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

OutcomesResearch

Task Force

Evidence-BasedRecommendations

Task Force________________

Central ReviewCommittee

ImplementationTask Force

Executive Committee

Topic subgroups

Topic subgroups

Topic subgroups

Topic subgroups

Recommendations Task Force(Knowledge Creation)

Annual systematic review and critical appraisal

of studies

Synthesis into recommendations

ScientificManuscripts

and Summaries

Identify New Knowledge, Select What is Old But Still Important

Adapt KnowledgeTo Local/Regional Context

Address Barriers to Knowledge Use

Tailor Tools for Interprofessional Team Members

Monitor Knowledge Use

EvaluateOutcomes

By Combining National and Provincial

Administrative Data

Knowledge Gaps, Best Practice Goals

Imp

lemen

tation

Task F

orce

Ou

tcom

es Research

Task F

orce

Canadian Hypertension Education Programs Knowledge Translation Annual Cycle

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

• 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: 1. A history of requiring a high level of published,

peer-reviewed evidence with patient outcomes for pharmacotherapy recommendations

2. A centralized systematic literature review

3. Multiple members in subgroups to represent different views

Can J Cardiol 2007;23:551-555

CHEP - MINIMIZING BIAS

4. A Central Review Committee (CRC) that is free of commercial ‘Conflicts of Interest (COI)’ oversees the evaluation of evidence and development of recommendations

5. The CRC presents the evidence/ recommendations at the consensus conference

6. The CRC chairs the consensus conference and drafting of recommendations

7. 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

8. Voting on recommendations with the removal of recommendations voted against by 30% of members.

9. 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.

10. 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.

11. 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

• 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)

• 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)

Adequate randomized controlled

trial (RCT) or subgroup analysis

OR systematic review of adequate

RCT with similar Rx arms

None of the aboveNone of the aboveNone of the aboveD

Validated surrogate outcome

measure OR extrapolation of

results from another population

Clinically relevant mortality

or morbidity outcome

measure and representative

population

Validated surrogate outcome

measure OR extrapolation of

results from another population

ApplicabilityPrecision Internal validityGrade

Studies in which the 95%

confidence intervals do not

exclude meaningful contrary

conclusions

Inadequate statistical power to

exclude clinically important

differences OR systematic

review with heterogeneity

Statistically significant results

OR adequate statistical power

to exclude clinically important

differences

Inadequate RCT or

subgroup analysis OR

cohort/case controlled studies

OR systematic review of RCT with

Rx arms from different studies

C

Adequate RCT or

subgroup analysis OR

systematic review of similar RCT

using similar Rx arms

B

A

Level of evidence used by the CHEP

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

• Recommendations Tools Division– Chair: Patrice Lindsay – Admin support: Susan Carter

• HCP Tools Division

– Co-Chairs: Guy Tremblay, Deb Reid– Admin Support: Jocelyne Bellerive

• Continuing Health Professional Education and Development Division– Chair: Sheldon Tobe– Admin Support: Diane Hua

• 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

• In the slide kit, special color codes have been associated with specific types of information.

• Here are some examples:

• A red flag has been posted where recommendations were updated for 2011.

Do not

Explanation,

Statement, or List

Recommendation Importantcomment,Warning

Reminder Do not

2011 Canadian Hypertension Education Program (CHEP)

Interprofessional Executive Summaries

Canadian Hypertension Recommendations.

“ A summary for everyone”

– 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 Surveys2. IMS Health Compuscript data3. Provincial Administrative Databases4. National Questionnaire Surveys5. National Hospitalization and Mortality Data6. Economic Analysis of Hypertension Management

Canadian Hypertension Education Program

Outcomes Research Task Force: Finlay McAlister (Chair), Oliver Baclic (Vice-chair)

Christina Bancej

Gillian Bartlett

Asako Bienek

Norm Campbell

Guanmin Chen

Sulan Dai

Steven Grover

Femida Gwadry-Sridhar

Brenda Hemmelgarn

Michael Hill

Michel Joffres

Helen Johansen

Janusz Kaczorowski

Nadia Khan

Scott Klarenbach

Patty Lindsay

Lisa Lix

Marianne Gee

Robert Nolan

Raj Padwal

Stephen Phillips

Hude Quan

Kim Reimer

Chris Robinson

Cynthia Robitaille

Mark Smith

Larry Svenson

Gary Teare

Karen Tu

Sheldon Tobe

Robin Walker

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– 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