Traditional Chinese Medicine in Hong Kong: Utilization Patterns and its Role in the Future Healthcare System

The RGC Public Policy Research Funding Scheme (Round 2)Principal Investigator: Prof. Sian GriffithsDirector, School of Public Health and Primary Care Faculty of MedicineThe Chinese University of Hong KongPostgraduate student trained: Vincent Chung BCM BSc PhD, Registered Chinese Medicine Practitioner

Developing Traditional, Complementary and Alternative Medicine (TCAM) International Perspective from the World Health Organization (WHO): Two major milestones:

The WHO Traditional Medicine Strategy 2002-5The WHO Congress of Traditional Medicine 2008

WHO and TCAM Development (1) The WHO Traditional Medicine Strategy 2002-5 specified the goals of 1) increasing governmental support for TCAM amongst member states; 2) promoting the integration of TCAM into member states national healthcare systems

In a WHO survey published in 2005: 51 out of 96 responding member states were planning a national policy for TM/CAM, while the remaining states have already formulated policies

The Beijing Declaration for Developing TCAM, 20081. formulate national policies, regulations and standards ensure appropriate, safe and effective use of traditional medicine2. integrating traditional medicine into their national health system4. communication between conventional and traditional medicine providers should be strengthened3. establish systems for the qualification, accreditation or licensing of traditional medicine practitioners.policy context, professional attitudes and training, patients choice, and financing of access and service development.

Health Services Research Framework for Analyzing the Development of TCAM: Policy, Profession, Patient and Price (4P)

Health Services Research Framework for Analyzing the Development of TM/CAM: Policy, Profession, Patient and Price (4P) TM/CAM - traditional medicine/complimentary and alternative medicine

Traditional Chinese Medicine (TCM) in Hong Kong: Policy Development since 1997Basic Law of Hong Kong SAR, Article 138

The Government of the Hong Kong Special Administrative Region shall, on its own, formulate policies to develop Western and traditional Chinese medicine and to improve medical and health services.

TCM in Hong Kong: Overview 1997 1999 2006 2009Before handover:Neither regulated or promoted allopathic western medicine (WM) has dominated the public healthcare systemAfter handover:The professional role of TCM is explicitly stated in the constitutional lawThe government repeatedly announce their commitment in developing TCMEstablishment of the Chinese Medicine Council of Hong Kong (CMCHK)New entrants must complete 5 year formal undergraduate training and passing the licensing examSick leave and health condition assessment certificates issued by registered TCM practitioners is recognized by law

14 TCM clinics established under tripartite management of NGO, University and the Hospital Authority Griffiths S, Chung V. (2009).Development and regulation of traditional Chinese medicine practitioners in Hong Kong.Perspective in Public Health. 2009, 129, 64.

3 Major AchievementsPolicy Address 1997

Policy Address 2001

Policy Address 2005

Policy Address 2009

1. Formal regulation and registration of TCM practitioners Chinese Medicine Council of Hong Kong (CMCHK) Chinese Medicine Ordinance.

2. Introduction of TCM services into the public healthcare systemEstablished 14 out of 18 planned TCM outpatient clinic. Private hospital with TCM service proposed. 3. Professional education in TCM Establishment of full time undergraduate training in TCM Compulsory Continuing Medical Education (CME) program for all registered TCM practitioners

Health Services Research Framework for Analyzing the Development of TM/CAM: Policy, Profession, Patient and Price (4P) TM/CAM - traditional medicine/complimentary and alternative medicine

Choice for TCM and integrative TCM-WM in the HK populationAn understanding of who, how and why patients are choosing TCM may offer valuable insights for policy making.

Data on the characteristics of TCM users in the population may be used to answer policy questions in all three domains of public health health services, health protection, and health promotion (Griffiths, Jewell, & Donnelly, 2005). Griffiths S, Jewell T, Donnelly P. Public health in practice: the three domains of public health. Public Health 2005; 119: 907-913.

How do Chinese populations perceive TCMs role in contemporary healthcare?

Who uses TCM in Hong Kong?

How do patients perceive the quality of communication in their outpatient encounters with TCM and WM professionals?

Does TCM have a role in tackling the challenges of increasing NCD prevalence in our aging population?

5) What are the policy implications of these findings? Five major research questions

VIEWS ON TRADITIONAL CHINESE MEDICINE AMONGST CHINESE POPULATIONS: A SYSTEMATIC REVIEW OF QUALITATIVE AND QUANTITATIVE STUDIES

Question 1: How do Chinese populations perceive TCMs role in contemporary healthcare?

Patient Education and Counseling, 2009, Under Review

We searched 5 electronic databases (MEDLINE, EMBASE, AMED, PsychINFO, and British Nursing Index) Since their inception till Jan 2009 for qualitative studies and quantitative surveys that investigated Chinese peoples views on TCMNo Limit on the location of the study populations (China, Taiwan, Hong Kong, Macao or overseas)Method and Literature Flow

The methodological quality of all included studies was assessed independently by two reviewers (VCH Chung and CH Lau) using the criteria proposed by Mills et al (Mills, E.J. 2006).Findings of all included studies were extracted independently by two investigators. We employed a qualitative approach for data synthesis, which involved three main steps of: (1) classifying studies, (2) comparing and contrasting findings, and (3) thematic analysis (Harden, A. 2004; Lucas, P. 2007; Garcia, J. 2002).Analysis of the extracted data generated 4 major themes: (1) cultural grounding, faith and lay construction of TCM knowledge; (2) perceived strength and weakness of TCM; (3) perceived complementarity of TCM and WM; (4) choice for integrated TCM-WM treatment.

Mills et al. Adherence to HAART: a systematic review of developed and developing nation patient-reported barriers and facilitators . PLoS Med 2006.Garcia et al. Womens View of Pregnancy Ultrasound; A Systematic Review. Birth 2002 29(4) 225-50.Lucas et al . A Systematic Review of Lay Views about Infant Size and Growth. Arch Dis Child 2007 92 120-7Harden et al. Applying systematic review methods to studies of people's views: an example from public health research . JECH 2004 58(9) 794-800

Data analysis

Summary of FindingsLay applications of ancient Chinese philosophies and TCM theories like Yin-Yang and Qi-Blood are commonly used to explain aetiology, interpret symptoms and to provide rationale for self care practices.

It is perceived that TCM is a lay form of healthcare in which recommendations from family and friends, instead of healthcare professionals, are of crucial value.

The perceived advantage of integrating TCM and WM is mainly confined to the improvement of physical health outcomes and holism would be achieved when the side effects of WM are minimized whilst the tonic effects of TCM is maximized.

2. Who uses TCM in Hong Kong?

3. Does TCM have a role in tackling the problem of chronic non-communicable disease on our aging population?

4. How do patients perceive the quality of communication in their outpatient encounters with TCM and WM professionals?

Datasets to answer the following questions

Thematic HouseholdSurvey 2002 & 2005Commissioned by the Census and Statistic Department, Hong Kong SAR Government

Conducted between May July, 2002 and Nov 2005 Mar 2006

Covered the entire land based population of HK, including both non-institutional and institutional residents

Survey data were collected through the use of structured questionnaire via face to face interviews during personal visit by trained enumerator

Covering BOTH non-institutional and institutional residents, 29,561 non-institutional (response rate: 97.2%, 2002)2,111 institutional (response rate: 78.4%, 2002)33,263 non-institutional (response rate: 79.2%, 2005)3,461 institutional (response rate: 93.7%, 2005)

Representing 6,504,255 (2002)/ 6,750,652 (2005) persons after applying population weight

Have you EVER consulted a Chinese Medicine (CM) practitioner?

61.7%>=15 yrs, Hong Kong Thematic Household Survey, 2005 (N=36,724)Financing Context: Western care is tax funded with wide accessibility TCM is mostly private, require out of pocket payment

DEMOGRAPHIC AND HEALTH RELATED CHARACTERISTICS OF TRADITIONAL CHINESE MEDICINE USERS IN HONG KONG

Question 2: Who uses TCM in Hong Kong?

Vincent Chung, Eric Wong, Jean Woo, Sui Vi Lo, Sian Griffiths (2007). Use of Traditional Chinese Medicine in Hong Kong Special Administrative Region of China. Journal of Alternative and Complementary Medicine, 13(3), 361-367.

Who are using TCM in Hong Kong?

Summary PointsCompared to the pre-1997 studies, three novel findings were noted.

Firstly, respondents from the higher socioeconomic class emerged as a new class of TCM users. Secondly, there was low TCM utilization rate among the institutionalized elderly.

Lastly, older respondents were less like to be covered by TCM insurance.

Policy Implications: Better understanding of 1. TCM accessibility among the elderly and2. Possible financing opportunities for community TCM services warrant further research.

COMPARING THE OUTPATIENT CONSULTATION EXPERINCES AMONGST WM AND TCM USERS

Question 3: How do patients perceive the quality of communication in their outpatient encounters with TCM and WM professionals?

Vincent Chung, Lau Chun Hong, Eric Wong, Eng Kiong Yeoh, Sian Griffiths (2009). Perceived Quality of Communication amongst Outpatients in Western and Traditional Chinese Medicine Clinics in a Chinese Population. Health Policy, 90, 66-72.

CAHPS 2.0 core component

Survey Assessment Items(1=strongly dissatisfied, 4=strongly satisfied)Questions adapted from CAHPS 2.0 Questionnaire Validated for measuring patient satisfaction 1. Did the doctor listen to what you had to say?2. Did the doctor explain the reasons for any treatment or action in a way that you could understand?3. Did the doctor treat you with respect and dignity?4. Were you given enough time to discuss your health or medical problem with the doctor?5. The doctor was effective in dealing with the problem for which you sought health care. Do you agree? 6. Global assessment: Using any number from 0 to 10 where 0 is the worst health care possible and 10 is the best health care possible, what number would you use to rate your latest outpatient consultation?

Patients are generally satisfied?

Summary PointsUsers of WM public services were more likely to be dissatisfied with all evaluated aspects.

The observed differences highlight the dissatisfaction with public WM services, which are mainly accessed by less affluent patients.

Compared to users of private WM services, multivariate analysis showed that TCM patients were more likely to rate their clinicians highly for listening skills but low for respect.

Further studies to better understand the reasons for dissatisfaction and the possible policy and organizational solutions are warranted.

The need in improving communication skill training in TCM higher education, especially in privacy protection, should be further studied.

INTERRELATIONSHIP BETWEEN AGE, CHRONIC DISEASE STATUS AND CHOICE FOR TCM AND WM

Question 4: Does TCM have a role in tackling the challenges of increasing NCD prevalence in our aging population?

Vincent Chung, Lau Chun Hong , Eng Kiong Yeoh, Sian Griffiths. Age, Chronic Disease Status and the Choice for Western and Chinese Medicine in a Chinese Population. BMC Health Service Research, In press.

>=15 yrs, Hong Kong Thematic Household Survey, 2005 (N=36,724)Visited WM practitioner only: 80.23%Visited both WM & TCM practitioners: 16.60% double consulters Visited TCM practitioners only: 3.17% Visited a healthcare professional in the past 12 months: (n=18,087)

AgeProbability of utilizationUsing WM only, with NCDUsing both WM and TCM, with NCD Curves for using WM only and double consulting forms a hyperbola, with vertex located at the middle aged Middle aged chronic disease patient are more probable to double consult, approaching a 7(WM): 3 (double) ratio Probability of health service utilization type by age and NCD status

Summary Points

Findings from previous parts of presentation showed that government initiative in TCM development have led to increasing patient choice for integrative TCM-WM care. However, corresponding inter-professional care between WM Doctors (WMD) and TCM Practitioners (TCMP) has not been facilitated.

Patient Choice and Need for Inter-professional Collaborations The preservation of continuity, coordination and comprehensiveness in a pluralistic primary care system poses a challenge to policy makers.

Fostering inter-professional collaboration between TCMP and WMD may improve quality of care,

but the current segregation of TCM and WM provisions in the Hong Kong health system implies that significant financial investments on education and service re-organization will be a prerequisite for better joint up working (e.g. sharing of electronic health records). Greenhalgh, 2007 Bell et al., 2002; Boon, Verhoef, O'Hara, & Findlay, 2004, Snyderman & Weil, 2002

Developing a policy framework for integration of traditional Chinese and allopathic medicine in Hong Kong using Delphi technique

Supported by RGC Public Policy Research Funding Scheme (Round 4)In Progress

Thank YouWebsite:http://www.sphpc.cuhk.edu.hk

Email address:info_sphpc@cuhk.edu.hk

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