Development and Internal Review
This evidence-based series was developed by the Supportive Care Guidelines Group (SCGG) of Cancer Care Ontario's (CCO's) Program in Evidence-Based Care (PEBC). The SCGG comprises medical, radiation, and surgical oncologists; psychiatrists; palliative care physicians; nurses; radiation therapists; methodologists; administrators; a psychologist; and an anesthetist.
External Review by Ontario Clinicians
Following review and discussion of Sections 1 and 2 of the original guideline document, the SCGG circulated the clinical practice guideline and systematic review to clinicians in Ontario for review and feedback.
Methods
Feedback was obtained through a mailed survey of 122 health care providers in Ontario including 70 palliative care physicians, 22 psychiatrists, 18 nurses, 5 radiation therapists, 4 pharmacists, 2 family medicine specialists, and 1 medical oncologist. One member of the SCGG, a palliative care physician who was an author on the report, was included in the survey sample in error but was not included in the analysis. The survey consisted of items evaluating the methods, results, and discussion used to inform the draft recommendations and whether the draft recommendations should be approved as a practice guideline. Written comments were invited. The survey was mailed out on February 1st and 2nd 2006. Follow-up reminders were sent at two weeks (post card) and four weeks (complete package mailed again). In addition, the draft report and survey were distributed to attendees of the Cancer Care Ontario 2006 Signature Event (March 6th, 2006, Toronto), which was on palliative care. One attendee returned a survey and was included in the following analysis. The SCGG reviewed the results of the survey.
Report Approval Panel
In December 2005, the evidence-based series report was reviewed by one member of the PEBC Report Approval Panel with expertise in clinical and methodology issues. The other Panel member contributed to the development of the report and was not eligible to provide feedback. Overall the report was considered very well conceived, thoroughly researched, and likely to be helpful to clinicians.
The Panel member suggested that it would be beneficial to include a section in the report on issues related to outcome assessment and measurement specific to this topic, particularly in relation to the magnitude of benefit associated with pain assessment instruments. For example, where there are statistically significant differences between randomized groups in pain scores, is it possible to qualify what these differences mean to a patient? Does a number needed-to-treat (NNT) of 2 reflect mild pain reduction or eradication of pain? Although outcome assessment is a complex topic in its own right, readers would benefit from the SCGG interpretation of magnitude.
In addition, the Panel member also suggested that expert advice on dose, schedule, and duration of therapy would be helpful. Although such recommendations would be informed by the evidence rather than strictly evidence-based, readers may benefit from the SCGG expertise.
The feedback from the Report Approval Panel was consistent with that received through the external review process. In response, the SCGG added further discussion of the complexity of pain assessment and the evaluation of clinically important differences, and have included a Qualifying Statement on medication dosing, based on clinical expertise and the trials reviewed in the report. The Report Approval Panel formally approved the Evidence-based Series Report in October 2006.