financial disclosure

I have the following financial interests or relationships to disclose:– OMIC-Ophthalmic Mutual Insurance

Company - C,L,– Santen, Inc. - C,

Financial Disclosure

PROMOTING AND IMPLEMENTING CLINICAL PRACTICE GUIDELINES IN DEVELOPING COUNTRIES:

THE CHINA EXPERIENCE

ACADEMIA OPHTHALMOLOGICA INTERNATIONALISINAUGURAL LECTURE

OCTOBER 24, 2009SAN FRANCISCO

RICHARD L. ABBOTT, M.DTHOMAS W. BOYDEN HEALTH SCIENCES PROFESSOR OF OPHTHALMOLOGY

UNIVERSITY OF CALIFORNIA SAN FRANCISCO

SENIOR ADVISOR FOR INTERNATIONAL EDUCATIONAMERICAN ACADEMY OF OPHTHALMOLOGY

CHAIRMAN CLINICAL GUIDELINES COMMITTEE

INTERNATIONAL COUNCIL OF OPHTHALMOLOGY

DOES ONE SIZE FIT ALL?

WHAT HAVE WE LEARNED FROM CHINA AND CAN IT BE APPLIED TO

OTHER COUNTRIES?

CLINICAL PRACTICE GUIDELINES

PROJECT IN CHINACOLLABORATIVE EFFORT

BETWEEN:

COS

CLINICAL PRACTICE GUIDELINES PROJECT IN

CHINADEVELOPMENT PHASE

(2004-2006)

CLINICAL PRACTICE GUIDELINES PROJECT IN

CHINA Development Promotion

– Awareness– Agreement– Adoption– Compliance

FOUR STEPS

PROMOTION OF CLINICAL PRACTICE GUIDELINES IN

CHINA

BEIJING 2006

AWARENESS

Must know that they exist

Must be familiar with concept

Must have educational programs

WHAT HAVE WE LEARNED FROM CHINA AND HOW CAN IT BE APPLIED TO OTHER COUNTRIES?

PROCESS FOR IMPLEMENTATION

Work through governmental, national and local societies

Create a “steering committee” of interested and influential leaders

THANK YOU! 谢谢 !more

KEY PRINCIPLES

LOCAL LEADERSHIP AND STRONG DESIRE TO IMPROVE QUALITY OF CARE (ZEALOT(S)!)

NEED FUNDING TO SUPPORT WORK

STRUCTURE OR ROAD MAP ON STEPS REQUIRED TO SUCCEED

INCENTIVES TO FOLLOW GUIDELINES

HOW ARE GUIDELINES BEST INCORPORATED INTO CLINICAL

PRACTICE? Create awareness through:

– Wide dissemination– Education process

(meetings, journals, internet)

– 14th COS Congress in Chongqing had entire day of seminars

Physician compliance with guideline use

is significant challenge

COMPLIANCE Ease of incorporation into

practice

Minimal change required by physician

Minimal cost

Little time constraints

COMPLIANCE

Need Incentives (or Penalties)– Bonus– Lower costs– More patients– Recognition

– Lower re-imbursement– Loss of licensure

GOVERNMENT SUPPORT

MINISTRY OF HEALTH RECOGNITION (April, 2009)!

STUDIES IN CHINA TO EXAMINE AWARENESS OF PPPs AND

BARRIERS TO USE (COMPLIANCE)

EYE CENTER OF PEOPLES HOSPITAL-PEKING UNIVERSITY– Professor Li Xiaoxin

TONGREN HOSPITAL – BEIJING– Professor Wang Ningli

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美国眼科临床指南的适用性研究 Assessment of Ophthalmological Care Before and

After the Introduction of Clinical Practice Guidelines in 3rd level Hospitals in Beijing ——青光眼部分 (Glaucoma section)北京同仁眼科中心

Beijing Tongren Eye Center王宁利Ningli Wang

Question 1:

Why do we have to implement CLINICAL PRACTICE GUIDELINES

in China?

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Answer:

Lack of consistent quality and evidence based diagnosis and treatment in China.

Tongren survey result:

Most of the doctors in 3rd level hospital know about clinical guideline content.

But few doctors completely follow recommendations in their clinical work.

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TONGREN HOSPITAL SURVEY RESULTS

GLAUCOMA (TONGREN VS PROVINCIAL HOSPITAL)

– ONH EVALUATION FOR GLAUCOMA PT? TONGREN: 100% PROVINCIAL: 35%

– INQUIRE ABOUT SYSTEMIC MECICAL HX? TONGREN:98% PROVINCIAL: 77%

– TARGET PRESSURE FOR EACH PT? TONGREN: 52% PROVINCIAL: 6%

– RECORD TIME OF IOP MEASURMENT? TONGREN: 44% PROVINCIAL: 14%

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Question 2:

Why have Clinical Guidelines not been implemented in

China?

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Answer:

Current practice pattern of diagnosis & management in China difficult to meet

requirements of clinical guideline

EXAMPLE OF CLINICAL GUIDELINE FOR ANGLE CLOSURE GLAUCOMA

Gonioscopy [A: ]Ⅲ

Documentation of the optic disc morphology, best performed by color stereophotography or computer based image analysis [A: ]Ⅱ

Visual field evaluation [A: ]Ⅲ

topical medications constitute effective initial therapy [A: ]Ⅲ

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Gonioscopy • lens often not available• time-consuming• no re-imbursement

optic disc morphology• no computer based image analysis center• time-consuming • no re-imbursement

Visual field • lack of equipment• waiting period too long• many patients lost to follow-up

topical medications• no or limited education for patients• poor compliance

Example:

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Question 3:

How do we implement clinical guidelines in China?

Require Administrative intervention?

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Answer: Its not easy!

High volume of patients would require more to be done for each

patient!

Doctors’ work load would be increased

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Question 4:

What can we do now?

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Answer:

Set up a simple, convenient and efficient diagnosis &

management system that can integrate with clinical

guidelines

Modify current medical record format according to PPP

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EX: Gonioscopy Descriptive

Static:

OD OS

Pigment trabecular 0: No-see. ( Label in quadrant area.) 1: see

Dynamic: Delineate PAS extent and degree by line.

OD│_│ 个钟点 OD│_│ 个钟点

FAILURE TO IMPLEMENT GUIDELINES

NOT CREDIBLE TO PRACTITIONER

TOO COMPLEX

REQUIRES RESOURCES THAT ARE NOT READILY AVAILABLE

RADICALLY DIFFERENT FROM PREVAILING TREATMENT NORM

THANK YOU!!THANK YOU!!