This national survey demonstrated that CM doctors have a positive attitude towards the national CPGs for CM. In addition, only half of the participants adhered to the CPG recommendations. However, most doctors thought the current CPGs were “very useful” or “useful” for improving the safety, efficacy and cost-effectiveness of their patients’ treatments.
Strengths
In China, to the best of our knowledge, this study is the first to explore the perceptions, beliefs and attitudes of CM clinicians. China Health Statistics (2012) indicated that there were approximate 26.7 hundred thousand registered CM doctors in China [
18]. The 4495 CM doctors surveyed in this study accounted for 1.7% of the whole CM doctor population in China. In addition, this survey covered China’s 28 provinces (excluding Inner Mongolia, Qinghai, the Tibetan autonomous region, Hong Kong and Macao Special Administrative Regions, and Taiwan).
In general, CM doctors in our study were familiar with CPGs. It is important to note that the positive attitude towards CPGs found in our sample of CM doctors may be related to the fact that all CM doctors were affiliated with CPG dissemination project hospitals. Certainly, this could be interpreted as a bias, since it can result in strong positive attitudes among the target group. While recognizing the potential benefits of practice guidelines, the overall adherence rate (50.39%) reported by CM doctors was much lower than their familiarity (85.56%) with the guideline recommendations. We further uncovered that the rates of adherence with the recommendations varied depending on clinical experience. For doctors with less than 5 years of qualification, the rate of CPG adherence was only 48.10%. An educational opportunity exists to encourage young doctors to follow CPGs and improve the quality of care. Many factors may influence the effective implementation of CPGs in practice. Barriers to guideline adherence can be related to the individual patient, the organizational context, and the social and cultural context of the healthcare system [
19]. Although these guidelines are widely available, clinical diagnoses and treatments in CM are less consistent; specifically, the strong clinical evidence and the standards are poorer, which can have a negative impact on the adherence of doctors to these recommendations. A qualitative analysis of the open questions included in our survey lead to a common suggestion: that CM recommendations may be further classified at the system and individual level. This conforms to the fundamental concepts of CM. Obviously, an adequate analysis of the barriers that prevent CM doctors from following CPGs in practice need to be demonstrated by further studies to improve guideline adherence.
To our surprise, after assessing 28,578 medical records, there was almost no difference in terms of general coincidence between traditional Chinese diagnosis (94.38%) and Western medicine diagnosis (92.56%). This lack of difference may be related to the fact that in recent decades, CM doctors in China received both CM and Western medicine training as well as continuous medical education. Moreover, from the points of view of 4495 CM doctors, the contents of the core elements of CM practice were optimal, and they agreed with the content of the common guidelines related to syndrome differentiation (81.96%), CM therapeutic principles & methods of treatment (88.34%), and herbal formulations (86.1%); correspondingly, the coincidences were 86.32%, 86.36% and 86.1%, respectively, when analyzing the patients’ records. Based on these results, we have reason to believe that there are no irreconcilable differences between the general CPGs for CM and the personal practices of CM doctors, when each is held in its proper place.
Our study also showed that the degree of familiarity and incorporation of CPGs in CM practice differed by specialty. Pediatricians were more aware of the national guidelines for CM treatments (85.06%) than doctors practicing other specialties, and they reported a higher rate of incorporation of these guidelines into their practice (62.76%) and higher levels of effectiveness (95.16%) and safety (95.85%) after incorporating these guidelines. In contrast, oncology specialists scored relatively lower than other doctors in terms of syndrome differentiation (79.51%), CM therapeutic principles & methods of treatment (78.57%) and herbal formulations (70.61%). These differences are due to variations in the internal characteristics of these specialties [
20]. Furthermore, the existence of different conditions with different prognoses could be another reason explaining the different views of pediatricians and oncologists on CPGs. Due to these contrasts, it is essential to have these differences in mind for the future development of CPGs.
Information gathered from the survey shows there is a need to harmonize CM health care approaches in the CPGs. A striking finding in our study was the low level of recognition (70.75%) that recommendations on CM health care approaches would benefit patients, showing the lowest adherence rate (67.49%) based on the patients’ records. In CM, traditional healthcare to promote health, prevent disease and enhance longevity is also called health preservation/cultivation [
21]. This diversified approach has become a feature of CM health care; consequently, the low adherence rate can be recognized.
Limitations
Our study has some potential limitations. As with most surveys, the main weakness of this study is the generalizability and reliability of CM doctors’ responses. These may be affected by various parameters. First, this is a self-reported survey. Although the questionnaire was anonymous, respondents may be tempted to idealize their practice. The second questionnaire asking the CM doctor to rate other doctors’ medical records in terms of compliance with CPG, may lead to social desirability bias. Second, the high response rate (99.82%) made it impossible to rule out selection bias and to know whether respondents differ from non-respondents. Third, due to the lack of other studies focusing on doctors’ attitudes towards CPGs for CM or TM, we cannot draw a parallel between this study and others. In general, a high response rate is likely to reduce bias; however, it is important not to overlook other types of bias which cannot be overcome with a high response rate. In this case, even a response rate of 99.82% would not guarantee that the results were free of bias because the data collection was confined to a network of hospitals selected as standardized CM treatment demonstration sites. Despite such limitations, a good number of responses were collected across 28 provinces in mainland China, and the findings are important and relevant even if they are not entirely generalizable.
Our previous study indicated that only approximately 60% of CM clinical studies used CPGs as their clinical assessment criteria [
22]. With the results of this survey, it seems that improved education of doctors, together with more time spent by doctors training on CPGs and improved financing for CM CPGs training programs, as well as clear and strong cultural and institutional changes in favor of evidence-based CM practice, would be the best way to improve adherence to CM CPGs.