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

Company - C,L,Company - C,L,– Santen, Inc. - C,Santen, Inc. - C,

Financial DisclosureFinancial Disclosure

PROMOTING AND PROMOTING AND IMPLEMENTING CLINICAL IMPLEMENTING CLINICAL PRACTICE GUIDELINES IN PRACTICE GUIDELINES IN DEVELOPING COUNTRIES:DEVELOPING COUNTRIES:

THE CHINA EXPERIENCETHE CHINA EXPERIENCE

ACADEMIA OPHTHALMOLOGICA INTERNATIONALISINAUGURAL LECTURE

OCTOBER 24, 2009SAN FRANCISCO

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

UNIVERSITY OF CALIFORNIA SAN FRANCISCOUNIVERSITY OF CALIFORNIA SAN FRANCISCO

SENIOR ADVISOR FOR INTERNATIONAL EDUCATIONAMERICAN ACADEMY OF OPHTHALMOLOGY

CHAIRMAN CLINICAL GUIDELINES COMMITTEE

INTERNATIONAL COUNCIL OF OPHTHALMOLOGY

DOES ONE SIZE FIT DOES ONE SIZE FIT ALL?ALL?

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

OTHER COUNTRIES?OTHER COUNTRIES?

CLINICAL PRACTICE CLINICAL PRACTICE GUIDELINES GUIDELINES

PROJECT IN CHINAPROJECT IN CHINA

COLLABORATIVE EFFORT COLLABORATIVE EFFORT BETWEEN:BETWEEN:

CO

S

CLINICAL PRACTICE CLINICAL PRACTICE GUIDELINES PROJECT IN GUIDELINES PROJECT IN

CHINACHINADEVELOPMENT PHASE

(2004-2006)(2004-2006)

CLINICAL PRACTICE CLINICAL PRACTICE GUIDELINES PROJECT IN GUIDELINES PROJECT IN

CHINACHINA

DevelopmentDevelopment PromotionPromotion

– AwarenessAwareness– AgreementAgreement– AdoptionAdoption– ComplianceCompliance

FOUR STEPS

PROMOTION OF CLINICAL PROMOTION OF CLINICAL PRACTICE GUIDELINES IN PRACTICE GUIDELINES IN

CHINACHINA

BEIJING 2006

AWARENESSAWARENESS

Must know that Must know that they existthey exist

Must be familiar Must be familiar with conceptwith concept

Must have Must have educational educational programsprograms

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

PROCESS FOR PROCESS FOR IMPLEMENTATIONIMPLEMENTATION

Work through governmental, Work through governmental, national and local societiesnational and local societies

Create a “steering committee” of Create a “steering committee” of interested and influential leadersinterested and influential leaders

THANK YOU! 谢谢 !more

KEY PRINCIPLESKEY PRINCIPLES

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

NEED FUNDING TO SUPPORT WORKNEED FUNDING TO SUPPORT WORK

STRUCTURE OR ROAD MAP ON STEPS STRUCTURE OR ROAD MAP ON STEPS REQUIRED TO SUCCEEDREQUIRED TO SUCCEED

INCENTIVES TO FOLLOW GUIDELINESINCENTIVES TO FOLLOW GUIDELINES

HOW ARE GUIDELINES BEST HOW ARE GUIDELINES BEST INCORPORATED INTO CLINICAL INCORPORATED INTO CLINICAL

PRACTICE?PRACTICE?

Create awareness through:Create awareness through:– Wide disseminationWide dissemination– Education process Education process

(meetings, journals, (meetings, journals, internet)internet)

– 1414thth COS Congress in COS Congress in Chongqing had entire day of Chongqing had entire day of seminarsseminars

Physician Physician compliancecompliance with guideline use with guideline use

is significant challengeis significant challenge

COMPLIANCECOMPLIANCE

Ease of incorporation into Ease of incorporation into practicepractice

Minimal change required by Minimal change required by physicianphysician

Minimal cost Minimal cost

Little time constraintsLittle time constraints

COMPLIANCECOMPLIANCE

Need Incentives (or Penalties)Need Incentives (or Penalties)– BonusBonus– Lower costsLower costs– More patientsMore patients– RecognitionRecognition

– Lower re-imbursementLower re-imbursement– Loss of licensureLoss of licensure

GOVERNMENT GOVERNMENT SUPPORTSUPPORT

MINISTRY OF HEALTH MINISTRY OF HEALTH RECOGNITION (RECOGNITION (April, 2009April, 2009)!)!

STUDIES IN CHINA TO EXAMINE STUDIES IN CHINA TO EXAMINE AWARENESS OF PPPs AND AWARENESS OF PPPs AND

BARRIERS TO USE BARRIERS TO USE (COMPLIANCE)(COMPLIANCE)

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

TONGREN HOSPITAL – BEIJINGTONGREN HOSPITAL – BEIJING– Professor Wang NingliProfessor Wang Ningli

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美国眼科临床指南的适用性研美国眼科临床指南的适用性研究究

Assessment of Ophthalmological Care Assessment of Ophthalmological Care Before and After the Introduction of Before and After the Introduction of

Clinical Practice Guidelines in 3Clinical Practice Guidelines in 3rdrd level level Hospitals in BeijingHospitals in Beijing

—— —— 青光眼部分青光眼部分 ((Glaucoma sectionGlaucoma section))

北京同仁眼科中心北京同仁眼科中心Beijing Tongren Eye CenterBeijing Tongren Eye Center

王宁利王宁利Ningli WangNingli Wang

Question 1:Question 1:

Why do we have to implement Why do we have to implement CLINICAL PRACTICE GUIDELINES CLINICAL PRACTICE GUIDELINES

in China?in China?

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Answer:

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

Tongren survey result:Tongren survey result:

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

But few doctors completely But few doctors completely follow recommendations in follow recommendations in their clinical worktheir clinical work..

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TONGREN HOSPITAL TONGREN HOSPITAL SURVEY RESULTSSURVEY RESULTS

GLAUCOMA GLAUCOMA (TONGREN VS PROVINCIAL HOSPITAL(TONGREN VS PROVINCIAL HOSPITAL))

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

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

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

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

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Question 2:Question 2:

Why have Clinical Guidelines Why have Clinical Guidelines not been implemented in not been implemented in

China?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 EXAMPLE OF CLINICAL GUIDELINE FOR ANGLE CLOSURE GLAUCOMAFOR ANGLE CLOSURE GLAUCOMA

GonioscopyGonioscopy [A: ]Ⅲ[A: ]Ⅲ

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

Visual fieldVisual field evaluationevaluation [A: ]Ⅲ [A: ]Ⅲ

topical medicationstopical medications constitute effective initial constitute effective initial therapytherapy [A: ]Ⅲ [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 3Question 3::

How do we implement clinical guidelines in China?How do we implement clinical guidelines in China?

Require Administrative intervention?Require Administrative intervention?

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Answer:Answer:

Its not easy!Its not easy!

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

Doctors’ work load would be increasedDoctors’ work load would be increased

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Question 4:Question 4:

What can we do now?What can we do now?

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Answer:Answer:

Set up a simple, convenient and Set up a simple, convenient and efficient diagnosis & management efficient diagnosis & management

system that can integrate with system that can integrate with clinical guidelinesclinical guidelines

Modify current medical record Modify current medical record format according to PPPformat 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 FAILURE TO IMPLEMENT GUIDELINESGUIDELINES

NOT CREDIBLE TO PRACTITIONERNOT CREDIBLE TO PRACTITIONER

TOO COMPLEXTOO COMPLEX

REQUIRES RESOURCES THAT ARE NOT REQUIRES RESOURCES THAT ARE NOT READILY AVAILABLEREADILY AVAILABLE

RADICALLY DIFFERENT FROM PREVAILING RADICALLY DIFFERENT FROM PREVAILING TREATMENT NORMTREATMENT NORM

THANK YOU!!THANK YOU!!