1998 clinical practice guidelines for the management of diabetes in Canada
Supplement to CMAJ 1998;159 (8 Suppl)
© 1998 Canadian Medical Association
Methods
After consultation with the Canadian Diabetes Advisory Board, the CDA's Clinical and Scientific Section, undertook the task of revising and updating the "Clinical practice guidelines for treatment of diabetes mellitus"9 with the intention of ensuring that the recommendations are evidence-based whenever possible. A Steering Committee was assembled and identified 4 broad areas of ambulatory diabetes care: organization of diabetes care; definition, classification, diagnosis and screening; management; and complications. It then recruited an Expert Committee made up of 37 key stakeholders that included people with diabetes, family physicians, dietitians and nurse educators, diabetologists and other subspecialists, and methodologists from across Canada. These people evaluated the literature and developed recommendations for each of the 4 broad areas.
The principles used for developing these guidelines, assigning levels of evidence to the relevant citations and making and grading recommendations were drawn from the guidelines literature10,11,12,13,14 and summarized in a series of documents for the Expert Committee. The system chosen for grading the recommendations is similar to that used to grade recommendations on hypertension and thrombosis10,11 and differed from that used to grade recommendations related to the periodic health examination.15
Key citations identified within each broad area were assigned a level of evidence based on the problem addressed and the design of the study (Table 1). Recommendations were developed and graded on the basis of these citations as well as the consensus opinion of the relevant subcommittee and the full Expert Committee (Table 2). Some recommendations were assigned a lower grade than supported by the evidence when the consensus opinion of the Expert Committee was that there was a need for further supportive evidence; recommendations were assigned a grade of "D" when they were based on the strong consensus opinion of the Expert Committee in the absence of clear supporting evidence or when evidence was weak. Before a final grade was assigned, all key citations and recommendations were reviewed by 3 methodologists, who were not directly involved in the initial assessment of evidence and the grading of the recommendations. Where appropriate, the assigned level of evidence and grade of recommendation were modified on the basis of their assessment.
Submissions were reviewed by the Steering Committee as they were being developed. In June 1997, a meeting of the full Expert Committee completed a working draft that was then circulated nationally and internationally for input from stakeholders and from experts in diabetes and related fields. This input was synthesized into a set of draft recommendations that were presented in a public forum at the 1997 CDA Professional Conference; input from this public forum was subsequently incorporated into this document.
Detailed discussions regarding the development and justification of each set of recommendations will be found in specific technical documents (in preparation). A summary of these discussions and recommendations is contained here.
