Effect of Patient Reminder/Recall Interventions on Immunization Rates
Abstract & commentarySynopsis: A variety of patient reminder systems were effective in improving rates in 80% of the studies, raising rates from 5-20 percentage points for both childhood and adult vaccinations in a variety of different settings. Telephone reminders were the most effective but also the most expensive.
Source: Szilagyi PG, et al. JAMA 2000;284:1820-1827.
Two independent reviewers evaluated all English-language studies published over 30 years through 1998 using patient reminder or recall systems for the commonly recommended adult and childhood vaccines. Five bibliographic search engines including MEDLINE were used, and reference lists from all relevant articles were also reviewed to identify suitable research. Studies had to include outcome measures of immunization rates, and study designs had to be either randomized controlled trials, controlled before-and-after studies, or interrupted time series studies.
A total of 109 studies were identified from which 41 met eligibility criteria and were further analyzed. The main reasons for exclusion were lack of a control group or using different outcome measures. Effectiveness was shown in 33 of the 41 studies (80%), as measured by increases in immunization rates from 8% to 18% over baseline. Increases were found for both children and adults, and also for different settings although private practice was somewhat lower than academic settings (8% increase vs 21%). All types of reminders showed increases, with the largest coming from telephone reminders (25%) and least from single letters (7%). Several studies combined reminders such as postcards and telephone calls, or combined patient reminders with physician reminders, and no clear advantages of one approach over another were seen, although more improvements were generally seen with more intensive and combined reminder systems. Analysis of those studies that did not show improvements in immunization rates revealed multiple confounding variables, such as small sample sizes, high baseline rates to begin with, or less targeted reminders. There were no clear trends in these failures for type of practice setting, patient population, or type of reminder/recall system used.
Fifteen of the studies included cost information, which varied widely both due to different types of reminder systems used, and because different methods were used to calculate costs. Short-term and single reminders were the least expensive, with ranges of $7-10 per patient vaccinated. Some studies noted that patient reminders had the added benefit of increasing preventive visits for other services in addition to immunizations, so enhanced benefits were seen. Based on the results of this extensive review, Szilagyi and colleagues recommend that all primary care physicians seriously consider incorporating reminder/recall systems into their practices.
Comment by Mary Elina Ferris, MD
Despite sustained efforts to increase immunization rates for both children and adults, there remains room for overall improvement in some childhood vaccination rates and in influenza and pneumococcal vaccinations for adults. Recent data for children in 1998 show 79% achieved the required shots by age 4, although only 43% had the recommended varicella shot. Adults reported by phone survey in 1997 that 65% had their annual flu shot, but only 45% recalled receiving pneumococcal vaccine.1,2 Certain populations such as African-Americans consistently have lower rates that also need public attention.
The question of "what works" to improve these rates is answered in this article and should provide support for the financing of patient reminder systems. All types of reminders were effective, and they worked in a variety of different settings. The only glaring deficiency in this information is whether the reminder/recall systems also worked for specific ethnic and cultural populations, who may have different barriers to immunization that would not be overcome with a simple reminder. Interviews with older adults who did not receive influenza and pneumococcal shots state most commonly that they didn’t know the shots were needed, although 40% of them also expressed concerns about vaccine safety and side effects.
Technology should be incorporated into our practices to assist us with routine reminders, not only for immunizations but for other preventive services as well. Szilagyi et al suggest that future research should focus on implementation strategies, and that primary care practices should begin now to use reminder systems as a proven population-based approach to affect the larger community beyond our individual encounters.
References
1. MMWR Morb Mortal Wkly Rep 1998;47:547-554.
2. MMWR Morb Mortal Wkly Rep 1998;47:797-802.
3. MMWR Morb Mortal Wkly Rep 1999;48:886-890.
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