-endorsed herbal medicine plants by the health practitioners is lacking.
OBJECTIVE: This study was done in order to determine the knowledge and utilization of the 10 DOH-endorsed herbal medicinal plants among the resident physician trainees of the University of Santo Tomas Hospital (USTH).
METHODS: A total of 143 randomly selected trainees from different specialties and year levels were included in this study. A one-time interaction with the residents was done, during which, they were asked to answer a 5-page face to face survey questionnaire.
RESULTS: The study revealed that majority of the respondents is aware of the 10-DOH endorsed herbal medicinal plants. However, most of them perceive the use of herbal medicines to be only " a little effective". Prescribers are prompted mainly by its affordability. The residents can fairly identify the herbal medicinal plants and are adept with the indication for use of these plants. In spite of this, majority of the residents are not familiar with the proper preparation methods.
CONCLUSION: Overall, the respondents appear to be more aware with certain herbal medicinal plants such as ampalaya, bawang, lagundi and sambong but obviously lack familiarity with other plants including ulasimang bato, yerba buena and niyog-niyogan.

Human ; Male ; Female ; Herbal Medicine ; Plants, Medicinal ; Icodextrin ; Phytotherapy ; Glucans ; Glucose ; Complementary Therapies ; Surveys And Questionnaires

BACKGROUND: As part of their requirements for Family Medicine rotation, the postgraduate interns (PGIs) are required to construct and present a family case report. Each team of PGIs, led by a family medicine (FM) resident, identifies a family to be enrolled in the Family Health Care Program. Although this has been ongoing for years, no feedback mechanism has yet been established.
OBJECTIVE: The purpose of this study was to determine the learning experiences and insights of PGIs in constructing and presenting a family case report during their rotation in the Family and Community Medicine.
METHODS: A survey questionnaire, consisting of 10 items, was given to the respondents. The respondents took as much time as they needed to complete the survey.
RESULTS: Overall, the results revealed that the construction and presentation of Family Case Reports provided the PGIs an avenue to practice certain competencies required in primary care setting such as patient engagement, health promotion and family oriented care. Critical thinking skills as well as patient-doctor communication were enhanced during this activity. However, a good number of PGIs resounded their sense of inadequacy and uneasiness with the application and interpretation of family assessment tools. They perceived this to be a main hindrance in coming up with the best possible case report.
CONCLUSION: The family case report remains to be a unique and productive learning endeavor for PGIs assigned in the Department of Family Medicine.

Human ; Male ; Female ; Community Medicine ; Family Health ; Patient Participation ; Family Practice ; Physician-patient Relations ; Primary Health Care ; Health Promotion

Background: Home health care is a system of clinical care provided by skilled practitioners to patients in their homes. These visitations have positive effect on health, quality of life (QOL) and promote independence among elderly Objective: This study aimed to evaluate the Quality of Life (QOL) of geriatric patients rendered home health care and ambulatory care in community-based clinic Subjects and Setting: Older adults from an urban-based barangay in Metro Manila who received medical care from Family Medicine residents and post graduate interns at home and in the community-based clinic. Methods: This cross-sectional study with ex post facto design used purposive sampling. The following tools were administered: WHOQOL-BREF FIL OP, validated for Filipino elderly to measure QOL; Katz’s Index Activities of Daily Living (ADLs) and Lawton’s Instrumental ADLs to determine the functional status. Descriptive statistics were used to summarize all data. Mann–Whitney U test and Pearson’s correlation coefficient were employed Results: A total of 29 patients were recruited. A comparison of QOL between outpatient (n=16) and home health care (n=13) showed that all domains: physical, psychosocial, social and environmental of home-visited patients had higher mean scores compared to ambulatory care patients. However, the difference was not statistically different. QOL was higher in the home care patients (mean 3.3125) versus the ambulatory care patients (mean 3.0000). Same trend was seen in perceived general health. Conclusion Home health patients still had higher mean scores in all domains of QOL than those who seek in outpatient care. They had better scores in perceived overall QOL and general health. These findings though statistically not significant suggest possible benefits of home care and its potential to improve the quality of life of older adults. Inclusion of QOL measures could allow for comprehensive evaluation of outcomes of treatment and home care services provided.
Quality of Life ; Activities of Daily Living ; Community Health Services

BACKGROUND

Integrative Medicine is an emerging approach that selectively incorporates elements of complementary and alternative medicine to promote health and well-being. Yet, there is no consensus on the required duration of treatment.

OBJECTIVE

The effects of 15 versus 30 minutes of Integrative Medicine (IM) regimen on well-being and pain were evaluated.

METHODS

The study used a single-blind, randomized, controlled design. 54 healthcare workers were randomly allocated to one of two intervention groups: a 15 minute IM regimen (3-minute meditation through guided imagery and myofascial release therapy of shoulder, back, arms with hands, and head) or the usual 30-minute IM regimen (6 minutes of each component). Well-being and muscle pain were dependent variables.

OUTCOMES

Time-bound regimens had no effect on positive mood, but both regimens increased the vitality and general interest of participants. However, the effects of both intervention arms on overall well-being were comparable. Improvement in pain was noted in the 30 minute regimen group.

CONCLUSION

The general benefits of both interventions were almost similar. Hence, the duration of the intervention did not matter much unless specific treatment outcomes were expected. A 30-minute regimen is recommended if relief from muscle pain is desired. On the other hand, if improvement in well-being is desired, a 15-minute regimen is more practical.

Integrative Medicine ; Myofascial Release Therapy

Background: Uninvestigated dyspepsia is a common complaint in family practice in the Philippines. Patients usually seek consult due to severity of symptoms which affect their quality of life. The goals of management are short- and long-term symptom control, with reversal of possible underlying mechanisms, achievable through a combination of pharmacologic and non-pharmacologic interventions. Objective: The main objective of this pathway is to guide family physicians and primary care physicians in the assessment, diagnosis and management of adult patients with uninvestigated dyspepsia through a shared decision-making process. Method: This clinical pathway is an update of the PAFP’s Clinical Pathways for the Management of Dyspepsia in Adults (2016). The current panel utilized the ADAPTE method and prioritized reviewing relevant clinical practice guidelines from 2017 to present. Grading of recommendation was achieved through a mixture of strength of available evidence and a consensus from a panel of experts. Summary of Recommendations: The main changes in the recommendations in this update are as follows: symptom-based classification of dyspepsia, screening for anxiety and depression, family and SCREEM assessment; initiation of therapeutic trial for most patients to whom H. pylori testing is not available; extension of initial PPI treatment to 4-8 weeks, consideration of antacids/alginates for immediate symptom relief, consideration of tricyclic antidepressants for non-responders to initial treatment; symptom-based non-pharmacologic advice, consideration of counseling and other psychosocial interventions; empowerment for self-treatment and as-needed therapy for those who have completed the initial treatment regimen Dissemination and Implementation This guideline shall be disseminated and implemented at the clinic and organizational level. It will be published in the “The Filipino Family Physician” journal, social media platforms and will be disseminated through PAFP local chapters, training institutions and during the national convention. Non-FCM primary care physicians will also be reached through relevant agencies. It shall be included in the references required during training activities and national exams of accredited training institutions, in coordination with the PAFP committee on Residency Training. It shall be incorporated in checklists for compliance in audits and QA cycles, with support from the PAFP committee on Quality Assurance and that on Standards for Family Practice. Feedback on utility and applicability will be actively sought from the intended users and other stakeholders.
Dyspepsia ; Community Health Services ; Critical Pathways

Background: During the last 10 years, there is an increase in the number of studies showing positive associations between spirituality and health. Studies cited that many patients would like spiritual issues embedded into their medical care but not many physicians deal with this elusive domain of well-being. Spiritual screening is a first step towards addressing the spiritual needs of patients. Objectives: To determine the prevalence of spiritual struggle in chronically ill patients. Data Collection: This is a descriptive cross-sectional type of study. Using the STATCALC of Epi Info Software for a simple random sampling, we enrolled 80 chronically ill patients from the service wards of the Quirino Memorial Medical Center, aged 19 years old and above, non-pregnant, and claimed to be Christians. Patients’ religious disposition was screened using the Religious Struggle Screening Protocol (RUSH Protocol) resulting to 3 actions: 1) referral to chaplain/spiritual counselor for a visit, 2) referral to chaplain/spiritual counselor for spiritual assessment, or 3) No Action. A patient perception feedback was likewise conducted. Results: Among 80 patients recruited, 100% of the subjects recognized the importance of spirituality in coping with their condition; of which 90% expressed desire to be visited or referred for spiritual support. As to the degree of comfort received from one’s religion or spirituality in their journey with illness, 82% receive complete level of comfort, and almost all of them (96%) wished to be visited by a chaplain. The remaining 18% claimed to receive less comfort than needed, and therefore, have the potential for religious/spiritual struggle -- 80% of which, desired to be referred for spiritual assessment. All patients found it helpful to be asked about their spiritual needs during history-taking, with 95% feeling comfortable with the way the spiritual needs were elicited by the researcher using the RUSH Protocol algorithm. Conclusion Spiritual issues should be considered as part of the patients’ medical care. The RUSH Protocol may be formally integrated in the history taking as an initial step for spiritual assessment to support vulnerable patients with chronic illness.
Chronic Disease ; Spirituality ; Humans