A little more than a year ago, in one of my first President’s Pages, I spoke to you about Canadian Cardiovascular Society (CCS) guidelines and discussed the closed-loop model for guideline development. Guidelines and position statements are one of the most important components of our commitment to member engagement and knowledge translation – the most important component is the annual Canadian Cardiovascular Congress. I am very proud of the leadership that the CCS has demonstrated so far in this critical area, but I know that there is an opportunity for us to continue improving our development processes to ensure that our recommendations and tools are built based on the highest quality of data to stand the test of time.
Dr Charles R Kerr
We currently have 16 CCS guidelines and position statements ‘in process’ (either under initial development or awaiting presentation and publication) that address important topics or issues that directly affect physician practice. I believe that the Guidelines Committee, expertly chaired by Michelle Graham and supported by Carolyn Pullen, the CCS staff Director of Knowledge Translation, has done a tremendous job overseeing this initiative. They have recruited some of our most influential CCS members from a cross-section of cardiovascular disciplines to lead the primary and secondary panels responsible for developing each guideline and position statement.
We have come a long way in our ability to create guidelines that positively impact physician practices; however, like many other organizations around the world, we continue to struggle with measurement. How do we properly evaluate our guidelines and position statements to ensure that they are both effective and useful? Are we creating tools that are accessible and can be used by both specialists and general practitioners? Are recommendations based on high-quality data?
I believe that implementing the closed-loop development model has helped the CCS address some of these areas to better meet your needs. Our heart failure guidelines were the first to be implemented using this iterative, feedback-driven process. This topic was the perfect candidate for the closed-loop model for two reasons. First, heart failure is increasing in prevalence within the population at large. It also poses a number of diagnostic, treatment and management challenges compared with other cardiovascular illnesses because the balance of care is shared among community cardiologists, general practitioners, nurses and other allied health professionals.
Over the past four years, the heart failure guidelines primary panel has successfully developed and implemented several tools designed to efficiently disseminate information to end users across the country. As an illustration of this success, the Heart Failure Consensus Conference Program Web site (www.hfcc.ca) has received a tremendous amount of interest, registering more than 500,000 hits. What is even more heartening is that 80% of those visiting the Web site move past the homepage to access and download guideline-specific information and tools – including clinical pocket guides for assessing and diagnosing patients, and educational slide kits – or to participate in training Webinars. The in-person workshops, which are organized in conjunction with existing regional cardiology events to better meet regional and provincial medical education requirements and end user needs, consistently attract between 2000 and 2500 participants every year. The ongoing development of this important program will continue from 2010 to 2012 under the direction of co-chairs Robert McKelvie and Gordon Moe.
I anticipate that our next topic – atrial fibrillation – will be a similar success. The primary panel, chaired by Anne Gillis and Allan Skanes, had their first meeting at the 2009 Congress in Edmonton, Alberta, and is already well underway in preparation for initial presentation and rollout.
One particularly exciting component of the new atrial fibrillation guideline is that it will be the first time that a CCS guideline implements the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system of evaluation. Effective January 2010, GRADE will be the CCS scale for rating recommendations, replacing the American Heart Association/American College of Cardiology scale that was used between 2004 and 2009.
The vast majority of guideline rating systems around the world are inconsistent in how they rate both the quality of the evidence and the strength of the recommendations. The GRADE system has become the gold standard because it addresses both of these issues.
Developed by a mainly Canadian team, including Drs Holger Schünemann and Gordon Guyatt at McMaster University (Hamilton, Ontario), the GRADE system demonstrates several distinct advantages over other rating systems because it provides a clear separation between quality of evidence and strength of the recommendation, offers explicit evaluation of outcomes, details comprehensive criteria for downgrading and upgrading quality of evidence, and uses a pragmatic approach to the interpretation of strong versus weak recommendations for clinicians, patients and policy makers.
‘GRADEing’ future CCS guidelines will require a slight change in mindset, so I expect that we will need time to become comfortable with this new approach; however, I strongly believe that the result will be well worth the effort. I look forward to sharing more information about the system in a future editorial to help every member fully understand the system, its rationale and process before our 2010 Congress in Montreal, Quebec, this autumn.
As always, I invite you to contact me via e-mail at president@ccs.ca with any questions, input, ideas or constructive criticism. I pledge to either reply to you personally, or have one of the appropriate members of our Executive Team or CCS staff respond to you directly.