circ20_2013 philpen

7/23/2019 circ20_2013 PhilPEN

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Republic of

h

hilippin

s

PHILIPPINE HE LTH

INSUR NCE CORPOR TION

Citystatc Centre Building,

709

Sh

aw

Boulevard, Pasig City

Heafthline 441 -7444 p h i l h ~ a f l h . g o v . p h

PHILHEAL

TH

CIRCULAR

N o . t b ~ s. 2013

X1

TO

SUBJECT

ALL PRIMARY CARE

BE

NEF

IT

PR OVIDERS (RURAL HEALTH

UNITS),

LO

CAL GOVERNiviEN

T UNITS, PHILHEALTH

REGIONAL

OFFICES, ALL

OTHERS CONCERNED

ADOPTION OF

THE

PHILIPPINE

PACKAGE

OF

ESSENTIAL NON-COMMUNICABLE DISEASE (NCD)

INTERVENTIONS

(PHIL

PEN) IN THE

IMPLEMENTATION OF

PHILHEALTH S PRIMARY CARE

BENEFIT PACKAGE

I .

RATIONALE

The

World

.Health

Organi

zation

(WHO) rep

o

rted that non-communicable

diseases

(NCD)

were

responsible for two-thirds o f all deaths globally

in

2011,

up from

60 in 2000. The four main

N CD s are

car

di

ov

ascular

di

seases, cancers, diabetes

and chronic

lung diseases. Cardiovascul

ar

diseases

alone

killed nearly 2 million m

ore people

in 2011 than in the year 2000.

Ba

sed

on

Philippine data

(N

atio nal Statistics office, 2009) cardi

o- and

cerebro-vascular diseases

topped

the

list

in

the top 10 cau ses of death, alo ng with diabetes and malignant neop l

asm.

Moreover, over

the pa

st

three

years, the m

os

t

common

proce

dur

es reimbursed by Phil.Health were du e to

co m

plicatio ns o f no

n-communicab

le

di

seases such as hemodialysis and che

mothera

py.

Ev

id

en

tly, the

pro

blem o f

NC

D

ha

s

reache

d great

proportions

both

in

the local and

intema

tio

na1

heal

th settin

gs. Meanwhile, the WHO claims that about

80

of deaths

due

to non

co

mmuni

cable diseases in low and middle

income

countries can

be

treated wi th essential

medicine

s i f

prescribed and used

rationally

along with

the effe cti

ve

u

se of

m edical devices.

7/23/2019 circ20_2013 PhilPEN


.,

1.

Provide cost-effective alternatives

in diagnosing

no n-communicable diseases

at

its early

st

age

using a ris k

assessment

appro

ac

h

2. Assure

access to

basic diagnostics and

medicines

3.

Deve

l

op

a

unified

reporting sys tem from which

will

be culled

data

relevant fo r both

DO

H

and

Pbill-:leal

th

,

in

line

with monitoring

quality

and benefit

utilization

III COVER GE

All

accredited rural

health units

RHU

s),

health

centers (HCs) and

ot

her

primary care

benefit 1 providers with assigned Pb.ilhealth

membe

rs who are enti tled to Prima1-y Care

Benefit

1 shall be required to adopt th e PhilPEN

protocol.

Otl1er

accredited

health

care

in

st

itutions

in

low resources ;uoeas arc encouraged

to

use

this

prot

oco

l

IV GENER L GU

ID

ELINE

S

1.

T he

Phil PEN Guidelines (Annex

A) shall be

disseminated

to all accredited Primary Cru·e

Benefit 1 providers, specifically n the rural health units R

HUs

) and health centers (HCs)

2.

Dissemination

shall

include

conducting

nationwide

orientati

on on

the protocols to

pr om

ote compliance.

3. Any enhancements/ evisions in

adopted

protocols shall likewise be di sseminated to all

RHUs and health center

s H Cs).

4. As an indi

cator of compliance to

PhilPEN, accredited PCB

1 providers are required to

procure or acquire all necessary basic diagnostic equipments to include but not limit

ed

to

a glucometer, glucostrips,

cholesterol

meter

an

d strips, BP apparatus, weighing scale,

uri

ne

dipsticks.

5

Paymen ts of

PCB

providers in managing hypertension an d diabetes shall be based on

compliance to

these

guidelines.

6 A

ll accredited

PCB

1 providers

shall be required to

use

the pres

cribed encoding

database / electronic

system

to be

dep

loyed to ilieir facility.

7.

Rep

o

rt

s

on diagno

sis

and management

of

diabetes

and

hyperten

s

ion

shall

be submitted

electronically

on

a

monilily ba

sis

using

ilie

encoding

database

that ha

s

been deployed to

ilieir facility.

8. Monitoring

compliance

to this

Circular

shall be done by ilie Phill-:lealili Regional Office

7/23/2019 circ20_2013 PhilPEN


VI

REPEALING

CLAUSE

All other related

issuance

s

inco

n

sistent or contrary to the provisions of

this Circular

are hereb

y

repeal

ed amended or modified

accordingl

y.

VII

.

EFFECTIVITY:

This circular shall take

effect

fifteen days

after it

s publication

in the

newspaper

of general

circulation and af

ter

deposit

thereof

with

the Nati

onal Administrative Regis ter at the

Univer

sity

of

the

Philippine

s Law Center.

ANNEXES:

A. Phil

PEN

Protocol on

the

Man ement

of Hypertension

and

Diabete

s

7/23/2019 circ20_2013 PhilPEN


..

Health

~ O r g a n i z a t i o n

I HO

Pack

a

ge

of

Essentia

l

NCO

PEN)

interventions

I

Protocol : P Integrated management of hyperten

sion

and diabe tes

(F

or

preven

io

nof heart attacks, strokes,

rena

l

ai lure,

amputationsand bli

ndness

)

(Total risk

approach using hypertensi

on, diabetes and tobacco use as

entry

points

l.rnl

1 :rorr;r.t:llr. Fiii • •

• Age > 40 years

• Smokers

:lll:urol •hJ;tl

• Known heart disease, stroke, TIA, diabetes, kidney disease

• Chest pain and/or breathlessness on exertion. pain in calf

on

walking

• Medicines that the patient is taking

• Current tobacco use (yes/no)

• Alr.nhol c:onsumption yP.s/nn)

• Occupation (scdtmtary or activ

e)

• Engaged in

more

than 30 minut

es of

physical adivity daily at least5 days a

week yes/no)

• Waist cin:urnference

*

• Palpation of heart. peripheral pulses and abdomen

• Auscultation heart and lungs

• Blood pressu

re

• Fasting or random plasma glucose DM=fasting>=7 mm ol/L 126 mg /dl) or randorn

>=11.1

mmol/L

2

00 mg/dl))

• Urine protein

• Urine ketones in newly diagn

os ed OM

• Plasma cholester

ol if

test available

• Test sensation of

fe

et and foot pulses if

DM

•

Use

the

WHO

/

ISH

risk c

hart

s relevant

to

the

WHO

subregion (Ann

ex

and

CD

)

I

• Obesity•

8 Raised

BP

• Diabetes

•

His

tory of premature CVD

in

first degree relatives

• History of diabetes or

kidney

disease in first degree relatives

• BPI

2:140

or 2: 90

mmHg

in

pe

ople 40 years to exclude secondary

hy

pertension)

• Known he

ar

t disease, stroke, TI

A,

DM. kidney disease (for

assessment as necessary)

•

Ang

ina, claudication

• Worsening heart failure

• Raised

BP 2:1

40/90 (in

OM above

130/80

mmHg) in

spite oftreatment

with 2 or 3 agents

• Any proteinuria

•

Newly

diagnos

ed

diabetes with urine ketones 2+

or in lean person of < 30

ye

ars

a OMwith fast

in

g

bl

o

od

glucose >14 mrooVI despite maximal

metformin with or without sulphonylurea

• OM with severe in

fection

and/or foo t ulcers

•

OM

with recent deterioration

o

v

is

ion or

no eye

exam in 2 years

/

...

: ·. 1

n

•

Use

age, gender, smoking status, systolic

bl

ood pressure. diabetes (and blood cholesterol if available)

If age 50-59 years select age group box 50 , if 60-69 years select age group hox etc.; for people

age

40 years select age group b

ox

40

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7/23/2019 circ20_2013 PhilPEN


~ ~ ~ o r l d Health

V fJ

Organiz.1tion

I

HO Packageof Essentia l NCO P

EN

interventi

ons

Protocol : lP continued)

Action 5

Treat s shown beside

Diabe

tes

Mellitus - A

dditi

o

nal acti

If despite a diabe

tic

diet

• fasting blood glucose is

ra

ised

start on m etformin

• Titrate metformin to tar get glucos

• Give advice on foot care

• Follow up

at

least every 3 mont

•

If

resources

allow

give a

statin

those

>

4

years

even if cardiovascular ris

Refer

for

eye examina

tion

every

IDS

..

:v alue

s

to

is low

years

• All

in

dividuals

with

persist

ent raised

BP

160/100 mmHg should

be

given

antihypertensive

treatment

• All p

atients

w

it

h

es

t

ablished

di

abetes

and

cardiovascu

l

ar disease

(coronary

heart

disease, myocardial infarction,

transient

ischaernic

attacks,

cer

ebrovascu

lar d i s ~ a s e or peripheral

vascular

disease):

if

stable,

should continue the r

rea

tment

alre

a dy

presc

r

ibed

and be

considered

as

with risk >30

• All individuals with

tota

l cholesterol

at or

above 8

mmolll

(320 mg

dl)

should

be.given lifestyle vise and statins

R

isk<

20 :

I

• Counsel on diet,

ph

ysical

act

T

ty

,

smoking

cessation (Protocols 3P

and

4Pl

• If risk< 10 follow

up

in

12 months

• I

risk

10- < 20 ro

follow up evJry 3

months

until

targ

ets

are

me t,

then

6 - 9 months thereafter

Risk

20 to

<30 :

• Counsel on diet. physical activity.

sm

o

king

cessation (Protocols 3P

and 4P)

• Per

sistent BP 14

0/

90

mmHg in DM 130

/ 80 mmHgl consider a

low dose of one of t

he

drugs: Hydrochlorthiazide 25-50 mg daily,

E

nalap

ril 5-20

mg

daily, Atenolol50-100

mg

daily

or

Amlodipine

5-10

mg

daily

• Follow

up

every

3-6 months

r

-

I

Ri

sk > 30 :

'

• Counsel on diet, physical activity, smoking

cessati

on

I

• Persisient BP

30/BO

should be given of one of the drugs:

I

\

thiazide.

ACE

inhibitor,

beta

-blocker, calcium channel blocker

\

Give a statio

• Follow up every 3 months

L

.

w)Yb

\ 1 ] 1 \I;)

7/23/2019 circ20_2013 PhilPEN


ll l i l World Hea lth

lftl.ll Organiza

tion [ WH O Package of Essenti

al

NCO PEN ) intervent ions I

Protocol : 1P (continued)

Repeat

Actions

2,

3

and

4

Follow

refenal criteria

for

all visits see Action 3

Treat

as shown below

• If

risk

<20 , follow up

in

12 mon

th

s

and

reassess cardiovascular

ris k

• Counsel on diet, physical activity, smoldng cessation (Pr otocols 3P

and 4P)

•

f ri

sk

is

20 to <30 , continue ~ s n Action 4 and follow up every

3 months

•

I•

fr isk i s s till >

30

af

ter

3-6 mon

th

s of prescr ibe d interventions

at first visi t, re

fe

r to next level

• Avoid ta ble salt and reduce salty foods such as pickles, sa lty fish, fast food, processed food, canned food and stock cubes

• Have your blood glucose level, blood press ure and urine checked regularly

Adv

i :

e specific for d ia betes

• If you are on any diabetes medication that may cause your blood glucose level to go too low. carry sugar or sweets with you

• If feas ible. have your eyes checked every year

•

Avoid

walk

in

g

ba

r efoot or with

out

socks

• Wash feet in lukewarm water and dry well especially betwe en the toes

•

Do

not cut

ca

lluses or corns , nor use chemical agents on them

•

Look

at your feet every day and if yo u see a problem or

an

injury go to your hea lth worker

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