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Australian and International Guidelines – their history and development

This is the first article in the “DFA Guides You Through” series on Australian and International diabetic foot disease guidelines. The next article provides an overview of both guidelines.

In 2011, the Australian National Evidence-Based Guideline “Prevention, Identification and Management of Foot Complications in Diabetes” was published. This guideline updated and replaced a foot-related chapter in the 2005 general diabetes management guidelines, and as such was the first standalone guideline completely dedicated to diabetic foot disease in Australia.

The Australian guidelines were written by three organisations experienced in guideline development, with clinical guideline input from a foot expert panel, guidelines advisory committee, and an online survey including various health professionals. For these guidelines, the literature up to 10 December 2009 was searched, based on seven research questions. The full methodology and all answers to these questions can be found in an impressively extensive (1777 pages) technical report. Using these literature search findings and following the NHMRC Grading method, 11 expert opinion and 14 evidence-based recommendations were formulated. The 25 recommendations are described in sections B-D of the Australian guidelines, preceded by an introductory chapter, and followed by chapters on research and implementation.

It is advised in the guidelines to “fully review and update them within five years”. However, the literature search is now more than 6 years old, and to our knowledge a new process has yet to be started. This makes comparison with the IWGDF guidelines published in 2015 a useful undertaking for this “DFA guides you through” series.

The International Working Group on the Diabetic Foot (IWGDF) was founded in 1996. With the absence at that time of any guideline on diabetic foot disease anywhere in the world, a group of experts decided to produce an expert opinion document with practical guidelines for the prevention and management of diabetic foot disease. This resulted in the first IWGDF guidelines, published in 1999. This document has since been updated every four years, with improvements in the methodological process accompanying each update. The fifth version of the “IWGDF Guidance on the Prevention and Management of Foot Problems in Diabetes” was published in May 2015.

Contrary to the Australian guidelines, which involves professional guideline developing institutes, the IWGDF Guidance was written solely by experts in the clinical and research field of diabetic foot disease. The 2015 Guidance is based on seven systematic reviews, following literature searches in July 2014. Five working groups of 7-10 international experts formulated recommendations following the GRADE system. Both the systematic reviews and recommendations were reviewed by the editorial board, and by over 100 international IWGDF members. An article describing the IWGDF methods can be found here.

The IWGDF Guidance boils down to a total of 77 recommendations, described in five different chapters. Each recommendation is graded as “strong” or “weak” to indicate the strength with which it is made. The quality of the evidence upon which the recommendation is based is graded as “high”, “moderate”, or “low”. Descriptions as to how the working groups came to these recommendations are given in each chapter.

The next update of the IWGDF Guidance will be published in May 2019, with the first steps of this process being undertaken.

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