LOVE - Philippine College of Chest Physicians



RESEARCH PRIORITIES IN THE PHILIPPINES, 2012

I. COPD

A. Demographics & risk factors for COPD:

1. Severity/quadrant distribution of COPD patients seen in the community, general practitioner or pulmonary subspecialist & ER/in-patient settings and their demographics/profile according to severity or quadrant classification

2. Co-morbidities

3. Demographics and risk factors for early-onset &late onset COPD

4. Demographics & risk factors for non-smoking COPD patients (biomass fuels, occupational risk factors, socioeconomic status, other diseases ex. TB, asthma)

5. Profile of COPD patients with TB

6. Profile of COPD patients with bronchiectasis

7. Outdoor air pollution and COPD in the Philippines

8. Secondhand smoke and COPD in the Philippines

9. Profile of Frequent exacerbator phenotype in the Philippines

10. Long-term course and prognostic factors of Filipino COPD patients

11. Impact of national anti-tobacco legislation/policies on COPD prevalence

B. Diagnosis of COPD

1. Validation of GOLD quadrant classification of COPD

2. Clinical prediction model to diagnose COPD in resource-limited settings (especially without a spirometer)

3. Adherence of HCP in utilizing GOLD guidelines in the diagnosis of COPD

C. Treatment of COPD

1. Health-care utilization profile of Filipino COPD patients

2. Drug utilization profile among Filipino COPD patients

3. Socio-economic impact of COPD

4. KSA characterization of Filipino physicians when handling COPD patients

5. Survey on the current use, cost, and relative distribution of medical & non-medical resources across the country for COPD.

6. Cost-effectivity studies on different pharmaceutical drug classes (e.g. ICS-LABA, long-acting LAMA, theophylline, round-the-clock inhaled SABA-SAMA, mucolytic carbocisteine) & non-pharmacologic interventions (pulmo rehab)

7. Effectivity of indigenous interventions & herbal medications for COPD (eg. Lagundi)

8. Cost-minimization study on the different treatment modalities for COPD, using the societal & economic perspectives

9. Validation of the GOLD treatment recommendations based on quadrant classification in the Philippines

10. Factors that predict steroid response among Filipino COPD patients

11. Characterization of COPD control using the chronic health disease model

D. Exacerbations

1. Profile of COPD exacerbations (including common triggers, infectious agents, co-morbidities & prognostic factors & outcomes) in the out-patient and in-patient settings

2. Definition of exacerbation utilized by Filipino COPD patients & HCP’s

3. Utilization of a developed reproducible, transportable definition of COPD exacerbation in the Filipino language and major dialect.

4. Socioeconomic impact of COPD exacerbations

5. Cost-minimization studies for different COPD exacerbation interventions

6. Optimal dose & duration of systemic steroids in COPD exacerbation

7. Validation & cost-effectivity of a locally developed exacerbation treatment plan

8. Effectivity of “COPD Action Plan” in preventing exacerbations

9. Effectivity of different therapeutic pharmacologic & non-pharmacologic interventions in preventing exacerbations

MANY OF THESE RESEARCH QUESTIONS CAN BE SIMULTANEOUSLY ADDRESSED BY CONDUCTING A NATIONAL COPD REGISTRY.

II. LUNG CANCER

1. Survival statistics in lung cancer based on stage and response to treatment

2. Utilization of international pulmonary technique in the management of lung cancer

3. Incidence of lung cancer in the Philippines

4. Health seeking behaviour and survival outcome in lung cancer

5. Response rate and survival outcome  of patients diagnosed with lung cancer who underwent stem cell treatment

6. Survival outcome for early stage NSLCA who underwent curative intent surgery

7. Is molecular targeted treatment superior than standard chemotherapy in the management of elderly patients with lung cancer?  

8. Does LDCT really is safe for early lung cancer detection for high risk individuals compared to the conventional chest CT scan?

9. Response rate and survival outcome of early stage lung cancer patients who chooses the non-surgical management options like curative intent radiotherapy

10. Is radiofrequency ablative treatment a promising modality for management of malignant SPN?

III. ASTHMA

Ongoing study:

To describe clinical features of the Filipino asthmatic?

Background: The asthma council has enrolled 500 patients diagnosed to have asthma from PCCP-accredited training hospitals. Data predominantly demographics are being analyzed presently.

Future Studies:

Are general MDs adherent to present asthma guidelines?

Background: The new guidelines are being disseminated. Tools on adherence to the guidelines (impact, change of practice) are being evaluated.

IV. PNEUMONIA

1. Epidemiological data for pneumonia

2. Resistance patterns for bacterial pneumonia

3. Health care related pneumonia and ventilator associated pneumonia

4. Epidemiological  patterns of the pathogens after immunization

V. TUBERCULOSIS

1) Area: Ensure the high political support for TB control as a priority of the national health plan and among the local government units (LGUs)

|POTENTIAL AREAS/TOPICS |AVAILABLE DOCUMENTS/ |RATIONALE/COMMENTS |

| |REFERENCES | |

|- Measurement of “political support” from LGUs |- list of policies, ordinances, |- limited data exists as to the best tool to |

|- Capacity of LGUs to support the TB program |resolutions, etc emanating from LGUs |measure the support given by LGUs (including its|

| |which are TB control-related (may vary per|evaluation & effectivity) |

| |area) |- no data as to the number of LGUs that really |

| |- data base on initiatives of LGUs to |extend support- these can be modelled |

| |support TB activities (from World Vision)-|- monitor implementation of policies; evaluation|

| |SMT project |of current Eos & AOs |

| |- list of PHIC accreditation (for | |

| |financing scheme and standardization) |- we should have “handbook “on advocacy- how to |

|- Menu/package that will effectively advocate to | |effectively engage the LGUs on a consistent |

|LGUs | |basis |

|a)effective body to mediate between NTP and LGU| |- there might be other stakeholders in the area |

|b) Readiness of LGUs to “localize” TB program | |which can effectively accomplish this needed |

|(capacity)- including the integration of the | |task and we need to interface with them |

|private sector | |- profiling of the LGU important to assure |

| | |sustainability of the TB program |

| | | |

| | |- need to identify measures/strategies so that |

| | |gains in advocacy will be constant and not |

| | |affected by “personalities” or terms of office |

| | | |

|- How to “institutionalize” current efforts at the| | |

|LGU level | |-community volunteers- we need to profile them |

|- Mechanisms to ensure consistent support to TB | |and see who will be the most effective person to|

|program | |mobilize communities; sustainability of this |

|- Situational Analysis per province (esp ARMM) | |strategy |

| | | |

| | |- important in evaluating if current system |

|- Best practices in mobilizing communities for | |appropriate in running a TB program (operation &|

|advocacy purposes | |implementation, monitoring, etc) |

| | | |

| | |These group may be tapped for supporting the TB |

|-Assessment of governance structure vis-a-vis TB | |control program, (ensure their commitment by |

|program | |MOA) |

| | | |

| | | |

| | | |

| | | |

|-Involvement of non- medical NGO’s, Organizations,| | |

|and Foundations | | |

2) Area: Improve the capabilities of a critical mass DOTS workers, both public and private, to sustain quality implementation of DOTS services

|POTENTIAL AREAS/TOPICS |AVAILABLE DOCUMENTS/ |RATIONALE/COMMENTS |

| |REFERENCES | |

|-Implementation of the Diagnostic Portion of the |- Quality Assurance Documents for |- may not be feasible to collect all 3 sputum |

|NTP |Laboratories (Operational) |samples for AFB in all instances esp if patient |

|a) 2 vs 3 sputum specimens |- “color fading” in TB testing |is coming from a far-flung area |

|b) explore other algorithms/”modifications” that |- healthcare providers trained/referring |- there may be problems with credentials of |

|may be applicable in the local setting |- labs which are certified |those doing the DSSM (not all are trained med |

| | |techs) |

| | | |

| | | |

|- Evaluation of quality assurance tool or | |-crucial in maintaining quality assurance |

|instrument | |mechanism of microscopy labs |

| | | |

| | |- very crucial as a capacity of DOTS providers. |

|- How to better manage drug supply? (ensuring | |This will affect acceptance of DOTS and its |

|uninterrupted/sufficient supply of anti-TB drugs)-| |implementation |

|include how to procure/forecast | | |

| | | |

|- How to improve access of marginalized people to | |- access problems for indigenous groups, |

|DOTS? | |elderly, prisoners, poor |

| | |- adopt an infrastructure which may be culture |

| | |sensitive and to possibly link any current |

| | |effort to DOTS initiatives |

| | | |

| | |-possibly explore other mechanisms of referral |

|- How to improve referral system? | |(eg, technology based like SMS) |

| | |- Use of return slip for acknowledging received |

| | |referrals from private Physicians |

| | |Simplify referral forms |

| | | |

| | |- incentives? Motivation? |

| | | |

| | | |

|- What factors may sustain interest/passion of | | |

|DOTS workers? | | |

|(Enroll all workers even contractual employees to | | |

|Phil health for health care benefits | | |

|Provide leadership seminars for these workers) | | |

| | |- should look at how one utilize available data |

| | |and its potential impact to the program |

|-Capacity of Workers to do monitoring, | | |

|supervision, &evaluation, how to monitor/manage | | |

|ADRs | |- Accreditation of these laboratories will speed|

| | |up treatment of active TB cases(No need for |

| | |repeat Sputum AFB for Non-DOTS results) |

|-Training of private/Government Laboratory | |DOH sponsors training of med-techs (All we need |

| | |is to inform private and government labs to send|

| | |their med techs for training) |

3) Area: Strengthen the implementation of DOTS certification &accreditation

|POTENTIAL AREAS/TOPICS |AVAILABLE DOCUMENTS/ |RATIONALE/COMMENTS |

| |REFERENCES | |

|- Infection Control Practices in Local |- data gathered from labs all over the |- as we begin to expand lab functions in certain|

|Laboratories |country |areas, we must not overlook the importance of |

| |- certification/accreditation manuals |infection control in the workplace |

| |- list of certified/accredited centers- | |

| |including the location | |

| | | |

| |- PHIC requirements |- steps may be redundant |

| | |- simplification may entice more centers to be |

|- Review of accreditation process to probably | |accredited; forms that need to be filled up |

|simplify steps involved | |-regulation and quality of implementation must |

| | |be reviewed ; links between PHIC & DOH |

| | |- certifiers may need regular training |

| | |- other aspects may be looked into: quality |

| | |assurance of accreditation, financing involved |

| | | |

| | | |

| | |- availability of adequate staff always a |

| | |concern |

| | |- motivation for the staff may be needed |

| | |- possible networking to address manpower needed|

| | |and costs |

| | | |

| | |- quality of services provided by these centers |

|- Operational research on human resources needed | |must be examined. Satisafaction of clients |

|for PPMDs | |considered as well. Is there any difference? |

| | |- Need to cover even non-PHIC members |

| | | |

| | |- based on realization that these cases are also|

| | |referred to PPMD units |

| | | |

|- How accredited centers perform (any impact?) | |- Ensure that the payment from PHIC will go |

| | |directly to the DOTS center and not in the |

| | |municipal or city hall office |

| | | |

| | |- Ensure adequate PHIC benefit of the DOTS |

| | |center to provide additional incentives for DOTS|

| | |workers |

|- Expansion of PPMD units to cover retreatment and| |- enrolment of indigent patients |

|possible MDR cases (feasibility study) | | |

| | | |

|- Review of PHIC guidelines on TB OPD package | | |

4) Area: Maintain support to key management functions, particularly monitoring and evaluation of NTP-DOTS implementation

|POTENTIAL AREAS/TOPICS |AVAILABLE DOCUMENTS/ |RATIONALE/COMMENTS |

| |REFERENCES | |

|- Operational Researches: |- data/report gathered from labs all over|- there may be constraints as to the number of |

|a) What is the Best Tool for M and E? |the country |personnel required |

|b) How many trained personnel do we need to |- administrative orders requiring quality |- currently, there are 300 laboratories seeking |

|support quality assurance as it is a requirement |assurance |annual registration; approx 3000 slides reviewed|

|for annual registration? |- data from program reviews |only by 3 persons |

|c) Mechanisms to assure feedbacks on the | |- timely receipt of data from various points may|

|performance of centers | |be ideal but not consistently followed |

|d) Ensuring the quality of referrals so that they | |- need to see if the issues of the unit’s |

|will be successful | |performance were addressed |

| | |- monitoring tools must be reviewed & accurately|

| | |designed |

| | | |

| | |-need to know what types of interventions are |

|-Impact of Training, Mentoring, and Coaching | |actually needed and expected to make an impact |

5) Area: Scale-up and enhance PPMDs in strategic sites

|POTENTIAL AREAS/TOPICS |AVAILABLE DOCUMENTS/ |RATIONALE |

| |REFERENCES | |

|- Factors that Influence Private Laboratories to |-data/report gathered from labs all over |- we need to target 35 centers offering quality |

|be Certified TB Microscopy or Culture Centers |the country |assurance of microscopy that will be under the |

| |-PPMD manual |NTRL |

|- How can private laboratories effectively |- program reviews | |

|interface in the DOTS scheme? |- surveys on private physicians (PPs) |- a lot of private centers are being established|

| |practices |that may be situated in strategic areas and may |

| |- PhilTIPS report |have more reach to patients and the private |

| | |practitioners |

| | | |

|- Evaluation of private sector participation in | |- we need to identify factors that effectively |

|PPMDs | |engage private sector participation; ? |

| | |support/incentive to PPMD staff and TBDC- to |

| | |ensure sustained involvement of the private |

| | |sector; depth/extent of engagement of PPs- might|

| | |have implications in future programs/projects |

| | |that involve PPs |

| | | |

| | |- factors should be analyzed as what |

| | |compels/entice PPs to refer their patients to |

| | |PPMDs |

|- Awareness of doctors (esp private physicians) of| |- there may be barriers as well in the referral |

|PPMDs in their areas and possible utilization of | |system (fear of losing their patients, etc)- |

|services | |these should be identified and effectively |

| | |addressed |

| | |- a lot of areas have low referrals from PPs |

| | |- Possibly requiring physicians to report cases |

| | |to DOTS or DOH |

| | |- Start with a small group then gradually |

| | |increase coverage (e.g. from PCCP, to PCP to PMA|

| | |-Simplify report form to suit the need of |

| | |DOTS/DOH |

| | | |

| | | |

| | |- having a feedback loop with clients (patients,|

| | |PPs, etc) esp as to the referral system may be |

| | |needed for sustainability |

| | | |

| | |- PPs may practice DOTS in their private |

| | |practice by referring to centers with DSSM & |

|-Satisfaction surveys on the PPMDs from the | |practice adherence measures. We may need to |

|various clients | |report these to the NTP. |

| | |- need to look at outcomes and possibly |

| | |integrate these numbers in the NTP statistics |

| | | |

|- Possibility of TB cases managed by PPs “outside”| | |

|the DOTS program to be counted in the NTP report | | |

|(?single practice network) | |-some elements in the NTP like recording & |

|- Outcomes of Cases Managed by PPs (DOTS & | |reporting may be difficult with PPs. Should |

|non-DOTS compliers) | |examine support mechanisms that may address |

| | |these |

| | | |

| | |- these are the elements that may be assessed by|

|- Factors that influence compliance with DOTS with| |potential funders & other administrative persons|

|the NTP | | |

| | | |

| | | |

| | | |

| | | |

|- Operational researches on PPMDs | | |

|a) staff needed (numbers) | | |

|b) strategies to sustain interest of staff | | |

|(training, infection control, etc) | | |

|c) advocacy tools at their level to ensure | | |

|political support | | |

|d) sustaining PPMDs beyond a project’s lifespan | | |

6) Area: Strengthen Public-Public collaborations between public hospitals and health centers to increase access to, and improve efficiency of, and improve efficiency of DOTS services

|POTENTIAL AREAS/TOPICS |AVAILABLE DOCUMENTS/ |RATIONALE/COMMENTS |

| |REFERENCES | |

|- How to establish and effectively operate a |- program reviews |- might be more practical for certain areas |

|hospital-based DOTS facility? |- PPMD manual |- some areas might be willing but just do not |

| | |know how to get started |

| | |- replicate successful models |

| | |- Make this a requirement for licensing of all |

| | |hosp by beaureu of health facility to ensure |

| | |compliance of all Government/DOH accredited |

| | |hospitals |

| | | |

| | | |

| | |- have to look at various aspects for |

| | |DOTS/networking to be effective |

| | |- looking at other functions aside from service |

|- Business Model Development/market segmentation | |delivery like governance |

| | |- how to effectively reach various “population” |

| | |in the market- not just the poor; private sector|

| | |involvement |

| | |- we may need to evaluate what models might be |

| | |effective for specific areas given their |

| | |peculiarities |

7) Area: Support the existing DOTS (+) initiatives and institutionalize these in the public sector

|POTENTIAL AREAS/TOPICS |AVAILABLE DOCUMENTS/ |RATIONALE/COMMENTS |

| |REFERENCES | |

|- Potential Use/Feasibility of Newer Diagnostic |- data gathered from labs all over the |- current available tests may require |

|Tests (eg genetic testing, line probe assay, etc) |country |significant amount of time for the results |

|in the Local Setting |- surveillance of TB culture & sensitivity|- newer tests may be currently expensive but may|

|- Improving EQA of TB culture through the use of |(Drug Resistance Surveillance) |have potential in the local setting |

|line probe assay |- documents/MOA as regards to the | |

| |operation of PTSI Tayuman clinic, KASAKA, | |

| |and QI MDR ward | |

| | | |

| | |- will be good in replicating the scenario from |

|- KAP studies focusing on healthworkers’ knowledge| |these establishments to other centers but we’ll |

|on handling MDR-TB patients | |need the experiences of the providers like the |

|- Infection Control Strategies esp in centers | |nurses |

|handling MDR TB | |- transfer of technology might be facilitated if|

| | |this data available |

|- MDR TB treatment outcomes of patients treated at| |- centers outside Metro Manila (like PTSI |

|halfway houses vs those exclusively treated at the| |branches in Cebu & Iloilo) will benefit from |

|community | |these documented experiences (lessons learned) |

| | | |

| | |-To minimize morbidity and mortality |

| | | |

|Predictors of risk for MDRTB related deaths in | | |

|PMDT (profiling patients) | |- To increase the success rate and minimize |

| | |potential source of further |

|Identifying risk factors for drop out among MDRTB | |dissemination/infecting others |

|in patients enrolled in a PMDT/ Ways and means in | | |

|improving retention in PMDT | | |

| | |-How to make to make them committed |

| | |-It is very expensive to have a PMDT unit in |

|Involvement of treatment partners/private sector | |terms of |

|in terms of possible provision of DOT (in the | |-meds |

|continuation phase of the treatment)/monitoring, | |-staff/salary (social worker ,psychiatrist, |

|or by helping thru diagnostics | |nurse, doctors) |

| | |- logistics |

| | |-diagnostics and microbiological test |

| | |-admission expenses |

| | |-half way houses |

| | | |

| | |- potential funders may be interested in this |

| | |type of data esp organizations with available |

| | |infrastructures already |

|- Operational researches looking at sustainability| | |

|of centers engaged in PMDT (esp cost benefits) | | |

| | | |

8) Area: Strengthen the integration of TB and HIV in accordance to the country’s disease scenario

|POTENTIAL AREAS/TOPICS |AVAILABLE DOCUMENTS/ |RATIONALE/COMMENTS |

| |REFERENCES | |

|- TB in HIV patients (burden; role of prophylaxis,|- possible data from DOH, other hospitals |- no local data that consolidates information |

|etc) |like San Lazaro, RITM |- burden, resistance, outcome |

| |-provider related counselling and testing | |

| | | |

| | |-HIV detection are not routinely performed in |

|-Statistics of HIV among newly diagnosed MDRTB | |MDRTB patients, it is only done for high risk |

| | |patients |

| | | |

|- Referral systems | |-feasibility of screening for HIV in DOTS center|

| | |and referrals |

| | | |

|-Infection control practices in these | | |

|centers/health facilities | | |

Other Potential Areas/Topics for Research:

|POTENTIAL AREAS/TOPICS |RATIONALE/COMMENTS |

|- How can specialists effectively manage MDR TB patients? |- current recommendation is to refer these to specialized centers but this |

| |option may not be always feasible (patient’s location, limited number of |

| |these centers, logistics involved) |

|- Infection Control Practices in various levels (RHU, hospitals, | |

|medical centers, etc) |- basics of infection control might be overlooked with all the current |

| |efforts for expansion |

| |- interventions may be engineering or architectural in nature and training |

|- Latent TB in the General Population |of staff may be extremely crucial |

| |- no data if we need intervention in the local setting, ? burden |

| |- value of prophylaxis? Cost-effective? |

| |- value of prioritizing certain groups (diabetics, health workers) |

| | |

|- Value of TBDCs for Smear Negative Cases; Validity of TBDC |- in view of certain recommendations to request for TB culture if facilities|

|Decisions (treatment outcome) |exist |

| | |

|- Sustainability of TBDCs | |

| |- cost-effectiveness of TBDCs |

| | |

|- How do we operationalize CUP? |-feasibility for having IRRs for the various agencies involved. How to |

| |monitor these? |

| |- How to ensure compliance? |

|- Analysis of the impact of TB-related projects years after their| |

|implementation |- analyze previous projects esp those with significant funding to analyze |

| |sustainability of gains; look at trends of TB statistics esp in areas of |

|- Addressing the Stigma of TB |implementation |

| |-most effective strategy in de-stigmatizing the disease for the patient, |

| |community, care providers |

| |- should look into interventions that will provide “consistent” effect |

| | |

|-What are the facilitating and inhibiting factors that affect | |

|FAITH BASED DOTS engagement in NTP. |-Documentation of FAITH BASED DOTS initiatives were not properly documented |

| |as case studies.  |

| | |

|-What enablers should be retained to ensure compliance of  MDR TB| |

|cases under medication and how to sustain it after the project |-to ensure sustainability of the program |

|end.  Where are the potential sources of enablers to be tapped by| |

|the different treatment centers. | |

| | |

| | |

| | |

|- Role of CXR in sputum negative new cases |- Speed up treatment of sputum negative virgin cases on the bases of |

| |clinical history and chest x-ray (What we do during TBDC) |

|-Co-morbidities and PTB Outcomes (DM, smokers, alcoholics) |-Their sputum conversion may be late if their co-morbidities not managed |

| |adequately; prone to relapse |

FOR MORE INFORMATION OR QUESTIONS, PLEASE CONTACT:

PHILIPPINE COLLEGE OF CHEST PHYSICIANS

Advancing the Frontiers of Pulmonary Medicine in the Philippines.

← 84-A Malakas St., Pinyahan, Quezon City 1100

( (632) 924-9204; ( Fax No. (632) 924-0144

( Text Link No. 0920-9605979

← E-mail address: pccp@.ph

← Website address:

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