Guideline harmonization and implementation plan for the BETTER trial: Building on Existing Tools to Improve Chronic Disease Prevention and Screening in Family Practice

Abstract

Background: The aim of the Building on Existing Tools to Improve Chronic Disease Prevention and Screening in Family Practice (BETTER) randomized controlled trial is to improve the primary prevention of and screening for multiple conditions (diabetes, cardiovascular disease, cancer) and some of the associated lifestyle factors (tobacco use, alcohol overuse, poor nutrition, physical inactivity). In this article, we describe how we harmonized the evidence-based clinical practice guideline recommendations and patient tools to determine the content for the BETTER trial.

Methods: We identified clinical practice guidelines and tools through a structured literature search; we included both indexed and grey literature. From these guidelines, recommendations were extracted and integrated into knowledge products and outcome measures for use in the BETTER trial. End-users (family physicians, nurse practitioners, nurses and dieticians) were engaged in reviewing the recommendations and tools, as well as tailoring the content to the needs of the BETTER trial and family practice.

Results: In total, 3-5 high-quality guidelines were identified for each condition; from these, we identified high-grade recommendations for the prevention of and screening for chronic disease. The guideline recommendations were limited by conflicting recommendations, vague wording and different taxonomies for strength of recommendation. There was a lack of quality evidence for manoeuvres to improve the uptake of guidelines among patients with depression. We developed the BETTER clinical algorithms for the implementation plan. Although it was difficult to identify high-quality tools, 180 tools of interest were identified.

Interpretation: The intervention for the BETTER trial was built by integrating existing guidelines and tools, and working with end-users throughout the process to increase the intervention's utility for practice.

Trial registration: ISRCTN07170460.

Conflict of interest statement

Competing interests:Jess Rogers was employed by the Centre for Effective Practice through the BETTER project to facilitate the guideline development process. Sandy Buchman has served as the regional primary care lead for the Toronto Regional Cancer Program. None declared for Denise Campbell-Scherer, Donna Manca, Kelly Lang-Robertson, Stephanie Bell, Ginetta Salvalaggio, Michelle Greiver, Christina Korownyk, Doug Klein, June Carroll, Mel Kahan, Jamie Meuser, Rebekah Barrett and Eva Grunfeld.

Figures

Figure 1:

Process for identifying and integrating evidence for the Building on Existing Tools to Improve Chronic Disease Prevention and Screening in Family Practice (BETTER) trial. Note: AGREE = Appraisal of Guidelines for Research and Evaluation.

Figure 2:

The evidence integration and implementation process for the Building on Existing Tools to Improve Chronic Disease Prevention and Screening in Family Practice (BETTER) trial. The triangle in the centre of the diagram is an extension of the “knowledge creation funnel” in the knowledge-to-action cycle. In our process, there is knowledge synthesis with each funnel representing existing literature captured in high-quality clinical practice guidelines. This is then contextually integrated for each patient’s family history and modifiable risk factors. The side bar shows the structured evidence review process of the clinical working group. The boxes around the circumference of the cycle refer to the steps for implementing the recommendations and tools in both the practice- and patient-level interventions of the BETTER trial. Note: CVD = cardiovascular disease, EMR = electronic medical record.

Figure 3:

The Building on Existing Tools to Improve Chronic Disease Prevention and Screening in Family Practice (BETTER) map for primary prevention and screening for type 2 diabetes and coronary artery disease summarizes all of the relevant recommendations from the clinical practice guidelines. Starting at the rectangular boxes in the middle of the diagram, each parameter is evaluated for the patient. If the patient is on target, follow the arrows up and reinforce positive lifestyle behaviour. If the patient is not on target, follow the arrow down, consider appropriate interventions and intervene on lifestyle behaviours. The risk calculator is used for shared decision-making to illustrate the impact of behaviours like smoking on cardiovascular health. Note: CAD = coronary artery disease.

Figure 4:

The Building on Existing Tools to Improve Chronic Disease Prevention and Screening in Family Practice (BETTER) map for primary prevention and screening for coronary artery disease in patients with pre-existing type 2 diabetes. This map summarizes the recommendations of the clinical practice guidelines. Note: CAD = coronary artery disease, LDL = low-density lipoprotein, UKPDS = United Kingdom Prospective Diabetes Study Risk Engine.

Figure 5:

The Building on Existing Tools to Improve Chronic Disease Prevention and Screening in Family Practice (BETTER) map for primary prevention and screening for common cancers in primary care. This algorithm incorporates tools that take family history into account to assess where routine population screening measures should be modified for patients at higher risk. It incorporates some regional differences in screening protocols between jurisdictions, all of which were deemed reasonable by the clinical working group. Note: AB = Alberta, FOBT = fecal occult blood test, HNCPP = hereditary nonpolyposis colorectal cancer, ON = Ontario, Pap = Papanicolaou smear.