Patient reminder and recall interventions to improve immunization rates
Abstract
Background
Immunization rates for children and adults are rising, but coverage levels have not reached optimal goals. As a result, 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 providers, it is important to understand and promote interventions that work in primary care settings to increase immunization coverage. One common theme across immunization programs in many nations involves the challenge of implementing a population‐based approach and identifying all eligible recipients, for example the children who should receive the measles vaccine. However, this issue is gradually being addressed through the availability of immunization registries and electronic health records. A second common theme is identifying the best strategies to promote high vaccination rates. Three types of strategies have been studied: (1) patient‐oriented interventions, such as patient reminder or recall, (2) provider interventions, and (3) system interventions, such as school laws. One of the most prominent intervention strategies, and perhaps best studied, involves patient reminder or recall systems. This is an update of a previously published review.
Objectives
To evaluate and compare the effectiveness of various types of patient reminder and recall interventions to improve receipt of immunizations.
Search methods
We searched CENTRAL, MEDLINE, Embase and CINAHL to January 2017. We also searched grey literature and trial registers to January 2017.
Selection criteria
We included randomized trials, controlled before and after studies, and interrupted time series evaluating immunization‐focused patient reminder or recall interventions in children, adolescents, and adults who receive immunizations in any setting. We included no‐intervention control groups, standard practice activities that did not include immunization patient reminder or recall, media‐based activities aimed at promoting immunizations, or simple practice‐based awareness campaigns. We included receipt of any immunizations as eligible outcome measures, excluding special travel immunizations. We excluded patients who were hospitalized for the duration of the study period.
Data collection and analysis
We used the standard methodological procedures expected by Cochrane and the Cochrane Effective Practice and Organisation of Care (EPOC) Group. We present results for individual studies as relative rates using risk ratios, and risk differences for randomized trials, and as absolute changes in percentage points for controlled before‐after studies. We present pooled results for randomized trials using the random‐effects model.
Main results
The 75 included studies involved child, adolescent, and adult participants in outpatient, community‐based, primary care, and other settings in 10 countries.
Patient reminder or recall interventions, including telephone and autodialer calls, letters, postcards, text messages, combination of mail or telephone, or a combination of patient reminder or recall with outreach, probably improve the proportion of participants who receive immunization (risk ratio (RR) of 1.28, 95% confidence interval (CI) 1.23 to 1.35; risk difference of 8%) based on moderate certainty evidence from 55 studies with 138,625 participants.
Three types of single‐method reminders improve receipt of immunizations based on high certainty evidence: the use of postcards (RR 1.18, 95% CI 1.08 to 1.30; eight studies; 27,734 participants), text messages (RR 1.29, 95% CI 1.15 to 1.44; six studies; 7772 participants), and autodialer (RR 1.17, 95% CI 1.03 to 1.32; five studies; 11,947 participants). Two types of single‐method reminders probably improve receipt of immunizations based on moderate certainty evidence: the use of telephone calls (RR 1.75, 95% CI 1.20 to 2.54; seven studies; 9120 participants) and letters to patients (RR 1.29, 95% CI 1.21 to 1.38; 27 studies; 81,100 participants).
Based on high certainty evidence, reminders improve receipt of immunizations for childhood (RR 1.22, 95% CI 1.15 to 1.29; risk difference of 8%; 23 studies; 31,099 participants) and adolescent vaccinations (RR 1.29, 95% CI 1.17 to 1.42; risk difference of 7%; 10 studies; 30,868 participants). Reminders probably improve receipt of vaccinations for childhood influenza (RR 1.51, 95% CI 1.14 to 1.99; risk difference of 22%; five studies; 9265 participants) and adult influenza (RR 1.29, 95% CI 1.17 to 1.43; risk difference of 9%; 15 studies; 59,328 participants) based on moderate certainty evidence. They may improve receipt of vaccinations for adult pneumococcus, tetanus, hepatitis B, and other non‐influenza vaccinations based on low certainty evidence although the confidence interval includes no effect of these interventions (RR 2.08, 95% CI 0.91 to 4.78; four studies; 8065 participants).
Authors' conclusions
Patient reminder and recall systems, in primary care settings, are likely to be effective at improving the proportion of the target population who receive immunizations.
PICOs
Plain language summary
Do strategies to remind people to have vaccinations increase the number of people who receive vaccinations?
Aim of this review
The aim of this review is to determine whether strategies to remind people to receive vaccinations increase the number of people who receive vaccinations. This is an update of a previously published Cochrane Review.
Key messages
Reminding people to receive their vaccinations increases vaccination rates across different populations.
What was studied
Vaccinations are used to prevent a number of diseases but there is wide variation in vaccination coverage across different regions and countries. This can lead to diseases that are otherwise preventable by vaccines, having a large effect on individuals and communities. Informing people of an upcoming vaccination or telling them that they have missed a vaccination might help to increase coverage and reduce the effect and impact of disease preventable by vaccine. We reviewed 75 studies to evaluate whether reminding people to get vaccinated worked. The studies we looked at were from different settings, such as rural areas, schools, private practices, and state health departments. Most studies were done in the USA. The studies included a range of different groups: infants and children, adolescents and adults requiring routine vaccination, as well as adults who required the influenza vaccine. In most of the studies reminders took the form of person to person telephone calls, automated calls, letters or postcards. In few recent studies text messaging was used.
Main results of the review
Our review found that reminding people to have vaccinations likely increases the number of people who receive vaccinations by an average of 8 percentage points, although there was variation in the results of the studies. Reminding people by telephone and autodialer calls, sending a letter or postcard, or sending a text message increased vaccinations. Combinations of reminders were also effective. Reminding people over the telephone was more effective than the other types of reminders. The increases in vaccinations were observed among children, adolescents, and adults.
How up‐to‐date is this review?
We reviewed studies that were published to January 2017.
