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Study flow diagram*Ineligible comparison or inappropriate control: e.g. physician reminder combined with another intervention vs usual care, physician reminder with a specific feature vs physician reminder without it, physician reminder vs another intervention$Not a provider reminder: e.g. audit and feedback, changes in medical records system, expert system for estimating diagnosis/risk/dosage, patient‐mediated intervention
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Figure 1

Study flow diagram

*Ineligible comparison or inappropriate control: e.g. physician reminder combined with another intervention vs usual care, physician reminder with a specific feature vs physician reminder without it, physician reminder vs another intervention

$Not a provider reminder: e.g. audit and feedback, changes in medical records system, expert system for estimating diagnosis/risk/dosage, patient‐mediated intervention

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Methodological quality summary: review authors' judgements about each methodological quality item for each included study.
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Figure 2

Methodological quality summary: review authors' judgements about each methodological quality item for each included study.

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Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies.
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Figure 3

Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies.

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Absolute improvement of quality of care by study, using the primary outcome defined by authors (represented by a red dot), and median improvement by study, using the median outcome of all reported quality of care outcomes (represented by a blue square (the median) and blue line (interquartile range))
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Figure 4

Absolute improvement of quality of care by study, using the primary outcome defined by authors (represented by a red dot), and median improvement by study, using the median outcome of all reported quality of care outcomes (represented by a blue square (the median) and blue line (interquartile range))

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Median effect and interquartile range (IQR) across comparisons by reminder feature (P values reflect Mann–Whitney test)
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Figure 5

Median effect and interquartile range (IQR) across comparisons by reminder feature (P values reflect Mann–Whitney test)

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Median effect and interquartile range (IQR) across comparisons by study feature (*Kruskall–Wallis test; other P values reflect Mann–Whitney test)
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Figure 6

Median effect and interquartile range (IQR) across comparisons by study feature (*Kruskall–Wallis test; other P values reflect Mann–Whitney test)

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Computer‐generated reminders delivered on paper to healthcare professionals, alone or in addition to co‐intervention(s), compared with usual care or the co‐intervention(s) without the reminder component

Patient or population: Healthcare professionals

Settings: Outpatient care in Canada, France, Israel, Kenya and USA

Intervention: Reminders automatically generated through a computerized system (computer‐generated) and delivered on paper to healthcare professionals, alone or in addition to one or more co‐interventions, aimed at enhancing compliance with preventive guidelines (e.g. cancer screening tests, vaccination) or disease management guidelines for acute or chronic conditions (e.g. annual follow‐ups, laboratory tests, medication adjustment, counseling)

Comparison: Usual care or co‐intervention(s) without reminder component

Outcomes

Median improvement

Number of studies (comparisons)

Certainty of the evidence
(GRADE)

Comments

Quality of care

Pooling data across the 40 comparisons, the median improvement in quality of care associated with the reminder intervention was 6.8% (IQR 3.8% to 17.5%).

34 studies

(40 comparisons)

⊕⊕⊕⊝
MODERATE1

Quality of care was measured by various rates: e.g. test ordering rates, vaccination rates, follow‐up rates, prescription rates, overall compliance rate.

Patient outcomes

Not estimable

6 studies

(7 comparisons)

⊕⊝⊝⊝
VERY LOW2

No measurable effect on i) blood pressure, glycated hemoglobin and cholesterol levels, ii) reaching blood pressure, glycated hemoglobin and cholesterol targets, and iii) mortality.

Adverse effects

Not reported

‐

‐

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

IQR: interquartile range

GRADE Working Group grades of evidence
High certainty: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate certainty: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low certainty: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low certainty: We are very uncertain about the estimate.

1 We downgraded the level of certainty of the evidence from high to moderate because of methodological limitations in the included studies and possible publication bias. We did not find other serious limitations in the other factors (indirectness of evidence, inconsistency of results, and imprecision of results).

2 We downgraded the level of certainty of the evidence from high to very low because of methodological limitations in the included studies, imprecision of results (wide confidence intervals) and inconsistency of the results.

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Computer‐generated reminders delivered on paper to healthcare professionals alone (single‐component intervention) compared with usual care

Patient or population: Healthcare professionals

Settings: Outpatient care in Canada, France, Israel, Kenya and USA

Intervention: Computer‐generated reminders delivered on paper alone (single‐component intervention)

Comparison: Usual care

Outcomes

Median improvement

Number of studies (comparisons)

Certainty of the evidence
(GRADE)

Comments

Quality of care

Pooling data across the 27 comparisons, the median improvement in quality of care associated with the reminder intervention was 11.0%

(IQR 5.4% to 20.0%)

27 studies

(27 comparisons)

⊕⊕⊕⊝
MODERATE1

Quality of care was measured by various rates: e.g. test ordering rates, vaccination rates, follow‐up rates, prescription rates, overall compliance rate.

Patient outcomes

Not estimable

4 studies

(4 comparisons )

⊕⊝⊝⊝
VERY LOW2

No measurable effect on i) blood pressure, glycated hemoglobin and cholesterol levels, ii) reaching blood pressure, glycated hemoglobin and cholesterol targets, and iii) mortality.

Adverse effects

Not reported

‐

‐

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

IQR: interquartile range

GRADE Working Group grades of evidence
High certainty: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate certainty: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low certainty: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low certainty: We are very uncertain about the estimate.

1 We downgraded the level of certainty of the evidence from high to moderate because of methodological limitations in the included studies and possible publication bias. We did not find other serious limitations in the other factors (indirectness of evidence, inconsistency of results, and imprecision of results).

2 We downgraded the level of certainty of the evidence from high to very low because of methodological limitations in the included studies, imprecision of results (wide confidence intervals) and inconsistency of the results.

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Computer‐generated reminders delivered on paper to healthcare professionals in addition to one or more co‐interventions (multi‐component intervention) compared with the co‐intervention(s) without the reminder component

Patient or population: Healthcare professionals

Settings: Outpatient care in Canada and USA

Intervention: Computer‐generated reminders delivered on paper in addition to one or more co‐interventions (multi‐component intervention)

Comparison: Co‐intervention(s) without the reminder component

Outcomes

Median improvement

(interquartile range)

Number of studies (comparisons)

Certainty of the evidence
(GRADE)

Comments

Quality of care

Pooling data across the 13 comparisons, the median improvement in quality of care associated with the reminder intervention was 4.0% (3.0% to 6.0%)

11 studies

(13 comparisons)

⊕⊕⊕⊝
MODERATE1

Quality of care was measured by various rates: e.g. test ordering rates, vaccination rates, follow‐up rates, prescription rates, overall compliance rate.

Patient outcomes

Not estimable

2 studies

(3 comparisons)

⊕⊝⊝⊝
VERY LOW2

No measurable effect on i) blood pressure, glycated hemoglobin and cholesterol levels, ii) reaching blood pressure, glycated hemoglobin and cholesterol targets, and iii) mortality.

Adverse effects

Not reported

‐

‐

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

IQR: interquartile range

GRADE Working Group grades of evidence
High certainty: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate certainty: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low certainty: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low certainty: We are very uncertain about the estimate.

1 We downgraded the level of certainty of the evidence from high to moderate because of methodological limitations in the included studies and possible publication bias. We did not find other serious limitations in the other factors (indirectness of evidence, inconsistency of results, and imprecision of results).

2 We downgraded the level of certainty of the evidence from high to very low because of methodological limitations in the included studies and imprecision of results (wide confidence intervals).

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Table 1. Improvement rates of quality of care, by study

Study ID

Primary outcome

Other outcomes (n)

Absolute improvement ‐ using primary outcome

Median absolute improvement ‐ using other outcomes (interquartile range)

Barnett 1983

 

percentage of eligible patients with: blood pressure values on record, follow‐up (2)

 

38.8% (18.4% to 59.1%)

Becker 1989

overall compliance rate with preventive care recommendations

percentage of eligible patients with: dental check, ocular pressure check, FOBT, flu vacc, pneumo vacc, tetanus vacc, mammography, pap smear (8)

4.7%

5.8% (3.0% to 10.2%)

Binstock 1997

percentage of eligible patients with pap smear

 

7.6%

 

Burack 1996_1

percentage of eligible patients with mammography

 

6.0%

 

Burack 1996_2

percentage of eligible patients with mammography

 

4.0%

 

Burack 1998_1

percentage of eligible patients with pap smear

 

1.0%

 

Burack 1998_2

percentage of eligible patients with pap smear

 

3.0%

 

Chambers 1989

percentage of eligible patients with mammography

 

7.1%

 

Chambers 1991

percentage of eligible patients with flu vacc

 

20.7%

 

Dexter 1998

 

percentage of eligible patients with: discussion of directives, completion of directives (2)

 

9.2% (6.1% to 12.3%)

Gilutz 2009

percentage of patients with adequate monitoring, percentage of eligible patients with initiation or up‐titration of statin therapy, percentage of eligible patients with up‐titration (3)

5.4% (1.2% to 6.1%)

Heidenreich 2005

percentage of eligible patients with ACE inhibitor prescription

 

11.5%

 

Heidenreich 2007

percentage of eligible patients with any β‐blocker prescription

percentage of eligible patients with recommended β‐blocker prescription

7.9%

6.7% (5.4% to 7.9%)

Heiman 2004

percentage of eligible patients with advance directives

percentage of eligible patients with: discussion or completion of directives, completion of healthcare proxy, completion of living will (3)

‐0.2%

‐0.3% (‐0.9% to ‐0.2%)

Javitt 2005

compliance rate with prescription reminders (start a new drug) (denominator: reminders)

 

7.0%

 

Le Breton 2016

adherence to colorectal cancer screening

1.7%

Lobach 1997

overall physician compliance rate

physician compliance rate with: foot exam, physical exam, glycated hemoglobin, urine protein determination, cholesterol level, eye exam, flu vacc, pneumo vacc (8)

16.4%

22.7% (11.0% to 28.4%)

Majumdar 2007

overall compliance rate with prescription reminders

percentage of eligible patients with: ACE inhibitor or ARB therapy prescription, statins prescription

6.0%

9.0% (0.0% to 18.0%)

Mazzuca 1990

 

physician compliance rate with: glycated hemoglobin, fasting blood glucose, home‐monitored blood glucose, diet clinic referral, oral hypoglycemic agents (5)

 

4.0% (4.0% to 5.0%)

McAlister 2009

overall compliance rate with prescription reminders

percentage of eligible patients with: statins, standardized statin dose, another lipid‐lowering drug, acetylsalicylic acid, acetylsalicylic acid or thienopyridine, ACE inhibitor, ACE inhibitor or ARB, β‐blocker, triple therapy (8)

6.6%

0.5% (‐0.4% to 2.2%)

McDonald 1976a

overall compliance rate with prescription reminders (denominator: reminders)

compliance with: observing a physical finding or inquiring about a symptom, ordering a diagnostic study, changing or initiating a therapeutic regimen (3)

28.9%

24.7% (21.1% to 38.8%)

McDonald 1976b

overall compliance rate with reminders (denominator: reminders)

percentage of patients with: test order, therapeutic change (2)

23.5%

20.3% (14.9% to 25.7%)

McDonald 1980

overall compliance rate with reminders (denominator: reminders)

 

18.6%

 

McDonald 1984

overall compliance rate with reminders

percentage of patients with: FOBT, pap smear, chest roentgenogram, pneumo vacc, tuberculosis skin test, serum potassium, mammogram, flu vacc, diet, digitalis, antacids, β‐blockers (12)

20.0%

13.0% (10.5% to 24.5%)

McPhee 1989_1

 

physician compliance rate with: FOBT, rectal exam, sigmoidoscopy, pap smear, pelvic exam, breast exam, mammography (7)

 

23.0% (20.0% to 33.0%)

McPhee 1989_2

 

physician compliance rate with:  breast exam, mammography (2)

 

23.2% (20.0% to 26.5%)

Morgan 1978

 

percentage of patients with: blood group and type, syphilis serology, prenatal counseling, pregnancy diet counseling, sickle cell preparation (5)

 

0.1% (‐1.9% to 2.0%)

Nilasena 1995

overall physician compliance rate with reminders

 

3.9%

 

Ornstein 1991_1

 

percentage of eligible patients with: FOBT, mammography, tetanus vacc, cholesterol, pap smear (5)

 

4.4% (3.9% to 6.9%)

Ornstein 1991_2

 

percentage of eligible patients with: FOBT, mammography, tetanus vacc, cholesterol, pap smear (5)

 

6.1% (3.9% to 7.0%)

Rosser 1991

overall compliance rate

percentage of eligible patients with: flu vacc, tetanus vacc, BP reading, pap smear (4)

19.2%

11.4% (6.0% to 16.4%)

Rossi 1997

percentage of eligible patients with prescription change

 

11.0%

 

Thomas 1983

compliance rate with reminders

 

12.9%

 

Tierney 1986_1

 

physician compliance rate with: FOBT, pneumo vacc, antacids, TB skin testing, β‐blockers, nitrates, anti‐depressants, calcium supplements, pap smear, mammography, metronidazole, digitalis, salicylates (13)

 

1.5% (0.5% to 11.0%)

Tierney 1986_2

 

physician compliance rate with: FOBT, pneumo vacc, antacids, TB skin testing, β‐blockers, nitrates, anti‐depressants, calcium supplements, pap smear, mammography, metronidazole, digitalis, salicylates (13)

 

1.0% (‐0.5% to 2.0%)

Turner 1989

 

physician compliance rate with: FOBT, rectal exam, pap smear, breast exam, mammography (5)

 

3.6% (‐5.8% to 10.1%)

Were 2013

completion of overdue clinical tasks (denominator: reminders)

completion of overdue clinical task for: ordering chest x‐ray, ordering 18‐mo human immunodeficiency virus enzyme‐linked immunosorbent assay, ordering other laboratory tests, beginning antiretroviral therapy, referring to nutritional support (5)

50.0%

39.0% (26.0% to 54.0%)

White 1984

compliance rate with reminders (denominator: reminders)

 

12.0%

 

Ziemer 2006_1

physician compliance rate

 

0.2%

 

Ziemer 2006_2

physician compliance rate

 

0.7%

 

ACE: angiotensin‐converting enzyme, ARB: angiotensin II receptor blockers, BP: blood pressure, flu: influenza, FOBT: fecal occult blood test, pneumo: pneumococcal, TB: tuberculosis, Vacc: vaccination

Figuras y tablas -
Table 1. Improvement rates of quality of care, by study
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Table 2. Median improvement of quality of care across all comparisons and according to the presence of co‐interventions

Median improvement (interquartile range)

Using primary (or median) outcome

Using largest outcome

Using smallest outcome

All (n = 40)

6.8%

(3.8% to 17.5%)

12.0%

(6.1% to 20.2%)

4.0%

(0.5% to 11.3%)

Reminders alone (n = 27)

11.0%

(5.4% to 20.0%)

12.3%

(7.0% to 33.5%)

6.1%

(1.2% to 12.9%)

Reminders with co‐intervention(s) (n = 13)

4.0%

(3.0% to 6.0%)

9.8%

(3.9% to 12.5%)

0.7%

(‐1.9% to 3.6%)
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Table 2. Median improvement of quality of care across all comparisons and according to the presence of co‐interventions
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Table 3. Improvement of patient outcomes, by study

Study ID

Patient outcome: percentage difference between groups at follow‐up

Patient outcome: mean difference between groups at follow‐up

Barnett 1983

Percentage of patients with BP<100 or receiving treatment at 12 mo: 18.1%

Gilutz 2009

Event‐free survival: ‐2.1%

LDL level: ‐2.4 mg/dL

Heidenreich 2005

Mortality: hazard ratio: 0.98 (95% CI: 0.78 to 1.23)

Diastolic BP: 0

Systolic BP: 0

McAlister 2009

Mortality: 1%

Rossi 1997

Diastolic BP: ‐4

Systolic BP: 0

Ziemer 2006_1

Percentage of patients with Hba1c<7.0%: OR: 0.98 (95% CI: 0.86 to 1.12)

Percentage of patients with systolic BP<130: OR: 1.04 (95% CI: 0.94 to 1.16)

Percentage of patients with LDL<100: OR 0.92 (95% CI: 0.79 to 1.08)

Hba1c: 0.1

Systolic BP: ‐1.2

LDL level: 2.5 mg/dL

Ziemer 2006_2

Percentage of patients with Hba1c<7.0%: OR: 0.99 (95% CI: 0.82 to 1.19)

Percentage of patients with systolic BP<130: OR: 0.92 (95% CI: 0.79 to 1.06)

Percentage of patients with LDL<100: OR 1.05 (95% CI: 0.84 to 1.31)

Hba1c: 0.4

Systolic BP: 0.8

LDL level: 3.0 mg/dL

BP: blood pressure, Hba1c: glycated hemoglobin, LDL: low‐density lipoprotein, mo: months

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Table 3. Improvement of patient outcomes, by study
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