Vaccination Programs: Provider Reminders

This review was conducted on behalf of the CPSTF by a team of specialists in systematic review methods, and in research, practice and policy related to increasing appropriate vaccination.

The systematic review included 28 studies.

• Overall vaccination rates increased by a median of 10 percentage points (22 studies).
  • Provider reminders used alone increased vaccination rates by a median of 12 percentage points (7 studies).
  • Provider reminders used with additional interventions increased vaccination rates by a median of 9 percentage points (15 studies).
• Of the six studies that did not provide a common measure of change for vaccination rates, five reported favorable results.

Four studies were included in the economic review (search period 1980 2012). All monetary values are reported in 2013 U.S. dollars.

• The median intervention cost was $7 per person per year (3 studies).
• The median cost per additional vaccinated person was $309 (3 studies).
• The cost tended to be higher for interventions that used a manual process instead of an immunization information system.
• The median intervention group size was 2,910 clients (4 studies).
• Three were from the U.S. and one was from Canada. Studies examined intervention effectiveness on uptake of influenza or pneumococcal vaccinations (2 studies), tetanus vaccinations (1 study), and the childhood series (1 study).

• What are effectiveness, cost-effectiveness, and utility of system-level implementation of provider reminder interventions including regional or state-level immunization information systems (IIS)?
• What are the strategies encourage regular and sustained use of reminder systems?
• How effective are these interventions for adolescent populations?
• What is the effectiveness of provider reminders in communities with disparities in vaccination rates?

• Included studies were conducted in a wide range of clinical vaccination settings including private practices, community health centers, ambulatory care clinics, and hospitals.
• Studies focused on uptake of different vaccinations including tetanus for adults and the childhood series.

Effectiveness Review

Analytic Framework

When starting an effectiveness review, the systematic review team develops an analytic framework. The analytic framework illustrates how the intervention approach is thought to affect public health. It guides the search for evidence and may be used to summarize the evidence collected. The analytic framework often includes intermediate outcomes, potential effect modifiers, potential harms, and potential additional benefits.

Economic Review

No content is available for this section.

Effectiveness Review

Summary Evidence Table – Effectiveness Review

Economic Review

No content is available for this section.

Effectiveness Review

Britto MT, Pandzik GM, Meeks CS, Kotagal UR. Combining evidence and diffusion of innovation theory to enhance influenza immunization. Joint Commission Journal on Quality and Patient Safety 2006;32(8):426-32.

Burns IT, Zimmerman RK, Santibanez TA. Effectiveness of chart prompt about immunizations in an urban health center. J Fam Pract 2002;51(12):1018.

Chan L, MacLehose RF, Houck PM. Impact of physician reminders on the use of influenza vaccinations: a randomized trial. Archives of Physical Medicine and Rehabilitation 2002; 83:371-375.

Coyle CM, Currie BP. Improving the rates of inpatient pneumococcal vaccination: impact of standing orders versus computerized reminders to physicians. Infection Control & Hospital Epidemiology 2004;25(11):904 -7.

Dexheimer JW, Talbot TR, Ye F, et al. A computerized pneumococcal vaccination reminder system in the adult emergency department. Vaccine 2011;29(40):7035-41. doi:10.1016/j.vaccine.2011.07.032.

Dexter PR, Perkins SM, Overhage JM, Maharry KS, Kohler RB, McDonald CJ. A computerized reminder system to increase the use of preventive care for hospitalized patients. New Engl J Med 2001;345(13):965-70.

Dexter PR, Perkins SM, Maharry KS, Jones K, McDonald CJ. Inpatient computer-based standing orders vs physician reminders to increase influenza and pneumococcal vaccination rates: a randomized trial. JAMA 2004;292:2366-71.

Dubey V, Mathew R, Iglar K, Moineddin R, Glazier R. Improving preventive service delivery at adult complete health check-ups: the preventive health evidence-based recommendation form (PERFORM) cluster randomized controlled trial. BMC Fam Pract 2006;7:44.

Fiks AG, Hunter KF, Localio AR, et al. Impact of electronic health record-based alerts on influenza vaccination for children with asthma. Pediatrics 2009;124(1):159-69.

Fishbein DB, Willis BC, Cassidy WM, Marioneaux D, Winston CA. A comprehensive patient assessment and physician reminder tool for adult immunization: effect on vaccine administration. Vaccine 2006;24:3971-83.

Flanagan JR, Doebbeling BN, Dawson J, Beekmann S. Randomized study of online vaccine reminders in adult primary care. Proceedings / AMIA Annual Symposium AMIA Symposium 1999;755-9.

Gill JM, Saldarriaga AM. The impact of a computerized physician reminder and a mailed patient reminder on influenza immunizations for older patients. Delaware Medical Journal 2000;72(10):425 -30.

Hambidge SJ, Davidson AJ, Phibbs SL, Chandramouli V, Zerbe G, LeBaron CW et al. Strategies to improve immunization rates and well-child care in a disadvantaged population: a cluster randomized controlled trial. Arch Pediatr Adolesc Med 2004;158(2):162-9.

Hogg W, Bass MJ, Colange N, Crouch H, Satenstein G. Randomized controlled study of customized preventive medicine reminder letters in a community practice. Canadian Family Physician 1998;44:81-8.

Honeycutt AA, Coleman MS, Anderson WL, Wirth KE. Cost-effectiveness of hospital vaccination programs in North Carolina. Vaccine 2007;25(8):1484 -96.

Humiston SG, Bennett NM, Long C, et al. Increasing inner-city adult influenza vaccination rates: a randomized controlled trial. Public Health Reports 2011;126:39-47.

Latessa RA, Cummings DM, Lilley SH, Morrissey SL. Changing practices in the use of pneumococcal vaccine. Family Medicine 2000; 32(3):196-200.

MacIntyre CR, Kainer MA, Brown GV. A randomised, clinical trial comparing the effectiveness of hospital and community-based reminder systems for increasing uptake of influenza and pneumococcal vaccine in hospitalised patients aged 65 years and over. Gerontology 2003; 49:33-40.

Margolis PA, Lannon CM, Stuart JM, Fried BJ, Keyes EL, Moore DE. Practice based education to improve delivery systems for prevention in primary care: randomised trial. BMJ 2004; 328:388.

Mason BW, Donnelly PD. Targeted mailing of information to improve uptake of measles, mumps, and rubella vaccine: a randomised controlled trial. Commun Dis Public Health 2000;3(1):67-8.

Muehleisen B, Baer G, Schaad UB, Heininger U. Assessment of immunization status in hospitalized children followed by counseling of parents and primary care physicians improves vaccination coverage: an interventional study. Journal of Pediatrics 2007; 151(6):704-6.

Nowalk MP, Middleton DB, Zimmerman RK, Hess MM, Skledar SJ, Jacobs MA. Increasing pneumococcal vaccination rates among hospitalized patients. Infection Control & Hospital Epidemiology 2003;24(7):526-31.

Patwardhan A, Kelleher K, Cunningham D, Spencer C. Improving the influenza vaccination rate in patients visiting pediatric rheumatology clinics using automatic best practice alert in electronic patient records. Pediatric Rheumatology 2012;10(Suppl 1):A106.

Rhew DC, Glassman PA, Goetz MB. Improving pneumococcal vaccine rates. Nurse protocols versus clinical reminders. Journal of General Internal Medicine 1999;14:351-6.

Shaw JS, Samuels RC, Larusso EM, Bernstein HH. Impact of an encounter-based prompting system on resident vaccine administration performance and immunization knowledge. Pediatrics 2000; 105:978-83.

Shevlin JD, Summers BC, Thomas D, Whitney CG, Todd D, Ray SM. A systematic approach for increasing pneumococcal vaccination rates at an inner-city public hospital. American Journal of Preventive Medicine 2002;22:92-7.

Tang PC, LaRosa MP, Newcomb C, Gorden SM. Measuring the effects of reminders for outpatient influenza immunizations at the point of clinical opportunity. Journal of the American Medical Informatics Association 1999;(2):115-21.

Zimmerman RK, Hoberman A, Nowalk MP, Lin CJ, Greenberg DP, Weinberg ST et al. Improving influenza vaccination rates of high-risk inner-city children over 2 intervention years. Annals of Family Medicine 2006;4(6):534-40.

Economic Review

Bell LM, Pritchard M, Anderko R, Levenson R. A program to immunize hospitalized preschool-aged children: evaluation and impact. Pediatrics 1997;100(2):192. http://dx.doi.org/10.1542/peds.100.2.192.

Frame PS, Zimmer JG, Werth PL, Hall WJ, Eberly SW. Computer-based vs manual health maintenance tracking: a controlled trial. Arch Fam Med 1994;3(7):581. http://dx.doi.org/10.1001/archfami.3.7.581.

Honeycutt AA, Coleman MS, Anderson WL, Wirth KE. Cost-effectiveness of hospital vaccination programs in North Carolina. Vaccine 2007;25(8):1484-96. http://dx.doi.org/10.1016/j.vaccine.2006.10.029.

Rosser WW, Hutchison BG, McDowell I, Newell C. Use of reminders to increase compliance with tetanus booster vaccination. CMAJ 1992;146(6):911.

Shevlin JD, Summers-Bean C, Thomas D, Whitney CG, Todd D, Ray SM. A systematic approach for increasing pneumococcal vaccination rates at an inner-city public hospital. Am J Prev Med 2002;22(2):92-7. http://dx.doi.org/10.1016/S0749-3797(01)00408-1.

Effectiveness Review

The CPSTF findings are based on studies included in the original review (search period 1980-1997) combined with studies identified in the updated search (search period 1997- February 2012). Reference lists of articles reviewed as well as lists in review articles were also searched, and members of our coordination team were consulted for additional references.

Details of the original search (1980-1997)

The following five electronic databases were searched during the original review period of 1980 up to 1997: MEDLINE, Embase, Psychlit, CAB Health, and Sociological Abstracts. The team also reviewed reference lists in articles and consulted with immunization experts. To be included in the review, a study had to:

• have a publication date of 1980 1997;
• address universally recommended adult, adolescent, or childhood vaccinations;
• be a primary study rather than, for example, a guideline or review;
• take place in an industrialized country or countries;
• be written in English;
• meet the evidence review and Guide chapter development team’s definition of the interventions; provide information on one or more outcomes related to the analytic frameworks; and
• compare a group of persons who had been exposed to the intervention with a group who had not been exposed or who had been less exposed. In addition, we excluded studies with least suitable designs for two interventions (provider reminder/recall and client reminder/recall) where the literature was most extensive.

Details of the update search (1997- February 2012)

The team conducted a broad literature search to identify studies assessing the effectiveness of Vaccine Preventable Disease interventions in improving vaccination rates. The following nine databases were searched during the period of 1997 up to February 2012: CABI, CINAHL, The Cochrane Library, EMBASE, ERIC, MEDLINE, PSYCHINFO, Soci Abs and WOS. Reference lists of articles reviewed as well as lists in review articles were also searched, and subject matter experts consulted for additional references. To be included in the updated review, a study had to:

• have a publication date of 1997- February 2012;
• evaluate vaccinations with universal recommendations;
• meet the evidence review and Guide chapter development team’s definition of the interventions;
• be a primary research study with one or more outcomes related to the analytic frameworks;
• take place in an high income country or countries;
• be written in English
• compare a group of persons who had been exposed to the intervention with a group who had not been exposed or who had been less exposed. In addition, we excluded studies with least suitable designs for two interventions (provider reminder/recall and client reminder/recall) where the literature was most extensive

Search Terms

1. Immunization
2. Vaccination
3. Immunization Programs

Economic Review

The present review included studies that reported economic outcomes from the 2000 review (search period 1980-1997) combined with studies identified from updated searches (search period 1997- February 2012) within the standard medical and health-related research databases, Google Scholar, and databases specialized to economics and social sciences. The details of the two sets of searches are provided below.

Details of the Updated Search (1997- February 2012)

The team conducted a broad literature search to identify studies assessing interventions to improve vaccination rates. The following nine databases were searched during the period of 1997 up to February 2012: CABI, CINAHL, The Cochrane Library, EMBASE, ERIC, MEDLINE, PSYCHINFO, Soci Abs and WOS. In addition, Google Scholar and specialized databases (CRD-University of York: NHS EED, EconLit, and JSTOR), were also searched. Reference lists of articles reviewed as well as lists in review articles were also considered, and subject matter experts consulted for additional references.

Search Terms

• Immunization
• Vaccination
• Immunization Programs

To be included in the updated review, a study had to do the following:

• Have a publication date of 1997- February 2012
• Evaluate vaccinations with universal recommendations
• Meet the evidence review and Community Guide review team’s definition of the interventions
• Be a primary research study with one or more outcomes related to the analytic framework(s)
• Take place in a high income country or countries
• Be written in English; and
• Compare a group of persons who had been exposed to the intervention with a group who had not been exposed or who had been less exposed.

Details of the Original Search (1980-1997)

The following five electronic databases were searched during the original review period of 1980 up to 1997: MEDLINE, Embase, Psychlit, CAB Health, and Sociological Abstracts. The team also reviewed reference lists in articles and consulted with immunization experts. To be included, a study had to do the following:

• Have a publication date of 1980 1997
• Address universally recommended adult, adolescent, or childhood vaccinations
• Be a primary study rather than, for example, a guideline or review
• Take place in an industrialized country or countries
• Be written in English
• Meet the definition of the interventions
• Provide information on one or more outcomes related to the analytic frameworks; and
• Compare a group of persons who had been exposed to the intervention with a group who had not been exposed or who had been less exposed. In addition, we excluded studies with least suitable designs for two interventions (provider reminder/recall and client reminder/recall) where the literature was most extensive.

• A subset of the included studies suggests that standing orders may be more effective than provider reminder systems in improving vaccination rates in both inpatient and outpatient settings.

Evidence-Based Cancer Control Programs (EBCCP)

Find programs from the EBCCP website that align with this systematic review. (What is EBCCP?)

Healthy People 2030

Healthy People 2030 includes the following objectives related to this CPSTF recommendation.

• Reduce the proportion of children who get no recommended vaccines by age 2 years — IID‑02
• Maintain the vaccination coverage level of 1 dose of the MMR vaccine in children by age 2 years — IID‑03
• Maintain the vaccination coverage level of 2 doses of the MMR vaccine for children in kindergarten — IID‑04
• Increase the coverage level of 4 doses of the DTaP vaccine in children by age 2 years — IID‑06
• Increase the proportion of people who get the flu vaccine every year — IID‑09
• Increase the proportion of adults age 19 years or older who get recommended vaccines — IID‑D03