Evidence base in guideline generation in diabetes

Factors Associated with the Quality and Transparency of National Guidelines: A Mixed-Methods Study

We assessed the methodological quality and transparency of all the national clinical practice guidelines that were published in Croatia up until 2017 and explored the factors associated with their quality rating. An in-depth quantitative and qualitative analysis was performed using rigorous methodology. We evaluated the guidelines using a validated AGREE II instrument with four raters; we used multiple linear regressions to identify the predictors of quality; and two focus groups, including guideline developers, to further explore the guideline development process. The majority of the guidelines (N = 74) were developed by medical societies. The guidelines’ quality was rated low: the median standardized AGREE II score was low, 36% (IQR 28–42), and so were the overall-assessments. The aspects of the guidelines that were rated best were the “clarity of presentation” and the “scope and purpose” (median ≥ 59%); however, the other four domains received very low scores (15–33%). Overall, the guideline quality did not improve over time. The guidelines that were developed by medical societies scored significantly worse than those developed by governmental, or unofficial working groups (12–43% per domain). In focus group discussions, inadequate methodology, a lack of implementation systems in place, a lack of awareness about editorial independence, and broader expertise/perspectives in working groups were identified as factors behind the low scores. The factors identified as affecting the quality of the national guidelines may help stakeholders who are developing interventions and education programs aimed at improving guideline quality worldwide.

The Predictive Value of the Monocyte-to-Lymphocyte Ratio and Monocyte-to-Haematocrit Ratio for Cardiac Rupture Patients with Acute Myocardial Infarction: A Propensity Score Matching Analysis

Background

Cardiac rupture (CR) is a serious complication of acute myocardial infarction (AMI). We aimed to explore the predictive value of blood cell parameters for identifying CR in patients with AMI using the introduction of propensity score matching (PSM).

Methods

This retrospective study enrolled patients who were diagnosed with AMI from January 2013 to May 2020. A total of 109 patients with CR were included, and 327 hospitalized non-CR patients were randomly selected at a 1:3 ratio. Based on the 1:1 nearest neighbour matching method by using SPSS, the covariances of the two groups were balanced. After PSM, the independent risk factors for CR were selected by using multivariate logistic regression analysis, and receiver operating characteristic (ROC) curve analysis was applied to evaluate the predictive value of blood cell parameters for CR. Ninety cases were matched successfully in each of the two groups.

Results

Among the 180 patients with AMI after PSM, the results of multivariate logistic regression analysis showed that the monocyte-to-lymphocyte ratio (MLR) (OR = 3.57, 95% CI: 1.28–9.97, P = 0.015) and monocyte-to-haematocrit ratio (MHR) (OR = 1.80, 95% CI: 1.02–3.20, P = 0.043) were independently related to the risk of CR. Additionally, the MLR (area under the curve (AUC): 0.74) and MHR (AUC: 0.73) were useful for distinguishing CR patients after PSM. To differentiate CR patients from the control subjects, the optimal cut-offs of the MLR and MHR were 0.61 (63% sensitivity and 80% specificity) and 2.06 (57% sensitivity and 81% specificity), respectively.

Conclusion

The blood cell parameters MLR and MHR were independently correlated with CR. Additional, the MLR and MHR were useful to predict CR in patients with AMI.

Association between MIF gene promoter rs755622 and susceptibility to coronary artery disease and inflammatory cytokines in the Chinese Han population

Macrophage migration inhibitory factor (MIF) is an essential mediator of atherosclerotic plaque progression and instability leading to intracoronary thrombosis, therefore contributing to coronary artery disease (CAD). In this study, we investigated the relationship between MIF gene polymorphism and CAD in Chinese Han population. Three single nucleotide polymorphisms (SNP, rs755622, rs1007888 and rs2096525) of MIF gene were genotyped by TaqMan genotyping assay in 1120 control participants and 1176 CAD patients. Coronary angiography was performed in all CAD patients and Gensini score was used to assess the severity of coronary artery lesions. The plasma levels of MIF and other inflammatory mediators were measured by ELISA. The CAD patients had a higher frequency of CC genotype and C allele of rs755622 compared with that in control subjects (CC genotype: 6.5% vs. 3.9%, P = 0.008, C allele: 24.0% vs. 20.6%, P = 0.005). The rs755622 CC genotype was associated with an increased risk of CAD (OR: 1.804, 95%CI: 1.221-2.664, P = 0.003). CAD patients with a variation of rs755622 CC genotype had significantly higher Gensini score compared with patients with GG or CG genotype (all P < 0.05). In addition, the circulating MIF level was highest in CAD patients carrying rs755622 CC genotype (40.7 ± 4.2 ng/mL) and then followed by GC (37.9 ± 3.4 ng/mL) or GG genotype (36.9 ± 3.7 ng/mL, all P < 0.01). Our study showed an essential relationship between the MIF gene rs755622 variation and CAD in Chinese Han population. Individuals who carrying MIF gene rs755622 CC genotype were more susceptible to CAD and had more severe coronary artery lesion. This variation also had a potential influence in circulating MIF levels.

NFKB1 gene rs28362491 ins/del variation is associated with higher susceptibility to myocardial infarction in a Chinese Han population

Myocardial infarction (MI), the leading cause of mortality and disability worldwide, is a disease in which multiple environmental and genetic factors are involved. Recently, researches suggested that insertion/deletion (ins/del) variation of NFKB1 gene rs28362491 is a functional polymorphism. In the present study, we aimed to explore the relation between variation of NFKB1 gene rs28362491 and MI by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) in 359 MI patients and 1085 control participants. Gensini score was used to evaluate the degree of coronary artery stenosis in MI patients. The plasma levels of interleukin-6 (IL-6), IL-8, malonaldehyde (MDA) and superoxide dismutase (SOD) were randomly measured by ELISA both in MI patients and control participants. We found that the detected frequencies of D allele (41.2% vs. 36.4%, P = 0.021) and DD genotype (17.5% vs. 12.0%, P = 0.022) were significantly higher in MI patients than in control participants. Compared with II or ID genotype carriers, the Gensini score in MI patients with DD genotype was 32-43% higher (both P < 0.001). Moreover, DD genotype carries had more diseased coronary arteries (P = 0.001 vs. II or ID genotype). Of note, IL-6 levels in MI patients carrying DD genotype were significantly higher than that in control participants and other genotype carriers in MI patients (both P < 0.05). In conclusion, NFKB1 gene rs28362491 DD genotype was associated with a higher risk of MI and more severe coronary artery lesion, which also had a potential influence on the level of inflammatory cytokine IL-6.

Anpassung internationaler Leitlinien in der Physiotherapie – ein Methodenpapier der Deutschen Gesellschaft für Physiotherapiewissenschaft e. V. (DGPTW)

Hintergrund Derzeit existieren nur für sehr wenige Indikationen medizinische Leitlinien, deren Empfehlungen auf die Bedingungen des deutschen Gesundheitswesens zugeschnitten und geeignet sind, Physiotherapeuten in der Auswahl geeigneter Maßnahmen zu unterstützen. Die Deutsche Gesellschaft für Physiotherapiewissenschaft (DGPTW) setzt sich für eine stärkere Verknüpfung von Wissenschaft und Patientenversorgung ein und möchte zu diesem Zweck die Bereitstellung von Leitlinien für die Physiotherapie vorantreiben. Die Anpassung von Leitlinien aus anderen Ländern kann eine pragmatische Alternative gegenüber einer Neuentwicklung darstellen.

Ziel Entwicklung eines Methodenpapiers, das als Handlungsempfehlung in der Übernahme und Anpassung hochwertiger internationaler Leitlinien für das Gebiet der Physiotherapie im deutschen Gesundheitswesen dienen soll.

Methode Eine Arbeitsgruppe der Sektion Leitlinien der DGPTW bestimmte zunächst Ziele und Vorgehensweise zur Erstellung des Methodenpapiers. Nach Recherche und Screening vorhandener Rahmenkonzepte zur Anpassung von Leitlinien wurden Vorschläge zu einem systematischen Vorgehen bei der Anpassung internationaler Leitlinien abgeleitet.

Ergebnisse Das Methodenpapier beschreibt Vorgehensweisen zur Festlegung des Themas, zur Recherche, zum Screening und zur Bewertung vorhandener Leitlinien sowie zur Auswahl einer geeigneten Leitlinie und deren Anpassung. Die Einbindung weiterer Akteure und der Review- bzw. Konsentierungsprozess bei der Leitlinienanpassung werden ebenfalls skizziert.

Diskussion Die Vorschläge zur Leitlinienanpassung wurden im Spannungsfeld zwischen dem Anspruch an eine möglichst systematische, transparente und umfassende Methodik und der Praktikabilität vor dem Hintergrund begrenzter Ressourcen ausgewählt. Das Methodenpapier wurde der Fachöffentlichkeit zur Diskussion vorgestellt und soll in einem nächsten Schritt im Rahmen einer Leitlinienanpassung erprobt werden.

Informed shared decision-making programme for patients with type 2 diabetes in primary care: cluster randomised controlled trial

OBJECTIVE

To translate an informed shared decision-making programme (ISDM-P) for patients with type 2 diabetes from a specialised diabetes centre to the primary care setting.

DESIGN

Patient-blinded, two-arm multicentre, cluster randomised controlled trial of 6 months follow-up; concealed randomisation of practices after patient recruitment and acquisition of baseline data.

SETTING

22 general practices providing care according to the German Disease Management Programme (DMP) for type 2 diabetes.

PARTICIPANTS

279 of 363 eligible patients without myocardial infarction or stroke.

INTERVENTIONS

The ISDM-P comprises a patient decision aid, a corresponding group teaching session provided by medical assistants and a structured patient-physician encounter.Control group received standard DMP care.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary endpoint was patient adherence to antihypertensive or statin drug therapy by comparing prescriptions and patient-reported uptake after 6 months. Secondary endpoints included informed choice, risk knowledge (score 0-11 from 11 questions) and prioritised treatment goals of patients and doctors.

RESULTS

ISDM-P: 11 practices with 151 patients; standard care: 11 practices with 128 patients; attrition rate: 3.9%. There was no difference between groups regarding the primary endpoint. Mean drug adherence rates were high for both groups (80% for antihypertensive and 91% for statin treatment). More ISDM-P patients made informed choices regarding statin intake, 34% vs 3%, OR 16.6 (95% CI 4.4 to 63.0), blood pressure control, 39% vs 3%, OR 22.2 (95% CI 5.3 to 93.3) and glycated haemoglobin, 43% vs 3%, OR 26.0 (95% CI 6.5 to 104.8). ISDM-P patients achieved higher levels of risk knowledge, with a mean score of 6.96 vs 2.86, difference 4.06 (95% CI 2.96 to 5.17). In the ISDM-P group, agreement on prioritised treatment goals between patients and doctors was higher, with 88.5% vs 57%.

CONCLUSIONS

The ISDM-P was successfully implemented in general practices. Adherence to medication was very high making improvements hardly detectable.

TRIAL REGISTRATION NUMBER

ISRCTN77300204; Results.

Prioritizing topics in guideline development: results of a two-phase online survey of dermatologist members of the EADV

BACKGROUND

Most clinical guidelines in dermatology are encyclopaedic, covering a disease and its aetiology, diagnosis, treatment and prevention in their entirety. The usability and uptake of guideline recommendations might be improved by guidelines that are more concise and address specific questions ranked by users according to their perceived importance.

OBJECTIVE

To survey the largest association of dermatologists in Europe, identify which questions in their everyday practice they felt would benefit from short, evidence-based guidance and rank these systematically.

METHODS

A two-phase online survey using a structured ranking approach and the members directory of the European Academy of Dermatology and Venereology (EADV).

RESULTS

The first survey yielded 265 suggestions, indicating a response rate of 3.7%. We grouped all responses according to themes and subsequently combined these into a list of 35 broader topics. These were presented to all members of the EADV in the second survey (response rate: 9.7%), which yielded a list of the top 10 topics participants felt were most in need of guidance. The first three were 'Systemic drug treatment in dermatology during pregnancy and for women wishing to have children in the near future', 'alopecia areata' and 'interpretation of laboratory results in connective tissue diseases'.

CONCLUSION

Our two-phase survey of EADV members and a structured ranking process were practical to implement and yielded a list of the top 10 topics in dermatology and venereology for guideline development. Guideline dissemination needs to be improved, and practical, more concise guidelines may facilitate efforts to do so.

Standardized screening for periodontitis as an integral part of multidisciplinary management of adults with type 2 diabetes: an observational cross-sectional study of cohorts in the USA and UK

OBJECTIVE

To determine prevalence and factors predictive of periodontitis by using a standardized assessment model in adults with type 2 diabetes.

RESEARCH DESIGN AND METHODS

We performed an observational cross-sectional study to determine the burden of periodontitis in adults with type 2 diabetes attending urban, ambulatory referral centers in the USA and UK. Full-mouth probing was performed and periodontitis was diagnosed based on either a low (≥5 mm at ≥1 site) or high pocket probing-depth threshold (≥6 mm at ≥1 site). Results were stratified into a five-stage schema and integrated with other clinical variables into the novel Diabetes Cross-Disciplinary Index to function as a balanced health scorecard. Corresponding demographic and routinely collected health data were obtained and comparisons were made between patients with and without periodontitis. Multivariable logistic regression was performed to identify factors predictive of the presence or absence of periodontitis.

RESULTS

Between our two cohorts, 253 patients were screened. Caucasians comprised >90% and Hispanic Americans >75% of the UK and US cohorts, respectively. Males and females were equally distributed; mean age was 53.6±11 years; and 17 (6.7%) were edentulous. Of the 236 dentate patients, 128 (54.2%) had periodontitis by low threshold and 57 (24.2%) by high threshold. Just 17 (7.2%) were periodontally healthy. No significant differences in age, HbA1c, blood pressure, body mass index, low-density lipoprotein cholesterol, or smoking status (all p>0.05) were identified between those with or without periodontitis (regardless of threshold) and none was found to be a significant predictor of disease.

CONCLUSIONS

Periodontitis is frequent in adults with type 2 diabetes and all should be screened. Periodontal health status can be visualized with other comorbidities and complications using a novel balanced scorecard that could facilitate patient-clinician communication, shared decision-making, and prioritization of individual healthcare needs.

Are nutrition messages lost in transmission? Assessing the quality and consistency of diabetes guideline recommendations on the delivery of nutrition therapy

AIM

To provide an overview of (1) the consistency of Type 2 Diabetes Clinical Practice Guidelines recommendations on the delivery of nutrition therapy and (2) Clinical Practice Guideline quality.

METHODS

Large international clinical practice guideline repositories, diabetes organisation websites, and electronic databases (Pubmed, Scopus), were searched to identify Clinical Practice Guidelines for adults with type 2 diabetes published 2005 to August 2014. Recommendations on the delivery of nutrition therapy were extracted and inductive content analysis was used to analyse consistency. Two researchers independently assessed guideline quality using the AGREE II tool.

RESULTS

Nine topics were identified from the recommendations. Overall the consistency of the recommendations was related to guideline type. Compared with nutrition-specific guidelines, the broad ones had a broader focus and included more patient-focused recommendations. The ten Clinical Practice Guidelines assessed included six broad guidelines and four nutrition specific guidelines. Based on AGREE II analysis, the broad guidelines were higher quality than nutrition-specific ones.

CONCLUSIONS

Broad Clinical Practice Guidelines were higher quality and included more patient-focused recommendations than nutrition-specific ones.

PRACTICE IMPLICATIONS

Our findings suggest a need for nutrition-specific guidelines to be modified to include greater patient-focus, or for practitioners delivering nutrition therapy to adopt broad Clinical Practice Guidelines.

Delay in treatment intensification increases the risks of cardiovascular events in patients with type 2 diabetes

BACKGROUND

The aim of the study was to evaluate the effect of delay in treatment intensification (IT; clinical inertia) in conjunction with glycaemic burden on the risk of macrovascular events (CVE) in type 2 diabetes (T2DM) patients.

METHODS

A retrospective cohort study was carried out using United Kingdom Clinical Practice Research Datalink, including T2DM patients diagnosed from 1990 with follow-up data available until 2012.

RESULTS

In the cohort of 105,477 patients mean HbA1c was 8.1% (65 mmol/mol) at diagnosis, 11% had a history of cardiovascular disease, and 7.1% experienced at least one CVE during 5.3 years of median follow-up. In patients with HbA1c consistently above 7/7.5% (53/58 mmol/mol, n = 23,101/11,281) during 2 years post diagnosis, 26/22% never received any IT. Compared to patients with HbA1c <7% (<53 mmol/mol), in patients with HbA1c ≥7% (≥53 mmol/mol), a 1 year delay in receiving IT was associated with significantly increased risk of MI, stroke, HF and composite CVE by 67% (HR CI: 1.39, 2.01), 51% (HR CI: 1.25, 1.83), 64% (HR CI: 1.40, 1.91) and 62% (HR CI: 1.46, 1.80) respectively. One year delay in IT in interaction with HbA1c above 7.5% (58 mmol/mol) was also associated with similar increased risk of CVE.

CONCLUSIONS

Among patients with newly diagnosed T2DM, 22% remained under poor glycaemic control over 2 years, and 26% never received IT. Delay in IT by 1 year in conjunction with poor glycaemic control significantly increased the risk of MI, HF, stroke and composite CVE.

An informed shared decision making programme on the prevention of myocardial infarction for patients with type 2 diabetes in primary care: protocol of a cluster randomised, controlled trial

Background

International and national societies claim a patient centred approach including shared decision making (SDM) in diabetes care. In a previous project, a SDM programme on the prevention of myocardial infarction has been developed. It is aimed at supporting patients with type 2 diabetes to make informed choices on preventive options, to share the decision making process with the health care team, and to improve adherence to the chosen treatment. In this study, the programme will be implemented and evaluated in primary care practices.

Methods/Design

A cluster randomised, controlled trial will be conducted to compare the SDM programme with standard care enrolling patients with type 2 diabetes (N = 306) from primary care practices (N = 24). The intervention programme comprises a six hours provider training, a patient decision aid including evidence-based information, a 90 minutes structured teaching session provided by medical assistants, a sheet to document the patients’ individual treatment goals, and a structured consultation with the general practitioner for sharing information, setting treatment goals, and for adapting treatment regimens if necessary. Patients in the control group receive a brief extract of recommendations of the German National Disease Management Guideline on the treatment of patients with type 2 diabetes. Primary outcome measure is adherence to blood pressure treatment and statin treatment at 6 months follow-up. Secondary outcome measures comprise informed choice and the achievement of patients’ treatment goals. Analyses will be carried out on intention-to-treat basis. Concurrent qualitative methods will be used to explore the implementation processes.

Discussion

At the end of this study, information on the efficacy of the SDM programme in the primary care context will be available. In addition, processes that might interfere with or that might promote a successful implementation will be identified.

Trial registration

ISRCTN77300204.

[On the overestimation of the benefit of prevention]

BACKGROUND

Both pharmacological and non-pharmacological preventive interventions can do more harm than good. Health checks target a healthy or symptomless population. This is why randomised controlled trials (RCTs) must be conducted to provide high-quality evidence for the benefit of an intervention. The present article presents examples to demonstrate that the benefit of preventive interventions is usually overestimated.

METHODS

Standard screening criteria are used to critically appraise selected preventive interventions. Screening criteria cover the disease, the test, the treatment and the whole programme including evaluation and quality assurance. Type-2 diabetes mellitus is used as an example to discuss specific criteria for preventive interventions. The current state of the evidence is outlined. The article is based primarily on systematic / Cochrane reviews of RCTs.

RESULTS

A recent Cochrane review including 16 RCTs concluded that there is no benefit of general health checks. High-quality evidence on individual components of health checks is frequently missing or inconclusive. Over the last 30 years reference values for normal blood glucose and normal blood pressure as well as treatment targets for patients with type-2 diabetes mellitus and hypertension have been repeatedly decreased though this is not supported by evidence. Recent high-quality RCTs have shown that these "hit hard and early" interventions are detrimental, particularly to those who were the primary target group. Consequently, treatment targets have again been raised and recent guidelines recommend individualisation of treatment goals taking age and comorbidities into account. Important criteria for the implementation of preventive interventions are not currently met. With regard to type-2 diabetes uncertainties remain as to the clinical significance of pre-diabetes, the treatment of pre-diabetes and early treatment of diabetes, the screening tests, and target groups. The ADDITION study was unable to prove the benefit of a diabetes screening. Intensive lifestyle interventions may result in modest reductions of body weight and fewer diabetes diagnoses. However, the clinical relevance of the underlying metabolic changes is doubtful or even negligible. After almost 10 years, the Look AHEAD study has been terminated early due to the ineffectiveness of its intensive lifestyle interventions and the lack of hope that the study will succeed in demonstrating any benefit on the primary cardiovascular endpoints during the originally planned study period of another 3 years.

CONCLUSION

The benefit of prevention is overestimated whereas harm is underestimated. It is most unlikely that medical preventive interventions targeting individual behaviour changes will result in better health for our population.