Adherence to Canadian Diabetes Association Clinical Practice Guidelines: DISCUSSION

30 Nov

guideline adherence

At least 63% of the patients in this study had initial monitoring parameters measured; however, achieve­ment of follow-up monitoring was much lower. The hemoglobin AK target was achieved for 93% of the patients, but less than 45% of patients achieved other laboratory targets. Less than 60% of eligible patients received recommended medications.
Much controversy surrounds the use of CPGs. Some guidelines do not adhere well to established method- ologic standards, and the 2003 CPGs of the CDA in particular have been criticized for possible financial conflicts of interest. Despite this criticism, these guidelines were used as the basis for the study reported here because they represent the current standard for management of diabetes in Canada.

The results reported here concur with previous Canadian studies that evaluated adherence to recommendations for monitoring frequency, laboratory targets, and medication use set out in the 1992 and 1998 versions of the CDA guidelines, as well as a large US study measuring comparable outcomes.

It was also of interest to determine how patients at the Lions Gate Diabetes Education Centre fared relative to the general population of patients with diabetes in British Columbia. As part of the BC Ministry of Health’s Chronic Disease Management Initiative, the frequency of claims to the Medical Services Plan is reviewed yearly for patients with diabetes. The most recent results of this review (2002/2003) indicate that achievement of provincially recommended monitoring frequencies was variable: 39% for hemoglobin Аю, 78% for lipid profile, 34% for urinary albumin to creatinine ratio, and 43% for eye examination. Although the provincially recommended monitoring frequencies were not specifically measured for the purposes of this study, the comparable monitoring frequencies recommended by the CDA were achieved for 62%, 81%, 47%, and 63% of the patients in this study, respectively. Therefore, although the BC Chronic Disease Management Initiative methodology has not been formally published, it appears that provincially recommended monitoring frequencies were achieved for a greater proportion of patients attending the Lions Gate Diabetes Education Centre than was the case for the general population of patients with diabetes in the province.

Another relevant finding is that the majority of suboptimal results pertained to undermanagement of cardiovascular risk factors. Cardiovascular disease is the primary cause of death among patients with diabetes. In the assessment reported here, one-third or fewer of the patients met targets for blood pressure (21%) and lipids (33% for LDL cholesterol, 34% for ratio of total to LDL cholesterol), and fewer than half of eligible patients were receiving antihypertensive agents (45%), statins (25%), or acetylsalicylic acid (26%). These rates of antihypertensive, statin, and acetylsalicylic acid use are similar to those reported in other Canadian diabetes studies. Of particular interest, all 3 of these classes of medications were used less frequently than antihyperglycemics. This finding is in concordance with the findings of Shah and others and supports the conclusion of those authors that preventive care for patients with diabetes may be too focused on glycemic control and that the management of other cardiovascular risk factors may be neglected.