Evaluation and comparison of guidelines for the management of people with type 2 diabetes from eight European countries

doi:10.1016/j.diabres.2009.10.020

Diabetes Research and Clinical Practice

Volume 87, Issue 2, February 2010, Pages 252-260

https://doi.org/10.1016/j.diabres.2009.10.020 Get rights and content

Abstract

Methods

The most recent nationally recognised guidelines for type 2 diabetes from eight European countries (Belgium, England/Wales, France, Germany, Ireland, Italy, the Netherlands and Sweden) were compared. The Appraisal of Guidelines for Research and Evaluation (AGREE) instrument was used for quality assessment. Details of recommendations for key process and outcome indicators were also extracted. Appraisal and data extraction were conducted independently by two researchers.

Results

AGREE domain scores varied between guidelines, including a range of 31–95% for rigour of development. The highest mean domain scores were for Scope and Purpose (81%) and Clarity and Presentation (85%); the lowest was for Stakeholder Involvement (49%). Specific recommendations, including targets relating to intermediate outcomes, were broadly similar. However, at detailed level, there were variations, particularly in terms of the level of information provided, for example, only two countries’ guidelines provided cut-off points in relation to risk associated with waist circumference.

Implications

Our findings suggest that there are some areas of good practice relating to guideline development where more attention is needed. Despite a substantial degree of consensus for specified targets, observed differences at detailed level suggest a lack of consistency in relation to some aspects of the information provided to clinicians across Europe.

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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Citation Excerpt :
However, less than 20% of T2DM patients reach all three clinical targets [2], and more than one third of patients do not reach glycemic control [3,4]. Besides adhering to medical prescriptions, self-managing clinical risk factors require patients to (simultaneously) change to a healthier diet and be more physically active, ideally leading to weight loss [5,6]. Diabetes self-management through changing health behaviors is often challenging for patients, because it is their habitual unhealthy lifestyle that has contributed to the development of T2DM [7–9].
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Seven practice nurses audio-recorded consultations with 66 patients. An existing instrument for assessing counseling quality was used to determine if the 5As were applied. Applied As were compared with quality criteria, to provide an in-depth assessment.
In almost every consultation, nurses assessed health behaviors, and arranged a follow-up meeting. However, nurses advised behavior change in less than half of the consultations, while setting goals and assisting patients to overcome barriers were used even less. Comparing applied As with quality criteria revealed several issues that could be improved.
Nurses consistently discussed health behaviors with patients, but important elements of self-management support were not applied.
Self-management support may benefit from training nurses in performing assessments that form the base for specific advice, setting goals, and addressing barriers to behavior change. Nurses also have to learn how to combine being medical expert and behavioral counselor. Clarifying both roles to patients may facilitate communication and establishing a collaborative relationship.
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View full text

Evaluation and comparison of guidelines for the management of people with type 2 diabetes from eight European countries

Abstract

Methods

Results

Implications

Introduction

Section snippets

Identification of guidelines and scope of assessment

Results

Summary of principal findings

Conflict of interest

Acknowledgements

Prim. Care Diabetes

Ethnic disparities in diabetes management and pay-for-performance in the UK: The Wandsworth Prospective Diabetes Study

PLoS Med.

Quality of diabetes care in the UK: comparison of published quality-of-care reports with results of the quality and outcomes framework for diabetes

Diabet. Med.

Standards of medical care in diabetes

Diabetes Care

Do guidelines for the diagnosis and monitoring of diabetes mellitus fulfill the criteria of evidence-based guideline development?

Clin. Chem.

Diagnosis of heart failure in primary care: an assessment of international guidelines

Br. J. Gen. Pract.

A comparative analysis of four clinical guidelines for hypertension management

J. Hum. Hypertens.

The quantity and quality of clinical practice guidelines for the management of depression in primary care in the UK

Br. J. Gen. Pract.

Guidelines on anticoagulant treatment in atrial fibrillation in Great Britain: variation in content and implications for treatment

BMJ

Inside guidelines: comparative analysis of recommendations and evidence in diabetes guidelines from 13 countries

Diabetes Care