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To the Editor: In their comprehensive systematic review of quality improvement strategies for improving glycemic control in patients with diabetes, Dr Shojania and colleagues¹ found that team changes and case management resulted in the largest reductions in levels of glycosylated hemoglobin (HbA_1c,), particularly when the case managers could make medication changes without prior physician approval.

We are concerned, however, that some of their findings may have been affected by misclassification of the intervention type. The authors reported that 2 reviewers independently screened and abstracted data, including (presumably) assigning the classification of the intervention, but they do not report a measure of agreement, such as a value. Authors of the included studies were not routinely contacted to confirm these classifications. Our trial,² for example, was classified as "patient education, case management" but was not considered to represent "team changes," even though it focused on expanding the capabilities of clinical pharmacists . . . [Full Text of this Article]

Michael Pignone, MD, MPH
pignone@med.unc.edu

Darren DeWalt, MD, MPH
Department of Medicine
University of North Carolina
Chapel Hill

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