Canada’s provincial governments appear poised and willing to provide financial support for a national strategy for clinical practice guidelines, if the federal government comes on board.
The provincial governments want to “ensure patients get the most appropriate quality of care” and “reduce unwanted variation in care delivery,” Ontario Assistant Deputy Health Minister Vasanthi Srinivasan told delegates to the Canadian Clinical Practice Guidelines Summit in Gatineau, Quebec.
Canada has a window of opportunity to implement a strategy that would “streamline the dissemination and implementation of the knowledge summarized in clinical practice guidelines,” she said in a Nov. 4 address to knowledge transfer experts. “My commitment on behalf of my colleagues is to look for ways to address the policy challenges and find an effective road for government to work with health practitioners in making this a reality for Canada.”
But the viability of such a strategy will depend on federal assistance, Srinivasan later stressed in an interview. “The only way we will sustain the interest and commitment is for everybody to have some stake in the game,” she says. “There needs to be some support beyond words.”
The issue will be raised at a meeting of federal, provincial and territorial health ministers later this month, she adds. “I don’t think anyone has the appetite to receive new funding requests,” but “to be honest I think there is money in the system” that can be redirected to the strategy.
“There’s always a time for these things, and I think we’ve hit that right time,” she explains.
Canada’s currently at a “crossroads in the history of publicly funded health care,” Srinivasan told delegates. “With costs spiralling, health systems across the country need to look at reforms that address how [care] is delivered.”
A national strategy for clinical practice guidelines ideally would coordinate the development, dissemination, implementation and financing of guidelines, set standards for their production and identify gaps in evidence to prioritize future research, according to knowledge transfer experts (www.cmaj.ca/lookup/doi/10.1503/cmaj.109-4048).
Canada currently lacks an “overarching coordinating function,” resulting in widespread duplication of effort and poor system uptake of best practices, as practitioners feel overwhelmed by the often conflicting and ever increasing number of guidelines, Jeremy Grimshaw, a senior scientist in clinical epidemiology at the Ottawa Hospital Research Institute in Ontario, told delegates.
The first role of a national strategy should be to establish a central accreditation process to identify and align guideline developers that are performing to international standards, and “do away with groups or individuals that are producing poor guidelines,” Doris Grinspun, executive director of the Registered Nurses’ Association of Ontario, argued.
Guidelines produced by nationally accredited bodies could then be accessed through a single public portal, Grimshaw said. “As a user of guidelines, I’d actually like to go to one place that’s fairly easy for me to find.”
However, the “elephant in the room” is that some developers will have to give up their activities, said Doug Stich, director of Toward Optimized Practice for the Alberta Medical Association. “We would lose the credibility of being a developer, and that backstops implementation activities, and lose local champions that arrive through the development process. What do we need to do to help those of us who are local organizations involved in implementation when you take that halo away from us?”
But guidelines developed by credible bodies with appropriate resources at a national level would still “need to be contextualized in local settings,” Grimshaw argued. “We can develop the guidelines centrally but we cannot implement them without it happening at the local level, so I think a model [for unaccredited organizations] of 90% implementation and 10% adaptation would be really good.”
To that end, the national strategy could oversee the development of standardized implementation tool kits, said Dr. Valerie Palda, guidelines advisory committee medical director for the Toronto, Ontario-based Centre for Effective Practice.
A national strategy would also enable the development of dissemination tools, such as summaries, to translate guidelines into “capsules that can be used by the practitioner and equally understood by the policy makers so we can work in tandem to address challenges,” Srinivasan told delegates.
Still at issue is exactly how much financial support the provinces might be willing to provide.
“Clearly there are some front end costs associated with moving the system forward on a quality agenda,” Srinivasan said. “We’re still looking at the ingredients that should make up this whole. It’s the function we’re looking at. The form will come later. And if it does have a cost associated with it we’ll have to go through the protocols but I really think the premier and his colleagues believe this is the right way to move forward.”
A similar initiative in 1994 cost the United Kingdom around £30 000 to jumpstart, but that sum could be recouped within a year by switching as few as 100 patients from the most expensive beta blocker to a generic, Grimshaw said. “What often happens is people aren’t prepared to say we need to invest in knowledge resources because we have these critical demands, without recognizing that what would be a relatively minor contribution in global terms may have a huge payback to the health system.”
But not all best practices necessarily equate to cost savings, other delegates warned.
“We’ve heard a lot that there’s good evidence that clinical practice guidelines change physicians’ behaviour, but we haven’t actually good evidence that they would decrease costs that would justify our requesting money,” explained Dr. Martin Reed, chair of the Canadian Association of Radiologists’ guidelines working group.
Grimshaw countered that it only takes “relatively small changes in clinical activity” to effect significant cost savings in the long run, “particularly if you’re embedding guidelines with some degree of cost perspective.”