The CTFPHC uses rigorous methods to assess evidence and guide preventive care. The current approach to guideline development takes advantage of improved technology and innovations in critical appraisal throughout the development process—from identifying priority topics to the strategy for knowledge translation and exchange.
The CTFPHC developed a list of topics in consultation with primary care physicians and potential partner organizations. A topic-prioritization working group asked members to rank the initial list independently, and then a final list was developed by consensus with the broader task force. The CTFPHC continues to solicit topic suggestions from primary care practitioners, partner organizations, and the public online (www.canadiantaskforce.ca
). Prioritization takes into account burden of illness; potential effects on disease burden and morbidity, mortality, or quality of life; public or provider interest; variation in care delivery; sufficiency of the existing evidence; and development of new evidence in the field.
The CTFPHC uses a structured approach to assess evidence and provide guidance for preventive care in practice. The task force will develop de novo recommendations when other guidelines do not exist. When there are existing systematic reviews or guidelines from other groups such as the US Preventive Services Task Force, the CTFPHC will build on these by conducting relevant evidence updates. When recent evidence-based guidelines already exist, the CTFPHC will verify their quality with a system that assesses the content and development process of the guideline with tools such as AGREE II (Assessment of Guidelines Research and Evaluation)8
, and endorse or adapt the guidelines.
The CTFPHC uses a rigorous method for framing and developing the key questions and analytic framework of the review, as well as a new approach to assessing the quality of evidence and formulating the recommendations. The search protocol, the analytical framework, and the key questions are all sent to peer reviewers (including family physicians) to ensure that they capture the questions and outcomes that clinicians and patients see as important.
GRADE evidence summaries
To determine the quality of evidence and formulate recommendations, the CTFPHC uses the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology to enhance rigour and transparency.9
The GRADE methodology has already been adopted by more than 50 organizations. While this system is new to most clinicians, the CTFPHC believes it is currently the best method for framing guideline recommendations and that it will ultimately provide better guidance for physicians and patients.
The GRADE approach assesses the quality of the evidence and the strength of the recommendation. Quality of evidence for important prespecified outcomes for patients—both desirable (benefits) and undesirable (harms)—is graded as high, moderate, low, or very low, and reflects its certainty. For example, if evidence is of high quality, further research is unlikely to change the estimate of effect; if evidence is of very low quality, the estimate of effect is very uncertain and could be changed by more research.
Previous CTFPHC recommendations have mainly taken into consideration reductions in morbidity or mortality for the disease or condition being prevented. The imperfect nature of prevention and screening means that often many more people are identified for further investigation or treatment than will actually benefit from it.10
The harm caused by these false-positive results varies, but sometimes it is substantial (eg, being diagnosed with cancer and treated with surgery, radiotherapy, or chemotherapy).11
The GRADE approach provides explicit guidance so that when doctors offer tests or preventive maneuvers, they are in a better position to inform patients about benefits and harms. This will result in people making different decisions based on personal attitudes and preferences in the context of the information they are given.
Recommendations are determined to be either strong or weak based on the balance between desirable and undesirable effects, the quality of evidence, and other important factors such as patient preferences and cost.12
Final recommendations will include ratings of the quality of evidence and the strength of the recommendations, presented using GRADE evidence summary tables (to show the magnitude of effect on each important outcome) and the GRADE quality rating (with notations to explain the rating). This process will often result in recommendations that are different from what practitioners are used to. For example, a screening test could be given a weak recommendation based on moderate-quality evidence, if the effect is small, or if patient preferences are especially likely to influence the decision to undergo screening ().9
Table 1 Interpreting strong and weak recommendations using the GRADE method9
Recommendations from the CTFPHC are guidelines and not prescriptions for managing patients—they will present factors that family physicians should consider when counseling patients about screening or preventive maneuvers. In the long term, patient participation in these decisions should improve satisfaction with care and perhaps enhance the uptake of beneficial services. Although these discussions might require more time from busy family doctors, they are important as people become more knowledgeable about health care choices.13
Although the evidence supporting preventive care is derived from the worldwide scientific literature, the effects of these data for formulating and implementing recommendations for practice require consideration of the Canadian context. Factors that might be considered include effects on quality of life or psychological distress; sociodemographic, ethnic, and cultural factors (such as the increased risk of hypertension in South Asians14
or the lower screening rates among First Nations people15
); living in urban, rural, or remote environments16
; multiple comorbidities17
; and issues of equity and resource use. For each relevant contextual issue identified, a literature search is done as part of guideline development. As this type of evidence often is limited, qualitative in nature, or found in the gray literature, narrative summary is the only practical way to assess and present this evidence.
Once the synthesis review is complete, draft recommendations are produced by the topic working group and presented to the full committee for debate. The full review and recommendations are sent to external topic-specific expert peer reviewers (including family physicians) for feedback.
Knowledge transfer and exchange
An integrated knowledge translation strategy is incorporated into all guidelines, based on the Knowledge to Action framework.18
Primary care practitioners are the main target for the guidelines, but other health care groups, policy makers, and the public are engaged through an interactive website. The synthesis reviews and full guideline statements will be published in peer-reviewed journals. Summary statements will be published elsewhere and will be available on the CTFPHC website. In addition to academic publication, decision aids will be created to help clinicians and patients understand the issues for informed decision making. The knowledge translation strategy will involve development of point-of-care tools, which can be used in conjunction with electronic medical records, and use of social media to disseminate guidelines to health professionals and the public.
The CTFPHC is extremely interested in how the guidelines perform in the real world of primary care, as well as their effects on policy makers and other organizations. Each guideline includes performance measurements that can assess the effectiveness of the guideline at these different levels. This evaluation will help improve the guidelines and monitor their effects.
The CTFPHC has developed partnerships with other preventive care organizations, based on the principles of excellence, credibility, and strategic links. These partnerships will ensure that guidance is maximally effective for improving the care of Canadians. Partners will be able to engage in guideline development and review, in dissemination and evaluation, or in an advisory capacity.