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Meta-Analysis
. 2019 Dec 18;12(12):CD001174.
doi: 10.1002/14651858.CD001174.pub4.

Manually-generated reminders delivered on paper: effects on professional practice and patient outcomes

Tomas Pantoja  1 , Jeremy M Grimshaw  2 , Nathalie Colomer  1 , Carla Castañon  1 , Javiera Leniz Martelli  1
Affiliations
Meta-Analysis

Manually-generated reminders delivered on paper: effects on professional practice and patient outcomes

Tomas Pantoja et al. Cochrane Database Syst Rev. .

Abstract

Background: Health professionals sometimes do not use the best evidence to treat their patients, in part due to unconscious acts of omission and information overload. Reminders help clinicians overcome these problems by prompting them to recall information that they already know, or by presenting information in a different and more accessible format. Manually-generated reminders delivered on paper are defined as information given to the health professional with each patient or encounter, provided on paper, in which no computer is involved in the production or delivery of the reminder. Manually-generated reminders delivered on paper are relatively cheap interventions, and are especially relevant in settings where electronic clinical records are not widely available and affordable. This review is one of three Cochrane Reviews focused on the effectiveness of reminders in health care.

Objectives: 1. To determine the effectiveness of manually-generated reminders delivered on paper in changing professional practice and improving patient outcomes. 2. To explore whether a number of potential effect modifiers influence the effectiveness of manually-generated reminders delivered on paper.

Search methods: We searched CENTRAL, MEDLINE, Embase, CINAHL and two trials registers on 5 December 2018. We searched grey literature, screened individual journals, conference proceedings and relevant systematic reviews, and reviewed reference lists and cited references of included studies.

Selection criteria: We included randomised and non-randomised trials assessing the impact of manually-generated reminders delivered on paper as a single intervention (compared with usual care) or added to one or more co-interventions as a multicomponent intervention (compared with the co-intervention(s) without the reminder component) on professional practice or patients' outcomes. We also included randomised and non-randomised trials comparing manually-generated reminders with other quality improvement (QI) interventions.

Data collection and analysis: Two review authors screened studies for eligibility and abstracted data independently. We extracted the primary outcome as defined by the authors or calculated the median effect size across all reported outcomes in each study. We then calculated the median percentage improvement and interquartile range across the included studies that reported improvement related outcomes, and assessed the certainty of the evidence using the GRADE approach.

Main results: We identified 63 studies (41 cluster-randomised trials, 18 individual randomised trials, and four non-randomised trials) that met all inclusion criteria. Fifty-seven studies reported usable data (64 comparisons). The studies were mainly located in North America (42 studies) and the UK (eight studies). Fifty-four studies took place in outpatient/ambulatory settings. The clinical areas most commonly targeted were cardiovascular disease management (11 studies), cancer screening (10 studies) and preventive care (10 studies), and most studies had physicians as their target population (57 studies). General management of a clinical condition (17 studies), test-ordering (14 studies) and prescription (10 studies) were the behaviours more commonly targeted by the intervention. Forty-eight studies reported changes in professional practice measured as dichotomous process adherence outcomes (e.g. compliance with guidelines recommendations), 16 reported those changes measured as continuous process-of-care outcomes (e.g. number of days with catheters), eight reported dichotomous patient outcomes (e.g. mortality rates) and five reported continuous patient outcomes (e.g. mean systolic blood pressure). Manually-generated reminders delivered on paper probably improve professional practice measured as dichotomous process adherence outcomes) compared with usual care (median improvement 8.45% (IQR 2.54% to 20.58%); 39 comparisons, 40,346 participants; moderate certainty of evidence) and may make little or no difference to continuous process-of-care outcomes (8 comparisons, 3263 participants; low certainty of evidence). Adding manually-generated paper reminders to one or more QI co-interventions may slightly improve professional practice measured as dichotomous process adherence outcomes (median improvement 4.24% (IQR -1.09% to 5.50%); 12 comparisons, 25,359 participants; low certainty of evidence) and probably slightly improve professional practice measured as continuous outcomes (median improvement 0.28 (IQR 0.04 to 0.51); 2 comparisons, 12,372 participants; moderate certainty of evidence). Compared with other QI interventions, manually-generated reminders may slightly decrease professional practice measured as process adherence outcomes (median decrease 7.9% (IQR -0.7% to 11%); 14 comparisons, 21,274 participants; low certainty of evidence). We are uncertain whether manually-generated reminders delivered on paper, compared with usual care or with other QI intervention, lead to better or worse patient outcomes (dichotomous or continuous), as the certainty of the evidence is very low (10 studies, 13 comparisons). Reminders added to other QI interventions may make little or no difference to patient outcomes (dichotomous or continuous) compared with the QI alone (2 studies, 2 comparisons). Regarding resource use, studies reported additional costs per additional point of effectiveness gained, but because of the different currencies and years used the relevance of those figures is uncertain. None of the included studies reported outcomes related to harms or adverse effects.

Authors' conclusions: Manually-generated reminders delivered on paper as a single intervention probably lead to small to moderate increases in outcomes related to adherence to clinical recommendations, and they could be used as a single QI intervention. It is uncertain whether reminders should be added to other QI intervention already in place in the health system, although the effects may be positive. If other QI interventions, such as patient or computerised reminders, are available, they should be preferred over manually-generated reminders, but under close evaluation in order to decrease uncertainty about their potential effect.

PubMed Disclaimer

Conflict of interest statement

TP is an editor with the Cochrane Effective Practice and Organisation of Care (EPOC) group.

JMG: none known.

NC: none known.

CC: none known.

JLM: none known.

Figures

1
1
Study flow diagram (Moher 2009)
2
2
A reminder to improve the adherence to lipid guidelines (Hung 2008)
3
3
A reminder to improve osteoporosis screening (Levy 2009)
4
4
A reminder to increase asthma guidelines knowledge and implementation by primary care physicians (Renzi 2006)
5
5
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
6
6
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
7
7
Reminders versus control/usual care: absolute improvements in processes of care outcomes by study using the primary outcome as defined by authors (red dot) and median improvement (blue dot)
8
8
Reminders versus control/usual care: median effects for process of care (adherence) outcomes by reminder feature (p values are from Kruskall‐Wallis and Mann‐Whitney tests)
9
9
Reminders versus control/usual care: median effects for process of care (adherence) outcomes by study feature care (p‐values are from Mann‐Whitney test)
10
10
Reminders plus another QI intervention versus another QI intervention: absolute improvements in processes of care outcomes by study using the primary outcome as defined by authors (red dot) and median improvement (blue dot)
11
11
Reminders plus another QI intervention versus another QI intervention:median effects for process adherence outcomes by reminder feature (p values are from Kruskall‐Wallis and Mann‐Whitney tests)
12
12
Reminders plus another QI intervention versus another QI intervention: median effects for process adherence outcomes by study feature (p values are from Kruskall‐Wallis and Mann‐Whitney tests)
13
13
Reminders versus another QI interventions: absolute improvements in processes of care outcomes by study using the primary outcome as defined by authors (red dot) and median improvement (blue dot)
14
14
Reminders versus another QI interventions: median effects for process adherence outcomes by reminder feature (p values are from Kruskall‐Wallis and Mann‐Whitney tests)
15
15
Reminders versus another QI interventions: median effects for process adherence outcomes by study feature (p values are from Kruskall‐Wallis and Mann‐Whitney tests)
See this image and copyright information in PMC

Update of

  • doi: 10.1002/14651858.CD001174.pub3

References

References to studies included in this review

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References to studies excluded from this review

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NCT00355004 2013 {published data only}
    1. NCT00355004. Computerized and mailed reminders in increasing the rate of colorectal cancer screening in adults with an average risk for colorectal cancer. clinicaltrials.gov/ct2/show/NCT00355004 (first received 20 July 2006).
NCT00699439 2009 {published data only}
    1. NCT00699439. A reminder system for paper‐based asthma guidelines in the pediatric emergency department. clinicaltrials.gov/ct2/show/NCT00699439 (first received 18 June 2008).
NCT01057888 2015 {published data only}
    1. NCT01057888. Evaluation of vaccination reminder/recall systems for adolescent patients. clinicaltrials.gov/ct2/show/NCT00715234 (first received 15 July 2008).
NCT01126034 2015 {published data only}
    1. NCT01126034. Improving metoclopramide prescribing practices at Penn through a physician‐targeted intervention. clinicaltrials.gov/ct2/show/NCT01126034 (first received 19 May 2010).
NCT01207232 2010 {published data only}
    1. NCT01207232. The effect of a planning prompt on seasonal influenza vaccination rates. clinicaltrials.gov/ct2/show/NCT01207232 ((first received 22 September 2010).
NCT01325116 2014 {published data only}
    1. NCT01325116. Delayed educational reminders in acute myocardial infarction (MI). clinicaltrials.gov/ct2/show/NCT01325116 (first received 29 March 2011).
NCT01352390 2017 {published data only}
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NCT01401621 2015 {published data only}
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References to other published versions of this review

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