Evaluation and comparison of guidelines for the management of people with type 2 diabetes from eight European countries
Introduction
Estimates have indicated that in 2007 there were 53 million cases of diabetes (combining types 1 and 2) in adults aged 20–79 years within the European Region as defined by the International Diabetes Federation (IDF), equating to an estimated prevalence of 6.6% [1]. Type 2 diabetes is the most common form of the condition; it is associated with considerable morbidity and increased healthcare costs which can be reduced by effective management including strategies for prevention of complications. However, despite there being international consensus on, and evidence about, management of people with type 2 diabetes, there are still large variations in care [2], [3].
Recognising the wealth of evidence relating to the management of diabetes, professional and patient organisations and governments, including the influential American Diabetes Association [4], have invested in the development of relevant guidelines. However, previous studies have reported variations between different guidelines relating to laboratory testing for diagnosis and monitoring of diabetes [5] and also between guidelines for the management of other conditions such as heart failure [6], hypertension [7], depression [8] and anticoagulation [9]. Reasons for this variation have been suggested, for example, the most powerful influence on recommendations may not be research evidence as the content may initially be decided through consensus and then evidence used to support this [10]. Recommendations may also vary due to the lack of an evidence-based approach [11] and preferential citation of evidence from a guideline's country of origin [10]. The influence of the context within which guidelines are produced (for example, public agencies and medical societies) has also been suggested in relation to observed inconsistencies between guidelines [7].
This study forms part of the Guideline Adherence to Enhance Care (GUIDANCE) initiative which is an international programme of study relating to the quality of care of people with diabetes in eight European countries, co-ordinated by the European Association for the Study of Diabetes. The objectives of the initial stage of this programme of study, as reported in this paper, were to assess the methodological rigour of eight European guidelines for the management of type 2 diabetes and to compare the recommendations for process and intermediate outcomes of care provided in these guidelines.
Section snippets
Identification of guidelines and scope of assessment
Guidelines for the management of people with type 2 diabetes were identified for the following countries: Belgium, France, Germany, the Netherlands, Ireland, Italy, Sweden and England/Wales. Study representatives in each participating country were responsible for selecting the most appropriate guideline for inclusion in the study, based on factors such as most recent date of publication, national recognition and relevance to the broad topic of management of type 2 diabetes. Guidelines were
Results
The selected national guidelines for the management of type 2 diabetes were published between 2000 and 2008 in the eight participating countries (Table 1).
Summary of principal findings
Comparison of guidelines for managing type 2 diabetes from eight European countries identified considerable variation in the quality of those aspects of the guidelines assessed by the AGREE evaluation instrument, including the rigour of the development processes described. However, there was a substantial degree of consensus between the different guidelines in terms of specific recommendation regarding the management of type 2 diabetes. Apart from the French guideline (where the information was
Conflict of interest
This study was funded through a grant from Merck & Co. Inc., Whitehouse Station, NJ, USA. Merck scientists participated in the initial study conceptualization and protocol development. The investigator selection, data collection, analyses and manuscript writing were conducted independently by the EASD. Dr. G Grassi was involved in the production of the Italian guideline, but this was evaluated by reviewers in the UK.
Acknowledgements
In addition to the named authors, the following members of the GUIDANCE study team who contributed to the study were Dr. M Grüsser, Professor A. Melander and Dr. K.G. Gorter (who acted as the second assessors in Germany, Sweden and the Netherlands respectively), Ms. Noemi Debacker, Professor Massimo Porta and Dr. Viktor Jörgens. The patience, co-ordination skills and excellent administrative support provided by Ms. Narelle Sulley from the EASD are particularly acknowledged.
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