Methodology
How we work — guideline development
The Task Force's guideline development process follows a rigorous sequence: (1) topic selection, (2) scoping, (3) identification of outcomes of interest, (4) conducting a systematic review of the evidence, (5) drafting recommendations (incorporating equity, feasibility, acceptability and cost), (6) drafting the guideline, (7) feedback from clinicians, peer reviewers and stakeholders, (8) creation of knowledge translation tools, (9) publication, (10) dissemination to clinicians, patients, decision-makers and the public, and (11) evaluation.
The process draws on input from governments, health professional associations, the College of Family Physicians of Canada, patients and the public, academic institutions and non-governmental organizations. Engagement opportunities include the Task Force's public advisors network. Invited content experts serve as advisors throughout the process, with no vote on the direction or strength of recommendations.
Procedure manual
This procedure manual documents the methods and processes used by the Canadian Task Force on Preventive Health Care to develop its recommendations.
It was developed in collaboration with Task Force members, the scientific team of the Public Health Agency of Canada (PHAC), the Evidence Review and Synthesis Centres (ERSCs), the knowledge translation team and the communications team.
This manual is intended primarily for the Task Force and its core partners as a guide for developing recommendations, and for the scientific team to ensure methodological rigour. It does not include administrative procedures (e.g., recording and approval of minutes). The manual may also be useful for organizations and individuals wishing to learn more about the Task Force's methods.
Sections of the manual are updated regularly as methods evolve. When a chapter is updated, a new version is published with the update date. Earlier versions remain available.
Download the manual chapters
Chapter 1
Overview of the Canadian Task Force on Preventive Health Care
Chapter 2
Prioritization, surveillance, review and selection of topics
Chapter 3
Initiating the guideline development process for selected topics
Chapter 4
Evidence review procedures and methods
Chapter 5
Development of recommendations
Chapter 6
External links
Chapter 7
Knowledge translation
GRADE methodology
Grading of Recommendations, Assessment, Development and Evaluation
Interpreting recommendations
| Target audience | Strong recommendation | Conditional recommendation* |
|---|---|---|
| For patients or the public | We believe that most people in this situation would want to follow the recommended action and only a small number would not. | We believe that most people in this situation would want to follow the recommended action, but many would not. Different choices are acceptable for each individual; clinicians must support patients and discuss their values and preferences to reach a decision. Decision aids can help. |
| For clinicians | The recommendation should apply to most people. Formal decision aids should not be necessary to help people make decisions consistent with their values and preferences. | Each patient may make different but appropriate choices for themselves. Clinicians must support each patient in reaching a decision that fits their values and preferences. Decision aids can help. |
| For decision-makers and developers of quality measures | The recommendation can be adapted as policy in most situations. Its observance can serve as a quality criterion or performance indicator. | Developing policy will require substantial debate and the involvement of various stakeholders. A well-documented decision-making process can be used as a quality indicator. |
* The Task Force formerly used the term "weak recommendation," which was replaced by "conditional recommendation" for greater clarity and to facilitate the application of recommendations. This change emphasizes the importance of shared decision-making and the fact that the application of a recommendation may depend on patients' values, the availability of resources or other contextual factors.
Quality of the evidence
The recommendations of the Canadian Task Force on Preventive Health Care (CTFPHC) are graded according to the GRADE approach. The assessment of the quality of the evidence reflects the degree of confidence that the available evidence correctly represents the true effect of the intervention.
High quality
We are very confident that the true effect is close to the estimated effect. For example: a broad range of studies with no major limitations, little variation across studies and a narrow confidence interval around the summary estimate.
Moderate quality
The true effect is likely to be close to the estimated effect, but it could be substantially different. For example: a few studies with certain limitations but no major flaws, or some variation across studies.
Low or very low quality
The true effect may be substantially different from the estimated effect. For example: studies with major flaws, substantial variation across studies, or a very wide confidence interval.
Strength of recommendations
In addition to the quality of the evidence, the strength of recommendations is influenced by:
- the balance between desirable and undesirable effects;
- variability or uncertainty in people's values and preferences;
- whether the intervention represents a wise use of resources.
Strong recommendations are those for which the expected effects of an intervention outweigh its undesirable effects (strong in favour), or vice versa (strong against). A strong recommendation assumes that most individuals will be best served by the recommended action.
Conditional recommendations are issued when the line between desirable and undesirable effects is thin, when certainty is lower, or when there is wide variability in patients' values and preferences. Different choices will be appropriate depending on the patient; clinicians must help them make a decision that fits their values and preferences.
Source: GRADE Working Group, 2011.
Patient and public engagement
The Canadian Task Force on Preventive Health Care (CTFPHC) integrates the perspective of patients and the public at every stage of guideline development. This participation helps formulate recommendations that reflect the values, preferences and needs of the people affected by preventive services.
Patients and members of the public participate notably through the Task Force's public advisors network, as well as through targeted consultations when setting outcomes of interest and reviewing draft recommendations.
Reaffirmation and sunsetting of guidelines
Context
Since 2011, the Canadian Task Force on Preventive Health Care has developed more than 20 unique guidelines. With this growing volume of topics, conducting full systematic reviews every five years to update guidelines is not always necessary or feasible. The Task Force therefore developed a rigorous, transparent and efficient method enabling the reaffirmation or sunsetting of guidelines unlikely to change.
Five-year review
The five-year review of guidelines includes the analysis of evidence from four sources:
- ongoing surveillance via Prevention Plus alerts (McMaster);
- targeted searches (rapid report commissioned from CADTH);
- searching clinical trial registries to identify ongoing studies;
- feedback from clinical experts and former chairs or members of the working group.
Reaffirmation and sunsetting methods
The methods were developed based on a modified version of the NICE (National Institute for Health and Care Excellence) process. They include a summary of previous guidelines, the analysis of new evidence collected during the five-year review, considerations for reaffirmation or sunsetting, and a dissemination plan.
The results of surveillance, the rapid report, upcoming evidence and expert opinions are collated and synthesized. The Task Force then votes to direct the topic to one of three pathways: full update, reaffirmation or sunsetting.
Piloting and conclusion
The process was successfully piloted on the 2015 guideline "screening for cognitive impairment in older adults," which was reaffirmed. The reaffirmation process is generally completed in a few months, compared to several years for a full update.
Reaffirmed guidelines continue to be subject to ongoing surveillance, and key stakeholders are informed of the reaffirmation.
Updating, reaffirmation and sunsetting clinical practice guidelines: Methods from the Canadian Task Force on Preventive Health Care
Full methodological document (PDF, English)
Download the document (PDF)