Transcript Document

Process for Guideline
Development in Canada
2011 Canadian Hypertension
Education Program
Recommendations
2011 Canadian Hypertension Education
Program (CHEP)
• Canada has had annually updated evidence-based
recommendations since 1999.
• The CHEP process was initiated in 2000 as part of a
national strategy to improve blood pressure control in
Canada.
• The 2000 process was linked to the periodic update
of lifestyle and hypertension management
recommendations in 1999.
2011 Canadian Hypertension
Education Program (CHEP)
• CHEP is based on a systematically developed
annually updated recommendations process linked to
an extensive implementation and evaluation program.
• CHEP scores highly on the ‘AGREE’ instrument and
is consistent with the ‘GRADE’ criteria for assessing
the strength of evidence.
Chest 2006; 129 174-181;
Quality and safety in health care: 12:1:18-23;
Annual Review of Public Health 1996;17:511-538
2011 Canadian Hypertension
Education Program (CHEP)
• Use of CHEP recommendations in clinical practice
requires an integration of the recommendations with
– Individual patient characteristics and preferences
– A consideration of the costs of therapy
2011 Canadian Hypertension
Education Program (CHEP)
• Slide kits and supporting literature can be
downloaded from www.hypertension.ca/chep
• Patient information and recommendations can be
found at www.hypertension.ca/bpc
• An extensive electronic patient support for home
blood pressure measurement and lifestyle change
can be found at www.heartandstroke.ca/bp
CHEP Organizational Chart
Executive Committee
Topic subgroups
Topic subgroups
Implementation
Task Force
Evidence-Based
Recommendations
Task Force
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Central Review
Committee
Topic subgroups
Topic subgroups
Outcomes
Research
Task Force
Canadian Hypertension Education Programs
Knowledge Translation Annual Cycle
Monitor Knowledge Use
Recommendations Task Force
(Knowledge Creation)
Evaluate
Outcomes
By Combining National
and Provincial
Administrative Data
Annual systematic
review and critical appraisal
of studies
Synthesis into
recommendations
Address Barriers to
Knowledge Use
Scientific
Manuscripts
and
Summaries
Adapt Knowledge
To Local/Regional Context
Knowledge Gaps, Best
Practice Goals
Identify New Knowledge, Select
What is Old But Still Important
Outcomes Research Task Force
Implementation Task Force
Tailor Tools for
Interprofessional
Team Members
2011 Canadian Hypertension
Education Program (CHEP)
• EXECUTIVE COMMITTEE: S Tobe (Chair), L Poirier,
O Baclic, F McAlister, G Tremblay, P Lindsay,
D Reid, N Campbell
• CENTRAL REVIEW COMMITTEE: N Khan (Chair), B
Hemmelgarn, R Padwal, M Hill, D Hackam, R Quinn,
S Daskalopoulou, D Rabi
• SUPPORT: Susan Carter at Debut Medical Education
CHEP - MINIMIZING BIAS
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CHEP recognizes bias as a serious threat to
recommendations processes and takes multiple
steps to reduce its impact.
Overt steps taken to reduce bias include:
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A history of requiring a high level of published,
peer-reviewed evidence with patient outcomes for
pharmacotherapy recommendations
A centralized systematic literature review
Multiple members in subgroups to represent different
views
Can J Cardiol 2007;23:551-555
CHEP - MINIMIZING BIAS
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A Central Review Committee (CRC) that is free of
commercial ‘Conflicts of Interest (COI)’ oversees the
evaluation of evidence and development of
recommendations
The CRC presents the evidence/ recommendations at the
consensus conference
The CRC chairs the consensus conference and drafting of
recommendations
Overt written disclosure of potential COI of CHEP
members at the time of the development of the
recommendations
Can J Cardiol 2007;23:551-555
CHEP - MINIMIZING BIAS
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11.
Voting on recommendations with the removal of
recommendations voted against by 30% of members.
Themes, key messages and major implementation tools
are developed through a consensus of the full executive.
Other internal implementation tools require the consensus
of two members of the executive.
External implementation tools must be completely
consistent with the content and intent of CHEP
recommendations and require a consensus of 3 members
of the executive.
The CHEP executive has prioritized minimizing the
potential impact of bias
Can J Cardiol 2007;23:551-555
The Canadian Hypertension
Education Program
A unique Canadian initiative
Can J Cardiol 2006;22:559-64
Evidence Based Recommendations
Task Force Subgroups
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Office Measurement of BP
Follow-up of BP
Risk Assessment
Self-measurement of BP
Ambulatory BP Monitoring
Routine Laboratory Testing
Echocardiography
Lifestyle Modification
Pharmacotherapy of Hypertension in Patients Without Other Compelling
Indications
Pharmacotherapy for Hypertension in Patients with Cardiovascular Disease
Diabetes and Hypertension
Renal and Renovascular Hypertension
Endocrine Forms of Hypertension
Adherence Strategies for Patients
Vascular Protection
Hypertension and Stroke
Recommendations Task Force Membership
S Tobe (Chair), L Poirier (Vice-chair)
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Central Review Committee: N Khan (Chair), B Hemmelgarn, R Padwal, M Hill, D Hackam, R Quinn, S
Daskalopoulou, D Rabi
Accurate Measurement of BP: L Cloutier, K Mann, M Lamarre-Cliche
Adherence Strategies for Patients: T Campbell (Chair), A Milot; J Stone, R Feldman, D Drouin
Follow-up of BP: P Bolli (Chair), G Tremblay
Risk Assessment: S Grover (Chair), G Tremblay, A Milot
Self-measurement of BP: D McKay (Chair), A Chockalingam, D McLean
Ambulatory BP Monitoring: M Myers (Chair), M Dawes
Routine Laboratory Testing: T Wilson (Chair); B Penner
Echocardiography: G Honos (Chair)
Lifestyle Modification: R Touyz (Chair), N Campbell, R Petrella, L Trudeau, S Bacon
Pharmacotherapy of Hypertension in Patients Without Other Compelling Indications:
R Herman (Chair), E Burgess, G Carruthers, G Fodor, P Hamet, R Lewanczuk, G Pylypchuk, G Dresser
Pharmacotherapy for Hypertension in patients with Cardiovascular Disease:
S Rabkin (Chair), M Arnold, G Moe, J-M Boulanger, J Howlett
Hypertension & Stroke: P Lindsay (Chair), J-M Boulanger, M Sharma
Hypertension & Diabetes: P Larochelle (Chair), R Gilbert, L Leiter, R Ogilvie, C Jones, S Tobe, V Woo
Renal and Renovascular HTN: M Ruzicka (Chair), K Burns, S Tobe, M Vallee, R Prasad, M Lebel
Endocrinological Forms of Hypertension: E Schiffrin (Chair)
Vascular Protection: R Feldman (Chair), R Hegele, P McFarlane, E Schiffrin
2011 Canadian Hypertension Education
Program : The Process
• Subgroups systematically reviewed the literature
using a Cochrane librarian and supplemented the
search with personal files to August 2010
• Application of an evidence-based grading scheme
• Use of a Central Review Committee comprised of
methodologists to improve consistency of grading
• 1 day conference to discuss recommendations and
evidence (Sept 2010)
• National presentation of draft recommendations
(International Society of Hypertension, Sept 2010)
• Voting and ratification of recommendations achieving
>70% acceptance (Nov 2010)
Level of evidence used by the CHEP
Grade
A
B
C
Internal validity
Precision
Applicability
Adequate randomized controlled
Statistically significant results
Clinically relevant mortality
trial (RCT) or subgroup analysis
OR adequate statistical power
or morbidity outcome
OR systematic review of adequate
to exclude clinically important
measure and representative
RCT with similar Rx arms
differences
population
Adequate RCT or
Inadequate statistical power to
Validated surrogate outcome
subgroup analysis OR
exclude clinically important
measure OR extrapolation of
systematic review of similar RCT
differences OR systematic
results from another population
using similar Rx arms
review with heterogeneity
Inadequate RCT or
Studies in which the 95%
Validated surrogate outcome
subgroup analysis OR
confidence intervals do not
measure OR extrapolation of
cohort/case controlled studies
exclude meaningful contrary
results from another population
OR systematic review of RCT with
conclusions
Rx arms from different studies
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None of the above
None of the above
None of the above
Algorithms used by CHEP to assess the
grading of recommendations
METHODOLOGY
The implementation of recommendations
Can J Cardiol 2006;22:595-98.
2011 Canadian Hypertension
Education Program (CHEP)
Implementation of CHEP recommendations is a
task for all CHEP members
Implementation Task Force Membership
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Recommendations Tools Division
– Chair: Patrice Lindsay
– Admin support: Susan Carter
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HCP Tools Division
– Co-Chairs: Guy Tremblay, Deb Reid
– Admin Support: Jocelyne Bellerive
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Continuing Health Professional Education and Development Division
– Chair: Sheldon Tobe
– Admin Support: Diane Hua
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ITF Members
– Greater than 40 members including GPs, Specialists, Pharmacists, Nurses
and other health care professionals.
Some annual dissemination initiatives
• Key messages and themes are updated annually
• Publications (3-4 summaries plus full scientific
documents) with more than 40 publications by or on
CHEP in 2010
• CHEP pocket cards (>100,000) and booklets (10,000)
• Dissemination through the websites
• Wall posters
• CHEP's "Train the Trainer" Sessions
Some annual dissemination initiatives
• Management algorithms
• PowerPoint slide sets
• Endorsement or co-development of education
programs with Rx&D companies
• Development of health care professional networks
(family doctors, nurses, dietitians, pharmacists,
internists, cardiologists, nephrologists, stroke
neurologists)
2011 Canadian Hypertension
Education Program (CHEP)
A slide kit and other educational resources can be
downloaded from
http://www.hypertension.ca
2011 Canadian Hypertension
Education Program (CHEP)
• In the slide kit, special color codes have been associated
with specific types of information.
• Here are some examples:
Explanation,
Recommendation
Statement, or List
Important
comment,
Warning
• A red flag has been posted where recommendations
were updated for 2011.
Reminder
Do not
Do not
Interprofessional Executive Summaries
Canadian Hypertension Recommendations.
“ A summary for everyone”
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1 page - clinical
4 page – short summary - clinical
6 page - scientific
4 page - public translation
CHEP booklet
Spiral book (Full recommendations and scientific summary)
METHODOLOGY
The evaluation of recommendations
Can J Cardiol 2006;22:556-558.
Outcomes Research Task Force
• An Outcomes Research Task Force was developed
to assess the impact of CHEP on hypertension
management
• A new slide set outlining changes in hypertension
management in Canada is available at
www.hypertension.ca
• Details of the Task Force mandate and methods can
be found in Can J Cardiol 2006;22:556-558.
Outcomes Research Task Force (ORTF)
• Collaborative effort with the Public Health Agency of
Canada, Statistics Canada, provinces and
organizations to develop a national surveillance
system for hypertension
• Subgroups include:
1. Physical Measures Surveys
2. IMS Health Compuscript data
3. Provincial Administrative Databases
4. National Questionnaire Surveys
5. National Hospitalization and Mortality Data
6. Economic Analysis of Hypertension Management
Canadian Hypertension Education Program
Outcomes Research Task Force: Finlay McAlister (Chair), Oliver Baclic (Vice-chair)
Christina Bancej
Michel Joffres
Hude Quan
Gillian Bartlett
Helen Johansen
Kim Reimer
Asako Bienek
Janusz Kaczorowski
Chris Robinson
Norm Campbell
Nadia Khan
Cynthia Robitaille
Guanmin Chen
Scott Klarenbach
Mark Smith
Sulan Dai
Patty Lindsay
Larry Svenson
Steven Grover
Lisa Lix
Gary Teare
Femida Gwadry-Sridhar
Marianne Gee
Karen Tu
Brenda Hemmelgarn
Robert Nolan
Sheldon Tobe
Michael Hill
Raj Padwal
Robin Walker
Stephen Phillips
Andrew Wielgosz
Kelly Zarnke
Physical Measures Surveys
Statistics Canada will have results of a national physical
measures survey assessing hypertension
prevalence, awareness, treatment and control in
2011
2011 Canadian Hypertension
Education Program (CHEP)
• CHEP HAS THE ABILITY TO IDENTIFY
MANAGEMENT ISSUES
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Gender differences
Age variability
Ethnic differences
Regional differences
Appropriateness and intensity of therapy
Temporal trends
Persistence with therapy
2011 Canadian Hypertension
Education Program (CHEP)
• Canada has had continuously updated hypertension
management recommendations since 1999
• A rigorous methodology is used to ensure the
recommendations are reliable
• An extensive implementation process is used to
ensure tools are available to aid uptake of the
recommendations in clinical practice
• The evaluation process is still being established but
preliminary data support a large increase in diagnosis
and treatment of hypertension
• For health care professionals
– sign up at
www.htnupdate.ca for
automatic updates and on
current hypertension
educational resources
• For your patients – ask them
to sign up at
www.myBPsite.ca for free
access to the latest
information & resources on
HBP