title: Printed educational messages aimed at family practitioners fail to increase retinal screening among their patients with diabetes: a pragmatic cluster randomized controlled trial [ISRCTN72772651].
abstract: BACKGROUND
  Evidence of the effectiveness of printed educational messages in narrowing the gap between guideline recommendations and practice is contradictory. Failure to screen for retinopathy exposes primary care patients with diabetes to risk of eye complications. Screening is initiated by referral from family practitioners but adherence to guidelines is suboptimal. We aimed to evaluate the ability of printed educational messages aimed at family doctors to increase retinal screening of primary care patients with diabetes.
  
  
  METHODS
  Design: Pragmatic 2×3 factorial cluster trial randomized by physician practice, involving 5,048 general practitioners (with 179,833 patients with diabetes). Setting: Ontario family practitioners. Interventions: Reminders (that retinal screening helps prevent diabetes-related vision loss and is covered by provincial health insurance for patients with diabetes) with prompts to encourage screening were mailed to each physician in conjunction with a widely-read professional newsletter. Alternative printed materials formats were an 'outsert' (short, directive message stapled to the outside of the newsletter), and/or a two-page, evidence-based article ('insert') and a pre-printed sticky note reminder for patients. Main Outcome Measure: A successful outcome was an eye examination (which includes retinal screening) provided to a patient with diabetes, not screened in the previous 12 months, within 90 days after visiting a family practitioner. Analysis accounted for clustering of doctors within practice groups.
  
  
  RESULTS
  No intervention effect was detected (eye exam rates were 31.6% for patients of control physicians, 31.3% for the insert, 32.8% for the outsert, 32.3% for those who received both, and 31.2% for those who received both plus the patient reminder with the largest 95% confidence interval around any effect extending from -1.3% to 1.1%).
  
  
  CONCLUSIONS
  This large trial conclusively failed to demonstrate any impact of printed educational messages on screening uptake. Despite their low cost, printed educational messages should not be routinely used in attempting to close evidence-practice gaps relating to diabetic retinopathy screening.
  
  
  BACKGROUND
  ISRCTN72772651.
authors.affiliation: Centre for Studies in Family Medicine, Department of Family Medicine, Schulich School of Medicine and Dentistry, Western University, 1465 Richmond Street, London, Ontario N6A 3K7, Canada. merrick.zwarenstein@ices.on.ca.
authors.forename: Merrick
authors.initials: M
authors.lastname: Zwarenstein
authors.forename: Susan K
authors.initials: SK
authors.lastname: Shiller
authors.forename: Ruth
authors.initials: R
authors.lastname: Croxford
authors.forename: Jeremy M
authors.initials: JM
authors.lastname: Grimshaw
authors.forename: Diane
authors.initials: D
authors.lastname: Kelsall
authors.forename: J Michael
authors.initials: JM
authors.lastname: Paterson
authors.forename: Andreas
authors.initials: A
authors.lastname: Laupacis
authors.forename: Peter C
authors.initials: PC
authors.lastname: Austin
authors.forename: Karen
authors.initials: K
authors.lastname: Tu
authors.forename: Lingsong
authors.initials: L
authors.lastname: Yun
authors.forename: Janet E
authors.initials: JE
authors.lastname: Hux
mesh_terms: D000368:Aged; D003930:Diabetic Retinopathy / Q000175:diagnosis*; D004502:Education, Medical, Continuing / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D008403:Mass Screening / Q000379:methods / Q000706:statistics & numerical data; D008875:Middle Aged; D010821:Physicians, Family / Q000193:education* / Q000706:statistics & numerical data; D015397:Program Evaluation
references.citation: Lancet. 1997 Jul 19;350(9072):197-204
references.pmid: 9250197
references.citation: Cochrane Database Syst Rev. 2000;(2):CD000172
references.pmid: 10796502
references.citation: Can J Cardiol. 2001 Jan;17(1):33-40
references.pmid: 11173312
references.citation: Cochrane Database Syst Rev. 2008 Jul 16;(3):CD004398
references.pmid: 18646106
references.citation: J Chronic Dis. 1967 Aug;20(8):637-48
references.pmid: 4860352
references.citation: Health Technol Assess. 2004 Feb;8(6):iii-iv, 1-72
references.pmid: 14960256
references.citation: Implement Sci. 2014 Aug 06;9:86
references.pmid: 25098442
references.citation: Neurology. 2000 May 23;54(10):1899-906
references.pmid: 10822426
references.citation: CMAJ. 1998;159 Suppl 8:S1-29
references.pmid: 9834731
references.citation: Cochrane Database Syst Rev. 2012 Oct 17;10:CD004398
references.pmid: 23076904
references.citation: Ann Fam Med. 2005 Nov-Dec;3(6):545-52
references.pmid: 16338919
references.citation: Annu Rev Public Health. 1991;12:41-65
references.pmid: 2049143
references.citation: Am J Ophthalmol. 1976 Apr;81(4):383-96
references.pmid: 944535
references.citation: Implement Sci. 2007 Nov 26;2:37
references.pmid: 18039361
references.citation: N Engl J Med. 2003 Jun 26;348(26):2635-45
references.pmid: 12826639
references.citation: Clin Trials. 2005;2(2):99-107
references.pmid: 16279131
references.citation: Diabetes Care. 2002 Mar;25(3):512-6
references.pmid: 11874939