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Living FRIendly Summaries of the Body of Evidence using Epistemonikos (FRISBEE)
Medwave 2020;20(06):e7962 doi: 10.5867/medwave.2020.06.7962
Multiple mail reminders to increase adherence to influenza vaccination
Camila Julio, Nicole Silva, Ángela Ortigoza
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Key Words: Vaccines, Reminder Systems, Primary health care, Epistemonikos, GRADE.

Abstract

INTRODUCTION
Different interventions have been proposed to reinforce the use of the influenza vaccine. The use of reminders, whether through letters, phone calls, pamphlets or technological applications, among others, has stood out among those aimed at increasing ad-herence to treatment. However, its effectiveness is not clear. In this summary, which is part of a series of reminder evaluations, we assess the use of multiple mail reminders.

METHODS
We conducted a search in Epistemonikos, the largest database of systematic health reviews, which is maintained by screening multiple sources of information, including MEDLINE, EMBASE, Cochrane, among others. We extracted the data from the identified reviews, analyzed the data from the primary studies, performed a meta-analysis and prepared a summary table of the results using the GRADE method.

RESULTS AND CONCLUSIONS
We identified eight systematic reviews including 35 primary studies, of which four analyze the use of more than one letter as a reminder. We conclude that the use of multiple mail reminders probably increase adherence to influenza vaccination in patients over 60; while it may make little or no difference in children under 6 years, but the certainty of the evidence is low.


 
Problem

Influenza is an acute respiratory disease caused by the influenza virus that can be prevented with a seasonal vaccine. Despite this, it remains an important cause of morbidity and mortality [1] since it is estimated that annual influenza epidemics cause 3-5 million serious cases of the disease and 290 000 to 650 000 deaths [2]. Additionally, these are associated with significant school and work absenteeism, generating significant productivity losses [2].
Various interventions have been proposed to increase the use of the influenza vaccine. Reminders can be provided through different communication channels: letters, phone calls, pamphlets or technological applications, among others. This article is part of a series of publications aimed at evaluating the use of reminders and will focus on the effects of sending two or more letters, postcards or pamphlet type reminders via traditional mail.

Methods

We conducted a search in Epistemonikos, the largest database of systematic health reviews, which is maintained through searches in multiple sources of information, including MEDLINE, EMBASE, Cochrane, among others. We extracted the data from the identified reviews and analyzed the data from the primary studies. With this information, we generate a structured summary called FRISBEE (Friendly Summaries of Body of Evidence using Epistemonikos), following a pre-established format, which includes key messages, a summary of the set of evidence (presented as an evidence matrix in Epistemonikos), meta-analysis of the total of the studies when possible, a summary table of results with the GRADE method and a section of other considerations for decision-making.

Key messages

  • Multiple mail reminders probably increase adherence to influenza vaccination in people over 60 years.
  • Multiple mail reminders may make little or no difference to adherence to influenza vaccination in children under six years.

About the body of evidence for this question

What is the evidence.
See evidence matrix  in Epistemonikos later

We found eight systematic reviews [3], [4], [5], [6], [7], [8], [9], [10] including 35 primary studies reported in 34 references [11], [12] , [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [ 25], [26], [27], [28], [29], [30], [31], [32], [33], [34], [35], [36], [37] , [38], [39], [40], [41], [42], [43], [44] of which, 32 are randomized trials reported in 31 references [11], [12], [13 ], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33], [34], [35], [36], [37], [38 ], [39], [40], [41].

Five trials were excluded [16], [18], [21], [33], [35] because they included co-interventions to increase influenza vaccination.

Twenty-two trials were excluded [11], [12], [13], [14], [15], [17], [20], [22], [23], [25], [26], [28 ], [29], [30], [32], [34], [36], [37], [38], [39], [40], [41] because the intervention consisted of a single mail reminder, which has already been analysed [45] .

In addition, observational studies [42], [43], [44] did not increase the certainty of the evidence, nor provided any additional relevant information.

This table and the summary in general are based on four randomized trials [19], [24], [27], [31].

What types of patients were included*

The trials included a total of 71 458 participants of all ages, including targeted risk population such as children over six months up to six years and adults over 60 years. 

Two trials included children [19], [24] and two trials included older adults (over 60 years old) [27], [31].

In general, the trials excluded patients who had already received the vaccine prior to the start of the trial, with egg allergy or participants living in nursing homes.

What types of interventions were included*

All trials evaluated the use of multiple reminders, defined as more than one reminder sent by traditional mail [24], [31], [19], [27].

All included trials compared against usual medical care.

What types of outcomes 
were measured
This systematic reviews identified only evaluated the adherence to the vaccine (influenza vaccination rate).
The average follow-up of the trials was seven months, ranging from six to 11 months.

* Information about primary studies is not extracted directly from primary studies but from identified systematic reviews, unless otherwise stated.

Summary of findings

Information on the effects of multiple mail reminders is based on four randomized trials that included 71 458 patients [19], [24], [27], [31].
Of these, two trials included population under 6 years with a total of 7 044 participants [19], [24], while the other two included population over 60 years with a total of 64 414 participants [27], [31].
All trials measured the outcome adherence to vaccination.

The summary of findings is as follows:

  • Multiple mail reminders probably increase adherence to influenza vaccination in people over 60 years.
  • Multiple mail reminders may make little or no difference to adherence to influenza vaccination in children under six years.

Follow the link to access the interactive version of this table (Interactive Summary of Findings – iSoF)

Other considerations for decision-making

To whom this evidence does and does not apply
  • The conclusions of this summary are applicable to children and adults over 60 years, and they are also considered to apply to general population. 
  • The evidence presented in this summary should not be extrapolated to participants allergic to influenza vaccine components.
  • These conclusions can be applied to any type of reminders sent more than once, at different times, combined or not with a postcard.
About the outcomes included in this summary
  • he outcomes selected are those considered critical for decision-making according to the opinion of the authors of this summary and generally coincide with those evaluated by the systematic reviews identified.
Balance between benefits and risks, and certainty of the evidence
  • Multiple mail reminders probably increase adherence to influenza vaccination in people over 60 years and may make, in children under six years, little or no difference to adherence to influenza vaccination.
  • However, there are certain limitations associated with the intervention evaluated, since the studies used pamphlets, letters and postcard reminders, varying both in the presentation of the information and its content (not reported). This heterogeneity in the intervention could explain the inconsistency found in the results of children under 6 years (I2 = 99%).
  • It should be noted that this is an intervention that should not pose any risk to the population.
Resource considerations
  • The costs of this intervention are very variable depending on the type of reminder, quantity and context where they are used.
  • Even though the intervention presents a favorable risk/benefit balance in the older population, the cost-effectiveness could vary according to the format, quantity and channel of delivery of the reminders.
What would patients and their doctors think about this intervention
  • In general, the use of reminders to prevent and promote health are well received by the population. Especially, when there are no direct costs associated to the patient.
  • From the point of view of healthcare workers or providers, the use of reminders would allow to implement a potentially effective preventive measure in the general population or in high-risk populations [8].
  • However, there may be some concerns regarding the use of vaccines in certain sectors of the population with certain values and preferences (lifestyles, religions, perceived lack of effectiveness, possible adverse effects, among others). This could influence decision making when assessing applicability and effectiveness of the intervention.

Differences between this summary and other sources
  • The conclusiones of this summary are consistent with those found in one of the systematic reviews [3], which analyzed the use of multiple mail reminders. Only one systematic review [8] reports that the intervention would be effective with a high certainty of the evidence, but it should be noted that it only included one [27]of the four trials analyzed in this summary.
  • The Task Force on Community Preventive Services [46] and Standards for immunization practices [47] guidelines recommend the use of reminders to increase adherence, without specifying the type or format of the reminder. The American Academy of Pediatrics [48] suggests that efforts should be devoted to the scope and infrastructure necessary to achieve optimal distribution of vaccines, so that more people are immunized.
Could this evidence change in the future?
  • The probability that future evidence changes the conclusions presented in this summary regarding older population is low. However, it is likely that the conclusions related to children do so, since the certainty of the evidence is low.
  • We identified one ongoing systematic review in the PROSPERO database [49] and one clinical trial in the International Clinical Trials Registry Platform [50] of the World Health Organization that could provide additional relevant information.

How we conducted this summary

Using automated and collaborative means, we compiled all the relevant evidence for the question of interest and we present it as a matrix of evidence.

 

Follow the link to access the interactive version: Mail reminders to increase adherence to influenza vaccination.

Notes

The upper portion of the matrix of evidence will display a warning of “new evidence” if new systematic reviews are published after the publication of this summary. Even though the project considers the periodical update of these summaries, users are invited to comment in Medwave or to contact the authors through email if they find new evidence and the summary should be updated earlier.

After creating an account in Epistemonikos, users will be able to save the matrixes and to receive automated notifications any time new evidence potentially relevant for the question appears.

This article is part of the Epistemonikos Evidence Synthesis project. It is elaborated with a pre-established methodology, following rigorous methodological standards and internal peer review process. Each of these articles corresponds to a summary, denominated FRISBEE (Friendly Summary of Body of Evidence using Epistemonikos), whose main objective is to synthesize the body of evidence for a specific question, with a friendly format to clinical professionals. Its main resources are based on the evidence matrix of Epistemonikos and analysis of results using GRADE methodology. Further details of the methods for developing this FRISBEE are described here (http://dx.doi.org/10.5867/medwave.2014.06.5997)

Epistemonikos foundation is a non-for-profit organization aiming to bring information closer to health decision-makers with technology. Its main development is Epistemonikos database (www.epistemonikos.org).

Potential conflicts of interest

The authors do not have relevant interests to declare.

Licencia Creative Commons Esta obra de Medwave está bajo una licencia Creative Commons Atribución-NoComercial 3.0 Unported. Esta licencia permite el uso, distribución y reproducción del artículo en cualquier medio, siempre y cuando se otorgue el crédito correspondiente al autor del artículo y al medio en que se publica, en este caso, Medwave.

 

INTRODUCCIÓN
Distintas intervenciones han sido propuestas para reforzar el uso de la vacuna contra la influenza. El uso de recordatorios, ya sea a través de cartas, llamadas telefónicas, panfletos o aplicaciones tecnológicas, entre otras, ha destacado dentro de aquellas orientadas a incrementar la adherencia al tratamiento. Sin embargo, su efectividad no está clara. En este resumen, que forma parte de una serie de evaluaciones de recordatorios, se abordará el envío de múltiples recordatorios enviados por correo.

MÉTODOS
Realizamos una búsqueda en Epistemonikos, la mayor base de datos de revisiones sistemáticas en salud, la cual es mantenida mediante el cribado de múltiples fuentes de información, incluyendo MEDLINE, EMBASE, Cochrane, entre otras. Extrajimos los datos desde las revisiones identificadas, analizamos los datos de los estudios primarios, realizamos un meta-análisis y prepara-mos una tabla de resumen de los resultados utilizando el método GRADE.

RESULTADOS Y CONCLUSIONES
Identificamos ocho revisiones sistemáticas que en conjunto incluyeron 35 estudios primarios, de los cuales cuatro corresponden a ensayos aleatorizados que analizan el uso de múltiples recordatorios enviados por correo. Concluimos que más de un recordatorio enviado por correo probablemente aumenta la adherencia a vacunación contra influenza en pacientes mayores de 60 años, mien-tras que podría resultar en poca o nula diferencia en menores de 6 años, pero la certeza de la evidencia es baja.

Authors: Camila Julio[1,2], Nicole Silva[1,2], Ángela Ortigoza[2,3]

Affiliation:
[1] Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile.
[2] Proyecto Epistemonikos, Santiago, Chile.
[3] Departamento de Medicina Familiar, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile.

E-mail: acortigoza@uc.com

Author address:
[1] Centro Evidencia UC
Pontificia Universidad Católica de Chile
Diagonal Paraguay 476
Santiago
Chile

Citation: Julio C, Silva N, Ortigoza A. Multiple mail reminders to increase adherence to influenza vaccination. Medwave 2020;20(06):e7962 doi: 10.5867/medwave.2020.06.7962

Submission date: 7/10/2019

Acceptance date: 19/12/2019

Publication date: 15/7/2020

Origin: This article is a product of the Evidence Synthesis Project of Epistemonikos Fundation, in collaboration with Medwave for its publication.

Type of review: Review not non-blind peers by the UC Evidence Center methodological team in collaboration with Epistemonikos Evidence Synthesis Project.

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Organización Mundial de la Salud [Internet]. [cited 2019 Ago 2]. | Link |

Organización Mundial de la Salud [Internet]. Noviembre 2018 [cited 2019 Ago 2]. | Link |

Aigbogun N.W. , Hawker J.I. , Stewart A. Interventions to increase influenza vaccination rates in children with high-risk conditions—A systematic review. Vaccine. 2015 Dic; (33): 759–770.

Jacobson Vann JC, Jacobson RM, Coyne-Beasley T, Asafu-Adjei JK, Szilagyi PG. Patient reminder and recall interventions to improve immunization rates (Review). Cochrane Database of Syst Rev. 2018, (1). | CrossRef |

Jones Cooper SN, Walton-Moss B. Using reminder/recall systems to improve influenza immunization rates in children with asthma. Journal of pediatric health care : official publication of National Association of Pediatric Nurse Associates & Practitioners. 2013;27(5):327-33.

Szilagyi PG, Bordley C, Vann JC, Chelminski A, Kraus RM, Margolis PA, Rodewald LE. Effect of patient reminder/recall interventions on immunization rates: A review. JAMA. 2000;284(14):1820-7.

Thomas RE, Russell ML, Lorenzetti DL. Systematic review of interventions to increase influenza vaccination rates of those 60 years and older. Vaccine. 2010;28(7):1684-701.

Thomas RE, Lorenzetti DL. Interventions to increase influenza vaccination rates of those 60 years and older in the community. The Cochrane database of syst rev. 2018;5:CD005188.

Ndiaye SM, Hopkins DP, Shefer AM, Hinman AR, Briss PA, Rodewald L, Willis B, Task Force on Community Preventive Services. Interventions to improve influenza, pneumococcal polysaccharide, and hepatitis B vaccination coverage among high-risk adults: a systematic review. American journal of preventive medicine. 2005;28(5 Suppl):248-79.

Sarnoff R, Rundall T. Meta-analysis of effectiveness of interventions to increase influenza immunization rates among high-risk population groups. MCRR. 1998;55(4):432-56.

Baker AM, McCarthy B, Gurley VF, Yood MU. Influenza immunization in a managed care organization. J Gen Intern Med. 1998;13(7):469-75.

Barnas GP, McKinney WP. Postcard reminders and influenza vaccination. Geriatrics. 1989;37(2):195.

Berg GD, Silverstein S, Thomas E, Korn AM. Cost and utilization avoidance with mail prompts: a randomized controlled trial. Am J Manag Care. 2008;14(11):748-54.

Brimberry R. Vaccination of high-risk patients for influenza. A comparison of telephone and mail reminder methods. The Journal of family practice. 1988;26(4):397-400.

Buchner DM, Larson EB, White RF. Influenza vaccination in community elderly. A controlled trial of postcard reminders. Geriatrics. 1987;35(8):755-60.

Carter WB, Beach LR, Inui TS. The flu shot study: using multiattribute utility theory to design a vaccination intervention. Organizational behavior and human decision processes.1986;38(3):378-91.

Centers for Disease Control and Prevention (CDC). Increasing influenza vaccination rates for Medicare beneficiaries--Montana and Wyoming, 1994. MMWR. 1995;44(40):744-6.

Clayton AE, McNutt LA, Homestead HL, Hartman TW, Senecal S. Public health in managed care: a randomized controlled trial of the effectiveness of postcard reminders. Am J Public Health. 1999;89(8):1235-7.

Daley MF, Barrow J, Pearson K, Crane LA, Gao D, Stevenson JM, Berman S, Kempe A. Identification and recall of children with chronic medical conditions for influenza vaccination. Pediatrics. 2004;113(1 Pt 1):e26-33.

Diaz Gravalos, GJ, Palmeiro, FG, Vazquez Fernandez, LA, Casado Gorriz, I, Fernandez Bernardez, MA, Sobrado Palomares, J. [Annual influenza vaccination. Causes of non-compliance among patients aged over 65 years]. Medifam - Revista de Medicina Familiar y Comunitaria. 1999;9(4):222-6.

Dietrich AJ, Duhamel M. Improving geriatric preventive care through a patient-held checklist. Family medicine. 1989;21(3):195-8.

Dombkowski KJ, Harrington LB, Dong S, Clark SJ. Seasonal influenza vaccination reminders for children with high-risk conditions: a registry-based randomized trial. American journal of preventive medicine. 2012;42(1):71-5.

Hogg WE, Bass M, Calonge N, Crouch H, Satenstein G. Randomized controlled study of customized preventive medicine reminder letters in a community practice. Can Fam Physician 1998;44:81-8.

Kempe A, Daley MF, Barrow J, Allred N, Hester N, Beaty BL, Crane LA, Pearson K, Berman S. Implementation of universal influenza immunization recommendations for healthy young children: results of a randomized, controlled trial with registry-based recall. Pediatrics. 2005;115(1):146-54.

Kemper KJ, Goldberg H. Do computer-generated reminder letters improve the rate of influenza immunization in an urban pediatric clinic?. American journal of diseases of children (1960). 1993;147(7):717-8.

Larson EB, Bergman J, Heidrich F, Alvin BL, Schneeweiss R. Do postcard reminders improve influenza compliance? A prospective trial of different postcard "cues". Medical care. 1982;20(6):639-48.

Maglione MA, Stone EG, Shekelle PG. Mass mailings have little effect on utilization of influenza vaccine among Medicare beneficiaries. American Journal of Preventive Medicine. 2002;23(1):43-6.

McCaul KD, Johnson RJ, Rothman AJ. The effects of framing and action instructions on whether older adults obtain flu shots. Health Psychol. 2002;21(6):624-8.

Minor DS, Eubanks JT, Butler KR, Wofford MR, Penman AD, Replogle WH. Improving influenza vaccination rates by targeting individuals not seeking early seasonal vaccination. Am J Med 2010;123(11):1031-5.

Moran WP, Nelson K, Wofford JL, Velez R, Case LD. Increasing influenza immunization among high-risk patients: education or financial incentive?.Am J Med. 1997;101(6):612-20.

Moran WP, Nelson K, Wofford JL, Velez R. Computer-generated mailed reminders for influenza immunization: a clinical trial. J Gen Intern Med. 1992;7(5):535-7.

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July 2022, Vol 22, Issue 6
icon Research papers
Association of biomarkers and severity of COVID-19: A crosssectional study

Systematization of initiatives in sexual and reproductive health about good practices criteria in response to the COVID-19 pandemic in primary health care in Chile

Clinical, psychological, social, and family characterization of suicidal behavior in Chilean adolescents: a multiple correspondence analysis

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