Update on task force terminology and outreach activities

Characteristics of trustworthy guidelines include transparency, explicitness, and rigour around methods and evidence evaluation. Guideline development should be free from influence related to conflicts of interest among guideline panelists and developers or funders, including specialty organizations with vested interests in recommendations, and should integrate values and preferences of patients; recommendations should be clear and actionable.^1–3 For most preventive services, multiple Canadian and international guidelines are available. These guidelines sometimes diverge in how they are developed, their adherence to optimal methodology, and their recommendations.^2–6 The Canadian Task Force on Preventive Health Care has established and continues to build upon an explicit framework intended to produce the most trustworthy and useful guidance possible. This is done to meet the needs of Canadian health care providers, stakeholders, and the public.

The task force is funded and supported by the Public Health Agency of Canada. We are a body that is composed of 12 to 15 primary health care providers, prevention experts, and methodologists; that is independent of the government; and that maintains independence from special interests by adhering to a rigorous conflict of interest policy. No current members have any industry conflicts of interest. The task force makes its methodology and the evidence reviews that support its guidelines available publicly.⁷ To ensure our guidelines reflect patient values and preferences, the task force incorporates evidence on this via work conducted by the Knowledge Translation Program at St Michael’s Hospital in Toronto, Ont, systematic review of published evidence, or both.⁷

Strength of recommendations

Summaries of task force recommendations by the media and others often focus on the direction of recommendations, “for” or “against,” rather than on the certainty of the evidence and who should specifically follow the recommendation. The task force follows the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to develop recommendations. According to the GRADE system, “weak” or “conditional” recommendations are typically made when there is uncertainty about the likely desirable and undesirable consequences of an intervention, when for most patients the desirable effects of an intervention probably outweigh the undesirable consequences (recommendations in favour of a service), or when the undesirable effects probably outweigh desirable effects (recommendations against a service). These recommendations imply that not all individuals in all settings will be best served by the same course of action. Previously, the task force used the term weak for these recommendations. To emphasize that there is not a high level of certainty on the best course of action or that different individuals will prefer different options, the task force will no longer label these types of recommendations as weak, but will label them as conditional instead; then we will specify the conditions under which the service should be provided and the conditions under which it should not. In many cases, these conditions will be related to patient priorities about the relative importance of possible benefits and harms and typically shared decision making will be emphasized.⁸ For example, the recent task force guideline on breast cancer screening conditionally recommends screening for breast cancer among women aged 50 to 69 years because the choice to undergo screening, or not, is conditional on the relative value an individual woman places on possible breast cancer survival benefits versus possible harms, including consequences of the overdiagnosis of cancer.⁹ The task force provides knowledge translation tools to support understanding of recommendations and to facilitate shared decision making, when appropriate, on its website (https://canadiantaskforce.ca).

Strong recommendations with low-certainty evidence

According to the GRADE Handbook,

A strong recommendation is one for which [the] guideline panel is confident that the desirable effects of an intervention outweigh its undesirable effects (strong recommendation for an intervention) or that the undesirable effects of an intervention outweigh its desirable effects (strong recommendation against an intervention).⁶

A strong recommendation might be made, even in the context of low-certainty evidence, for example, when there is low-certainty evidence of benefit and high certainty of harms or important resource implications. The task force is mindful of the resource constraints faced by our primary health care system and the resource burden of engaging in activities that consume scarce financial resources or limit access to primary care providers. Thus, when resource implications are certain to be important and benefits have not been demonstrated or require substantial speculation about chains of events that might lead to benefits, the task force will make a strong recommendation against a new service in the context of low certainty in the evidence, suggesting that it should not be offered. In the recent task force guideline on breast cancer screening,⁹ the task force makes a strong recommendation against offering alternatives to mammography, such as ultrasound or tomosynthesis as first-line screening strategies. In this case, we did not find evidence of benefit from the service but are certain that additional valuable health care resources would be consumed if the service were implemented.

Outreach activities

The task force is an independent body that answers to the Canadian public rather than to particular disease-based or special interest groups. In this context, we have developed a number of outreach programs to increase engagement with key stakeholders. Recently, the task force introduced an internship program that offers mentored training opportunities for health care trainees and early career professionals to work with task force members on guideline development. The Clinical Prevention Leaders Network is another program that provides the opportunity for clinicians to train in task force methods and in guideline development, to promote the uptake of evidence-based guidelines, and to address barriers to implementation of recommendations. Finally, to promote understanding of its guideline recommendations and facilitate guideline implementation, the task force develops online continuing medical education modules in partnership with the College of Family Physicians of Canada. Information about all of these opportunities is available on the task force website.

Sharing information about the task force processes might help to promote transparency, but accountability requires input and feedback from those who act on task force recommendations. We want to hear from health care providers about where more guidance is needed and how it should be presented. We invite you, the readers of Canadian Family Physician, to visit the “Submit Topic Suggestions” page of our website (https://canadiantaskforce.ca/submit-topic-suggestions), where you can suggest guideline topics. We hope our work will be distinguished by its focus on issues important to Canadians and its reliance on the best available methods.