Study On Factors Affecting The Implementation Of Guidelines Of Clinical Practice With Acupuncture And Moxibustion

BackgroundAcupuncture and moxibustion have been widely used worldwide.Due to the uneven level of clinical staff and quality of clinical research on acupuncture and moxibustion in various countries,the formulation of clinical practice guidelines for acupuncture and moxibustion has become more and more urgent,while there is currently no internationally recognized clinical practice guidelines for acupuncture and moxibustion.By the end of 2019,nearly 30 clinical practice guidelines for acupuncture and moxibustion have been formulated and issued in China.The vitality of the guidelines lies in the clinical application,but the application and implementation of these clinical practice guidelines for acupuncture and moxibustion and their clinical applicability are still in the research blank.So,what is the quality of the published clinical practice guidelines of acupuncture and moxibustion in China,and can they be well applied in clinical practice?How consistent is it with the clinical practice of acupuncture?This is related to whether we can smoothly push the domestic acupuncture practice guidelines to the international level in the next step,so it is an important issue that needs attention in the current standardization and clinical evaluation research of acupuncture and moxibustion.PurposeThe quality of clinical practice guidelines of acupuncture and moxibustion was evaluated by using guideline quality assessment tools and questionnaires,and the existing problems in methodology and report quality in the current formulation of acupuncture and moxibustion guidelines were explored.Through in-depth interviews,the attitudes,opinions,experience and problems encountered in the use of clinical practice guidelines of acupuncture and moxibustion of guideline users were understood,and the impact of clinical practice guidelines of acupuncture and moxibustion was analyzed.On the basis of the above studies,this paper explores the construction ideas of the evaluation system for the applicability of acupuncture clinical practice guidelines,so as to provide a reference for the formulation and promotion of acupuncture clinical practice guidelines.MethodsThis study includes the following four parts:1.To evaluate the methodological quality and report quality of 7 clinical practice guidelines of acupuncture and moxibustion issued in 2019;2.A questionnaire on quality and application barriers of clinical practice guideline of acupuncture and moxibustion;3.Conduct in-depth interviews with the users of the guidelines on the problems in the implementation of current clinical practice guideline of acupuncture and moxibustion;4.Establish an applicability evaluation system for clinical practice guidelines of acupuncture and moxibustion.The specific methods are as follows:(1)The methodological quality and reporting quality of seven clinical practice guidelines of acupuncture and moxibustion issued by the Chinese Acupuncture and Moxibustion Society in 2019 were analyzed using the internationally recognized guideline evaluation tools AGREE? and RIGHT statement,and the existing problems in the methodology,format and style of the seven guidelines were analyzed.(2)Questionnaires were used to investigate the quality of published clinical practice guidelines on acupuncture.The survey subjects were mainly guideline developers,evaluators and relevant scientific researchers.The setting of questions in the questionnaire combined with AGREE ? evaluation items,mainly evaluated the quality of acupuncture clinical practice guidelines and the existing problems in the application process.Questionnaires were sent out in the form of electronic questionnaires by questionnaire stars.(3)The purpose sampling,stratified sampling and snowball sampling were used to conduct in-depth interviews with 12 guide users,mainly acupuncture clinicians,and survey the attitudes of guide users,mainly acupuncture doctors,on the clinical practice guidelines And understanding,problems encountered in the process of using,experience of using,using the thematic analysis method to analyze the interview data,and explore the factors that affect the implementation of the clinical practice guidelines for acupuncture and moxibustion.(4)On the basis of literature research and in-depth interviews,an evaluation system for the applicability of clinical practice guidelines for acupuncture and is constructed by means of expert questionnaires and consultation at expert meetings.Results1.In 2019,a total of 7 clinical practice guidelines for acupuncture were issued in China,all of which were issued by the Chinese Acupuncture Society.They are "Evidence-Based Guidelines of Clinical Practice with Acupuncture and Moxibustion:Moxibustion Therapy" "Evidence-Based Guidelines of Clinical Practice with Acupuncture and Moxibustion:Fire Needling Therapy" "Evidence-Based Guidelines of Clinical Practice with Acupuncture and Moxibustion:Cupping Therapy" "Evidence-Based Guidelines of Clinical Practice with Acupuncture and Moxibustion:Bloodletting Therapy" "Evidence-Based Guidelines of Clinical Practice with Acupuncture and Moxibustion:Acupotmy Therapy" "Evidence-Based Guidelines of Clinical Practice with Acupuncture and Moxibustion:Electric acupuncture Therapy" " Evidence-Based Guidelines of Clinical Practice with Acupuncture and Moxibustion:Acupoint Application Therapy".The AGREE II evaluation scores of the seven guidelines in scope and purpose,stakeholder involvement,rigour of development,clarity of presentation,applicability,editorial independence were:81.7%,55.6%,43.9%,81.7%,20.8%,0.0%.The evaluation results of RIGHT statement are:"basic Information" "background","evidence","recommendations","review and quality assurance","funding and conflict of Interest declaration and management" and "other Information" in 7 areas Reported items accounted for only 28.6%,unreported items accounted for 51.8%,and some reports(not applicable)accounted for 16.7%.2.A total of 35 questionnaires were distributed and 35 were recovered,with a recovery rate of 100%.The evaluators were mainly acupuncturists,and all participated in the development or evaluation of guidelines.At the "scope and purpose" level,26(74%)experts believed that the clinical problems of acupuncture clinical practice guidelines issued in China needed to be improved.Fifteen(42.9%)experts considered the patient population unclear.Nine(25.7%)experts believed that the overall purpose of the guidelines needed to be further refined.6(17.1%)experts believed that there was no need for improvement in "purpose and scope ".About " rigour of development ",19(50%)experts believed that the rigor of association between recommendations and supporting evidence was insufficient.17(48.6%)experts believed that the strengths and limitations of the body of evidence were problematic.Sixteen experts believed that the recommendations needed to be improved.Fourteen(40.0%)experts believed that the inclusion of evidence in the description of side-effect risk factors in exclusions and recommendations needed to be improved.4(11.4%)experts believed that the rigor of guideline development did not need to be improved.At the level of clarity of expression,more than 60%of experts believe that the content and expression of recommendations can be improved.The severity of the three most important problems in the process of application is in turn:"unable to judge the difference in prognostic outcomes between strong and weak recommendation schemes" is the application problem that experts are more concerned about.25(71.4%)experts believe that the problem exists in the published clinical practice guidelines of acupuncture and moxibustion;19(54.3%)experts believe that the clinical problems of the existing clinical practice guidelines of acupuncture and moxibustion are not clear.Fourteen(40.0%)experts considered the content of existing acupuncture guidelines difficult to obtain.3.The analysis of interview data through the thematic analysis method has many factors that affect the implementation of the clinical practice guidelines for acupuncture.Among them,the methodological quality,accessibility,and clinical applicability of the clinical practice guidelines for acupuncture are considered to be the three main reasons that affect the implementation of the clinical practice guidelines for acupuncture.Other factors include the form of the guide,unfamiliarity with the content of the guide,user perceptions and habits,and lack of managerial support.4.After two rounds of expert questionnaires and one expert meeting consultation,the basic structure of the applicability evaluation system of acupuncture clinical practice guidelines was finally determined.The architecture consists of 19 items in three areas:global consideration,readability and executability.(1)Global consideration mainly focuses on the overall purpose of the clinical practice guidelines for acupuncture and moxibustion,including the evaluation of the scope of the disease,the guideline development group,etc.(2)Readability is mainly evaluated for the clarity and clarity of the text expression and recommendations;(3)The key point of the executability is the recommendation part,which mainly evaluates the compliance of the recommendation,including the key points of clinical diagnosis and treatment of acupuncture and moxibustion,such as diagnosis,differentiation of symptoms and signs,treatment principles,acupoint selection,acupuncture/moxibustion techniques,etc.,to judge whether the guidelines are consistent with the clinical operation of acupuncture and moxibustion.The objective of the clinical practice guideline of acupuncture and moxibustion is to guide clinical practice,which is suitable for the expert review before the guideline is issued or the applicability survey after it is issued.The purpose is to collect the contents of the clinical practice guideline of acupuncture and moxibustion that are contrary to the clinical practice of acupuncture and moxibustion,so as to timely amend and improve the contents of the guideline.Conclusion1.The evaluation results showed that the methodological quality and reporting quality of the seven clinical practice guidelines for acupuncture and moxibustion were poor.The main problems are lack of report on the evaluation process of evidence quality,unclear report on the process of converting evidence to recommendations,unclear division of labor among the members of the guideline development team,lack of description of funding and conflict of interest,and lack of recommendations for implementation of the guideline.It is suggested that in the future,the guideline evaluation tools such as AGREE II and RIGHT statement should be combined to improve the transparency of the guideline formulation process and explore a guideline version more suitable for the reading of acupuncture clinicians.2.Through the investigation of guideline makers,there are some problems in the current acupuncture guidelines in the process of "scope and purpose","clarity of presentation","rigour of development "and application.Among them,the scores of "scope and purpose" and "clarity of presentation" in the evaluation results ofAGREEII are high,but there are still many problems in the two aspects of the questionnaire survey.The reason may be that the perspectives and positions are different,the requirements for the guidelines are different,and the guideline makers are also users,who have a better understanding of the clinical practice guidelines for acupuncture.The results of the questionnaire survey make up for the inability of the AGREE II evaluation to evaluate the quality of the method in the application process.The result of both is a more comprehensive assessment of the quality of the guidelines.3.The factors affecting the implementation of the clinical practice guidelines for acupuncture are numerous and complicated.This study analyzes the factors affecting the implementability of the clinical practice guidelines for acupuncture from three aspects:the quality of the guideline,the individual user,and the implementation environment.(1)The quality of the guidelines covers the guidelines development method,clinical applicability,and report form.(1)The current problems in the development of acupuncture clinical practice guidelines are as follows:The WHO guidelines development method is used in the development of acupuncture clinical practice guidelines,but the use of methods in the process is not standardized,and the methods have not been completely used correctly.The existing methods are There are unreasonable points in the development of acupuncture guidelines.The main reason is that the complexity of the acupuncture treatment process and the characteristics of acupuncture experience are not considered in the evaluation of the quality of the evidence.Classical medical books and medical records trusted by clinicians are used as the lowest quality evidence.The quality of acupuncture clinical trials is low,leading to the generally low quality of evidence supporting recommendations.(2)Clinical applicability:The clinical applicability of the guidelines is the most concerned issue for clinicians.There are still some problems with the applicability of the clinical practice guidelines for acupuncture,for example,the recommendations do not conform to the routine clinical practice,the clinical issues are vague,and the guidelines for issues that clinical concerns are not given.Factors affecting the efficacy of acupuncture include acupoint selection,acupuncture techniques,and syndrome differentiation.This is also something to consider during the formulation of the guideline,but the acupuncture diagnosis and treatment plan in clinical research may have some gaps with clinical practice.The lack of clear clinical issues is also a big issue in current clinical practice guidelines for acupuncture.The optimal timing of acupuncture intervention and outcome evaluation indicators are relatively vague.In addition,current acupuncture guidelines cannot meet the needs of clinicians,and the issues that clinicians really care about are not reflected in the guidelines.(3)The format of the guideline is also one of the influencing factors.The guideline that conforms to the reading habits of clinicians is easier to promote and implement.(2)Starting from the individual users,the reasons affecting their use include accessibility,cognitive concepts and habits.(1)Accessibility is the premise of personal use guidelines.The current acupuncture clinical practice guidelines are issued in a limited form,with limited promotion channels.It is a major problem for users to not know the existence of guidelines and where to download them.This has largely limited the spread of acupuncture guidelines,and their promotion efforts have been insufficient.(2)Most acupuncture clinicians lack scientific understanding of the methods and contents of acupuncture guidelines.In addition,they rely more on the accumulation of classical medical books and experience.Most people do not have the habit of using guidelines.(3)From the perspective of implementation environment,because acupuncture clinical practice guidelines are recommended standards in China,and lack of support from managers,it is difficult to promote them.4.The value of the guideline lies in clinical application.Although the development of the guideline is important,it is also important to follow up and monitor the implementation and application of the guideline.According to the results of this study,the following suggestions are made for the development and implementation of clinical practice guidelines for acupuncture:(1)the use of standardized methods in the formulation process,and the participation and guidance of methodologists;(2)the characteristics and operations of clinical diagnosis and treatment of acupuncture The complexity of the acupuncture should not only rely on clinical research evidence,value the opinions of acupuncture clinicians in the formation of recommendations,and the role of expert consensus in the development of acupuncture clinical practice guidelines;(3)explore the ancient literature,experience of famous doctors and other non-The method of synthesizing the results of clinical trial research in the evidence and perfecting the method of formulating clinical practice guidelines for acupuncture.(4)Before the publication of the guideline,consult the doctors on the recommendations,especially the technical operation part of acupuncture therapy,including clinical compliance of diagnosis,acupuncture,acupuncture/moxibustion techniques,etc.;(5)Clinical practice in acupuncture In the process of compiling the guide,refer to the guide evaluation tools such as AGREE and RIGHT,and pay attention to the report quality and completeness of the guide.(6)Strengthen the promotion of the clinical practice guidelines for acupuncture,and increase everyone's awareness of the methods and contents of the clinical practice guidelines for acupuncture through continuing education training and seminars.The acupuncture operations in the recommendations in the guidelines can also be disseminated in videos and other forms;(7)Broadening the channels for the spread of acupuncture clinical practice guidelines and making full use of the network platform to disseminate the guidelines;(8)Establishing an acupuncture clinical practice guidelines application-feedback platform to collect Clinical users' opinions and suggestions on the guidelines;(9)After the implementation of the guidelines,investigate the clinical application to find out the problems in the acupuncture guidelines and improve them when they are updated.5.The construction of the applicability evaluation system for acupuncture clinical practice guidelines is the first step in the study of clinical applicability of acupuncture guidelines.The purpose is to evaluate the consistency of acupuncture clinical practice guidelines with the clinical practice of acupuncture,and to judge the compliance of the guidelines'recommendations To help improve the clinical practice guidelines for acupuncture.It is used by acupuncture clinicians.However,the system has not been clinically verified,and currently it is not possible to judge its applicability,and further operability needs to be verified.