Title: Methodology
1Methodology
22008 Canadian Hypertension Education Program
- 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. -
32008 Canadian Hypertension Education Program
(CHEP)
- The CHEP is based on a systematically developed
annually updated recommendations process linked
to an extensive implementation and evaluation
program. - CHEP is based on the AGREE protocol and meets
the GRADE criteria for producing guidelines.
42008 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
52008 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
6CHEP Organizational Chart
Steering Committee
Executive Committee
Evidence-Based Recommendations Task
Force ________________ Central Review Committee
Topic subgroups
Topic subgroups
Topic subgroups
Topic subgroups
Outcomes Research Task Force
Implementation Task Force
72008 Canadian Hypertension Education Program
(CHEP)
STEERING COMMITTEE N Campbell (Chair, BPC), R
Touyz (CHS), M Godwin (CFPC), M Lum-Kwong (HSFC),
L Vardy (PHAC), S Matheson (CCCN), L Poirier
(CPA), J Kaczorowski, R Lewanczuk, O Baclic, S
Tobe, M Lebel, F McAlister EXECUTIVE COMMITTEE N
Campbell (Chair), J Kaczorowski, O Baclic, S
Tobe, M Lebel, R Lewanczuk, F McAlister CENTRAL
REVIEW COMMITTEE B Hemmelgarn (Chair), F
McAlister, C Bell, N Khan, R Padwal, M Hill, J
Mahon SUPPORT Susan Carter and Grace Apea Ata
at Debut Medical Education
8Sponsoring organizations and partners
- Sponsoring organizations
- Blood Pressure Canada
- Canadian Council of Cardiovascular Nurses
- Canadian Hypertension Society
- Canadian Pharmacy Association
- College of Family Physicians of Canada
- Heart and Stroke Foundation of Canada
- Public Health Agency of Canada
- Partner organizations
- Canadian Cardiovascular Society
- Canadian Society of Nephrology
- Canadian Stroke Network
- Canadian Society of Internal Medicine
- Kidney Foundation of Canada
- Volunteers (gt100)
9Financial Support
In creating the 2008 recommendations, CHEP
received financial support from the Public Health
Agency of Canada, the Canadian Hypertension
Society and the Canadian Institute for Health
Research. CHEP receives indirect support from
the Heart and Stroke Foundation and Blood
Pressure Canada CHEP outcomes studies have been
supported by the Public Health Agency of Canada,
Canadian Institute for Health Research and the
Heart and Stroke Foundation
10CHEP - 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
- 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
11CHEP - MINIMIZING BIAS
- A Central Review Committee (CRC) that is free of
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
12CHEP - MINIMIZING BIAS
- 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
13METHODOLOGYthe production of recommendations
Can J Cardiol 200622559-64
14Recommendations Task Force Membership
S Tobe (Chair), M Lebel (Vice-chair) Central
Review Committee B Hemmelgarn (Chair), C Bell, M
Hill, J Mahon, N Khan, F McAlister, R
Padwal Accurate Measurement of BP C Abbott
(Chair), K Mann, L Cloutier Adherence Strategies
for Patients T Campbell (Chair), A Milot J
Stone, R Feldman 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 Ambulatory BP
Monitoring M Myers (Chair), M Dawes Routine
Laboratory Testing T Wilson (Chair) B Penner, E
Burgess Echocardiography G Honos
(Chair) Lifestyle Modification R Touyz (Chair),
N Campbell, R Petrella, L Trudeau, P
Katzmarzyk Pharmacotherapy of Hypertension in
Patients Without Other Compelling Indications
R Herman (Chair), G Carruthers, J DeChamplain,
G Fodor, P Hamet, R Lewanczuk, G
Pylypchuk Pharmacotherapy for Hypertension in
patients with Cardiovascular Disease S Rabkin
(Chair), M Arnold, G Moe, Jean-Martin
Boulanger Diabetes P Larochelle (Chair), L
Leiter, R Ogilvie, C Jones, S Tobe, V Woo, P
McFarlane Renal and Renovascular HTN S Tobe
(Chair), K Burns, M Ruzicka Endocrine forms of
hypertension E Schiffrin (Chair) Vascular
Protection E Schiffrin (Chair), R Hegele, P
McFarlane, R Feldman
15Evidence 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
- Concordance Strategies for Patients
- Vascular Protection
162008 Canadian Hypertension Education Program
The process
- Subgroups systematically reviewed the literature
using a Cochrane librarian and supplement the
search with personal files to Sept 2007 - 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 (Oct 2007) - National presentation of draft recommendations
(Canadian Cardiovascular Congress, Oct 2007) - Voting and ratification of recommendations
achieving gt70 acceptance (Nov 2007)
172008 Canadian Hypertension Education Program
(CHEP)
- Detailed methodology of the system to grade
evidence can be found in Can J Cardiol
200622559-64.
18Level of evidence used by the CHEP
Applicability
Precision
Internal validity
Grade
Adequate randomized controlled trial (RCT) or
subgroup analysis OR systematic review of
adequate RCT with similar Rx arms
Clinically relevant mortality or morbidity
outcome measure and representative population
Statistically significant results OR adequate
statistical power to exclude clinically
important differences
A
Validated surrogate outcome measure OR
extrapolation of results from another population
Inadequate statistical power to exclude
clinically important differences OR systematic
review with heterogeneity
Adequate RCT or subgroup analysis OR systematic
review of similar RCT using similar Rx arms
B
Validated surrogate outcome measure OR
extrapolation of results from another population
Studies in which the 95 confidence intervals do
not exclude meaningful contrary conclusions
Inadequate RCT or subgroup analysis
OR cohort/case controlled studies OR systematic
review of RCT with Rx arms from different studies
C
None of the above
None of the above
None of the above
D
19Algorithms used by CHEP to assess the grading of
recommendations
20METHODOLOGYthe implementation of recommendations
Can J Cardiol 200622595-98.
212008 Canadian Hypertension Education Program
(CHEP)
- Implementation of CHEP recommendations is a task
for all CHEP members
22Implementation Task Force Membership
- Pharmacists Sub-group Ross Tsuyuki
- Luc Poirier
- William Semchuk
- Ann Thompson
- Website
- Faisal Jandhir (chair)
- Sheldon Tobe
- Janusz Kaszorowski
- Guy Tremblay
- Cindy Bolton
- Ann Thompson
-
- Members at largeJean-Martin Boulanger
(Neurology)Anil Gupta (Cardiology)Ross Feldman
Norm Campbell Sheldon TobeAlain Milot Guy
TremblayRhian Touyz Oliver Baclic - Rick Ward
- Co-ChairsJanusz Kaczorowski
- Richard Lewanczuk
- Nurses Sub-groupJo-Anne Costello Lyne Cloutier
- Cindy Bolton
- Teri Green
- Donna McLean
- Sandra Matheson
- Family Physician Sub-groupMartin Dawes John
Hickey Robert Petrella - Mark Gelfer
-
232008 Canadian Hypertension Education Program
(CHEP)
- The College of Family Physicians of Canada, The
Canadian Pharmacy Association and the Canadian
Council of Cardiovascular Nurses joined the CHEP
steering committee to oversee the integrity and
relevance of the process for their disciplines
and to aid dissemination - Specific subgroups of nurses, pharmacists and
family doctors were formed to tailor the tools
and messages to their discipline and develop
dissemination strategies and networks within
their discipline.
24Some 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 2007 - CHEP pocket cards (gt100000) and booklets (10000)
- Dissemination through the websites
- Wall posters
- CHEP's "Train the Trainer" Sessions
25Some annual dissemination initiatives
- Management algorithms
- Power point slide sets
- Endorsement or co-development of education
programs with RxD companies - Media releases with the Heart and Stroke
Foundation - Development of health care professional networks
(family doctors, nurses and pharmacists,
internists, cardiologists, nephrologists, stroke
neurologists)
262008 Canadian Hypertension Education Program
(CHEP)
- A slide kit and other educational resources can
be downloaded from http//www.hypertension.ca
272008 Canadian Hypertension Education Program
(CHEP)
In the slide kit, special color codes have been
associated with specific types of
information. Here are some examples
Reminder
- A red flag is been posted where recommendations
were updated for 2008.
28Interdisciplinary Executive Summaries
Canadian Hypertension Recommendations. A
summary for everyone.
1 page - clinical 4 page - clinical 6 page -
scientific 4 page - public patient
29METHODOLOGYthe evaluation of recommendations
Can J Cardiol 200622556-558.
30Outcomes 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 200622556-558.
31Outcomes 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
- Physical Measures Surveys
- IMS Health Compuscript data
- Provincial Administrative Databases
- National Questionnaire Surveys
- National Hospitalization and Mortality Data
- Economic Analysis of hypertension management
32Canadian Hypertension Education Program
Outcomes Research Task Force Finlay McAlister
(Chair), Oliver Baclic (Vice-chair)
Michel Joffres Helen Johansen Janusz
Kaczorowski Nadia Khan Patty Lindsay Lisa Lix Wei
Luo Colleen Maxwell Finlay McAlister Robert
Nolan Jay Onysko
Gillian Bartlett Asako Bienek Rollin Brant Norm
Campbell Guanmin Chen Denis Drouin Bill
Ghali Steven Grover Femida Gwadry-Sridhar Brenda
Hemmelgarn Michael Hill
Raj Padwal Stephen Phillips Hude Quan Chris
Robinson Mark Smith Larry Svenson Greg
Taylor Karen Tu Lianne Vardy Robin Walker Andrew
Wielgosz Kelly Zarnke
33Physical Measures Surveys
- Statistics Canada will have results of a national
physical measures survey assessing hypertension
prevalence, awareness, treatment and control in
2009
34Changes in antihypertensive prescriptions in
Ontario using IMS Compuscript data
CHEP was initiated in 1999
Hypertension 2006 4722-28
35Changes in initiation of antihypertensive
prescriptions in elderly Ontarians using
provincial administrative data
Hypertension 2006 4722-28
36National Questionnaire Surveys (Canadian
Community Health Surveys (CCHS), National
Population Health Surveys (NPHS)
- Large national questionnaire surveys
- Results are representative of the Canadian
population
37Changes in Diagnosis of Hypertension in Canada
1994-2003
- Post 1999 compared
- to pre 1999
- Marked increase in the rate of diagnosis of
hypertension - Closing of the gender gap
National Questionnaires (CCHS,
NPHS) Hypertension 200648853-60
38Changes in Treatment of Hypertensionin Canada
1994-2003
- Post 1999 compared
- to pre 1999
- Doubling of the rate of treatment of hypertension
- Closing of the gender gap
National Questionnaires (CCHS,
NPHS) Hypertension 200648853-60
39Changes in proportion of aware hypertensive
Canadians not treated with antihypertensive drugs
1994-2003
- Post 1999 compared
- to pre 1999
- Marked decrease in proportion of aware
hypertensives that are untreated - Closing of the gender gap
National Questionnaires (CCHS,
NPHS) Hypertension 200648853-60
40Changes in Management of Hypertension in Canada
Canadian Heart Health Survey (CHHS) 1985-1992
HSFO 2006
Heart and Stroke Foundation of Ontario (HSFO)
Survey as presented at the Canadian
Cardiovascular Congress Oct 2007 Data represent
the Ontario population
412008 Canadian Hypertension Education Program
(CHEP)
- CHEP NOW HAS THE ABILITY TO IDENTIFY MANAGEMENT
ISSUES - Gender differences
- Age variability
- Ethnic differences
- Appropriateness and intensity of therapy
- Temporal trends
- Persistence with therapy
422008 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
43New Initiatives (CHS-BPC-CHEP)
- To translate the hypertension recommendations and
disseminate to the public and patients with
hypertension. - Linking to community based programs and local
hypertension/ atherosclerosis clinics to
facilitate the update of hypertension best
management programs