The effect of automatically generated reminders delivered to providers on paper on quality of care and patient outcomes

What is the aim of this review?

The aim of this Cochrane review was to find out if reminders, automatically generated through a computer, but delivered on paper to doctors help them provide the best recommended care. Cochrane researchers identified 35 studies and analyzed 34 of these studies to answer this question.

Key messages

Providing reminders to doctors probably improves slightly the quality of care patients receive. However, because the certainty of the evidence is moderate, more high-quality studies on the effectiveness of reminders are needed to confirm to findings of this review.

What was studied in the review?

Doctors do not always provide care that is recommended or that reflects the latest research, partly because of too much information or inaccessible information. Reminders may help doctors overcome these problems by reminding them about guidelines and research findings, or by providing advice, in a more accessible and relevant format, at a particularly appropriate time. For example, when a doctor sees a patient for an annual check-up, the doctor would receive the patient's chart with a reminder section listing the screening tests due that year, such as colorectal cancer screening. In this review, we evaluated the effects of reminders on the quality of care delivered by physicians, on patient outcomes, and on adverse effects. These reminders were automatically generated through a computer system but delivered on paper.

What are the main results of the review?

Twenty-nine studies were from the USA and six studies were from Canada, France, Israel and Kenya. The studies examined reminders to doctors to order screening tests, to provide vaccinations, to prescribe specific medications, or to discuss care with patients.

The review shows that:

- overall, reminders probably improve slightly quality of care by 6.8% (in 34 studies (40 comparisons), moderate-certainty evidence);

- reminders alone (single-component intervention) probably improve quality of care by 11.0% compared with usual care (in 27 studies (27 comparisons), moderate-certainty evidence);

- adding reminders to one or more co-interventions (multi-component intervention) probably improve slightly quality of care by 4.0% compared with the co-intervention(s) without the reminder component (in 11 studies (13 comparisons), moderate-certainty evidence);

- it is uncertain whether reminders improve patient outcomes because the certainty of the evidence is very low;

- none of the included studies reported outcomes related to harms or adverse effects.

How up to date is this review?

The review authors searched for studies that had been published up to 21 September 2016.

Authors' conclusions: 

There is moderate-certainty evidence that computer-generated reminders delivered on paper to healthcare professionals probably slightly improves quality of care, in terms of compliance with preventive guidelines and compliance with disease management guidelines. It is uncertain whether reminders improve patient outcomes because the certainty of the evidence is very low. The heterogeneity of the reminder interventions included in this review also suggests that reminders can probably improve quality of care in various settings under various conditions.

Read the full abstract...
Background: 

Clinical practice does not always reflect best practice and evidence, partly because of unconscious acts of omission, information overload, or inaccessible information. Reminders may help clinicians overcome these problems by prompting them to recall information that they already know or would be expected to know and by providing information or guidance in a more accessible and relevant format, at a particularly appropriate time. This is an update of a previously published review.

Objectives: 

To evaluate the effects of reminders automatically generated through a computerized system (computer-generated) and delivered on paper to healthcare professionals on quality of care (outcomes related to healthcare professionals' practice) and patient outcomes (outcomes related to patients' health condition).

Search strategy: 

We searched CENTRAL, MEDLINE, Embase, six other databases and two trials registers up to 21 September 2016 together with reference checking, citation searching and contact with study authors to identify additional studies.

Selection criteria: 

We included individual- or cluster-randomized and non-randomized trials that evaluated the impact of computer-generated reminders delivered on paper to healthcare professionals, alone (single-component intervention) or in addition to one or more co-interventions (multi-component intervention), compared with usual care or the co-intervention(s) without the reminder component.

Data collection and analysis: 

Review authors working in pairs independently screened studies for eligibility and abstracted data. For each study, we extracted the primary outcome when it was defined or calculated the median effect size across all reported outcomes. We then calculated the median improvement and interquartile range (IQR) across included studies using the primary outcome or median outcome as representative outcome. We assessed the certainty of the evidence according to the GRADE approach.

Main results: 

We identified 35 studies (30 randomized trials and five non-randomized trials) and analyzed 34 studies (40 comparisons). Twenty-nine studies took place in the USA and six studies took place in Canada, France, Israel, and Kenya. All studies except two took place in outpatient care. Reminders were aimed at enhancing compliance with preventive guidelines (e.g. cancer screening tests, vaccination) in half the studies and at enhancing compliance with disease management guidelines for acute or chronic conditions (e.g. annual follow-ups, laboratory tests, medication adjustment, counseling) in the other half.

Computer-generated reminders delivered on paper to healthcare professionals, alone or in addition to co-intervention(s), probably improves quality of care slightly compared with usual care or the co-intervention(s) without the reminder component (median improvement 6.8% (IQR: 3.8% to 17.5%); 34 studies (40 comparisons); moderate-certainty evidence).

Computer-generated reminders delivered on paper to healthcare professionals alone (single-component intervention) probably improves quality of care compared with usual care (median improvement 11.0% (IQR 5.4% to 20.0%); 27 studies (27 comparisons); moderate-certainty evidence). Adding computer-generated reminders delivered on paper to healthcare professionals to one or more co-interventions (multi-component intervention) probably improves quality of care slightly compared with the co-intervention(s) without the reminder component (median improvement 4.0% (IQR 3.0% to 6.0%); 11 studies (13 comparisons); moderate-certainty evidence).

We are uncertain whether reminders, alone or in addition to co-intervention(s), improve patient outcomes as the certainty of the evidence is very low (n = 6 studies (seven comparisons)). None of the included studies reported outcomes related to harms or adverse effects of the intervention.

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