The HANDI Project
Advances in non-drug treatments in the past few decades have been substantial and diverse: exercise for heart failure and COPD, the Epley manoeuvre for benign paroxysmal positional vertigo, knee taping for osteoarthritis, cognitive therapy for depression (and almost everything else!), ‘bibliotherapy’ (specific guided self-help books for some conditions), to name just a few.
Nearly half the thousands of clinical trials conducted each year are for non-drug treatments. However, the effective non-drug methods are less well known, less well promoted, and less well used than their pharmaceutical cousins.
There are well-established drugs/medications formularies such as the Australian Medicines Handbook. However, until now, no such formulary or resource for non-drug treatments (interventions) exists.
The HANDI project is a commitment by the RACGP National Standing Committee for Quality Care to promote effective non-drug treatments, making them visible and easy to use. HANDI is an online formulary of non-drug interventions in health care, which have solid evidence of their effectiveness.
Based on the idea of modern pharmacopoeias, each HANDI entry includes indications, contraindications and ‘dosing’. The aim is to make ‘prescribing’ a non-drug therapy almost as easy as writing a prescription for a drug.
HANDI enables clinicians to offer a greater choice of interventions to a patient, who may wish to avoid pharmacotherapy and the risks and life style changes often associated with drug treatment regimes.
HANDI publication process
HANDI is aimed at promoting effective non-drug treatments for General Practice/primary care1. Non-drug treatments, in the broadest sense, refer to any intervention that would not normally appear in a pharmacopoeia including exercise, physical therapies, diets, supplements and herbal treatments.
The HANDI team (the Committee) only consider the assessment of non-drug treatments that are relevant to primary care which might be classed as:
- Interventions performed by a GP or other primary care clinician ( e.g., the Epley manoeuvre);
- Interventions performed by the patient under the GP/primary care clinician’s guidance or (e.g., wet combing)2;
- Interventions usually performed by the GP/primary care clinician that can be taught to patients under special circumstances (e.g., knee taping for OA);
- Interventions that require referral after initial assessment from GP/primary care clinician (e.g., IBS referral for FODMAP, or psychologist referral for CBT or depression).
Class 4 is only considered for assessment under the following conditions:
A. the intervention is not widely known by GPs/primary care clinicians, and;
B. the non-drug intervention would not be the routine therapy for that condition (e.g., FODMAP diet for IBS)
The HANDI team collect possible topics from a variety of sources including online evidence summaries (e.g., ACCESS and Cochrane databases), suggestions from the Committee members and suggestions posted to the HANDI website.
Committee members choose topics that are relevant to general practice and for which there is existing evidence. This is followed by a search for (i) other systematic reviews and (ii) subsequent trials.
Each potential HANDI entry then goes through a 3-stage process before being published:
Stage 1: Assessing the evidence & relevance
The Committee assess the effectiveness of the proposed non-drug intervention in this stage. Individual members present their assessment to the team, using a standard assessment template, followed by general discussion and a voting process. The Committee consider two questions for assessing inclusion in the handbook:
Q1.Is the evidence strong enough?
Q2.Is the intervention relevant to and practical for GPs?
For inclusion in HANDI interventions must be supported by at least two positive good quality Randomised Controlled Trials (RCTs) with patient-relevant outcomes, or one RCT with strong supportive evidence for the causal connection under investigation.
At this first presentation the Committee note issues that need to be considered in drafting the handbook entry.
The RAGCP currently use the NHMRC levels of evidence and in the future we will move to a GRADE process. Criteria for inclusion in HANDI are high; despite looking only at treatments with promising evidence, about half of the proposed interventions based on the criteria above are rejected.
Stage 2: Drafting the HANDI entry.
If the evidence is strong and the intervention is relevant to general practice, the intervention is accepted for publication. The Committee works with a medical writer, and also with trial authors and other experts in the type of intervention where possible, to develop a detailed “how to” guide for the use of the non-drug intervention.
The format is similar to that of a drug formulary. It includes indications, contraindications, precautions, adverse effects, availability and description of intervention. It also includes consumer resources
Stage 3: Final review
Once drafted, the entry is reviewed at a subsequent committee meeting prior to finalisation and publication onto the HANDI website.
The committee currently meets 6 times per year, and considers around 4 – 6 new potential entries at each meeting. Each committee meeting is about 3 hours, in which about half of this time is spent discussing the evidence for new possible entries and the other half discussing draft entries that are being developed.
1. Glasziou P. Making non-drug interventions easier to find and use. Aust Fam Physician. 2013 Jan-Feb;42(1-2):35.
2. Handbook Of Non Drug Intervention (HANDI) Project Team. Wet combing for the eradication of head lice. Aust Fam Physician. 2013 Mar;42(3):129-30.
The RACGP gratefully acknowledge funding received from the Jack Brockhoff Foundation and BUPA Foundation to develop the HANDI project.