Background: Clinical Practice Guidelines are made to help practitioners in decision making towards improving appropriateness of care. However, successful implementation strategies are still lacking. Patient mediated intervention as away of CPG implementation is being recommended. Methods: This study is a three-phase, randomized controlled trial. Following a 3-month baseline period, a one-hour interactive lecture on guideline recommendations was conducted among family medicine residents. After 3 months, clinic days were randomized to days with and days without public health lecture. A one-hour interactive lecture on the recommendations on sinusitis and rhinitis was conducted on patients at the out-patient waiting area on pre-selected days. Appropriateness of care by chart audit was done at every phase. Results: Baseline appropriateness of care was low at 10.8 percent on history taking and physical examination, 56.8 percent on request for diagnostics, 75.7 percent on antibiotic prescription, 48.6 percent on overall treatment. Referrals at baseline were appropriately high at 94.6 percent. Interactive lecture did not increase appropriateness of care. The addition of public health lecture significantly increased appropriateness in history taking and physical examination to 25.9 percent, and request of diagnostics to 70.6 percent. No change noted on antibiotic prescription at 41.2 percent, overall treatment at 41.2 percent and referrals at 88.2 percent. Conclusions: The addition of public health lecture to interactive lecture was effective in increasing appropriateness of care in history and physical examination and request of diagnostics.
Human ; PATIENT EDUCATION ; PUBLIC HEALTH ; PRACTICE GUIDELINE

The COVID-19 pandemic has resulted into issues on occupational health, especially in health care services sector. Due to the nature of their work, this sector is at an increased risk of exposure to the virus. In this issue, we further discuss the importance of occupational health as our special theme. Occupational Health is an area of work in public health to promote the highest degree of physical, mental, and social well-being of workers in all occupations. Occupational health deals with all aspects of health and safety in the workplace and has a strong focus on primary prevention of hazards. The Philippine College of Occupational Medicine (PCOM), which is an affiliate specialty society of the PAFP, is responsible for promoting occupational health in the country. PCOM, formerly known as the Philippine Occupational and Industrial Medical Association (POIMA), was established in 1977 through the merger of three occupational health associations, namely the Industrial Medical Association of the Philippines (IMAP), the Philippine Association of Occupational Health (PAOH), and the Philippine Association of Compensation Medicine (PACOM). As a medical specialty society and a DOLE-accredited safety and health training organization, PCOM is a prime mover in the preservation, promotion, protection, and enhancement of health, safety and wellness of workers in all occupations through its active members nationwide and collaboration with various stakeholders both locally and internationally.

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

Background: Atherosclerotic cardiovascular disease (ASCVD) is a top cause of mortality in the Philippines. A known modifiable risk factor for ASCVD is dyslipidemia. Thus, proper diagnosis and management of dyslipidemia in family practice clinic could significantly decrease the burden of cardiovascular disease in the country Objectives: This clinical pathway was developed to guide family and community physicians on the diagnosis and management of dyslipidemia. Methods: To develop evidence -based recommendations, the authors searched for the latest guidelines of reputable international and local societies. They also searched PubMed using the terms “dyslipidemia”, “diagnosis”, “therapeutics”, “family” and “community medicine”. The more rigorous meta-analysis of clinical trials and observational studies were prioritized over lowquality trials in the formulation of the recommendations. Recommendations: Thorough ASCVD risk assessment for all adults should be done during initial visit in family practice. The physician should review patient’s present medication; probe regarding lifestyle habits; conduct complete physical examination; use family assessment tools; and assess risk for ASCVD using calculators or risk factor counting method. For patients ≥ 45 years old and all adult patients regardless of age at increase ASCVD risk the following should be requested: lipid profile, urinary albumin- creatinine ratio/ urinary dipstick test, alanine transaminase (ALT), 12-lead electrocardiography (12-L ECG) and fasting blood sugar (FBS). During subsequent visits, re-assessment of ASCVD risk; checking compliance to non-pharmacologic intervention; and review of medication adherence and adverse effects should be performed. Repeat measurement of lipid profile should be done 6-8 weeks after initiation of statin therapy; 8-12 weeks after dose adjustment; and biannually for patients with controlled lipid levels. For individuals on statin therapy who have already achieved their low-density lipoprotein cholesterol (LDL-C) goal, compute for non- high density lipoprotein cholesterol (non-HDL C). Repeat ALT 6-8 weeks after initiation of statin therapy for those at high risk of statin-induced liver injury. Request creatine kinase (CK) if with development of muscle symptoms while on statin therapy. For primary prevention, start low-moderate intensity statins for following: individuals with diabetes mellitus (DM) Type 2 without ASCVD; individuals with mild-moderate chronic kidney disease (CKD); and individuals without ASCVD aged ≥ 45 years old with LDL -C ≥ 130 mg/dl AND with ≥ 2 risk factors. Start high intensity statins for individuals diagnosed with Familial Hypercholesterolemia. Give high intensity statins as secondary prevention for individuals with established ASCVD. For individuals with ASCVD on maximally tolerated statin therapy not meeting target LDL-C, ezetimibe could be added to their regimen. Low saturated fat diet rich in fruits and vegetable; regular exercise; and smoking cessation should be advised for all adult patients. The physician should also engage other family members to adopt healthy lifestyle. Formation of a community-based lifestyle intervention program to reduce cardiovascular risk should also be supported by the family physician. Implementation Adherence to pathway recommendations that are graded as either A-I, A-II or B-I is strongly advised. However, the authors also recommend using sound clinical judgment and patient involvement in the decision making before applying the recommendations.
Family Practice ; Dyslipidemias

Background: Diarrhea is among the common causes of morbidity and mortality in children. It is defined as the passage of three or more loose or liquid stools per day (or more frequent passage than is normal for the individual). It does not include frequent passing of formed stool and passing of loose, pasty stools by breastfed babies. It is usually a symptom of an infection in the intestinal tract, caused by variety of organisms, which is spread through contaminated food or drinking water, or from person-to-person as a result of poor hygiene. Diarrhea can last several days and can leave the body without the water and salts that are necessary for survival causing significant number of mortality and morbidity among children. At the level of primary care, diagnosis, management and treatment of food- and waterborne-diseases, which commonly present as diarrhea, lack the necessary protocols and standards, thus, the creation of this clinical pathway. Objective: The main goal of this clinical pathway was to provide guidance to family and community physicians, and other primary care physicians in managing acute diarrhea among immunocompetent pediatric patients. Methods: ADAPTE process was used in CPG development. Existing guidelines on acute diarrhea among pediatric patients were retrieved and appraised using the AGREE II tool. Recommendation statements from the guidelines that passed the AGREE II tool were reviewed. Recommendation statements that will help answer the clinical questions posed in the creation of the clinical pathway were adapted. For clinical questions were not answered by the available guideline recommendations, a de novo method was conducted. The adapted recommendation statements and the supporting summary of evidences were sent for external review prior to consensus development. Suggestions provided in both steps were discussed and incorporated in the final manuscript, as appropriate. Key Recommendation Statements: These key recommendation statements addressing the clinical assessment, diagnosis, interventions (pharmacologic and nonpharmacologic), and patient outcomes that are relevant in the outpatient or primary care setting in the Philippines were based on the summarized key evidences from the systematic review of literature conducted using the ADAPTE process. Clinical Assessment Recommendation 1. A focused medical history that includes questions on duration, frequency, characteristics, associated symptoms, consumption of raw, ill-prepared, or rotten food; intake of antibiotics, contaminated food or water; and history of travel should be obtained. (Strong recommendation, High quality evidence) Recommendation 2. Physical examination should be done to assess the nutritional status, degree of dehydration, severity of disease, and presence of complications and comorbid conditions. (Strong recommendation, High quality evidence) Recommendation 3. Degree of dehydration should be classified into No Dehydration, Mild to Moderate Dehydration, or Severe Dehydration. (Weak recommendation, Moderate quality evidence) Recommendation 4. Children with acute infectious diarrhea who have any of the following conditions should be admitted to the hospital: severe dehydration, inability to tolerate fluids orally, suspected electrolyte abnormalities, altered consciousness, abdominal distention, respiratory distress, pneumonia, meningitis/encephalitis, sepsis, moderate to severe malnutrition, suspected surgical condition, or conditions for safe follow-up and home management are not met. (Strong recommendation, High quality evidence) Diagnostic Tests Recommendation 5. Routine diagnostic tests are not necessary among children with acute diarrhea. (Strong recommendation, Low quality evidence) Recommendation 6. Stool examination may only be requested if the patient present with moderate to severe condition, bloody diarrhea, or amoebiasis and parasitism is being considered at time of epidemic. (Strong recommendation, High quality evidence) Recommendation 7. Diagnostic tests may be requested if concomitant conditions like pneumonia, urinary tract infection, sepsis or meningitis are suspected; or if abdominal distension is observed post-hydration. (Strong recommendation, High quality evidence) Recommendation 8. Stool culture, serologic test, rapid diagnostic test, PCR determination and serum biomarkers are not recommended in family and community practice. (Strong recommendation, High quality evidence) Pharmacologic Treatment Recommendation 9. Reduced osmolarity oral rehydration solution (ORS), commercial or home-made is recommended to replace previous and ongoing losses. (Strong recommendation, High quality evidence) Recommendation 10. The volume and frequency of reduced osmolarity oral rehydration solution (ORS) should be dependent on patient’s age or weight, severity of dehydration and ongoing losses. (Strong recommendation, High quality evidence) Recommendation 11. Severe dehydration should be managed in the hospital with intravenous hydration. (Strong recommendation, High quality of evidence) Recommendation 12. Routine empiric antibiotic treatment is not recommended in children with acute infectious diarrhea. (Strong recommendation, Very low quality evidence) Recommendation 13. Antibiotic treatment may be given to children with Cholera, Shigella, typhoidal Salmonella, amoebiasis, and giardiasis. The choice of antibiotic must be guided by the local Antibiotic Surveillance Program. (Strong recommendation, High quality evidence) Recommendation 14. In general, antibiotic treatment should not be given in children with non-typhoidal Salmonella. It may be given in children with underlying conditions i.e., immunodeficiency, corticosteroid or immunosuppressive therapy. (Strong recommendation, Very low quality evidence) Recommendation 15. Among children older than six months, zinc supplementation of 10-20 mg per day for 10-14 days may be offered to reduce the duration and severity of diarrhea, and recurrence in the next two to three months (Strong recommendation, High quality evidence) Recommendation 16. Racecadotril may be offered to reduce ongoing loss of water and electrolytes. (Strong recommendation, High quality evidence) Recommendation 17. Probiotics may be offered to reduce the duration of diarrhea. Lactobacillus rhamnosus GG (LGG), Saccharomyces boulardii and Lactobacillus reuteri are strains with evidence of effectiveness. (Strong recommendation, High quality evidence) Recommendation 18. Anti-emetics and antidiarrheal drugs are generally not recommended because of their side-effects. (Strong recommendation, High quality evidence) Non-pharmacologic Interventions Recommendation 19. Among children with acute diarrhea, age-appropriate feeding should be continued. There is no need to modify or restrict diet. (Strong recommendation, Moderate quality of evidence) Recommendation 20. Among infants with diarrhea, breastfeeding must be continued. (Strong recommendation, High quality evidence) Recommendation 21. If diet was restricted because of frequent vomiting, early refeeding must be done. (Strong recommendation, Moderate quality evidence) Recommendation 22. All members of the family must be encouraged regular hand washing with soap and water. (Strong recommendation, Moderate quality evidence) Recommendation 23. Family members must observe proper food handling, have access to safe drinking water, and observe proper waste disposal. (Strong recommendation, Low quality evidence) Recommendation 24. Community level intervention that encourages hand washing, proper food handling, appropriate waste disposal and ensuring safe drinking water must be done. (Strong recommendation, Low quality evidence) Expected Patient Outcomes Recommendation 25. After each encounter the patient or guardian must understand the nature of acute diarrhea, its management and potential complications. (Strong recommendation, Low quality evidence) Recommendation 26. The management plan must be a mutual agreement between the family physician and the guardian. (Strong recommendation, Low quality evidence) Recommendation 27. For the management of a child with acute diarrhea, the family physician must target for resolution of dehydration, resolution of diarrhea, prevention of relapse, hospitalization, complications and early detection of adverse events. (Strong recommendation, High quality evidence) Dissemination and Implementation This clinical pathway will be published in the “The Filipino Family Physician” journal, which is accessible in the PAFP journal website. PAFP’s Committee on Research will disseminate the clinical pathway through distribution to its subspecialty and affiliate societies, chapters, training programs, and primary care practitioners; and continuing development sessions of the PAFP. Monitoring of the uptake of the clinical pathway will be through the number of downloads at the website and requests for copies. This clinical pathway may be used as a guide by family and community physician and primary care physicians in a primary care setting. Tabular presentation of the clinical pathway was included as a tool for implementation. Monitoring of implementation will be via continuous quality improvements activities, which can be a self-initiated activity of the member as recommended in the Universal Healthcare, or as a chapter or group activity.

Human ; Physicians, Family ; Practice Guideline

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