Evidence Reviews for…
Canadian Clinical Preventive Guidelines for
Newly Arriving Immigrants and Refugees for
Primary Care Practitioners
Kevin Pottie MD MClsSc
Centre for Global Health, Institute of Population
Health, University of Ottawa
Website: www.ccirh.uottawa.ca
Policy Implications
• Disease surveillance: Statistics Canada to
routinely disaggregate morbidity and
mortality data for immigrants and refugees
• Need to define and study “Health Settlement”
• Need to link IME, settlement with primary
care practitioners and community brokershealth settlement model
• Need to study health literacy and language
proficiency as predictors of health settlement
Canadian Collaboration for Immigrant and
Refugee Health (CCIRH) (www.ccirh.uottawa.ca)
• 43 Delphi participants
• 23 Interdisciplinary chapter teams
• 10 Steering Committee Members:
Kevin Pottie (co-chair), Peter Tugwell (co-chair), John
Feightner, Vivian Welch, Chris Greenaway, Laurence
Kirmayer, Helena Swinkels, Meb Rashid, Lavanya Narasiah,
Noni MacDonald
• 7 Collaborating Partners: Public Health Agency of Canada,
Citizenship and Immigrant Canada, IOM, Edmonton
Multicultural Health Broker, Calgary Refugee Program,
Champlain LIHN, CIHR.
Evidence-Based Methods for Clinical Actions
Synthesis of Effectiveness of:
• ‘what works’
• implementation ‘how it works’
• resource effectiveness - at what cost/benefit?
• experiential effectiveness - users’ views
• likely diversity of effectiveness
“Health Settlement”
• CIC Immigration Medical Exam and health
system information
• Canadian Settlement Services
• Canadian Urgent care-ER
• Primary and Preventive Health Care
• Community Lay Health Promoters
Overview CCIRH Project
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Objective of Project
Delphi Selection
Evidence Reviews
GRADE approach to Recommendations
Recommendations
Dissemination
Project Objective
• Develop evidence-based clinical preventive
guidelines for immigrants and refugees new to
Canada (focus on first 5 years) for primary
care practitioners.
Canadian Context
• > 70 % of immigrants to Canada from LMIC
Canadian Census 2006
• Issues:
– increased mortality from preventable and
treatable illness DesMeules 2005
– lower health care and preventive service
utilization rates
Health Status of New Immigrants
• Healthy Immigrant Effect (due to preselection)
• Lower all cause mortality (SMR=0.34-0.40)
BUT
Singh Can J Public Health 2004:95:14-21
DesMeules Can J Public Health 2004:95:22-26
DesMeules J Imm Health 2005:7:221-232
Standardized Mortality Ratios in Immigrants as
compared to Canadians
Immigrant
Males
Immigrant
Females
Refugee
Males
Refugees
Females
SMR
95% CI
SMR
95% CI
SMR
95% CI
SMR
95% CI
All Cause
0.34
0.330.35
0.4
0.39-0.41
0.48
0.45-0.51
0.58
0.54-0.63
Infectious Diseases
0.8
0.660.94
0.91
0.69-1.13
0.72
0.54-0.91
1.97
1.2-2.7
AIDS
1.0
0.771.24
3.66
2.1-5.23
0.62
0.41-0.84
Hepatitis
1.78
1.052.51
3.81
1.87-5.67
All Cancers
0.38
0.360.41
0.62
0.54-0.7
Nasopharyngeal
2.9
1.514.24
Liver cancer
2.18
1.692.68
0.4
0.38-0.43
0.59
0.53-0.66
1.77
1.18-2.37
4.89
3.29-6.49
DesMeules J Imm Health 2005:7:221-232
2007 National Physician Survey
• 83% of family physicians provide care for
recent immigrants to Canada
• 6.4% family physicians report that recent
immigrants make up greater than 10% of their
practice.
– 41.0 % were less than 45 years or age
– 53.2 % spoke two or more languages
– 79.9 % were from urban/suburban and inner city
practice location
Practitioner Perspective
• 1. Practitioners face differing patterns of prevention
priorities (Dental, Hep B, PTSD)
• 2. Practitioners face new clinical management
challenges (i.e. intestinal parasites, HIV pre-test
counseling)
• 3. Practitioners face implementation challenges
(language and culture barriers, immigrants limited
exposure to preventive and chronic care)
Immigrant and Refugee Preventive Care
Checklist
First visit
Second visit
(2-7 days)
Third visit
(1-3 mo)
Later visits
(3-6 mo)
Psychosocial
assessment
•Housing situation
•Religious beliefs
•Watch for signs for
PTSD
Watch for
depression
Education
•Counseling (breastfeeding)
•Exercise
•STD prevention
•Cervical screening
•Travel home (e.g.,
malaria)
•Dental care
Screening
investigations
•Mantoux skin test
•CBC diff, ferritin (children,
females)
•Varicella titre
•Hep B Ag/Ab
•HIV with informed consent
•Stool for O&P X 3
•Urine pregnancy test
•Chest x-ray if
mantoux >10mm
Immunizations
•Children: age dependent (DPT-P,
MMR, Hib, etc.)
•Adults: DPT, MMR
•Influenza
•Varicella (nonimmune)
DPT booster
•Hep A
•Hep B
Overview
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Objective of Project
Delphi Selection
Evidence Reviews
GRADE approach to Recommendations
Recommendations
Dissemination
Delphi Selection Process
Selecting priority
preventable and treatable
conditions for recently
arrived immigrants and
refugees
• Importance
• Usefulness
• Disparity
(Oxman et al WHO priority setting 2006)
20 selected conditions
Infectious Diseases
• Hepatitis B*
• Hepatitis C
• HIV/ AIDS*
• Intestinal Parasites*
• Malaria
• MMR/DPTP-HIB
• Syphilis
• Tuberculosis*
• Varicella (Chicken Pox)
Mental Health
• Depression *
• Abuse and Domestic Violence *
• Anxiety and Adjustment Disorder *
• Torture and Post Traumatic Stress
Disorder*
Other Chronic Disease
• Cancer of the Cervix
• Contraception
• Diabetes*
• Dental Caries/Peridontal disease*
• Iron Deficiency Anemia*
• Pregnancy Care
• Vision Disorders
Swinkels H, Pottie K, Tugwell P, Rashid M, Narasi8h L. Selecting Priority Preventable and Treatable Conditions for Recently
Arrived Immigrants and Refugees to Canada: Delphi Consensus. 2009 (under peer review CMAJ)
Overview
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Objective of Project
Delphi Selection
Evidence Reviews
GRADE approach to Recommendations
Recommendations
Dissemination
Methods
• We adapted methods for conducting evidence
reviews (Canadian/US Task Force (Harris 2001), Cochrane Collaboration, NICE)
• We adapted GRADE Collaboration approach
for making evidence-based recommendations
(GRADE approach: Guyatt et al: BMJ 2008 series).
CCIRH 14 Step Methods Process
• Logic model approach developed by the (U.S. and
Can Task Forces)
• Search strategies and summary of findings
tables and equity considerations (Cochrane Equity)
• Review Appraisals (NICE; AGREE, EPOC)
• Quality assessment (GRADE collaboration)
Step 1: Clinician Summary Table
Population
Immigrant/Refugee
Adults
Immigrant/Refugee
Children (under 5)
Clinical Conclusions
A – Service X is recommended
D – Service X is not recommended
Population Specific Clinical Considerations
(burden of disease, baseline risk, adverse
outcomes: mortality and morbidity, genetic
and culture issues, compliance variation)
Condition X is more common among:
- Immigrants/refugees from sub-Saharan countries of origin (list countries)
- Adult men are less likely to be screened for condition X
Clinical Actions during Migration
During migration refugees / immigrants are/are not screened/treated for condition X
(Based on the Citizenship and Immigrant Canada Health Examination, and International
Organization Pre-Departure Screening/Treatment)
Screening tests
Condition X is diagnosed with test Y. When using test Y the following clinical criteria
indicate a positive result:
For Men:
For Women:
Screening interval
Not applicable – only one screen in adulthood within health settlement period needed
Treatment
Treatment includes:
Other Guideline Sources
Health Canada also recommends screening for this condition; their recommendation
states that…..
This document can be found at: www.
Implementation Issues and Cost Reference
Cost of treatment ….,
Step 2: Develop Logic model and key
questions
• Adapted from US Task Force
Value-Added
Evidence-Based Approach
• clinical preventive action and weigh desirable
and undesirable effects
• population specific clinical considerations
• implementation issues
Extrapolation (Cochrane Equity)
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Baseline risk
Clinically important outcomes
Genetic and cultural factors (diet, lifestyle)
Compliance variation (patient and physician
adherence)
Overview
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Objective of Project
Delphi Selection
Evidence Reviews
GRADE Approach to Recommendations
Recommendations
Dissemination
Making a recommendation
degree of confidence that desirable effects of
adhering to recommendation outweigh the
undesirable effects.
Desirable effects
•health benefits
•less burden
•savings
Undesirable effects
•harms
•more burden
•costs
The Grades of Recommendation, Assessment,
Development, and Evaluation (GRADE)
• Reviewed existing grading systems
• Developed a system for grading the quality of evidence and strength of
recommendations of CPGs that has done its best to address disadvantages of
prior systems :
– the lack of separation between quality of evidence and strength of recommendation,
– the lack of transparency about judgments,
– the lack of explicit acknowledgment of values and preferences .
Atkins D, Best D, Briss PA, Eccles M, Falck-Ytter Y, Flottorp S, Guyatt GH, Harbour RT, Haugh MC, Henry D, et al. Grading quality of evidence and strength of
recommendations. BMJ 2004;328:1490.
GRADE uptake
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UpToDate
World Health Organization
British Medical Journal
American Thoracic Society
ACP
Cochrane Collaboration
BMJ Clinical Evidence
Polish Institute for EBM
Society of Vascular Surgery
Society of Pediatric Endocrinology
European Respiratory Society
American Endocrine Society
Society of Critical Care Medicine
Surviving sepsis campaign
American College of Chest Physicians
European Soc of Thoracic Surgeons
EBM Guidelines Finland
Allergic Rhinitis in Asthma Guidelines
National Institute for Clinical Excellence (NICE)
Agency for Health Care Research and Quality (AHRQ)
Swedish National Board of Health and Welfare
Canadian Agency for Drugs and Technology in Health
Ontario MOH Medical Advisory Secretariat
Agencia sanitaria regionale, Bologna, Italia
The German Agency for Quality in Medicine
Evidence-based Nursing Sudtirol, Alta Adiga, Italy
Norwegian Knowledge Centre for the Health Services
University of Pennsylvania Health System Center for EB Practice
Journal of Infection in Developing Countries - International
Making Recommendations
(GRADE Approach)
• Determine GRADE Question (PICOT)
• Determine most important positive and
negatives outcomes (SoF table)
• Rate quality of evidence (directness)
• Determine recommendation (yes/no)
GRADE Approach
• Balancing Desirable and Undesirable Effects
• Quality of the Evidence
• Values and Patient Preferences
• Cost (Resource Allocation)
GRADE: The Grades of Recommendation, Assessment, Development, and Evaluation
Dissemination
Canadian Medical Association Journal
and
(electronic CMAJ-web)
Proposed CMAJ e-guideline
• 6 introductory chapters
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Summary of Recommendations
Migration and Health Overview
Needs Assessment: Selecting Priority Conditions
Evidence-Based Methods
Pediatric Context
Mental Illness overview
• 10 conditions: evidence reviews over 2 phases
academic publications (up to 4000 words)
Proposed CMAJ Supplement
(English/ French)
• 1. Overview
• 2. Guideline Development Process/Methods
• 3. Working with interpreters, culture-brokers and community
resources
• 4. One page Clinical Action GRADE Recommendations
• 5. Clinical use of Guidelines:
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Conducting a migration history
Special Populations
Preventive care checklist (practical implementation tool)
• References and Committee Members
Policy Implications
• Disease surveillance: Stats Canada to routinely
disaggregate morbidity and mortality data
• Need to define and study “Health Settlement”
• Need to link IME, settlement with primary
care practitioners and community brokershealth settlement model
• Need to study health literacy and language
proficiency as predictors of health settlement
THANK YOU
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METHODS IN THE EVALUATION OF EVIDENCE BASED …