Anaesthesia (Canada) PSP protocol

Purpose of the PSP and background

The purpose of this protocol is to set out the aims, objectives and commitments of the Canadian Anesthesia Research Priority Setting Partnership (PSP) and the basic roles and responsibilities of the partners therein. It is recommended that the Protocol is reviewed by the Steering Group and updated on at least a quarterly basis.

The James Lind Alliance (JLA) is a non-profit making initiative, established in 2004. It brings patients, carers and clinicians together in Priority Setting Partnerships (PSPs). These partnerships identify and prioritise uncertainties, or ‘unanswered questions’, about the effects of treatments that they agree are the most important. The aim of this is to help ensure that those who fund health research are aware of what really matters to both patients and clinicians. The UK’s National Institute for Health and Care Research (NIHR – www.nihr.ac.uk) funds the infrastructure of the JLA to oversee the processes for priority setting partnerships, based at the NIHR Evaluation, Trials and Studies Coordinating Centre (NETSCC), University of Southampton.

Canadian Anesthesia Research Priority Setting: Canadian anesthesia research is generally delivered through ‘responsive funding’ programs in which researchers propose topics to funding bodies. As Chair of one of the nation’s largest funding programs and leader of this PSP, Dr. Dolores McKeen has been looking for direction and funding priorities. The Canadian funding pool continues to shrink and our research dollars are limited. There is now recognition for ‘needs-led’ programs, driven by a systematic approach to identifying and setting research and development priorities. The opportunity to engage patients’ perspectives is timely. We assume Canadian patients will want to know that their anesthesia care will help cure disease, improve health, reduce pain or lead to the safe delivery of their newborn; that they expect tolerable postoperative discomfort, minimal risk of complications, and rapid return of function, yet their priorities can only be truly discovered through the continuum of patient-oriented research and patient engagement.

Over the past year, an initial team has been identified and its members aim to co-build a national Anesthesia research agenda for patients, families, clinicians, and researchers. Our pan-Canadian team represents research interests of 17 Association of Canadian University Departments of Anesthesia (ACUDA), the Canadian Anesthesia Research Foundation (CARF), the Perioperative Anesthesia Clinical Trials (PACT) group and the Canadian Anesthesia Society (CAS) and society journal, the Canadian Journal of Anesthesia (CJA).

To address Canadian experiences and concerns, we will conduct a Canadian Anesthesia Research Priority Setting Partnership (CAR-PSP). The aim is to primarily conduct a Priority Setting Partnership using the JLA methodology and guidance to lead the identification of clinically important anesthesia research questions and emerging priorities for key Canadian stakeholders, including patients, caregivers, clinicians (knowledge users and policy makers) and researchers. Identifying Canadian Anesthesia Research priorities will help focus our research agenda and link to patient-oriented research efforts.

Scope of the PSP

The Canadian Anesthesia and Perioperative Care Research PSP will cover aspects of care during anesthesia and the perioperative period, and the management of longer-term problems that have their origin during this period. Hence, the management of chronic pain will not be considered unless the pain originates around the time of anesthesia. The initial scope was discussed and further defined and clarified as part of the first Steering Group meeting.

Inclusion criteria: The scope should include all the work conducted by anesthesiologists, including obstetric and resuscitation care, and that conducted by the wider perioperative team and the care pathway from initial intention to treat/operate onwards. “Onwards” is an open-ended word signifying that long-term problems attributable to this surgery/intervention and management period must also be considered. The perioperative period spans the time from when a decision is made to have surgery or anesthesia care to the time that the patient has 1) returned to preoperative function or has 2) fully recovered from having surgery or 3) recovered to a stable functional level with care transferred back to primary care provider. There is no age limit to the criteria and we actively encourage consideration of, and representation from, more vulnerable populations such as newborns, young children, the elderly and disabled.

Exclusion criteria: As this priority setting partnership has its focus on “perioperative care”, we will exclude commentary on surgery itself or its management (e.g. of pain) outside of secondary care that is unrelated to anesthetic care. We want to focus on the management of patients’ physical wellbeing throughout all anesthetic procedures and its impact on recovery thereafter. We acknowledge many anesthesiologists provide Critical Care, but do not wish to include commentary on this area and thus will not seek questions on this subspecialty area.

Aims, objectives and scope of the PSP

The aim of the Canadian Anesthesia Research PSP is to identify the unanswered questions about anesthesia and perioperative care from patient and clinical perspectives and then prioritise those that patients and clinicians agree are the most important.

The objectives of the Canadian Anesthesia Research PSP are to:

• work with patients, caregivers and clinicians to identify uncertainties about anesthesia and perioperative care
• to agree by consensus on a prioritised list of those uncertainties, for research
• to publicise the results of the PSP and process
• to take the results to research commissioning bodies to be considered for funding.

The Steering Group

The Canadian Anesthesia Research PSP will be led and managed by the following:

Patient representatives:

Nova Scotia

• Mary Anne Earle
• Claire Ward

Alberta

• Kathy Kovacs Burns

Quebec

• Thierry de Greef

Manitoba

• Donna Penner

British Columbia

• Colleen McGavin

Clinical representative/s:

Dalhousie University/IWK Health Centre

• Dolores McKeen

University of Ottawa/The Ottawa Hospital

• Dan McIsaac
• Jason McVicar

Université de Montreal/ Hôpital Notre Dame du CHUM

• Gilbert Blaise

The Partnership and the priority setting process will be supported and guided by:

The James Lind Alliance (JLA)

• Katherine Cowan

University of Toronto/St. Michael’s Hospital

• Andreas Laupacis

Dalhousie University’s Department of Anesthesia, Pain Management & Perioperative Medicine

• Jillian Banfield

The Steering Group includes representation of patient/carer groups and clinicians.

The Steering Group will agree the resources, including time and expertise that they will be able to contribute to each stage of the process. The JLA will advise on this.

Partners

Organisations will be invited to be involved with the PSP as partners. Partners are groups that will commit to supporting the PSP by disseminating the PSP survey and helping the PSP to gather questions and uncertainties of practical clinical importance relating to the treatment and management of the health problem in question. Partners represent the following groups:

• people who have experience with anesthesia and/or perioperative care
• carers of people who have had anesthesia and/or perioperative care
• medical doctors, nurses and professionals allied to medicine with clinical experience of anesthesia and/or perioperative care.

It is important that all organisations that can reach and advocate for these groups should be invited to become involved in the PSP. The JLA Adviser and PSP coordinator will take responsibility for ensuring the various stakeholder groups are able to contribute equitably to the process.

Exclusion criteria

Some organisations may be judged by the JLA or the Steering Group to have conflicts of interest. These may be perceived to adversely affect those organisations’ views, causing unacceptable bias. As this bias is likely to affect the ultimate findings of the PSP, those organisations will not be invited to participate. It is possible, however, that interested parties may participate in a purely observational capacity when the Steering Group considers it may be helpful.

The methods the PSP will use

This section describes a schedule of proposed stages through which the PSP aims to fulfil its objectives. The process is iterative and dependent on the active participation and contribution of different groups. The methods adopted in any stage will be agreed through consultation between the Steering Group members, guided by the PSP’s aims and objectives.

Step 1: Identification and invitation of potential partners

Potential partner organisations will be identified through a process of peer knowledge and consultation, through the Steering Group members’ networks. Potential partners will be contacted and informed of the establishment and aims of the Canadian Anesthesia Research PSP. Partners will be invited to raise awareness of the project among their membership.

Step 2: Identifying treatment uncertainties

Each partner will help solicit from its members questions and uncertainties of practical clinical importance relating to anesthesia and perioperative care. The survey will be open for approximately 2 months. The time allocated to collate, analyse, and categorise responses will be approximately 3 months.

The methods may be designed according to the nature and membership of each organisation, but must be as transparent, inclusive and representative as practicable. Methods may include membership meetings, email consultation, postal or web-based questionnaires, internet message boards and focus group work.

Existing sources of information about treatment uncertainties for patients and clinicians will be searched. These can include question-answering services for patients and carers and for clinicians; research recommendations in systematic reviews and clinical guidelines; protocols for systematic reviews being prepared and registers of ongoing research.

A key resource for identifying sources of uncertainties and research recommendations is Cochrane Canada: http://canada.cochrane.org/

Step 3: Refining questions and uncertainties

The consultation process will produce “raw” unanswered questions about anesthesia and care around the time of surgery. These raw questions will be assembled and categorised and refined by the Steering Group, with the support of the PSP Coordinator, into “collated indicative questions” which are clear, addressable by research and understandable to all. Similar or duplicate questions will be combined where appropriate.

Systematic reviews and guidelines will be identified and checked by the Evidence Synthesis team (IWK Health Centre librarian, Maritime SPOR SUPPORT Unit Evidence Synthesis Coordinator, a research assistant, and a student or intern) to see to what extent these refined questions have, or have not, been answered by previous research. Sometimes, uncertainties are expressed that can in fact be resolved with reference to existing research evidence – i.e. they are "unrecognised knowns" and not uncertainties. If a question about treatment effects can be answered with existing information but this is not known, it suggests that information is not being communicated effectively to those who need it. Accordingly, the JLA recommends strongly that PSPs keep a record of these 'answerable questions' and deal with them separately from the 'true uncertainties' considered during the research priority setting process.

Uncertainties that are not adequately addressed by previous research will be collated and recorded (on a template supplied by the JLA) by the Evidence Synthesis team. This will demonstrate the checking undertaken to make sure that the uncertainties have not already been answered. This is the responsibility of the Steering Group, which will need to have agreed personnel and resources to carry this accountability. The data will be submitted to the JLA for publication on its website on completion of the priority setting exercise, taking into account any changes made at the final workshop, in order to ensure that PSP results are publicly available.

Step 4: Prioritisation – interim and final stages

The aim of the final stage of the priority setting process is to prioritise through consensus the identified uncertainties relating to the treatment or management of anesthesia and perioperative care. The format will be agreed by members of the Steering Group and is likely to involve the wider partnership that represents patients and clinicians.

• The interim stage, to proceed from a long list of uncertainties to a shorter list to be discussed at the final priority setting workshop (e.g. up to 30), may be carried out over email or online, whereby organisations consult their membership and choose and rank their top 10 most important uncertainties.
• The final stage, to reach 10 prioritised uncertainties, will be conducted in a face-to-face meeting, using group discussions and plenary sessions.
• The methods used for this prioritisation process will be determined by consultation with the Steering Group and with the advice of the JLA Adviser.

The JLA will facilitate this process and ensure transparency, accountability and fairness. Participants will be expected to declare their interests in advance of this meeting.

Dissemination of findings and results

Findings and research

It is anticipated that the findings of the Canadian Anesthesia Research PSP will be reported to funding and research agenda setting organisations such as the Canadian Institutes for Health Research and the Canadian Anesthesia Research Foundation. Steering Group members and partners are encouraged to develop the prioritised uncertainties into research questions, and to work to establish the research needs of those unanswered questions to use when approaching potential funders, or when allocating funding for research themselves, if applicable.

Publicity

As well as alerting funders, partners and Steering Group members are encouraged to publish the findings of the Canadian Anesthesia Research PSP using both internal and external communication mechanisms. The Steering Group may capture and publicise the results through descriptive reports of the process itself in plain language. This exercise will be distinct from the production of an academic paper, which the partners are also encouraged to do. However, production of an academic paper should not take precedence over publicising the final results.

Agreement of the Steering Group

This protocol was agreed by the Steering Group on July 25, 2018.