Don't Forget! Reminders Boost Vaccination Rates

Diana Mahoney

January 18, 2018

Reminders and recall systems are effective interventions for improving immunization rates among adults and children across settings, according to a new report.

In a systematic literature review on the efficacy of immunization reminder and recall interventions, Julie C Jacobson Vann, PhD, RN, assistant professor in the School of Nursing at the University of North Carolina at Chapel Hill, and colleagues determined that reminding adults that they or their children are due for a vaccination increases immunization uptake by approximately 8% compared with no reminders.

"We found that reminder and recall systems were effective for children, adolescents, and adults, in all types of medical or health settings, including private practices, academic medical centers, and public health department clinics, and for universally recommended vaccinations such as routine childhood vaccinations, as well as targeted vaccinations, such as influenza vaccine," the authors write in the review, published online in the Cochrane Library today.

Reminder systems notify patients a few days before their scheduled appointment, often by postcard, automated or manual telephone call, or text, whereas recall systems contact patients who have missed appointments and encourage them to reschedule.

For the review, the researchers included 75 studies of mixed design published through January 2017, looking at the effectiveness of reminders and recalls targeting children, adolescents, and adults. The outcome measures were receipt of any immunizations except special travel vaccines.

Based on 23 studies with 31,099 patients, the authors found with a high certainty of evidence that reminders are associated with a 22% relative increase in immunization rates for childhood vaccinations (95% confidence interval [CI], 1.15 - 1.29; risk difference, 8%). Similarly, data from 10 studies with 30,868 participants demonstrated a 29% relative increase for adolescent vaccinations (95% CI, 1.17 - 1.42; risk difference, 7%).

Data from five studies (9265 participants) show with moderate certainty that reminders are associated with a 51% relative increase in influenza vaccination rates among children (95% CI, 1.14 - 1.99; risk difference, 22%), and 15 studies (59,328 participants) indicated a 29% relative increase among adults (95% CI, 1.17 - 1.43; risk difference, 9%).

The data, however, are less clear on the benefit for other vaccines. A low certainty of evidence indicates that reminders improve vaccination rates for pneumococcus, tetanus, hepatitis B, and other noninfluenza vaccinations (risk ratio, 2.08, 95% CI, 0.91 to 4.78; four studies; 8065 participants).

Although all methods of reminder and recall communication appear to be effective, increasing immunization uptake from 5% to 20% relative to controls, "[t]elephone reminders were the most effective single intervention type, followed by letter reminders, which were somewhat more effective than text message, postcard, and autodialer interventions," the authors write. However, combining interventions did not increase immunization rates compared with single interventions.

In clinical practice, the choice of reminder or recall modality should reflect provider and practice needs and resources. "While person-to-person telephone reminders are most effective, they may also be more costly than other methods, and have not been studied extensively in children, except for the use of autodialers, which were found to have smaller but positive effects," the authors write. "Practical issues relevant to choices of reminder and recall systems include: characteristics of current computer systems, staffing, perceived accuracy of patient telephone numbers or addresses, availability of computer programmers, and estimated patient responsiveness to different types of reminders."

Based on the variation, immunization strategists should tailor interventions to their own settings and interpret the findings in this review with respect to their own setting. "For example, settings with widely used computerized immunization registries could adopt postcard reminders sent by the registries," the researchers suggest. "Practitioners today can tailor their own billing systems to function as reminder and recall systems for simple procedures, such as selecting all patients over 65 years of age for reminders about influenza or pneumococcal vaccination," they write, noting that many billing systems have tools for tracking immunization status.

Also to be considered is the complexity of the underlying rules driving the reminder/recall system, which will vary based on the target population. For example, adult patients with certain comorbidities may or may not be candidates for the same immunizations as their peers without the same health issues, the authors explain.

In addition to improving immunization rates, vaccination reminders and recall interventions may boost preventive health efforts. "Studies have shown that patients behind with immunizations are also behind in other measures of preventive care, and that reminder or recall systems targeting immunizations can also have 'spillover effects' to improve other aspects of preventive care, if they are used within primary care practices," Dr Jacobson Vann and colleagues write.

"The use of patient reminder and recall systems provides the primary care practitioner with real-life experience at practicing population-based care, by improving the care for the entire population served by the practice."

The researchers also point to research implications of the current findings, particularly around new and evolving technologies such as smart phone-based interventions. As some of the technologies included in the current review change and mature, they write, "researchers should consider how they can enhance reminder and recall interventions and what improvements in their effect can be achieved."

The authors have disclosed no relevant financial relationships.

Cochrane Database System Rev. 2018;1:CD003941. Abstract

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