Are Primary Care Practitioners Ready for Evidence-based Clinical Practice?

Abstract

Primary care practitioners have the distinct advantage of being at the forefront of healthcare delivery. They are generally the go-to medical staff who are likely to be living within the same community as the patients. With the enactment of the Universal Health Care (UHC) law in 2019 mandating the development of human resources in the health system through the formulation and implementation of the National Health Human Resource Master Plan, every Filipino is assured of equitable access to quality and affordable health care services, medications and other related goods, and are protected from financial risks. This ensures that medical practitioners adhere to standard of care, bounded by clinical practice guidelines (CPG) in the present age of evidence-based medicine.

In the original article by Ramoso R et al. in this publication, the findings obtained from electronic medical records (EMR) of pediatric patients seen at three pilot sites of the Philippine Primary Care Studies in 2019 may suggest a bleak prospect of the successful implementation of the UHC in the Philippines. Inappropriate medications and interventions were observed in the management of primary care pediatric conditions in a great majority of cases. Assessed in the study were patient records. Would the pattern or trend be different currently, five years after the conduct of the study, or with a different design evaluating health care practitioners themselves? While the subject population studied seemed large enough with 8,724 EMR reviewed, was this being served by only a few physicians whose choice of medical management may been replicated causing an unduly skewed observation? It behooves us to raise several issues regarding the physicians who served this population subset across the primary care sites such as the level of competency (as accredited by medical professional organizations), personal astuteness in acquiring continuing medical education (beyond the piece of written certification), among others. Nonetheless, of notable interest are the observations that zinc prescription for diarrheic patients was highly adhered to by physicians in the rural and remote compared to urban areas, and compliance in most of the clinical conditions were highest in the remote communities (Table 5). This latter observation may not be explained by the perceived inequity of opportunities for continuing professional enrichment among those in remote settings. It is likely that access to updated information can be sourced beyond the standard conference settings, probably through the web or other digital resources.

In a related study assessing adherence to clinical practice guidelines, the subjects in the cross-sectional study were the 149 primary care physicians themselves (consultants, specialists, and general practitioners) randomly selected from 20 public sector primary health centers in Bahrain conducted in 2021 using an online survey. Their findings revealed that the vast majority (98%) reported having implemented CPGs in their practice and encountered minimal barriers with only non-cooperativeness of patients as a significant barrier.

In a qualitative study interviewing general practitioners and cardiologists in the care of patients with suspected chronic coronary syndrome in the ambulatory setting in Germany, the most cited barrier to guideline adherence was the structural aspect at the system level. These included the interdependency of factors affecting expediency such as reachability of providers and services, waiting times, reimbursement through health insurance providers, among others.

How may sustainability of guideline adherence in primary care be promoted? Identifying and addressing the barriers to CPG implementation, both in the personal (and professional) and system levels, may better promote appropriate patient management (to maximize the use of limited resources), minimize medical errors, and provide judicious allocation of resources (amidst the fragmented health service delivery and inefficient financing systems). These are key measures that are extremely relevant for the successful implementation of the UHC in the Philippines.