iDSI colleagues travelled to Beijing to take part in a dissemination event for the “Clinical Pathways Phase 2” project. The event was part of a long-standing collaboration with the China National Health Development Research Center (CNHDRC).
The purpose of the project was to introduce clinical pathways for chronic obstructive pulmonary disease (COPD) and stroke. The pathways cover prevention, treatment and rehabilitation guidance for clinicians at different levels of healthcare delivery.
Domestic and international experts discussed the early findings from the project and their relevance to other areas of clinical practice and policy. These findings are available in a report by the CNHDRC which describes the design and progress of the project. Full appendices for the report are also available here: (1), (2), (3), (4), (5).
The clinical pathways
The clinical pathways were developed with Chinese and international clinical input and were part of a varied intervention including:
- multi-stakeholder engagement,
- changes to IT infrastructure and
- performance management strategy within the pilot hospitals and capacity building activities.
The most recent phase of the pathway (2012 onwards), supported efforts to improve the integration of care across multiple levels of the rural health system in China. It emphasised pathways for non-communicable disease (stroke and COPD).
The intervention was designed to address concerns that inappropriate behaviour by providers, such as overuse of antibiotics and intravenous delivery of medication against clinical evidence, has fuelled cost growth and affected quality of care and patient safety.
The misuse of resources may in part be due to an absence of practical clinical guidelines and effective monitoring mechanisms for use of medicine and medical devices. This is especially concerning for non-communicable diseases (NCDs), which account for an estimated 87% of annual deaths and 69% of the total disease burden in China. NCDs are expected to account for an increasing share of health expenditure.
The project launched in four pilot counties in November 2013. By May 2015, 5,490 patients had been managed by the clinical pathways. This figure represents 90% of those who entered the pathways (some had to leave the pathways, for example after developing unusual complications) and 54% of all eligible inpatients.
860 COPD patients also received free pneumococcal vaccines, experiencing reductions in acute exacerbations of their COPD and stays in hospital.
The project also built capacity for rehabilitation services, with each pilot site establishing locally-developed, integrated rehabilitation networks.
A year after the launch of the project, analysis of routine clinical data in the pilot sites suggests that:
- The intervention is associated with greater use of those services recommended in the clinical pathway.
- Services with the most significant increase in usage were statins and brain imaging (within 24 hours of hospitalisation) for stroke treatment.
- There was a reduction in the growth of resource use, and reduced average lengths of inpatient stay, in the four pilot sites.
- The proportion of out-of-pocket (OOP) expenses also decreased.
The findings of this early analysis are discussed in more detail in the full report.
A ‘revolutionary’ impact
The most striking outcome of this project is the increased willingness among clinicians and policymakers to use evidence. This has led to broader changes in how clinical care is delivered, which was highlighted in a report by Itad on our engagement in China
At the management level, Huangdao People’s Hospital described the training they had received as ‘revolutionary’, stating that it changed the way they think about treatment.
According to one senior interviewee, clinicians who had previously based treatment on their own experience were now basing treatment on evidence.
Stakeholders also indicated that the implementation of clinical pathways is changing doctor-patient relations. Clinical staff reported improvements in communication with patients and patients’ understanding of their care. This had increased transparency and patient adherence to treatment.
Representatives from Qianjiang also noted the great value of the project in building managerial capacity and teaching healthcare providers to establish mechanisms for collaboration and referral across different tiers of the health system.
A separate report from Itad highlights the impact of the pathways:
|Policy influence||Other forms of influence|
|1. National policy influence: As clearly stated by Liang Wannian, this pilot is providing a model for development of national policy and will be replicated in 1,000 counties and 100 cities nationwide. This is a very substantial achievement.||1. The impact of the project as a whole has been greater than the impact of the pilots: the project has had a large impact in changing ideas and attitudes at central/policy levels.
This impact is probably greater, and of greater importance, than specific pilot experience. CNHDRC have been very good at leveraging this and getting central people involved in meetings [and] discussions of the pilots. They also have a direct policy channel to the centre.
|2. Sub-national policy influence:
The pilot is developing substantial policy traction, in both Chongqing/Qianjiang and Qingdao/Huangdao. This is a substantial achievement.
Saying this, it will be important to see how other counties implement this model, and how technical support is managed to ensure that implementation is of evidence-based clinical pathways, and does not become codification of non-evidence based practices.
|2. NICE are creating a reputation
for the UK in healthcare management; the attention of policy-makers is now
focussed on the UK and Canada, in that order. This is believed to be of greater
importance than the pilots and shows an overall change in leadership thinking.
|3. CNHDRC, in particular the team under Zhao Kun, are getting more attention domestically and are in great demand.|
Areas for future work
At the event in Beijing, Chinese physicians commented on how development of the pathways involved joint learning, with contributions from national and international experts valued. Areas for future improvement were also discussed, including how to further discourage non-evidence-based interventions often demanded by patients and improving national data coordination and analysis.
International representatives at the event were struck by the technical and political achievements and buy-in achieved by the project across all pilot sites. Local implementers and policy-makers also emphasized the change in attitudes and greater understanding of the principles of evidence-based medicine. This is improving as clinical pathway reforms are rolled out in each district for up to 60 additional conditions.
The CNHDRC-NICE model of integrated care pathway development was specifically recommended by NHFPC to be scaled up as part of these reforms.
To help secure cost control and financial protection for patients it will be important to maintain a focus on payment reform. This will require a move away from the dominant ‘fee-for-service’ model, towards further case payments implemented as part of this project.
CNHDRC has the local demand and ability to become a hub for health technology assessment and evidence-informed priority-setting within the decentralised Chinese health system, and to support countries in the region as part of China’s developmental technical assistance.
The dissemination event (translated page) included representatives from the:
- National Health and Family Planning Commission (NHFPC)
- UK Foreign and Commonwealth Office
- Ministry of Human Resources and Social Security
- National Development and Reform Commission
- Ministry of Commerce
- Ministry of Finance
- Municipalities and healthcare institutions involved in the pilots
- and the International Decision Support Initiative (iDSI)