The Implementation of guidelines in clinical practice : Benefits and challenges exemplified by international guidelines in Diabetes Mellitus in children

Abstract

Background: Diabetes mellitus is a group of chronic metabolic diseases characterized by high concentration of glucose in the blood. The most common form of diabetes among children and adolescents is type 1 diabetes (T1D). This is the second most common chronic disease acquired in childhood and adolescence, and the incidence is increasing globally. The disease is associated with autoimmunity and complications causing high morbidity and mortality. With the globalization, the need of international consensus is increasing in medicine. International and national guidelines are established for diagnostics, treatment and follow up of children with diabetes to optimize treatment and reduce complications. Guidelines are mainly worked out with reference to medicine in the western world. Aims: The aim of this study is to explore and discuss the challenges in implementing internationally agreed guidelines in clinical practice in two hospitals in USA and one in Norway. To assess this, we used established guidelines for diabetes; International Society of Pediatric and Adolescence Diabetes (ISPAD) and American Diabetes Association (ADA). Many aspects of these guidelines are transferable to other medical conditions as T1D is a chronic disease, acquired early in life, demanding lifelong treatment and with a potential risk of complications. Our thesis is part of a larger project where the aim is a comparison of strategies towards implementing internationally agreed guidelines in different countries. Our group of 12 students has been in different parts of the world. Methods: We made an electronic questionnaire based on the 2009 ISPAD's and ADA's guidelines. The questionnaire was designed to collect information about T1D in children less than 15 years of age. Health personnel were interviewed and the survey contains no personal identifiable data. We did our interviews at Children’s Hospital of Orange County (CHOC) in California, University of Minnesota Amplatz Children's hospital in Minneapolis and Ullevål University Hospital in Oslo. Results: Our results mainly refer to children younger than 18 years of age. Exclusive data from children less than 15 years were not available. All the hospitals we visited used guidelines in their clinics. At CHOC they used ADA's guidelines, in Minneapolis and Oslo ISPAD's guidelines were adhered to. There are discrepancies between the treatment goals in ISPAD's and ADA's guidelines. At CHOC the insulin treatment was not optimal according to the ADA recommendations of multi-injection therapy for all age groups, with a two-shot regimen for all children in school age, mainly due to practical and economic reasons. Discussion: Challenges in implementing guidelines are mainly economical and practical, also in the western part of the world. The challenges are probably even greater in countries where there is lack of high quality health facilities and resources, and a less well organized health care system for all. Conclusion: Guidelines are important tools in the diagnostics, treatment and follow up of patients with chronic diseases. They help to manage the disease in a standardized and consistent way according to the best international knowledge. However, local adjustments have to be made.