A t the fourth meeting of the Guideline InternationalNetwork, held in Toronto in August 2007, worldexperts from 31 countries met to discuss the chal-

lenges and innovations afforded by clinical practice guide-lines.1 Although each country faces unique local challengesto the implementation of effective health care, members ofthe guideline community have repeatedly and generouslyshared their solutions to these challenges, many of whichare applicable in other countries. Nevertheless, it can bedifficult for the local implementer with limited resources toharness this knowledge.

The Canadian Medical Association has long been a cham-pion of enhancing the quality of clinical practice guidelines.2

The objective of the recently published Canadian Medical As-sociation Handbook on Clinical Practice Guidelines3 (Box 1,Table 1) is to gather up-to-date, evidence-based, experience-driven guidance on how to use guidelines most effectively toimprove patient care. This new handbook combines and up-dates the 1994 and 1997 documents “Guidelines for CanadianClinical Practice Guidelines”4 and “Implementing ClinicalPractice Guidelines: a Handbook for Practitioners.”5 The newhandbook places the role of guidelines in health care into per-spective, outlining where they are most useful. It helps thereader to decide if an existing guideline can be adapted or if anew guideline should be created, providing resources for bothscenarios. The handbook also reviews evidence to guide thoseresponsible for implementing recommendations through thebewildering array of available implementation strategies. Inrecognition of increasing demands for accountability and in-creasing emphasis on quality of care, the final chapter reviewsthe process of evaluating the effectiveness of guidelines.3

The handbook reviews in depth the methodologic steps inthe guideline process, including the biases inherent in guide-line development, the struggle to write accurate recommen-dations and an approach to implementation.

Readers of the new handbook will be able to use it in 3ways: as a review for the key parts of the process, with refer-ence to the published evidence; as a source of practical ap-proaches to complete the part of the cycle in which the user isinvolved; and as an illustrative inventory of resources andlinks. Guideline developers and implementers may be healthcare practitioners, administrators, health organizations orpolicy-makers. Experienced guideline developers and imple-menters may find within the handbook innovations from theinternational community that apply to their work. For guide-line users, knowledge of what makes a guideline “good” al-lows selection of the best guidelines, saving time and poten-

tially improving patient outcomes. It is our hope that thehandbook may even inspire a few guideline users to becomelocal champions of best practices.

Dealing with bias in guideline development

One of the significant changes in the field of guideline devel-opment has been widespread acceptance of a standardizedmethodology for the production of clinical practice guide-lines. Just as the writing of randomized controlled trials hasbeen informed by the CONSORT (Consolidated Standards ofReporting Trials) statement6 and the writing of systematic re-views improved by the QUORUM (Quality of Reporting ofMeta-analyses) statement,7 so the AGREE (Appraisal ofGuidelines Research and Evaluation) Collaboration has pro-moted validated criteria for writing clinical practice guide-lines (www.agreecollaboration.org). The elements of theAGREE instrument are summarized in Table 2.

Each domain in the AGREE instrument reflects either apotential source of bias or issues related to clarity and under-standing of the guideline. In trials, investigators aim to mini-mize bias to get closer to the “truth”: the same experimentconducted repeatedly should yield the same results. In clinicalpractice guidelines, minimizing bias should likewise lead var-ious groups of developers who consider the same evidence tocome up with similar recommendations. Sources of bias inthe evidence-review process include the type of literature

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Valerie A. Palda MD MSc, Dave Davis MD, Joanne Goldman MSc

A guide to the Canadian Medical Association Handbookon Clinical Practice Guidelines

Commentary

All editorial matter in CMAJ represents the opinions of the authors and not necessarily those of the Canadian Medical Association.

From the Departments of Medicine (Palda), Health Policy Management andEvaluation (Palda, Davis), and Continuing Education and Professional Devel-opment, Faculty of Medicine (Goldman), University of Toronto, Toronto, Ont.;and the Association of American Medical Colleges (Davis), Washington, DC

CMAJ • November 6, 2007 • 177(10)© 2007 Canadian Medical Association or its licensors

11222211

Box 1: Canadian Medical Association Handbook on Clinical Practice Guidelines in a nutshell

The new Canadian Medical Association Handbook on Clinical Practice Guidelines3 combines 2 earlier documents, which have been updated and revised for use by individuals and groups interested in the development, adaptation, implementation and evaluation of clinical practice guidelines. The handbook reviews the key parts of each step of the guideline-development process, with appropriate reference to the published evidence. It suggests practical approaches to completing each component of the guideline cycle, using illustrative examples and referencing print and electronic resources to aid the reader.

Commentary

search used, the method used to evaluate the quality of the lit-erature, and editorial independence.

As for any systematic review, it is vital that a systematicsearch strategy be used in the development of clinical practiceguidelines. Relying on experts’ recollection of the literature,as was common with consensus guidelines, is no longer suf-ficient. For example, Gilbert and associates8 compared his-torical recommendations with a systematic review of observa-tional studies of the effect of infant sleeping position onsudden infant death syndrome. They found that by 1970, theliterature demonstrated a statistically significantly increasedrisk of sudden infant death for sleeping on the front relativeto sleeping on the back (pooled odds ratio 2.93, 95% confi-dence interval 1.15–7.47); however, guidelines did not consis-tently recommend the back-sleeping position until 1992.These authors concluded that use of systematic review tech-niques could have led to earlier recognition of the risks ofsleeping on the front and might have prevented more than10 000 infant deaths in the United Kingdom and at least50 000 in Europe, the United States and Australasia.8 The rec-

ommendations in any clinical practice guideline should con-sider the results of the totality of the literature, giving greaterweight to better-designed studies. One recent study9 foundthat applying 2 different quality-evaluation methods (Coch-rane or best-evidence synthesis) led to different recommenda-tions. Listing a level of evidence for each recommendationforces the guideline developer to identify the strength of theevidence supporting the statement.

Editorial independence, the sixth and last domain in theAGREE instrument (Table 2), asks the reader to evaluateconflict of interest. Financial conflict of interest has been thetype of bias most widely discussed. One study of clinicalpractice guidelines published between 1991 and 1999 foundthat 87% of guideline authors had interactions with thepharmaceutical industry, 58% had received financial supportfor research, and 38% had been employees of or consultantsfor a pharmaceutical company.10 To score well in this do-main of the AGREE instrument, the guideline must state notonly that all group members have declared whether they haveany conflict of interest (using standard forms), but also that

CMAJ • November 6, 2007 • 177(10)11222222

Table 1: Summary of contents of the Canadian Medical Association Handbook on Clinical Practice Guidelines3

Chapter number and title Description of content Highlights

1. Introduction to clinical practice guidelines

• Introduces the field of quality of health care and discusses the significance of the process by which knowledge, specifically evidence-based research, is incorporated into routine practice

• Discusses the key role of guidelines within this broader framework of quality of health care

• Knowledge-to-action framework • Benefits and challenges of clinical practice

guidelines • Key websites and articles providing perspective in

this area

2. Adaptation and development of CPGs

• Clarifies the role of guidelines by answering the question, “Do you need a CPG?”

• Presents common salient elements in the adaptation and development of clinical practice guidelines

• Outlines a process for adapting guidelines for local or regional use

• Highlights key elements of guideline development

• Offers resources to assist with these initiatives

• Chart of major steps in creating a clinical practice guideline

• Practical considerations for focusing the topic • Guidance on assembling a working group, including

consideration of bias • Description of ADAPTE process for adapting

guidelines for local use • Description of AGREE instrument for assessing

quality • Description of GRADE, SIGN and SORT taxonomies

for making recommendations • Websites for finding, adapting and appraising

clinical practice guidelines

3. Implementation of CPGs to change practice and outcomes

• Outlines the nature and challenges of knowledge translation, the process by which best-evidence guidelines are adopted by clinicians, patients and policy-makers

• Describes the stages in planning a guideline-implementation strategy: analyzing the context, reviewing the relevant literature and designing a strategy based on this information

• Guidance on assessing contextual barriers to and facilitators of change

• Review of known strategies for implementing guidelines

• Theories of behavioural and organizational change • Steps to developing a local, targeted

implementation plan • Websites of experienced implementation groups

4. Evaluation of CPGs • Provides a brief overview of methods for evaluating clinical practice guidelines

• Definition of quality indicators • Review of data collection techniques and outcome

measures • Websites and published articles to inform

measurement strategies

Note: ADAPTE = ADAPTE Collaboration, AGREE = Appraisal of Guidelines Research and Evaluation (collaboration), GRADE = Grading of Recommendations Assessment, Development and Evaluation (working group), SIGN = Scottish Intercollegiate Guidelines Network, SORT = Strength of Recommendation Taxonomy.

CMAJ • November 6, 2007 • 177(10) 11222233

Commentary

the views or interests of the funding body have not influ-enced the final recommendations. The American College ofChest Physicians guards against this type of bias by disallow-ing participation of any guideline panel member who doesnot complete a conflict of interest disclosure form and bycareful review of each disclosure form. Conflicts declared bypanel members are reviewed using a graded considerationbased on the potential level of conflict, whether the conflictcan be managed within established parameters and whetherthe panel member has expertise that would allow participa-tion in a related area that does not involve the conflict. Thedisclosures that prove most difficult to evaluate receive fullcommittee review.11

Many journals now refuse to publish clinical practiceguidelines unless statements of conflict of interest areavailable, and many guideline developers ask participantsin the guideline development process to fill out standardconflict of interest forms. A description of how potentialconflicts have been addressed is often lacking, however.Given that 7% of the authors surveyed by Choudhry and as-sociates10 stated that their own relationships influencedrecommendations, and 19% thought that their coauthors’recommendations were influenced, this form of bias re-mains a significant challenge to the reliability of clinicalpractice guidelines. Other potential sources of bias also ex-ist, such as long-term service to government committeesor private insurers, participants’ previously established“stake” in an issue, the way in which developers make theirliving and personal experiences.12

Developing recommendations: grading systems

Many guideline developers provide a legend to explain howthey came to each of the recommendations. The strength ofrecommendations is often categorized according to a spe-cific “grading system,” which usually considers only levels ofevidence but sometimes also addresses other factors thatmight influence the strength of the recommendation, suchas the magnitude of the therapeutic risk reduction and themagnitude of potential harms and benefits for possible out-comes. The GRADE (Grading of Recommendations, Assess-ment, Development and Evaluation) system is an interna-tional effort to standardize the approach to makingrecommendations (www.gradeworkinggroup.org). TheGRADE approach assigns evidence “quality” at 1 of 4 levels— very low, low, moderate or high — on the basis of specificcriteria. Each recommendation is then based on a judgmentof net benefits, including whether the net benefits are posi-tive, negative or uncertain. This and other gradingschemes13,14 that are less explicit but still provide trans-parency are compared in Table 3. In 2003, the GRADE Work-ing Group itself acknowledged that there is no published evi-dence on how best to communicate grades of evidence andrecommendations.15

Guideline developers often modify grading systems to re-flect their specific needs. The US Preventive Services Task

Force, an active participant in the GRADE Working Group,has chosen to maintain its own recommendation grading sys-tem16 to reflect this organization’s more narrow focus on pre-vention, in contrast to the broader clinical scope of theGRADE Working Group. Until sufficient evidence accumu-lates to demonstrate the superiority of one system over an-other, concentrating on making recommendations clear andreflective of the evidence is a reasonable approach for mostguideline developers.

Table 2: The AGREE instrument: domains and descriptions of key items*

Domain Key items

Scope and purpose

• Objective(s) of the guideline is (are) specifically described

• Clinical question(s) is (are) specifically described

• Target patients are specifically described

Stakeholder involvement

• Guideline-development group includes all relevant professional groups

• Patients’ views and preferences have been sought

• Target users of the guideline are clearly defined

• Guideline has been piloted by target users

Rigour of development

• Systematic methods were used to search for evidence

• Criteria for selecting the evidence are clearly described

• Methods used for formulating the recommendations are clearly described

• Health benefits, side effects and risks were considered in formulating the recommendations

• There is an explicit link between the recommendations and the supporting evidence

• Guideline has been externally reviewed by experts before its publication

• A procedure for updating the guideline is provided

Clarity and presentation

• Recommendations are specific and unambiguous

• Different options for management of the condition are clearly presented

• Key recommendations are easily identifiable • Guideline is supported with application tools

Applicability • Potential organizational barriers in applying the recommendations are discussed

• Potential cost implications of applying the recommendations have been considered

• Guideline presents key review criteria for monitoring and audit purposes

Editorial independence

• Guideline is editorially independent from the funding body

• Conflicts of interest of the guideline-development group have been recorded

*Details about each question and more specific explanations are available in the AGREE instrument (www.agreecollaboration.org/pdf/agreeinstrumentfinal.pdf).

Commentary

Implementation of guidelines

In the end, even well-designed guidelines in the same areawill occasionally differ in their recommendations. Developersshould therefore consider, during the development phase ofany guideline, its ease of implementation (implementability).The recent GLIA (GuideLine Implementability Appraisal) in-strument takes the developer through a series of validatedquestions that ask about factors known to predict the relativeease of implementation of guideline recommendations.17 Thecurrently recommended approach to implementation is sum-

marized in Box 2. Implementation strategies may be most ef-fective when they are targeted to locally identified facilitatorsand barriers to implementation. Barriers may be effectivelyidentified through a process as simple as structured reflectionby the implementation group.18 Many implementation strate-gies have shown modest benefit, and multiple strategies of-ten work better than single ones.19 Although the sheer num-ber of possible implementation strategies precludes theirdescription here, the interested reader is directed to the hand-book,3 which reviews the major implementation strategiesthat have been assessed in the literature.

CMAJ • November 6, 2007 • 177(10)11222244

Table 3: Various strategies for developing recommendations

Strategy Strengths Weaknesses

GRADE system • Working group is an international collaboration interested in developing a common grading system to address limitations and draw on strengths of existing systems

• System sequentially assesses quality of evidence, balance between risks and benefits, and judgment about the strength of recommendations

• Final recommendation categories are simple: Strong: recommendations reflect evidence that the benefits

do, or do not, outweigh risks and burdens Weak: recommendations reflect evidence that the benefits,

risks and burdens are finely balanced, or there is appreciable uncertainty about the balance; furthermore, the recommendation is classified as “weak” if, across the range of patient values, fully informed patients are liable to make different choices

• Application is complicated • Often difficult for recommendation

developers to use formulaic approaches to global judgments about evidence

SIGN method • Represents a collaboration to improve the quality of health care for patients in Scotland by reducing variation in practice and outcomes, through the development and dissemination of national clinical guidelines

• Levels of evidence (1++, 1+, 1–, 2++, 2+, 2–, 3 or 4) depend on type and quality of study design; grade of recommendation (A, B, C or D) reflects assigned level of evidence

• “Considered judgement” forms are used to help guideline development if decisions must be made according to experience as well as knowledge of evidence and underlying methods; forms address quantity, quality and consistency of evidence, generalizability of study findings, directness and clinical impact

• System lacks transparency; no rationale provided to clarify which factors are weighted more heavily for any particular recommendation

• Use of numbers and letters may not be intuitive

SORT taxonomy • Developed by US family medicine and primary care journals and the Family Practice Inquiries Network to address the need for a single consistently applied taxonomy of evidence

• Emphasizes patient-oriented outcomes (i.e., “outcomes that matter to patients and help them live longer or better lives, including reduced morbidity, mortality or symptoms, improved quality of life or lower cost”14)

• Rates quality of individual studies as follows: 1 = good-quality patient-oriented evidence, 2 = limited-quality patient-oriented evidence, 3 = other evidence

• Grades strength of recommendations by letters: A recommendations are based on consistent, good-quality patient-oriented evidence; B recommendations are based on inconsistent or limited-quality patient-oriented evidence; C recommendations are based on consensus, usual practice, opinion, disease-oriented evidence or case series for studies of diagnosis, treatment, prevention or screening

• Limited guidance for developers on how to classify studies within the numeric categories (1, 2 or 3)

• Use of numbers and letters may not be intuitive

Note: GRADE = Grading of Recommendations, Assessment, Development and Evaluation system (www.gradeworkinggroup.org), SIGN = Scottish Intercollegiate Guidelines Network method (www.sign.ac.uk),13 SORT = Strength of Recommendation Taxonomy.14

CMAJ • November 6, 2007 • 177(10) 11222255

Commentary

Other guideline manuals

Many guideline development organizations have manuals out-lining their methods for interested readers.13,20,21 For users whodo not have the resources to develop their own clinical practiceguidelines, help is available for finding, evaluating and adaptingexisting guidelines for local use (Box 3). Other groups have pro-vided guides for implementation and chart-type tools to guidepractice (Box 3). For those wanting to test how well their guide-line has worked, evaluation strategies are harder to find: usuallythe process of designing and performing a guideline evaluationinvolves a review of primary studies of guideline evaluation todetermine which evaluation strategy would be most suitable.22

Other organizations that offer extensive English-languagecollections of resources and references include Australia’sfederal guideline agency, the New Zealand Guidelines Group,the Scottish Intercollegiate Guidelines Network and the UKNational Institute for Health and Clinical Excellence (Box 3).The Guidelines International Network provides a wealth ofinternational resources (Box 3). To our knowledge, untilnow, no Canadian organization has brought all these re-sources together in a single document, but these are all listedin the Canadian Medical Association Handbook on ClinicalPractice Guidelines.3

What the future holds for guidelines and the handbook

Current research related to clinical practice guidelines includesstudies of the role of patient involvement in guideline develop-ment, the validation of tools to enhance the implementability

and evaluation of guidelines, and examination of the balancebetween studying and implementing guidelines. As the field ofguideline methodology matures, developers will also strugglewith providing guidance in the context of multidisciplinary ap-proaches to care and with addressing the needs of patients whohave multiple chronic conditions.

The new handbook, like clinical practice guidelines them-selves, should be considered a living document, responsive tochanges in the literature and feedback from guideline imple-menters. It will therefore need regular updating to incorporateadvances in knowledge about clinical practice guidelines. Wewelcome any comments that readers of this article may have.

Box 2: Stages in planning an implementation strategy3

• Analyze the context and do a needs assessment: Ask about barriers such as physicians’ knowledge gaps, patients’ attitudes, organizational factors, resource constraints and legislative restrictions.

• Review the relevant literature: Find interventions that address identified barriers. For example, if the main barrier is physician knowledge, educational interventions may be effective.

• Design a targeted implementation strategy: Use information gathered from the needs assessment and the literature review to design a targeted implementation strategy that uses as many interventions as resources allow. Multiple methods of implementation are usually more effective than single interventions. For example, to improve physician knowledge and create acceptance of the need for practice change, interventions might include educational materials and meetings, supplemented by audit and feedback, as well as identification and training of local opinion leaders.

• Build evaluation into the strategy: Examples of evaluation activities include before-and-after tracking of electronically recorded quality indicators and multi-arm randomized trials.

Box 3: Internet tools for developing, finding, assessing and

using guidelines

Validated criteria for writing guidelines

• AGREE: Appraisal of Guidelines Research and Evaluation Collaboration www.agreecollaboration.org

Grading guidelines

• GRADE: Grading of Recommendations, Assessment, Development and Evaluation www.gradeworkinggroup.org

Guideline development organizations

• SIGN: Scottish Intercollegiate Guidelines Network www.sign.ac.uk/guidelines/fulltext/50/index.html

• NICE: National Institute for Health and Clinical Excellence (UK) www.nice.org.uk/page.aspx?o=422956

Compendia of guidelines

• Evidence-Based Medicine Resource Center, New York Academy of Medicine Library www.ebmny.org/cpg.html

• Canadian Medical Association Infobase mdm.ca/cpgsnew/cpgs/index.asp

• National Guideline Clearinghouse (US) www.guideline.gov

Other resources

• Registered Nurses Association of Ontario (implementation toolkit) www.rnao.org/bestpractices/PDF/BPG_Toolkit.pdf

• College of Family physicians of Canada (toolkit) www.toolkit.cfpc.ca/en/continuity-of-care/appendix.php

• ADAPTE Collaboration (adaptation of guidelines for local use) www.adapte.org

• National Health Medical Research Council (Australia) www.nhmrc.gov.au/publications/synopses/_files/cp30.pdf

• New Zealand Guidelines Group www.nzgg.org.nz/

• Guidelines International Network www.g-i-n.net

Competing interests: None declared.

Contributors: All of the authors made substantial contributions to the con-tent and framework of the article, revised it critically for important intellec-tual content and provided final approval of the version to be published.

Commentary

REFERENCES1. Guidelines International Network. Collaboration in clinical practice guidelines —

local, national and international cooperation in synthesizing and applyingbest evidence. Proceedings of the 4th G-I-N (Guidelines International Network)Conference; 2007 Aug 22–25; Toronto. Available: www.g-i-n.net/index.cfm?fuseaction=news&fusesubaction=docs&documentID=57 (accessed 2007 Oct 1).

2. Rich P. CMA helping doctors navigate guidelines maze. Ottawa: Canadian MedicalAssociation; 2004. Available: www.cma.ca/index.cfm?ci_id=4409&la_id=1 (ac-cessed 2007 Oct 1).

3. Davis D, Goldman J, Palda VA. Canadian Medical Association handbook on clini-cal practice guidelines. Ottawa: Canadian Medical Association; 2007.

4. Guidelines for Canadian clinical practice guidelines. In: CMA Infobase: clinicalpractice guidelines. Ottawa: Canadian Medical Association. Available: mdm.ca/cpgsnew/cpgs/gccpg-e.htm (accessed 2007 Oct 1).

5. Implementing clinical practice guidelines: a handbook for practitioners. In: CMAInfobase: clinical practice guidelines. Ottawa: Canadian Medical Association; 1997.Available: mdm.ca/cpgsnew/cpgs/handbook/index.htm (accessed 2007 Oct 1).

6. Begg C, Cho M, Eastwood S, et al. Improving the quality of reporting of random-ized controlled trials. The CONSORT statement. JAMA 1996;276:637-9.

7. Moher D, Cook DJ, Eastwood S, et al. Improving the quality of reports of meta-analyses of randomised controlled trials: the QUORUM statement. Lancet 1999;354:1896-900.

8. Gilbert R, Salanti G, Harden M, et al. Infant sleeping position and the sudden in-fant death syndrome: systematic review of observational studies and historical re-view of recommendations from 1940 to 2002. Int J Epidemiol 2005;34:874-87.

9. Van der Velde G, van Tulder M, Cote P, et al. The sensitivity of review results tomethods used to appraise and incorporate trial quality into data synthesis. Spine2007;32:796-806.

10. Choudhry NK, Stelfox HT, Detsky AS. Relationships between authors of clinicalpractice guidelines and the pharmaceutical industry. JAMA 2002;287:612-7.

11. Herrerias C, Lewis SZ, Harris DA, et al. American College of Chest Physicians evi-dence-based guideline methodology. Presented at the 4th G-I-N (Guidelines Inter-national Network) Conference; Toronto; 2007 Aug 22–25.

12. Detsky AS. Sources of bias for authors of clinical practice guidelines [editorial].CMAJ 2006;175:1033.

13. Sign 50: a guideline developer’s handbook. Edinburgh: SIGN — Scottish Intercol-

legiate Guidelines Network; 2004. Available: www.sign.ac.uk/guidelines/fulltext/50/index.html (accessed 2007 Oct 1).

14. Ebell MH, Siwek J, Weiss BD, et al. Simplifying the language of evidence to improvepatient care. Strength of Recommendation Taxonomy (SORT): a patient-centeredapproach to grading evidence in the medical literature. J Fam Pract 2004;53:111-20.

15. Schünemann HJ, Best D, Vist G, et al; GRADE Working Group. Letters, numbers,symbols and words: how to communicate grades of evidence and recommenda-tions. CMAJ 2003;169:677-80.

16. Barton MB, Miller T, Wolff T, et al.; U.S. Preventive Services Task Force. How toread the new recommendation statement: methods update from the U.S. Preven-tive Services Task Force. Ann Intern Med 2007;147:123-7.

17. Shiffman RN, Dixon J, Brandt C, et al. The GuideLine Implementability Appraisal(GLIA): development of an instrument to identify obstacles to guideline imple-mentation. BMC Med Inform Decis Mak 2005;5:23.

18. Fretheim A, Oxman AD, Flottorp S. Improving prescribing of antihypertensive andcholesterol-lowering drugs: a method for identifying and addressing barriers tochange. BMC Health Serv Res 2004;4:23.

19. Grimshaw JM, Thomas RE, MacLennan G, et al. Effectiveness and efficiency ofguideline dissemination and implementation strategies. Health Technol Assess2004;8:iii-iv, 1-72.

20. The guidelines manual. London (UK): National Institute for Health and Clinical Excel-lence; 2007. Available: www.nice.org.uk/page.aspx?o=422956 (accessed 2007 Oct 1).

21. Harris RP, Helfand M, Woolf SH, et al; Methods Work Group, Third US PreventiveServices Task Force. Current methods of the US Preventive Services Task Force: areview of the process. Am J Prev Med 2001;20(3 Suppl):21-35.

22. Shojania KG, McDonald KM, Wachter RM, et al. Series overview and metho-dology. Vol 1 of Closing the quality gap: a critical analysis of quality improvementstrategies [Technical review 9]. Rockville (MD): Agency for Healthcare Researchand Quality; 2004. Contract no 290-02-0017 to the Stanford University — UCSF Ev-idence-based Practices Center. AHRQ Publication no 04-0051-1.

CMAJ • November 6, 2007 • 177(10)11222266

Correspondence to: Dr. Valerie A. Palda, Department of Medicine,University of Toronto, St. Michael’s Hospital, Rm. CC4-154,30 Bond St., Toronto ON M5B 1W8; fax 416 864-5541;va.palda@utoronto.ca

Association médicale canadienne

Prix spéciaux pour l’an 2008 – Appel de candidatures

L’Association médicale canadienne sollicite des candidatures àses prix spéciaux pour l’an 2008.• Médaille d’honneur• Prix F.N.G. Starr• Médaille de service• Prix May-Cohen pour femmes mentors• Prix Sir-Charles-Tupper d’action politique• Prix d’excellence en promotion de la santé• Prix des jeunes chefs de file• Prix Dr-William-Marsden d'éthique médicale

Voir «Prix et distinctions de l’AMC» sur le site amc.ca pour lescritères détaillés de chaque prix ou contacter la coordonnatricedes prix au 800 663-7336, poste 2280.

Les candidatures doivent être soumises à la :

Présidente, Comité des archives et des distinctionsa/s Coordonnatrice des comitésAffaires généraleAssociation médicale canadienne1867, promenade Alta VistaOttawa (Ontario) K1G 3Y6

Les candidatures doivent être présentées au plus tard le 30 novembre 2007.

Canadian Medical Association

2008 Special Awards – Call for Nominations

The Canadian Medical Association invites nominations for the2008 special awards.

• Medal of Honour• F.N.G. Starr Award • Medal of Service• May Cohen Award for Women Mentors• Sir Charles Tupper Award for Political Action• Award for Excellence in Health Promotion• Award for Young Leaders• Dr. William Marsden Award in Medical Ethics

Refer to the “Awards from CMA” section on cma.ca for detailedcriteria on each of the awards or contact the awards co-ordinatorat 800 663-7336 x2280.

Nominations should be submitted to:

Chair, Committee on Archives and Awardsc/o Committee Co-ordinatorCorporate AffairsCanadian Medical Association1867 Alta Vista Dr.Ottawa ON K1G 3Y6

Closing date for receipt of nominations is Nov. 30, 2007.

For prescribing information see page 1256

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Commentary

All editorial matter in CMAJ represents the opinions of the authors and not necessarily those of the Canadian Medical Association.

From a public health perspective, radon is second onlyto smoking as a cause of lung cancer. It is estimated tocause about 10% of lung cancers,1,2 or more than 2000

cases each year in Canada. Radon is recognized as a group 1carcinogen by the International Agency for Research on Can-cer.3 In addition, there is a synergistic effect between cigarettesmoking and radon gas in the development of lung cancer. Atequivalent levels of radon exposure, people who smoke are athigher risk for lung cancer than nonsmokers (Box 1).

Radon is a colourless, odourless inert radioactive gas. Itoccurs naturally in soil and rocks as uranium decays. Radonhas a half-life of 3.82 days, and it decays into a series ofshort-lived radioisotopes (often referred to as radon daugh-ters or radon decay products) that can be inhaled. The move-ment of radon gas into basements and ground-level living ar-eas can result in a much higher level of radiation exposureindoors than would occur outdoors. Because of this, and be-cause it is not feasible to reduce the radon level outdoors,radon-reduction initiatives have been targeted at reducing in-door exposure.

New Canadian guideline for radon exposure

Health Canada has recently updated its guideline for the ac-ceptable level of radon in indoor air from 800 Bq/m3 to 200 Bq/m3 (Box 2).4 (A becquerel, or Bq, is the amount of ma-terial that will produce 1 nuclear disintegration per second).This brings the Canadian guideline closer to the guidelinesadopted by other countries. Switzerland has a guideline of400 Bq/m3, and China, Australia and most of Europe have seta guideline of 200 Bq/m3.4 The United States continues tohave the most stringent guideline (150 Bq/m3).4 Several Euro-pean countries have been moving aggressively to develop andimplement strategies to reduce radon exposure. In January2002, the European Commission established an ongoing scientific-led industrial forum aimed at sharing the progressin radon programs made by over 20 countries and dissemin-ating research findings to industry and the public.

Even with the new Canadian guideline, lifetime exposureat 200 Bq/m3 is still associated with a much greater risk of de-veloping cancer than is permitted by most other guidelinesand standards intended to protect against environmental car-cinogens. Such guidelines frequently try to reduce the attrib-utable lifetime cancer risk from the carcinogen of concern tothe range 1 per 10 000–1 000 000. Reduction of the residualrisk for radon exposure to this level is not possible.

Although the new Canadian guideline is welcome andoverdue, the question remains whether the change in the ac-ceptable level of indoor exposure will reduce the risk for

radon-related cancer. This question is not because of scien-tific uncertainty, nor is it because of a lack of effective preven-tive measures. Instead, this question remains becauseCanada does not have a record of aggressive action for publi-cizing or implementing national action on radon.

Turning the new guideline into action to reduce radon ex-posure presents some challenges (Box 3). Although Canadi-ans spend more time in their homes than in any other indoorenvironment, radon exposure, unlike many other environ-mental hazards, provokes little “outrage.” Radon gas is nat-urally occurring, is undetectable by smell or sight and, al-though carcinogenic, it does not result in catastrophic events.These factors likely contribute to a perceived risk that is lessthan the actual risk.

Radon exposure: Can we make a difference?

Ray Copes MD MSc, Jeff Scott MD

Public health

Ray Copes is with the British Columbia Centre for Disease Control, and theDepartment of Health Care and Epidemiology, University of British Columbia,Vancouver, BC. Jeff Scott is with the Government of Nova Scotia, Halifax, NS.D

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Box 1: Risk of lung cancer for smokers and nonsmokers,

by lifetime exposure level4

Smokers

• Indoor exposure at 800 Bq/m3: 30/100

• Indoor exposure at 200 Bq/m3: 17/100

• Outdoor exposure: 12/100

Nonsmokers

• Indoor exposure at 800 Bq/m3: 5/100

• Indoor exposure at 200 Bq/m3: 2/100

• Outdoor exposure: 1/100

Box 2: Summary of the new Canadian radon guideline4

• Remedial measures should be undertaken in a dwelling* if the annual average radon concentration exceeds 200 Bq/m3 in the normal occupancy area.†

• The higher the radon concentration, the sooner remedial measures should be undertaken.

• When remedial action is taken, the radon level should be reduced to a value that is as low as is practicable.

• The construction of new dwellings should involve techniques that will minimize radon entry and will facilitate post-construction radon removal if necessary.

*Dwellings include homes, schools, hospitals, long-term care residences and correctional facilities. †Normal occupancy areas include the parts of a dwelling where a person spends more than 4 hours per day.

Commentary

CMAJ • November 6, 2007 • 177(10)11223300

Measures such as sealing basements against radon intru-sion, depressurizing soil and improving ventilation have beenproven effective for reducing radon levels. Building remedia-tion efforts have focused on homes, both because of their de-sign and because they are where people spend the most time.Perhaps because remediation of a private home is felt to bethe responsibility of the homeowner and not the government,there has been little pressure for action from the public andfrom nongovernment organizations that are often effectiveadvocates for environmental measures. A recent publicationby the David Suzuki Foundation is an exception to this.5

How can we ensure that the new guidelineresults in action?

Radon levels vary considerably in different parts of Canada.They can also vary from one house to the next on the samestreet owing to differences in soil conditions and home con-struction. Radon levels are highest in basements and on theground floor, and higher stories are generally not affected.Although testing of individual buildings is necessary, someradon-prone areas are known. For example, the interior re-gions of British Columbia have higher levels of radon com-pared to coastal regions. Although testing has been per-formed in some provinces and in the United States, we lackthe nation-wide information necessary to construct a usefulradon map of Canada. Such a map would provide useful guid-ance on where we should focus further efforts for radon test-ing and reduction. Identification of radon-prone areas wouldallow homeowners, public health officials and governmentsto focus on the parts of the country where the problem is thegreatest. This might improve the cost-effectiveness,5 but notthe effectiveness of radon-reduction programs.

Although educational materials about radon have beendeveloped for homeowners,6 we should direct additional ef-forts to make testing easier and less expensive. Setting up ahotline for homeowners to request a radon monitor to testthe levels in their home and allowing them to return themonitor for analysis may increase compliance with testingrecommendations. Approved monitors could be made avail-able at government offices in areas that have been identified

as being radon prone. Ideally, this would be a national pro-gram and would be effectively delivered at the local or re-gional level, possibly through public health units. In addi-tion, a program to train or certify contractors in radonreduction and to ensure that radon testing is performed in anaccurate manner may also be helpful. Adding a questionabout radon levels to real estate disclosure forms could pro-vide an additional incentive to homeowners to preformradon testing.

Governments can lead by example. Although privatehomes need to be tested, many public buildings and licensedfacilities such as day-care centres and community-living fa-cilities are also candidates for radon testing. British Colum-bia already has a program for testing schools and for miti-gating exposure when necessary. Action to date has shownthat reduction, typically 75%–90%, is achievable at a rela-tively moderate cost. If governments publicly commit to per-forming radon testing for buildings in their jurisdictions,their advice to the public to test their homes will have morecredibility. Nova Scotia, for example, has already begun test-ing public buildings.

Recent efforts by occupational health and safety regulatorsto restrict smoking in the workplace have reduced this work-place health risk for a sizable group of Canadians. Like en-vironmental tobacco smoke, radon is a “nontraditional”workplace hazard that merits attention. Even if we spend lesstime at work than at home, the risk for cancer from radon at200 Bq/m3 is well above the target risk level set for manyworkplace carcinogens. Efforts by occupational health andsafety regulators to assess radon and, where necessary, to re-duce radon exposure in the workplace may also stimulatepublic awareness that the radon is “real.” Many public build-ings are also workplaces, and workplace health and safetyregulators should be encouraged to adopt the new 200 Bq/m3

guideline as their workplace limit.Development and application of building code require-

ments designed to prevent the intrusion of radon and othersoil gases into newly constructed buildings may be a soundpreventive measure. The effectiveness of these measuresshould be evaluated.

Finally, physicians, particularly primary care physicianswho practise in radon-prone areas, can encourage patients tohave their homes checked for radon. For nonsmokers, thismay be the single most effective measure to prevent lung can-cer. Physicians’ organizations can play an active role in lobby-ing governments at all levels to take action to implement thenew radon guideline. Although there have been advances inthe treatment of lung cancer, the relative 5-year survival isonly 14% for men and 17% for women.7 This is still a cancerwith very serious morbidity and mortality — prevention is in-deed better than cure.

This article has been peer reviewed.

Competing interests: None declared.

Contributors: Both of the authors contributed substantially to the conceptionand design of the manuscript. Ray Copes wrote the first draft, and Jeff Scottcontributed additional material. Both of the authors revised the manuscript forimportant intellectual content and approved the final version for publication.

Box 3: Elements of a successful radon-reduction program

Information

• Radon mapping

• Public awareness

Testing

• Make accurate radon monitors readily available to homeowners at low or no cost

Reduction of high levels

• Provide understandable instructions on what can be done by the “do-it-yourselfer”

• Require certification or other quality assurance testing for radon-reduction contractors

CMAJ • November 6, 2007 • 177(10) 11223311

Commentary

REFERENCES1. Krewski D, Lubin JH, Zielinski JM, et al. A combined analysis of North American

case–control studies of residential radon and lung cancer. J Toxicol Environ HealthA 2006;69:533-97.

2. Darby S, Hill D, Auvinen A et al. Radon in homes and risk of lung cancer: collabo-rative analysis of individual data from 13 European case–control studies. BMJ2005;330:223. Epub 2004 Dec 21 ahead of print.

3. International Agency for Research on Cancer. France: The Agency; 2007. Avail-able: http://monographs.iarc.fr/ENG/Classification/crthallalph.php (accessed2007 Oct 4).

4. Health Canada. Report of the Radon Working Group on a new radon guideline forCanada. Ottawa: Health Canada; 2006 Mar. Available: www.hc-sc.gc.ca/ahc-asc/public-consult/consultations/col/radon/rep-rapp_e.html (accessed 2007 Aug 30).

5. Boyd DR. Radon: the unfamiliar killer. Vancouver: The David Suzuki Foundation;2007. Available: www.polisproject.org/publications/researcharea/lawpoliticalecology(accessed 2007 Sept 25).

6. Canadian Mortgage and Housing Corporation. Radon: a guide for Canadianhomeowners. Ottawa: Canadian Mortgage and Housing Corporation and HealthCanada; 1997. Available: www.cmhc-schl.gc.ca/odpub/pdf/61945.pdf (accessed2007 Sept 25).

7. National Cancer Institute of Canada. Canadian Cancer Statistics 2002. Toronto:The Institute; 2002. p. 77.

Correspondence to: Dr. Ray Copes, BC Centre for Disease Control,655 West 12th Ave., Vancouver BC V5Z 4R4; fax 604 660-6628;ray.copes@bccdc.ca

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