 |
 |
 |
 |
 |
 |
 |
 |
 |
 |
 |
 |
  |
 |
Documents
Clinical Practice Guidelines for Adults: Introduction Introduction Scope and objectives These guidelines address urinary incontinence in community-dwelling adults. Pediatric incontinence and incontinence in institutions are excluded, not because they are unimportant, but because they involve different needs, and different professionals, organizations, and government departments. The guidelines have been developed in response to needs identified both by consumers concerning their frustrations and lack of knowledge about incontinence and treatment options (Klag, 1999; The Canadian Continence Foundation, 1998), and by healthcare professionals, particularly those in the community, many of whom do not receive extensive training in the management of urinary incontinence (The Canadian Continence Foundation 1998; Schulz et al, 1999). The development team has tried, through a consensus process, to develop guidelines that are evidence-based, up-to-date, and easy to understand, and which can readily be implemented within the Canadian healthcare system. In a parallel consensus process we have developed models of continence care which demonstrate how the guidelines may be put into practice in typical Canadian settings. The guidelines are directed at physicians, nurses, physiotherapists, and other healthcare professionals who advise and care for people with incontinence. Consistent with the consumer focus of the project, a consumer-directed version of the guidelines will be produced to allow consumers to make informed decisions about their assessment and treatment and to encourage open discussion with the health professionals who are caring for them. There has been recent discussion of the advantages and disadvantages of standardized guidelines (Multidisciplinary Summit, 1999; Woolf et al, 1999). Some see a danger in guidelines, that they imply that society has all the answers for a particular health issue. Thus, they may negate the judgment that is inevitably required between a professional and a patient in each unique situation, and may stifle the research necessary to improve the status quo (Multidisciplinary Summit, 1999). It is emphasized that these guidelines are intended to be an educational tool, to assist health professionals and people with incontinence and to help promote high quality continence care, by keeping consumers, healthcare professionals and other stakeholders up-to-date. Future updating and refinement are an essential part of the development process. The Canadian Continence Foundation recognizes that health care professionals act within the boundaries of their professional standards of practice in collaboration with a physician. The guidelines are not legally binding in any way, nor are they intended to restrict the unique and irreplaceable professional-patient relationship. They are not the only possible approach to the assessment and management of incontinence. However, they do reflect a wide consensus regarding assessment and treatment options and the order in which they should be considered. Method: The Guidelines Development Process A recent report referred to conclusions from the National Institutes of Health in the U.S.: "The institutes conclude that guideline development should be a multidisciplinary enterprise involving consultation with both patients and front-line health professionals, whose input is as essential as that of academics" (Multidisciplinary Summit, 1999). The method used in developing these guidelines was designed to ensure that, as far as possible, the judgments represent a consensus of those concerned with management and treatment of urinary incontinence in Canada, whether as professionals or as clients/consumers. To arrive at a Canadian consensus, the guidelines were developed as follows: The core committee decided on three broad classes of client/consumer for whom guidelines were needed. A small team of authors was selected for each class and asked to review the recent literature and draft evidence-based guidelines and a flow chart to represent them in visual form. Participants were selected for a consensus conference, based primarily on nominations from national associations of health professionals and consumer groups, but bearing in mind also the need for geographic representation across Canada. The draft guidelines were circulated to the conference participants for review. Consensus was established by voting: over 80% representing consensus, 60-79% representing partial consensus. The resulting consensus guidelines were sent to community reactor panels across the country for review. As a starting point, the core committee reviewed existing national and international guidelines for the management of incontinence. Two in particular form the basis of these Canadian guidelines: The guidelines of the U.S. Agency for Healthcare Policy and Research (AHCPR) were first published in 1992. The 1996 revision is based on reviews of the literature up to 1995. Our committee did not reanalyse this literature, which is referenced in the AHCPR Guideline book, Edition 2, 1996. The recommendations arising from the AHCPR Guidelines 1996, became the starting point. The committee reviewed the recommendations and endorsed or modified them according to new literature (1995 onward) that either supported them or provided new evidence for new recommendations. Description of the literature search Core committee teams systematically searched the Cochrane Incontinence Group's trials register, Medline, Cinahl, Embase, PsychLit and ERIC and Ageline for the period January 1995 to January 2000. The following search terms were applied: incontinence, urinary, male, post prostatectomy, stimulation, electrical stimulation, biofeedback, pelvic muscle exercises, Kegel exercises, behavioural, behaviour, behaviour therapy, behaviour modification therapy, physiotherapy, surgery, continence, bladder control, quality of life, randomized controlled trial, evaluation, effectiveness, efficacy and outcomes. In addition we performed hand searching of abstracts and consulted with colleagues. Levels of evidence for the recommendations To develop recommendations for each assessment and treatment method, the core committee considered (1) the quality and amount of evidence, (2) the consistency of findings among studies, (3) the clinical applicability of the evidence to adult patients with urinary incontinence (UI), and (4) the evidence on harms or costs. For all guideline statements taken over without revision from the AHCPR list, the original strengths of evidence are given, as defined in Table 1. For all new or revised guideline statements, levels of evidence were assigned following a scheme recently used in the Canadian Medical Association Journal and in Canadian Clinical Practice Guidelines (Table 2) (Patterson et al, 1999) We have used the customary terms "strength" or "level" of evidence, even though they may be misleading. On the one hand, the most convincing evidence for an intervention is a combination of expert opinion (level 3) with evidence from randomized controlled trials (level 1); on the other hand, interventions may be supported by expert opinion but not by randomized controlled trials, or vice versa. Thus different "levels" of evidence may reinforce or contradict one another. Table 1. Strengths of evidence for recommendations taken over without modification from the AHCPR list
"Please note that these ratings represent the strength of the supporting research evidence, not the strength of the recommendation itself. The strength of each recommendation is conveyed in the language describing it." (AHCPR p 12) Levels of evidence for new or revised recommendations, added to or modified from the AHCPR list
Authorship This document represents a substantial consensus of all who contributed to its preparation. Although it reflects the generous participation of many individuals, The Canadian Continence Foundation, through the core committee, is the author of record of these guidelines and is wholly responsible for their content. The members of the core committee are: Michael Borrie (geriatrician, co-chair), Luc Valiquette (urologist, co-chair), Claudia Brown (physical therapist), Harold Drutz (urogynecologist), Donna Fedorkow (gynecologist), Sender Herschorn (urologist), George Kuchel (geriatrician), Christianne Lepage (family practitioner), Grace Littler (consumer), Katherine Moore (nurse), Lisa Lacroix (ex-officio, Health Canada), Simone Powell (ex-officio, Health Canada), David Reid (ex officio, project evaluator), Derek Griffiths (ex-officio, Consensus Conference Coordinator).Publication date and revisions These guidelines are based on literature published up to January 2000. They will need continuing, regular revision, which the core committee recommends should take place every 2 years. It is important for readers to check the publication date of any guideline they are reading. It is expected that use of the flow charts in practice will indicate desirable revisions and refinements. Any feedback or suggestions for improvement of the guidelines or flow charts can be sent to: The Canadian Continence Foundation |
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||