Gaps in Guidelines for the Management of Diabetes in Low- and Middle-Income Versus High-Income Countries-A Systematic Review

Abstract

Objective: The extent to which diabetes (DM) practice guidelines, often based on evidence from high-income countries (HIC), can be implemented to improve outcomes in low- and middle-income countries (LMIC) is a critical challenge. We carried out a systematic review to compare type 2 DM guidelines in individual LMIC versus HIC over the past decade to identify aspects that could be improved to facilitate implementation.

Research design and methods: Eligible guidelines were sought from online databases and websites of diabetes associations and ministries of health. Type 2 DM guidelines published between 2006 and 2016 with accessible full publications were included. Each of the 54 eligible guidelines was assessed for compliance with the Institute of Medicine (IOM) standards, coverage of the cardiovascular quadrangle (epidemiologic surveillance, prevention, acute care, and rehabilitation), translatability, and its target audiences.

Results: Most LMIC guidelines were inadequate in terms of applicability, clarity, and dissemination plan as well as socioeconomic and ethical-legal contextualization. LMIC guidelines targeted mainly health care providers, with only a few including patients (7%), payers (11%), and policy makers (18%) as their target audiences. Compared with HIC guidelines, the spectrum of DM clinical care addressed by LMIC guidelines was narrow. Most guidelines from the LMIC complied with less than half of the IOM standards, with 12% of the LMIC guidelines satisfying at least four IOM criteria as opposed to 60% of the HIC guidelines (P < 0.001).

Conclusions: A new approach to the contextualization, content development, and delivery of LMIC guidelines is needed to improve outcomes.

Figure 1

Distribution of target audience stated in LMIC and HIC DM guidelines. Each guideline was assessed for target audiences as stated in the guidelines text, with none assumed if the intended audience was not stated by the guideline.

Figure 2

Spectrum of DM care addressed by DM guidelines. Each guideline was assessed with respect to surveillance, prevention, diabetes emergencies (diabetic ketoacidosis, hyperosmolar hyperglycemic state, and hypoglycemia), special care (glucose control during acute hospital admission for nonglucose issues, e.g., intensive care unit, surgeries, pregnancy, and Ramadan), cardiovascular (CV) comorbidities (hypertension, dyslipidemia, and obesity), and noncardiovascular comorbidities (e.g., diabetic foot, retinopathy, etc.).

Figure 3

Translatability, ethical, legal, and socioeconomic considerations. A guideline was judged to have ethical, legal, social, and psychological considerations when information concerning ethical dilemmas, DM-related legal issues, the impact of diabetes on daily routines and relationships, and psychological issues were explicitly stated. A guideline was deemed translatable when solutions were categorized according to the ease of successful implementation.

Figure 4

Profiles of IOM component and total scores for LMIC and HIC guidelines. Each guideline was assessed for compliance with the IOM standards for developing clinical practice guidelines. A point was awarded for each standard satisfied, and the total score for each guideline was computed. Univariate analysis was carried out to assess income class differences. Individual IOM components are indicated on the horizontal axis. Proportion of IOM standard and mean total score are reported.