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Printed Educational Messages to Promote Retinal Screening Not Effective

Aug 23, 2014

In a Canadian study, printed educational messages (PEMs) aimed at family practitioners were not effective in promoting retinal screening among diabetes patients….

Diabetic retinopathy is a common complication of diabetes, and it is the leading cause of preventable blindness in people aged 30 to 69. Even though early detection and treatment of diabetic retinopathy can decrease the risk of vision loss by 90% and Canadians who live in Ontario can receive free eye examination, the rate of retinal screening in Ontario is still only around 43% to 50%. Printed educational messages (PEMs) sent to family practitioners are normally used as a cost-effective way to promote retinal screening in diabetes patients. Nonetheless, previous studies indicated that the effectiveness of PEMs is contradictory.


According to Zwarenstein et al., sending PEMs to family practitioners might not be an effective way to promote retinal screening among diabetes patients. This was a pragmatic, factorial, cluster-randomized controlled trial involving 5,048 active family practitioners with 179,833 diabetes patients in Ontario during 2003 and 2004. Family practitioners would be randomly assigned to receive either a reminder (that retinal screening can help prevent vision loss caused by diabetes and is covered by health insurance), an outsert (which contained short, directive message) or an insert (which contained directive message plus background information and evidence-based guidelines) along with a professional newsletter. The primary outcome measure was whether or not an eligible patient received an eye exam within 90 days of their doctor visit during the one-year period following the PEMs mail-out.

After one year of follow-up, "neither the adjusted nor the unadjusted results show any evidence that the interventions (alone or in combination) were effective in increasing rates of eye examination among eligible trial patients." The P-value for unadjusted intervention was 0.97, and for adjusted intervention was 0.66. In addition, the rate of eye exam for patient of control physicians was 31.6%, for insert was 31.3%, for outsert was 32.8%, for both insert and outsert was 32.3% and for insert + outsert + reminder was 31.2%.

Based on the results, it was reasonable to say that PEMs were not effective in improving practitioners" knowledge about retinal screening and free eye exams for diabetes patients as well as influencing the transmission of this message to diabetes patients. Possible reasons for low retinal screening rates could be: the practitioners did recommend screening to the patients but forgot to make a referral, or the practitioners made a referral but the patients failed to keep their eye exam appointments. Other patient factors that could influence retinal screening rates included motivation or geographical access.

In conclusion, PEMs might not be an effective way in changing family practitioners behavior on retinal screening recommendations or increasing retinal screening rate among diabetes patients.

Practice Pearls:
  • PEMs might not be an effective way in changing family practitioners behavior on retinal screening recommendations.
  • Reading the PEMs and effectively transmitting the information to patients are keys to increase screening rate.
  • Patient factors such as motivation or access to screening should be considered when given recommendations.

Zwarenstein M, Shiller S, Croxford R, et al. Printed educational messages aimed at family practitioners fail to increase retinal screening among their patients with diabetes: a pragmatic cluster randomized controlled trial. Implementation Science 2014; 9:87.