Is Traditional Chinese Medicine Recommended in Western Medicine Clinical Practice Guidelines in China? A systematic analysis For peer review only

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1 Is Traditional Chinese Medicine Recommended in Western Medicine Clinical Practice Guidelines in China? A systematic analysis Journal: Manuscript ID: bmjopen-0-00 Article Type: Research Date Submitted by the Author: 0-Sep-0 Complete List of Authors: Ren, Jun; Beijing University of Chinese Medicine, Centre for Evidence- Based Chinese Medicine Li, Xun; Beijing University of Chinese Medicine, Centre for Evidence-Based Chinese Medicine Jin, Sun; Beijing University of Chinese Medicine, Centre for Evidence-Based Chinese Medicine Han, Mei; Beijing University of Chinese Medicine, Centre for Evidence- Based Chinese Medicine Yang, Guo-Yan; Beijing University of Chinese Medicine, Centre for Evidence-Based Chinese Medicine Li, Yuan; Beijing University of Chinese Medicine, Centre for Evidence-Based Chinese Medicine Robinson, Nicola; London South Bank University, Lewith, George; Southampton University, Liu, Jian-Ping; Beijing University of Chinese Medicine, Centre for Evidence- Based Chinese Medicine <b>primary Subject Heading</b>: Evidence based practice Secondary Subject Heading: Evidence based practice Keywords: COMPLEMENTARY MEDICINE, TRANSPLANT MEDICINE, GENERAL MEDICINE (see Internal Medicine) : first published as 0./bmjopen-0-00 on June 0. Downloaded from on 0 April 0 by guest. Protected by copyright. -

2 Page of Title : Is Traditional Chinese Medicine Recommended in Western Medicine Clinical Practice Guidelines in China? A systematic analysis Jun Ren #, Xun Li #, Jin Sun, Mei Han, Guo-Yan Yang, Wen-Yuan Li, Nicola Robinson, George Lewith, Jian-Ping Liu * # These authors contributed equally to this study. Centre for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China London South Bank University, London, UK Southampton University, Southampton, UK * Corresponding author: Jian-Ping Liu, Bei San Huan Dong Lu, Chaoyang District, Beijing, 000, CHINA Liujp@bucm.edu.cn Phone number: ; (cell phone) Key words: clinical practice guidelines, Western medicine, traditional Chinese medicine, treatment recommendations, systematic analysis Word count: : first published as 0./bmjopen-0-00 on June 0. Downloaded from on 0 April 0 by guest. Protected by copyright.

3 Page of Abstract Background:Evidence-based medicine promotes and relies on the use of evidence in developing of clinical practice guidelines (CPGs). The Chinese healthcare system includes both traditional Chinese medicine (TCM) and western medicine, which should be equally reflected in Chinese CPGs. Objective:To evaluate the inclusion of TCM related information in western medical CPGs in China and the use of evidence. Data sources and study selection: All national clinical guidelines were identified from the China Guideline Clearing house (CGC), the major organization issuing guidelines in China, and included guidelines issued by the Ministry of Health of the People s Republic of China, the Chinese Medical Association, and the Chinese Medical Doctors Association. Data extraction:tcm related contents were extracted from all the included CPGs identified. Extracted items included; the institution issuing the guideline, date of issue, disease, location of TCM content, recommendations relating to TCM, evidence level of the recommended content, and references supporting the recommendations. Results: A small number of western medicine CPGs (/0; %) recommended TCM treatments, of these, only (/, %) had applied evidence grading. Of the included CPGs, the types of diseases were classified into disease systems according to International Classification of Diseases 0 th edition.tcm content (/, %) was reported in the treatment part of the guidelines. Most of the recommendations (/, %) concerned Chinese herbal medicine (single herbs or treatment based on syndrome differentiation). Conclusions: Few Chinese western medicine CPGs mention TCM therapies and only a few guidelines provide systematic evidence for the TCM therapy recommended. We suggest that future guideline - : first published as 0./bmjopen-0-00 on June 0. Downloaded from on 0 April 0 by guest. Protected by copyright.

4 Page of development should involve a multi-disciplinary approach and include TCM expertise when formulating guidelines. Strengths and limitations of this study: This is the first comprehensive analysis on the details of TCM contents inclusion in Chinese Western medicine clinical practice guidelines. We have highlighted the implications for future updating or development of clinical practice guidelines. We did not include guidelines from other countries that recognise TCM. We did not conduct a rigorous quality assessment of Chinese clinical practice guidelines. - : first published as 0./bmjopen-0-00 on June 0. Downloaded from on 0 April 0 by guest. Protected by copyright.

5 Page of Introduction Clinical practice guidelines (CPGs) are systematically developed statements to assist clinicians and health care professionals in making appropriate clinical decisions in specific circumstances., Previously guidelines were mostly based on informal expert consensus, which was influenced by expert clinical experience, training and subjective judgment. With the development of evidence-based medicine (EBM), guidelines increasingly involve evidence, applying the principles of EBM to the process of guideline development. Generation of the recommendations involves both content and methodology experts, and the process is clearly defined and reproducible. The commonly used standard that underpins the development of evidence-based CPGs was developed by the Scottish Intercollegiate Guidelines Network (SIGN). The China Guideline Clearinghouse (CGC) is the major resource for CPGs in China, and jointly initiated and run by the Evidence-Based Medicine Specialty Committee under Chinese Medical Doctor s Association and Chinese Medical Association journal board. CGC is an internet collection of CPGs published in Chinese medical journals and is used as a platform for clinicians and the public. Western medicine and TCM are two parallel and equally politically important health care systems in China, and the Chinese government has encouraged the integration of western medicine and TCM. Currently the use of Chinese patent herbal medicine is widespread and reimbursed by the government insurance system. Reports have claimed 0% of Western medicine doctors in integrated medical hospitals in Beijing prescribe patent herbal medicines( is also reported that large-scale investigation organized by Beijing Municipal Administration of Traditional Chinese Medicine and Beijing Association of Chinese Medicine found that 0% of prescriptions of - : first published as 0./bmjopen-0-00 on June 0. Downloaded from on 0 April 0 by guest. Protected by copyright.

6 Page of patent herbal medicine among Western medicine doctors was inappropriate. The aim of this study was to assess the frequency of TCM recommended in involving western medicine CPGs to understand the potential use of TCM evidence in clinical practice guidelines. Methods Inclusion and exclusion criteria: Guidelines approved and issued by the Ministry of Health of the People s Republic of China, Chinese Medical Association and Chinese Medical Doctor Association were included for review. All western medical CPGs containing TCM guidance were included in the study. The guidelines jointly published by multiple agencies were excluded, CPGs jointly issued by more than one agencies or older version guidelines with existing updates were also excluded. Data Source: All the CPGs were identified and retrieved the latest updated to August 0h, 0. We searched modifications were made according to different Chinese databases. All CPGs in the CGC were identified from China National Knowledge Infrastructure (CNKI), Chinese Scientific Journal Database (VIP) and Wanfang database. The search strategy and the search terms were as follows: (title= clinical (linchuang) or prevention or practice or treat or operation or pharmacy or drug or treatment ) and (title= guideline or standard or proposal or recommendation or consensus or criterion ) and (full text = Ministry of Health of the People s Republic of China or Chinese Medical Association" or Chinese Medical Doctor Association ). Data extraction Three authors (Ren Jun, Sun Jin and Li Wen Yuan) extracted the following items relating to TCM: institution issuing the guideline, date of issue, disease, location in guidelines of TCM content, - : first published as 0./bmjopen-0-00 on June 0. Downloaded from on 0 April 0 by guest. Protected by copyright.

7 Page of recommended TCM content, evidence level of the recommended content, and references supporting the recommendation. Data was extracted onto a Microsoft Excel 00 spread sheet for data manipulation. Data analyses: Frequency data was generated for descriptive statistical analysis. Results A total of 0 CPGs issued between 00 and 0 were identified, and (%) of CPGs with any TCM content were included (Table ). - Three organizations issued these 0 CPGs, the number of CPGs developed and approved appeared to have increased during the past 0 years. The results showed there was a gradual increase but with annual fluctuations among the included Western medicine CPGs with respect to TCM content in the period 00 to 0. The number of published guidelines including TCM content between 00 and 0 reached a maximum level, peaking at new guidelines in 0 (because full 0 data cannot be recorded). The China western medicine CPGs first recommended TCM in 00, but only for one CPG. (Figure) According to the International Classification of Diseases, 0 th edition (ICD-0), 0 CPGs involved systems. Of the included CPGs, kinds of diseases were involved with disease systems. (Figure ) Table Distribution of clinical practice guidelines among three organizations Names of organizations No. CPGs Ministry of Public Health (%) *(%) Chinese Medical Association (%) *(%) Chinese Medical Doctors Association (%) *(%) Total 0 (%) Notes: * excluding those jointly issued by multiple agencies and old version guidelines with existing updated ones No. CPG recommending TCM (%) In the CPGs with TCM content, one mentioned TCM in the introduction (%),one in the - : first published as 0./bmjopen-0-00 on June 0. Downloaded from on 0 April 0 by guest. Protected by copyright.

8 Page of diagnosis of syndrome differentiation (%) but most of the guidelines mentioned TCM in the description of the treatment (, %).In addition TCM guidelines were described under the methods of prevention (%) and in relation to rehabilitation (%). Five guidelines mentioned TCM in more than one section of the guidelines. Among the CPGs with TCM content, CPGs recommended a Chinese herbal decoction (including single herb and treatment based on syndrome differentiation) (%), recommended Chinese proprietary medicine, these were Chinese patent medicines or Chinese herbal preparations processed by hospitals or clinical departments without commercial marketing (%), mentioned acupuncture (%), one CPG mentioned acupoint injection (%), some guidelines recommended or more TCM therapies. (Table ) - : first published as 0./bmjopen-0-00 on June 0. Downloaded from on 0 April 0 by guest. Protected by copyright.

9 Page of Traditional Chinese medicine Table.Traditional Chinese Medicine therapy recommended in clinical practice guidelines TCM therapy No. CPGs Diseases involved (No. guidelines if more than ) Chinese herbal medicine (including single herb, treatment chronic hepatitis B(), bronchial asthma (), nasosinusitis (), Chronic obstructive pulmonary disease (), type diabetes mellitus (), allergic rhinitis, avascular necrosis of the femoral heed, Common kidney disease in children, based on syndrome childhood diarrhea, hepatolenticular degeneration, osteoporotic fracture, heart failure, colorectal cancer, influenza, differentiation) difficult asthma, pelvic inflammatory disease, spleen injury, spleen retained, prostatitis, eczema, baby allergic disease, primary hepatic carcinoma, haemorrhoids, obesity, psoriasis, severe acute pancreatitis, spinal cord injury, colorectal cancer, Drug-induced liver injury caused by anti-tuberculosis drugs, limb atherosclerosis, inflammatory bowel disease, vasomotor rhinitis, acute pancreatitis, chronic constipation, influenza, hand-foot-and-mouth disease,optic neuritis,chronic venous disease Chinese proprietary Cerebrovascular disease (), primary liver cancer (), dementia and cognitive impairment (), Inflammation of liver, medicine(chinese patent medicine or Chinese herbal preparation or Chinese herb extracts)or traditional Chinese preparation((not specify the forms)) Acupuncture and (or) moxibustion Acupoint injection Children diarrhea disease Notes: * As one guide may recommend more than one kind of TCM therapy, the total number of guidelines involved is larger than disease of gastrointestinal, behcet disease, adult onset still's disease, rheumatoid arthritis, influenza, Marla color bacteria related diseases, eczema, vascular cognitive impairment, bronchial asthma, type diabetes mellitus, acute ischemic stroke, psoriasis, management of menopause, nasosinusitis, influenza, hand-foot-and-mouth disease, acute paraquat poisoning, fatty liver disease stroke, irritable bowel syndrome, childhood diarrhea, prostatitis, fibromyalgia syndrome, haemorrhoids, adult insomnia, acute ischemic stroke, migraine, management of menopause, chronic constipation, child autism, acne - : first published as 0./bmjopen-0-00 on June 0. Downloaded from on 0 April 0 by guest. Protected by copyright.

10 Page of Of the CPGs with some TCM content, only guidelines (%) gave specific recommendations regarding the level of evidence.,,,,,, Three guidelines gave level I evidence related to TCM, guidelines provided level II evidence related to acupuncture and herbal extracts,,,, guidelines had level III evidence related to Chinese patent medicine and massage,,, all guidelines providing a description of the herbal contents. (Table ) - : first published as 0./bmjopen-0-00 on June 0. Downloaded from on 0 April 0 by guest. Protected by copyright.

11 Page 0 of Table Recommendations level of evidence for Traditional Chinese Medicine contents in conventional medicine guidelines Recommendation Level Guideline Title Treatment Recommendation Contents Chinese guidelines of diagnosis and Chinese herbal Ginkgo leaf preparation has mild effect in slowing down memory in management for cognitive impairment and preparation normal old aged people (grade A evidence); dementia Could not stop or slow down the development from MCI to dementia Level I Level II Level III Chinese guidelines of rehabilitation treatment for Stroke (0 Full version) * Guidelines of e management for stroke rehabitation(simplify) * Chinese guidelines of diagnosis and management for cognitive impairment and dementia (V): dementia therapy (grade A evidence). traditional Chinese In the rehabilitation process of stroke, traditional Chinese medicine medicine therapy therapies can be added conventional rehabilitation therapy (grade A evidence). traditional Chinese In the rehabilitation process of stroke, traditional Chinese medical medicine therapy therapies can be included in conventional rehabilitation therapy (grade A evidence). Chinese herbal Ginkgo leaf may improve the neuropsychic symptoms and slowdown medicine and the disease progression of dementia (grade B evidence), Chinese herbal Ginkgo leaf extract was not able to reduce the AD incidence in preparation normal or mild cognitive impairment aged people (grade B evidence); thus there is no conclusion for the effect of ginkgo leaf, Chinese herbal medicine sage (Salvia officinalis) extract is able to improve the cognitive function in slight and moderate AD patients, and relief the agitated symptoms (grade B evidence). Chinese guidelines of prevention and treatment for acute ischemic stroke(00) acupuncture Whether to choose acupuncture should take patient s willingness into consideration (level I recommendation-grade B evidence) Chinese guidelines of rehabilitation treatment for Stroke (0 Full version) Guidelines of e management for stroke rehabitation(simplify) Chinese guidelines of prevention and treatment for acute ischemic stroke(00) Chinese guidelines of rehabilitation treatment for Stroke (0 Full version) Chinese guidelines of rehabilitation treatment for Stroke (0 Full version) acupuncture Acupuncture is able to speed up the physical recovering and improve the motor ability during flaccid paralysis stage of stroke patients (level II recommendation-grade B evidence); It is suggested that acupuncture be applied in bulbar paralysis patients (level II recommendation-grade B evidence). acupuncture It is suggested that acupuncture be applied in bulbar paralysis patients (level II recommendation-grade B evidence) Chinese patent The decision of acupuncture (level II recommendation-grade B medicine massage massage evidence) should take patient s willingness into consideration, Chinese proprietary medicine (level III recommendation-grade C evidence). Recommendation of massage application in patients with severe limb spasm to relief fatigue and muscular tension (level III recommendation-grade C evidence). Recommendation of massage application in patients with severe limb spasm to relief fatigue and muscular tension (level III recommendation-grade C evidence). Notes: *Though the two articles have partially similar content, we regarded them as different guidelines because of different (Form and part of the content) - : first published as 0./bmjopen-0-00 on June 0. Downloaded from on 0 April 0 by guest. Protected by copyright.

12 Page of **If level of evidence involved did not identify a specific standard, we assess it based on GRADE standard. Quality Evidence based on GRADE: High-quality A, Moderate-quality B, Low-quality C, Very low-quality D Quality level based on GRADE:. High: we are very confidence that the true effect lies close to that of the estimate of the effect. Moderate: we are moderately confident in the effect estimate:the true effect is likely to be close to the estimate of the effect,but there is a possibility that it is substantially different. Low: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect. Very low: we have very little confidence in the effect estimate: the effect is likely to be substantially different from the estimate of effect In the CPGs which had some TCM content, two guidelines mentioned that due to the limited literature involving TCM studies and small sample sizes, more evidence was needed before making a firm recommendation, and further high-quality studies should be taken to confirm the effects of TCM treatments., Three guidelines did not provide further comments after recommending TCM treatments.,, The other Westernmedicine guidelines did not provide the evidence level for their recommendation of TCM treatments, but only listed general information, for example, TCM treatment: apply TCM treatment methods such as herbal medicines acupuncture, acupoint injection and tuina should be based on syndrome differentiation. In the CPGs which involved TCM content, only Western medicine guidelines mentioned TCM contents with appropriate references, such as systematic reviews(n=) ;,, randomized controlled trials(n=) ;,,,,, non-randomized controlled trials(n=) ;,,,, case series(n=); other(n=) (historical TCM classical texts). Discussion Western medicine CPGs with TCM content accounted for % (/) of all guidelines in China. There was no definite trend as to when the Western medicine CPGs that involved TCM content were published. TCM content mostly appeared in the treatment sections of the guidelines. Only very few guidelines with TCM content provided a specific level of evidence to justify their inclusion. Most of - : first published as 0./bmjopen-0-00 on June 0. Downloaded from on 0 April 0 by guest. Protected by copyright.

13 Page of the recommendations (%) concerned Chinese herbal medicine (single herbs or treatment based on syndrome differentiation). This research identified that TCM was part of CPGs guidelines for out of instances where guidelines were available, (%) of chronic diseases, which included; cancer, chronic hepatitis B, bronchial asthma, and type- diabetes mellitus. The TCM content of all the included guidelines failed to provide adequate references to research published in international journals. In addition, the methodology regarding how the papers were retrieved and subsequent review process was lacking. All of the final guidelines failed to mention the details of previous versions. Evidence-based guidelines have become a mainstream in the development of guidelines internationally, but evidence-based approaches are less well recognised in the establishment and implementation of guidelines in China. The mechanism of Guideline production in China is not transparent.tcm clinical research has many methodological problems, such as the generally low quality of clinical trials, failure to give the details of randomization and blinding methods, insufficient sample size, and inadequate out comes with poor long-term follow-up. Establishing high quality CPGs requires a multidisciplinary, 0 team and the development teams for Chinese guidelines do not involve adequate TCM expertise. Our study has some limitations:()the included guidelines were all from China Guideline Clearing House issued by Ministry of Health, Chinese Medical Association and Chinese Medical Doctor s Association. These guidelines had institutional authority and universality, however they were not comprehensive. () We did not include guidelines from other countries that recognize TCM, for instance the use of acupuncture for pain in the US and Europe so we are unable to comment about the international use of specific evidence for TCM in these treatment guidelines. () We did not conduct a quality assessment of Chinese CPGs, nor was the recommended strength of evidence cited in the guidelines appraised and further research is needed in order to provide convincing recommendations - : first published as 0./bmjopen-0-00 on June 0. Downloaded from on 0 April 0 by guest. Protected by copyright.

14 Page of for clinical practice. Future studies should focus on the quality and methodology of the evidence included in each guideline. Other research has mostly described the application of guidelines. One article published in 0 identified 0 guidelines issued by East-Asian countries on traditional medicine (TM) (acupuncture, moxibustion, cupping, herbal medicine, traditional Chinese medicine, manual therapy and tuina) for low back pain. This study suggested that the current East-Asian CPGs did not fully reflect the evidence for TM interventions. Similarly, our study found that Western medicine CPGs in China did not adequately include the relevant research to support the guidelines recommendations concerning TCM. This was particularly the case for acupuncture and only a few guidelines provide the level of evidence for the TCM they recommended. This reflects the inconsistency between the recommendations related to TCM in Western medicine guidelines and the real situation within clinical practice in China. The East-Asian CGPs study also concluded that, as relevant studies such as systematic reviews and meta-analyses are conducted and evidence increases, the current evidence on acupuncture, cupping, and manual therapy should be considered carefully in the process of developing or updating the CPG system. Similarly, in a recent UK, study of National Health Service Western medical clinical guidelines issued by the National Institute of Clinical Excellence (NICE) guidelines, demonstrated a low proportion mentioning at least one Complementary and Alternative Medicine (CAM). Out of UK clinical guidelines issues during 00-0 only % mentioned CAM, with acupuncture and natural products/ herbal medicine being the most common. For acupuncture, guidelines recommended its use, stated it could be considered but the evidence was weak, (could not be recommended) and advised against acupuncture use and guidelines mentioned various natural products use. Of interest is that there were more western guidelines mentioning acupuncture in - : first published as 0./bmjopen-0-00 on June 0. Downloaded from on 0 April 0 by guest. Protected by copyright.

15 Page of the UK than there were in China over the same time period. Suggestions for future guidelines: ()We suggest strengthening cooperation and ensuring involving a multi-disciplinary team in developing CPGs. There should be combination of expertise in methodology, health economics, statistics, clinical epidemiology, evidence-based medicine and Traditional Chinese medicine, as well as Western medicine; ()We suggest strengthening the transparency of methodology when developing guidelines. Reference should be made to Scottish intercollegiate guideline network (SIGN). We suggest using AGREE II to evaluate the quality of evidence. The evaluation of guidelines should be strengthened, as good-quality guidelines are a vital starting point for clinical performance improvement. ()Adopting evidence-based approaches to developing CPGs has become an international mainstream trend. The essential concept of evidence-based guidelines is to synthesize the clinical evidence and generate clinical recommendations. () Clinical Practice guidelines should be brief, east to access and based on scientific evidence. Paradoxically the longest guidelines have the highest proportion of recommendations based on the lowest level of evidence. () Further research is warranted to identify the priorities for TCM research and these data should then serve as supporting evidence in the process of developing of evidence-based CPGs in combination with clinical experience in TCM. We conclude that the western medicine CPGs including TCM accounted for / of the total guidelines in China. There has been a gradual increase in the number of Western medicine CPGs involved TCM content but this has fluctuated over the years.tcm content mostly appear in the treatment part of the included guidelines. Only very few guidelines with TCM content provided a specific evidence level supporting their recommendations. Future guideline development in China should be carried out by multidisciplinary, nationally representative teams. The transparency of - : first published as 0./bmjopen-0-00 on June 0. Downloaded from on 0 April 0 by guest. Protected by copyright.

16 Page of methodology and the specification of the evidence available should be strengthened. Evidence-based methods should be adopted for analysis and synthesis. Further research on TCM is warranted to provide high-level evidence and a robust basis for the future guideline developments. There is a real need to support the development and application of clinical guidelines in order to assist clinical decision making and benchmark clinical practice. Acknowledgments: We thank the following people for their contribution In the study identification, and data extraction including: Kang Zhang, Congcong Wang, and Qianyun Chai. Contributors: JP Liu and J Ren conceived the review; J Ren and JP Liu developed search strategy, study selection and data extraction. J Ren, J Sun and WY Li performed literature searching, study selection and data extraction, J Ren, J Sun and WY Li participated in data analyses. J Ren and X Li drafted the paper. JP Liu, X Li, M Han, GY Yang, N Robinson, G Lewith provided methodological perspectives and revised the manuscript. Funding This work was supported by the Innovative Research Team of Beijing University of Chinese Medicine (Grant No.:0-CXTD-0). This work was supported by "the th -five year plan" Capacity Building Project for TCM Clinical Researchers (Grant No.: 0000) from the State Administration of TCM in China. Competing interests None. Provenance and peer review - : first published as 0./bmjopen-0-00 on June 0. Downloaded from on 0 April 0 by guest. Protected by copyright.

17 Page of Not commissioned; externally peer reviewed. References. Marilyn J. Field, Kathleen N. Lohr. Clinical practice guidelines: directions for a new program. Washington (DC): National Academy Press; 0:.. Hayward RSA, Wilson MC, Tunis SR, et al. Users guides to the medical literature. VIII. How to Use Clinical Practice Guidelines. A. Are the Recommendations Valid? JAMA;, 0-.. Wendy Lim, Donald M. Arnold, VeronikaBachanova, et al. Evidence-Based Guidelines An Introduction. Hematology00;: -0.. ScotishIntereollegiateGuidelinesNetwork(SIGN).Aguidelinedeveloper shandbook.edinburgh:sign, 00. sign. ae. uk. Date accessed: June 0.. The CGC website : accessed: June 0.. Cerebrovascular disease group of Chinese society of neurology of Chinese medical association, et al. China guidelines of prevention and treatment for cerebrovascular disease, abstract (III).Journal of Apoplexy and Nervous Diseases00;():-.. Cerebrovascular disease group of Chinese society of neurology of Chinese medical association, et al. Guidelines of diagnosis and treatment for behcet disease. Chinese Journal of Rheumatology0; ():-. NasologygroupofChinesesociety of otorhinolaryngology of Chinese medical association, et al. Guidelines of diagnosis and treatment for allergic rhinitis (00, wuyi mountain).chinese Journal of Otorhinolaryngology Head and Neck Surgery00;,: -.. The anus colorectal surgery group of Chinese society of Surgery of Chinese medical association, et al. Guidelines of diagnosis and treatment for constipation surgical (protocol).chinese Journal of - : first published as 0./bmjopen-0-00 on June 0. Downloaded from on 0 April 0 by guest. Protected by copyright.

18 Page of Gastrointestinal Surgery00;():-. 0. The gastrointestinal dynamics group of Chinese society of Digestive Diseases of Chinese medical association, et al. Expert consensus of diagnosis and treatment for Irritable bowel syndrome (00, changsha). Chinese Journal of Digestion00; ():-0.. The microscopic repair group of Chinese society of orthopedics of Chinese medical association, et al. Expert consensus of diagnosis standard for adult femoral head necrosis. Chinese Journal of Bone and joint surgery0;():-.. Chinesesociety of Rheumatology of Chinese medical association, et al. Guidelines of diagnosis and treatment for adult Steele disease. Chinese Journal of Rheumatology00;():-.. Chinese society of Renal Diseases of Chinese medical association, et al. Evidence-based guidelines of diagnosis and treatment for common renal diseases in children (for trial) (V): Guidelines of diagnosis and treatment for HBV-associated glomerulonephritis. Chinese Journal of Pediatrics00; ():-.. The digestology group of Chinese society of Pediatrics of Chinese medical association, et al. Experts consensus of diagnosis and treatment for diarrheal diseases in children. Chinese Journal of Pediatrics00;():-.. Chinese society of neurology of Chinese medical association, et al. Guidelines of diagnostic testing and management for Wilson's disease. Chinese Journal of Neurology00;():-.. Chinese society of Orthopedics of Chinese medical association, et al. Guidelines of diagnosis and treatment for osteoporosis. Chinese Journal oforthopaedics00;(0):-.. Chinese Society of Osteoporosis and Bone Mineral Research of Chinese medical association, et al. Guidelines of diagnosis and treatment for osteoporosis and bone mineral diseases (draft). - : first published as 0./bmjopen-0-00 on June 0. Downloaded from on 0 April 0 by guest. Protected by copyright.

19 Page of International Journal of Endocrine Metabolism00; (): appendix -- appendix -0.. Chinese Society of Cardiovascular Diseases of Chinese medical association, et al. The gastrointestinal surgery group. Chinese Guidelines of diagnosis and comprehensive treatment for heart failure (V0). Chinese Journal of Cardiology0; ():-.. Standardized treatment of colorectal cancer expert working group of Ministry of Health of China, et al. Guidelines of the diagnosis and treatment for colorectal cancer (00).Chinese journal of medical frontier00; (): Chinese Society of Rheumatology of Chinese medical association, et al. Guidelines of diagnosis and treatment for rheumatoid arthritis. Chinese Journal of Rheumatology00; ():-0.. Chinese Society of Respiratory Diseases of Chinese medical association, et al. Guidelines of diagnosis and treatment for influenza (00 revised draft).journal of Diagnostics Concepts & Practice00; ():-.. The fungus group of Chinese Society of Dermatology Diseases of Chinese medical association, et al. Guidelines of the diagnosis and treatment for Malassezia-related diseases (00). Chinese Journal of Dermatology00;(0):-0.. Nasology group of Chinese society of otorhinolaryngology of Chinese medical association, et al. Guidelines of diagnosis and treatment for chronic nasal sinusitis.the ent head and neck surgery00; ():-.. Chinese Society of Ophthalmology of Chinese medical association, et al. Experts consensus of diagnosis and treatment foroptic neuritis. Chinese Journal of Ophthalmology0;0():-. Chinese Society of liver diseases of Chinese medical association, et al. Guidelines of prevention and treatment for chronic hepatitis B (00).Chinese Journal of Hepatology0;(): : first published as 0./bmjopen-0-00 on June 0. Downloaded from on 0 April 0 by guest. Protected by copyright.

20 Page of Chinese Society of Surgery of Chinese medical association, et al. Expert consensus of diagnosis and treatment for Chronic venous disease. Chinese Journal of General Surgery0; ():-.. The asthma group of Chinese Society of Respiratory Diseases of Chinese medical association, et al. Expert consensus of diagnosis and treatment for refractory asthma. Chinese Journal of Tuberculosis and Respiratory Diseases00; ():-. The Infectious diseases group of Chinese Society of Obstetrics and Gynecology of Chinese medical association, et al. Guidelines of diagnosis and treatment for pelvic inflammatory disease (Recension).Chinese Journal of Obstetrics and Gynecology0; ():0-0. The function of spleen and spleen surgery group of Chinese Society of Surgery of Chinese medical association, et al. Guidelines for spleen reserved surgery. Chinese Journal of Practical Surgery00; ():-. 0. Chinese Urological Association of Chinese medical association, et al. Guidelines of diagnosis and treatment for Prostatitis ( Trial version ).The Chinese Modern Journal of Surgery00; ():-.. Sections of Immunology of Chinese Society of Dermatology of Chinese medical association, et al. Guidelines of prevention and treatment for eczema (0).Chinese Journal of Dermatology0; ():-.. Chinese Society of Infectious Diseases of Chinese medical association, et al. Experts consensus of prevention and treatment for inflammation of liver. Chinese Journal of Practical Internal Medicine0;():-.. Chinese Society of Digestive Endoscopy of Chinese medical association, et al. Chinese digestive - : first published as 0./bmjopen-0-00 on June 0. Downloaded from on 0 April 0 by guest. Protected by copyright.

21 Page 0 of endoscopy-related bowel preparation guide (draft).chinese Journal of Practical Internal Medicine 0;():0-0.. Chinese Society of Rheumatology of Chinese medical association, et al. Guidelines of the management for fibromyalgia Syndrome Pain. Chinese Journal of Rheumatology0;():-.. The dementia and cognitive impairment group of Chinese Society of Neurology of Chinese medical association, et al. Guidelines of diagnosis and treatment for vascular cognitive impairment. Chinese Journal of Neurology0;():-.. Chinese Society of Rheumatology of Chinese medical association, et al. Guidelines of diagnosis and treatment for psoriatic arthritis. Chinese Journal of Rheumatology00;():-.. Sections of Immunology of Chinese Society of Pediatrics of Chinese medical association, et al. Expert consensus of prevention, diagnosis and treatment for allergic diseases in infants. Chinese Journal of Pediatrics00;():-.. The liver cancer group of Chinese Society of liver diseases of Chinese medical association, et al. Expert consensus of the management for primary liver cancer. Chinese Journal of Hepatology00;():0-0.. Chinese Society of Osteoporosis and Bone Mineral Research of Chinese medical association, et al. Guidelines of prevention and treatment for primary osteoporosis (discussion draft).chinese Journal of General Practitioners00; ():-. 0. The asthma group of Chinese Society of Respiratory Diseases of Chinese medical association, et al. Chinese guidelines of prevention and treatment for asthma. Chinese Journal of Asthma(Electronic Version)00;(): : first published as 0./bmjopen-0-00 on June 0. Downloaded from on 0 April 0 by guest. Protected by copyright.

22 Page of The anus colorectal surgery group of Chinese Society of Surgery of Chinese medical association, et al. Guidelines of the management for hemorrhoids (00).Chinese Journal of Gastrointestinal Surgery00;():-.. Chinese Society of Diabetes of Chinese medical association, et al. Chinese guidelines for type diabetes (00).Chinese Journal of Diabetes0; 0():S-S.. The sleep disorder group of Chinese Society of Neurology of Chinese medical association, et al. Guidelines of the diagnosis and treatment for adult insomnia in China. Chinese Journal of Neurology0;():-0.. The dementia and cognitive impairment group of Chinese Society of Neurology of Chinese medical association, et al. Chinese guidelines of diagnosis and management for cognitive impairment and dementia. Chinese Medical Journal00;0():-. The dementia and cognitive impairment group of Chinese Society of Neurology of Chinese medical association, et al. Chinese guidelines of diagnosis and management for cognitive impairment and dementia (V): dementia therapy. Chinese Medical Journal0; ():0-.. The endocrine surgery group of Chinese Society of Surgery of Chinese medical association, et al. Chinese guidelines of treatment for obesity surgery (00). Chinese Journal of Practical Surgery00;(0):-.. Cerebrovascular epidemiology group of Chinese Society of Neurology of Chinese medical association, et al. Chinese guidelines of prevention and treatment for acute ischemic stroke(00).chinese Journal of Neurology00;():-.. The neurological rehabilitation group of Chinese Society of Neurology of Chinese medical association, et al. Chinese guidelines of rehabilitation treatment for Stroke (0 Full - : first published as 0./bmjopen-0-00 on June 0. Downloaded from on 0 April 0 by guest. Protected by copyright.

23 Page of version).chinese Journal of Rehabilitation Theory and Practice0; ():0-.. The head pain group of Chinese Society of Pain Management of Chinese medical association, et al. Chinese guidelines of diagnosis and treatment for migraine. Chinese Journal of Pain Medicine0;():-. 0. Sections of Immunology of Chinese Society of Dermatology of Chinese medical association, et al. Guidelines of treatment for atopic eczema (atopic dermatitis).chinese Journal of Dermatology00;():-.. The psoriasis group of Chinese Society of Dermatology of Chinese medical association, et al. Guidelines of diagnosis and treatment for Psoriatic arthritis (0).Chinese Journal of Dermatology0; ():-.. Cerebrovascular epidemiology group of Chinese Society of Neurology of Chinese medical association, et al. Guidelines of e management for stroke rehabitation(simplify).chinese Journal of Neurology0;():0-0.. The pancreas surgery group of Chinese Society of Surgery of Chinese medical association, et al. Guideline of diagnosis and treatment for severe acute pancreatitis. Chinese Journal of Surgery00, ():-.. Nasologygroup of Chinese society of otorhinolaryngology of Chinese medical association, et al. Diagnosis and treatment recommendations for chronic sinusitis children(0, Kunming).Chinese Journal of Otorhinolaryngology Head and Neck Surgery0;():-. The urinary control group of Chinese Urological Association of Chinese medical association, et al. Guidelines of urinary system management and clinical rehabilitation for Spinal Cord Injury. Chinese Journal of Rehabilitation Theory and Practice0;(). - : first published as 0./bmjopen-0-00 on June 0. Downloaded from on 0 April 0 by guest. Protected by copyright.

24 Page of The gastrointestinal surgery group of Chinese Society of Surgery of Chinese medical association, et al. Guidelines of diagnosis and comprehensive treatment for liver metastatic colorectal cancer. (V0). Chinese Journal of Gastrointestinal Surgery0;():0-.. The menopause group of Chinese Society of Obstetrics and Gynecology of Chinese medical association, et al. Guidelines of management and hormone replacement therapy for menopause (0).Chinese Journal of Obstetrics and Gynecology0;(0):-.. Chinese Society of Tuberculosis of Chinese medical association, et al. Expert consensus of diagnosis and treatment for drug-induced liver injury caused by anti- tuberculosis drugs. Chinese Journal of Tuberculosis and Respiratory Diseases0;(0):-.. Chinese Society of Geriatrics of Chinese medical association, et al. Chinese expert consensus of diagnosis and treatment for limb atherosclerosis disease in the elderly (0).Chinese Journal of Geriatrics0;():-. 0. NasologygroupofChinesesociety of otorhinolaryngology of Chinese medical association, et al. Guidelines of diagnosis and treatment for chronic nasal sinusitis (00, Kunming).Chinese Journal of Otorhinolaryngology Head and Neck Surgery0;():-.. Chronic obstructive pulmonary disease group of Chinese Society of Respiratory Diseases of Chinese medical association, et al. Guidelines of diagnosis and treatment for chronic obstructive pulmonary diseases (0 Part ).Clinical Education of General Practice0;,:-. Inflammatory bowel epidemiology group of Chinese Society of Digestive Diseases of Chinese medical association, et al. Chinese expert consensus of diagnosis and treatment standard for inflammatory bowel disease (0, Guangzhou).Journal of Internal Medicine Concepts and Practice0;,: : first published as 0./bmjopen-0-00 on June 0. Downloaded from on 0 April 0 by guest. Protected by copyright.

25 Page of NasologygroupofChinesesociety of otorhinolaryngology of Chinese medical association, et al. Recommendations of diagnosis and treatment for vasomotor rhinitis (0, Suzhou).Chinese Journal of Otorhinolaryngology Head and Neck Surgery0;():-.. Chinese Society of Digestive Diseases of Chinese medical association, et al. Chinese guidelines of the management for acute pancreatitis (Shanghai, 0).Chinese Journal of Digestion0;, : -. The gastrointestinal dynamics group of Chinese Society of Digestive Diseases of Chinese medical association, et al. Chinese guidelines of management for chronic constipation (0, Wuhan). Chinese Journal of Digestion0;,:-.. The asthma group of Chinese Society of Respiratory Diseases of Chinese medical association, et al. Chinese guidelines of prevention and treatment for bronchial asthma (Basic version)(ii). Chinese Community Doctors0;,:0-. The asthma group of Chinese Society of Respiratory Diseases of Chinese medical association, et al. Chinese guidelines of prevention and treatment for bronchial asthma (Basic version).chinese Journal of Tuberculosis and Respiratory Diseases0;,:-.. The Ministry of Health of China. Guidelines of diagnosis and rehabilitation for childhood autism. Chinese Journal of Child Care0;():-.. The Ministry of Health of China. Guidelines of diagnosis and treatment for pandemic influenza(0). International Journal of Respiration0;(): The Ministry of Health of China. Guidelines for chronic obstructive pulmonary disease(0). Chinese Journal of the Frontiers of Medical Science (Electronic version)0;():-.. The Ministry of Health of China. Guidelines of diagnosis and treatment for hand-foot-mouth - : first published as 0./bmjopen-0-00 on June 0. Downloaded from on 0 April 0 by guest. Protected by copyright.

26 Page of disease(00).international Journal ofrespiration00;0():-.. The Ministry of Health of China. Guidelines of the management for primary liver cancer (0). Journal of ClinicalOncology0;(0):-.. The Ministry of Health of China. Guidelines of diagnosis and treatment for NDM generic drug resistant enterobacteriaceae bacterial infection. Infectious Disease Information00;(0):-0,.. The Ministry of Health of China. Guidelines of diagnosis and treatment for gastric cancer (0).Chinese Journal of the Frontiers of Medical Science (Electronic version)0;():-.. Department of Disease Control of Ministry of Health of China. Chinese guidelines of prevention and treatment for cerebrovascular disease (excerpts).chinese Journal of Modern Neurological Diseases00;():, 0.. The Beauty professional group of China dermatologist association. Guidelines of diagnosis and treatment for corticosteroid dependent dermatitis. Journal of Clinical Dermatology00;():-0.. China dermatologist association. Chinese guidelines of treatment for Acne (discussion draft).journal of Clinical Dermatology00;():-.. Emergency physicians branch of Chinese medical doctor association. Expert consensus of diagnosis and treatment for acute paraquat poisoning(0). Chinese Journal of Critical Care Medicine 0;:-.. Expert committee on fatty liver disease of Chinese medical doctor association. Expert consensus of standardization management for fatty liver disease. Journal of Clinical Hepatology0;: : first published as 0./bmjopen-0-00 on June 0. Downloaded from on 0 April 0 by guest. Protected by copyright.

27 Page of Tari Turner, MarieMisso, Claire Harris, et al. Development of evidence-based clinical practice guidelines (CPGs): comparing approaches. Implement Sci00, :. Hyun-Woo Cho, Eui-Hyoung Hwang, Byungmook Lim, et al.. How Current Clinical Practice Guidelines for Low Back Pain Reflect Traditional Medicine in East Asian Countries: A Systematic Review of Clinical Practice Guidelines and Systematic Reviews. PLOS ONE 0;,, e0. Lorenc A, Leach J, Robinson N. Clinical guidelines in the UK: Do they mention Complementary and Alternative Medicine (CAM)-are CAM professional bodies aware? Eur J Integr Med (Special issue on Clinical guidelines) 0: (); -. Richard M. Rosenfeld, Richard N. Clinical practice guideline development manual: A quality-driven approach for translating evidence into action. Otolaryngol Head Neck Surg AGREE II : accessed: June 0.. A Gordon Baird, James R Lawrence. Guidelines: is bigger better? A review of SIGN guidelines.bmj OPEN 0;:e00. doi:0... Robinson N, Liu JP, Lee MS. Clinical Guidelines: the way forward for integrated practice. Eur J Integr Med 0; (): : first published as 0./bmjopen-0-00 on June 0. Downloaded from on 0 April 0 by guest. Protected by copyright.

28 Page of Figures Figure Number of clinical practice guidelines approved in China The figure showed the trend among the included Western medicine CPGs with respect to TCM content in the period 00 to 0. Figure Category of disease involved in clinical practice guidelines in China The figure showed the number of category of disease involved in the total number of CPGs and conventional medicine CPGs related to TCM contents respectively. Supplementary file: The list of include guidelines in china: This table showed the title, years and organization name of the conventional medicine CPGs related to TCM contents. No. Names of The name of guidelines Year organizations Guidelines of diagnosis and treatment for influenza (00 revised 00 Chinese draft) Medical Guidelines of diagnosis and treatment for osteoporosis and bone 00 Association mineral diseases (draft) Guidelines of diagnosis and treatment for Prostatitis (Trial version) 00 Guidelines of prevention and treatment for chronic hepatitis B (III) 00 Guidelines of prevention and treatment for primary osteoporosis (discussion draft) 00 Guidelines of the management for hemorrhoids (00) 00 Guidelines for spleen reserved surgery 00 Chinese guidelines of treatment for obesity surgery (00) 00 Guideline of diagnosis and treatment for severe acute pancreatitis 00 0 Guidelines of diagnosis and treatment for constipation surgical 00 (protocol) Expert consensus of diagnosis and treatment for Irritable bowel 00 syndrome (00, Changsha) Guidelines of diagnostic testing and management for Wilson's disease 00 Guidelines of diagnosis and treatment for osteoporosis 00 Guidelines of the diagnosis and treatment for Malassezia-related 00 : first published as 0./bmjopen-0-00 on June 0. Downloaded from on 0 April 0 by guest. Protected by copyright. -