Current guidelines on the management of gestational diabetes mellitus: a content analysis and appraisal
Mengxing Zhang, Yingfeng Zhou, Jie Zhong, Kairong Wang, Yan Ding, and Li Li
In this interview, Dr. Christian Göbl, the Associate Editor who guided peer review for this paper and accepted it for publication in BMC Pregnancy and Childbirth, has presented questions that highlight the most important and interesting aspects of this new paper.
Dr. Yingfeng Zhou has answered on behalf of all the authors.
In your recent publication, you aimed to evaluate the recommendations in current guidelines for the management of gestational diabetes mellitus. Could you briefly explain the motivation for your research and summarize the results of your study?
Gestational diabetes mellitus (GDM) is a very common disease in women of child-bearing age, especially in the context of the two-child policy in China. However, management of GDM seems to be unsatisfactory. Clinical nurses are still confused about how to care for women with GDM. After searching databases, we found that there were abundant international guidelines based on evidence. So we intended to adapt a guideline appropriate to the Chinese context based on the current guidelines for GDM. But it is still unknown the quality of methodology and contents of the current guidelines for management of GDM. First, we adopted the AGREE II instrument to measure the development methods of the guidelines. Nevertheless, practice guidelines with the best methodological quality were not necessarily the most valid in their recommendations. So we developed a “recommendation matrix” on the basis of the CAN-Implement© method as a more informative instrument to extract and evaluate the recommendations of the current guidelines. With this recommendation matrix, we evaluated the methodological quality of current guidelines, extracted recommendations with corresponding evidence for every question, and then evaluated the consistency of recommendation and evidence. Finally, we summarized the recommendations into five aspects: diagnosis of GDM, prenatal care, intrapartum care, neonatal care, and postpartum care. As to the consistency of guidelines, we found that current guidelines on GDM are of varied consistency, and guidelines developed in internationally recognized guideline development methodology showed better consistency.
How can clinicians judge the methodological quality of a guideline and decide whether the recommendations provided in guidelines are valid?
I think there are three points clinicians may consider. Firstly, the AGREE II instrument is a valuable tool when it comes to guideline assessment. As the manual notes, the AGREE instrument is a tool that assesses the methodological rigor and transparency in which a guideline is developed. It can help clinicians with a quick recognition of quality of a guideline. Secondly, clinicians should also read through “Evidence to recommendations,” which can help to understand how the recommendations were developed from the current evidence and to judge about whether the recommendation is credible. Lastly, whether the recommendation is applicable to the local clinical context is also very important.
Could you give us an explanation for the observed discrepancies in the consistency of GDM guidelines?
The result showed that current guidelines on GDM care were of varied consistency, and guidelines developed in internationally recognized guideline development methodology showed better consistency. It probably has something to do with reporting quality of guidelines. Some guidelines included do not even explain how the recommendations were developed, let alone search strategies, selection of evidence, and evidence interpretation. The review also revealed that transparency of evidence may be ignored when disseminating guidelines.
Do you have any suggestions to improve methodological quality and/or consistency of clinical practice guidelines?
Maybe there are two aspects we can do better: guidance for developing guidelines and reporting quality. Clinical Guideline is an effective tool for disseminating medical knowledge which helps clinicians with their decision-making. So the methodological quality of guidelines should be guaranteed. A guideline development manual can provide stepwise advice on the technical aspects of developing guidelines. So guideline development committees are strongly encouraged to make use of such manuals when drafting guidelines.Reporting quality of guidelines is also crucial when disseminating guidelines, since only if the guideline is well reported can readers use the recommendations confidently. So we do hope that reporting criteria be emphasized when guidelines are reported.
From a clinical perspective: Which aspects of GDM management (diagnosis of disease, prenatal care, intrapartum care, neonatal care, and postpartum care) showed the highest level of agreement (or disagreement) between the guidelines?
In our review, it is found that diagnosis of disease showed the highest level of agreement between the guidelines, which may be the result of the International Association of the Diabetes and Pregnancy Study Groups (IADPSG) (2010) criteria was adopted by more and more institutes. However, there are some discrepancies in treatment therapy, mainly regarding the priority of using oral hypoglycemic agents and insulin.
Dr. Yingfeng Zhou is an associate professor in School of Nursing, Fudan University. She is the deputy director of Fudan University Centre for Evidence-based Nursing: A Joanna Briggs Institute Centre of Excellence, which is the first evidence-based nursing research institute in mainland China, established in 2004.
Dr. Christian Göbl is head of the pregnancy outpatient department at the Medical University of Vienna. He has a research focus on metabolic disorders in pregnancy and has served as an Associate Editor for BMC Pregnancy and Childbirth since 2017.