Critical Appraisal Of Clinical Practice Guidelines On The Management Of Diabetic Foot Ulcer: Still A Controversy

Objective: Despite the availability of clinical practice guidelines(CPGs),achieving optimal diabetic wound control is a major challenge in many parts of the world;the prime cause being their variable quality.This study aimed to systematically evaluate the quality of CPGs and compare their recommendations for managing diabetic foot ulcer(DFU)to facilitate health care provider make solid clinical decisions in time.Methods: Electronic databases were searched for CPGs written in English on the management of DFU,published between January 2006 and December 2016.We included six guidelines obtained from literature selection process.Two raters independently appraised each CPG using the Appraisal Guidelines Research and Evaluation II(AGREE-II)tool and the Institute of Medicine(IOM)criteria and using a novel method,we combined both AGREE-II and IOM criteria to evaluate the overall quality of the selected guidelines.In addition,we further evaluated the consistency or nonconformity of the recommendations on the management of DFU.Conflicts were resolved by mutual discussion or involving a third reviewer.Results: Based on the AGREE-II,none of the selected guidelines stoodsatisfactory in all domains.Nevertheless,the National Institute for Health and Clinical Excellence(NICE)guideline demonstrated higher scores compared to other guidelines in IOM criteria and hence recommended for clinical use.Regarding the content of the CPGs,considerable differences in DFU management recommendations arose.These variances resulted from evidence interpretation bias,different composition of the guidelines' development groups and omission of the guidelines for updating,and externally reviewing the recommendations.Conclusions: Most of the selected CPGs among different organizations were poor in quality,and remarkable differences exist while recommending the same clinical topic.Therefore,in order to establish a dependable guideline,preparation in accordance with the AGREE-II and IOM criteria is necessary.