Changing clinical practice through patient specific reminders available at the time of the clinical encounter: systematic review and meta-analysis

Abstract

Objective: To synthesise current evidence for the influence on clinical behaviour of patient-specific electronically generated reminders available at the time of the clinical encounter.

Data sources: PubMed, Cochrane library of systematic reviews; Science Citation Index Expanded; Social Sciences Citation Index; ASSIA; EMBASE; CINAHL; DARE; HMIC were searched for relevant articles.

Study eligibility criteria, participants and interventions: We included controlled trials of reminder interventions if the intervention was: directed at clinician behaviour; available during the clinical encounter; computer generated (including computer generated paper-based reminders); and generated by patient-specific (rather than condition specific or drug specific) data.

Study appraisal and synthesis methods: Systematic review and meta-analysis of controlled trials published since 1970. A random effects model was used to derive a pooled odds ratio for adherence to recommended care or achievement of target outcome. Subgroups were examined based on area of care and study design. Odds ratios were derived for each sub-group. We examined the designs, settings and other features of reminders looking for factors associated with a consistent effect.

Results: Altogether, 42 papers met the inclusion criteria. The studies were of variable quality and some were affected by unit of analysis errors due to a failure to account for clustering. An overall odds ratio of 1.79 [95% confidence interval 1.56, 2.05] in favour of reminders was derived. Heterogeneity was high and factors predicting effect size were difficult to identify.

Limitations: Methodological diversity added to statistical heterogeneity as an obstacle to meta-analysis. The quality of included studies was variable and in some reports procedural details were lacking.

Conclusions and implications of key findings: The analysis suggests a moderate effect of electronically generated, individually tailored reminders on clinician behaviour during the clinical encounter. Future research should concentrate on identifying the features of reminder interventions most likely to result in the target behaviour.

Figure 1.

PRISMA flow diagram for systematic review.

Figure 2.

Forest plot of all studies (44 comparisons) reporting binary outcomes, grouped by area of care. These are based on raw extracted data prior to our adjustment for clustering.

Figure 3.

Forest plot of all studies reporting binary outcomes, grouped according to presence or absence of a unit of analysis (UoA) issue, with correction to account for clustering in the first group. In the published source papers a similar correction had been applied to some but not all of these by the authors.

Figure 4.

Risk of bias tables (a) for each study (b) aggregated.