Diabetes Care: Interventions in the Community

In the timely review by Renders et al. (1), phoning patients with reminders for follow-up visits is suggested as an intervention of possible value. In the studies quoted, this intervention had not been used in isolation. We recently completed a prospective study looking at the effectiveness of this single intervention in a primary care environment. We hypothesized that having a nurse call patients to remind them of their follow-up visit would be beneficial.

A total of 59 patients diagnosed with type 2 diabetes were recruited between July 1999 and January 2000 while attending outpatient diabetes teaching programs at the University of Alberta Hospitals. A nurse contacted the patients in the test group by telephone at 1, 3, 6, 9, and 12 months after attendance at the Metabolic Center to advise them of the need to attend follow-up visits with their family doctor at those intervals. Patients in the control group were not contacted or reminded of their need for follow-up visits with their physicians, other than a suggested follow-up visit at the time of discharge from the program. There was concern that obtaining information prospectively regarding how often patients in the control group visited their own physicians would undermine the control group. We obtained this information retrospectively. Patients were randomly allocated to either the test or the control group.

Subject characteristics were not significantly different between the two groups at study entry. The mean age in the control and experimental groups was 51.8 ± 12.2 and 54.2 ± 12.4 years, respectively. The duration of diabetes was 6.69 ± 8.5 and 4.21 ± 4.6 years in the control and experimental groups, respectively. In the control and experimental groups, 13.8 and 21.4% required insulin and 48.3 and 42.9% used oral hypoglycemic agents alone, respectively. The primary end point was glucose control as assessed by HbA_1c. Data are reported as the means ± SD. Student’s t test was used for statistical analysis, with a significance level set at P < 0.05.

In total, 57 subjects completed the study. Our research nurse was successful in contacting patients in the test group regarding their visit 95% of the time. Despite telephone reminders, only 9 of the 28 test group participants completed follow-up visits with their family physicians at all time points (i.e., 1, 3, 6, 9, and 12 months), a success rate of only 32%. A further seven test group patients completed at least half of the expected follow up visits. A retrospective analysis of the control group subjects’ attendance at their family doctor’s office (21 of 29 doctor’s offices responded to our query) indicated that the frequency of visits was not significantly different from that of the test group.

HbA_1c and lipid values were obtained for 85% of study participants at the study end. No significant difference was found between the HbA_1c or lipid values of the control and test groups. HbA_1c at entry was 7.6 ± 1.8 and 7.6 ± 1.8% for the control and test groups, respectively, and at 1 year, HbA_1c was 7.6 ± 1.8 and 7.5 ± 1.6%, respectively. Total cholesterol at entry was 5.16 ± 0.9 and 5.41 ± 1.3 mmol/l for the control and test groups, respectively, and at 1 year, it was 5.14 ± 1.0 and 5.06 ± 1.2 mmol/l, respectively. The relatively good lipid and HbA_1c values may have reduced our chance of seeing an effect.

The single intervention of providing telephone reminders did not significantly improve compliance, and there was no measurable improvement in diabetes care. Although it seemed reasonable to expect that reminding patients to see their physicians at recommended intervals would improve diabetic care, the study does not support this assumption. It is clear that more than simple telephone reminders are required.