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 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; ; Quality and safety in health care: 12:1:18-23; Annual Review of Public Health 1996;17:

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 Patient information and recommendations can be found at An extensive electronic patient support for home blood pressure measurement and lifestyle change can be found at

CHEP Organizational Chart Outcomes Research Task Force Evidence-Based Recommendations Task Force ________________ Central Review Committee Implementation Task Force Executive Committee Topic subgroups

Recommendations Task Force (Knowledge Creation) Annual systematic review and critical appraisal of studies Synthesis into recommendations Scientific Manuscripts and Summaries Identify New Knowledge, Select What is Old But Still Important Adapt Knowledge To Local/Regional Context Address Barriers to Knowledge Use Tailor Tools for Interprofessional Team Members Monitor Knowledge Use Evaluate Outcomes By Combining National and Provincial Administrative Data Knowledge Gaps, Best Practice Goals Implementation Task Force Outcomes Research Task Force 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:

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:

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:

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 above D 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:

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

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 Do not Explanation, Statement, or List Recommendation Important comment, 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:

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 Details of the Task Force mandate and methods can be found in Can J Cardiol 2006;22:

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 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

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