A Pilot Study on Clinician-Perceived Efficacy of Rehabilitative Services in China

Transcription

1 The Health Care Manager Volume 27, Number 3, pp Copyright # 2008 Wolters Kluwer Health Lippincott Williams & Wilkins Serving Billions A Pilot Study on Clinician-Perceived Efficacy of Rehabilitative Services in China Mei Zhao, PhD; D. Rob Haley, PhD, MBA, MHS; JoAnn M. Nolin, JD; Kerry Dunning, MHA, MSH; Jian Wang, MD, PhD; Qiangsan Sun, MD China has the world s largest number of disabled people, and this number is projected to grow. Although there is ample literature on the utilization and efficacy of Western medicine as it pertains to rehabilitation services, there is far less research on the perceived efficacy of traditional Chinese medicine (TCM). A structured questionnaire was designed for a pilot study on TCM and Western medicine used for rehabilitation services in China, their associated charges, and perceived efficacy. A sample of 33 clinicians responded to the questionnaire. The analysis found that clinicians most frequently prescribed Fenbid and Chinese herbs to treat rehabilitation morbidities, and the most common TCM treatments were acupuncture and massage therapy. The average patient charge for each visit for TCM therapy varied from 56 Yuan ($7.30) for Chinese herbal medicine to 12 Yuan ($1.60) for cupping therapy. The most frequently prescribed Western therapies were occupational, physical, and speech. The average charge for each visit for Western medicine varied from 111 Yuan ($14.60) for physical therapy to 48 Yuan ($6.30) occupational therapy. Clinicians indicated that acupuncture, Chinese herbal medicine, massage, speech, occupational, and physical therapies were effective or highly effective in treating morbidities requiring rehabilitation services. Key words: charge, China rehabilitation service, efficacy, traditional Chinese medicine, western medicine CHINA S POPULATION IS aging at a staggering rate. The strict family planning or one-child policy implemented almost 25 years ago tried to slow the growth of the country s more than 1 billion population. Because of a decreasing younger population and an increasing older population, China faces the prospect of having too Author Affiliations: Public Health Department, University of North Florida, Jacksonville (Drs Zhao, Haley, and Nolin); Dunning Consulting and Health Administration Program, University of North Florida Brooks College of Health, Jacksonville (Ms Dunning); Center for Health Management and Policy, Shandong University, Jinan, Shandong, PR China (Dr Wang); and The Second Hospital of Shandong University, Jinan, Shandong, PR China (Dr Sun). Corresponding author: Mei Zhao, PhD, Public Health Department, University of North Florida, 1 UNF Drive, Jacksonville, FL (mzhao@unf.edu). This research was supported in part by a grant from the University of North Florida Foundation/Brooks Health Foundation. 252 few children to provide care and support for a rapidly aging population. 1 In addition to the one-child policy, China is also experiencing improved longevity as the country has made vast improvements in health over the past 5 decades. As a result, the country currently has about 102 million elderly representing over one-fifth of the world s elderly population. The percentage of this population is projected to increase from 8% to 24% by 2050, totaling 322 million people. This will have a profound impact on China s healthcare system, especially in rehabilitation services. 2,3 China currently has the world s largest number of disabled people, with an estimated 60 million having some type of disability. 4 This number is expected to grow as China s population continues to rapidly age. 5 China has a long tradition of providing rehabilitative services for the disabled through traditional Chinese medicine (TCM). These therapies typically include herbal remedies, acupuncture, acupressure, massage,

2 Efficacy of Rehabilitative Services in China 253 meditation, and moxibustion, which is a form of herbal therapy. 6 However, China s healthcare system has undergone tremendous economic and social change over the past several decades as it reforms from a centrally planned economy to a marketoriented economy. As a result, China is becoming a country where Western medicine and TCM increasingly coexist at almost every level of their healthcare system. 7 Typical therapies for Western medicine include physical therapy (PT), occupational therapy (OT), and speech therapy. Although TCM therapies have been widely used in China s rehabilitative institutions, in recent years, both Western and TCM therapies have been increasingly integrated. 8 For example, patients with spinal cord injuries are treated with PT, OT, and recreational therapy, as well as acupuncture, herbs, massage, and other TCM techniques. 9 Before the 1980s, Western medicine for rehabilitative services was barely provided in China because of the scarcity of professionals trained in these types of therapies. 10 For this study, PT is defined as the use of exercises and physical activities to help control muscles and restore strength of movement. 11 Occupational therapy is defined as skilled treatment that helps people return to ordinary tasks around home and at work by maximizing physical potential through lifestyle adaptations and possible use of assistive devices. 12 All medical schools in China were required to develop teaching programs for physical, occupational, and speech therapies; it is estimated that China had only 6,000 rehabilitation specialists trained in Western medicine in 2002 for a population of more than 1.3 billion people. 13 In addition to a shortage of these types of clinicians, there is also a scarcity of rehabilitation equipment and facilities, especially in rural areas. As a result, rehabilitation services in rural areas are limited and dominated by TCM. 6 Whereas there is an abundance of literature on the utilization and efficacy of Western medicine and rehabilitative services, there is far less research on the perceived outcome and efficacy of TCM therapies used for rehabilitative services. One recent study did find that the outcome of rehabilitation TCM therapy provided in China s rural community centers was perceived by patients as unsatisfactory, with more than 80% of patients indicating that they were not satisfied with the services they received. 8 However, no systematic study has been performed to examine the perceptions of China s clinicians on the quality and the efficacy of providing TCM and Western medicine for rehabilitative care. Therefore, the purpose of this pilot study is to gain preliminary insight on clinicians perceptions of the utilization, charges, and efficacy of both Western medicine and TCM in China as it pertains to rehabilitation therapy. This research offers several contributions to international healthcare and alternative medicine literature and identifies potential policy implications for the Chinese healthcare system. First, this study provides new insight into the perceived effectiveness of Western and TCM medicine for rehabilitative services. Second, it provides primary research into the cost and duration of both Western and TCM rehabilitative procedures. Third, it provides information into the type and frequency of pharmaceutical prescribing among China s rehabilitative clinicians. STUDY DATA AND METHODS Instruments A structured questionnaire was designed to collect information on the type of TCM and Western medicine provided for rehabilitation services, their associated charges, disease types, and the treatments associated with rehabilitation services, as well as the perceived efficacy of TCM and Western medicine treatments. Respondents were also provided with the opportunity to record open-ended comments at the end of the structured portion of the questionnaire. The questionnaire was translated into Mandarin and was initially administered to a rehabilitation

3 254 THE HEALTH CARE MANAGER/JULY SEPTEMBER 2008 Table 1. Basic information on the clinicians who responded to the survey Variable No. % Age, y Sex Female Male Education and training Traditional Chinese medical physician Western physician Both TCM and western physician Physical therapist degree Nurse degree and other Professional level Primary Junior Middle Senior Working department Hospital outpatient (OP) Both inpatient and OP Community clinic Institutional level Provincial City County and below clinician for clarity and validity. It was then administered to another rehabilitation clinician for reliability. Each clinician has more than 10 years of experience in rehabilitative medicine. A database was designed using Microsoft Excel. Data were entered with 2 levels of independent verification to ensure accuracy. Sample Researchers from Shandong University s Center for Health Policy and Management administered the survey to the population of 65 rehabilitation clinicians within Shandong Province as identified by the Shandong Rehabilitation Association (April 2007). Of the 65 respondents, 33 (50.8%) of the questionnaires were fully completed and used in the study analysis. Researchers read from a script explaining the purpose of the study and vocalized directions on completing the survey instrument. All communication was provided in Mandarin. Analysis indicates that there is no significant difference between respondents and nonrespondents. Subjects More than two-thirds of the sample were male and younger than 50 years. More than 60% possessed an earned degree in TCM, 33% are Western physicians, and 15% had a degree in PT. Many of these clinicians work primarily in a hospital outpatient facility. More than half of the respondents were considered middle- to senior-level clinicians (Table 1). STUDY RESULT Data collected from the convenience sample of 33 rehabilitation practitioners revealed that the 4 most common diseases identified for rehabilitation therapy were strokes (44%), arthritis (29%), traumatic brain injuries (16%), and spinal cord injuries (11%) (Table 2). Clinicians most frequently prescribed Fenbid (Goldshield, UK) (58%), an ibuprofen pain reliever, as well as Chinese herbs (42%) such as Shexiangzhenggugao ( )to treat rehabilitation morbidities. The most common TCM treatment modalities were acupuncture (82%) and massage therapy (64%), and the most common Western therapies were OT (79%) and PT (73%) (Table 3). The average patient charge for each service visit for TCM therapy varied from 56 Yuan ($7.30) for Chinese herbal medicine to 12 Yuan ($1.60) for cupping. Cupping is a traditional Asian therapy in which the practitioner creates suction in a cup and then applies that cup to the body, drawing Table 2. Top 4 diseases for rehabilitation services Diseases Mean, % SD Stroke Arthritis Trauma brain injuries Spinal cord injuries

4 Efficacy of Rehabilitative Services in China 255 Table 3. Rehabilitation services and treatments: medication, TCM, and Western medicine Item No. % Most commonly prescribed medication Fenbid Chinese herbs Naproxen Indomethacin enteric coated tablets Loxonin Most commonly used TCM Acupuncture Massage Cupping Chinese herbal medicine Most commonly used Western medicine OT PT Speech therapy Ultrashortwave Electrotherapy Ultrasound Magnetotherapy Electromagnetic stimulator the skin under the cup. The average charge for each service visit of Western medicine was as high as 111 Yuan ($14.60) for PT and 48 Yuan ($6.30) for OT. The average time needed to provide TCM treatment for rehabilitation services varied from 17 minutes per treatment for Chinese herbal medicine to 54 minutes for massage therapy. Western medicine ranged from 20 minutes for electrotherapy to 52 minutes for PT. Regarding the efficacy of TCM and Western medicine, clinicians indicated that acupuncture, massage therapy, and Chinese herbal medicine were effective or highly effective in treating rehabilitation morbidities. Speech therapy, OT, and PT were identified as effective or highly effective Western medical therapies (Table 4). Table 5 indicates clinicians perceptions of patient participation, functional independence measure (FIM) assessment, and satisfaction with the rehabilitation technology availability. About 88% of these clinicians indicated that they included patients in their treatment decisions, but only 52% used FIM to assess patients health status. The FIM is an 18-item ordinal scale that is a widely accepted functional assessment measure for the assessment of progress during rehabilitation. In terms of clinician satisfaction with the technology that is available for rehabilitation, 67% indicated that they were either satisfied or very satisfied (Table 5). Furthermore, the survey instrument included 2 open-ended questions for clinicians to provide comments and suggestions regarding the provision of rehabilitation services and the patient experience. Clinicians identified the following themes as areas for Table 4. Average charge, time, and effectiveness of TCM and Western medicine Item Mean Charge, Yuan ($) Mean Time, min Effective or Highly Effective, % TCM Acupuncture 26.1 (3.5) Massage 26.7 (3.5) Cupping 12.3 (1.6) Chinese herbal medicine 55.5 (7.3) Western medicine OT 47.9 (6.3) PT (14.6) Speech therapy 21.4 (2.8) Ultrashortwave 17.5 (2.3) Electrotherapy 14.9 (2.0) Ultrasound 14.7 (1.9) Magnetotherapy 12.5 (1.7) Electromagnetic stimulator 13.9 (1.8)

5 256 THE HEALTH CARE MANAGER/JULY SEPTEMBER 2008 Table 5. Clinician s perception of patient participation, FIM assessment, and satisfaction with the technology for rehabilitation services Item No. % Patient participation in treatment decision Use FIM to assess patients health status Satisfaction with the technology that is available for rehabilitation Very satisfied Satisfied Neither satisfied or dissatisfied Very dissatisfied further improvement, hypothesis development, and research: There is a strong need for information and education (including the social value, economic value, and cultural value) regarding rehabilitation services. Clinicians indicated that community and employer education could prevent injury, help those who are injured more quickly return to productivity, and improve the population s quality of life. There is a need to provide clinical pathways and standardized procedures for the diagnosis and treatment of rehabilitation morbidities, including greater collaboration with clinicians of other medical specialties. Standardized education and training for rehabilitation professionals should be implemented to improve the quality of care. There was a consistent theme that this training should encourage the use of TCM for rehabilitation services. Some rehabilitative morbidities, such as infantile brain paralysis, autism, and stroke, require time- and labor-intensive services. Clinicians indicated that a reimbursement or insurance mechanism needs to be identified to fund extended and costly treatment. DISCUSSION As China s population of 1.3 billion continues to age, rehabilitation services will be in even greater demand. However, very little research has been conducted on the perceived efficacy of TCM and Western medicine as it relates to China s rehabilitative services. In fact, this pilot research is one of the first studies on the utilization of rehabilitative services and clinician s perceptions of the effectiveness of treatment modalities. This is somewhat surprising because diseases that are typically associated with rehabilitative treatment, such as rheumatoid arthritis and stroke, are China s leading causes of morbidity. 14,15 In addition, as the country continues to industrialize, the rate of traumatic brain injuries resulting from automobile and industrial accidents continues to increase at an astonishing rate. 16 This study supports the need for research related to rehabilitative therapies and services in China. Interestingly, we found that the most prevalent TCM used among rehabilitation clinicians within the study sample is acupuncture. This finding is consistent with the fact that acupuncture has been used to treat many types of muscular ailments for more than 2,000 years. Research indicates that acupuncture is a relatively simple and inexpensive TCM treatment for motor, sensation, speech, and other neurological functions in patients with stroke. For example, one study demonstrated that acupuncture proved to be more effective in aiding stroke rehabilitation on functional independence and motor recovery when compared with placebo and standard rehabilitation alone. 17 Similarly, almost two-thirds of clinicians in our study perceived acupuncture to be effective as a rehabilitative treatment modality. Massage therapy also has had a long history as a rehabilitative therapy in China. Research indicates varying levels of evidence supporting the efficacy of massage therapy for different chronic pain conditions. 18,19 This study also found that PT and OT are the two most widely accepted Western rehabilitative services in China. Clinicians indicated that these are efficacious treatment therapies. We found that PT is most often used for stroke patients and those with spinal cord injuries. The PT and OT professions have continued to grow in response to the aging population, the

6 Efficacy of Rehabilitative Services in China 257 increasing incidences of head and spinal cord injury due to increased violence in urban areas, and epidemics such as AIDS and cancer. 20 Our study also found that more than 60% of the sample used speech therapy and believe that it is an efficacious rehabilitative therapy. Similarly, other studies found that speech therapy was an effective treatment in treating patients with speech disorders after pharyngoplasty and patients with cleft palate in China. 15,21 Although almost 60% of respondents used Fenbid as a prescribed pain reliever for those needing rehabilitative services, we were surprised to find that the second most prescribed medication was Chinese herbs. This may be because of the fact that more than 60% of these respondents received TCM training in their education. One study found that folk healers or providers (clinicians who use traditional medicine for disease treatment) can influence women s use of herbal medicine in Kazakhstan. 22 In addition, herbal medicine was proved to be very effective in some specific conditions. 23 We also found that Chinese herbal medicine was one of the most expensive TCM treatments, followed by massage, acupuncture, and cupping. Interestingly, two of the more affordable TCM treatments, acupuncture and massage, were perceived to be more efficacious than any other treatment. This finding necessitates the need for further research into potential health policy implications. Finally, almost all respondents reported that they involved patients in treatment decisions. This finding indicates that additional research is needed to gain patients perspectives as to their perceived involvement in treatment decisions and their satisfaction with rehabilitation services. LIMITATIONS OF THIS STUDY There are several limitations in this study. First, this is a pilot study with a sample of 33 respondents. The size and nature of this sample do not allow us to generalize the findings to all rehabilitation clinicians within China or the Shandong Province. However, an important consideration is that this sample did come from a Provincial Annual Rehabilitation Conference, which typically attracts attendees with the latest knowledge and skills from all types of rehabilitation professionals. In addition, the respondents own training and experiences may bias self-reported measures. Estimates of prevalence, charge, and frequency of various measures were based solely on the respondent s memory and, perhaps, conjecture at the time of the survey and may or may not have included precise knowledge of the summary data reported. Finally, this study examined only the clinician perceptions of rehabilitation services. Future research should investigate if there is any discrepancy between clinicians and patients in their perceptions of the charges, quality, and prevalence of rehabilitation services. POLICY IMPLICATIONS This pilot study identifies the need for additional research to test hypotheses that can have significant policy implications for the Chinese healthcare system. For example, in China, acupuncture and massage therapy are lower-priced treatments relative to Western medicine rehabilitation therapies. In addition, these lower-cost TCM therapies are perceived to be effective rehabilitation therapies. Therefore, policy makers may want to consider making acupuncture and massage therapy regular modalities in rehabilitation services for certain diseases. Similarly, this study also indicates that clinicians within the sample perceived OT, PT, and speech therapy to be efficacious. As a result, research and education are needed to identify clinical pathways and rehabilitation protocols that combine TCM and Western therapies in terms of cost, efficiency, and optimal clinical outcomes. Finally, as China s population ages because of the one-child policy, there will be far fewer people capable of caring for their family members who are in need of rehabilitation and other healthcare services. Therefore, it will be vital for policies to be developed and implemented for community education on wellness and preventive care.

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