methodology used for the production of the canadian

2007

Methodology used for the

production of the Canadian

22007 Canadian Hypertension Education Program Recommendations

2007 Canadian Hypertension Education Program

• CHEP recommendations are based on critically evaluated clinical trial evidence and highly value improved patient outcomes

• 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


Slide kits, clinical practice algorithms and supporting literature for full recommendations can be downloaded from

www.hypertension.ca



• 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.

• The production of recommendations are linked a separate and specific implementation plan and to an evaluation strategy.

Canadian Recommendations for the Management of Hypertension

2007 Canadian Hypertension Education Program Recommendations 5

CHEP Organizational Chart

OutcomesResearch

Task Force

Evidence-BasedRecommendations

Task Force________________Central Review

Committee

ImplementationTask Force

Steering Committee

Executive Committee

Topic subgroups

Topic subgroups

Topic subgroups

Topic subgroups


STEERING COMMITTEE: N Campbell (Chair), M Lebel (CHS), R Petrella (CFPC, BP Canada), S Samis (HSFC), G Taylor (PHAC), S Matheson (CCCN), L Poirier (CPA), D Drouin, J Kaczorowski, J Onysko, S Tobe, R Touyz

EXECUTIVE COMMITTEE: N Campbell (Chair), D Drouin, J Kaczorowski, J Onysko, S Tobe, R Touyz (to 2006) R Lewanczuk (from 2006)

CENTRAL REVIEW COMMITTEE: B Hemmelgarn (Co-Chair), F McAlister (Co-Chair), N Khan, R Padwal, M Hill, J Mahon

Canadian Hypertension Education Program 2007


Sponsoring organizations and partners

• Sponsoring organizations– Canadian Hypertension Society– Blood Pressure Canada– Public Health Agency of Canada– Heart and Stroke Foundation of Canada– College of Family Physicians of Canada– Canadian Council of Cardiovascular Nurses – Canadian Pharmacy Association

• Partner organizations– Canadian Cardiovascular Society– Canadian Society of Nephrology– Canadian Stroke Network– Canadian Society of Internal Medicine– Kidney Foundation of Canada

• Volunteers (>90)


Financial Support

Pharmaceutical Sponsors of CHEP are:

• Abbott Laboratories • Merck Frosst Canada

• AstraZeneca • Novartis

• Bayer HealthCare • Pfizer Canada

• Biovail Pharma • Sanofi-Aventis

• Boehringer Ingelheim • Servier Canada

• Bristol-Myers Squibb • Solvay Pharma

CHEP is financially supported by the Public Health Agency of Canada and the Canadian Hypertension Society.

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


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 evidence with patient outcomes for pharmacotherapy recommendations2) A centralized systematic literature review 3) Multiple members in subgroups to represent different views


CHEP- MINIMIZING BIAS

4) A Central Review Committee (CRC) that is ‘free of COI’ to oversee the evaluation of evidence, development of recommendations and to present the evidence/ recommendations

5) Overt written disclosure of potential COI at the time of the development of the recommendations

6) A consensus approach to the drafting of the recommendations chaired by the CRC

7) Voting on recommendations with the removal of recommendations voted against by 30% of members.


CHEP- MINIMIZING BIAS

8) 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.

9) 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 prioritized minimizing the

potential impact of bias at it’s business planning retreat in May 2006.


METHODOLOGY

the production of recommendationsCan J Cardiol 2006;22:559-64


Recommendations Task Force: S Tobe (Chair), R Lewanczuk (Vice-chair) Accurate Measurement of BP: C Abbott (Chair), K Mann, L Cloutier Adherence Strategies for Patients: R Feldman (Chair), A Milot; J Stone, T CampbellFollow-up of BP: P Bolli (Chair), G TremblayRisk Assessment: S Grover (Chair), G Tremblay, A MilotSelf-measurement of BP: D McKay (Chair), A ChockalingamAmbulatory BP Monitoring: M Myers (Chair), S Rabkin, M DawesRoutine Laboratory Testing: T Wilson (Chair); B Penner, E BurgessEchocardiography: G Honos (Chair)Lifestyle Modification: R Touyz (Chair), N Campbell, N Gledhill, R Petrella, L TrudeauPharmacotherapy of Hypertension in Patients Without Other Compelling Indications:

F McAlister (Chair), G Carruthers, J DeChamplain, G Fodor, P Hamet, R Herman, 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 McFarlaneRenal and Renovascular HTN: S Tobe (Chair), B Culleton, K Burns, M RuzickaEndocrine forms of hypertension: E Schiffrin (Chair)Vascular Protection: R Feldman (Chair), R Hegele, P McFarlane

Canadian Hypertension Education Program


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


2007 Canadian Hypertension Education Program : The process

• Subgroups systematically review the literature using a Cochrane librarian and supplement the search with personal files to Sept 2006

• 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 2006)• National presentation of draft recommendations (Canadian

Cardiovascular Congress Vancouver, Oct 2006)• Voting and ratification of recommendations achieving >70%

acceptance



Detailed methodology of the system to grade evidence can be found in Can J Cardiol 2006;22:559-64


Level of evidence used by the CHEP (2000)

Adequate randomized controlledtrial (RCT) or subgroup analysis OR systematic review of adequateRCT with similar Rx arms

None of the aboveNone of the aboveNone of the aboveD

Validated surrogate outcome

measure OR extrapolation of

results from another population

Clinically relevant mortalityor morbidity outcomemeasure and representativepopulation

Validated surrogate outcome

measure OR extrapolation of

results from another population

ApplicabilityPrecision Internal validityGrade

Studies in which the 95% confidence intervals do notexclude meaningful contraryconclusions

Inadequate statistical power toexclude clinically importantdifferences OR systematic review with heterogeneity

Statistically significant resultsOR adequate statistical power to exclude clinically importantdifferences

Inadequate RCT orsubgroup analysis ORcohort/case controlled studiesOR systematic review of RCT withRx arms from different studies

C

Adequate RCT orsubgroup analysis ORsystematic review of similar RCTusing similar Rx arms

B

A


METHODOLOGY

the implementation of recommendations

Can J Cardiol 2006;22:595-98



Implementation Task Force: D Drouin (Chair), J Kaczorowski (Vice-chair)

Nurses Sub-group: Jo-Anne Costello, Kori Kingsbury, Sandra Matheson

Pharmacists Sub-group: Luc Poirier, Bill Semchuk, Ross Tsuyuki Family Physicians Sub-group: Martin Dawes, John Hickey, Rob

Petrella

Members at large: Jean-Martin Boulanger, Norm Gledhill, Ross Feldman, Norm Campbell, Sheldon Tobe, Alain Milot, Guy Tremblay, Rhian Touyz, Jay Onysko, Rick Ward



• An important function of the CHEP executive is the development and updating of key CHEP implementation tools

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



• Between 2001 and 2005, 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

• In 2005 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.


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 2006

• CHEP pocket cards (140000) and booklets (10-20000)

• Dissemination through the websites• Wall posters• CHEP's "Train the Trainer" Sessions


Some annual dissemination initiatives

• Management algorithms• Power point slide sets• Palm application• Endorsement or co-development of

education programs with RxD companies

• Media releases with HSF• Development of HCP networks (family

doctors, nurses and pharmacists)



A slide kit and other educational resources can be downloaded from

http://www.hypertension.ca


In the slide kit, special color codes have been associated with specific types of information.Here are some examples:

Do not

Explanation,

Statement, or ListRecommendation

Importantcomment,Warning

Reminder Do not


A red flag is been posted where recommendations were updated for 2007.


Multidisciplinary Executive Summaries

Canadian Hypertension Recommendations. “What’ new and what’s old but still important”.

One page - clinical

4 page - clinical

6 page - scientific


METHODOLOGY

the evaluation of recommendations

Can J Cardiol 2006;22:556-558


Outcomes Research Task Force

• An Outcomes Research Task Force was developed to assess the impact of CHEP on hypertension management

• Details of the Task force can be found in Can J Cardiol 2006;22:556-558



Ernest Amankwah Gillian Bartlett Tari Bhattia

Rollin Brant Denis Drouin (Ex Officio) Michael Eliasziw

Bill Ghali Brenda Hemmelgarn Ru-Nie Gao

Steven Grover Nadia Khan Michael Hill

Helen Johansen Raj Padwal Colleen Maxwell

Finlay McAlister Mark Smith Stephen Phillips

Hude Quan Karen Tu Larry Svenson

Greg Taylor Jennifer Zhang Andy Wielgosz

Kelly Zarnke

Outcomes Research Task Force: N Campbell (Chair), J Onysko (Vice-chair)


Outcomes Research Task Force ORTF

Collaborative effort with PHAC, Statistics Canada, provinces and organizations to develop a national surveillance system for hypertension

1) Physical Measures Surveys2) IMS Health Compuscript data3) Provincial Administrative Databases4) National Questionnaire Surveys (CCHS, NPHS)5) National Hospitalization and Mortality Data


Physical Measures Surveys

• Ontario HSF will have results of an Ontario physical measures survey assessing hypertension prevalence, awareness, treatment and control in 2007

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


Changes in antihypertensive prescriptions in Ontario using IMS Compuscript data

Hypertension 2006; 47:22-28


Changes in initiation of antihypertensive prescriptions in elderly Ontarians using

provincial administrative data

Hypertension 2006; 47:22-28


National Questionnaire Surveys (CCHS, NPHS)

• Large national questionnaire surveys

• Results are representative of the Canadian population


35

Changes in diagnosis of hypertension in Canada

Post 1999 compared to pre 1999

• Doubling of the rate of diagnosis of hypertension

• Closing of the gender gap

Hypertension 2006;48:853-60

Hypertension Diagnosis by Gender

10

15

20

1992 1994 1996 1998 2000 2002 2004

Year

Perc

enta

ge o

f Pop

ulat

ion

Females

Males &Females

Males


36

Changes in the treatment of hypertension

Post 1999 compared to pre 1999• Doubling of the rate of

treatment of hypertension

• Closing of the gender gap


Hypertension Treatment by Gender

5

10

15

20

1992 1994 1996 1998 2000 2002 2004

Year

Perc

enta

ge o

f Pop

ulat

ion

Females

Males & Females

Males


37

Changes in the proportion of thosediagnosed that are not treated

Post 1999 compared to pre 1999

• Marked decrease in proportion of aware hypertensives that are untreated

• Closing of the gender gap.


Hypertensives who were aware but not treated

10

20

30

40

1992 1994 1996 1998 2000 2002 2004

Year

Per

cent

age

of P

opul

atio

nFemales

Males &FemalesMales



CHEP NOW HAS THE ABILITY TO IDENTIFY MANAGEMENT ISSUES

• Almost 50% of women over age 60 are on drug therapy

• A low proportion of younger hypertensives are on drug therapy

• More than 10% of uncomplicated elderly hypertensives are started on Beta Blocker therapy.


• 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 associated with a reduction in cardiovascular complications



CHEP New Initiatives

• To translate the hypertension recommendations and disseminate to the public and patients with hypertension. (A partnership with Blood Pressure Canada, Canadian Hypertension Society, the Heart and Stroke Foundation and the World Hypertension League (World Hypertension Day))

• Linking to community based programs and local hypertension/ atherosclerosis clinics to facilitate the update of hypertension best management programs

methodology used for the production of the canadian

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