Patient reminder and recall systems 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 of low immunization rates, 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 physicians, it is important to understand and promote interventions that work in primary care settings to increase immunization coverage. A common theme across immunization programs in all nations involves the challenge of determining the denominator of eligible recipients (e.g. all children who should receive the measles vaccine), and identifying the best strategy to ensure high vaccination rates. Strategies have focused on patient-oriented interventions (e.g. patient reminders), provider interventions, and system interventions. One intervention strategy involves patient reminder and recall systems.

Objectives

To assess the effectiveness of patient reminder and recall systems in improving immunization rates, and compare the effects of various types of reminders in different settings or patient populations.

Search methods

A systematic search was performed for the initial review using MEDLINE (1966-1998) and 4 other bibliographic databases: EMBASE, PsychINFO, Sociological Abstracts, and CAB Abstracts. Authors also performed a search of The Effective Practice and Organisation of Care (EPOC) register in April 2001 to update the review. Two authors reviewed the lists of titles and abstracts, and used the inclusion criteria to mark potentially relevant articles for full review. The reference lists of all relevant articles and reviews were back searched for additional studies. Publications of abstracts, proceedings from scientific meetings, and files of study collaborators were also searched for references. In May 2007 the EPOC register was searched to identify relevant articles to update the review. In May 2007, the EPOC register search was supplemented by searches of CINAHL and PubMed. One study was identified through prior knowledge of this study.

Selection criteria

Study Design
Randomized controlled trials (RCT), controlled before and after studies (CBA), and interrupted time series (ITS) studies written in English.

Types of participants
Health care personnel who deliver immunizations and children (birth to 18 years) or adults (18 years and up) who receive immunizations in any setting.

Types of interventions
Any intervention that falls within the EPOC scope and that includes patient reminder or recall systems, or both, in at least one arm of the study.

Types of outcome measures
Immunization rates, or the proportion of the target population up-to-date on recommended immunizations. Outcomes were acceptable for either individual vaccinations (e.g. influenza vaccination) or standard combinations of recommended vaccinations (e.g. all recommended vaccinations by a specific date or age).

Data collection and analysis

Data Collection
Each study was read independently by two reviewers. Disagreements between reviewers were resolved by a formal reconciliation process to achieve consensus.

Analysis
Results are presented for individual studies as relative rates for randomized controlled trials, and as absolute changes in percentage points for controlled before and after studies. Pooled results for RCTs only were for presented using the random effects model.

Main results

Four new studies were added for the 2007 update for a total of 47 studies. Increases in immunization rates due to reminders were in the range of 1 to 20 percentage points. Reminders were effective for childhood vaccinations (OR = 1.47, 95% CI =1.28, 1.68), childhood influenza vaccinations (OR = 2.18, 95% CI = 1.29, 3.70), adult pneumococcus, tetanus, and Hepatitis B (OR = 2.19, 95%CI = 1.21, 3.99), and adult influenza vaccinations (OR = 1.66, 95% CI = 1.31, 2.09). The effectiveness of patient reminders for childhood influenza vaccinations declined overall from an odds ratio of 2.87 in the previous review. However, reminders were not effective in the one new study of adolescent immunizations in an urban setting (OR = 1.14, 95% CI = 0.98, 1.31). All types of reminders were effective (postcards, letters, telephone or autodialer calls), with telephone being the most effective but also the most costly.

Authors' conclusions

Patient reminder and recall systems in primary care settings are effective in improving immunization rates in developed countries.

 

Plain language summary

Does reminding people to have vaccinations increase the number of people who receive vaccinations?

Increasing the number of people who are vaccinated could lower death and disease rates throughout the world. Many strategies to increase vaccinations have been used. One way is to remind people to receive their vaccinations. This review of 47 studies evaluated whether reminding people worked.

This review found that reminding people to have vaccinations increased the number of people vaccinated, whether the people were due or overdue for vaccinations. The increases were observed in both children and adults for all types of vaccines, but not among urban adolescents in one study. Reminding people over the telephone, sending a letter or postcard, or speaking to them in person increased vaccinations. Providing numerous reminders was more effective than single reminders. Reminding people over the telephone was more effective than postcard or letter reminders, but reminders over the telephone may be expensive compared with alternative approaches. Reminders also worked whether it was from a private doctor's office, a medical center, or a public health department clinic. The studies in this review were from developed countries; and, it is therefore not clear whether reminders to patients would work in low- and middle-income countries.

 

摘要

背景

促進免疫接種率的病患提醒與病患召回系統

兒童與成人的免疫接種率有提升，但涵蓋的程度未達到最終的目標。由於免疫接種率低，預防性疫苗的疾病仍會發生。在免疫接種程序愈來愈複雜的現在，對於初級照護與大量的初級照護醫師的需求有愈來愈多的期望，重要的是了解並促進介入措施在初級照護機構中增加免疫接種涵蓋範圍的作用。各國的免疫接種計畫中普遍的主題是關於決定合格接種者的分母(如所有的小孩都應接種麻疹疫苗)，以及找到能夠確保高接種率的最佳策略。目前的策略有以病人為導向的介入措施(例如，病患提醒)，提供者的介入措施與系統介入措施。有一種介入策略關於病患提醒與召回系統。

目標

評估病患提醒與召回系統對於促進免疫接種率的效果，並比較各類的提醒方式在不同機構或患者族群中的影響。

搜尋策略

系統性檢索採用MEDLINE (1966 – 1998年)以及四個其他的書目資料庫：EMBASE，PsychINFO，Sociological Abstracts，及CAB Abstracts。另外作者也在2001年4月檢索The Effective Practice and Organisation of Care (EPOC)登記資料庫以更新回顧。兩名作者檢視標題與摘要，並使用納入標準標示可能相關的文章以進行全文回顧。回頭檢索所有相關文章與回顧的參考文獻以獲得其他研究。另外也檢索發表的摘要，科學會議記錄與研究合作者的文件以獲得參考文獻。在2004年12月檢索the EPOC登記資料庫以尋找相關的文章來更新回顧。

選擇標準

研究設計：以英文書寫的隨機對照試驗(DesignRandomized controlled trials (RCT))，前後對照研究(controlled before and after studies (CBA))與間斷時間序列(interrupted time series (ITS))研究。研究對象：任何機構中提供免疫接種的健康照護人員以及接受免疫接種的兒童(出生後至18歲)或成人(18歲以上)。介入措施：EPOC範圍內的所有介入措施(詳見各組的細節)，以及包括病患提醒或召回系統或兩者，研究中需包含至少一種介入措施。測量結果：免疫接種率或目標族群接種最新建議的免疫疫苗的比例。可接受的結果為個別的疫苗(如感冒疫苗)或建議疫苗的標準組合(如特定日期或年齡的所有建議的疫苗)。

資料收集與分析

資料蒐集：由兩名回顧者分別閱讀每一篇研究。回顧者間不一致的看法經由正式的調解過程以達成共識。分析：個別隨機對照試驗的結果以相對比率呈現，而前後對照研究的結果則以百分點的絕對改變量呈現。採用隨機效果模式加總RCTs的結果。

主要結論

這篇更新的回顧加入了五篇新的研究。因為提醒使免疫接種率增加了1至20個百分點。提醒對於兒童疫苗(OR = 1.45，95% CI = 1.28至1.66)，兒童感冒疫苗(OR = 2.87，95% CI = 1.65至4.98)，成人肺炎鏈球菌，破傷風，及B型肝炎(OR = 2.19，95% CI = 1.21至3.99)，以及成人感冒疫苗(OR = 1.66，95% CI = 1.31至2.09)有效。所有類型的提醒方式都是有效的(明信片，信件，電訪或自動撥號)，電訪是最有效的方式但成本最高。

作者結論

基層照護機構中的病患提醒與召回系統可以有效促進已開發國家的免疫接種率。

翻譯人

本摘要由高雄榮民總醫院金沁琳翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

提醒民眾可以增加民眾接種疫苗的人數嗎？增加接種疫苗的人數可以降低世界各地的死亡與疾病率。目前有許多策略用來增加疫苗接種。其中一種方法就是提醒民眾接種疫苗。這篇包含43篇研究的回顧評估是否提醒民眾是有效的方式。這篇回顧發現提醒民眾會增加民眾接種疫苗的人數，不論是預定或逾期接種疫苗。兒童與成人接種各種類型的疫苗人數都會增加。透過電話提醒民眾，發送信件或明信片，或當面告知會增加疫苗接種。提供許多提醒並透過電話提醒民眾是最有效的方式，但費用也最昂貴。不論是來自私人的醫師診所，醫學中心或公共衛生診所，提醒都能發揮作用。這篇回顧的研究都是來自已開發國家，因此不清楚是否提醒在中低收入國家中也能發揮作用。