Canadian Hypertension Education Program: The evolution of hypertension management guidelines in Canada

Abstract

The Canadian Hypertension Education Program (CHEP) is a unique Canadian initiative to improve awareness, treatment and control of hypertension through the education of health care professionals. It is the culmination of an over 30-year effort in the development of hypertension management recommendations in Canada. Important transitions in this evolution included adoption of a consensus approach, rigorous evidence grading, enhanced dissemination strategies, recommendation consolidation, sophisticated adjudication procedures, an annual process and the ‘branding’ of the effort as a distinct entity. CHEP is composed of expert health care ‘volunteers’, organized via steering, executive and central review committees, in conjunction with three task forces: the Recommendations Task Force, the Implementation Task Force and the Outcomes Research Task Force. CHEP espouses philosophies that strengthen effectiveness and cohesion: multiple partnerships, stakeholders, supporters and multidisciplinary participants ensure that key messages are disseminated with great impact to broad audiences. Over the past 10 years, there have been unprecedented advances in the treatment of hypertension and the reduction of related diseases in Canada. CHEP, a likely contributor, is being increasingly viewed as an international model for knowledge translation.

In response to the need to improve awareness, treatment and control of hypertension in Canada, the Canadian Hypertension Education program (CHEP), a professional education program, was initiated (1,2). It developed from a confluence of groups involved in the development of recommendations for the management of hypertension (which occurred over 30 years, but these were consolidated into the annual update process in 1999). CHEP is a group of multidisciplinary hypertension experts and a coalition of societies and agencies with mandates to improve blood pressure control, including the Canadian Hypertension Society and Blood Pressure Canada. CHEP has been increasingly successful in developing strategies to annually update recommendations for hypertension management and provide greater opportunities for their implementation into clinical practice.

As is becoming increasingly evident since the initiation of the annual hypertension recommendation update process and CHEP, there have been many significant changes in the treatment of hypertension in Canada and the reduction of hypertension-related diseases, including increases in prescriptions of antihypertensive medications, improvements in awareness, diagnosis and treatment of hypertension, reductions in hospitalization for stroke and heart failure, reductions in mortality for stroke, heart failure, acute myocardial infarction and, most recently, an unprecedented increase in hypertension control rates (to levels that far surpass those of any other jurisdiction globally) (3–9). Although CHEP may not be able to claim full responsibility for these changes reported in observational studies, the program has to be viewed as a contributor to many of them.

THE CHEP ORGANIZATIONAL STRUCTURE

The structure of the CHEP has evolved over time to address perceived needs and gaps in care in the awareness, management and surveillance of hypertension in Canada. Multiple partnerships, stakeholders, supporters and multidisciplinary participants have been encouraged so that the key messages of the CHEP recommendations process may be disseminated to broader audiences and have greater impact.

The CHEP is composed of a steering committee, an executive committee and a central review committee, operating in conjunction with the three task forces (Figure 1).

Figure 1).

The Canadian Hypertension Education Program organizational structure (from the Canadian Hypertension Education Program 2006 Business Plan)

In 2007, the CHEP involved over 100 multidisciplinary, hypertension experts who volunteered their time and expertise. The CHEP engages national opinion leaders and hypertension experts to develop recommendations for the management of hypertension, implementing those recommendations into clinical practice and evaluating outcomes. CHEP formally partners with several professional and scientific organizations, including the Canadian Cardiovascular Society, the Canadian Society of Nephrology, the Canadian Stroke Network, the Canadian Society of Internal Medicine and the Kidney Foundation of Canada. Member organizations that participate in the CHEP steering committee include: the Canadian Hypertension Society, Blood Pressure Canada, the Public Health Agency of Canada, the Heart and Stroke Foundation of Canada, The College of Family Physicians of Canada, the Canadian Council of Cardiovascular Nurses and the Canadian Pharmacists Association.

Recommendations Task Force (10,11)

In the development of the 2008 recommendations, 50 members contributed their expertise to the development of the evidence-based guidelines, through participation in 15 topic subgroups and the central review committee. Literature searches in each topic area are used to develop draft recommendations, which are reviewed by the central review committee and presented at the Canadian Cardiovascular Congress. Recommendations that achieve over 70% support from the full task force and executive are adopted.

The recommendations process is standardized to increase rigour and reduce bias. Standardized literature searches were developed for all topics and are performed annually with the aid of a Cochrane librarian. Subgroups of more than one individual are selected to reduce individual bias. Subgroups reports, comprising their literature review and consequent recommendations, are reviewed by a central review committee composed of experts in evidence-based medicine (who specifically do not have potential financial conflicts of interest) to ensure consistency in grading of evidence and incorporation of evidence into recommendations. At a consensus conference, the potential recommendations are discussed and the evidence is presented by the central review committee. The conflicts of interest of all members are disclosed in writing and available to all in attendance at the consensus conference. Finally, recommendations that have the support of less than 70% are removed. CHEP has a consistent history of requiring a high level of evidence with patient relevant outcomes for pharmacotherapy recommendations.

Implementation Task Force (10,11)

In the development of the 2008 recommendations, the 27 multidisciplinary members participated in five subgroups (family physician, pharmacy, nursing, exercise physiology and specialty subgroups) to tailor the CHEP key implementation messages and annual themes that highlight important CHEP initiatives to their disciplines. The task force is also charged with the responsibility of using all possible avenues to see that the recommendations are adopted into clinical practice. Notably, the major implementation tools are updated annually through a consensus process including the full CHEP executive.

Outcomes Research Task Force (12,13)

In 2007, 36 expert members participated in subgroups in various project areas, including physical measures surveys, national questionnaire surveys, Intercontinental Medical Statistics (IMS) Health Canada drug prescription and office visit data, death and hospitalization data, provincial administrative data and economics. Much of the work is partnered with the Public Health Agency of Canada, Statistics Canada, the Heart and Stroke Foundation of Canada and independent investigators.

THE ROOTS OF THE CHEP

The evolution of the CHEP recommendations has occurred over the past 30 years. Its development was based on several convergent interests. First, there was an early appreciation in Canada in the 1980s of the importance of evidence-based recommendations with the emergence of the Canadian Hypertension Society as a ‘learned society’. This scientific society was initially constituted by clinician scientists who saw evidence-based knowledge translation regarding the management of hypertension as an important part of their mandate. This perspective led to their early development of a series of hypertension management recommendations, which were the forerunners of the CHEP. Second, the early focus of the Canadian hypertension recommendation processes on developing an effective means of their dissemination and implementation was based, in part, on the very significant influence of the Canadian Coalition for High Blood Pressure Prevention and Control (now Blood Pressure Canada). The education of health care practitioners and broader dissemination of evidence-based recommendations was adapted as one of the mandates of this organization. These goals were enunciated as part of the national high blood pressure prevention and control strategy, a joint initiative of Health Canada and Blood Pressure Canada, and by their increasing efforts in developing hypertension recommendations and disseminating them directly and through industrial partnerships. It should be noted that while the final report of this initiative was not released until 2000, draft versions had been widely circulated since 1997. These initial versions informed the 1999 Canadian Hypertension Society recommendations process and the lifestyle recommendations process (see below), and ultimately led to the formation of the annual review process, which first reported in 2000. Last, the strong clinical epidemiology and outcomes research communities in Canada led to the early development of the rigorous criteria for grading the evidence underlying recommendations development (which has been a hallmark of the CHEP program) and the early incorporation of an outcomes research task force into CHEP to critically evaluate the impact of the program.

A short history of hypertension management recommendations in Canada

The initial recommendations for the management of hypertension in Canada can be traced back to 1977 (Report of the Ontario Council of Health, Ontario Council Health). This initiative was a joint effort of the Canadian Cardiovascular Society, the Canadian Heart Foundation (now the Heart and Stroke Foundation) and the Ontario Council of Health. However, these recommendations became quickly outdated with the publication of the seminal Veterans Administration studies in the management of hypertension. The newly constituted Canadian Hypertension Society took on this mandate and, in 1982, developed a task force for the development of recommendations. This culminated in the 1984 publication of the “Report of the Canadian Hypertension Society’s consensus conference on the management of mild hypertension” (14). The development of these recommendations was based on an expert panel format and predated the development of the current criteria for evaluating evidence. A consensus conference on the management of hypertension in the elderly was held in 1985 and subsequently published (15). This initiative was followed by the “Recommendations from the Canadian Hypertension Society Consensus Conference on Hypertension and Diabetes” (16). A consensus conference on nonpharmacological approaches to the management of hypertension was held in 1989 and subsequently published (17). Again, the development of these latter recommendations was based on a single consensus conference format. Also notable, there was a lack of any formal plan for knowledge dissemination and translation in these early efforts.

The 1988 “Recommendations from the Canadian Hypertension Society consensus conference on the pharmacologic treatment of hypertension” (18) again recapitulated the model of the previous consensus conferences. Details regarding the evaluation criteria used and the translation plan are limited and not included in the formal publication of the process.

The process culminating in the 1993 recommendations began the transition toward the process currently being used. It was characterized by the development of multiple topic committees, the grading of evidence based on uniform criteria, and the dissemination of the recommendations somewhat beyond the restraints of the series of peer-reviewed publications resulting from the process, including a simplified guide to the recommendations and an accompanying slide set (19–23).

The second half of the 1990s was characterized by the development of a range of position papers in various aspects of the management of hypertension. All were based on the format established for the 1993 recommendations process and all had limited dissemination outside of the scientific publication. These included the recommendations for sick-leave from work for patients with hypertension from the Canadian Hypertension Society (24), and the reports of the Canadian Hypertension Society consensus conference on the definitions, evaluation, classification and management of hypertensive disorders in pregnancy (25–27).

Blood Pressure Canada (then the Canadian Coalition for High Blood Pressure Prevention and Control), using a parallel process, developed three series of recommendations, in conjunction with a number of partnering agencies. These included self-measurement of blood pressure – recommendations of the Canadian Coalition for High Blood Pressure Prevention and Control (28–31); recommendations regarding lifestyle modifications to prevent and control hypertension, in conjunction with the Canadian Hypertension Society, Laboratory Centre for Disease Control at Health Canada, and the Heart and Stroke Foundation of Canada (32–38); and “Adherence to management of high blood pressure: Recommendations of the Canadian Coalition for High Blood Pressure Prevention and Control” (39). The Blood Pressure Canada efforts were especially notable because they included dissemination plans and used industrial partners to aid in the dissemination. These included the development of standardized slide sets, clinical summaries, pocket cards, posters, partnership with primary care disciplines and train-the-trainer sessions at national meetings.

The 1999 recommendations process continued the evolution of the process (40,41). It integrated a ‘referee’ into the system (Dr Brian Haynes was responsible for adjudicating whether the recommendations were based on a fair grading of the evidence), included a broad dissemination plan and a range of industrial partnerships to help disseminate the messages.

It was based on this ‘history’ that the annual updates of the recommendations process was started in 2000. It was this initiative (which, at that time, was not greeted with any real enthusiasm from the network of hypertension experts, who had just finished two two-year cycles in the production of the lifestyle and 1999 recommendations) that really began the development of the effort that over the next several years matured into CHEP. The rationale of this annual update effort, headed by the Canadian Hypertension Society in conjunction with the Heart and Stroke Foundation of Canada, the Canadian Coalition for High Blood Pressure Prevention and Control, as well as Health Canada, was to develop “strategies to maintain annually updated recommendations for hypertension management and to provide greater opportunities for their implementation into clinical practice” (2). The current structure of the Recommendations Task Force with the central review committee was developed at this time.

The annual updating of the recommendations was critical in providing a platform for the ongoing engagement of the network of hypertension experts. In addition, it was the lynchpin allowing for the emergence and growth of the Implementation Task Force (which now have a yearly ‘product’ to disseminate) and the Outcomes Research Task Force (which can begin to evaluate an increasingly intensive effort), and ultimately the ‘branding’ of the program that is now CHEP.

Key tenets and ‘philosophy’ of the CHEP

Multiple shortfalls have previously been identified that limit the impact of hypertension guidelines (or management guidelines for any chronic disease). These shortfalls were considered and the structure of CHEP has developed to minimize them. These shortfalls, as enumerated by McAlister (42), relate to 1) limitations in endorsement, 2) the sporadic nature of guidelines development, 3) opaque methodologies, 4) inadequate management of competing interests, 5) inadequate recognition of the importance of the development of dissemination and implementation programs, and 6) inadequate recognition of the importance of the development of evaluation programs.

1. Endorsement: The development of CHEP was based on the broad-based support of key stakeholder organizations involved in the management of hypertension. Many of these are represented in the steering committee of CHEP.

2. Periodicity: Substantial interruptions between recommendations releases (every five to seven years) ensured that development of each process would require ‘rediscovering the wheel’. Furthermore, in the intervening years between recommendations processes, the integrity of the key opinion leader ‘network’ developed for each process would naturally dissipate. Also, with long periods between guidelines, there was a ‘lost opportunity’ to maintain hypertension ‘on the radar screen’ for policy makers, who are often attracted to the next ‘new’ set of guidelines. These limitations were minimized with the introduction of the yearly updates. This has allowed the development of a culture of change such that the process evolves each year. Initiatives and approaches that are successful are expanded, and those that fail are examined and revised or discontinued. Many of the procedures to increase rigour and reduce bias, improve and extend implementation, and evaluate outcomes have become much more extensive and sophisticated over the years.

3. Methodology: The Canadian hypertension recommendations process has always been characterized by its rigour in grading evidence and formulating recommendations. This process was further refined with the institution of the central review committee, whose task it was to both refine the grading system and monitor the integrity of the process on an ongoing basis.

4. Management of competing interests: Since its inception, CHEP has been a model for its management of competing interests. Policies were developed to ensure the full disclosure of any perceived competing interests (on an annual basis) and for outlining how these competing interests would be handled during the course of recommendation development and implementation.

5. Implementation: The development of the Implementation Task Force has allowed for the development of more effective dissemination methods, as well as for the ability to disseminate and implement these recommendations to a range of stakeholders beyond the key national opinion leaders (including general practitioners, nurses and pharmacists).

6. Evaluation: The development of the Outcomes Task Force has stimulated the critical evaluation of the impact of CHEP on both intermediate goals (eg, prescribing practices) and longer-term goals (eg, blood pressure control rates and incidence of hypertensive complication rates).

An additional tenet of the program, not mentioned by McAlister, is the inclusiveness of the system. In contrast to other national and international recommendation processes, which use only a minor fraction of their key hypertension opinion leaders (namely, Joint National Committee [JNC], European Society of Hypertension [ESH] and International Society of Hypertension [ISH]), the majority of hypertension ‘experts’ in the country are included in CHEP at some level. Thus, the membership of CHEP far surpasses the memberships in either the JNC or ISH-ESH processes, despite the much larger populations they serve. Part of the ‘buy-in’ by health care practitioners of the CHEP recommendations (as opposed to other national or international recommendations) must relate to the ‘inclusiveness’ of the program with regard to its membership.

The CHEP ‘philosophy’

To understand the structure and development of the program, it needs to be appreciated that the development of rigorous evidence-based recommendations has been the ‘engine’ driving the program’s development and growth (including the growth of the other task forces, as noted above). This is based on several convergent considerations. First, the development and effectiveness of CHEP has been highly dependent on its ability to obtain the ‘buy-in’ of the national key opinion leaders in hypertension. The ability to obtain the consensus of these experts around a common set of recommendations has been highly dependent on the ability of the program to ‘constrain’ the extent to which the range of their ‘expert opinions’ would cause divergence of their ‘personal’ recommendations from the ‘consensus’ recommendations (a phenomenon that has been all too common for a number of national guideline systems, including the JNC process in the United States, and has led to the minimal impact of these programs on patient care). The success of CHEP in this effort can be linked to the development of the very rigorous system for grading evidence and developing recommendations. Second, it should also be pointed out that the ‘philosophy’ underlying the development of the CHEP recommendations has helped to foster and sustain the integrated network of hypertension experts that has been critical in the success of the program in knowledge translation. For a number of other national and international processes (including JNC and ISH-ESH), management ‘guidelines’ have been produced. These guidelines publications have included a range of anecdotal advice and purport to offer comprehensive guides to the management of hypertension. The CHEP recommendations have never aspired to such a level of comprehensiveness. Instead, CHEP has sought to develop recommendations only in those areas in which there is adequate evidence to support them, and to leave those areas of uncertainty to other sources (including local expert networks, textbooks and international bodies). The ability of the program to avoid espousing a ‘definitive’ opinion in areas of uncertainty (and thus areas in which strength of opinion tend to predominate over strength of evidence) has helped to ratify its position as a rigorous arbiter of the evidence supporting its recommendations. Also, this ‘philosophy’ has helped to maintain the ‘common ground’ on which all of the key opinion leaders in hypertension in Canada can co-operatively formulate recommendations that all opinion leaders could ultimately support. This orientation also helps to explain the position of the program to avoid pharmacoeconomic analyses as the basis of recommendations development. This does not reflect the rejection by CHEP of the importance of these considerations. However, it does reflect the real concerns regarding the levels of uncertainty intrinsic in these analyses and the current lack of high-quality economic analyses available that are applicable to the management of hypertension in the context of the Canadian health care system.

The implications of the development and maintenance of this ‘common front’ of key opinion leaders are obvious. This has led to much more homogeneous messaging of these key opinion leaders (they almost all use the annually updated CHEP slide sets in their continuing medical education presentations). Also, the solidarity of this network has helped to contribute to the more homogeneous messaging with regard to the management of hypertension that has come from partnerships of these key opinion leaders with pharmaceutical companies in the development of industry-sponsored continuing medical education programs.

In summary, CHEP reflects the current culmination of an over 30-year effort to develop and disseminate and translate recommendations for the management of hypertension in Canada. This effort, on a global perspective, remains unprecedented in the context of its effectiveness, and is being seen increasingly as a model for development of knowledge translation systems for the management of hypertension and, more broadly, for efforts to improve chronic disease management.