Background: Stroke is a leading cause of morbidity and mortality not only in our country but in other countries as well imposing a substantial economic burden on individuals and society overall. The financial cost of stroke is considerable but few cost effectiveness studies are available to guide clinical practice. It is the aim of this research then to provide comparison of cost-effectiveness or cost-benefit in stroke care to cast new light on which methods are better than others. Objectives: To compare cost-effectiveness of Home care versus Hospital care program in stroke patients age 35-70 years old at General Hospital from January 1998 to January 1999. Perspective: The study was done in a program perspective for the General Hospital. Methods: A decision analysis based on available published information was formulated. The probable outcomes were 1) probability of survival, 2) probability of good quality of life, 3) probability of poor quality of life and 4) probability of mortality after 1 year. Effectiveness measure was evaluated as the product of 1 year survival and good quality of life for both home care and hospital-based care. The cost of each branch was then divided by these 2 outcomes. The cost-effectiveness was compared between the 2 alternative programs. Results: The probability of 1 year survival for home care is 0.84 while in hospital care, probability was higher at 0.87. The probability of dying from stroke in 1 year for home care was .16 while only 0.13 was noted in hospital care. It is apparent that hospital care is more effective than home care alternative. In contrast to the results of the decision analysis, the cost-effectiveness of home care was P56,900.45 per stroke patient with good quality of life in contrast to hospital care which was higher at P65,291.70 per stroke patient with good quality of life. Although hospital-based care was more effective, incremental analysis showed that the cost of the advantage was P669,462. Conclusion: Hospitals are more effective than home care based on probability analysis while cost-effectiveness analysis favors the home care alternative.
Human ; Aged ; Middle Aged ; Adult ; HOME CARE SERVICES ; COST-BENEFIT ANALYSIS ; STROKE

Background: The cost of DM treatment in the Philippines is mainly shouldered by the patient. Most patients rely on “outof-pocket” expenses, namely, laboratory procedures and daily medications. There are guidelines available, unfortunately its dissemination and implementation rely on passive strategies. This clinical pathway is an attempt to operationalize these guideline recommendations in family and community outpatient practice. Methods: The PAFP Clinical Pathways Group reviewed the published medical literature to identify, summarize, and operationalize the evidence in the management of patients with type 2 diabetes mellitus in family and community practice. The recommendations are time-bound tasks on patient care processes, in terms of history and physical examination, laboratory tests, pharmacologic and non-pharmacologic interventions. Recommendations: First Visit •Elicitsymptomsofhyperglycemiai.e.polyuria,polyphagia,polydipsia,nocturiaandweightloss(A-II) •Generalphysicalexaminationfocusoncardiac,renal,peripheralpulseretinopathy,neuropathy,skinandBMI(A-II) •ConductriskscreeningforasymptomaticandBMI≥25kg/m2or≥45yearsold(A-II) •RequestforFBSorRBSorOGTTorHgbA1C(A-I) •Notadvisabletogiveroutinevitaminsupplementationwithantioxidants,suchasvitaminsEandCandcarotene(A-I) •Structuredhealtheducationonlifestylechanges(alcoholandsmoking),moderateweightloss,regularphysicalactivity, reduced calories, sugar and dietary fat intake (A-III) •Arrangefordevelopmentandimplementationoffamily-focusedandcommunity-orientedintervention(A-III) •Patientisawareofdiabetestype2andmanagementplan(A-III) Second Visit •Reviewthelaboratoryresultsandestablishthediagnosisasdiabetestype2,pre-diabetesornon-diabetes(A-II) •Ifdiabetestype2orpre-diabetes,assessthepatientandfamily’sdietarypatterns,physicalactivityhabits,nutritionalstatus and weight history, diabetes understanding, psychological, social and community health support systems (A-III) •Evaluatesocialdeterminantsofhealth(SCREEM)(A_III) •Ifdiabetestype2,requestforlaboratoryteststodetectcomplicationortargetorgandamage(A-II).Ifnormal,repeat testing every year if there are risk factors and at least at 3-year intervals if there are no risk factors (B-III) •FirststepmedicationisMetformin500mgtwiceaday(A-I) •IfwithmarkedsymptomsandsignificantlyelevatedbloodglucoselevelsorA1C,considermetforminandinsulinfromthe outset (A-II) •Ifpre-diabetesmetformin500mgoncedailymaybeconsideredifthereisimpairedglucosetoleranceorimpairedfasting glucose or A1C of 5.7–6.4% (A-II) •Developandagreeonthemanagementplan(A-III) •Providediabetesself-managementeducationandcounselling(A-II) •Medicalnutritiontherapyfocusingonlimitationofcarbohydrateandfatintakeandweightloss(A-I) •Emphasizeincreaseinphysicalactivity(A-I) •Limitalcoholintake,smokingcessation(A-II) Involveafamilymember/caregiverinthediabetesself-managementeducationandcounselling,medicalnutritiontherapy, physical activity and limitation of alcohol intake (A-II) •Setupatelemedicineandotherdigitalapplicationtocomplementface-to-facemanagementofpatients(A-I) •Patientoutcomesare:1)agreeonmanagementplanandgoals,2)Awareonmedications,doseandsideeffects,3)aware on what to do if hyoglycemia occur (A-III) Continuing Care •Reviewoftreatmentregimens(medicationadherence,mealplan,physicalactivitypatterns,andlifestylechange)and response to treatment (self-monitoring or A1C records) (A-II) •Checkforhypoglycemicepisodesandotheradverseevents(A-II) •Randomorfastingbloodsugartestingduringclinicvisitmaybedonetoguidetimelytreatmentchanges(A-III) •A1Ctestquarterlyortwiceayeardependingonresponsetotreatment(A-III) •Basedoninitialresponse,titratemetformindosefor3monthstoachievetreatmentgoal(A-I).Ifthediabetesisnotcontrolled by metformin after 1 month add basal insulin or another oral hypoglycemic drugs (A-I) (be aware of contraindications) •Enhancediabetesself-managementeducationandcounselling,medicalnutritiontherapy,physicalactivityandlimitation of alcohol intake (A-II) •Enhancethefamilymember/caregiver’sroleinthediabetesself-managementeducationandcounselling,medicalnutrition therapy, physical activity and limitation of alcohol intake (A-II) •Coordinatereferralforsocialandeconomicsupportforthepatientifneeded(A-III) •Empowercommunityhealthworkersanddiabeticpatientsforcoordinationandmonitoring(A-III) •Patientoutcomesshouldbe:1)achievementoftreatmentgoals(A-I),2)improvedqualityoflife(A-I),3)satisfactionto management plan (A-III), 4) continuing compliance to diabetes self-management (A-III) Implementation We recommend that at the clinic level, self-reviews of chart records using the recommendations of this clinical pathway as the criteria may be done. Identification of barriers and developing interventions to promote compliance to the clinical pathway recommendations may be more effective.

Background: Cough is one of the most common symptoms that make patients consult in family practice. Acute bronchitis is usually the diagnosis given to these patients. Existing guidelines for the treatment of acute bronchitis emphasize appropriate clinical evaluation, minimal laboratory tests and symptomatic treatment. Objective: The general objective of this clinical pathway is to improve outcomes of patients with acute bronchitis being seen in family and community practice. It hopes to achieve this by: 1) promotion of a standardized management of patients with acute bronchitis, and 2) promoting quality improvement initiatives at the clinic and organizational level. Method: The PAFP Clinical Pathways Group reviewed the previous Clinical Practice Guideline for the Treatment of Acute Bronchitis in Family Practice, a local guideline developed by the Family Medicine Research Group and adopted as policy statement by the Philippine Health Insurance Corporation. A Medline search was done but there is only one guideline published in Dutch for the Diagnosis and Treatment of Cough. The group also reviewed published medical literature to identify, summarize, and operationalize the clinical content of diagnostics, interventions and clinical indicators or outcomes to develop an evidence-based clinical pathway in family medicine practice. Recommendations: Patient history focusing on the duration of cough, character and sputum production and accompanying symptoms such as fever, difficulty of breathing or chest pain should be done. Other points to focus on the history should include past history of asthma, recurrent respiratory disease, exposure to respiratory viral or bacterial infection, smoking or exposure to toxic inhalants. A complete and thorough physical examination of the upper airways, chest and lungs and peak expiratory flow rate must be done. There is no recommended laboratory test but chest x-ray may be helpful for those with probable pneumonia. Symptomatic treatment for acute bronchitis is recommended i.e. bronchodilators, mucolytics, anti-pyretics and fluids. Herbal and complimentary alternative medication may also be given. Antibiotics are generally not necessary but may be given to those with severe symptoms and highly probable bacterial infection. Health education and assurance about the self-limiting condition of acute bronchitis must be given to the patient. Implementation To promote rational antibiotic prescription, outreach visits to individual family physician’s clinic have been identified as an intervention that may improve the practice of health care professionals. This type of ‘face to face’ visit has been referred to educational detailing or academic detailing.
Community Health Services ; Bronchitis ; Acute Disease ; Critical Pathways

Background: Urinary tract stones or calculi are low-density crystals in any part of the urinary tract that result from either excessive excretion or precipitation of salts in the urine or lack of substances to inhibit its formation. Prevention and management of urinary tract stones is also now medically feasible and recommended. Objectives: This clinical pathway was developed to guide family and community physicians on the diagnosis and initial management of urinary tract stone in terms of: 1) clinical history and physical examination; 2) laboratory and ancillary procedures to be requested; 3) pharmacologic interventions; 4) non-pharmacologic interventions; and 5) patient outcomes to expect. Methods: The PAFP Clinical Pathways Group reviewed the previous guidelines for the treatment of urinary tract stones, published medical literature (PubMed and HERDIN) to identify, summarize, and operationalize the clinical content of diagnostics, interventions and clinical indicators or outcomes to develop an evidence-based clinical pathway in family medicine practice. Recommendations: Family physicians should elicit patient history of flank pain, tenderness, dysuria and hematuria. They must be described in detail in terms of, characteristics, date of onset and severity. Other patient history to elicit should include stone passage, recurrent UTI, dietary history, fluid intake, recurrent UTI, medications and family history of being a stone former or some metabolic disorder. The laboratory should include ultrasound of kidney, ureter and bladder (plain CT is second line imaging study), urinalysis and blood chemistry (BUN, creatinine, calcium and uric acid). Symptomatic treatment with non-steroidal anti-inflammatory drugs or opioid analgesic in severe pain should be started even before the definitive diagnosis. Anti-spasmodic therapy may also be given. If stone is present, medical dissolution therapy for all stone sizes (alone or as complementary to medical expulsion, lithotripsy or surgery), medical expulsion therapy for stone size 5-10 mm and lithotripsy or surgery if greater than 10 mm. Non-pharmacologic treatment includes patient education, increased fluid intake to achieve at least 2-2.5 liters of urine per day and limit sodium intake (no evidence to limit calcium or protein intake). Family intervention to adjust family diet preference to low sodium is also recommended. Implementation To promote rational management of urinary tract stone in family practice, outreach visits to individual family physician’s clinic have been identified as an intervention that may improve the practice of health care professionals. This type of ‘face to face’ visit has been referred to educational detailing or academic detailing. Organizational activities such as quality improvement activities will also be encouraged.
Urinary Calculi ; Humans ; Urinalysis ; Family Practice