Patient reminder and recall systems to improve immunization rates

Jacobson Vann JC, Szilagyi P

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Summary

Does reminding people to have vaccinations increase the number of people who receive vaccinations?

Increasing the number of people who are vaccinated could lower death and disease rates throughout the world. Many strategies to increase vaccinations have been used. One way is to remind people to receive their vaccinations. This review of 47 studies evaluated whether reminding people worked.

This review found that reminding people to have vaccinations increased the number of people vaccinated, whether the people were due or overdue for vaccinations. The increases were observed in both children and adults for all types of vaccines, but not among urban adolescents in one study. Reminding people over the telephone, sending a letter or postcard, or speaking to them in person increased vaccinations. Providing numerous reminders was more effective than single reminders. Reminding people over the telephone was more effective than postcard or letter reminders, but reminders over the telephone may be expensive compared with alternative approaches. Reminders also worked whether it was from a private doctor's office, a medical center, or a public health department clinic. The studies in this review were from developed countries; and, it is therefore not clear whether reminders to patients would work in low- and middle-income countries.

This is a Cochrane review abstract and plain language summary, prepared and maintained by The Cochrane Collaboration, currently published in The Cochrane Database of Systematic Reviews 2009 Issue 4, Copyright © 2009 The Cochrane Collaboration. Published by John Wiley and Sons, Ltd.. The full text of the review is available in The Cochrane Library (ISSN 1464-780X).
This record should be cited as: Jacobson Vann JC, Szilagyi P. Patient reminder and recall systems to improve immunization rates. Cochrane Database of Systematic Reviews 2005, Issue 3. Art. No.: CD003941. DOI: 10.1002/14651858.CD003941.pub2.

This version first published online: October 21. 2002
Last assessed as up-to-date: February 20. 2008

Abstract

Background

Immunization rates for children and adults are rising, but coverage levels have not reached optimal goals. As a result of low immunization rates, vaccine-preventable diseases still occur. In an era of increasing complexity of immunization schedules, rising expectations about the performance of primary care, and large demands on primary care physicians, it is important to understand and promote interventions that work in primary care settings to increase immunization coverage. A common theme across immunization programs in all nations involves the challenge of determining the denominator of eligible recipients (e.g. all children who should receive the measles vaccine), and identifying the best strategy to ensure high vaccination rates. Strategies have focused on patient-oriented interventions (e.g. patient reminders), provider interventions, and system interventions. One intervention strategy involves patient reminder and recall systems.

Objectives

To assess the effectiveness of patient reminder and recall systems in improving immunization rates, and compare the effects of various types of reminders in different settings or patient populations.

Search strategy

A systematic search was performed for the initial review using MEDLINE (1966-1998) and 4 other bibliographic databases: EMBASE, PsychINFO, Sociological Abstracts, and CAB Abstracts. Authors also performed a search of The Effective Practice and Organisation of Care (EPOC) register in April 2001 to update the review. Two authors reviewed the lists of titles and abstracts, and used the inclusion criteria to mark potentially relevant articles for full review. The reference lists of all relevant articles and reviews were back searched for additional studies. Publications of abstracts, proceedings from scientific meetings, and files of study collaborators were also searched for references. In May 2007 the EPOC register was searched to identify relevant articles to update the review. In May 2007, the EPOC register search was supplemented by searches of CINAHL and PubMed. One study was identified through prior knowledge of this study.

Selection criteria

Study Design
Randomized controlled trials (RCT), controlled before and after studies (CBA), and interrupted time series (ITS) studies written in English.

Types of participants
Health care personnel who deliver immunizations and children (birth to 18 years) or adults (18 years and up) who receive immunizations in any setting.

Types of interventions
Any intervention that falls within the EPOC scope and that includes patient reminder or recall systems, or both, in at least one arm of the study.

Types of outcome measures
Immunization rates, or the proportion of the target population up-to-date on recommended immunizations. Outcomes were acceptable for either individual vaccinations (e.g. influenza vaccination) or standard combinations of recommended vaccinations (e.g. all recommended vaccinations by a specific date or age).

Data collection and analysis

Data Collection
Each study was read independently by two reviewers. Disagreements between reviewers were resolved by a formal reconciliation process to achieve consensus.

Analysis
Results are presented for individual studies as relative rates for randomized controlled trials, and as absolute changes in percentage points for controlled before and after studies. Pooled results for RCTs only were for presented using the random effects model.

Main results

Four new studies were added for the 2007 update for a total of 47 studies. Increases in immunization rates due to reminders were in the range of 1 to 20 percentage points. Reminders were effective for childhood vaccinations (OR = 1.47, 95% CI =1.28, 1.68), childhood influenza vaccinations (OR = 2.18, 95% CI = 1.29, 3.70), adult pneumococcus, tetanus, and Hepatitis B (OR = 2.19, 95%CI = 1.21, 3.99), and adult influenza vaccinations (OR = 1.66, 95% CI = 1.31, 2.09). The effectiveness of patient reminders for childhood influenza vaccinations declined overall from an odds ratio of 2.87 in the previous review. However, reminders were not effective in the one new study of adolescent immunizations in an urban setting (OR = 1.14, 95% CI = 0.98, 1.31). All types of reminders were effective (postcards, letters, telephone or autodialer calls), with telephone being the most effective but also the most costly.

Authors' conclusions

Patient reminder and recall systems in primary care settings are effective in improving immunization rates in developed countries.

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