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