Process Overview

The Development of the Guidelines, Implementation & Evaluation

Each year, the CHEP Guidelines are developed through a highly structured and systematic process designed to minimize bias. The CHEP Guidelines Committee comprises a number of sub-groups, each with a librarian who conducts systematic literature searches. The evidence collected is graded using an evidence-based grading scheme and draft guidelines are developed. The draft guidelines are reviewed by the Central Review Committee (CRC), the members of which are unbiased experts in evidence-based medicine and clinical epidemiology, to ensure that the guidelines are developed through a consistent approach. The CRC may suggest revisions to the sub-groups.

The draft guidelines and supporting evidence are presented by the CRC to Guidelines Committee members in attendance at an annual consensus meeting, and there may be further revisions. The finalized draft guidelines are then put forward for electronic voting by the full Guidelines Committee, and must achieve greater than 70% support to be adopted. The adopted guidelines are then published, and their dissemination is supported by short summaries, handouts, posters, pocket cards, advertisements, educational slide kits, text books, and workshops that can be easily understood and used by health care professionals.

The Outcomes Research Task Force (ORTF) examines outcomes data across Canada related to hospitalization and mortality; awareness and treatment of hypertension; diagnosis of hypertension; national prescriptions of antihypertensive medication; and the economics of hypertension in order to assess the impact of the CHEP Guidelines.

Why the process is important

The CHEP Guidelines process updates clinical practice recommendations annually to keep the management and prevention mechanisms up-to-date with current research. The ability to revisit contentious issues and review new evidence annually results in credible, current guidelines referenced by Hypertension Canada members and the wide health care professional community within Canada and around the world.  The Guidelines Committee is multidisciplinary involving pharmacists, family doctors, nurses and other medical specialists and allied health professionals. The collective skill set of membership includes expertise in hypertension, public health, continuing health education, knowledge translation, epidemiology, outcomes research, and specific disciplines within the hypertension framework. Messaging is tailored to specific health care disciplines.

AGREE II assessment of CHEP Guidelines process

AGREE II Item Details
Domain 1. Scope and Purpose
1. The overall objective(s) of the guideline is (are) specifically described The CHEP Guidelines process provides annually updated evidence-based clinical practice guidelines for health care professionals, with the ultimate goal of improving hypertension prevention, detection, and management in Canada.
2. The health questions(s) covered by the guideline is (are) specifically described. These are described in each guideline section (e.g. diagnosis and treatment recommendations arranged by subsection). Health questions are selected for inclusion based upon their importance to hypertension diagnosis and management and also based upon the availability and quality of the underlying evidence. As such, important health questions for which there are no data to inform a guideline may not be included.
3. The population (patients, public, etc.) to whom the guideline is meant to apply is specifically described. The guideline is primarily meant to apply to adult Canadians who are at risk for or who have hypertension.
Domain 2. Stakeholder Involvement
4. The guideline development group includes individuals from all the relevant professional groups. The CHEP Guidelines Committee is a multidisciplinary panel comprised of 2 co-chairs and 23 subgroups (in 2012). Subgroup members, considered content experts in their fields, are responsible for reviewing annual search results and, if indicated, drafting new guidelines or proposing changes to old guidelines. An independent central review committee of methodology experts who have no industry affiliations separately review, grade, and refine proposed guidelines, which are then presented at a 1-day consensus conference. Members of C-CHANGE, the Canadian Task Force on Preventive Health Care, Canadian Diabetes Association Guidelines Committee, Canadian Society of Nephrology, Canadian Stroke Network, and the Canadian Cardiovascular Harmonized National Guideline Endeavour Initiative also collaborate with CHEP Guidelines subgroup members to ensure harmonization of guidelines between organizations.
5. The patients’ views and preferences have been sought. Currently, no formal mechanism is in place but ways to incorporate patients’ views and preferences are being considered for future iterations.
6. The target users of the guideline are clearly defined. These guidelines focus on adult care and are predominantly targeted toward primary care providers. Educational materials based on the hypertension guidelines and designed for patient and public education have been developed to assist health care professionals managing hypertension. They are available at hypertension.ca.
7. Systematic methods were used to search for evidence. A systematic literature search is performed by a Cochrane Collaboration librarian in MedLine/PubMed using text words and MeSH headings. Search terms include hypertension [MeSH], hypertens*[ti, ab], and blood pressure; these are combined with topic-specific terms to generate search results for each subgroup to review. Bibliographies of identified articles are also manually searched. Randomized controlled trials and systematic reviews of randomized trials are reviewed for treatment recommendations and cross-sectional and cohort studies are reviewed for assessing diagnosis and prognosis. Searches are performed annually.
8. The criteria for selecting the evidence are clearly described. Cardiovascular morbidity and mortality and total mortality outcomes are prioritized. For health behaviour recommendations, BP is considered an acceptable surrogate and, in patients with CKD, progressive renal impairment is considered to be a clinically important outcome. Study characteristics and study quality are assessed using prespecified, standardized algorithms developed by Hypertension Canada for critical appraisal of randomized controlled trials and cohort studies.
9. The strengths and limitations of the body of evidence are clearly described. Guidelines are graded according to the strength of their underlying evidence ranging from Grade A (strongest evidence, based on high-quality randomized clinical trials) to Grade D (weakest evidence, based on low power, imprecise studies or expert opinion alone). Details are provided in the Supplementary Appendix of the main manuscript.
10. The methods for formulating the recommendations are clearly described. After a 1-day consensus meeting, proposed guidelines are finalized and submitted to all voting members (62 in 2012) of the CHEP Guidelines Committee for approval. Members with potential conflicts of interest recuse themselves from voting on specific guidelines. Guidelines receiving more than 70% approval are passed.
11. The health benefits, side effects, and risks have been considered in formulating the recommendations. These are guideline specific. Additional details are provided in the text following each new guideline.
12. There is an explicit link between the recommendations and the supporting evidence. See Grading system described above.
13. The guideline has been externally reviewed by experts prior to its publication. Three external primary care experts review the draft guidelines annually.
14. A procedure for updating the guideline is provided. The guidelines are updated annually.
Domain 4. Clarity of Presentation
15. The recommendations are specific and unambiguous. Judged by end-user.
16. The different options for management of the condition or health issue are clearly presented. The guidelines cover the spectrum of hypertension diagnosis and management including health behaviour modification, antihypertensive pharmacotherapy and additional non-blood-pressure-related treatments recommended for reducing global vascular risk.
17. Key recommendations are easily identifiable. Guidelines are stated explicitly and are separated from background text.
18. The guideline describes facilitators and barriers to its application. The Implementation Task Force, a separate branch of Hypertension Canada, conducts an extensive knowledge translation effort to enhance uptake and applicability of these recommendations. These efforts include knowledge exchange forums, targeted educational materials for primary care providers and patients, and freely available slide kits and summary documents of all guidelines on Hypertension Canada web site (http://www.hypertension.ca). Documents are available in French and English, and some documents are translated into other languages. Although the number of primary care providers that directly receive CHEP Guidelines materials on a regular basis has dramatically increased, Hypertension Canada is continuing to address the challenge of identifying and reaching all active primary care providers across Canada, through use of our online platforms and professional networks.
19. The guideline provides advice and/or tools on how the recommendations can be put into practice. Educational materials based on the CHEP Guidelines have been designed for patients and the public, and to assist health care practitioners managing hypertension. They and are freely available at: http://www.hypertension.ca.
20. The potential resource implications of applying the recommendations have been considered. Hypertension Canada currently does not take economic considerations into account when drafting guidelines.
21. The guideline presents monitoring and/ or auditing criteria. The Outcomes Research Task Force conducts hypertension surveillance studies and reviews existing Canadian health surveys to identify gaps between current and best practices. The implementation task force also regularly receives feedback from end users to improve guideline processes and content.
Domain 6. Editorial Independence
22. The guideline is editorially independent from the funding body. The members of the CHEP Guidelines Committee are unpaid volunteers who contribute their time and expertise to the annual development and dissemination of the CHEP Guidelines. To maintain professional credibility of the content, the process for the development of the recommendations is fully independent and free from external influence. External partners assist with the dissemination of the approved recommendations.
23. Conflicts of interest of guideline development members have been recorded. Members with potential conflicts of interest recuse themselves from voting on specific guidelines (a list of conflicts for each member and each year can be found in the Supplemental Appendix to the main paper).