Degenerative arthritis, a chronic disease, is characterized by gradual damage to the cartilage that protects the joints and causes damage to the subchondral bone and surrounding synovial structures, resulting in inflammation and pain [1]. It most frequently occurs in weight- bearing knee and hip joints, followed by the digital joints and spine [2].

The incidence rate among patients aged > 55 years is approximately 80%, and it occurs in nearly all patients aged > 75 years [3]. Degenerative hip and hand arthritis are significant social and economic burdens in an aging society [4]. They are common among older people, significantly reducing their quality of life and increasing healthcare costs and social burden [5]. Therefore, consistent treatment and management are essential to improve the quality of life of patients and reduce overall healthcare costs [6].

According to the Health Insurance Review and Assessment 2022 report on frequent diseases among Korean medicine outpatients, knee arthritis ranked the highest among joint diseases treated over the past 3 years (13th overall), followed by other arthrosis (including digital joints, 46th overall) and other arthritis (including degenerative arthritis, 54th overall) [7]. Many patients visit Korean medicine medical institutions to receive treatment, and patients’ preference for Korean medicine treatment is high.

The standard clinical pathway (CP) refers to the optimal path developed to minimize time delays and resource utilization and maximize the quality of care when medical staff applies interventions such as for diagnosis or procedures to efficiently provide treatment to patients [8]. The standard CP takes the form of a time-task matrix, where the horizontal axis lists the treatment and interventions chronologically, whereas the vertical axis presents the components of care such as patient status assessment, diet, tests, medications, procedures, and education [9]. According to the current status of existing CPs and related previous studies, CP application reduces the length of hospital stay and medical costs and increases patient and caregiver satisfaction with care [10].

Since 2005, the Korean medicine community has been developing clinical practice guidelines (CPGs) through the Korean Medicine Innovation Technology Development Project, and based on these guidelines, CPs are being developed. CPs for various diseases developed to date include those for lumbar disk herniation, depression, and ankle sprain [11-13]. In addition, treatment methods for degenerative hip and hand arthritis include conservative approaches such as acupuncture, pharmacopuncture, and herbal medicine. Although these treatments are frequently used in recent clinical practice, they largely rely on the clinical skills of practitioners, and not all decision-makers are using standard CPs to assist in making appropriate judgments. In this context, CPs are standard care procedures intended to minimize discrepancies between planned care and actual outcomes through discussions among participants in the clinical setting [8].

Therefore, the authors of this study developed three types of CPs based on the CPGs for degenerative hip and hand arthritis, published in May 2024, taking into account the differences in the medical environment of various medical institutions. These CPs are intended for use in Korean medicine clinics, Korean medicine hospitals/public medical centers, and collaborative hospitals, and this study aimed to report on their development.

1. Setting goals for the development of standard clinical pathways

The primary aim of this study was to develop a standard CP in Korean medicine for patients with degenerative hip and hand arthritis to ensure consistency in patient care, maximize treatment effectiveness, and increase applicability in clinical settings. The CP encompasses diagnosis, treatment, and management to improve patients’ quality of life through a comprehensive approach that integrates Korean and Western medicine. Furthermore, CP development was evidence-based and achieved through expert consultation and literature review. The initial effectiveness of the CP was verified through pilot testing, followed by final revisions and future clinical application.

2. Study design

This study aimed to develop a draft of the standard CP for Korean medicine targeting patients with degenerative hip and hand arthritis. The CP was validated with a panel of experts, and the demand and satisfaction with the CP draft was evaluated, which led to the development of a final standard CP. The CP for managing degenerative hip and hand arthritis was systematically developed based on the May 2024 publication of the standard CPGs, which provide evidence-based recommendations for each treatment intervention. The CP was presented in two forms: a time-task matrix and an algorithm, and it was tailored for three types of healthcare institutions: Korean medicine clinics, Korean medicine hospitals/public medical centers, and collaborative hospitals. After establishing the conceptual framework, a draft of the Korean medicine CP was prepared. A validity survey titled “Validation Study for CP Development and Application” was conducted with 11 experts working in various medical institutions, including Korean medicine clinics, Korean medicine hospitals, collaborative hospitals, and public institutions, to refine the CP.

This research did not involve any human or animal experiments.

3. Standard clinical pathway development process

1) Conceptual framework formation

A multidisciplinary committee, consisting of research practitioners, methodological experts, and clinical professionals, was formed. The intervention and review items for the draft of the standard CP in Korean medicine were determined through consensus among clinical experts.

A time frame was set on the horizontal axis, whereas the intervention areas were set on the vertical axis. The time frame was divided into the initial visit and visits are 1–3, 3–6, and after 6 months. The intervention areas were categorized into measurement/observation, differential diagnosis, tests, evaluation scales, treatment, education, and others.

2) Standard clinical pathway development group composition

To incorporate diverse academic and professional opinions, a development committee, advisory committee, and approval committee were established to develop the standard CP. The development committee oversaw the entire CP development process and consisted of 5 clinical experts. The advisory committee, consisting of 11 members, included the research team developing the standard CPGs for each disease and stakeholders involved in the application of the standard CP, such as Korean medicine doctors and nurses from Korean medicine clinics, Korean medicine hospitals, collaborative hospitals, and public medical centers. The advisory committee included 73% male and 27% female, and by age distribution, 7 members were in their 30s, 3 members in their 40s, and 1 member in their 50s.

3) Validity verification for clinical pathway development and application study

To validate the content of the draft of the standard CP for degenerative hip arthritis and hand arthritis in Korean medicine, consultation was sought from an expert panel. This panel consisted of individuals who are directly involved in the management of patients with degenerative hip and hand arthritis or who have specialized knowledge in the field. This included university professors (including attending physicians); specialists in acupuncture and moxibustion, Korean internal medicine, and Korean rehabilitation medicine; private practitioners; and public health Korean medicine doctors. To validate the draft CP, a validity survey questionnaire for experts was administered to 11 participants (Supplementary Material 1). The questionnaire required responding to each item of the draft CP using a 10-point Likert scale, where 0 indicated “not necessary for the CP” and 10 indicated “absolutely necessary for the CP.” Items with a median score < 5 were considered to have low validity and were deleted.

1. Development of the clinical pathway time-task matrix

1) Axis in a Table

The horizontal axis (time) was set to the initial visit and visits at 1–3, 3–6, and after 6 months. The vertical axis, representing actions, was categorized into measurement/observation, differential diagnosis, tests, evaluation scales, treatment, education, and others (Tables 1, 2).

Table 1 . Time-task matrix for osteoarthritis of the hip.

Item	Initial visit	1–3 months	3–6 months		After 6 months
Measurement and observation	- Measurement: V/S, height, weight	Measure as needed
	- History taking: onset time, location, pain characteristics, past history, family history, treatment history, medication use	-
	- Physical examination: inspection, palpation, range of motion evaluation, neurological examination, etc.	-
Pattern identification	- Conduct pattern identification: inspection, listening, and smelling; inquiring and palpation; coldness and hotness; stool; urination; sleep; tongue diagnosis; pulse diagnosis	Re-evaluate diagnosis as needed
Examination	- Medical care when needed: radiological examination (X-ray, CT, MRI, etc.), blood test - Check test data when bringing test results	Follow-up imaging tests if needed
	- Perform Korean medicine tests when necessary (HRV, Yangdorak diagnosis, DITI, pulse test, SCAT, etc.)	-
Evaluation scales	Hip arthritis evaluation questionnaire (HAQ, WOMAC), NRS, VAS, QoL	Conduct evaluation scales for progress monitoring (periodically, every 10 treatments)
Treatment plan	- Set treatment plan based on patient’s condition - Treatment according to the TCM pattern diagnosis (acupuncture, herbal medicine, physical therapy) - Conduct complex treatment as needed	Acupuncture, electroacupuncture, bee venom acupuncture, chuna manual therapy, physical therapy, laser acupuncture, etc.		- Adjust the number of visits when symptoms improve - If symptoms improvement or deterioration, increase the number of outpatient visits or add necessary treatment
		Medical treatment when necessary
	- Acupuncture treatment: including electroacupuncture, bee venom acupuncture, etc. * Representative acupuncture points: Ashi points around the greater trochanter, Juliao (GB 29), Huantiao (GB 30), Yanglingquan (GB34), Xiaxi (GB 43), Neiting (ST 44), trigger points of the iliopsoas, rectus femoris, tensor fasciae latae, gluteus medius, and gluteus minimus
	- Herb medicine * Representative prescription: Ojeoksan, Dokhwalgisaeng-tang, Daebangpung-tang, Jakyakgamcho-tan
	- Chuna manual therapy: hip mobilization techniques in supine (joint play movements), myofascial chuna technique (rectus femoris [muscle energy technique and stretching], gluteus medius [strain/counterstrain technique])
	- Physical therapy: thermotherapy of cutaneous and muscle meridian, infrared therapy
Education	- Description of future treatment plan - Medication guidance - Lifestyle training for symptom management - Exercise training - If necessary, lifestyle habits training according to the Sasang constitution	- Lifestyle habits and exercise education according to the progression of the disease
Others	* The treatment plan is the general course of the disease and may vary depending on the patient’s condition * Treatment period and frequency, completion of treatment, etc. are judged according to the severity of the disease and clinical evaluation results * Depending on the severity and clinical course of the disease, hospitalization, medical consultation, or transfer to another medical institution may be required * In case of bee venom herbal acupuncture treatment, skin test and patient education are conducted

V/S, vital sign; CT, computed tomography; MRI, magnetic resonance imaging; HRV, heart rate variability; DITI, digital infrared thermal imaging; SCAT, Sasang constitutional analysis tool; HAQ, health assessment questionnaire; WOMAC, Western Ontario and McMaster Universities Arthritis Index; NRS, numerical rating score; VAS, visual analog scale; QoL, quality of life assessment; TCM, traditional Chinese medicine; -, not applicable..

Table 2 . Time-task matrix for osteoarthritis of the hand.

Item	Initial visit	1–3 months	3–6 months		After 6 months
Measurement and observation	- Measurement: V/S, height, weight	Measure as needed
	- History taking: onset time, location, pain characteristics, past history, family history, treatment history, medication use	-
	- Physical examination: inspection, palpation, range of motion evaluation, neurological examination, etc.	-
Pattern identification	- Conduct pattern identification: inspection, listening, and smelling; inquiring and palpation; coldness and hotness; stool; urination; sleep; tongue diagnosis; pulse diagnosis	Re-evaluate diagnosis as needed
Examination	- Medical care when needed: radiological examination (X-ray, CT, MRI, US, bone scan, etc.), blood test - Check test data when bringing test results	Follow-up imaging tests if needed
	- Perform Korean medicine tests when necessary (HRV, Yangdorak diagnosis, DITI, pulse test, SCAT, etc.)	-
Evaluation scales	Hand arthritis evaluation questionnaire, NRS, VAS, QoL	Conduct evaluation scales for progress monitoring (periodically, every 10 treatments)
Treatment plan	- Set treatment plan based on patient’s condition - Treatment according to the TCM pattern diagnosis (acupuncture, moxibustion, herbal medicine, physical therapy) - Conduct complex treatment as needed	Acupuncture, bee venom acupuncture, moxibustion, physical therapy, laser acupuncture, etc.		- Adjust the number of visits when symptoms improve - If symptoms improvement or deterioration, increase the number of outpatient visits or add necessary treatment
		Medical treatment when necessary
	- Acupuncture treatment: including bee venom acupuncture, etc. * Representative acupuncture points: Ashi points, Pal-sa (EX-UE9), Shaohai (HT 3) - Check for adverse reactions
	- Herb medicine * Representative prescription: Sopunghwalhyeol-tang, Youngsunjetong-Eum, Gumiganghwal-tang, Daeganghwal-tang - Check for adverse reactions
	- Physical therapy: thermotherapy of cutaneous and muscle meridian, infrared therapy
Education	- Description of future treatment plan - Medication guidance - Lifestyle training for symptom management - Exercise training - If necessary, lifestyle habits training according to the Sasang constitution	- Lifestyle habits and exercise education according to the progression of the disease
Others	* The treatment plan is the general course of the disease and may vary depending on the patient’s condition * Treatment period and frequency, completion of treatment, etc. are judged according to the severity of the disease and clinical evaluation results * Depending on the severity and clinical course of the disease, hospitalization, medical consultation, or transfer to another medical institution may be required * In case of bee venom herbal acupuncture treatment, skin test and patient education are conducted

V/S, vital sign; CT, computed tomography; MRI, magnetic resonance imaging; US, ultrasound; HRV, heart rate variability; DITI, digital infrared thermal imaging; SCAT, Sasang constitutional analysis tool; NRS, numerical rating score; VAS, visual analog scale; QoL, quality of life assessment; TCM, traditional Chinese medicine; -, not applicable..

2) Measurement/observation

This category included checking and recording vital signs, medical history, and physical examinations during the initial visit.

3) Pattern identification

This category included elements for conducting traditional Korean medicine differential diagnosis, such as inspection, listening and smelling, inquiring and palpation, coldness and hotness, stool, urine, sleep, tongue diagnosis, and pulse diagnosis.

4) Tests

This category included the possibility of conducting radiological tests (X-ray imaging, computed tomography [CT], and magnetic resonance imaging [MRI]) and blood tests through Western medical consultations when necessary. Patients were advised to bring with them results of tests conducted at other hospitals for review during subsequent visits. Various tests (heart rate variability [HRV], Yangdorak diagnosis, digital infrared thermal imaging [DITI], pulse test, Sasang constitutional analysis tool, etc.) were considered parts of the traditional Korean medicine diagnostic process if needed.

5) Evaluation scales

The evaluation scale category included the implementation of the numerical rating score, visual analog scale, and quality of life assessments during the initial visit. For specific diseases, the health assessment questionnaire/Western Ontario and McMaster Universities Arthritis Index questionnaire for degenerative hip arthritis and the functional index of hand osteoarthritis questionnaire for degenerative hand arthritis were considered. Follow-up evaluations using these scales were included to monitor progress and assess improvements at intervals of 10 treatments.

6) Treatment

The treatment category for degenerative hip arthritis included acupuncture treatments for the Ashi points around the greater trochanter, Juliao (GB 29), Huantiao (GB 30), Yanglingquan (GB 34), Xiaxi (GB 43), and Neiting (ST 44) and trigger points of the iliopsoas, rectus femoris, tensor fasciae latae, gluteus medius, and gluteus minimus.

Herbal medicine prescriptions included Ojeoksan, Dokhwalgisaeng-tang, Daebangpung-tang, and Jakyakgamcho-tang. Chuna therapy included hip mobilization techniques in supine (joint play movements), myofascial chuna technique (rectus femoris [muscle energy technique andstretching] and gluteus medius [strain/counterstrain technique]). Physical therapy included thermotherapy of the cutaneous and muscle meridian and infrared therapy. The number of outpatient visits was adjusted from the standard 10 sessions based on the degree of symptom improvement or deterioration.

In the treatment category for degenerative hand arthritis, acupuncture treatments included Ashi points, Pal-sa (EX-UE9), and Shaohai (HT 3). Herbal medicineprescriptions included Sopunghwalhyeol-tang, Youngsunjetong-Eum, Gumiganghwal-tang, and Daeganghwal-tang. Physical therapy included thermotherapy of the cutaneous and muscle meridian and infrared therapy. The number of outpatient visits was adjusted from the standard 10 sessions based on the degree of symptom improvement or deterioration.

7) Patient education

In the patient education category, the treatment plan and medication guidance were explained during the initial visit. In addition, lifestyle modifications and exercise methods for symptom management were taught. If necessary, the Sasang constitution test was performed to provide personalized education based on the patient’s constitution.

2. Validity verification by the expert group

In the measurement and observation category, three items, including medical history taking, physical examination, and traditional Korean medicine differential diagnosis, had both mean and median values > 8. Notably, the physical examination item, which included inspection, palpation, and physical examinations, had a very high mean value of 9.91.

In the test category, radiological tests (X-ray imaging, CT, MRI, ultrasound, etc.) had both mean and median values of 9; however, Korean medicine tests (HRV, Yangdorak diagnosis, etc.) showed relatively lower values of 6.36 and 7, respectively. In the differential diagnosis category, diseases that need to be differentiated from degenerative hip and hand arthritis were listed, and both the mean of 9.09 and median of 10 indicated that these were highly necessary for the standard CP in Korean medicine.

In the referral category, the necessity of transferring to a higher-level hospital in the case of a “red flag” showed mean and median values of 9.64 and 10, respectively. However, the routine collaborative referral to Western medicine showed relatively lower values of 7.36 and 8, respectively.

In the treatment category, acupuncture, pharmacopuncture, and moxibustion generally showed mean and median values of ≥ 8 and ≥ 9, respectively. However, laser acupuncture had the lowest scores among all items, with mean and median values of 5.64 and 6, respectively.

In the education category, items such as “description of treatment plans” and “medication guidance” had overall mean and median values of ≥ 9. However, “lifestyle habits training according to the Sasang constitution” showed very low scores of 6.45 and 7, respectively.

Other items such as the preparation of treatment consent forms and reassessment of pain and symptoms had mean and median values of 8.00 and ≥ 9, respectively (Table 3).

Table 3 . Results of the standard clinical pathway validity survey.

Item	0	1	2	3	4	5	6	7	8	9	10	Average	Median
Measurement/observation
Measurement: V/S, height, weight	-	-	-	1	-	-	-	1	1	3	5	8.64	9
History taking: onset time, location, pain characteristics, etc.	-	-	-	-	-	-	-	-	-	4	7	9.64	10
Physical examination: inspection, palpation, etc.	-	-	-	-	-	-	-	-	-	1	10	9.91	10
Initial assessment of the pain and symptoms	-	-	-	-	1	-	-	-	-	1	9	9.36	10
Pattern identification: coldness and hotness, stool, sleep, etc.	-	-	-	-	-	-	1	1	4	1	4	8.55	8
Examination
Radiological examination (X-ray, CT, MRI, etc.), blood test	-	-	-	-	-	-	-	2	1	3	5	9.00	9
Korean medicine tests (HRV, DITI, etc.)	-	-	1	1	-	-	2	5	1	-	1	6.36	7
Differential diagnosis
Hip	-	-	-	-	-	-	1	1	1	1	7	9.09	10
a. Rheumatoid arthritis b. Avascular necrosis of the femoral head c. Bursitis d. Femoral nerve entrapment syndrome e. Radiating pain from L-HIVD
Hand	-	-	-	-	-	-	1	-	1	2	7	9.27	10
a. Rheumatoid arthritis b. Gouty arthritis c. Hand sprain d. Trigger resin e. De Quervain’s tendinitis
Medical referral
In case of a red flag, transfer to a higher-level hospital	-	-	-	-	-	-	-	-	1	2	8	9.64	10
Request for collaboration with the medical department	-	-	1	1	-	1	1	1	1	-	5	7.36	8
Treatment
Acupuncture	-	-	-	-	-	-	1	1	1	2	6	9.00	10
Pharmacopuncture	-	-	-	1	-	-	-	1	-	2	7	8.91	10
Laser acupuncture	1	1	-	1	-	2	1	1	2	1	1	5.64	6
Moxibustion	-	-	-	-	-	-	1	3	-	3	4	8.55	9
Cupping therapy	-	-	-	1	-	-	3	1	3	1	2	7.36	8
Herbal medicine	-	-	-	-	-	-	-	1	2	2	6	9.18	10
Chuna manual therapy	-	-	-	1	-	1	-	1	2	1	5	8.18	9
Physical therapy	-	-	-	-	-	2	-	4	2	1	2	7.55	7
Education
Description of the treatment plan	-	-	-	-	-	-	-	-	1	2	8	9.64	10
Medication guidance	-	-	-	-	-	-	-	-	3	4	4	9.09	9
Lifestyle training for symptoms management and exercise training	-	-	-	-	-	-	-	-	2	1	8	9.55	10
Lifestyle habits training according to the Sasang constitution	-	-	1	-	1	2	1	2	2	1	1	6.45	7
Others
Fill out the consent form for chuna manual therapy	-	-	-	-	1	1	1	1	-	1	6	8.27	10
Fill out the consent form for bee venom acupuncture	-	-	-	-	-	2	-	-	2	-	7	8.73	10
Outpatient visit (F/U)
Adjust the treatment frequency based on the symptoms	-	-	-	-	-	-	-	2	1	1	7	9.18	10
Inspection for progress observation F/U	-	-	-	-	-	1	1	-	1	1	7	8.91	10
Reassessment of pain and symptoms	-	-	-	-	-	1	-	1	1	1	7	9.00	10
Check for adverse reactions	-	-	-	-	-	-	1	-	1	-	7	8.73	10
Discharge and completion of treatment
Reassessment of pain and symptoms	-	-	-	-	-	1	-	2	-	1	7	8.91	10
Physical examination, systematic questionnaire, etc.	-	-	-	1	-	-	1	2	-	2	5	8.27	9

V/S, vital sign; CT, computed tomography; MRI, magnetic resonance imaging; HRV, heart rate variability; DITI, digital infrared thermal imaging; L-HIVD, lumbar herniated intervertebral disc; F/U, follow up; -, not applicable..

3. Development of the clinical pathway algorithm

1) Korean medicine clinic

The CP developed for Korean medicine clinics reflected the characteristics of these clinics, which primarily focus on outpatient care. This CP involves conducting a thorough medical history and initial assessment upon the patient’s visit to perform an appropriate traditional Korean medicine differential diagnosis and establishing a customized treatment plan. It primarily includes acupuncture, herbal medicine, and physical therapy and, if necessary, incorporates electroacupuncture or pharmacopuncture. The goal is to continuously monitor changes in the patient’s symptoms, promptly address treatment-related issues, and provide care tailored to the patient’s needs (Figs. 1, 2).

Figure 1. Clinical pathway of degenerative hip arthritis in Korean medicine clinics (algorithm). CT, computed tomography; MRI, magnetic resonance imaging; NRS, numerical rating score; VAS, visual analog scale; QoL, quality of life assessment.

Figure 2. Clinical pathway of degenerative hand arthritis in Korean medicine clinics (algorithm). CT, computed tomography; MRI, magnetic resonance imaging; NRS, numerical rating score; VAS, visual analog scale; QoL, quality of life assessment.

2) Korean medicine hospitals/public medical centers

The CP for Korean medicine hospitals/public medical centers was developed to reflect the characteristics of hospital-level medical institutions that can provide inpatient and outpatient care. This CP encompasses the process from the initial diagnosis and treatment planning to inpatient care, outpatient care, and follow-up observation for patients with degenerative hip and hand arthritis. The treatment is intended to integratively apply methods such as acupuncture, herbal medicine, chuna therapy, and physical therapy through traditional Korean medicine differential diagnosis and treatment planning (Figs. 3, 4).

Figure 3. Clinical pathway of degenerative hip arthritis for Korean medicine hospitals and public medical centers (algorithm). CT, computed tomography; MRI, magnetic resonance imaging; NRS, numerical rating score; VAS, visual analog scale; QoL, quality of life assessment.

Figure 4. Clinical pathway of degenerative hand arthritis for Korean medicine hospitals and public medical centers (algorithm). CT, computed tomography; MRI, magnetic resonance imaging; NRS, numerical rating score; VAS, visual analog scale; QoL, quality of life assessment.

3) Collaborative hospitals

The CP for collaborative hospitals was developed for patients who require integrative care from Korean and Western medicine. This CP involves identifying red flags through thorough medical history taking and physical examinations during the initial evaluation and promptly referring the patient to Western medical care if necessary. The treatment process combined Korean medicine and Western medicine for the selection of various treatment methods based on the patient’s condition. For instance, integrated complex treatments such as electroacupuncture, pharmacopuncture, herbal medicine, and physical therapy are utilized to alleviate pain and improve patient functioning (Figs. 5, 6).

Figure 5. Clinical pathway of degenerative hip arthritis in collaborative hospitals (algorithm). CT, computed tomography; MRI, magnetic resonance imaging; NRS, numerical rating score; VAS, visual analog scale; QoL, quality of life assessment.

Figure 6. Clinical pathway of degenerative hand arthritis in collaborative hospitals (algorithm). CT, computed tomography; MRI, magnetic resonance imaging; NRS, numerical rating score; VAS, visual analog scale; QoL, quality of life assessment.

This study focused on developing a standard CP for patients with degenerative hip and hand arthritis. These conditions are common issues in an aging society and require consistent treatment and management. The CP was designed based on the latest Korean medicine CPGs and was supplemented through a literature review and expert consultation. The goal is to provide consistent treatment across different healthcare institutions.

The results of the expert validity survey showed that the median values of most items were ≥ 8, indicating high validity; therefore, no items needed to be deleted or modified. However, the median values of the three items were ≤ 7.

In the survey question about the necessity of “Korean medicine tests (HRV, Yangdorak diagnosis, DITI, pulsed wave analysis, Sasang constitution, etc.)” in the test category, the median and average values were 7 and 6.36, respectively, with some respondents indicating that these tests are “not necessary at all” for the standard CP. Thus, these tests were perceived as unnecessary in the diagnostic process for degenerative hip and hand arthritis. These conditions primarily result from degenerative changes in the joints and cartilage and are typically diagnosed and managed through physical examinations, imaging (X-ray imaging and MRI), and subjective symptom assessments (pain intensity and functional limitations). Therefore, Korean medicine tests such as HRV, Yangdorak diagnosis, DITI, pulsed wave analysis, and Sasang constitution might be viewed as less directly related to the physical and functional evaluations of these diseases. However, considering that Korean medicine involves comprehensive evaluation and differential diagnosis based on each patient’s constitution and condition, Korean medicine tests remain valid and can have significant clinical utility. For instance, temperature difference was observed between the affected and unaffected sides of patients with degenerative knee arthritis using DITI, and a significant correlation with symptom severity indices was noted [14]. In certain clinical cases, DITI were used for diagnosing patients with goosefoot bursitis, and a comparative study on patients with rheumatoid arthritis according to the Sasang constitution revealed that Soeumin was the most susceptible to rheumatoid arthritis compared with other constitutions [15,16].

In the survey question about the necessity of “laser acupuncture” in the treatment category, the median and average values were 6 and 5.64, respectively, recording the lowest average among all items. This proposes that laser acupuncture is perceived as unnecessary in treating degenerative hip and hand arthritis. These conditions are primarily managed with physical therapy, medications, and, in some cases, surgical interventions, leading to a lower recognition of relatively new treatment methods such as laser acupuncture. In addition, clinical evidence supporting its effectiveness compared with traditional treatment methods may be insufficient. However, studies on the efficacy and safety of laser acupuncture are currently being actively conducted [17]. An animal experimental study that was conducted to observe the combined treatment effects of laser acupuncture and electroacupuncture on osteoarthritis revealed that 650-nm laser acupuncture and electroacupuncture inhibited the collagenase-induced release of inflammatory mediators in osteoarthritis [18]. Future studies may provide concrete evidence on how this treatment can benefit the management of these conditions, thereby clarifying the effectiveness and applicability of laser acupuncture.

In the survey question about the necessity of “lifestyle habits training according to the Sasang constitution” in the education category, the median and average values were 7 and 6.45, respectively, with some respondents indicating that this is “not necessary at all” for the standard CP. This type of education is perceived as unnecessary in the management of degenerative hip and hand arthritis. Typically, education focuses on pain management and exercise therapy, leading to the perception that lifestyle education based on the Sasang constitution, which aims for overall lifestyle improvement rather than addressing specific physical condition changes, does not provide direct therapeutic effects. Despite the importance of direct management, focusing on preventive and overall health promotion is equally crucial. Studies have confirmed that understanding the Sasang constitution and providing systematic and individualized health management according to the constitution can contribute to health maintenance [19]. A study showed constitutional differences in pain areas, medical history, and diagnosis of patients with chronic low back pain and shoulder-arm pain [20]. Therefore, lifestyle education based on the Sasang constitution is still considered useful.

The CP for Korean medicine clinics was developed to reflect the characteristics of these clinics, which primarily focus on outpatient care. During patient visits, a thorough medical history and initial assessment are conducted to perform an appropriate traditional Korean medicine differential diagnosis and establish a customized treatment plan. Because Korean medicine clinics mainly cater outpatients, continuous communication and education with the patient are crucial to ensure treatment continuity and satisfaction. This encourages patients to actively participate in the treatment process, thereby contributing to maximizing treatment outcomes. Korean medicine clinics provide personalized care to patients through close relationships with the local community.

The CP for Korean medicine hospitals and public medical centers was designed considering their use in hospital-level medical institutions. This CP is suitable for inpatient and outpatient care and encompasses initial evaluation, treatment planning, inpatient care, outpatient care, and follow-up observation. This approach allows for responding promptly to changes in the patient’s symptoms and adjusting the treatment plan. However, this integrated approach requires coordination among complex medical procedures and various treatment methods, necessitating close collaboration among healthcare providers. In addition, hospital-level medical institutions can fully utilize various Korean medicine treatments, making it advantageous for providing personalized patient care.

The CP for collaborative hospitals was developed for patients who require integrative care from Korean and Western medicine. This CP involves identifying red flags through thorough medical history taking and physical examinations during the initial evaluation and promptly referring the patient to Western medicine, if necessary. It is designed to combine Korean and Western medicine. The goal is to harmoniously integrate the advantages of both Korean and Western medicine to alleviate the patient’s pain and improve function. The CPGs for degenerative hip and hand joint arthritis, published in May 2024, suggest considering a combination of herbal and conventional medicines to improve pain and function in patients with degenerative hip arthritis. This collaborative model allows comprehensive evaluation of the patient’s condition and provision of holistic care; however, it requires smooth collaboration and information sharing among healthcare providers. In particular, cooperation with Western medicine enables obtaining a more accurate diagnosis and efficient treatment planning. In collaborative hospitals, this approach helps provide more comprehensive medical services to patients.

This study has limitations. First, the CP development process, including this study, did not fully reflect the opinions of a broader range of stakeholders. This carries the risk of not adequately addressing the needs and realities of different healthcare institutions. Despite the need to gather diverse opinions through collaboration with various healthcare institutions, this was not fully achieved because of the limited time and resources.

Second, this study did not directly evaluated the clinical application of the CP. The inability to verify the treatment duration or cost-saving effects after CP implementation is regrettable. This suggests the need for future research to assess the effectiveness of the CP through actual clinical application and supplement the CP based on the results.

Third, the study did not sufficiently consider whether the recommended treatment items are practically available in healthcare institutions. Some recommendations included unprepared treatment methods, making it unclear, which were essential and optional. This could hinder practical applicability in clinical settings, indicating that future research must address these issues to develop a more realistic CP.

Future studies should evaluate the effectiveness of the CP through actual clinical application and perform additional supplementary work. It is necessary to analyze data from CP application in various healthcare institutions to further substantiate the CPs effectiveness and modify and supplement the CP if needed.

In this study, a standard CP was developed for patients with degenerative hip and hand arthritis, and foundational work was conducted for its application. The actual clinical application of the CP is anticipated to demonstrate its effectiveness and provide consistent guidelines for patient treatment, thereby contributing to the improvement of patients’ quality of life. To achieve this, data obtained after applying the CP in various healthcare institutions must be analyzed, and additional supplementary work is warranted to further substantiate the effectiveness of the CP.

Supplementary data is available at https://doi.org/10.13045/jar.24.0026.

Conceptualization: MJK. Data curation: CWS. Formal analysis: All authors. Funding acquisition: MJK. Investigation: CWS. Methodology: MJK. Supervision: MJK. Visualization: CWS. Writing – original draft: CWS. Writing – review & editing: MJK.

The authors have no conflicts of interest to declare.

This research was supported by a grant from the Korea Health Technology R&D Project through the Korea Health Industry Development Institute (KHIDI), funded by the Ministry of Health and Welfare, Republic of Korea (grant number: RS-2021-KH111889).

This research did not involve any human or animal experiments. The figures were acquired from the authors who participated in this study and provided voluntary consent for publication.