Clinical practice guideline and pathways for the evaluation and management of patients with dizziness in family and community practice

Background@#Dizziness is a commonly encountered symptom in the primary care which can be caused, most of the time by benign condition and rarely due to serious conditions needing higher level of care.@*Objective@#To develop a clinical guideline and pathway that will serve as guide in the diagnosis and management of adult patients with dizziness in primary care and outpatient setting@*Methods@#A guideline development team was formed which is composed of family and community medicine specialists from different institutions. Searching, selection and assessment of the latest evidence on dizziness diagnosis and management was done using the search terms: “dizziness”, “diagnosis”, “management”, and “primary care”. Formulation of the recommendation was done using Grade approach and graded with modified GRADEPro and expert panel consensus. External review was also done by an expert in otorhinolaryngology.@*Recommendations@#Clinical Assessment •Recommendation1.Askforthepatient’sdescriptionofdizzinessandclassifythepatientintooneofthefourtypes: vertigo, presyncope, disequilibrium, and lightheadedness and classify as acute/episodic or chronic/sustained. (Strong Recommendation, Low Quality Evidence) •Recommendation2.Obtainamedicalhistoryfocusingonthetiming,triggers,associatedsymptoms,riskfactorsfor atherosclerotic vascular disease, and functional status or quality of life. (Strong Recommendation, High Quality Evidence) •Recommendation3.Performaphysicalexaminationfocusingonvitalsigns,HEENT(includingotoscopy),cardiovascular and neurologic examination. (Strong Recommendation, High Quality Evidence) •Recommendation4.PerformspecialphysicalexaminationslikeDix-Hallpikemaneuverforacuteepisodictriggeredvertigo to check for BPPV (most common cause of peripheral vertigo), HINTS plus test for spontaneous episodic vertigo to check for stroke and hyperventilation provocation test for patients suspected of anxiety (Strong Recommendation, High Quality Evidence) •Recommendation5.Elicitredflagsthatshouldwarrantreferrallikeseveredizzinessandassociated,alteredmentalstatus, loss of consciousness and abnormal vital signs. Other symptoms like chest pain, palpitations, dyspnea, neurologic deficit may warrant referral for evaluation and management. (Strong Recommendation, High Quality Evidence) •Recommendation6.Forpatientsconsultingviatelemedicine,obtainamedicalhistoryfocusingonthetiming,triggers, associated symptoms, risk factors for atherosclerotic vascular disease, and functional status or quality of life, and observe and conduct self-physical examination (vital signs, mental status, ocular and facial nerve) (Strong Recommendation, Low Quality Evidence) Diagnostic •Recommendation7.Laboratorytestingisnotroutinelyrecommendedamongpatientswithdizziness.However,testingmay be requested if there is a need to identify a definite etiology to guide treatment and should be guided by the classification of dizziness, possible etiology, and the medical history and physical examination. (Strong Recommendation, High Quality Evidence).Recommendation8.Forpatientswithvertigoandwithauditorysymptoms(i.e.,hearingloss,tinnitusandauralfullness, etc.), pure tone audiometry speech test may be requested if available. (Strong Recommendation, High Quality Evidence) •Recommendation9.Forpatientswithpresyncope/syncopeandachronicmedicalconditionisbeingconsidered,complete blood count may be requested for those with probable blood dyscrasia, serum blood glucose may be requested for those with diabetes, electrocardiogram and lipid profile may be requested for those with cardiovascular disease. (Strong Recommendation, High Quality Evidence) •Recommendation10.Forpatientswithdisequilibriumandwithanabnormalneurologicphysicalexaminationfinding,CT scan may be requested. (Strong Recommendation, High Quality Evidence) Pharmacologic •Recommendation11.Empirictrialofshortcourse(7days)pharmacologictreatmentforsymptomreliefshouldbeoffered. Referral should be considered if the dizziness become more severe or it did not improve in 7 days. (Strong Recommendation, High Quality Evidence) •Recommendation12.Forpatientswithmildtomoderatevertigo,offerhistamineanalogue(betahistine)orantihistamine (meclizine, diphenhydramine, dimenhydrinate or cinnarizine) for symptom relief. (Strong Recommendation, High Quality Evidence) •Recommendation13.Forpatientswithmildtomoderatevertigoassociatedwithmigraine(vestibularmigraine),aside from symptom relief, offer any of the triptans as preventive medication. (Strong Recommendation, High Quality Evidence) •Recommendation14.Forpatientswhosedizzinessisdescribedasdisequilibrium(gaitimbalance)orpresyncope(near faintness) or dizziness with anxiety attack, offer symptomatic treatment and intervention based on the underlying cause or consider referral to appropriate specialist. (Strong Recommendation, High Quality Evidence) Non-pharmacologic •Recommendation15.Allpatientsshouldbeprovidedwithhealtheducationoncauses,triggersandfollowup.(Strong Recommendation, Low Quality Evidence) •Recommendation16.Allpatientsshouldbeadvisedonappropriatedietandlifestylemodification.(StrongRecommendation, Low Quality Evidence) •Recommendation17.Dependingonthenatureofvertigo,educateandtrainthepatientoncanalrepositioningmaneuver and vestibular rehabilitation. Referral to rehabilitation medicine may be considered. (Strong Recommendation, High Quality Evidence) •Recommendation18.Thepatient’sfamilymustalsobeprovidedwithhealtheducationandidentifyacaregivertoassist and promote compliance to management. (Strong Recommendation, Low Quality Evidence) •Recommendation19.Encouragecommunity-basedvestibularrehabilitationactivitiessuchasgroupbalancetraining exercise. (Strong Recommendation, Low Quality Evidence) Patient Outcomes •Recommendation20.Thepatientshouldknowthenatureofdizziness,causesandpotentialcomplicationsanddevelop skills in postural exercises. (Strong Recommendation, Moderate Quality Evidence) •Recommendation21.Decreaseinfrequencyandseverityshouldexpectedwithin48hoursandresolutionisexpectedwithin a month. (Strong Recommendation, Moderate Quality Evidence) •Recommendation22.Improvedqualityoflifeshouldalsobeelicited.(StrongRecommendation,ModerateQualityEvidence) •Recommendation23.Referraltoappropriatespecialtyshouldbedoneifnoresolutionorprogressionofsymptomsor impaired quality of life for more than a month. (Strong Recommendation, Expert Opinion)@*Implementation@#The committee shall disseminate the guidelines through presentations and via journal publications. The QA committee shall be in charge of implementation of the guideline and pathway.

Effectiveness of health education interventions directed to patient, family, community on Chronic Obstructive Pulmonary Disease in family and community practice: A meta-analysis

Background@#Chronic obstructive pulmonary disease (COPD) is one of the contributors to the burden of non-communicable disease. Health education is a key component in COPD management. Effective health education interventions directed to patient, family and community are necessary to prevent exacerbations, emergency room visits, hospitalizations and improve quality of life for patients with COPD. The general objective of the study was to determine effectiveness of health education interventions directed to patient, family and community. Specifically, to determine the effect on the number of acute exacerbations, COPD related emergency room visits and hospitalizations, improvement in the quality of life and patient satisfaction.@*Methods@#This study only included comparative clinical trials randomized or non- randomized, parallel or cross-over clinical trial design, cohort study involving humans as the participants. It also includes published studies in peer reviewed journals of PubMed, clinical trials registered Cochrane Central Register of Controlled Trials, and the grey literature. There were no foreign language studies included relevant to this review. The non-comparative clinical trials, outcomes research or real-world data, animal experiments, reviews and case reports were excluded. The study population of reviewed literature has an established diagnosis of Chronic Obstructive Pulmonary Disease based on the Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria for diagnosis of COPD. Studies involving COPD patients who have other co morbidities were also included. The patients with COPD in the study were similar to patients consulting in family and community medicine practice clinics in the Philippines. Data synthesis was done separately for each type of intervention, i.e., patient directed, family directed, community directed health education intervention on Chronic Obstructive Pulmonary Disease. Quantitative analysis was only possible for studies reporting similar outcomes and units of measures such as number of COPD-related hospitalizations and emergency room visits for health education intervention directed to patient and improvement in the quality-of-life scores for health education intervention directed to family and community. Narrative synthesis was done when it was not feasible to include studies to do pooled analysis due to any of the following reasons such as different outcomes and when outcomes not reported as means with standard deviation. The Review Manager 5 software was used in the analysis of the data. Sensitivity analysis was done by restricting the analysis to published studies and with low risk of bias.@*Results@#A total of ten studies were included. Health education interventions directed to patient has no benefit in decreasing the number of COPD related emergency room visits (1.84, 95% CI 0.94,2.74) and insufficient evidence to decrease the number of COPD related hospitalizations (4.33,95%CI-4.69,13.34). Health education intervention directed to family have insufficient evidence to improve the quality of life among patients with COPD (0.35,95% CI -0.49,1.19). Community directed health education intervention have significantly improved the quality of life among patients with COPD (-1.95,95% CI -3.37, -0.53).The studies had low risk for bias in terms of random sequence generation, allocation concealment and blinding of outcome assessment except for one study that was a non-randomized trial (Tabari et al, 2018). The highest risk for bias across the studies was the non-blinding of the participants. The withdrawals or dropouts in one study exceeded 20%. Three studies reported non possibility of blinding the assessor (Marques et al 2015, Nguyen et al 2019, Tabari et al 2018). Furthermore, five studies (Gallefos, 2004, Hernandez et al 2015, Tabari et al 2018, Van Wetering et al 2010, Marques et al, 2015) did not report the use of intention to treat analysis@*Discussion@#Effective health education interventions directed to patient, family and community in conjunction with standard of care may decrease exacerbations, hospitalizations, emergency visits, better quality of life and patient satisfaction. The studies included for this review were heath education interventions solely directed to patient, to family and to community and not a combination of the interventions directed to patient and family, or patient and community, or patient and family and community. Overall, health education interventions are integrated in a patient centered family focused community-oriented care for COPD. Health education is just one of the components of the integrated care on COPD. Better control of COPD is likely due to the combined effects of the different care components. Hence, there is a need for more randomized controlled trials on health education interventions directed to patient and family. Inclusion of COPD related hospitalizations, emergency room visits, acute exacerbations as outcome measures in health education interventions directed to patient, family and community is useful to provide evidence in effectiveness of the intervention. The authors declare no financial or funding involvement in the development and implementation of this study. This protocol was registered with Research Grants Administration Office (RGAO) with Registration No. RGAO-2020-1276, Research Implementation Development Office (RIDO) and to the Research Committee of the Philippine Academy of Family Physicians. The study was given Certification of Exemption from Ethical Review by the University of the Philippines Research Ethics Board (UPMREB CODE: UPMREB 2020-783-EX

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.

Intensification in the management of Type 2 Diabetes Mellitus (T2DM) using insulin in family practice

Background@#Diabetes mellitus type 2 (T2DM) is a chronic metabolic disease leading to target organ complications over time. The delays in treatment and glycemic control have significant implications in short and long-term health outcomes resulting in increased healthcare resource utilization thus timely insulin initiation and intensification is recommended@*Objective@#This clinical pathway was developed to guide family and community physicians on how to intensify the treatment of Type 2 Diabetes Mellitus (T2DM) using insulin intended for patients who require insulin initiation or titration@*Methods@#The PAFP Clinical Pathways Group reviewed published literature in order to identify, summarize and operationalize the evidence in the management of T2DM patients on insulin use 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 and patient outcomes@*Summary of Recommendations@#The recommendations on clinical history and physical examination, laboratory, pharmacologic interventions, non-pharmacologic interventions subdivided into patient-centered, family-focused and community-oriented and patient outcomes are grouped into first visit and second visit, continuing visits

Clinical pathway for the diagnosis and management of patients with COVID-19 in family practice

Background@#Coronavirus disease 2019 (COVID-19) has rapidly spread worldwide, causing a pandemic. The Philippines ranks 3rd in Southeast Asia with more than 15,000 confirmed cases, and a case fatality rate of 6.01%, close to the global average of 6.33%.@*Objective@#This clinical pathway was developed to guide family and community physicians on the diagnosis and initial management of COVID-19 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.@*Method@#The PAFP Clinical Pathways Group reviewed the published medical literature to identify, summarize, and operationalize the evidence in clinical publication on the management of patients with COVID-19 in family and community practice.@*Recommendations@#The recommendations are time-bound tasks on patient care processes, in terms of history and physical examination, laboratory tests, pharmacologic and non-pharmacologic interventions. The recommendations are presented as a table and algorithm.@*Implementation@#At the clinic level, self-audit using the recommendations of this clinical pathway as the standard may be done. At the organizational level, the PAFP should establish a new model of quality improvement initiative where self-practice audits are included as part of the program.

Association of shared decision making and the patient and physician characteristics of adult Filipino patients with Type 2 Diabetes Mellitus at the family medicine clinic of the outpatient department of the Philippine General Hospital

Background@#Shared decision-making (SDM) is the active process of collaborative clinical decision making between patient and physician. Factors associated with use of shared decision making have been investigated previously, but few have explored this topic locally.@*Objective@#To determine patient and physician characteristics associated with shared decision making of adult Filipino patients with type 2 diabetes mellitus.@*Methods@#A cross sectional study was conducted from January to April 2020 among patients of the Family Medicine Clinic (FMC) of the Philippine General Hospital (PGH) with type 2 diabetes mellitus and all residents of the Department of Family and Community Medicine (DFCM). Sociodemographic characteristics and clinical characteristics were obtained using self-administered questionnaires, and shared decision making was measured using the SDM Q-9 Filipino Version. Responses were encoded using Microsoft Excel and analyzed using SPSS.@*Results@#A total of 153 patients and 36 residents were recruited into the study. The patients had an average age of 59 (SD + 9.52) years, with the majority being female (68.6%), and a mean HbA1c level of 7.76% (SD + 2.53%). The physicians had an average age of 29.6 (SD + 4.59) years, and more than half were female (66.67%). The mean level of perceived shared decision making was 85.77% (SD + 14.12%). Patients who were not aware of the current HbA1c level were less likely to have high shared decision making, while having two or less comorbidities increased the likelihood of having a highly participative consultation.@*Conclusion@#The perceived mean shared decision making was 85.77%. Shared decision making was associated with lack of knowledge on HbA1c level and few comorbidities among adult Filipino patients with Type 2 diabetes mellitus at the Family Medicine Clinic of the Outpatient Department of the Philippine General Hospital. None of the physician characteristics were linked to patient participation.

Patient flow, health delivery processes, and areas for improvement in the UP Health Service (UPHS) during May to June 2020 of the COVID-19 Pandemic

@#Background. Workplace or employees’ clinics play a vital role in disease outbreaks as there could be an influx of sick personnel. Processes and patient flows during pandemics should be documented to identify good practices and sources of operational inefficiencies. Objective. To describe the patient flow, health delivery processes, and areas for improvement at the UPHS during the early phase of the COVID-19 pandemic from May to June 2020. Methods. This was a cross-sectional study involving patient flow analysis of processes at the employees’ clinic of the University of the Philippines-Philippine General Hospital. The study was divided into two major components: clinic process time measurement and process flow mapping. Data collection involved time elements and narrative descriptions of good practices and problems in the process flow. Results. The UPHS staff attended to 1,514 employees’ visits during the 15 working days from May to June 2020. The total UPHS service time from arrival to end of consultation of an employee with a COVID-19-related concern was an average of 1 hour 3 minutes (SD±39 minutes) with a mean total waiting time of 46 minutes (SD±37 minutes). Good practices identified were personnel flexibility in doing other tasks, good communication, and infection control measures. Areas for improvement included symptom screening, implementation of physical distancing, and disinfection practices. Conclusion. The process flows in the UPHS clinic consisted of COVID-19 related consultations, non-COVID-19 related concerns, and swabbing services. Good communication, staff flexibility, infection control measures, and leadership were identified as good practices. Occasional lapses in symptom screening at triage, physical distancing among employees in queuing lines, and inconsistent disinfection practices were the areas for improvement.

Summary recommendations on the various disinfection strategies in the community

Background@#Local government units conduct community – based responses to control spread of COVID-19 infection. Initiatives include city-wide disinfecting operations on streets and establishments, and mist spraying outside houses, vehicles, and even directly on persons.@*Objective@#To provide a list of recommendations on the different disinfection strategies applicable for use in the community@*Methodology@#Articles and guidelines about community disinfection were searched in various research databases. All evidencebased recommendations were reviewed, appraised, evaluated and summarized@*Recommendations@#General disinfection in households and community recommends use of diluted bleach solution of 75ml Sodium hypochlorite in 3.8L or 1 gallon of water (1000ppm). It is recommended to clean and disinfect frequently touched surfaces such as tables, doorknobs, light switches, handles, desks, toilets, faucets, sinks and electronics. In disinfecting local quarantine facilities, all surfaces must be regularly cleaned using damp cleaning cloth and mops. Ethyl alcohol (70%) is used for small surfaces and well-ventilated spaces while diluted household bleach is used for surface disinfection. Spraying or fogging with ethyl alcohol or bleach disinfectant may be hazardous and has no proven benefit on disease prevention and control@*Conclusion@#The use of properly diluted household disinfectant solution for direct surface cleaning is an effective infection control measure in the community setting. Available evidence, however, recommends against the use of spraying, misting or fogging

Summary recommendations on the use of protective equipment for health care personnel involved in triage and ambulatory consult of patients in COVID-19 pandemic

Background@#In a low resource setting, strategies to optimize Personal Protective Equipment (PPE) supplies are being observed. Alternative protective measures were identified to protect health care personnel during delivery of care@*Objective@#To provide list of recommendations on alternative protective equipment during this Coronavirus Disease 2019 (COVID-19) pandemic@*Methodology@#Articles available on the various research databases were reviewed, appraised and evaluated for its quality and relevance. Discrepancies were rechecked and consensus was achieved by discussion.@*Recommendations@#The use of engineering control such as barriers in the reception areas minimize the risk of healthcare personnel. Personal protective equipment needed are face shields or googles, N95 respirators, impermeable gown and gloves. If supplies are limited, the use of N95 respirators are prioritized in performing aerosol-generating procedures, otherwise, surgical masks are acceptable alternative. Cloth masks do not give adequate protection, but can be considered if it is used with face shield. Fluid-resistance, impermeable gown and non-sterile disposable gloves are recommended when attending to patients suspected or confirmed COVID-19. Used, soiled or damaged PPE should be carefully removed and properly discarded. Extended use of PPE can be considered, while re-use is only an option if supplies run low. Reusable equipment should be cleaned and disinfected every after use@*Conclusion@#In supplies shortage, personal protective equipment was optimized by extended use and reuse following observance of standard respiratory infection control procedures such as avoid touching the face and handwashing. The addition of physical barriers in ambulatory and triage areas add another layer of protection

Community-oriented health care during a COVID-19 epidemic: A consensus statement by the PAFP task force on COVID-19

Initial Planning@#Statement 1: A Community-oriented Health Care Plan that contains tasks and activities related to the community organization, environment, health care and social processes in order to mitigate the effect of the COVID-19 epidemic on the community should be developed. Statement 2: The plan should also include adjustments needed to continue the delivery of other health services i.e. maternal and child health, immunization, treatment of other communicable and non-communicable disease but with strict COVID-19 transmission precautions.@*Adjustment in the Community Organization and Environment@#Statement 3: A local task force should be organized to develop and implement the community health plan. The task force should be recognized and supported by the whole community. Statement 4: A facility in the barangay that can be used for isolation in case that a member will be diagnosed to have mild COVID-19. A hospital facility for referral of high-risk cases should also be identified and an emergency referral and transport plan should be established. Statement 5: All community health workers should wear appropriate personal protective equipment in the process of performing their community health work. Statement 6: Households in the community who have members at high-risk i.e. more than 60 years old, with existing chronic illness or other life-threatening condition should be identified and advised to take extra precautions i.e. personal hygiene, wearing mask and physical distancing. Statement 7: During the declared community quarantine period by the community or higher-level authority, all community members and household should be advised to stay at home, limit celebrations and community gatherings@*Performance of Routine Tasks and Activities@#Statement 8: A community-directed information, education and communication (IEC) plan should be developed and implemented for the following: a) Informing every household in the community on the basic and accurate information about COVID-19 and the community plan. b) Encouraging everyone to practice personal hygiene that includes regular and appropriate hand washing, daily bath, coughing and sneezing etiquette, wearing of mask, minimizing hand contact with eyes, nose and mouth and strict personal use of eating utensils, bath towels, etc. c) Encouraging everyone to clean everyday frequently touched surface like doorknobs, light and appliance control switch, gadgets, armchairs and tabletops. Cleaning agents can be ordinary detergents and water or 70% alcohol. d) Encouraging everyone to report and seek help to the community health worker if a household member is exposed and developed mild symptoms of COVID-19@*What to Do When a Member or Household is Exposed or Diagnosed COVID-19@#Statement 9: If there is a household whose member is exposed to a COVID-19, the person should be encouraged to stay home preferably in a room or area adequate for isolation, wear mask and maintain at least 2 meters physical distance from other family members. Statement 10: Other household members should be advised to watch out and monitor for the appearance of symptoms like fever, colds and cough. If the person is low risk but there is difficulty of breathing or worsening of symptoms or if the person is high risk i.e. elderly or with existing chronic disease and symptoms appear, they encouraged to inform the community health worker and facilitate the necessary referral and transport arrangement to the hospital. Call first before going. Statement 11: If the symptoms are mild, continue home isolation or in the isolation facility identified by the community, take over-thecounter medications like paracetamol for fever, increase water intake and ensure adequate nutrition, sleep and rest. Family members and community health workers are encouraged to provide psychological and social support to isolated patients. Discontinuation of isolation can be done if symptoms resolve within 14-21 days@*Epidemiology and Surveillance@#Statement 12: The municipal or city health office should be provided daily with a situation report of the implementation of communityoriented health care for COVID-19. Situation report should include: a) The number of exposed, number of diagnosed cases, number of mild cases, number of cases referred to the hospital and number of cases recovered or died in the community. b) Brief description of best practices

Family-focused home care plan during a COVID 19 epidemic: A consensus statement by the PAFP task force on COVID 19

Initial Planning@#Statement 1: Develop a Family-focused Care Plan that contains tasks and activities related to the family structure, home environment and processes in order to mitigate the effect of the COVID-19 epidemic@*Adjustment in the Family Structure and Home Environment@#Statement 2: Identify a Family Caregiver who will remind the family to follow and implement the plan. Make sure this person is supported by all the members of the family. Statement 3: Identify a room or area that can be used for isolation in the event that a family member will be exposed to a diagnosed COVID-19 patient. Statement 4: Identify those who are at risk i.e. more than 60 years old, with existing chronic illness or other life-threatening condition and advice to take extra precaution. Statement 5: During the declared community quarantine period, all family members should stay at home, limit family celebrations, avoid home parties with outside guests, cancel travels as much as possible and be ready to have more members staying at home@*Performance of Routine Tasks and Activities @#Statement 6: Practice personal hygiene that includes regular and appropriate hand washing, daily bath, cough and sneezing etiquette, minimize hand contact with eyes, nose and mouth and strict personal use of eating utensils, bath towels, etc. Statement 7: Daily cleaning of frequently touched surface like doorknobs, light and appliance control switch, gadgets, armchairs and tabletops. Cleaning agents can be ordinary detergents and water or 70% alcohol@*What to Do When a Member is Exposed@#Statement 8: Advice an exposed family member to stay home and in the room or area allocated for isolation, wear mask and maintain at least 2 meters physical distance from the other family members. Make sure their clothing, personal belongings and other things that they usually hold is cleaned regularly and not touch by other members. Statement 9: Watch out and monitor for the appearance of symptoms like fever, colds and cough. If the person exposed is low risk and there is difficulty of breathing or worsening of symptoms, consult your family doctor. If the person is high risk i.e. elderly or with exiting chronic disease and symptoms appear, consult your family doctor right away. Call first before going to the clinic or hospital. Statement 10: If the symptoms are mild, continue home quarantine, take over-the-counter medications like paracetamol for fever, increase water intake and ensure adequate nutrition, sleep and rest. Other family members are encouraged to provide psychological and social support to an exposed and isolated member. Statement 11: Symptoms usually resolved within 14 days, after which home quarantine can be discontinued between 14-21 days. If symptoms persist beyond 14 days consult your family doctor for advice

Perception and satisfaction survey of foster families hosting students of the University of the Philippines in the community rotation

Background@#Immersion programs under the Community Health and Development Program (CHDP) of the University of the Philippines involved students living in a foster home. The experiences of foster families are valuable in improving the community immersion program.@*Objective@#To determine the perceptions and satisfaction of foster families in hosting students of the University of the Philippines rotating in the five select municipalities of Cavite@*Methods@#This was a cross sectional study utilized a semi-structured questionnaire. Data collection was done by a research assistant who was not involved with the students rotation@*Results@#A total of 90 foster parents who hosted 430 students in three consecutive years were included. In general, there was favorable perception towards hosting students with a mean score of 8.47 (SD± 1.37). The lowest scores were reported by 13 families (14%) at a score of 6/10. The weekly monetary contributions, free consultations, monitoring of health conditions, acquiring additional knowledge about health prevention and if needed, an easy referral to Philippine General Hospital were some of the reported benefits. On the other hand, poor socialization, negative attitudes, non-performance of household chores and lack of privacy were the disadvantages expressed by families@*Conclusion@#Foster families were generally happy and satisfied however there were mixed positive and negative perceptions in hosting UP students rotating in the community

The Patient-centered, Family-focused and Communityoriented (PFC) Matrix: A toolkit for biopsychosocial approach in primary care

@#Biopsychosocial (BPS) approach to care is essential in family practice. Teaching this approach in family medicine is usually highlighted in family case presentations and counseling sessions. Little is done in showing how the biopsychosocial approach can be used in the day to day family practice. This article discusses the development of a learning tool called the PFC matrix which is a patient-centered, family-focused and community-oriented approach to care for individual patients and their families. The patient-centered care utilizes understanding of the interplay of biomedical psychosocial factors disease in order to implement management that is tailor-fitted to the needs and values of the patient. The family-focused component of the matrix utilizes family assessment to generate assumptions on how the family dynamics affect or facilitate the prescribed management of the patient’s disease. Lastly, the community-oriented component enables the family physician to use social determinants of health and health systems as a lens to understand how larger systems support or hinder the provision of care. Through the use of this matrix, the family physician is able to manage the patient in a holistic manner by recognizing patient needs, creating an enabling family support environment and helping the patient and family navigate various community resources. This results not only in optimal health for the patient but impacts to create a more responsive health system. In the future, further documentation of the use of the PFC matrix particularly in primary care in the light of universal health care and how it impacts on outcomes and how it connects patients and families at the correct tiers of the health system.

Clinical pathways for the management of hypertension in family and community practice

@#<p style="text-align: justify;"><strong>BACKGROUND:</strong> Hypertension is a major risk factor for cardiovascular disease. The prevalence of hypertension in the Western Pacific Region is 37% of adults older than 24, while in the Philippines it is 25% of adults 21 years old and above. Several guidelines have been developed for the management of hypertension. All these guidelines have recommendations for assessment and treatment.<br /><strong>OBJECTIVES:</strong> The overall objective of the development and implementation of this clinical pathway is to improve outcomes of patients with hypertension seen in family and community practice.<br /><strong>METHODS:</strong> The PAFP Clinical Pathways Group 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. The group developed a time-related representation of recommendations on patient care processes, in terms of history and physical examination, laboratory tests, pharmacologic and non-pharmacologic interventions as well as social and community strategies to treat hypertension and prevent complications.<br /><strong>RECOMMENDATIONS:</strong> Recommendations were made based on the number of visits. During the first visit, all adult patients consulting at the clinic should be screened for hypertension with appropriate BP measurement. A thorough history focusing on symptoms, family history using genogram, smoking and other lifestyle and co-existing chronic disease and a thorough physical examination focusing on the weight/BMI, waist/hip ration, funduscopy, neurological, cardiac, renal and peripheral arteries should be done. For the laboratory, request for 12-lead ECG, urinalysis, FBS, creatinine, serum K and lipid profile to determine co-morbidities and baseline values. If the patient is already diagnosed hypertensive, start/continue medications with either or a combination of thiazide-type diuretic, calcium channel blockers, angiotensin-converting enzyme inhibitors and angiotensin receptor blocker depending on co-morbidities or side effects. But if there is a need for further confirmation, no medication is warranted. Educate the patient about hypertension, risk factors and complications. If medications were prescribed, explain the dose, frequency, intended effect, possible side effects and importance of medication adherence. Lifestyle modifications focusing on weight control, exercise and smoking cessation should be advised. During the first first visit is expected that the patient is aware of the diagnosis of hypertension, its risks factors and complications to encourage compliance.<br /><strong>IMPLEMENTATION:</strong> Education, training and audit are recommended strategies to implement the clinical pathway.</p>

The Family Medicine Integrated Clinical Pathways Project (FM ICliP): Methods of development and implementation

@#<p style="text-align: justify;">Continuing care in family and community medicine is a dynamic process that requires regular patient assessments and adjustments of treatment strategies as the patient goes through the wellness and disease process. Family and community physicians need to be aware of any changes in the patient's clinical condition and re-assess therapeutic interventions when such changes occur. The use of clinical pathways can optimize the management of patients with a given disorder in our setting. The overall goal of the project is to improve the quality of health care in Philippine family and community medicine practice.<br />Clinical pathway is defined as a "tool to guide family and community medicine practitioners to implement evidence- based care and holistic interventions to specific group of patients and populations within a specific timeframe adjusted for acceptable variations that may be due to patient and practice setting characteristics designed to achieve optimum health outcome for the patient and community and efficient use of health care resources." In this definition, holistic interventions refer to interventions directed to the individual patient within the context of the family and community. In this context the PAFP Clinical Pathways Project will be developed to promote and implement the clinical pathways in family and community medicine. The PAFP Clinical Pathways Project will be implemented by a group who will review 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. The group will also identify processes and indicators to measure the effect of implementation of clinical pathways. Linear time-related representations of patient care processes, in terms of assessments, pharmacologic and non-pharmacologic interventions as well as social and community strategies to prevent complications and maintain wellness will be developed. The clinical pathways will be disseminated to the general PAFP membership and other stakeholders for consensus development. We hope that with this process, family and community medicine practitioners will be dedicated to a common goal and overcome organizational, personal, and professional perspectives barriers to the implementation of the clinical pathway.<br />The implementation of the clinical pathways to be adopted by the PAFP will include a nation-wide dissemination, education, quality improvement initiatives and feedback. Dissemination will be in a form of publication in the Family Filipino Physician Journal, conference presentations and focused group discussions. Quality improvement activities will be in a form of patient record reviews, audit and feedback. Audit standards will be the assessment and intervention recommendations in the clinical pathway. Variations will be discussed in focused group meeting and feedback sessions. The clinical pathways recommendations may also be revised if the variations are justified. Quality improvement activities will also be used to identify barriers in the implementation of clinical pathway. An electronic medical information system may also be used to facilitate the implementation.<br />To monitor the implementation of clinical pathways the PAFP need to select, define and use outcomes and impact to monitor the success of implementation. Outcomes and impact will be at the practice level and the organizational level. Practice level can be a simple count of family and community medicine practice using and applying the clinical pathways. Patient outcomes will also be measured based on quality improvement reports. Organizational outcomes can be activities of the PAFP devoted to the promotion, development, dissemination and implementation of clinical pathways.</p>