Background: A primary care-based health care system has the potential to make the health system more efficient. The high hospitalization rate for diseases that can be treated in an outpatient setting in areas where there is low access to primary care physicians leads to higher cost of care. Objective: This study was conducted to determine the primary care orientation of the different family and community medicine training programs in Manila. Methods: This was a self-administered questionnaire survey using the primary care assessment tool provider survey (PCAT-PS) conducted on resident physicians undergoing training in family medicine in the different hospitals in Manila. Based on the PCAT scoring, we used a cut-off score of 3.5 as the desirable level of orientation. Results: A total of 24 residents from 8 hospitals responded to the questionnaire. A significant percentage of patients are being seen in their clinic over a period of 1-4 years. Majority of the patients they see are those aged 20 years old or more. Of all the 9 domains, the programs had very good scores in coordination of care, information system, family-centeredness and cultural competence. However, improvement is needed for services that are available, services being provided, ongoing care and community orientation. In terms of the overall primary care score for the core indicators, the training programs in family medicine did not reach the target mean score of 3.5. However, when the other domains were added the overall mean primary care score with the expanded domains had a mean of 3.55. This suggests that the current training programs in the Manila are strong in their family-centeredness and their cultural competence. Conclusion: In conclusion, our training programs may be improved to be more primary care oriented. We need to be patient-centered by asking our patients and determine what health service they need and want. Then we need to train our residents in providing these services, with greater exposure to outpatient rotations and community clinics.
PRIMARY CARE

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: 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: 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

Quality health care is one of the central themes in the reform areas of the Universal Health Care (UHC). But in low- and middleincome countries like the Philippines, quality of health care is suboptimal. There are several challenges in implementing quality improvement in family and community practice. These include a weak health system arising from inadequate human resource and capacity, low utilization of data for health care improvement, and minimal involvement of patients to demand better quality and safety. There are also barriers, such as lack of access to evidence-based medicine resources, poor insurance systems compound the complexity of addressing health care quality. While the PAFP has already done these trainings in the past and available experiences on primary care CQI initiatives published in the local literature, in this article, we propose simple steps in line with what may be the requirement of the UHC reform.
Quality of Health Care ; Delivery of Health Care

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

A good health system is supposed to improve the health of the population by providing effective health services equitably. Thus, the Universal Health Care (UHC) Act was designed to adopt a health care system that provides all Filipinos access to quality and cost-effective promotive, preventive, curative, rehabilitative and palliative health services without causing financial hardship especially the poor sector. There are four major elements in the UHC where family physicians can play a major role. The first is the population to be covered where there is now a shift of coverage from membership by premium payments to citizenship. The next is the health interventions to be included. This benefit package should be the one affordable to the whole society with priority to the worst-off sector. The next is the network of health professionals who will provide the health services. The network must be adequately distributed to provide service coverage for the whole population including the geographically isolated and disadvantaged areas. The last is the financing, where the delivery of health services must provide financial protection for the poor. To translate this into a realizable health sector reform agenda at the national and local level, there is a need for context-specific technical analyses and consultations from various sectors especially the private sector.
Universal Health Care ; Population

The internationally accepted definition of dyspepsia is "chronic or recurrent pain or discomfort centered on the upper abdomen."Gastro-esophageal reflux disease on the other hand is defined as the presence of risks of physical complications of gastroesophageal reflux, or the experience of clinically significant impairment of health-related well being (quality of life) due to reflux related symptoms. Several theories have been proposed regarding the etiology of these disorders, including acid exposure, visceral hypersensitivity, impaired fundal accommodation, delayed gastric emptying, and H. pylori infection. There seems to be a significant overlap of pathophysiological disorders between dyspepsia and GERD. The diagnosis of dyspepsia is challenging. The use of self administered questionnaires in routine clinical care has been questioned by other authors as studies showed that the rate of recognition of heartburn differed between questionnaires. Endoscopy is the preferred procedure to detect lesions in the upper gastrointestinal tract. However, experts suggest empiric treatment over prompt endoscopy because of cost and limited availability of endoscope facilities. After a diagnosis of dyspepsia or GERD, the primary care physician can choose between the following strategies: symptom-guided empirical treatment, direct referral for endoscopy, non-invasive testing for H pylori and subjecting the H pylori positive patients to endoscopy ("test-and-scope"), and. non-invasive testing for H pylori and treatment of the infection in H pylori positive patients ("test-and-treat"). While the role of H pylori in peptic ulcer has been clearly established, its role in dyspepsia is still being debated. A recent meta-analysis suggested that there is a small benefit of about 10% over placebo. Considering the pathophysiology as acid reflux and dysfunctional motility as being the main problem, the combination of a prokinetic like domperidone and a PPI like pantoprazole may offer improved response to empiric treatment. Starting the patient on high potency drugs or combination treatment (step-down approach) is therefore a new strategy that has potential impact to improve response. Potential advantages of the step-down approach include faster healing, maximum symptom relief and a more rapid improvement in the patient's quality of life. Adherence to treatment is also an issue for a chronic and relapsing illness like dyspepsia and GERD. Adherence to prescribed self-administered medication is low in patients with chronic conditions. It is estimated to average only 50%. Fixed dose and sustained release formulations are designed to decrease the number of pills to be taken and the frequency of dosing Le. simplifying the treatment regimen thereby improving adherence. Dyspepsia is a multi-factorial syndrome. Abnormalities include disturbances of GI motor and sensory function as well as specific psychological disorders including depression and anxiety. An intensive medical treatment targeting GI abnormalities with psychological interventions will result to better long-term improvement of symptoms.
DYSPEPSIA ; INDIGESTION

OBJECTIVE: To evaluate the effectiveness of chart reminder flyers in increasing the appropriateness of coronary primary preventive care. DESIGN: Randomized controlled trial. SETTING: A university-based clinic in the period January-June, 2000. PATIENTS: 120 charts randomly selected from 256 patients in the intervention group were considered. Another 120 randomly chosen from 295 patients were selected for the control. These subjects were those who consulted from January-June 2000 at the university clinic. INTERVENTIONS: Each clinic day was randomized to be either "with reminder flyer day" or "without reminder flyer day." On "with reminder flyer days", a one-page flyer that contained a letter of reminder for physicians to perform coronary primary preventive care was placed on the charts of all patients consulting at the clinic. The reminder flyer was detached from the chart right after each consultation. On "without reminder flyers days", no intervention was done. At the end of the trial, 120 charts from each group were randomly selected for auditing for appropriateness of coronary primary preventive care. RESULTS: The proportions of charts that recorded appropriate history taking, physical examination and pharmacological and non-pharmacological interventions were all significantly greater in the intervention group than in the control group (p values 0.001, 0.005 and 0.0001). When coronary primary prevention was taken as a whole, the proportion of charts that reflected appropriate care was significantly greater in the intervention group than in the control group (25 percent vs. 5 percent, p 0.001). Reminder flyers reduced the relative risk of not being given appropriate coronary prevention to 0.79 (p, 0.001). MAIN OUTCOME MEASURES: Proportion of charts that documented appropriate primary coronary preventive care in the intervention and controlled groups were compared using the test for equality of proportions. The changes in appropriateness of the preventive care from baseline for each group was taken and compared. CONCLUSION: The proportion of charts that recorded appropriate coronary primary preventive care was significantly higher in the reminder flyer group.
Human ; DELIVERY OF HEALTH CARE ; PRIMARY PREVENTION ;

While the definition of EBM can be straightforward in other medical field, family and community medicine practitioners take on very different roles in different health systems. Despite the challenges presented, EBM is still necessary in family and community practice. Family and community medicine practitioners must be able to obtain, assess, apply and integrate new knowledge based on available evidence throughout their professional life. From the definition of EBM and the nature of family practice described previously, we propose to define “Evidence-based Family Practice as the conscientious and judicious use of the current, relevant, applicable and best available evidence in making shared clinical decisions for patient care. Such decisions must account for the capacity and setting of the family practitioner and patient preference”. The proposed steps are: 1) Framing the Clinical Problem, 2) Searching for the Evidence, 3) Critical Appraisal, 4) Informing the Patient About the Evidence, 5) Shared Decision Making, and 6) Evaluation of the Decision.
Evidence-Based Medicine ; Evidence-Based Practice