FormalPara To the Editor:

Dr R. Kahn recently wrote a Commentary in Diabetologia regarding the need to improve clinical guidelines [1]. We would like to highlight some practical and readily available ways of overcoming many of the problems raised by Kahn in his excellent paper.

The Finnish Current Care Guideline for diabetes (FCCD) [2] was published in 2007 and is authorised by the Finnish Medical Society Duodecim and the Finnish Society of Internal Medicine. The guideline treats the timing of the clinical decision for intervention as the main priority. Several approaches have been used.

FormalPara Publication

Only a browser-operated online version of the FCCD is available, which offers several benefits. Online publication facilitates both the actual update process and enables a quick response to changes (e.g. withdrawal of a drug from the market). Most importantly, however, online publication ensures that all healthcare professionals have the latest version of the guideline at their disposal. In addition, it means that the guideline is readily available at the physician’s office.

As an electronic document, the table of contents in the FCCD is linked to the corresponding section of the guideline so that readers can quickly locate the subject of interest. Each statement in the text is hyperlinked to a summary of supporting evidence and is graded by the level of evidence. The actual guideline is published in Finnish, but a summary is available in English [3].

FormalPara Interactivity and personalisation

Kahn raised important questions regarding personalised treatment and target setting as, in general, guidelines deal poorly with these issues. Guidelines on these were provided in the second update of the FCCD in 2009, after results from the Action to Control Cardiovascular Risk in Diabetes (ACCORD, [4]) study, the Veterans Affairs Diabetes Trial (VADT, [5]) and Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified-Release Controlled Evaluation (ADVANCE, [6]) study were published. These studies emphasised the need for individual goal setting and treatment. The problem with most evidence-based guidelines is that they only deal with the average patient, without recognizing specific clinical features of the patient. In real life, however, many patients do not fit these criteria, and guidelines for these all too many outliers are lacking. The FCCD contains an interactive algorithm (an English version of which is available [7]) that allows you to select the main feature of the clinical condition of the patient.

The FCCD includes six common clinical features, out of which the clinician is able to easily choose the one that most closely describes his patient. The selected situations/features are ‘early diabetes’, ‘chronic diabetes (>10 years)’, ‘morbid obesity (BMI >30 kg/m2)’, ‘elderly patient’, ‘transport occupation’ and ‘impaired kidney function’. The algorithm changes according to the chosen clinical feature to optimise the medical intervention and the goal. Within the algorithm the FCCD has a balanced strengths–weaknesses analysis for each drug class and even more detailed stratification of the clinical suitability of the selected therapy (Fig. 1).

Fig. 1
figure 1

Illustration of the strengths–weaknesses analysis of the FCCD using metformin as an example. Published with permission from the Finnish Medical Society Duodecim [2]

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