The effect of manually-generated reminders delivered to providers on paper on professional practice and patient outcomes

What is the aim of this review?

In this Cochrane Review we aimed to find out if health workers who are given reminders on paper give better health care. The reminders contained information about the patients, for instance recommendation to measure blood pressure. We collected and analysed all relevant studies and found 63 studies.

Key messages

It seems likely that providing reminders to health workers probably leads to small-to-moderate improvements in their practice measured as adherence to clinical recommendations. It is uncertain whether providing reminders has an effect on patient outcomes.

What was studied in the review?

Health workers do not always provide care that is recommended by clinical guidelines or standards, because of too much information or unconscious forgetfulness. One possible solution is to give them paper reminders that were not created by a computer. These are particularly important in countries where electronic records are not widely available. Reminders may help health workers overcome those problems by prompting them to follow clinical recommendations in guidelines or by providing information in a simple and timely way. In this review we evaluated the effects of reminders generated manually and delivered on paper on professional practice and patient outcomes.

What are the main results of the review?

We identified 63 studies and included 57 in our analysis. The studies evaluated reminders aimed at ordering screening tests, providing vaccinations, prescribing specific medications, or discussing care with patients. The studies show that:

- reminders alone (single-component intervention) probably improve professional practice, measured as compliance with recommendations, compared with usual care;

- reminders added to one or more co-interventions (multicomponent intervention) may slightly improve professional practice, measured as compliance with recommendations, compared with the co-intervention(s) without the reminder component;

- reminders may lead to slightly worse professional practice than other interventions for quality improvement, such as patients reminders;

- it is uncertain whether reminders compared with usual care or other quality-improvement interventions improve patient outcomes;

- reminders added to other quality-improvement interventions may make little or no difference to patient outcomes compared with the quality intervention alone;

- there were additional costs to obtain the effects described above, but the relevance of the figures presented was uncertain;

- 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 published up to December 2018.

Authors' conclusions: 

Manually-generated reminders delivered on paper as a single intervention probably lead to small to moderate increases in outcomes related to adherence to clinical recommendations, and they could be used as a single QI intervention. It is uncertain whether reminders should be added to other QI intervention already in place in the health system, although the effects may be positive. If other QI interventions, such as patient or computerised reminders, are available, they should be preferred over manually-generated reminders, but under close evaluation in order to decrease uncertainty about their potential effect.

Read the full abstract...
Background: 

Health professionals sometimes do not use the best evidence to treat their patients, in part due to unconscious acts of omission and information overload. Reminders help clinicians overcome these problems by prompting them to recall information that they already know, or by presenting information in a different and more accessible format. Manually-generated reminders delivered on paper are defined as information given to the health professional with each patient or encounter, provided on paper, in which no computer is involved in the production or delivery of the reminder. Manually-generated reminders delivered on paper are relatively cheap interventions, and are especially relevant in settings where electronic clinical records are not widely available and affordable. This review is one of three Cochrane Reviews focused on the effectiveness of reminders in health care.

Objectives: 

1. To determine the effectiveness of manually-generated reminders delivered on paper in changing professional practice and improving patient outcomes.
2. To explore whether a number of potential effect modifiers influence the effectiveness of manually-generated reminders delivered on paper.

Search strategy: 

We searched CENTRAL, MEDLINE, Embase, CINAHL and two trials registers on 5 December 2018. We searched grey literature, screened individual journals, conference proceedings and relevant systematic reviews, and reviewed reference lists and cited references of included studies.

Selection criteria: 

We included randomised and non-randomised trials assessing the impact of manually-generated reminders delivered on paper as a single intervention (compared with usual care) or added to one or more co-interventions as a multicomponent intervention (compared with the co-intervention(s) without the reminder component) on professional practice or patients' outcomes. We also included randomised and non-randomised trials comparing manually-generated reminders with other quality improvement (QI) interventions.

Data collection and analysis: 

Two review authors screened studies for eligibility and abstracted data independently. We extracted the primary outcome as defined by the authors or calculated the median effect size across all reported outcomes in each study. We then calculated the median percentage improvement and interquartile range across the included studies that reported improvement related outcomes, and assessed the certainty of the evidence using the GRADE approach.

Main results: 

We identified 63 studies (41 cluster-randomised trials, 18 individual randomised trials, and four non-randomised trials) that met all inclusion criteria. Fifty-seven studies reported usable data (64 comparisons). The studies were mainly located in North America (42 studies) and the UK (eight studies). Fifty-four studies took place in outpatient/ambulatory settings. The clinical areas most commonly targeted were cardiovascular disease management (11 studies), cancer screening (10 studies) and preventive care (10 studies), and most studies had physicians as their target population (57 studies). General management of a clinical condition (17 studies), test-ordering (14 studies) and prescription (10 studies) were the behaviours more commonly targeted by the intervention.

Forty-eight studies reported changes in professional practice measured as dichotomous process adherence outcomes (e.g. compliance with guidelines recommendations), 16 reported those changes measured as continuous process-of-care outcomes (e.g. number of days with catheters), eight reported dichotomous patient outcomes (e.g. mortality rates) and five reported continuous patient outcomes (e.g. mean systolic blood pressure).

Manually-generated reminders delivered on paper probably improve professional practice measured as dichotomous process adherence outcomes) compared with usual care (median improvement 8.45% (IQR 2.54% to 20.58%); 39 comparisons, 40,346 participants; moderate certainty of evidence) and may make little or no difference to continuous process-of-care outcomes (8 comparisons, 3263 participants; low certainty of evidence). Adding manually-generated paper reminders to one or more QI co-interventions may slightly improve professional practice measured as dichotomous process adherence outcomes (median improvement 4.24% (IQR −1.09% to 5.50%); 12 comparisons, 25,359 participants; low certainty of evidence) and probably slightly improve professional practice measured as continuous outcomes (median improvement 0.28 (IQR 0.04 to 0.51); 2 comparisons, 12,372 participants; moderate certainty of evidence). Compared with other QI interventions, manually-generated reminders may slightly decrease professional practice measured as process adherence outcomes (median decrease 7.9% (IQR −0.7% to 11%); 14 comparisons, 21,274 participants; low certainty of evidence).

We are uncertain whether manually-generated reminders delivered on paper, compared with usual care or with other QI intervention, lead to better or worse patient outcomes (dichotomous or continuous), as the certainty of the evidence is very low (10 studies, 13 comparisons). Reminders added to other QI interventions may make little or no difference to patient outcomes (dichotomous or continuous) compared with the QI alone (2 studies, 2 comparisons).

Regarding resource use, studies reported additional costs per additional point of effectiveness gained, but because of the different currencies and years used the relevance of those figures is uncertain.

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

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