BACKGROUND

Ischemic heart disease is the leading cause of mortality in the Philippines. Despite strong recommendations from clinical practice guidelines for reperfusion for acute myocardial infarction (AMI), local data reveal low rates of primary percutaneous coronary intervention (PCI) and early invasive strategies due to financial constraints and system inefficiencies. The recent expansion of the Philippine Health Insurance Corporation (PHIC) AMI benefits package presents an opportunity to improve access to appropriate care. A standardized, evidence-based national clinical pathway is needed to guide healthcare providers and ensure consistent, high-quality care of AMI across various healthcare settings.

To develop a standardized, evidence-based national clinical pathway for the management of AMI patients eligible under the PHIC IHD-AMI benefits package.

Existing AMI clinical pathways from nine public and private hospitals in the Philippines were collected and reviewed. A multidisciplinary Technical Working Group (TWG) appraised current guidelines using the AGREE II tool and evaluated the collected pathways to identify strengths, gaps and variations in practice. A draft pathway was created and refined through consensus-building with cardiology experts and stakeholders to develop the final pathway.

The final national AMI clinical pathway integrates evidence-based best practices and accounts for differences in institutional resources. It standardizes the use of ECG and cardiac biomarkers for diagnosis, provides clear criteria and timelines for reperfusion therapy, defines indications for coronary angiography and PCI, and recommends optimal medical therapy and cardiac rehabilitation.

The national AMI clinical pathway is a critical step toward improving the quality, equity and efficiency of AMI care in the Philippines. Developed through a collaborative, evidence-based process, it aligns clinical management with international standards while addressing local healthcare system realities. Adoption by PHIC as a quality standard is expected to enhance guideline adherence, inform health policy and financing, and drive improvements in health outcomes. Continued implementation support, monitoring and evaluation are necessary to ensure its impact, particularly in under-resourced or geographically isolated settings.

BACKGROUND

Acute myocardial infarction (AMI) is the leading cause of morbidity and mortality among Filipinos. The guideline-recommended treatment for AMI includes emergency care, early electrocardiogram, emergent coronary angiogram and angioplasty, intensive care, medical management and cardiac rehabilitation. However, the cost of treatment is very high and not affordable for most Filipinos. To address this, the Philippine Health Insurance Corporation (PHIC) released the ischemic heart disease – acute myocardial infarction (IHD-AMI) Benefits Package under Circular No. 2024-0032 on December 21, 2024. This package significantly increased the insurance coverage for AMI to include invasive procedures and cardiac rehabilitation. The UP-Philippine General Hospital (UP-PGH) was the first to implement this package. This paper documents the initial planning, system changes and innovations undertaken by UP-PGH to support implementation.

This qualitative descriptive study used retrospective document review to detail revision of the existing acute coronary syndrome (ACS) pathway and development of the AMl pathway, restructuring of patient flow and upgrades in infrastructure and hospital capabilities. Meeting minutes from the Division of Cardiovascular Medicine and UP-PGH were reviewed to describe the hospital's preparation and implementation process.

UP-PGH established an efficient, evidence-based ACS and AMI pathway. Hospital protocols, staffing, infrastructure and equipment were aligned to implement the PHIC IHD-AMI Benefit Package. Key steps included resources upgrade, stakeholder consultations, pathway redesign, workflow development, process alignment and monitoring systems.

The PHIC IHD-AMI Benefit Package can be successfully implemented in a tertiary hospital with catheterization laboratory. The documented process at UP-PGH can serve as a model for other institutions planning to utilize the package.

BACKGROUND

Ischemic heart disease is the leading cause of mortality in the Philippines. Despite strong recommendations from clinical practice guidelines for reperfusion for acute myocardial infarction (AMI), local data reveal low rates of primary percutaneous coronary intervention (PCI) and early invasive strategies due to financial constraints and system inefficiencies. The recent expansion of the Philippine Health Insurance Corporation (PHIC) AMI benefits package presents an opportunity to improve access to appropriate care. A standardized, evidence-based national clinical pathway is needed to guide healthcare providers and ensure consistent, high-quality care of AMI across various healthcare settings.

To develop a standardized, evidence-based national clinical pathway for the management of AMI patients eligible under the PHIC IHD-AMI benefits package.

Existing AMI clinical pathways from nine public and private hospitals in the Philippines were collected and reviewed. A multidisciplinary Technical Working Group (TWG) appraised current guidelines using the AGREE II tool and evaluated the collected pathways to identify strengths, gaps and variations in practice. A draft pathway was created and refined through consensus-building with cardiology experts and stakeholders to develop the final pathway.

The final national AMI clinical pathway integrates evidence-based best practices and accounts for differences in institutional resources. It standardizes the use of ECG and cardiac biomarkers for diagnosis, provides clear criteria and timelines for reperfusion therapy, defines indications for coronary angiography and PCI, and recommends optimal medical therapy and cardiac rehabilitation.

The national AMI clinical pathway is a critical step toward improving the quality, equity and efficiency of AMI care in the Philippines. Developed through a collaborative, evidence-based process, it aligns clinical management with international standards while addressing local healthcare system realities. Adoption by PHIC as a quality standard is expected to enhance guideline adherence, inform health policy and financing, and drive improvements in health outcomes. Continued implementation support, monitoring and evaluation are necessary to ensure its impact, particularly in under-resourced or geographically isolated settings.

BACKGROUND

Acute myocardial infarction (AMI) is the leading cause of morbidity and mortality among Filipinos. The guideline-recommended treatment for AMI includes emergency care, early electrocardiogram, emergent coronary angiogram and angioplasty, intensive care, medical management and cardiac rehabilitation. However, the cost of treatment is very high and not affordable for most Filipinos. To address this, the Philippine Health Insurance Corporation (PHIC) released the ischemic heart disease – acute myocardial infarction (IHD-AMI) Benefits Package under Circular No. 2024-0032 on December 21, 2024. This package significantly increased the insurance coverage for AMI to include invasive procedures and cardiac rehabilitation. The UP-Philippine General Hospital (UP-PGH) was the first to implement this package. This paper documents the initial planning, system changes and innovations undertaken by UP-PGH to support implementation.

This qualitative descriptive study used retrospective document review to detail revision of the existing acute coronary syndrome (ACS) pathway and development of the AMl pathway, restructuring of patient flow and upgrades in infrastructure and hospital capabilities. Meeting minutes from the Division of Cardiovascular Medicine and UP-PGH were reviewed to describe the hospital's preparation and implementation process.

UP-PGH established an efficient, evidence-based ACS and AMI pathway. Hospital protocols, staffing, infrastructure and equipment were aligned to implement the PHIC IHD-AMI Benefit Package. Key steps included resources upgrade, stakeholder consultations, pathway redesign, workflow development, process alignment and monitoring systems.

The PHIC IHD-AMI Benefit Package can be successfully implemented in a tertiary hospital with catheterization laboratory. The documented process at UP-PGH can serve as a model for other institutions planning to utilize the package.

INTRODUCTION

The sudden designation as a COVID-19 Referral Center at the beginning of the pandemic brought about immense change to the Cardiac Catheterization Laboratory (CCL) services of a National Referral Center for tertiary care. As a proactive strategy to determine actions that can be undertaken should an unforeseen event ever happen again, this study was done to explore the impact of COVID-19 to the institution’s CCL caseload, and to review the challenges, innovations and adjustments made by the CCL to become pandemic-capable and crisis-ready.

A qualitative cross-sectional study was conducted, with the first phase describing the CCL census starting from the baseline pre-COVID year of 2019 to the pandemic years of 2020-2022, and the second phase involving Key Informant Interviews (KII) and Focus Group Discussion (FGD) with the hospital and CCL healthcare staff.

The study revealed a large reduction in the urgent, elective and overall number of cases of the CCL in the first year, but has seen a steady increase in subsequent years. Surges of COVID variants were also seen to affect the CCL caseload. The following were noted to be the key elements in the CCL’s transformation to become COVID-19 capable: (a) changes in operations and patient selection, (b) appropriate use of PPE, (c) strict adherence to an infection control protocol, and (d) staffing modifications to reduce infectivity and protect staff availability.

The preparation of the hospital’s CCL to become a pandemic capable laboratory has been difficult and faced many challenges. However, the innovations and adjustments done through efforts and ingenuity of the CCL healthcare team allowed continuous delivery of the highest level of care to patients in spite of the changing pandemic landscape. These changes were duly documented as a basis for response to possible future global and/or national healthcare crises.

The country’s cardiology centers have been producing subspecialists in the field of Invasive and Interventional Cardiology. To date, 11 hospitals and/or medical centers are involved in training these subspecialists in a 1 to 2-year program. And to this date, there have been no uniform standards and guidelines as to what comprises the basic and/or acceptable training outcomes for the interventionalist in training. This paper describes the development of the core curriculum for an interventional cardiovascular training program to prepare its trainees to be competent in performing invasive diagnostic and interventional cardiovascular procedures as part of comprehensive patient care. The task force for the core curriculum of the interventional training program gathered several officers and leaders of the PSCCI, the training heads of the various interventional programs in the country, as well as experts in the field of cardiology education. Through a series of meetings, consultations, and workshops, the task force laid out the template on which all the training programs would be based. Such a framework considered the international standards regarding minimum caseloads for interventional training and the peculiar situation of each training institution. International standards like the Core Cardiovascular Training Statement (COCATS 4) Task Force 10: Training in Cardiac Catheterizations and the 2020 EAPCI Core Curriculum for Percutaneous Cardiovascular Interventions served as the reference framework for key recommendations. A consensus was achieved that upheld the highest standards of competence without disenfranchising certain institutions due to intricacies and uniqueness of hospital set-up and training situation.

BACKGROUND AND OBJECTIVE

Due to their academic load, medical students are highly susceptible to stress. Stress is one of the factors that can alter sleep quality which may consequently affect the cognitive performance of medical students. There has been a lack of published local literature that looks into the association between stress and sleep quality, especially during the COVID-19 pandemic. With this, the general objective of this study is to determine the effect of stress on the sleep quality of medical students from the University of the Philippines Manila - College of Medicine (UPCM).

A cross-sectional study was conducted using a stratified random sample of 273 males and females of Learning Unit (LU) III (1st year) to VII (5th year) medical students from a college of medicine based in the Philippines, UPCM, during the second semester of the academic year 2021-2022. A self-administered questionnaire was distributed to assess sleep quality using the Pittsburgh Sleep Quality Index (PSQI), and stress level using the Kessler Psychological Distress Scale (K10). Kruskal-Wallis was used to test statistical differences between stress scores and the sleep quality of students from different year levels. Spearman's Rho was used to determine the correlation between stress and sleep, and a binary logistic regression was employed to study the association of stress with sleep while accounting for confounding variables namely caffeine intake, year level, daytime nap, duty hours, clinical rotation, sex, and age.

A high prevalence of stress (79.71%) and poor sleep quality (59.73%) among LU III to LU VII UPCM students were found, with a statistically positive correlation (⍴=0.44) 95CI [0.33-0.55] (p-value < 0.001). Both the stress scores and sleep quality indices were not statistically significantly different across LUs. Gathered data and interpreted results showed that medical students suffering from stress are more likely to have poor sleep quality, which can lead to low academic performance and high susceptibility to chronic diseases, compared to those medical students with low levels of stress. Only being an LU IV [OR=1.38 95CI (0.036-4.625)] and LU V [OR=2.13 95CI (0.296-6.936)] student had increased odds of having poor sleep quality compared to LU III students. Caffeine intake, daytime nap, duty hours, clinical rotation, sex, and age were not associated with poor sleep quality.

This study documents a statistically significant association between stress and poor sleep quality among LU III to LU VII UPCM students. A larger study covering multiple medical schools in the Philippines may be of merit for future investigations to generate nationwide data. Additional recommendations include: a) conducting a cross-sectional or a longitudinal study to detect changes in the characteristics of the population, b) observing the differences in the contributing factors at multiple points throughout the year, c) investigating the effect of dwelling set-up on sleep quality may also be investigated and d) determining if sleep quality affects the level of perceived stress of medical students.

BACKGROUND: Acute coronary syndrome (ACS) is a leading cause of admission and mortality in a tertiary care hospital in the Philippines. The significant burden of the disease necessitates that evidence-based care set by international and local guidelines be met to improve service delivery and quality of care (QOC). Institution-specific QOC studies showed gaps between guideline recommendations and compliance. Development and utilization of a clinical pathway are among the identified strategies to improve compliance. It is also crucial for implementation of standard-of-care set specific to a hospital setting based on its needs and resources. METHODS: This is a descriptive research on the development of a clinical pathway for ACS appropriate for the emergency room setting of a tertiary care hospital from March 2021 to August 2022. Local QOC studies and evidence behind the latest international guideline recommendations on the management of ACS were reviewed to create the interim ACS Pathway. Two-level content validation of the interim pathway was done: internal validation with the consultants and fellows of the Division of Cardiovascular Medicine and external validation through focused group discussions with different hospital units and stakeholders to assess applicability and feasibility based on the resources of the setting, identify hindrances, and propose solutions in its implementation. RESULTS: An evidence-based clinical pathway for ACS that encompasses identification and management of ST-segment elevation myocardial infarction and non–ST-segment elevation acute coronary syndrome with judicious use of locally available and feasible resources applicable for local emergency room hospital setting was created. CONCLUSION Review of local QOC studies and interdepartmental collaboration are necessary components in developing institution-specific clinical pathway for ACS.
Acute Coronary Syndrome ; Critical Pathways ; Quality of Health Care

BACKGROUND

Coronary artery disease is the leading cause of death in the Philippines and can present as acute coronary syndrome. Hospitalization for ACS has epidemiologic and economic burden. In fact, last 2017, there were 1.52% or 152 admissions for every 10,000 hospitalized patients for medical conditions in PhilHealth-accredited hospitals locally. However, coronary angioplasty was performed in only less than 1% of these cases mainly because of its cost and the out-of-pocket expense that the treatment entail, when primary percutaneous intervention has been proven to be effective in reducing mortality in STEMI and early invasive intervention performed during index hospitalization for NSTEMI is likewise recommended. Moreover, there is a big disparity between the current case rates for ACS for medical therapy alone and for invasive intervention compared to the actual ACS hospitalization cost.

1) To propose revisions to the current PhilHealth case rates for acute coronary syndrome (ACS); and 2) To determine the budget impact of the proposed ACS case rates.

The Philippine Heart Association with the assistance of a technical working group undertook the study. A panel of experts composed of general and invasive cardiologists from Luzon, Visayas, and Mindanao was formed. The ACS hospitalization costs based on the recent study by Mendoza were presented and discussed during the focus group discussions with the panelists. Issues pertinent to their localities that may affect the costs were discussed. The proposed revised costs on the particular ACS conditions and therapeutic regimens were then voted and agreed upon. A budget impact analysis of the proposed case rates was then performed.

The proposed case rates for ACS ranged from Php 80,000 (for low risk unstable angina given medical treatment) to Php 530,000 (for ST-elevation myocardial infarction initially given a thrombolytic agent then underwent PCI which necessitated the use of three stents). The budget impact analysis showed that the proposed ACS rates would require an additional PHP 1.5 billion to 2.3 billion during the first year of a 3- versus 5-year implementation period, respectively. The period of implementation will be affected by budgetary constraints as well as the availability of cardiac catheterization facilities in the country.

The proposed revised PhilHealth hospitalization coverage for ACS is more reflective or realistic of the ACS hospitalization costs in contrast with the current PhilHealth case rates. The corresponding budget impact analysis of these proposed case rates showed that PHP 7.6 billion is needed for full implementation. However, given the budget constraints, the percentage of the total costs for the first and subsequent years of implementation may be modified.

BACKGROUND

Hospitalization for acute coronary syndrome (ACS) has epidemiologic and economic burden. The coverage for hospitalization in the local setting is much less than the actual costs. Many patients do not consent to or avail of the optimal and timely management because of financial challenges.

The paper aimed to propose revised PhilHealth case rates/packages for ACS, namely: 1) unstable angina (UA), 2) non-ST-elevation myocardial infarction (NSTEMI), and 3) STelevation myocardial infarction (STEMI).

A consensus panel was organized to provide inputs such as cost and other matters pertaining to the revision of the PhilHealth ACS case rates/packages. The results of the cost of hospitalization of the different ACS conditions derived from a study on hospitalization cost for ACS were presented to the panel. Several focused group discussions were held afterward for propositioning new case rates through votation and by nominal group technique, using the costs from the study as the bases of rate adjustment.

Final costs agreed upon by the consensus panel for medical management alone for UA, NSTEMI, and STEMI were adjusted or amended in increments of Php 20,000, (80,000, 100,000, and 120,000, respectively). Thrombolysis of a patient admitted for STEMI increased the cost to Php 140,000. An additional cost of Php 150,000 was added on top of the cost for medical management and coronary angiogram for NSTE- ACS for PCI with use of a single stent. For STEMI, the same category had an additional cost of Php 180,000. For each additional stent used for all clinical scenarios undergoing PCI, Php 65,000 was added, to cover up to a total of 3 stents.

Based on the consensus process with Philippine Heart Association ACS panelists, the cost proposed ranges from 80,000 pesos to 530,000 pesos depending on the clinical scenarios.