Clinical pathway for the management of uninvestigated Dyspepsia among adults in family and community practice: Updated 2021

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.

Diagnosis and management of acute Tonsillopharyngitis in family practice

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.

Diagnosis and management of Dyslipidemia in 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.