Response to Shandro et al.

We read with interest the letter from Shandro et al. (1) in this issue of Diabetes Care. In our systematic review, in which we reviewed the effectiveness of interventions targeted at health care professionals and/or the structure of care to improve the management of diabetes in primary care, outpatient, and community settings, only a few of the studies that were included sent reminders to patients for follow-up visits. In these studies, this intervention was usually combined with other interventions. Consequently, the effectiveness of this single intervention was difficult to assess.

The only study in which sending reminders to patients was used as a single intervention was the study carried out by Halbert et al. (2). In that study, the intervention affected process measures only in the short term. Its effectiveness on patient outcomes was not assessed.

The other studies included in the review investigated the effectiveness of multifaceted interventions, and sending reminders to patients for follow-up visits was combined with other professional or organizational interventions, or with patient education. These multifaceted interventions improved the process of care, and if they were combined with patient education or the enhancement of the role of nurses in diabetes care, they also resulted in improvements in patient outcomes.

Shandro et al. conclude in their study that simple telephone reminders are not enough to improve diabetes care. This supports the conclusion of our review that multifaceted interventions that facilitate structured and regular review of patients are effective in improving the process of diabetes care. In studies on the effectiveness of multifaceted interventions, little effort has been made to disentangle the effects of the various components. However, it seems that only a combination of different elements is effective in improving diabetes care, but which specific combination is the most effective is not clear. The addition of patient education or a nurse to multifaceted interventions aimed at facilitating structured care seems to be of important additional value in improving patient outcomes as well as the process of care (3).