Methodology

1
Methodology
2
2008 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.

3
2008 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.

4
2008 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

5
2008 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
6
CHEP 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
7
2008 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
8
Sponsoring 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)

9
Financial 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
10
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
• 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

11
CHEP - 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

12
CHEP - 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

13
METHODOLOGYthe production of recommendations
Can J Cardiol 200622559-64
14
Recommendations 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
15
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
• Concordance Strategies for Patients
• Vascular Protection

16
2008 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)

17
2008 Canadian Hypertension Education Program
(CHEP)

• Detailed methodology of the system to grade
  evidence can be found in Can J Cardiol
  200622559-64.

18
Level 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
19
Algorithms used by CHEP to assess the grading of
recommendations
20
METHODOLOGYthe implementation of recommendations
Can J Cardiol 200622595-98.
21
2008 Canadian Hypertension Education Program
(CHEP)

• Implementation of CHEP recommendations is a task
  for all CHEP members

22
Implementation 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

23
2008 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.

24
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 2007
• CHEP pocket cards (gt100000) and booklets (10000)
• Dissemination through the websites
• Wall posters
• CHEP's "Train the Trainer" Sessions

25
Some 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)

26
2008 Canadian Hypertension Education Program
(CHEP)

• A slide kit and other educational resources can
  be downloaded from http//www.hypertension.ca

27
2008 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.

28
Interdisciplinary Executive Summaries
Canadian Hypertension Recommendations. A
summary for everyone.
1 page - clinical 4 page - clinical 6 page -
scientific 4 page - public patient
29
METHODOLOGYthe evaluation of recommendations
Can J Cardiol 200622556-558.
30
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 200622556-558.

31
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
• Physical Measures Surveys
• IMS Health Compuscript data
• Provincial Administrative Databases
• National Questionnaire Surveys
• National Hospitalization and Mortality Data
• Economic Analysis of hypertension management

32
Canadian 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
33
Physical Measures Surveys

• Statistics Canada will have results of a national
  physical measures survey assessing hypertension
  prevalence, awareness, treatment and control in
  2009

34
Changes in antihypertensive prescriptions in
Ontario using IMS Compuscript data

CHEP was initiated in 1999
Hypertension 2006 4722-28
35
Changes in initiation of antihypertensive
prescriptions in elderly Ontarians using
provincial administrative data
Hypertension 2006 4722-28
36
National Questionnaire Surveys (Canadian
Community Health Surveys (CCHS), National
Population Health Surveys (NPHS)

• Large national questionnaire surveys
• Results are representative of the Canadian
  population

37
Changes 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
38
Changes 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
39
Changes 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
40
Changes 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
41
2008 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

42
2008 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

43
New 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