Ainsley Moore

Purpose: To inform recommendations by the Canadian Task Force on Preventive Health Care on potentially inappropriate prescribing and over-the-counter (OTC) medication use among adults aged 65 years and older in primary care settings. This protocol outlines the planned scope and methods for a systematic review of the benefits and harms and acceptability of interventions to reduce potentially inappropriate prescriptions and OTC medication use. Methods: De novo systematic reviews will be conducted to synthesize the available evidence on (a) the benefits and harms of interventions to reduce potentially inappropriate prescriptions and OTC medications compared to no intervention, usual care, or non- or minimally active intervention among adults aged 65 years and older and (b) the acceptability of these interventions or attributes among patients. Outcomes of interest for the benefits and harms review are all-cause mortality, hospitalization, non-serious adverse drug reactions, quality of life, emergency department visits, injurious falls, medical visits, and the number of medications (and number of pills). Outcomes for the acceptability review are the preference for and relative importance of different interventions or their attributes. For the benefits and harms review, we will search MEDLINE, Embase, and Cochrane Central Register of Controlled Trials for randomized controlled trials. For the acceptability review, we will search MEDLINE, Embase, PsycInfo, Cochrane Central Register of Controlled Trials, and the NHS Economic Evaluation Database for experimental and observational studies with a comparator. Websites of relevant organizations, other grey literature sources, and reference lists of included studies and reviews will be searched. Title and abstract screening will be completed by two independent reviewers using the liberal accelerated approach. Full-text review, data extraction, risk of bias assessments, and GRADE (Grading of Recommendations Assessment, Development and Evaluation) will be completed independently by two reviewers, with any disagreements resolved by consensus or by consulting with a third reviewer. The GRADE approach will be used to assess the certainty of the evidence for outcomes. Discussion: The results of this systematic review will be used by the Canadian Task Force on Preventive Health Care to inform their recommendation on potentially inappropriate prescribing and OTC medication use among adults aged 65 years and older. Systematic review registration: PROSPERO (KQ1: CRD42022302313; KQ2: CRD42022302324); Open Science Framework (https://osf.io/urj4b/).

Background Volunteers are increasingly promoted to improve health-related outcomes for community-dwelling elderly without synthesized evidence for effectiveness. This systematic review and meta-analysis evaluates the effects of unpaid volunteer interventions on health-related outcomes for such seniors. Methods MEDLINE, EMBASE and Cochrane (CENTRAL) were searched up to November 2018. We included English lan­guage, randomized trials. Two reviewers independently identi­fied studies, extracted data, and assessed evidence certainty (using GRADE). Meta-analysis used random-effects models. Univariate meta-regressions investigated the relationship between volunteer intervention effects and trial participant age, percentage females, and risk of bias. Results 28 included studies focussed on seniors with a variety of chronic conditions (e.g., dementia, diabetes) and health states (e.g., frail, palliative). Volunteers provided a range of roles (e.g., counsel­lors, educators and coaches). Low certainty evidence found that volunteers may improve both physical function (MD = 3.2 points on the 100-point SF-36 physical component score [PCS]; 95% CI: 1.09, 5.27) and physical activity levels (SMD = 0.5, 95% CI: 0.14 to 0.83). Adverse events were not increased. Conclusion Volunteers may increase physical activity levels and subject­ive ratings of physical function for seniors without apparent harm. These findings support the WHO call to action on evidence-based policies to align health systems in support of older adults.

Background: An estimated 20–30% of community-dwelling Canadian adults aged 65 years or older experience one or more falls each year. Fall-related injuries are a leading cause of hospitalization and can lead to functional independence. Many fall prevention interventions, often based on modifiable risk factors, have been studied. Apart from the magnitude of the benefits and harms from different interventions, the preferences of older adults for different interventions as well as the relative importance they place on the different potential outcomes may influence recommendations by guideline panels. These reviews on benefits and harms of interventions, and on patient values and preferences, will inform the Canadian Task Force on Preventive Health Care to develop recommendations on fall prevention for primary care providers. Methods: To review the benefits and harms of fall prevention interventions, we will update a previous systematic review of randomized controlled trials with adaptations to modify the classification of interventions and narrow the scope to community-dwelling older adults and primary-care relevant interventions. Four databases (MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Ageline), reference lists, trial registries, and relevant websites will be searched, using limits for randomized trials and date (2016 onwards). We will classify interventions according to the Prevention of Falls Network Europe (ProFANE) Group’s taxonomy. Outcomes include fallers, falls, injurious falls, fractures, hip fractures, institutionalization, health-related quality of life, functional status, and intervention-related adverse effects. For studies not included in the previous review, screening, study selection, data extraction on outcomes, and risk of bias assessments will be independently undertaken by two reviewers with consensus used for final decisions. Where quantitative analysis is suitable, network or pairwise meta-analysis will be conducted using a frequentist approach in Stata. Assessment of the transitivity and coherence of the network meta-analyses will be undertaken. For the reviews on patient preferences and outcome valuation (relative importance of outcomes), we will perform de novo reviews with searches in three databases (MEDLINE, PsycInfo, and CINAHL) and reference lists for cross-sectional, longitudinal quantitative, or qualitative studies published from 2000. Selection, data extraction, and risk of bias assessments suitable for each study design will be performed in duplicate. The analysis will be guided by a narrative synthesis approach, which may include meta-analysis for health-state utilities. We will use the CINeMa approach to a rate the certainty of the evidence for outcomes on intervention effects analyzed using network meta-analysis and the GRADE approach for all other outcomes. Discussion: We will describe the flow of literature and characteristics of all studies and present results of all analyses and summary of finding tables. We will compare our findings to others and discuss the limitations of the reviews and the available literature. Systematic review registration: This protocol has not been registered.

GPs and other guideline users are likely unaware of the extent of organisational financial conflict of interest (FCOI) due to industry sponsorship of guideline-producing organisations. Understanding how guidelines are susceptible to bias when such organisational FCOI is present and potential mitigating strategies helps critically appraise guidelines that are encountered in practice.

In 2018, the World Health Organization reported that depression is the most common cause of disability worldwide, with over 300 million people currently living with depression. Depression affects an individual’s physical health and well-being, impacts psychosocial functioning, and has specific negative short- and long-term effects on maternal health, child health, developmental trajectories, and family health. The aim of these reviews is to identify evidence on the benefits and harms of screening for depression in the general adult population and in pregnant and postpartum women. Search strategies were developed and tested through an iterative process by an experienced medical information specialist in consultation with the review team. We will search MEDLINE, Embase, PsycINFO, CINAHL, and the Cochrane Library, and a randomized controlled trial filter will be used. The general adult review will be an update of a systematic review previously used by the Canadian Task Force on Preventive Health Care for their 2013 guideline recommendation. The search strategy will be updated and will start from the last search date of the previous review (May 2012). The pregnant and postpartum review will be a de novo review with no date restriction. For both reviews, we will search for unpublished documents following the CADTH Grey Matters checklist and relevant websites. Titles and abstracts will be screened using the liberal accelerated method. Two reviewers will independently screen full-text articles for relevance using pre-specified eligibility criteria and assess the risk of bias of included studies using the Cochrane Risk of Bias tool. Outcomes of interest for the general adult population review include symptoms of depression or diagnosis of major depressive disorder, health-related quality of life, day-to-day functionality, lost time at work/school, impact on lifestyle behaviour, suicidality, false-positive result, labelling/stigma, overdiagnosis or overtreatment, and harms of treatment. Outcomes of interest for the pregnant and postpartum review include mental health outcomes (e.g. diagnosis of major depressive disorder), parenting outcomes (e.g. mother-child interactions), and infant outcomes (e.g. infant health and development). These two systematic reviews will offer informative evaluations of depression screening. The findings will be used by the Task Force to help develop guideline recommendations on depression screening in the general adult population and in pregnant and postpartum women in Canada. PROSPERO (CRD42018099689, CRD42018099690)

Chlamydia trachomatis and Neisseria gonorrhoeae are the most commonly reported sexually transmitted infections in Canada. Existing national guidance on screening for these infections was not based on a systematic review, and recommendations as well as implementation considerations (e.g., population groups, testing and case management) should be explicit and reflect the quality of evidence. The aim of this systematic review is to synthesize research on screening for these infections in sexually active individuals within primary care. We will also review evidence on how people weigh the relative importance of the potential outcomes from screening, rated as most important by the Canadian Task Force on Preventive Health Care (CTFPHC) with input from patients and stakeholders. We have developed a peer-reviewed strategy to comprehensively search MEDLINE, Embase, Cochrane Library, CINAHL, and PsycINFO for English and French literature published 1996 onwards. We will also search trial registries and conference proceedings, and mine references lists. Screening, study selection, risk of bias assessments, and quality of findings across studies (for each outcome) will be independently undertaken by two reviewers with consensus for final decisions. Data extraction will be conducted by one reviewer and checked by another for accuracy and completeness. The CTFPHC and content experts will provide input for decisions on study design (i.e., when and whether to include uncontrolled studies for screening effectiveness) and for interpretation of the findings. The results section of the review will include a description of all studies, results of all analyses, including planned subgroup and sensitivity analyses, and evidence profiles and summary of findings tables incorporating assessment based on Grading of Recommendations Assessment, Development and Evaluation (GRADE) methods to communicate our confidence in the estimates of effect. We will compare our findings to others and discuss limitations of the review and available literature. The findings will be used by the CTFPHC—supplemented by consultations with patients and stakeholders and from other sources on issues of feasibility, acceptability, costs/resources, and equity―to inform recommendations on screening to support primary health care providers in delivering preventive care. International Prospective Register of Systematic Reviews (PROSPERO), registration number CRD42018100733.

There are diverse opinions and confusion about defining and including patient values and preferences (i.e. the importance people place on the health outcomes) in the guideline development processes. This article aims to provide an overview of a process for systematically incorporating values and preferences in guideline development. In 2013 and 2014, we followed the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to adopt, adapt and develop 226 recommendations in 22 guidelines for the Ministry of Health of the Kingdom of Saudi Arabia. To collect context-specific values and preferences for each recommendation, we performed systematic reviews, asked clinical experts to provide feedback according to their clinical experience, and consulted patient representatives. We found several types of studies addressing the importance of outcomes, including those reporting utilities, non-utility measures of health states based on structured questionnaires or scales, and qualitative studies. Guideline panels used the relative importance of outcomes based on values and preferences to weigh the balance of desirable and undesirable consequences of alternative intervention options. However, we found few studies addressing local values and preferences. Currently there are different but no firmly established processes for integrating patient values and preferences in healthcare decision-making of practice guideline development. With GRADE Evidence-to-Decision (EtD) frameworks, we provide an empirical strategy to find and incorporate values and preferences in guidelines by performing systematic reviews and eliciting information from guideline panel members and patient representatives. However, more research and practical guidance are needed on how to search for relevant studies and grey literature, assess the certainty of this evidence, and best summarize and present the findings.

Accumulating health problems of the elderly requires recognition of geriatric syndromes, while shifting away from a conventional disease-specific approach. We surveyed 179 practitioners representing Family Physicians (FPs), Nurse Practitioners (NPs) and geriatricians in Ontario, in order to quantify how they prioritize syndromes, diseases and conditions in the elderly. Identifying differences may inform opportunities for interprofessional sharing of expertise among professionals pursuing a common goal, which is expected to improve interprofessional collaboration. Our survey (response rate 36%) identifies that NP, FP and geriatrician respondents all recognize co-occurrence of “multiple morbidities” as one of the most frequently encountered issues when serving the elderly, however FPs and NPs place higher priority on managing individual chronic diseases than explicitly prioritizing geriatric syndromes. Our findings identify a need for a more clearly defined role for the geriatrician as syndrome-educator and implies further need for collaborative approaches to caring for seniors that values different professional’s expertise.

To revise diagnostic strategies for Alzheimer disease (AD), update recommendations on symptomatic treatment of dementia, and provide an approach to rapidly progressive and early-onset dementias. Experts and delegates representing relevant disciplines from diverse regions across Canada discussed and agreed upon revisions to the 2006 guidelines. The GRADE (grading of recommendations, assessment, development, and evaluation) system was used to evaluate consensus on recommendations, which was defined as when 80% or more of participants voted for the recommendation. Evidence grades are reported where possible. Important for FPs, despite advances in liquid biomarkers and neuroimaging, the diagnosis of dementia in Canada remains fundamentally clinical. New core clinical criteria for the diagnosis of AD now recognize less common, non-amnestic forms. Early-onset dementia, a rare but important condition, should prompt referral to specialists with access to genetic counselors. Rapidly progressive dementia, poorly defined in the literature, is described to facilitate detection of this rare but important condition. There are new expanded indications for cholinesterase inhibitors beyond AD, as well as guidelines for their discontinuation, which had not been previously described. New evidence regarding use of memantine, antidepressants, and other psychotropic medications in dementia care is presented. Several recommendations from the Fourth Canadian Consensus Conference on the Diagnosis and Treatment of Dementia are relevant to FPs. For guidelines to remain useful, family physicians should participate in all stages of the ongoing development process, including topic selection.