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Clinical guidelines

National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people Second edition

Methodology

The review and updating of the first (2005) edition of the National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people was undertaken by NACCHO and the RACGP in 2010, and funded by the Office for Aboriginal and Torres Strait Islander Health. It was led by a project executive whose role was to coordinate all aspects of the project including liaison with the funder, convening a project reference group, commissioning a clinical editor, commissioning authors to develop chapter drafts for specific topic areas, coordinating expert individual and organisational reviews, formatting and editing the final version, seeking endorsement and developing print and electronic strategies for dissemination. The role of the project reference group was to contribute to and clarify the overall scope of the National Guide, provide advice regarding its development, periodically appraise the content of draft chapters, and provide advice regarding its dissemination. The project reference group included representation from NACCHO, the RACGP, the Office for Aboriginal and Torres Strait Islander Health, the Australian College of Rural and Remote Medicine and selected Aboriginal Community Controlled Health Services and GP representatives.

The development of the second edition comprised three stages:

  • Review of the first edition of the National Guide
  • Evidence review and formulation of recommendations
  • Editorial review, expert review and stakeholder consultation.

Review of the first edition

A formal review of the first edition of the National Guide was conducted to determine current usage and how the structure, content and modes of dissemination could be improved. An online survey involving 86 healthcare practitioners – comprising GPs, nurses and AHWs – was conducted in September 2010. Following this, 11 key informant interviews were conducted with a purposive sample to gain a more in-depth understanding of ways to improve the National Guide. A diverse sample was sought to include representatives from Aboriginal Community Controlled Health Services, other Aboriginal health services, general practices and government departments working in urban, rural and remote settings. Some key findings from this consultation process are summarised below.

Use of the National Guide varied considerably, with staff from Aboriginal Community Controlled Health Services reporting greatest usage. A range of health professionals accessed the National Guide including GPs, public health medical officers, practice nurses and AHWs. The National Guide was used for clinical care, teaching, developing policies and guidelines for best practice, general information, designing health practice protocols, and developing research and quality improvement questions. Features that made the National Guide easy to use included the summary charts, layout and provision of evidence for recommendations and its use as a resource when explaining health issues with staff, patients, students and trainees. The main barriers to use included general lack of awareness of the National Guide, out-of-date recommendations, excessively ‘busy’ charts and summaries, and a lack of electronic integration with clinical software.

Suggestions to improve the content included:

  • provision of more regular updates
  • a summary of disease burden data
  • practical actions that primary care practitioners can undertake to improve access to best practice care, including activities that can be undertaken by non-medical staff.

Formatting suggestions included:

  • the provision of practice points
  • arranging the content in themes
  • evidence of recommendations to be provided in a full reference document.

It was generally considered important that the National Guide be accessible in a range of formats to enhance accessibility. Both print and electronic versions were considered necessary. Incorporation into clinical software was frequently suggested as an effective publication method. Respondents also felt that greater awareness of the National Guide could be attained through public presentation opportunities and a targeted marking strategy to various primary care stakeholders. While most respondents considered it important to have a separate preventive health guide for Aboriginal and Torres Strait Islander people, a number of people recommended greater consistency in recommendations between it and the RACGP Guidelines for preventive activities in general practice (‘red book’).9 

Evidence review and formulation of recommendations

Defining the scope

The review of the first edition of the National Guide underscored the importance of providing practical recommendations to primary care practitioners in the prevention of disease affecting Aboriginal and Torres Strait Islander people. The focus is on health issues that were preventable and amenable to primary healthcare intervention and contributed greatly to the morbidity and mortality of Aboriginal and Torres Strait Islander people. Existing topic areas from the first edition were reviewed by the project reference group and all were considered appropriate for inclusion in the second edition. It was agreed that the following new topics would also be included: antenatal care, adolescent health, rheumatic heart disease prevention, asthma, depression prevention, bronchiectasis and the health of older people.

Despite its breadth, for mainly practical reasons related to time and resource constraints, it was not possible to include a number of other important preventive health issues. Examples include genetic testing, pre-conception counselling, certain cancers and urinary incontinence. Readers are therefore encouraged to consult other preventive health guides for advice in these areas.

Preventive activities are typically classified as:10

Primary prevention, which avoids the development of a disease. Population-based health promotion activities are examples of primary preventive measures.
Secondary prevention, which focuses on early disease detection and implementation of interventions to prevent disease progression and emergence of symptoms.

Tertiary prevention, which reduces the negative impact of an already established disease by restoring function and reducing disease-related complications.

The emphasis of the National Guide was on primary prevention activities. Additionally, for some topic areas, it was considered important to include secondary prevention activities if these were considered effective, feasible to implement and able to make a substantial contribution to reduction in overall disease burden. For example, it is well established that a large number of cardiovascular disease (CVD) events occur in people who have had a prior event and consequently secondary prevention interventions targeting this group play a key role in reducing overall CVD-related disease burden. Thus, a pragmatic approach was taken for each topic area to determine if any secondary prevention activities should be included. This was facilitated by regular communication between authors, editors, the project reference group and, at the later stages, expert reviewers.

Developing recommendations

Preventive interventions were:

  • classified according to their type and assessed for their effectiveness based on critical review of established guidelines and empirical literature (see ‘appraisal process’)
  • assessed for whether the evidence base informing them was considered generalisable to an Aboriginal and Torres Strait Islander healthcare context
  • assessed for whether they were feasible to implement in a primary healthcare setting.

Classification of preventive interventions

Interventions were classified into five categories to ensure a systematic and comprehensive approach to prevention.11 

  • Immunisation involves the administration of vaccines to prevent the onset of infectious disease.
  • Screening involves the systematic detection and management of disease before symptoms develop. Screening is warranted when management of the disease in the preclinical phase confers benefits beyond those from when the person becomes symptomatic and seeks clinical help. Examples include screening for diabetes, cancer, osteoporosis and high cardiovascular risk.
  • Behavioural interventions involve any interventions that target the actions a person may take for the purpose of promoting or maintaining health (eg. physical activity), or brief interventions, for example, to support smoking cessation or safe sex.
  • Chemoprophylaxis involves the use of medication to prevent the onset of disease or reduce the risk of acquiring disease: for example, use of angiotensin converting enzyme inhibitors to prevent kidney disease and the use of antiviral drugs to prevent influenza.
  • Environmental influences include community and public health focused structural interventions that are considered relevant to primary care practitioners either via direct implementation or via involvement in peripheral activities such as advocacy and liaison with other agencies. It also includes systems based interventions conducted in the health service. Examples include community based programs to ensure improved food supply, school based interventions, implementation of systematic recall and reminder system, advocacy to government stakeholders for local/regional liquor licencing regulations, and involvement of the health service in social marketing activities.

Generalisability of recommendations to an Aboriginal and Torres Strait Islander health context

The National Guide was developed with the view that there had to be specific evidence against generalising national and international recommendations, before interventions were deemed not to apply to Aboriginal and Torres Strait Islander populations. Further, the vast heterogeneity of Aboriginal and Torres Strait Islander populations means that statements based purely on genetic predisposition to disease are generally unhelpful. Individual predisposing risk factors such as family history and genetic markers may, however, be relevant.

Factors to consider when assessing whether the evidence was valid for application in the Aboriginal and Torres Strait Islander health context included:

  • differences in prevalence of disease/risk factors for Aboriginal and Torres Strait Islander populations that may influence the population benefits, cost-effectiveness of the intervention, and predictive value of screening tests
  • whether sociocultural factors might predicate a different approach
  • whether the effectiveness of the intervention is known to exhibit wide variation depending on geographical region.

Relevance and applicability to primary healthcare

Interventions were also assessed for the context of service delivery in which they would be principally implemented. Some preventive activities, although clearly linked to improved health outcomes, were omitted because they are generally implemented outside the primary healthcare context. Examples include screening for tuberculosis, interventions to increase workforce participation and housing and education initiatives.

Other considerations influencing whether recommendations were suitable for primary healthcare included whether the information was useful for clinical decision making, particularly for areas where there is clinical practice uncertainty or where the issue is considered contentious or controversial.

Searching the evidence base and drafting recommendations

The evidence base for the National Guide was informed primarily by national and international evidence-based guidelines. Published guidelines from several national and international guideline developer groups were sourced. Where Australian guidelines were being updated or newly developed, the guideline developers were contacted to review the most current drafts.

The following guideline developers groups/repositories were reviewed:

  • Australian National Health and Medical Research Council (NHMRC) guidelines portal12 
  • UK National Institute for Health and Clinical Excellence (NICE)13 
  • New Zealand Guidelines Group (NZGG)14 
  • Scottish Intercollegiate Guidelines Network (SIGN)15
  • US Preventive Services Task Force (USPTF)16
  • US Agency for Healthcare Research and Quality.17

Clinical practice guidelines developed by non-government organisations were also reviewed. Examples included the RACGP Guidelines for preventive activities in general practice,9 the Central Australian Rural Practitioners’ Association manual18 and the Therapeutic Guidelines.19 

Where existing or newly developed guidelines were considered insufficient for particular topic areas, systematic reviews and meta-analyses of the primary research literature were reviewed. In the absence of these studies, or where the scope was considered insufficient, authors were instructed to conduct literature reviews of empirical research where relevant. Empirical literature searches focused on studies published from June 2005 (the date of completion of evidence reviews for the first edition) to December 2011. In the absence of any empirical research, authors sought to source expert opinion statements to guide best practice recommendations. The following sources were used to search for empirical literature: Cochrane Database of Systematic Reviews, MEDLINE, Informit, Australian Indigenous Health Infonet, evidence reviews from the British Medical Journal’s Clinical Evidence and Dynamed, and the USA Centers for Disease Control.

Authors were instructed to objectively examine the evidence and summarise the recommendation, critically appraise the source of the recommendation, assign the level and strength of evidence (see below) and record the relevant references (see below). To update chapters from the first edition authors were provided with documents outlining the evidence base used for the relevant chapter draft.10 They were then asked to review the evidence to identify whether existing recommendations remained appropriate, whether any recommendations could no longer be substantiated and needed to be deleted, and whether any additional recommendations needed to be included. For sections not covered in the first edition, authors conducted reviews of national and international guidelines and the empirical literature via the process described above.

The RACGP Guidelines for preventive activities in general practice format for providing recommendations was adapted to incorporate the five prevention categories used to guide the scope of interventions.9 It was assumed that the populations of interest for all recommendations in the National Guide are Aboriginal and Torres Strait Islander people. Although a recommendation may have been equally applicable to other populations, this was considered outside the scope of this project. A reporting template was used to guide authors in the format of the recommendations. An example follows.

Topic: Smoking prevention and cessation
Preventive intervention typeWho is at risk?What should be done?How often?Level/strength of evidence
Screening People aged ≥10 years Smoking status should be assessed for every patient over 10 years of age on a regular basis Opportunistic and as part of an annual health assessment IA9,20–22

Critical appraisal and assigning the level and strength of evidence

For guidelines that were already endorsed or developed by the following organisations, authors were instructed to not conduct a critical appraisal process: NHMRC, NICE, SIGN, USPSTF, NZGGG. For other guidelines, authors were recommended to use the AGREE critical appraisal tool to assess for guideline quality.23 For systematic reviews and randomised controlled trials the SIGN appraisal tools were recommended.24,25

Although it was not intended that these questions be formally reported in the National Guide, authors were provided with the following questions to assist in the assessment of a study/guideline recommendation:

  • What are the most relevant primary and secondary preventive interventions to report in the National Guide on this topic?
  • Is the intervention relevant to primary healthcare?
  • For relevant interventions, what is the magnitude of effect? This may be represented by absolute rates and number needed to treat (NNT) or harm (NNH), or by absolute differences or differences in relative risk.
  • Are the benefits/harms clinically significant?
  • Is the intervention generalisable to the Aboriginal and Torres Strait Islander population?
  • Are there any caveats to implementing this intervention?

Each recommendation was graded according to the NHMRC classification scheme for assigning level (Table 1) and strength (Table 2).26 For some interventions there was limited evidence from which to draw conclusions on the intervention’s effectiveness. Expert opinion was therefore considered very important in interpreting the evidence and making judgements about the relevance of recommendations to Aboriginal and Torres Strait Islander health (see generalisability above). Expert opinion based recommendations were assigned as good practice points (GPP). In determining GPP, there was regular discussion between authors, the editors and, at the later stages of the project, the project reference group and external experts. This process was especially important for determining the optimal frequency of an intervention or the age from which to commence an intervention. For example, on the basis of disease prevalence data, many preventive interventions are recommended to commence at an earlier age in Aboriginal and Torres Strait Islander people than in the general population. Where needed the project reference group was also consulted to assist writers by taking a consensus approach to recommendations.

NHMRC levels of evidence and grades for recommendations

These are derived from the NHMRC Levels of evidence and grades for recommendations for developers of guidelines (2009).26

Table 1. Level of evidence hierarchy

A systematic review of level II studies

II

A randomised controlled trial

III–1 

A pseudorandomised controlled trial (ie. alternate allocation or some other method)

III–2 

A comparative study with concurrent controls:
Non-randomised, experimental trial; cohort study; case-control study; interrupted time series with a control group

III–3 

A comparative study without concurrent controls:
Historical control study; two or more single arm study; interrupted time series without a parallel control group

IV     

Case series with either post-test or pre-test/post-test outcomes
Table 2. Body of evidence matrix
ComponentA (Excellent)
Body of evidence can be trusted to guide practice
B (Good)
Body of evidence can be trusted to guide practice in most situations
C (Satisfactory)
Body of evidence provides support for some recommendation(s) but care should be taken with this application
D (Poor)
Body of evidence is weak and recommendation must be applied with caution

Evidence
base*

One or more level I studies with a low risk of bias or several level II studies with a low risk of bias

One or two level II studies with a low risk of bias or a SR/several level III studies with a low risk of bias

One or two level III studies with a low risk of bias, or level I or II studies with a moderate risk of bias

Level IV studies, or level I to III studies/SRs with a high risk of bias

Consistency†

All studies consistent

Most studies consistent and inconsistency may be explained

Some inconsistency reflecting genuine uncertainty around clinical question

Evidence is inconsistent

Clinical impact

Very large

Substantial

Moderate

Slight or restricted

Generalisability

Population/s studied in body of evidence are the same as the target population for the guideline

Population/s studied in the body of evidence are similar to the target population for the guideline

Population/s studied in body of evidence differ to target population for guideline but it is clinically sensible to apply this evidence to target population‡

Population/s studied in body of evidence differ to target population and hard to judge whether it is sensible to generalise to target population

Applicability

Directly applicable to the Australian healthcare context

Applicable to the Australian healthcare context with few caveats

Probably applicable to the Australian healthcare context with some caveats

Not applicable to the Australian healthcare context

SR = systematic review, several = more than two studies
*  Level of evidence determined from the NHMRC evidence hierarchy (Table 1)
†  If there is only one study, rank this component as ‘not applicable’
‡  For example, results in adults that are clinically sensible to apply to children OR psychosocial outcomes for one cancer that may be applicable to patients with another cancer

Editorial review, expert review and stakeholder consultation

Authors submitted their drafts to the clinical editor, who reviewed and provided feedback for suggested revisions. Several chapters, including those authored by the clinical editor, were also reviewed by the public health medical officer from NACCHO. Following this a three-member editorial team comprising the clinical editor, the NACCHO public health medical officer and the medical advisor to the RACGP Faculty of Aboriginal and Torres Strait Islander Health held several meetings, each of two days duration, to review all chapter drafts.

Drafts were sent to several independent expert reviewers for appraisal. Reviewers were given a template to complete in which they were asked the following questions:

  • Are the recommendations consistent with your knowledge of the evidence?
  • If applicable to this topic, are the good practice points consistent with your understanding?
  • Where there is a deviation in the above, is that deviation acceptable within the limits of our knowledge?
  • In relation to primary prevention (and possibly secondary prevention), is there anything that is vital to this topic that has been missed? If so, what?
  • Please include any other feedback you may have on this topic.

Reviewers were also invited to make specific comments and suggested wording changes within each topic draft. The recommended changes to the topic draft were reviewed by the clinical editor, who then corresponded with the author to respond to the recommendations. Members of the project reference group and external peak body organisations were also consulted to review chapter recommendations and their feedback was incorporated through editorial team review. The editorial team determined the final content of the drafts in consultation with authors. The contributing authors, external reviewers and external peak body organisations invited to comment are listed in the acknowledgements.

Role of the funding source and conflicts of interest

The revision and updating of the National Guide is a joint project of the NACCHO and the RACGP National Faculty of Aboriginal and Torres Strait Islander Health. A grant from the Australian Government Department of Health and Ageing was provided to the RACGP, to assist in the development of the content and to assist with the editing and dissemination process. The funding body for this project had no involvement in the conception and design of the National Guide, and development of the content. Australian Government departmental representatives were invited to appraise drafts and make recommendations to NACCHO and the RACGP for improvements and the decision to act on these recommendations was independently made by the editorial team. All contributing authors were asked to declare any pecuniary or other conflicts of interest and these declarations are included in the list of authors section. External reviewers and organisations were not funded and the generosity of their contribution is greatly appreciated.

References

  1. The Royal Australian College of General Practitioners. Guidelines for preventive activities in general practice (the red book), 7th edn. South Melbourne: The RACGP, 2009 cited 2011 October 10.
  2. National Aboriginal Community Controlled Health Organisation. Evidence base to a preventive health assessment in Aboriginal and Torres Strait Islander peoples. South Melbourne: The Royal Australian College of General Practitioners, 2005.
  3. Jamison DT, Mosely WH, Measham AR, Bobadilla JL (editors). Disease control priorities in developing countries: an overview. Oxford University Press for the World Bank, 1993.
  4. National Health and Medical Research Council, National Institute of Clinical Studies. Clinical practice guidelines portal. Canberra: Australian Government Department of Health and Ageing, 2011. Cited October 2011. Available at www.clinicalguidelines.gov.au/.
  5. National Institute for Health and Clinical Excellence. Find guidance. London: National Institute for Health and Clinical Excellence, 2011. Available at http://guidance.nice.org.uk/.
  6. New Zealand Guidelines Group. Guidance library. Wellington: New Zealand Guidelines Group, 2011. Available at www.nzgg.org.nz/search.
  7. Scottish Intercollegiate Guidelines Network. Published guidelines. SIGN, 2011. Cited October 2011. Available at www.sign.ac.uk/guidelines/index.html.
  8. US Preventive Services Task Force. Recommendations. Washington DC: US Department of Health and Human Services, 2011. Cited October 2011. Available at www.uspreventiveservicestaskforce.org/ recommendations.htm.
  9. Agency for Healthcare Research and Quality. Evidence based practice. US Department of Health and Human Services, 2011. Cited October 2011. Available at www.ahrq.gov/clinic/epcix.htm.
  10. Central Australian Rural Practitioners Association. CARPA standard treatment manual, 5th edn. Alice Springs, NT: CARPA, 2009.
  11. Therapeutic Guidelines Limited. Therapeutic guidelines products. Melbourne: Therapeutic Guidelines Limited, 2011. Cited October 2011. Available at www.tg.org.au/index.php?sectionid=97.
  12. Fiore MC, Jaen CR. Tobacco Use and Dependence Guideline Panel. Treating tobacco use and dependence 2008 update: clinical guideline. Rockville, MD: US Department of Health and Human Services, 2008. Cited October 2011. Available at www.ncbi.nlm.nih.gov/ books/NBK12193/.
  13. Ministry of Health. New Zealand smoking cessation guidelines. Wellington: Ministry of Health, 2007.
  14. US Preventive Services Task Force. Counseling and interventions to prevent tobacco use and tobacco-caused disease in adults and pregnant women: US Preventive Services Task Force reaffirmation recommendation statement. Annals of Internal Medicine 2009;150(8):551-5.
  15. AGREE Research Trust. Appraisal of Guidelines for Research and Evaluation (AGREE) Instrument 2011. Cited October 2011. Available at www.agreetrust.org/.
  16. Scottish Intercollegiate Guidelines Network. Methodology checklist 1: systematic reviews and meta-analyses. SIGN, 2011. Cited October 2011. Available at www.sign.ac.uk/guidelines/fulltext/50/checklist1.html.
  17. Scottish Intercollegiate Guidelines Network. Methodology checklist 2: randomised controlled trials. SIGN, 2011. Cited October 2011. Available at www.sign.ac.uk/guidelines/fulltext/50/checklist1.html.
  18. National Health and Medical Research Centre. NHMRC levels of evidence and grades for recommendations for developers of guidelines. Canberra: NHMRC, 2009. Cited October 2011. Available at www.nhmrc.gov.au/ _files_nhmrc/file/guidelines/evidence_statement_form.pdf.
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