The Canadian Task Force on Preventive Health Care (CTFPHC) is composed of experts who develop recommendations for clinical preventive services delivered by Canadian primary care practitioners. The CTFPHC is responsible for prioritizing the topics that will be reviewed and works with the Global Health and Guidelines Division (GHGD) of the Public Health Agency of Canada to define the analytic framework and scope of each topic. In the preparation of evidence reviews and the development of recommendations for each topic, the CTFPHC collaborates with two evidence review and synthesis centres and the GHGD. The CTFPHC also leads knowledge translation (KT) activities to promote guideline reach and uptake.
Message From the Chair
Greetings! In this issue, I am happy to share a piece by CTFPHC member Dr. James Dickinson as he reflects on his time with the CTFPHC.
The CTFPHC is working on several guidelines that will be published in 2017, including screening for hepatitis C, tobacco smoking prevention and treatment in children and youth, and screening for abdominal aortic aneurysm. Stay tuned for more information.
As always, we appreciate your interest in the CTFPHC, and we encourage you to stay up to date on our work by visiting our website at www.canadiantaskforce.ca.
Marcello Tonelli, MD SM
Reflections on Leaving the CTFPHC
James A. Dickinson, MD
The Canadian Task Force on Preventive Health Care is one of Canada’s gifts to world medicine. The first report of the CTFPHC in 1979 (then called the Canadian Task Force on Periodic Health Examination) was a landmark, demonstrating a new way to appraise preventive procedures. It differed from previous panels comprised of groups of experts who summarized the thinking of their groups, often with bias. Instead, the CTFPHC was formed as a group of “non-experts” who asked the various experts to bring forth their evidence so they could judge its quality and meaning as an independent jury. Its methods were part of the sequence of clinical epidemiology ideas developed in Canada that led to evidence-based medicine. The CTFPHC established hierarchies for quality of evidence, which were revolutionary in their time, giving greatest credence to trials, then non-experimental studies, and giving the lowest rank to case series and opinions of experts. Its revelation of the limited evidence available to support much standard practice led to research that filled many of the gaps, often leading to different solutions.
The CTFPHC model was copied ten years later by the United States, and for a time, the two groups collaborated closely. Sadly, the funding agreements from the provinces were slowly lost, and the CTFPHC lost its support, though it continued producing valuable reports. At the time, I was in Australia editing preventive guidelines and the CTFPHC always stood out as a beacon of objective science to which we looked for guidance. While the US Preventive Services Task Force reports were also valuable, it was noticeable that they often were more ”activist” – recommending activities with marginal value, in tone with the approach in their society and political pressures.
My career brought me back to Canada, and I had the opportunity to become a member of the resurrected CTFPHC. The new CTFPHC uses methods that have evolved since the original, including the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach. This method uses contracted systematic review groups and assesses the harms and benefits of screening. Experts are asked to advise and check the evidence assessment, but the decisions on final recommendations are made by the independent members of the CTFPHC. These methods have already evolved in response to challenges in particular topics and will continue to do so.
The CTFPHC has produced controversial reports that contradict conventional ideas. It is criticized by those with opposing preconceptions and preferences. In particular, critics often assert that the CTFPHC should include experts in their field, so we would know what we are doing. They misunderstand the value of the jury to which experts can bring their evidence. Rather than arguing for change based on their opinion, they should develop and bring convincing evidence.
The other criticism often levelled has been that we recommend against activities or for less frequent repeat intervals to save money for government since we are funded by the Public Health Agency of Canada. The CTFPHC is a volunteer organization, so members have no vested interests and are not paid for their work. This is a weakness: it is difficult to find enough people with expertise who can take time away from their regular work to spend often large amounts of time reading, writing, and preparing for meetings. In the future, some method of independent funding must be created to support the members’ effort devoted to the CTFPHC.
It has been a joy to be part of this team for six years, and I leave it with regret but know that the process of turnover and renewal is necessary.
Attending key conferences is an important component of the CTFPHC’s strategy for ensuring that practitioners have direct access to our clinical practice guidelines, KT tools, and other resources. The CTFPHC recently attended the Congrès annuel de medicine from October 11 to October 14 in Montreal, QC and
Family Medicine Forum from November 10 to 12 in Vancouver, BC.
Congrès annuel de medicine
October 11–14, 2016
The CTFPHC exhibited at the 2016 Congrès annuel de médecin hosted by the Médecins francophones du Canada (MFC) from October 11 to October 14, 2016 in Montreal, Quebec. The MFC represents Canada’s French-speaking physicians, and the annual conference attracts over 650 physicians and members of the health care team, including those working within family medicine. The CTFPHC also presented two brief presentations (in French) on the screening for colorectal cancer and screening for lung cancer guidelines.
Click here for more information about this conference.
Family Medicine Forum
Vancouver, British Columbia
November 9–12, 2016
The CTFPHC also exhibited at the Family Medicine Forum (FMF) from November 10 to November 12, 2016. Hosted by the College of Family Physicians of Canada, the conference took take place in Vancouver, British Columbia. There were approximately 3100 delegates that attended the FMF this year, including primary care practitioners, residents, medical students, and nurse practitioners. The CTFPHC distributed many of the CTFPHC’s KT tools, including our most recently published tools on screening for lung cancer, colorectal cancer, developmental delay and cognitive impairment. Members of the CTFPHC also presented a session on “Using 1000 Person Infographics to Improve Risk Communication with Patients in Preventive Health Screening”.
Click here for more information about this conference.
The CTFPHC develops its guidelines using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) method. This is an internationally recognized method for evaluating systematic review evidence to develop clinical practice guidelines.
As part of its KT activities, the CTFPHC is conducting a project to identify the best ways to organize and present guideline recommendations and content to Canadian primary care practitioners. Interviews with primary care practitioners are now complete. Data analysis of findings is in progress and the results
will inform how the CTFPHC presents recommendations and guideline information in its guidelines and KT tools.
For more information on how the CTFPHC applies the GRADE method in its guideline development work, visit www.canadiantaskforce.ca/methods/grade.
GRADE: Question and Answer
In each issue of the CTFPHC newsletter, we will discuss one frequently asked question about GRADE posed by primary care practitioners.
What are the challenges associated with GRADE recommendations?
Practitioners, patients, researchers, and policy makers face some key challenges with GRADE recommendations. The main challenges include understanding how to interpret and implement weak recommendations and discordant recommendations (e.g., strong recommendations with low quality evidence). Another key
challenge with using GRADE recommendations is that patients differ in the values they place on the harms and benefits related to screening. Some patients may place more or less value on the harms and benefits of different actions or interventions. For example, some women aged 20–24 years may still prefer to be
screened for cervical cancer despite the evidence that there are potential harms and little known benefits for women in this age category.
Opportunities for Engagement
Patient Engagement in Guideline Development
The CTFPHC now engages patients in its guideline development process. Specifically, the CTFPHC recruits patients to provide input at up to two stages of the process: (1) when outcomes are selected for inclusion in the systematic review protocol that informs the guideline and (2) when the guideline recommendations are developed. The CTFPHC uses feedback provided by patients to guide the search for evidence on the harms and benefits of preventive health care interventions and to develop KT tools to accompany the guidelines.
The CTFPHC conducts an annual evaluation of its work to measure the impact of dissemination activities and the uptake of clinical practice guidelines, KT tools, and KT resources. We invite practitioners to take part in the evaluation by either completing an online survey (for a chance to enter an iPad draw) or participating in a one-hour telephone interview ($100 compensation). Recruitment for the annual evaluation begins in January 2017. For more information on how to get involved, email Kavitha Thiyagarajah, research assistant, at firstname.lastname@example.org with the subject line “Annual Evaluation 2016”.
Usability Testing of Practitioner Tools
The CTFPHC produces KT tools to support each of its guidelines. To ensure that the content, layout, navigation, and aesthetics of these tools are appropriate and useful for practice, we conduct usability testing with practitioners. If you are interested in reviewing and providing feedback on one of our upcoming guideline tools, please email Kavitha Thiyagarajah, research assistant, at email@example.com for more information. Note that we offer $100 compensation for a one-hour telephone interview.
Guidelines in Progress
Forthcoming guidelines developed by the CTFPHC will focus on the following topics:
- Tobacco smoking prevention and treatment in children and youth
- Screening for hepatitis C
- Screening for abdominal aortic aneurysm
- Screening for impaired visual acuity
- Screening for esophageal cancer
- Screening for fetal aneuploidy
- Screening for asymptomatic bacteriuria in pregnancy
Is there a preventive health topic that you would like to see the CTFPHC develop a clinical practice guideline for? Let us know what you are passionate about! We accept topic suggestions on a rolling basis and would love to hear from you. To submit a suggestion, please email us at firstname.lastname@example.org with the subject line “Topic Suggestions”.
Suggestions for the next newsletter
Is there a subject that you would like to see addressed in the next issue of the CTFPHC newsletter? Let us know what you’d like to see covered! We accept suggestions on a rolling basis. To submit a suggestion, please email Kavitha Thiyagarajah, research assistant, at email@example.com with the subject line