Evidence Reviews for… Canadian Clinical Preventive Guidelines for Newly Arriving Immigrants and Refugees for

Primary Care Practitioners

Kevin Pottie MD MClsScCentre for Global Health, Institute of Population

Health, University of Ottawa

Website: www.ccirh.uottawa.caWebsite: www.ccirh.uottawa.ca

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

Canadian Collaboration for Immigrant and Refugee Health (CCIRH) (www.ccirh.uottawa.ca)(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: 7 Collaborating Partners: Public Health Agency of Canada, Public Health Agency of Canada, Citizenship and Immigrant Canada, IOM, Edmonton Multicultural Citizenship and Immigrant Canada, IOM, Edmonton Multicultural

Health Broker, Calgary Refugee Program, Champlain LIHN, CIHR.Health Broker, Calgary Refugee Program, Champlain LIHN, CIHR.

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

“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

Overview CCIRH Project

• Objective of Project• Delphi Selection • Evidence Reviews• GRADE approach to Recommendations• Recommendations• Dissemination

Project Objective

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

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

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

Standardized Mortality Ratios in Immigrants as compared to Canadians

Immigrant Males

Immigrant Females

Refugee Males

Refugees Females

SMR 95% CI SMR 95% CI SMR 95% CI SMR 95% CI

All Cause 0.34 0.33-0.35

0.4 0.39-0.41 0.48 0.45-0.51 0.58 0.54-0.63

Infectious Diseases 0.8 0.66-0.94

0.91 0.69-1.13 0.72 0.54-0.91 1.97 1.2-2.7

AIDS 1.0 0.77-1.24

3.66 2.1-5.23 0.62 0.41-0.84

Hepatitis 1.78 1.05-2.51

3.81 1.87-5.67

All Cancers 0.38 0.36-0.41

0.4 0.38-0.43 0.59 0.53-0.66 0.62 0.54-0.7

Nasopharyngeal 2.9 1.51-4.24

Liver cancer 2.18 1.69-2.68

1.77 1.18-2.37 4.89 3.29-6.49

DesMeules J Imm Health 2005:7:221-232

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

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)

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

Overview

• Objective of Project• Delphi Selection • Evidence Reviews• GRADE approach to Recommendations• Recommendations• Dissemination

Delphi Selection ProcessSelecting priority preventable and treatable conditions for recently arrived immigrants and refugees

• Importance

• Usefulness

• Disparity

(Oxman et al WHO priority setting 2006)

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)

Overview

• Objective of Project• Delphi Selection • Evidence Reviews• GRADE approach to Recommendations• Recommendations• Dissemination

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).

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)

Step 1: Clinician Summary TablePopulation Immigrant/Refugee

Adults Immigrant/RefugeeChildren (under 5)

Clinical Conclusions A – Service X is recommended D – 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 Migration During 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 tests Condition X is diagnosed with test Y. When using test Y the following clinical criteria indicate a positive result: For Men: For Women:

Screening interval Not applicable – only one screen in adulthood within health settlement period needed

Treatment Treatment 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.

Step 2: Develop Logic model and key questions

• Adapted from US Task Force

Value-Added Evidence-Based Approach

• clinical preventive action and weigh desirable and undesirable effects

• population specific clinical considerations• implementation issues

Extrapolation (Cochrane Equity)

– Baseline risk – Clinically important outcomes – Genetic and cultural factors (diet, lifestyle)– Compliance variation (patient and physician

adherence)

Overview

• Objective of Project• Delphi Selection • Evidence Reviews• GRADE Approach to Recommendations• Recommendations• Dissemination

Making a recommendation

degree of confidence that desirable effects of degree of confidence that desirable effects of adhering to recommendation outweigh the adhering to recommendation outweigh the undesirable effects. undesirable effects.

Desirable Desirable effectseffects•health benefitshealth benefits•less burdenless burden•savingssavings

Undesirable Undesirable effectseffects•harmsharms•more burdenmore burden•costscosts

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.

GRADE uptake• UpToDate World Health Organization• British Medical Journal American Thoracic Society • ACPACP Cochrane CollaborationCochrane Collaboration • BMJ Clinical Evidence BMJ Clinical Evidence Polish Institute for EBM Polish Institute for EBM • Society of Vascular SurgerySociety of Vascular Surgery Society of Pediatric Endocrinology Society of Pediatric Endocrinology• European Respiratory SocietyEuropean Respiratory Society American Endocrine Society American Endocrine Society• Society of Critical Care Medicine Surviving sepsis campaignSociety of Critical Care Medicine Surviving sepsis campaign• American College of Chest PhysiciansAmerican College of Chest Physicians European Soc of Thoracic Surgeons European Soc of Thoracic Surgeons• EBM Guidelines FinlandEBM Guidelines Finland Allergic Rhinitis in Asthma Guidelines 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 WelfareSwedish 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 SecretariatOntario MOH Medical Advisory Secretariat• Agencia sanitaria regionale, Bologna, ItaliaAgencia sanitaria regionale, Bologna, Italia• The German Agency for Quality in Medicine The German Agency for Quality in Medicine • Evidence-based Nursing Sudtirol, Alta Adiga, ItalyEvidence-based Nursing Sudtirol, Alta Adiga, Italy• Norwegian Knowledge Centre for the Health ServicesNorwegian Knowledge Centre for the Health Services• University of Pennsylvania Health System Center for EB PracticeUniversity of Pennsylvania Health System Center for EB Practice • Journal of Infection in Developing Countries - InternationalJournal of Infection in Developing Countries - International

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)

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

Dissemination

Canadian Medical Association Journal and

(electronic CMAJ-web)

Dissemination

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 phasesacademic publications (up to 4000 words)

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

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

THANK YOU