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Canadian Pharmacists Association
Canadian Pharmacists Association
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Chapter 1: Introduction

Canadian Diabetes Association 2013 Clinical Practice Guidelines

  • Every 5 years, the Canadian Diabetes Association (CDA) publishes comprehensive evidence-based clinical practice guidelines (CPGs) for health care professionals, which provide recommendations regarding the screening, diagnosis, prevention, education, and ongoing management of type 1 and 2 diabetes.
  • The CDA CPGs are regarded in Canada and abroad as being among the best in the world with respect to quality, rigour and process.
The Challenge of Diabetes
  • In Canada alone, it is estimated that 2.4 million people (6.8% of the population) are living with diabetes (as of 2009). This number is expected to grow to 3.7 million by 2019.
  • Diabetes is the leading cause of blindness, end-stage renal disease, and non-traumatic amputation in Canada. It is also associated with cardiovascular disease (CVD), which is 2- to 4-fold more prevalent in those with diabetes and is the leading cause of death worldwide.
  • Over 6 million Canadians* currently live with prediabetes, which places them at increased risk for progression to diabetes, especially if lifestyle changes and aggressive management are not initiated promptly (see More Canadians than ever before now at risk).
  • Early recognition of prediabetes and associated risk factors is important to prevent the onset of diabetes and minimize complications.
Delaying the Onset of Type 2 Diabetes
  • There is good evidence that delaying the onset of type 2 diabetes results in significant health benefits, including lower rates of CVD and renal failure.
  • There is an urgent need for governments to invest in research and define effective strategies and programs to prevent and treat obesity and to encourage physical activity.
  • Some ethnic groups are disproportionally affected by diabetes. Health promotion and disease prevention/management strategies should both be culturally appropriate and tailored to specific populations.
Optimal Care of Diabetes
  • Diabetes care should be delivered within the framework of the Chronic Care Model and centred around the individual who is practicing, and supported in, self-management.
  • An interprofessional team with appropriate expertise is required, and the system needs to support and allow for sharing and collaboration between primary care and specialist care as needed.
  • A multifactorial approach addressing healthy behaviours, glycemic control, blood pressure control, lipid management and vascular protection measures has been shown to effectively and dramatically lower the risk of development and progression of serious complications for individuals with diabetes.
  • People with diabetes require training in goal setting, problem solving and health monitoring, all of which are critical components of self-management. They also need access to a broad range of tools, including medications, devices and supplies to help them achieve the recommended blood glucose, cholesterol and blood pressure targets.
Research
  • Regulatory agencies should not apply the CPGs in a rigid way with regard to clinical research in diabetes. It is suggested that study protocols may include guideline recommendations, but individual decisions belong in the domain of the patient-physician relationship.
Cost Considerations
  • In 2009, the CDA commissioned a report to evaluate the economic burden of diabetes and estimated it to be $12.2 billion in 2010 and projected to increase by another $4.7 billion by 2020.
  • These CPGs, like those published before, have purposefully not taken into account cost effectiveness in the evaluation of the evidence surrounding best practice.
  • Drug costs are, however, included in Appendix 5, allowing for easy reference for both clinicians and patients alike.
Other Considerations
  • The American Diabetes Association, the European Association for the Study of Diabetes, and IDF released a consensus statement in 2007 regarding the shift to dual reporting of A1C with the IFCC’s SI units (mmol/mol) and NGSP units (%), with the hope of eventually phasing out the use of NGSP units (%).
  • At this time, dual reporting has not been implemented in Canada, so NGSP units are still used. For readers who wish to convert units, the conversion factor for NGSP units to SI units is: IFCC = 10.93(NGSP) – 23.50.
Dissemination and Implementation
  • A Dissemination & Implementation Committee is involved in creating a 3-year plan to translate the evidence compiled in the guidelines into community practice.
Clinical Practice Guidelines and Clinical Judgement
  • People with diabetes are a diverse and heterogeneous group; therefore, it must be emphasized that treatment decisions need to be individualized.
  • Guidelines are meant to aid in decision making by providing recommendations that are informed by the best available evidence. However, therapeutic decisions are made at the level of the relationship between the healthcare professional and the patient.
  • Evidence-based guidelines try to weigh the benefit and harm of various treatments; however, patient preferences are not always included in clinical research. Therefore, patient values and preferences must be incorporated into clinical decision making.
  • Clinical practice guidelines are not intended to be a legal resource in malpractice cases as outlined in the Canadian Medical Association Handbook on Clinical Practice Guidelines.
Conclusions
  • The hope is that these guidelines will provide government officials with the evidence they need when rationalizing access to health care so that the potentially beneficial health outcomes are maximized for people living with diabetes.
  • Healthcare professionals are encouraged to judge independently the value of the diagnostic, prognostic and therapeutic recommendations contained in the CPGs.

If you would like more details on this topic, including references, please visit the Canadian Diabetes Association Clinical Practice Guidelines: Chapter 1.