Resumen Ejecutivo: Guía de Práctica Clínica Retinopatía Diabética 2017

Objectives

The guideline aims to generate recommendations, based on the best available evidence, for managing people with diabetic retinopathy. It applies to people receiving primary- or secondary-level care in Chile’s public or private health sectors and is intended for health professionals responsible for their care.[1]Its priority clinical areas include retinal panphotocoagulation, anti-angiogenic treatment, optical coherence tomography, and management of clinically significant macular oedema.[2][1]

• Develop recommendations through the GRADE, or Grading of Recommendations Assessment, Development, and Evaluation, system after prioritising clinical questions, synthesising evidence, and considering patient values and preferences, implementation feasibility, resource use, and costs.[3]
• Classify recommendations as strong or conditional, for or against an intervention, while identifying some standards as good clinical practice recommendations.[4]
• Assess certainty of evidence as high, moderate, low, or very low.[5]
• Support retinal panphotocoagulation combined with anti-angiogenic treatment, rather than panphotocoagulation alone, for high-risk proliferative diabetic retinopathy.[2]
• Use anti-angiogenic treatment rather than macular laser grid treatment for clinically significant macular oedema, supported by a strong recommendation based on high-certainty evidence.[1]
• Consider retinal panphotocoagulation rather than clinical follow-up for selected people with type 2 diabetes and severe non-proliferative retinopathy, including people who may struggle to maintain follow-up, those with some chronic kidney disease, pregnant people, or people with proliferative retinopathy in the other eye.[2][1]

Implementation

The guideline uses a structured, multidisciplinary evidence-to-recommendation model. A thematic co-ordinator, methodological advisers, evidence-search and synthesis leads, and an expert panel contribute to development, while the panel considers research evidence alongside clinical or personal experience, patient preferences, feasibility, resources, and costs.[1][3]Recommendation development begins by assessing whether recommendations in the previous diabetic retinopathy guideline remain current, then updating them through prioritised questions and evidence synthesis.[1]

• Convene an expert panel involving clinicians and representatives of the Ministry of Health and National Health Fund, and involve patients where possible.[1]
• Define priority questions by specifying the population, intervention, and comparison through the expert panel, thematic co-ordinator, and methodological advisers.[1][3]
• Rank potential questions through a survey of panel members and select those with the highest average scores.[1][3]
• Search for and synthesise evidence on desirable and undesirable effects, patient values and preferences, intervention costs, and cost-effectiveness before formulating recommendations.[3]
• Consider outcomes including mortality, days of hospitalisation, and quality of life alongside expert clinical or personal experience.[3]
• Interpret conditional recommendations by considering the supporting evidence and discussing options in line with individual patient values and preferences.[4]
• Select the specific anti-angiogenic agent for high-risk proliferative diabetic retinopathy through discussion between the clinician and patient, taking available resources into account.[2]
• Consider depot intravitreal corticosteroids as an additional treatment option where relevant.[2][1]
• Maintain currency through a notification platform that periodically identifies relevant systematic reviews and primary studies addressing guideline questions, incorporating relevant new evidence into the synthesis and potentially modifying recommendations.[3][4]
• Adjust evidence-certainty assessments for study limitations, inconsistency, indirectness, imprecision, publication or reporting bias, strong associations, dose-response gradients, and residual confounding.[5]
• Recognise that the source does not specify quantitative implementation indicators, reporting schedules, implementation targets, audit mechanisms, surveillance arrangements, or named accountability bodies beyond the expert panel and evidence-notification platform.[2][1][3]
• Recognise that the source does not specify budgets, financing sources, funding gaps, monetary allocations, or economic assumptions, although resource use, costs, cost-effectiveness, and feasibility form part of deliberations.[3]

Monitoring & Evaluation

The guideline development and updating process is centred on the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) system, which structures the formulation of recommendations after clinical questions have been prioritised and evidence has been synthesised.[1][3]Recommendations are classified as strong or conditional, either for or against an intervention, while some standards may be designated as good clinical practice recommendations.[4]Evidence certainty is assessed as high, moderate, low, or very low.[5]

• Review whether recommendations in the preceding diabetic retinopathy guideline remain current before undertaking updates.[1]
• Prioritise questions through an expert-panel process that defines the population, intervention and comparison and ranks candidate questions through a panel-member survey.[1][3]
• Search and synthesise evidence on beneficial and harmful effects, patient values and preferences, costs, cost-effectiveness and implementation considerations before recommendations are formulated.[3]
• Apply explicit recommendation strength and evidence-certainty ratings, including conditional recommendations based on moderate- or low-certainty evidence and a strong recommendation supported by high-certainty evidence for anti-angiogenic treatment rather than macular laser grid treatment for clinically significant macular oedema.[2][1]
• Interpret conditional recommendations through consideration of the supporting evidence and discussion of options that reflect individual patient values and preferences.[4]
• Assess and, where appropriate, adjust initial evidence-certainty ratings for study limitations, inconsistency, indirectness, imprecision, publication or reporting bias, strong associations, dose-response gradients and residual confounding.[5]
• Maintain the currency of recommendations through a notification platform that periodically identifies relevant systematic reviews and primary studies addressing guideline questions.[3]
• Incorporate relevant newly published evidence into evidence syntheses and modify recommendations when warranted.[4]

The source does not specify quantitative implementation indicators, outcome targets, routine service-performance measures, reporting schedules, surveillance systems, audit requirements, or formal accountability mechanisms.[2][1][3]The expert panel and evidence-notification platform are identified as elements of the development and update process, but no additional named body is assigned responsibility for implementation monitoring or public reporting.[3]

Costing & Financing

Economic and resource considerations are incorporated into recommendation development rather than presented as a separate budgeted implementation plan. Evidence searches and syntheses include intervention costs and cost-effectiveness, and the expert panel considers resource use, costs and implementation feasibility alongside clinical effects and patient values and preferences.[3]

• Consider the availability of resources when selecting an anti-angiogenic treatment for high-risk proliferative diabetic retinopathy, with the specific agent determined jointly in light of clinician judgement, patient considerations and available resources.[2][1]
• Consider depot intravitreal corticosteroids as an additional treatment option in the relevant clinical context.[2][1]
• Incorporate evidence on intervention costs and cost-effectiveness into the evidence base used by the panel to formulate recommendations.[3]
• Assess implementation feasibility and resource use during panel deliberations on clinical recommendations.[3]

The source does not specify monetary costs, programme budgets, budget allocations, financing sources, funding gaps, resource-mobilisation arrangements, reimbursement mechanisms, or economic assumptions.[2][1][3]No explicit costed activities, funding periods, currencies or financial targets are provided.[3]