Development of the Champlain primary care cardiovascular disease prevention and management guideline

Formation of evidence-monitoring committees

In order to develop the guideline, evidence-monitoring committees and a guideline coordinator were established for serious CVD risk factors and conditions. (Figure 1 provides a flowchart of the guideline development process.) The overall purpose of the evidence-monitoring committees was to critically review current clinical practice guidelines and provide recommendations for implementation at the primary care level. A total of 8 evidence-monitoring committees were established, with more than 45 local experts and opinion leaders sitting as members. Several committee members were also involved in national guideline working groups within their areas of expertise. Each committee was led by an established knowledge expert known for his or her work in the particular area of vascular prevention and management. Other committee members included experts from the academic or specialty setting and from the community or primary practice setting. The guideline coordinator attended each committee meeting.

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Figure 1

Summary of the guideline development process

CVD—cardiovascular disease.

Evidence-monitoring committee deliberations

Committee members reviewed the most recent Canadian guidelines, as well as other international guidelines or sources of evidence as required. Gaps or limitations in the guidelines were identified, and evidence from alternate sources was considered as needed. Practice recommendations from the guidelines applicable to primary care were extracted and discussed with respect to usual practice in the Champlain LHIN. Each committee submitted a report that summarized recommendations for the diagnosis and management of the specific risk factor or condition. Once all reports were submitted, the leads of each committee came together with the objective of harmonizing management overlaps and target outcome measures. The goal was to ensure consistent recommendations and targets throughout each prevention and management area.

Guideline harmonization

The review process demonstrated that recommendations were consistent across the 8 groups with a few exceptions. For example, one inconsistency noted was that of albumin-to-creatinine ratio targets and estimated glomerular filtration rate referral parameters, specifically for individuals with diabetes. Collaboration between the nephrology group and the diabetes group resulted in the decision to use recommendations from the nephrology guideline.⁸

Another difference noted involved waist circumference targets, specifically for individuals diagnosed with dyslipidemia. Waist circumference recommendations vary not only across guidelines but also across various ethnic groupings. The Adult Treatment Panel III¹² recommends a waist circumference below 102 cm for men and 88 cm for women; however, the Canadian Cardiovascular Society Dyslipidemia Working Group⁶ stated that waist circumference values varied across cultures, specifically for individuals of European background, but any waist measurement greater than 94 cm for men or 80 cm for women was considered to increase risk of heart disease and other health concerns. Additionally, this group recommends using the International Diabetes Federation waist circumference targets for specific ethnic groups. Although the final guideline harmonization includes the Adult Treatment Panel III targets for practical screening purposes, it refers to the Dyslipidemia Working Group recommendations for target waist circumference across all specific ethnic groups.

Algorithm development

Based on the reports submitted by each evidence-monitoring committee, a brief 1- to 2-page algorithm was developed for the detection and management of each risk factor and disease area included in the guideline. Supplemental information was summarized as required on protocols such as obtaining an accurate waist circumference or proper blood pressure measurement. Pharmacotherapy summary charts were created as a quick reference for important evidence-based medications used in the prevention and management of CVD. All sections of the guideline were organized using a common presentation template to facilitate ease of use by busy clinicians.

Pilot testing

The initial guideline draft, approved by leaders from all 8 evidence-monitoring committees, was then pilot-tested by a small group of family physicians and modified based on feedback received. Pilot testing identified primary care clinicians’ lack of awareness of available community-based programs and services to support CVD prevention and management.

Community resources

In order to make the guideline relevant to local physicians, a database of community resources pertinent to each vascular condition and risk factor was developed. The purpose of the community resources database was to highlight opportunities for physicians to integrate resources from the community into patient management and care interventions. Community resources included specialty clinics and associated referral guidelines, available community programs or patient education sessions, or any other community resources that could facilitate patient management. The database included program descriptions, referral information, and costs of each program or service. The final result was a harmonized, overall vascular management strategy tailored to primary care practitioners in the Champlain LHIN.

Dissemination strategy

The final guideline document was integrated into CCPN’s overall knowledge translation strategy and is primarily being implemented through the Improved Delivery of Cardiovascular Care (IDOCC) project. This quality-improvement initiative, which is being delivered to 84 primary care practices throughout the Champlain LHIN, aims to increase uptake of evidence-based practice for the prevention and management of patients with or at high risk of developing CVD. The IDOCC project centres on the use of an intervention model called outreach facilitation, in which health professionals skilled in facilitating practice change serve as expert resources to primary care practices. In this model, the facilitators provide hands-on support in the following areas:

• practice performance assessment, feedback, and goal setting;

• clinical, technical, organizational, and practical advice; and

• encouragement to move through the implementation of system change.

The guideline is an important resource used by the facilitators, as it provides intervention strategies, target outcome measurements, and associated tools used to promote practice change. One aspect of evaluating the IDOCC program and its effect on patient care will involve using data collected before and after facilitation through medical chart audits to measure physician adherence to the recommendations outlined in the guideline.

A copy of the guideline was distributed to each primary care practitioner working in the Champlain District in 2009, as well as specialists involved in CVD prevention and management. In total, 1300 guidelines were distributed. A Web-based version of the guideline was also created and can be accessed at www.idocc.ca. The guideline will be updated every 2 years to ensure that it reflects the latest evidence for the prevention, detection, and treatment of CVD, as well as new programs and services to support practitioners within the region.