Email updates

Keep up to date with the latest news and content from BMC Health Services Research and BioMed Central.

Open Access Research article

Guidelines adherence in the treatment of patients with newly diagnosed type 2 diabetes: a historical cohort comparing the use of metformin in Quebec pre and post-Canadian Diabetes Association guidelines

Ting-Yu Wang123*, Tewodros Eguale3 and Robyn Tamblyn13

Author Affiliations

1 Department of Medicine, McGill University, Montreal, Quebec, Canada

2 Department of Endocrinology, McGill University, Montreal, Quebec, Canada

3 Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada

For all author emails, please log on.

BMC Health Services Research 2013, 13:442  doi:10.1186/1472-6963-13-442

Published: 25 October 2013



Given the high prevalence of diabetes, guidelines are updated frequently to reflect optimal treatment recommendations. Our study aims to measure the response of primary care physicians to changes in choice of initial therapy for patients with type 2 diabetes in relationship to a change in Canadian Diabetes Association (CDA) Guidelines in 2008. We also assessed patients’ and physicians’ factors which may affect this change.


Historical cohort study of primary care physicians’ participating in an electronic medical record research network in Quebec, Canada. 111 primary care physicians and 1279 newly treated patients with diabetes with a prescription of an oral hypoglycemic agent (OHA) between January 20 2003 and December 29 2011 were included. Multivariate GEE logistic regression was used to estimate the impact of guideline change on treatment choice controlling for patients’ and physicians’ characteristics.


After the new CDA guidelines, there was an increase in incident use of metformin from 89.7% to 94.6% (OR 1.86, 95% CI 1.20-2.90) with an accompanying reduction in the use of thiazolidinediones (OR 0.21, 95% CI 0.08-0.55), and reduction in the initiation of sulfonylureas (OR 0.78, 95% CI 0.43-1.09). Physicians’ attitudes to evidence-based practice did not significantly modify response to a change in guidelines recommendations. However, older patients and those with renal failure were less likely to receive metformin.


Metformin initiation in newly diagnosed diabetes patients has increased post 2008 CDA guidelines. However, due to the nature of the study design, we can not determine whether the observed change in metformin prescribing was causally related to the change in the guideline.

Type 2 diabetes; Metformin; Guidelines adherence; Medical informatics