1. Evidence Reviews for… Canadian Clinical Preventive Guidelines for Newly Arriving Immigrants and Refugees for Primary Care Practitioners Kevin Pottie MD MClsSc Centre for Global Health, Institute of Population Health, University of Ottawa Website: www.ccirh.uottawa.ca

2. Policy Implications Disease surveillance: Statistics Canada to routinely disaggregate morbidity and mortality data for immigrants and refugees Need to define and study Health Settlement Need to link IME, settlement with primary care practitioners and community brokers- health settlement model Need to study health literacy and language proficiency as predictors of health settlement

3. (www.ccirh.uottawa.ca) Canadian Collaboration for Immigrant and Refugee Health (CCIRH) (www.ccirh.uottawa.ca) 43 Delphi participants 23 Interdisciplinary chapter teams 10 Steering Committee Members: Kevin Pottie (co-chair), Peter Tugwell (co-chair), John Feightner, Vivian Welch, Chris Greenaway, Laurence Kirmayer, Helena Swinkels, Meb Rashid, Lavanya Narasiah, Noni MacDonald 7 Collaborating Partners: Public Health Agency of Canada, Citizenship and Immigrant Canada, IOM, Edmonton Multicultural Health Broker, Calgary Refugee Program, Champlain LIHN, CIHR. 7 Collaborating Partners: Public Health Agency of Canada, Citizenship and Immigrant Canada, IOM, Edmonton Multicultural Health Broker, Calgary Refugee Program, Champlain LIHN, CIHR.

4. Evidence-Based Methods for Clinical Actions Synthesis of Effectiveness of: what works implementation how it works resource effectiveness - at what cost/benefit? experiential effectiveness - users views likely diversity of effectiveness

5. Health Settlement CIC Immigration Medical Exam and health system information Canadian Settlement Services Canadian Urgent care-ER Primary and Preventive Health Care Community Lay Health Promoters

7. Overview CCIRH Project Objective of Project Delphi Selection Evidence Reviews GRADE approach to Recommendations Recommendations Dissemination

8. Project Objective Develop evidence-based clinical preventive guidelines for immigrants and refugees new to Canada (focus on first 5 years) for primary care practitioners.

9. Canadian Context > 70 % of immigrants to Canada from LMIC Canadian Census 2006 Issues: – increased mortality from preventable and treatable illness DesMeules 2005 – lower health care and preventive service utilization rates

10. Health Status of New Immigrants Healthy Immigrant Effect (due to pre- selection) Lower all cause mortality (SMR=0.34-0.40) BUT Singh Can J Public Health 2004:95:14-21 DesMeules Can J Public Health 2004:95:22-26 DesMeules J Imm Health 2005:7:221-232

11. Standardized Mortality Ratios in Immigrants as compared to Canadians Immigrant Males Immigrant Females Refugee Males Refugees Females SMR95% CISMR95% CISMR95% CISMR95% CI All Cause 0.340.33- 0.35 0.40.39-0.410.480.45-0.510.580.54-0.63 Infectious Diseases 0.80.66- 0.94 0.910.69-1.130.720.54-0.911.971.2-2.7 AIDS 1.00.77- 1.24 3.662.1-5.230.620.41-0.84 Hepatitis 1.781.05- 2.51 3.811.87-5.67 All Cancers 0.380.36- 0.41 0.40.38-0.430.590.53-0.660.620.54-0.7 Nasopharyngeal 2.91.51- 4.24 Liver cancer 2.181.69- 2.68 1.771.18-2.374.893.29-6.49 DesMeules J Imm Health 2005:7:221-232

12. 2007 National Physician Survey 83% of family physicians provide care for recent immigrants to Canada 6.4% family physicians report that recent immigrants make up greater than 10% of their practice. – 41.0 % were less than 45 years or age – 53.2 % spoke two or more languages – 79.9 % were from urban/suburban and inner city practice location

13. Practitioner Perspective 1. Practitioners face differing patterns of prevention priorities (Dental, Hep B, PTSD) 2. Practitioners face new clinical management challenges (i.e. intestinal parasites, HIV pre-test counseling) 3. Practitioners face implementation challenges (language and culture barriers, immigrants limited exposure to preventive and chronic care)

14. Immigrant and Refugee Preventive Care Checklist First visit Second visit (2-7 days) Third visit (1-3 mo) Later visits (3-6 mo) Psychosocial assessment Housing situation Religious beliefs Watch for signs for PTSD Watch for depression Education Counseling (breastfeeding) Exercise STD prevention Cervical screening Travel home (e.g., malaria) Dental care Screening investigations Mantoux skin test CBC diff, ferritin (children, females) Varicella titre Hep B Ag/Ab HIV with informed consent Stool for O&P X 3 Urine pregnancy test Chest x-ray if mantoux >10mm Immunizations Children: age dependent (DPT-P, MMR, Hib, etc.) Adults: DPT, MMR Influenza Varicella (non- immune) DPT booster Hep A Hep B

15. Overview Objective of Project Delphi Selection Evidence Reviews GRADE approach to Recommendations Recommendations Dissemination

16. Delphi Selection Process Selecting priority preventable and treatable conditions for recently arrived immigrants and refugees Importance Usefulness Disparity (Oxman et al WHO priority setting 2006)

17. 20 selected conditions Infectious Diseases Hepatitis B* Hepatitis C HIV/ AIDS* Intestinal Parasites* Malaria MMR/DPTP-HIB Syphilis Tuberculosis* Varicella (Chicken Pox) Mental Health Depression * Abuse and Domestic Violence * Anxiety and Adjustment Disorder * Torture and Post Traumatic Stress Disorder* Other Chronic Disease Cancer of the Cervix Contraception Diabetes* Dental Caries/Peridontal disease* Iron Deficiency Anemia* Pregnancy Care Vision Disorders Swinkels H, Pottie K, Tugwell P, Rashid M, Narasi8h L. Selecting Priority Preventable and Treatable Conditions for Recently Arrived Immigrants and Refugees to Canada: Delphi Consensus. 2009 (under peer review CMAJ)

18. Overview Objective of Project Delphi Selection Evidence Reviews GRADE approach to Recommendations Recommendations Dissemination

19. Methods We adapted methods for conducting evidence reviews (Canadian/US Task Force (Harris 2001), Cochrane Collaboration, NICE) We adapted GRADE Collaboration approach for making evidence-based recommendations (GRADE approach: Guyatt et al: BMJ 2008 series).

20. CCIRH 14 Step Methods Process Logic model approach developed by the (U.S. and Can Task Forces) Search strategies and summary of findings tables and equity considerations (Cochrane Equity) Review Appraisals (NICE; AGREE, EPOC) Quality assessment (GRADE collaboration)

21. Step 1: Clinician Summary Table PopulationImmigrant/Refugee Adults Immigrant/Refugee Children (under 5) Clinical ConclusionsA – Service X is recommendedD – Service X is not recommended Population Specific Clinical Considerations (burden of disease, baseline risk, adverse outcomes: mortality and morbidity, genetic and culture issues, compliance variation) Condition X is more common among: - Immigrants/refugees from sub-Saharan countries of origin (list countries) - Adult men are less likely to be screened for condition X Clinical Actions during MigrationDuring migration refugees / immigrants are/are not screened/treated for condition X (Based on the Citizenship and Immigrant Canada Health Examination, and International Organization Pre-Departure Screening/Treatment) Screening testsCondition X is diagnosed with test Y. When using test Y the following clinical criteria indicate a positive result: For Men: For Women: Screening intervalNot applicable – only one screen in adulthood within health settlement period needed TreatmentTreatment includes: Other Guideline Sources Health Canada also recommends screening for this condition; their recommendation states that….. This document can be found at: www. Implementation Issues and Cost Reference Cost of treatment …., barriers to provision of services… The full recommendation paper can be found at: www.

22. Step 2: Develop Logic model and key questions Adapted from US Task Force

23. Value-Added Evidence-Based Approach clinical preventive action and weigh desirable and undesirable effects population specific clinical considerations implementation issues

24. Extrapolation (Cochrane Equity) – Baseline risk – Clinically important outcomes – Genetic and cultural factors (diet, lifestyle) – Compliance variation (patient and physician adherence)

25. Overview Objective of Project Delphi Selection Evidence Reviews GRADE Approach to Recommendations Recommendations Dissemination

26. Making a recommendation degree of confidence that desirable effects of adhering to recommendation outweigh the undesirable effects. degree of confidence that desirable effects of adhering to recommendation outweigh the undesirable effects. Desirable effects health benefitshealth benefits less burdenless burden savingssavings Undesirable effects harmsharms more burdenmore burden costscosts

27. The Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) Reviewed existing grading systems Developed a system for grading the quality of evidence and strength of recommendations of CPGs that has done its best to address disadvantages of prior systems : – the lack of separation between quality of evidence and strength of recommendation, – the lack of transparency about judgments, – the lack of explicit acknowledgment of values and preferences. Atkins D, Best D, Briss PA, Eccles M, Falck-Ytter Y, Flottorp S, Guyatt GH, Harbour RT, Haugh MC, Henry D, et al. Grading quality of evidence and strength of recommendations. BMJ 2004;328:1490.

28. GRADE uptake UpToDate World Health Organization British Medical Journal American Thoracic Society ACP Cochrane Collaboration ACP Cochrane Collaboration BMJ Clinical Evidence Polish Institute for EBM BMJ Clinical Evidence Polish Institute for EBM Society of Vascular Surgery Society of Pediatric Endocrinology Society of Vascular Surgery Society of Pediatric Endocrinology European Respiratory Society American Endocrine Society European Respiratory Society American Endocrine Society Society of Critical Care Medicine Surviving sepsis campaign Society of Critical Care Medicine Surviving sepsis campaign American College of Chest Physicians European Soc of Thoracic Surgeons American College of Chest Physicians European Soc of Thoracic Surgeons EBM Guidelines Finland Allergic Rhinitis in Asthma Guidelines EBM Guidelines Finland Allergic Rhinitis in Asthma Guidelines National Institute for Clinical Excellence (NICE) National Institute for Clinical Excellence (NICE) Agency for Health Care Research and Quality (AHRQ) Agency for Health Care Research and Quality (AHRQ) Swedish National Board of Health and Welfare Swedish National Board of Health and Welfare Canadian Agency for Drugs and Technology in Health Canadian Agency for Drugs and Technology in Health Ontario MOH Medical Advisory Secretariat Ontario MOH Medical Advisory Secretariat Agencia sanitaria regionale, Bologna, Italia Agencia sanitaria regionale, Bologna, Italia The German Agency for Quality in Medicine The German Agency for Quality in Medicine Evidence-based Nursing Sudtirol, Alta Adiga, Italy Evidence-based Nursing Sudtirol, Alta Adiga, Italy Norwegian Knowledge Centre for the Health Services Norwegian Knowledge Centre for the Health Services University of Pennsylvania Health System Center for EB Practice University of Pennsylvania Health System Center for EB Practice Journal of Infection in Developing Countries - International Journal of Infection in Developing Countries - International

29. Making Recommendations (GRADE Approach) Determine GRADE Question (PICOT) Determine most important positive and negatives outcomes (SoF table) Rate quality of evidence (directness) Determine recommendation (yes/no)

30. GRADE Approach Balancing Desirable and Undesirable Effects Quality of the Evidence Values and Patient Preferences Cost (Resource Allocation) GRADE: The Grades of Recommendation, Assessment, Development, and Evaluation

31. Dissemination Canadian Medical Association Journal and (electronic CMAJ-web) Dissemination

32. Proposed CMAJ e-guideline 6 introductory chapters – Summary of Recommendations – Migration and Health Overview – Needs Assessment: Selecting Priority Conditions – Evidence-Based Methods – Pediatric Context – Mental Illness overview 10 conditions: evidence reviews over 2 phases academic publications (up to 4000 words)

33. Proposed CMAJ Supplement (English/ French) 1. Overview 2. Guideline Development Process/Methods 3. Working with interpreters, culture-brokers and community resources 4. One page Clinical Action GRADE Recommendations 5. Clinical use of Guidelines: – Conducting a migration history – Special Populations – Preventive care checklist (practical implementation tool) References and Committee Members

34. Policy Implications Disease surveillance: Stats Canada to routinely disaggregate morbidity and mortality data Need to define and study Health Settlement Need to link IME, settlement with primary care practitioners and community brokers- health settlement model Need to study health literacy and language proficiency as predictors of health settlement

35. THANK YOU