Guidelines – Key features and learning points for the CFPC Examination

1. Guidelines – Key features and learning points for the CFPC Examination Dr. Michael Green Associate Professor Associate Director of Research Dept of Family Medicine

2. Outline • CFPC Evaluation Objectives and Key Points • CPGs – grading, rating, personalizing • Top ten CPGs • Critical appraisal resources

3. CFPC Objective “The physician practices evidence-based medicine skillfully. This implies not only critical appraisal and information-management capabilities , but incorporates appropriate learning from colleagues and patients.” CFPC – The evaluation objectives in family medicine

4. Key points • Does not give undue weight to EBM • Adjusts for individual patient characteristics and context • Incorporates own experience and those of colleagues and team members • Open and respectful when dealing with patient questions and review of materials patients bring in

5. Key points 2 • Does NOT change plans for patients who are only temporarily under their care unless discussed and agreed with regular provider. • Checks regularly to ensure practices and plans are consistent with recent evidence and makes changes as required.

6. Red Flags/ “X” factors • Does not use resources to get up to date information • Relies too much on a limited set of inappropriate resources • Does not critically question information • Following group discussion does not incorporate agreed upon changes into clinical practice

7. Assessing guideline quality • AGREE – Appraisal of Guidelines Research and Evaluation Instrument available at www.agreecollaboration.org • 23 items, 6 domains – 4 point Likert scale • Scope/purpose • Stakeholder involvement • Rigour of Development • Clarity and Presentation • Applicability • Editorial Independence

8. Clinical Practice Guidelines (CPGs) - Rating • SORT – Strength of Recommendation Taxonomy • Individual Studies rated 1-3: 1 – good-quality patient oriented evidence 2 – limited-quality patient oriented evidence, 3 – other evidence (ie DOE) • Recommendations rated A-C: A – consistent good-quality patient oriented evidence B – inconsistent or limited-quality patient oriented evidence C – consensus, usual practice, DOE etc..

9. Assessing CPGs for use in YOUR patient • Study populations relevant? • Similar context for care delivery? • Strength of evidence? • Magnitude of benefit vs risks of additional harm (ie. Polypharmacy) • Role of co-morbidities • Patient preferences/values/priorities • ?Guidance rather than Guidelines

10. Top 10 CPGs (CMA CPG Infobase – Feb 25, 2014) • Drug therapy for migraine- Can Headache Society • Diabetes guidelines– CDA • Renal denervation for resistant HTN– CHEP • Dx and Rx of Dyslipidemia– CCS • Measurement/assessment of BP - CHEP

11. Top 10 CPGs (CMA CPG Infobase Feb 25, 2014) • Concussion/Mild TBI – OntNeurotrama Foundation • Colorectal Cancer Screening – TOP • Management of HTN 2013- CHEP • Heart Failure in Children – CCS • Antiplatelet therapy update 2012– CCS

12. Resources to identify CPGs • Several different places to get CPGs (some with ratings) • http://www.cma.ca/clinicalresources/practiceguidelines - CMA’s CPG warehouse site – check out the top 10 CPGs here • http://www.bcguidelines.ca/gpac/ - BC recommended/rated guidelines • http://www.effectivepractice.org/ - includes GAC guidelines from Ontario • http://www.topalbertadoctors.org/ - Towards Optimized Practice – Alberta guidelines

13. International Sources • NICE – National Institute for Clinical Excellence (Britain) http://www.nice.org.uk/ • Institute for Healthcare Improvement (US) http://www.ihi.org/ihi

14. Critical Appraisal Resources • Evidence Based Medicine Series “Users Guide to the Medical Literature” • CMAJ Series : Tips for Learners of EBM – available online in the Topic Collection section of CMAJ online. Good review for the exam. • Should really understand well – NNTB, NNTH, PPV, NPV, Sensitivity vs Specificity, Absolute vs relative risk reduction