Financial Disclosure

1. Financial Disclosure • I have the following financial interests or relationships to disclose: • OMIC-Ophthalmic Mutual Insurance Company - C,L, • Santen, Inc. - C,

2. PROMOTING AND IMPLEMENTING CLINICAL PRACTICE GUIDELINES IN DEVELOPING COUNTRIES:THE CHINA EXPERIENCE ACADEMIA OPHTHALMOLOGICA INTERNATIONALIS INAUGURAL LECTURE OCTOBER 24, 2009 SAN FRANCISCO

3. RICHARD L. ABBOTT, M.DTHOMAS W. BOYDEN HEALTH SCIENCES PROFESSOR OF OPHTHALMOLOGYUNIVERSITY OF CALIFORNIA SAN FRANCISCO SENIOR ADVISOR FOR INTERNATIONAL EDUCATION AMERICAN ACADEMY OF OPHTHALMOLOGY CHAIRMAN CLINICAL GUIDELINES COMMITTEE INTERNATIONAL COUNCIL OF OPHTHALMOLOGY

4. DOES ONE SIZE FIT ALL? WHAT HAVE WE LEARNED FROM CHINA AND CAN IT BE APPLIED TO OTHER COUNTRIES?

5. CLINICAL PRACTICE GUIDELINES PROJECT IN CHINA COLLABORATIVE EFFORT BETWEEN: COS

6. CLINICAL PRACTICE GUIDELINES PROJECT IN CHINA DEVELOPMENT PHASE (2004-2006)

7. CLINICAL PRACTICE GUIDELINES PROJECT IN CHINA • Development • Promotion • Awareness • Agreement • Adoption • Compliance FOUR STEPS

8. PROMOTION OF CLINICAL PRACTICE GUIDELINES IN CHINA BEIJING 2006

9. AWARENESS • Must know that they exist • Must be familiar with concept • Must have educational programs

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

11. PROCESS FOR IMPLEMENTATION • Work through governmental, national and local societies • Create a “steering committee” of interested and influential leaders

12. THANK YOU! 谢谢! more

13. 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

14. 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

15. Physician compliancewith guideline use is significant challenge

16. COMPLIANCE • Ease of incorporation into practice • Minimal change required by physician • Minimal cost • Little time constraints

17. COMPLIANCE • Need Incentives (or Penalties) • Bonus • Lower costs • More patients • Recognition • Lower re-imbursement • Loss of licensure

18. GOVERNMENT SUPPORT MINISTRY OF HEALTH RECOGNITION (April, 2009)!

19. 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

20. 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 20

21. Question 1: Why do we have to implement CLINICAL PRACTICE GUIDELINES in China? 21

22. Answer: Lack of consistent quality and evidence based diagnosis and treatment in China. 22

23. 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. 23

24. 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%

25. Question 2: Why have Clinical Guidelines not been implemented in China? 25

26. Answer: Current practice pattern of diagnosis & management in China difficult to meet requirements of clinical guideline 26

27. 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 fieldevaluation [A:Ⅲ] topical medicationsconstitute effective initial therapy [A:Ⅲ] 27

28. Example: • 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 28

29. Question 3: How do we implement clinical guidelines in China? Require Administrative intervention? 29

30. Answer: Its not easy! High volume of patients would require more to be done for each patient! Doctors’ work load would be increased 30

31. Question 4: What can we do now? 31

32. Answer: Set up a simple, convenient and efficient diagnosis & management system that can integrate with clinical guidelines 32

33. 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 Modify current medical record format according to PPP 33

34. FAILURE TO IMPLEMENT GUIDELINES • NOT CREDIBLE TO PRACTITIONER • TOO COMPLEX • REQUIRES RESOURCES THAT ARE NOT READILY AVAILABLE • RADICALLY DIFFERENT FROM PREVAILING TREATMENT NORM

35. THANK YOU!! THANK YOU!!