Country update: Korea
Current status of clinical practice guidelines in Korea
Prepared by Hyeong Sik Ahn, Korea University
1. Korean Health Care System
Korea has undergone remarkable social changes over the last four decades. Unprecedented high economic growth rates from the 1960s through the 1990s have been accompanied by industrialization, urbanization, and democratization. Along with these social changes came the development of the healthcare system, which was largely influenced by Western medicine. The most noticeable change in the Korean health-care system was the establishment of the NHI system. The expansion of health insurance coverage toward the whole population was a popular issue and received a strong political support from Korea people.
The work of healthcare delivery is performed mostly by the private sector. The private sector, which was dominant in Korea before the insurance plans were introduced, has grown further with the increase in per capital income and the expansion of health insurance coverage. There are 425,098 health professionals (101,569 doctors, 270,393 nurses, 19,097 doctor of oriental medicine, 25,425 dentist and 8,614 nurse-midwife) working in Korea. Healthcare providers are tiered into general hospitals, local hospitals, and clinics. In 2009 public local hospitals accounted for only 7% of all local hospitals, public general hospitals accounted for 20% of all general hospitals, and clinics are 100% private. There are 7.1 hospital beds per 1000Koreans, 87% of which are in private hospitals and clinics.
2. Current Status of Guideline in Korea
As with other countries in the world, the healthcare system in Korea faces the difficulty of maintaining high quality of care while containing the healthcare cost. In the face of limited resources, healthcare demands in Korea are rapidly rising because of the introduction of new and expensive technology and the increase in the elderly population. This situation has led both decision-makers and clinicians to become very interested in clinical practice guidelines.
The majority of guidelines are developed by medical academic societies. Other guideline developers primarily include professional organizations and research consortium groups. According to a survey in 2006, of 146 medical academic societies belonging to the KAMS (Korean Academy of Medical Sciences) which is the association of qualified academic societies, half of academic societies either have experience of or plans to develop guidelines. The Korea government funds the development of some guidelines. Currently, about seventy five clinical practice guidelines have been developed through medical academic societies.
2.1. Characteristics of Korean Clinical Practice Guidelines
Based on analysis of seventy guidelines included in the clinical practice information system, the average development time for a clinical practice guideline is 7-12 months; the professionals involved in clinical practice guideline development were mostly physicians of one specialty within the same medical field. Multi disciplinary groups of practitioners being involved in clinical practice guideline development have been relatively rare. Of the development methods, adaptation of foreign guidelines was the most common (23%), followed by consensus among specialists (19%), and then by evidence based methods (15%). A mixture of these methods was also common (42%). The cost of developing clinical practice guidelines came from the academic organizations' own budgets, and was between $10,000 and $30,000.
2.2. Dissemination and Implementation of Clinical Practice Guidelines
The dissemination methods for clinical practice guidelines are mainly in the form of printed material (28%) or presentations at academic proceedings (23%), and other methods of dissemination include dissemination at academic proceedings and sales. About one third of academic associations claimed to have a planned budget for disseminating clinical practice guidelines but the remainder did not have separate budget for dissemination.
Awareness and implementation of guidelines among physicians were not high. Although 70% of paediatricians were aware of the clinical practice guidelines for treatment of childhood asthma, only 30% of them were actually using them. Conducting educational training for guidelines was not frequent. In a survey of paediatricians, the lack of promotion and training of clinical practice guidelines were pointed out as being needed.
2.3. Problems in developing Clinical Practice Guidelines in Korea
The problems in developing clinical practice guidelines include:
- Few examples of interdisciplinary approaches in developing clinical practice guidelines
- Even though there is intention to use an evidence based approach, guidelines actually using rigorous evidence based approaches are scarce
- Although there is a need for them to be relevant to the local situation in Korea, there is a lack of locally based research
- In most cases, the link between recommendations and evidence is not clear
- There were few methodologists in the guideline development groups and the methods are not often fully described.
3. Issues Related to Clinical Practice Guidelines in Korea
3.1. Concerns among the Healthcare Providers
Many physicians in Korea have frowned on clinical practice guidelines. According to a survey more than 70% agreed that they are intended to improve the quality of healthcare, and were helpful in making good clinical decisions and improving good educational tools; but more than 50% said that they were intended to decrease both healthcare costs and physician reimbursement, that they were a challenge to physician autonomy, and were too simple and rigid to apply to individual patients.
Their concerns can be summarized as guidelines possibly impeding the creativity and diversity of practice, being used as an external evaluation and assessment tool, and against doctors in legal actions.
The merits of clinical practice guidelines can only be achieved through active participation of the practitioners themselves in developing and actually using them. In order to further expand practice guidelines in Korea, it is necessary for providers to properly recognize guidelines. To stimulate the proper recognition of guidelines, there needs to be a mechanism to include the providers in developing guidelines and for providing logistic support.
3.2. De novo development or adaptation of guidelines
Since most data for guidelines come from international research, is it necessary to develop guidelines de novo or can international guidelines be adapted, costing less time and money? Eventually, as domestic research increases, it would make sense to develop guidelines based on that evidence, but, in the short term, there is a valid and practical argument for evaluating the quality of internationally developed guidelines and adapting the high quality ones. Therefore, when adapting international guidelines, it would be important to establish acceptance criteria such as what information is necessary and what process to go through.
3.3. Government policies and support
In order to develop high quality clinical practice guidelines, an investment in human and financial resources is required. Until now, there has not been a sufficient infrastructure for developing clinical practice guidelines and so investment is now needed. The government needs to provide support for professional staff and allocate an adequate budget, in order to set up systematic clinical practice guideline programs. In other words, Korea needs to establish policies on how to develop, expand, and implement clinical practice guidelines.
3.4. Manpower for Evidence-based Medicine methods
Although the methods of evidence based medicine and systematic reviewing are key for developing clinical practice guidelines, there are currently not enough professionals with the relevant experience. So we need not only to find and support people with this knowledge and experience but also to develop our own methods based on those of respected international guideline agencies or associations, and to distribute these nation-wide.
3.5. Reflection of situation in Korea
Korean clinical guidelines need to be relevant to the situation in Korea. This means understanding the epidemiological characteristics of a disease, and properly assessing the effectiveness of interventions for the Korean healthcare system . So there is clearly a need for more locally based clinical research.
Although it is possible to conduct comprehensive literature searches for international literatures using Pubmed, Embase, and Cochrane Library databases, the search for domestic literatures is difficult to do using such databases, and in most cases, physicians have to resort to hand searching . So we need to build a searchable database that effectively aids comprehensive search of the domestic literature.
Clinical practice guidelines must be developed by reasonable and well-planned methods. If not, they will not provide helpful support in the field where actual healthcare is provided, but they may in fact have adverse impact; therefore, clinical practice guidelines must provide broad, critical, and unbiased information about the benefits and limitations of various diagnostic and treatment methods. Clinical practice guidelines can modify practitioners' behaviours and improve treatment results. Koreans must develop methods that are appropriate for the current condition of the nation. For this, not only is policy-backed support from the government required but it is also now time that the medical community and government worked constructively together.