Review
Identifying the quantity and assessing the quality of clinical practice guidelines for the treatment and management of type 2 diabetes: A systematic review

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Abstract

Aims

Type 2 diabetes (T2D) is a condition where the body becomes insulin resistant and cannot use insulin made by the pancreas or is relatively insulin deficient causing high blood glucose levels. Assessing the quality of clinical practice guidelines (CPGs) for T2D is important to identify knowledge gaps and where improvements can be made. The purpose of this review was to identify the quantity and assess the quality of CPGs for the treatment and/or management of T2D.

Methods

A systematic review was conducted to identify T2D CPGs. MEDLINE, EMBASE, CINAHL and GIN were searched from 2008 to 2018. Eligible guidelines published on the treatment and/or management of T2D were assessed with the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument.

Results

Seventeen CPGs were found to be eligible. Scaled domain percentages (highest to lowest) were: clarity of presentation (81.2%), scope and purpose (77.1%), stakeholder involvement (52.8%), applicability (42.9%), rigour of development (41.5%), and editorial independence (35.1%).

Conclusions

CPGs that achieved higher AGREE II scores and favourable overall recommendations could be used by healthcare providers to facilitate informed discussions surrounding T2D therapies. CPGs that received lower scaled domain percentages or overall recommendations could be improved by using the AGREE II instrument.

Introduction

Diabetes is a condition whereby the body is not able to either produce or use the hormone insulin which helps regulate blood sugar [1]. The most common form is type 2, affecting 90% of those with diabetes [2]. This type is commonly developed in adulthood and occurs when the body is insulin resistant or insulin deficient resulting in high blood glucose levels; screening involves testing fasting plasma glucose [1], [2], [3]. Diabetes research is of great importance, given that as of 2019 approximately 463 million adults live with this condition worldwide, with the proportion of people with type 2 diabetes specifically increasing in most countries [4], [5]. The most common pharmaceutical treatments for type 2 diabetes include the oral drug metformin, which helps the body use its own insulin more effectively, and sulfonylureas, which stimulates the pancreas to produce more insulin [3]. The most promising methods of managing type 2 diabetes include lifestyle management such as monitoring diet, exercise, maintaining healthy body weight, and smoking cessation [3]. Over time, oral medications or insulin administration can also be beneficial if needed [3].

Diabetes can result in serious complications if poorly managed. A common short-term complication of type 2 diabetes is hypoglycaemia, which results from poor management of the condition or taking too much insulin [6]. Longer term complications include neuropathy or poor circulation in the feet, which can cause weakness, numbness, and tingling. These problems can result in amputation of the lower extremities due to peripheral arterial disease which can ultimately negatively affect a patient’s quality of life and warrant the need for special accommodations [7], [8]. The risk of being diagnosed with other pancreatitis and pancreatic cancer, both approximately double in patients with type 2 diabetes [6]. Conditions connected to diabetes including, insulin resistance, inflammation, and high blood sugar all contribute to the development of pancreatic cancer [6]. Diabetes also alters kidney function from high blood sugar levels, resulting in kidney disease which can cause loss of sleep, poor appetite, upset stomach, weakness, difficulty concentrating, and eventually kidney failure if left untreated [8]. Other complications often associated with diabetes are high blood pressure, stroke, diabetic retinopathy, and depression [8], [9].

Given that diabetes is a complex condition associated with many possible comorbidities, it is important for clinicians to be well informed when making decisions surrounding the treatment and management of each patient. Clinical practice guidelines (CPGs) provide evidence-based recommendations to support informed decision making surrounding a disease or condition, with diabetes being no exception [10]. Only a few studies have assessed the quality of type 2 diabetes CPGs and have not been comprehensive, only assessing CPGs published over a short timeframe or searched unsystematically [11], [12], [13]. Thus, the purpose of this study is to systematically review the guidelines literature to identify the quantity and assess the quality of CPGs for the treatment and/or management of type 2 diabetes.

Section snippets

Approach

A systematic review was conducted to identify CPGs for the treatment and/or management of type 2 diabetes using standard methods [14] and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria [15]. A protocol was registered with PROSPERO, registration number CRD42019132458. Eligible guidelines were assessed with the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument [16]. AGREE II is commonly used to appraise the quality of CPGs and has

Search results (Fig. 1)

Searches retrieved 2467 items, 2218 were unique, and 2178 titles and abstracts were eliminated, leaving 40 full-text articles that were considered. Of those, 23 were not eligible, because they were not focused on treatment or management of type 2 diabetes (n = 6), they were guideline summaries (n = 5), they were not CPGs (n = 5), they were not full guidelines (n = 3), they could not be retrieved (n = 2), a newer guideline was available (n = 1), or the guideline was not in English (n = 1),

Discussion

The purpose of this review was to identify the quantity and assess the quality of CPGs for the treatment and/or management of type 2 diabetes; this study identified 17 eligible CPGs published between 2009 and 2018. Quality as assessed by the 23-item AGREE II instrument varied widely across guidelines overall and by domain; four guidelines scored 5.0 or higher in both average appraisal score and average overall assessment [22], [23], [31], [32], and 5 guidelines scored 4.0 or lower in both of

Conclusions

This study identified 17 CPGs for the treatment and/or management of type 2 diabetes published between 2009 and 2018. Therapies included pharmaceutical medications, nutritional interventions, physical activity, psychological management, surgeries, and complementary and alternative medicine. Appraisal of these guidelines with the AGREE II instrument revealed that the quality varied within and across CPGs. Guidelines that achieved higher AGREE II scores and favourable overall recommendations

Ethics approval and consent to participate

This study involved a systematic review of peer-reviewed literature only; it did not require ethics approval or consent to participate.

Consent for publication

All authors consent to this manuscript’s publication.

Availability of data and materials

All relevant data are included in this manuscript.

Funding

JYN was awarded a Research Scholarship and an Entrance Scholarship from the Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences at McMaster University.

Authors contribution

JYN: conceptualized and designed the study, collected and analysed data, drafted the manuscript, and gave final approval of the version to be published.

KDV: assisted with the collection and analysis of data, drafted the manuscript, and gave final approval of the version to be published.

Acknowledgements

We gratefully acknowledge Kevin Gilotra for assisting with screening and data extraction.

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