Quality of Clinical Practice Guidelines for Diabetic Foot Management: A Systematic Review Using the AGREE II and AGREE-REX Instruments

Objective: To evaluate the methodological quality and the excellence of recommendations in clinical practice guidelines (CPGs) for diabetic foot ulcer (DFU) management, and to synthesize their clinical treatment recommendations. Methods: A systematic search of PubMed, EMBASE, Web of Science, and guideline databases was conducted to identify DFU guidelines published between January 1, 2015, and May 1, 2025. The quality of included guidelines was appraised by reviewers using the AGREE II and AGREE-REX instruments. Domain scores are presented as median (interquartile range). Recommendations for DFU clinical treatment were synthesized, and the supporting evidence was graded using the OCEBM system. Results: Fifteen CPGs were included (6high-quality, 9moderate-quality). The highest AGREE II domain score was for Editorial Independence (100.00% 97.22– 100.00%), followed by Scope and Purpose (96.30% 88.89– 100.00%), Clarity of Presentation (96.30% 92.59– 100.00%), Rigor of Development (75.69% 41.67– 93.06%), and Stakeholder Involvement (74.07% 62.96– 83.33%). The lowest scoring domain was Applicability (52.78% 36.11– 59.72%). The lowest AGREE-REX score was for Values and Preferences (47.22% 43.06– 52.78%), while Clinical Applicability (79.63% 66.67– 81.48%) and Implementability (77.78% 72.22– 80.56%) scored respectably. Seventeen key DFU treatment recommendations were synthesized, mostly Grade B recommendations supported by moderate-quality evidence. Conclusion: Existing DFU guidelines are developed using systematic methods but show limitations in applicability, stakeholder involvement, and rigor of development. The quality of recommendations is inconsistent, with notably low scores in the domain of values and preferences. Enhancing these aspects and improving the underlying evidence quality are crucial strategies for future guideline development and implementation. Keywords: diabetic foot ulcer, clinical practice guidelines, AGREE II, AGREE-REX, systematic review