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Study flow diagram.
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Figure 1

Study flow diagram.

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'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.
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Figure 2

'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.

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Funnel plot of comparison: Patient reminder or recall summary measure versus control
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Figure 3

Funnel plot of comparison: Patient reminder or recall summary measure versus control

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Comparison 1 Patient reminders (summary), Outcome 1 Immunized.
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Analysis 1.1

Comparison 1 Patient reminders (summary), Outcome 1 Immunized.

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Comparison 2 Patient telephone reminder or recall, Outcome 1 Immunized.
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Analysis 2.1

Comparison 2 Patient telephone reminder or recall, Outcome 1 Immunized.

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Comparison 3 Patient letter reminder or recall, Outcome 1 Immunized.
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Analysis 3.1

Comparison 3 Patient letter reminder or recall, Outcome 1 Immunized.

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Comparison 4 Patient postcard reminder or recall, Outcome 1 Immunized.
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Analysis 4.1

Comparison 4 Patient postcard reminder or recall, Outcome 1 Immunized.

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Comparison 5 Patient text message reminder or recall, Outcome 1 Immunized.
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Analysis 5.1

Comparison 5 Patient text message reminder or recall, Outcome 1 Immunized.

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Comparison 6 Patient autodialer message reminder or recall, Outcome 1 Immunized.
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Analysis 6.1

Comparison 6 Patient autodialer message reminder or recall, Outcome 1 Immunized.

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Comparison 7 Combination patient mail and telephone reminder or recall, Outcome 1 Immunized.
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Analysis 7.1

Comparison 7 Combination patient mail and telephone reminder or recall, Outcome 1 Immunized.

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Comparison 8 Combination patient reminder or recall with outreach, Outcome 1 Immunized.
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Analysis 8.1

Comparison 8 Combination patient reminder or recall with outreach, Outcome 1 Immunized.

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Comparison 9 Combination patient reminder or recall with provider reminder, Outcome 1 Immunized.
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Analysis 9.1

Comparison 9 Combination patient reminder or recall with provider reminder, Outcome 1 Immunized.

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Summary of findings for the main comparison. Overview: Patient reminder or recall interventions for receipt of immunizations ‐ any kind

Patient reminder or recall interventions compared with no patient reminder or recall for receipt of immunizations

Patient or population: children, adolescents, and adults with a need for routine immunizations, excluding travel immunizations

Settings: patient telephone reminder or recall interventions are typically received in the home; the interventions originate from outpatient departments of hospitals, community‐based clinical settings, local and state public health departments, and other clinical settings

Intervention: patient reminder or recall interventions

Comparison: no‐intervention control groups, standard practice activities that did not include immunization‐focused patient reminder or recall interventions, media‐based activities aimed at promoting immunizations, and simple practice‐based immunization awareness campaigns

Intervention type

Outcome: received immunizations

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of participants
(studies)

Certainty of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Without intervention

With intervention

Patient reminder or recall summary measure

290 per 1000

371 per 1000

(357 to 392)

RR 1.28a (1.23 to 1.35)

138,625
(55)

Moderateb

—

Patient telephone reminder or recall

164 per 1000

287 per 1000

(197 to 417)

RR 1.75 (1.20 to 2.54)

9120

(7)

Moderatec

—

Patient letter reminder or recall

320 per 1000

412 per 1000

(387 to 442)

RR 1.29 (1.21 to 1.38)

81,100

(27)

Moderated

—

Patient postcard reminder or recall

327 per 1000

386 per 1000

(353 to 425)

RR 1.18 (1.08 to 1.30)

27,734

(8)

Highe

—

Patient text message reminder or recall

161 per 1000

208 per 1000

(185 to 232)

RR 1.29 (1.15 to 1.44)

7772

(6)

High

—

Patient autodialer message reminder or recall

365 per 1000

427 per 1000

(376 to 482)

RR 1.17 (1.03 to 1.32)

11,947

(5)

High

—

Combination of patient mail and telephone reminder or recall

277 per 1000

354 per 1000

(316 to 402)

RR 1.28 (1.14 to 1.45)

6506

(8)

Moderatef

—

Combination of patient reminder or recall with outreach intervention

360 per 1000

439 per 1000

(396 to 486)

RR 1.22 (1.10 to 1.35)

2701

(3)

High

—

Combination of patient reminder or recall with provider reminder intervention

202 per 1000

588 per 1000

(540 to 644)

RR 2.91 (2.67 to 3.19)

4120

(2)

Moderateg

—

*The basis for the assumed risk, e.g. the median control group risk across studies, is provided in footnotes. The corresponding risk, and its 95% confidence interval, is based on the assumed risk in the comparison group and the relative effect of the intervention, and its 95% CI.
CI: confidence interval; RR: risk ratio

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

aIt is important to note that this review is the third update of the initial review that was published in 2002; the results for each update have been relatively stable and consistent with the original review.

bWe downgraded the certainty of the evidence by 1 point. GRADE was reduced by 0.5 points because of a small degree of inconsistency in outcomes. Generally, most included studies reported relatively small positive risk ratios, with several negative outliers and several with stronger positive effects; the patient reminder recall interventions also varied. We downgraded precision slightly (‐0.5) because the confidence intervals were wide for several included studies.

cWe downgraded the certainty of the evidence by 1 point. GRADE was reduced by 0.5 points because of a small degree of inconsistency in outcomes; the interventions were relatively homogeneous. We downgraded precision slightly (‐0.5) because the confidence intervals were wide for a few included studies.

dWe downgraded the certainty of the evidence by 1 point because of a small degree of inconsistency in outcomes (0.5 point); the interventions were relatively homogeneous. We downgraded precision slightly (‐0.5) because the confidence intervals were wide for several included studies.

eWe downgraded the certainty of the evidence by 0.5 points because of a high risk of bias for one or two of eight criteria for 15 studies.

fWe downgraded the certainty of the evidence by 1 point. GRADE was reduced by 0.5 points because of a small degree of inconsistency in outcomes, with one outlier; the interventions were more varied than the single intervention types. We downgraded precision slightly (‐0.5) because the confidence interval was wide for one outlier.

gWe downgraded the certainty of the evidence by 1.5 points. GRADE was reduced by 0.5 points because of a moderate risk of bias in one of three comparisons within two studies. We downgraded precision by 1 point because of two wide confidence intervals in three comparisons.

Figuras y tablas -
Summary of findings for the main comparison. Overview: Patient reminder or recall interventions for receipt of immunizations ‐ any kind
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Summary of findings 2. Summary: Patient reminder or recall interventions by type of immunization

Patient reminder or recall intervention for receipt of immunization, by type of immunization

Patient or population: children, adolescents, and adults with a need for routine immunizations, excluding travel immunizations

Settings: patient reminder or recall interventions are typically received in the home; the interventions originate from outpatient departments of hospitals, community‐based clinical settings, local and state public health departments, and other clinical settings

Interventions: patient reminder or recall interventions, including telephone calls, autodialer calls, letters, postcards, text messages, combination of mail or telephone, or combination of patient reminder or recall with outreach; this summary measure excludes patient reminder or recall interventions combined with provider reminders

Comparison: no‐intervention control groups, standard practice activities that did not include immunization‐focused patient reminder or recall interventions, media‐based activities aimed at promoting immunizations, and simple practice‐based immunization awareness campaigns

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of participants
(studies)

Certainty of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Without intervention

With intervention

Childhood immunizations

333 per 1000

406 per 1000

(383 to 430)

RR 1.22 (1.15 to 1.29)

31,099

(23)

Higha

—

Childhood influenza immunizations

431 per 1000

651 per 1000

(491 to 857)

RR 1.51 (1.14 to 1.99)

9265

(5)

Moderateb

—

Adult immunizations ‐ other than influenza or travel ('Other adult')

109 per 1000

227 per 1000

(99 to 521)

RR 2.08 (0.91 to 4.78)

8065

(4)

Lowc

—

Adult influenza immunizations

292 per 1000

376 per 1000

(342 to 418)

RR 1.29 (1.17 to 1.43)

59,328

(15)

Moderated

—

Adolescent immunizations

244 per 1000

314 per 1000

(285 to 346)

RR 1.29 (1.17 to 1.42)

30,868

(10)

Highe

—

*The basis for the assumed risk, e.g. the median control group risk across studies, is provided in footnotes. The corresponding risk, and its 95% confidence interval, is based on the assumed risk in the comparison group and the relative effect of the intervention, and its 95% CI.
CI: confidence interval; RR: risk ratio

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

aWe did not downgrade the certainty of the evidence: no serious risk of bias, serious inconsistency, serious indirectness, or serious imprecision was identified among the 23 studies; however, one study was an outlier (RR 5.33).

bWe downgraded the certainty of the evidence by 1.5 points because of some imprecision (‐1) and inconsistency (‐0.5). One of five studies had a wide confidence interval and effect sizes ranged from 1.08 to 4.6.

cWe downgraded the certainty of the evidence by 2 points because of lack of agreement between studies (‐1) and some imprecision (‐1). Effect sizes ranged from 1.08 to 3.61 and two of five studies had wide confidence intervals.

dWe downgraded the certainty of the evidence by 1.5 points because of some inconsistency in results (‐0.5) and some imprecision (‐1). Effect sizes ranged from 0.91 to 3.11 and one of 15 studies had a wide confidence interval.

eWe did not downgrade the certainty of the evidence: no serious risk of bias, serious inconsistency, serious indirectness, or serious imprecision was identified among the 10 studies.

Figuras y tablas -
Summary of findings 2. Summary: Patient reminder or recall interventions by type of immunization
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Table 1. Sensitivity analyses ‐ omitted studies from patient reminder or recall summary measure

Group or subgroup

RR (CI) for full set of included studies

RR (CI) after deleting studies with 'high' risk of bias for random sequence generation, allocation concealment, and/or incomplete outcomes

RR (CI) after deleting studies with primary outcome of received all needed vaccinations

Summary measure

1.28 (1.23 to 1.35)

1.29 (1.23 to 1.36)

1.32 (1.25 to 1.39)

Child

1.22 (1.15 to 1.29)

1.19 (1.12 to 1.27)

1.24 (1.15 to 1.34)

Influenza – child

1.51 (1.14 to 1.99)

1.51 (1.14 to 1.99)

1.37 (1.05 to 1.77)

Adult – other

2.08 (0.91 to 4.78)

2.35 (2.02 to 2.74)

2.08 (0.91 to 4.78)

Influenza – adult

1.29 (1.17 to 1.43)

1.33 (1.20 to 1.48)

1.29 (1.17 to 1.43)

Adolescent

1.29 (1.17 to 1.42)

1.26 (1.15 to 1.39)

1.33 (1.20 to 1.48)

CI: confidence interval
RR: risk ratio

Figuras y tablas -
Table 1. Sensitivity analyses ‐ omitted studies from patient reminder or recall summary measure
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Comparison 1. Patient reminders (summary)

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Immunized Show forest plot

55

138625

Risk Ratio (M‐H, Random, 95% CI)

1.28 [1.23, 1.35]

1.1 Childhood immunizations

23

31099

Risk Ratio (M‐H, Random, 95% CI)

1.22 [1.15, 1.29]

1.2 Childhood influenza immunizations

5

9265

Risk Ratio (M‐H, Random, 95% CI)

1.51 [1.14, 1.99]

1.3 Adult immunizations ‐ other

4

8065

Risk Ratio (M‐H, Random, 95% CI)

2.08 [0.91, 4.78]

1.4 Adult influenza immunizations

15

59328

Risk Ratio (M‐H, Random, 95% CI)

1.29 [1.17, 1.43]

1.5 Adolescent immunizations

10

30868

Risk Ratio (M‐H, Random, 95% CI)

1.29 [1.17, 1.42]
Figuras y tablas -
Comparison 1. Patient reminders (summary)
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Comparison 2. Patient telephone reminder or recall

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Immunized Show forest plot

7

9120

Risk Ratio (M‐H, Random, 95% CI)

1.75 [1.20, 2.54]

1.1 Childhood immunizations

2

234

Risk Ratio (M‐H, Random, 95% CI)

2.27 [1.12, 4.63]

1.2 Adult immunizations ‐ other

2

6630

Risk Ratio (M‐H, Random, 95% CI)

1.58 [0.55, 4.57]

1.3 Adult influenza immunizations

2

1838

Risk Ratio (M‐H, Random, 95% CI)

1.53 [0.73, 3.20]

1.4 Adolescent immunizations

1

418

Risk Ratio (M‐H, Random, 95% CI)

2.04 [1.05, 3.95]
Figuras y tablas -
Comparison 2. Patient telephone reminder or recall
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Comparison 3. Patient letter reminder or recall

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Immunized Show forest plot

27

81100

Risk Ratio (M‐H, Random, 95% CI)

1.29 [1.21, 1.38]

1.1 Childhood immunizations

9

13009

Risk Ratio (M‐H, Random, 95% CI)

1.16 [1.06, 1.27]

1.2 Childhood influenza immunizations

5

9265

Risk Ratio (M‐H, Random, 95% CI)

1.51 [1.14, 1.99]

1.3 Adult immunizations ‐ other

2

1435

Risk Ratio (M‐H, Random, 95% CI)

3.13 [1.44, 6.84]

1.4 Adult influenza immunizations

11

44454

Risk Ratio (M‐H, Random, 95% CI)

1.35 [1.19, 1.52]

1.5 Adolescent immunizations

2

12937

Risk Ratio (M‐H, Random, 95% CI)

1.91 [0.71, 5.11]
Figuras y tablas -
Comparison 3. Patient letter reminder or recall
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Comparison 4. Patient postcard reminder or recall

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Immunized Show forest plot

8

27734

Risk Ratio (M‐H, Random, 95% CI)

1.18 [1.08, 1.30]

1.1 Childhood immunizations

4

2806

Risk Ratio (M‐H, Random, 95% CI)

1.24 [1.05, 1.46]

1.2 Adult influenza immunizations

3

19265

Risk Ratio (M‐H, Random, 95% CI)

1.15 [0.95, 1.39]

1.3 Adolescent immunizations

1

5663

Risk Ratio (M‐H, Random, 95% CI)

1.23 [0.98, 1.54]
Figuras y tablas -
Comparison 4. Patient postcard reminder or recall
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Comparison 5. Patient text message reminder or recall

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Immunized Show forest plot

6

7772

Risk Ratio (M‐H, Random, 95% CI)

1.29 [1.15, 1.44]

1.1 Childhood immunizations

1

304

Risk Ratio (M‐H, Random, 95% CI)

1.22 [1.11, 1.33]

1.2 Adult influenza immunizations

1

204

Risk Ratio (M‐H, Random, 95% CI)

1.05 [0.71, 1.58]

1.3 Adolescent immunizations

4

7264

Risk Ratio (M‐H, Random, 95% CI)

1.38 [1.16, 1.64]
Figuras y tablas -
Comparison 5. Patient text message reminder or recall
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Comparison 6. Patient autodialer message reminder or recall

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Immunized Show forest plot

5

11947

Risk Ratio (M‐H, Random, 95% CI)

1.17 [1.03, 1.32]

1.1 Childhood immunizations

3

8583

Risk Ratio (M‐H, Random, 95% CI)

1.27 [1.19, 1.35]

1.2 Adolescent immunizations

2

3364

Risk Ratio (M‐H, Random, 95% CI)

1.08 [0.99, 1.17]
Figuras y tablas -
Comparison 6. Patient autodialer message reminder or recall
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Comparison 7. Combination patient mail and telephone reminder or recall

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Immunized Show forest plot

8

6506

Risk Ratio (M‐H, Random, 95% CI)

1.28 [1.14, 1.45]

1.1 Childhood immunizations

7

4910

Risk Ratio (M‐H, Random, 95% CI)

1.27 [1.09, 1.48]

1.2 Adolescent immunizations

1

1596

Risk Ratio (M‐H, Random, 95% CI)

1.36 [1.20, 1.53]
Figuras y tablas -
Comparison 7. Combination patient mail and telephone reminder or recall
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Comparison 8. Combination patient reminder or recall with outreach

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Immunized Show forest plot

3

2701

Risk Ratio (M‐H, Random, 95% CI)

1.22 [1.10, 1.35]

1.1 Childhood immunizations

3

2701

Risk Ratio (M‐H, Random, 95% CI)

1.22 [1.10, 1.35]
Figuras y tablas -
Comparison 8. Combination patient reminder or recall with outreach
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Comparison 9. Combination patient reminder or recall with provider reminder

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Immunized Show forest plot

2

4120

Risk Ratio (M‐H, Random, 95% CI)

2.91 [2.67, 3.19]

1.1 Adult immunizations ‐ other

1

264

Risk Ratio (M‐H, Random, 95% CI)

4.07 [1.13, 14.70]

1.2 Adult influenza immunizations

2

3856

Risk Ratio (M‐H, Random, 95% CI)

2.91 [2.66, 3.18]
Figuras y tablas -
Comparison 9. Combination patient reminder or recall with provider reminder
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