Clinical practice guidelines in ChinaBMJ 2018; 360 doi: https://doi.org/10.1136/bmj.j5158 (Published 05 February 2018) Cite this as: BMJ 2018;360:j5158
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We read with disappointment the analysis of Yaolong Chen and colleagues about the status of the clinical practice guidelines in China (1) as an oversimplification of the reality of general practitioners and primary care. Since the New Medical Reform in 2009, the Chinese government has focused on improving primary health care services by increasing access for the Chinese population with a goal of 2 to 3 general practitioners per 10, 000 people or 300,000 by 2020, and to 5 general practitioners per 10,000 people or 700,000 by 2030 (2). We opine the current challenge for China is not only the shortage of general practitioners, but also the lack of an evidence base to construct practice guidelines to provide standardized primary care services appropriate for general practitioners.
We retrieved the published clinical practice guidelines for general practitioners in China. There are only four clinical practice guidelines, and seven expert consensus position papers or proposals. The four guidelines cover prevention and treatment of hypertension, diabetes, bronchial asthma, and obstructive sleep apnea hypopnea syndrome. The first guideline for general practice on management of hypertension was published in 2009. It was updated in 2014 and 2017, while the remaining three guidelines were published from 2013 to 2015 and have not since been updated.
There are four key problems with general practitioners using guidelines in China. First, the content of the guidelines is only partially aligned with the realities of primary health care. Most of the guidelines are shorter versions of guidelines developed primarily with specialists in mind and do not consider feasibility of implementation by general practitioners in clinical practice. For example, both the diabetes and obstructive sleep apnea hypopnea syndrome guidelines refer to surgical treatment of obesity, options best considered after specialist consultation. Second, most of the guidelines have been poorly publicized and promoted, rendering it difficult for general practitioners to reference them. For example, before 2017, the four available guidelines were published exclusively in Chinese journals of clinical sub-specialties rendering them virtually inaccessible by general practitioners, and especially rural doctors. In 2017, the latest version of the guideline for prevention and treatment of primary hypertension was issued as a national guideline and promoted as the general practitioner standard before even being accepted by the China General Practice Association (3). Third, the guidelines in China predominantly are based on research conducted by sub-specialists in specialty care settings and wrought with limitations of selection bias. Fourth, some of the existing guidelines are written more like reviews than operating manuals as they do not mention problems that general practitioners may encounter or evidence-based solutions, e.g., appropriate criteria for referral, etc. These shortcomings make it difficult for general practitioners to establish the diagnosis and treat patients according to the guidelines. Fifth, it is well known that focus on the whole patient rather than a single disease is a key characteristic of general practice, and a single disease focus does not reflect the decision making challenges required to function in primary care.
There are four critical solutions needed. First, meaningful participation of general practitioners in the clinical practice guideline development process in China is prerequisite. Current guidelines invariably are led and written by sub-specialists, with only limited participation by general practice specialists. On guideline committees when general practice specialists do participate, both their status and their numbers pale in comparison to other sub-specialists on the panel. Second is a related problem, the need to recognize general practitioners as specialists with expertise in common problems, the complex management of multiple morbidities, and the full spectrum of primary to quaternary prevention. Third is the imperative fund and conduct research on common problems in general practice in China. Fourth is the profound need to expand the number of general practitioners in advanced degree research programs to conduct the required research.
As modern general practice in China has just emerged in the past decade, the corpus of scientific research that matters in primary care remains diminishingly small. Hence, general practitioners have difficulty offering better suggestions and alternatives for inclusion in guidelines due to the lack of evidence. The current frenzy for general practice educators to rapidly expand training capacity and produce as many general practitioners as possible is imperative to meet the primary health care needs, but this focus is overshadowing the need for improvement of primary care services. Evidence-based research, training of primary care researchers and research funding to support health services and mixed methods research that will address the complexity of primary care require attention as much as aggressive policies to increase the number of general practitioners. Greater parity in training and clinical research funding is needed to guarantee not just the quantity, but also the quality of primary health care services.
1. Chen Y, Wang C, Shang H, et al. Clinical practice guidelines in China. BMJ 2018; 360:j5158 doi: 10.1136/bmj.j5158
2. The State Council. The People’s Republic of China. China to train more general practitioners. 2018. http://english.gov.cn/policies/latest_releases/2018/01/24/content_281476...
3. CNR News. Publication of national guidelines for the management of hypertension in primary care (2017). 2017. http://health.cnr.cn/jkgdxw/20171110/t20171110_524020592.shtml
Competing interests: No competing interests
Many countries, including China and Russia, try to do their best in developing the health care system by developing national clinical practice guidelines (CPG) through adapting the best Western CPG. This article is a commendable effort.
One of the problems, not mentioned in the article, is that specialists are not eager to adapt the International/European CPGs but just to translate them. They want to say proudly that they are working using the best CPGs. And this behavior is in conflict with the resources of the system.
Another problem, visible here, is that the worries of the Western world are superimposed onto the national health/care system despite available evidence. Eg. in this article the CPG for obesity is described as modified by lowering the threshold for intervention. The reason: the surrogate outcome demonstrates that the "the risks of hypertension, type 2 diabetes, and dyslipidaemia increase dramatically with a BMI >24". But mortality - the important outcome - is not increased so much in Asian populations (DOI: 10.1056/NEJMoa1010679), at least below BMI 27. The obesity CPG of Western origin may be modified for China in the opposite direction.
This is an example also of a missed opportunity to reduce the burden of medical interventions in an underfunded system.
Competing interests: No competing interests