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 Prevention Guidelines Division 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 the Evidence Review and Synthesis Centre and the Prevention Guidelines Division. The CTFPHC also leads knowledge translation (KT) and dissemination activities to promote guideline reach and uptake.
Message From the Chair
Greetings! In this issue, I am pleased to announce the release of our newest clinical practice guideline. In November 2015, the CMAJ published the CTFPHC’s Recommendations on Screening for Cognitive Impairment in Older Adults. For more information about the cognitive impairment guideline, systematic reviews, and associated KT tool, please visit the CTFPHC cognitive impairment guideline page.
I am also happy to share a piece written by CTFPHC member Dr. Roland Grad on applying screening recommendations in clinical practice. 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
Release of the CTFPHC’s Cognitive Impairment Guideline
The CMAJ published the CTFPHC’s ninth guideline in November 2015. This latest guideline addresses screening for cognitive impairment in adults aged 65 years and older.
Cognitive impairment occurs on a continuum that includes aging-related cognitive decline, mild cognitive impairment (MCI), and dementia. Studies from the United States have reported that the prevalence of MCI ranges from 9.9% to 35.2% of adults aged 70 years or older. The incidence of dementia in Canadian adults aged 65 to 79 years is 43 per 1000 persons and rises with age (to 212 per 1000 in Canadians aged 85 years and older). Cognitive impairment is commonly assessed using the Mini Mental State Examination (MMSE), the Montreal Cognitive Assessment (MoCA) tool, or the Alzheimer’s Disease Assessment Scale (ADAS-Cog). Treatments for cognitive impairment include medications, such as cholinesterase inhibitors; dietary supplements/vitamins; and non-pharmacological interventions.
There is a lack of direct evidence concerning the benefits of screening for cognitive impairment and a lack of evidence showing that treatment for mild cognitive impairment produces clinically significant benefits. There is also the potential for false positives following screening. As a result, the CTFPHC recommends against screening for cognitive impairment in community-dwelling asymptomatic older adults (≥65 years of age). This recommendation does not apply to men and women who are concerned about their cognitive performance, who are suspected of having cognitive impairment, or who have symptoms suggestive of cognitive impairment. Physicians should remain alert, however, when family members or caregivers express concern about possible cognitive impairment and undertake appropriate diagnostic inquiry as warranted.
To accompany its screening for cognitive impairment guideline, the CTFPHC developed a one-page clinician FAQ sheet. The FAQ sheet provides answers to common questions that clinicians may have about screening for cognitive impairment. Copies of the clinician FAQ are available to download for free on the cognitive impairment guideline page on the CTFPHC website. As always, the CTFPHC encourages members of the public to discuss screening for cognitive impairment with their primary care practitioner, who is aware of their health background and family history.
Applying “Negative” Screening Recommendations: A Challenge for Clinicians
Roland Grad, MD MSc
An otherwise well 64-year-old woman named Rachel politely asked why had I not sent her husband for a PSA test. We had just completed her routine Pap test, and this question caught me by surprise. In my mind, I was already trying to get ready for the next patient. But now, Rachel’s question turned my attention to her 73-year-old husband. Sitting just outside the office door, he and I had met a few months ago. At that office visit, we confirmed his blood pressure was at “target”, discussed renewal of his medication (including a preventive treatment for gout), and briefly exchanged thoughts around why I recommended against PSA screening. As a CTFPHC member, I was, after all, aware of our recommendation:
For men 70 years of age and older, we recommend not screening for prostate cancer with the prostate-specific antigen test.
(Strong recommendation; low quality evidence)
Now, in retrospect, I understand why Rachel challenged my negative recommendation on PSA screening. After all, her husband had been screened in the past by other doctors. She asked, was it because he was “too old”?
That comment put me on the spot — this wasn’t about being too old for screening. I have come to learn that many of my older patients want to continue cancer screening beyond the guideline recommended age limits for exclusion. Yet how could I explain the potential harms of screening for prostate cancer in just 1–2 minutes? I decided to email Rachel a link to the KT tools on PSA screening produced by the CTFPHC for patients. This decision was accompanied with an offer to meet again if, on further reflection, a PSA test was still desired.
PSA testing of asymptomatic men is a complex matter. While testing may improve prostate cancer survival rates in a best-case scenario, it can also lead to substantial harm, such as repeated investigation and the very unwanted consequences of treatment, such as incontinence and impotence. Rachel’s surprise with my recommendation not to test needed to be interpreted in light of the psychology behind decisions to stop screening.
In my daily work as a family doctor, I strive for decisions that are patient-centred and evidence-informed — hopefully leading me to provide what some might call “Goldilocks” care. More recently, I have recognized that the phenomenon of “overdiagnosis” can happen when my patients get a diagnosis they don’t need. For example, it can happen when people without symptoms are diagnosed and then treated for a disease that won’t actually cause them any symptoms, and it can happen for people whose symptoms are given a diagnostic label that brings them more harm than good. There is evidence suggesting that people are overdiagnosed across many different conditions, including asthma, cancer, and hypertension.
One common way overdiagnosis can happen is when healthy people receive tests during check-ups and are subsequently diagnosed and treated for the early form of a disease that would never, in fact, have harmed them. With breast cancer screening, for example, one systematic review suggests that up to one in three of the cancers detected via screening may be overdiagnosed.1 There are similar concerns with overdiagnosis of prostate cancer.
I hope this story from practice encourages clinicians to use the KT tools produced by the CTFPHC when they engage with their patients around “negative” screening recommendations in everyday practice.
KT tools, preventing overdiagnosis, implementing negative screening recommendations.
Carter J, Coletti R, Harris R. Quantifying and monitoring overdiagnosis in cancer screening: a systematic review of methods. BMJ. 2015; 350: g7773.
Attending key conferences is an important component of the CTFPHC’s strategy for ensuring that practitioners have direct access to our clinical practice guidelines, decision support tools, and other key resources. The CTFPHC attended the following conferences in 2015:
Canadian Association of Advanced Practice Nurses (CAAPN/ACIIPA) Biennial Conference
September 23–25, 2015
The CTFPHC held a half-day workshop on implementing the CTFPHC’s child and adult obesity guidelines at the CAAPN/ACIIPA biennial conference. This 3-hour workshop discussed the adult and child obesity guidelines written by the CTFPHC and the considerations for practice for nurse practitioners.
Family Medicine Forum
November 11–14, 2015
CTFPHC team at the 2015 Family Medicine Forum
CTFPHC team at the 2015 Family Medicine Forum
The FMF is Canada’s premier family medicine conference and is hosted annually by the College of Family Physicians of Canada (CFPC). The CTFPHC hosted a booth at the conference to distribute guideline tools and resources, answer questions, and connect with primary care practitioners and other key professionals who use the CTFPHC guidelines.
GRADE: Question and Answer
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. In each issue of the CTFPHC newsletter, we will discuss one frequently asked question regarding the use of GRADE.
Question: How do I implement a weak recommendation in my practice?
Answer: When the CTFPHC issues a weak recommendation, it means we believe that most patients for whom the recommendation applies would want the recommended course of action (whether it is for or against using a screening test) but many patients would not. The CTFPHC appreciates that different choices are acceptable for each patient and recommends that clinicians support patients by discussing their values and preferences to assist them in reaching a decision.
We recommend facilitating this conversation by educating patients about the known harms and benefits of the intervention and helping them make an evidence-informed decision. The CTFPHC produces a number of KT decision support tools to support this dialogue, including patient and clinician FAQ sheets, algorithms, and infographics. More detailed information about the interventions discussed in these tools can be found in the guidelines. To access the CTFPHC’s guidelines and tools, please visit our website at www.canadiantaskforce.ca or download our free mobile app on iTunes or Google Play.
Opportunities for Engagement
Learn how to appraise clinical practice guidelines with the CTFPHC!
The CTFPHC is currently recruiting family physicians to help them appraise clinical practice guidelines developed by other organizations. Appraising clinical practice guidelines is important for identifying the quality of existing guidelines and their utility for a particular context.
As an appraiser for the CTFPHC, you will first receive online training on how to use a validated guideline appraisal tool (AGREE II) and have the opportunity to complete a practice guideline appraisal and receive feedback. You will be eligible to earn Mainpro-M2 credits for completing the training activities. Once you have completed your training, you will be invited to appraise up to three guidelines per year and will be eligible to receive Mainpro-M1 credits for each guideline that you appraise.
If you are interested or know a colleague who may be interested, please contact Sabrina Jassemi at email@example.com, on behalf of Dr. Sharon Straus (Principal Investigator), for an information sheet and application form. No prior experience is necessary.
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 is currently engaging patients in Stage 2 for its guideline on tobacco smoking prevention and cessation in children and adolescents. In early 2016, we will engage patients in Stage 2 for the CTFPHC’s guidelines on screening for abdominal aortic aneurysm and screening for hepatitis C.
Usability Testing of Practitioner Tools
The CTFPHC produces practitioner 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 firstname.lastname@example.org for more information. Note that we offer $100 compensation for a one-hour telephone interview.
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 (e.g., website and mobile app). 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 2016. For more information on how to get involved, email us at email@example.com with the subject line “Annual Evaluation 2015.”
Guidelines in Progress
Forthcoming guidelines developed by the CTFPHC will focus on the following topics:
- Screening for lung cancer
- Screening for developmental delay
- Screening for abdominal aortic aneurysm
- Screening for hepatitis C
- Tobacco smoking prevention and cessation in children and adolescents
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 “Newsletter Suggestions”.