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Background: Excessive exposure to ultraviolet radiation increases the risk of skin cancer and other conditions. SMS text reminders may be a useful tool to improve sun protection habits due to its massive reach, low cost, and accessibility., Objective: To perform a systematic review of randomized controlled trials (RCTs) that evaluated the effects of SMS text reminders in promoting sun protection habits., Methods: We performed a systematic search in PubMed, Central Cochrane Library, and Scopus; following the PRISMA recommendations to perform systematic reviews. We included RCTs published up to December 2018, which evaluated the benefits and harms of SMS text reminders to improve sun protection habits. Random-effects meta-analyses were performed whenever possible. The certainty of the evidence was assessed for RCTs estimates using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. The study protocol was registered in PROSPERO (CRD42018091661)., Results: Five RCTs were included in this review. When pooled, the studies found no effect of SMS text reminders in "sunburn anytime during follow-up" (two studies, risk ratio: 0.93; 95% confidence interval: 0.83-1.05). Contradictory results were obtained for sunscreen use (three RCTs) and sun protection habits (two RCTs), however, they could not be meta-analyzed because outcomes were measured differently across studies. The certainty of the evidence was very low for these three outcomes according to GRADE methodology., Conclusions: RCTs that assessed effects of SMS text reminders did not find a significant benefit on objective outcomes, such as having a sunburn, sunscreen use and composite score of sun protection habits. Since certainty of the evidence was very low, future high-quality studies are needed to reach a conclusion regarding the balance of desirable and undesirable outcomes., Protocol Registration Number: PROSPERO (CRD42018091661)., Competing Interests: The authors have declared that no competing interests exist.

Background: Although autodialer centralized reminder and recall (C-R/R) from state immunization information systems (IISs) has been shown to raise childhood vaccination rates, its impact on human papillomavirus (HPV) vaccination rates is unclear., Methods: In a 4-arm pragmatic randomized controlled trial across 2 states, we randomly selected practices representative of the specialty (pediatrics, family medicine, and health center) where children received care. Within each practice, patients 11 to 17.9 years old who had not completed their HPV vaccine series (NY: N = 30 616 in 123 practices; CO: N = 31 502 in 80 practices) were randomly assigned to receive 0, 1, 2, or 3 IIS C-R/R autodialer messages per vaccine dose. We assessed HPV vaccine receipt via the IIS, calculated intervention costs, and compared HPV vaccine series initiation and completion rates across study arms., Results: In New York, HPV vaccine initiation rates ranged from 37.0% to 37.4%, and completion rates were between 29.1% and 30.1%, with no significant differences across study arms. In Colorado, HPV vaccine initiation rates ranged from 31.2% to 33.5% and were slightly higher for 1 reminder compared with none, but vaccine completion rates, ranging from 27.0% to 27.8%, were similar. On adjusted analyses in Colorado, vaccine initiation rates were slightly higher for 1 and 3 C-R/R messages (adjusted risk ratios 1.07 and 1.04, respectively); completion rates were slightly higher for 1 and 3 C-R/R messages (adjusted risk ratios 1.02 and 1.03, respectively)., Conclusions: IIS-based C-R/R for HPV vaccination did not improve HPV vaccination rates in New York and increased vaccination rates slightly in Colorado., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2020 by the American Academy of Pediatrics.)

Background: In times of vaccine hesitancy and decreasing immunization coverage, it is crucial to exploit the potential of digital solutions to support immunization programmes and ultimately increase vaccine uptake. Scant evidence exists on the impact of email-based immunization reminders. In particular, while email communication is exponentially increasing at the global level, its use for health communication is still sporadic and limited data exists on its application to immunization programmes. The objective of this study is to systematically retrieve and critically appraise the available literature on the effectiveness of email-based reminders to increase vaccine uptake, with the ultimate aim to inform and encourage its integration in the implementation of immunization programmes., Methods: We conducted a systematic review of literature following the PRISMA. We included studies providing quantitative comparative data on any measure of vaccine uptake. We extracted data on study design, study population, vaccine type and details of email-based interventions; data were pooled by type of comparison (no reminders, traditional reminders, other digital reminders)., Results: Eleven studies were included, 90% with experimental study designs. While email communication succeeds in increasing vaccine uptake when compared with no intervention, weak and heterogeneous data exist supporting the superiority of email reminders, as compared to traditional methods or other digital reminders. Encouraging evidence report the effectiveness of reminder methods combining different strategies and tailored to target populations' preferences., Conclusions: Theoretically, email communication offers many advantages: it is cheaper and faster, it can be automated and linked to electronic immunization registries, and reach people on the move. As we urge the need for further research to prove email communication impact on vaccine uptake in different settings, we underline the importance of identifying how to best integrate email communication in vaccine delivery equipping immunization programmes with technical infrastructures and normative frameworks suitable to embrace innovation., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Dementia is a leading cause of disability, and the prevalence of dementia is steadily increasing. Although people with dementia are living longer lives in the community, without adequate support for their declining physical and psychological needs, the majority of these individuals end up in nursing homes. With no cure in sight, and in the context of population ageing, we must consider how to care for these individuals in the future. Technologies that augment existing care can maintain a person comfortably in their community, maximize individual autonomy and promote social participation. However, to date, such technologies have rarely been used in dementia care. This Perspectives article highlights the need for affordable and appropriate technologies to assist future dementia care, outlines some of the technologies currently available and describes the many challenges to integration of such technologies. Finally, guidelines are suggested for the development and implementation of new technologies in dementia care.

Objective: To describe opportunities for pharmacists to use mobile messaging and real-time monitoring to engage with patients taking long-term medications., Summary: The proliferation of mobile phone use across the United States has been met with increased application of these devices by the medical community. However, beyond simple text messages and app-based functions, use of these devices by pharmacies and pharmacists has not been leveraged to improve patient outcomes, such as medication adherence. Resources now exist that can facilitate more advanced mobile communication between patients and pharmacists, which can be managed and informed by data available in most pharmacies. Such tailored messaging can be personalized further by being reactive to patient behavior using real-time medication use monitoring tools, facilitating low-cost, high-reach interventions for patients in need of ongoing guidance., Conclusion: Mechanisms now exist for pharmacies to engage patients more proactively with their prescribed therapy using mobile communication and devices. By facilitating such engagement, pharmacists can remain connected with patients throughout their care, better interpret their needs, navigate adherence-related issues, and more holistically counsel patients based on observed behaviors. Community pharmacy leadership should pursue the use of these advanced mobile messaging techniques as another tool in their arsenal to improve patient outcomes., (Copyright © 2019 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.)

Objectives: Excessive alerts are a common concern associated with clinical decision support systems that monitor drug-drug interactions (DDIs). To reduce the number of low-value interruptive DDI alerts at our hospital, we implemented an iterative, multidimensional quality improvement effort, which included an interdisciplinary advisory group, alert metrics, and measurement of perceived clinical value., Methods: Alert data analysis indicated that DDIs were the most common interruptive medication alert. An interdisciplinary alert advisory group was formed to provide expert advice and oversight for alert refinement and ongoing review of alert data. Alert data were categorized into drug classes and analyzed to identify DDI alerts for refinement. Refinement strategies included alert suppression and modification of alerts to be contextually aware., Results: On the basis of historical analysis of classified DDI alerts, 26 alert refinements were implemented, representing 47% of all alerts. Alert refinement efforts resulted in the following substantial decreases in the number of interruptive DDI alerts: 40% for all clinicians (22.9-14 per 100 orders) and as high as 82% for attending physicians (6.5-1.2 per 100 orders). Two patient safety events related to alert refinements were reported during the project period., Conclusions: Our quality improvement effort refined 47% of all DDI alerts that were firing during historical analysis, significantly reduced the number of DDI alerts in a 54-week period, and established a model for sustained alert refinements., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2019 by the American Academy of Pediatrics.)

Background: With the accessibility and widespread use of mobile phones, mobile phone apps targeting medication adherence may be useful tools to help patients take medications as prescribed., Objective: Our objectives were to (1) characterize and assess mobile phone medication adherence apps guided by a conceptual framework on the focus of adherence interventions and (2) conduct a content analysis of Web-based reviews to explore users' perspectives and experiences with mobile phone medication adherence apps., Methods: We searched for mobile phone medication adherence apps using keyword searches in Apple and Android operating systems. We characterized all apps in terms of number of downloads, ratings, languages, cost, and disease target. We categorized apps according to 4 key features of (1) alerting to take medication, (2) tracking medication taking, (3) reminding to refill or indicating amount of medication left, and (4) storing medication information. We then selected representative apps from each operating system for detailed quality assessment and user testing. We also downloaded Web-based reviews for these selected apps and conducted a qualitative content analysis using an inductive approach involving steps of initial open coding, construction of categories, and abstraction into themes., Results: We identified 704 apps (443 from Apple and 261 from Android). The majority of apps across both operating systems had 1 or 2 features-specifically, 37.2% (165/443) and 38.1% (169/443) of Apple apps, respectively, and 41.4% (108/261) and 31.4% (108/261) of Android apps, respectively. Quality assessment and user testing of 20 selected apps revealed apps varied in quality and commonly focused on behavioral strategies to enhance medication adherence through alerts, reminders, and logs. A total of 1323 eligible Web-based reviews from these 20 selected apps were analyzed, and the following themes emerged: (1) features and functions appreciated by users, which included the ability to set up customized medication regimen details and reminders, monitor other health information (eg, vitals, supplements, and manage multiple people or pets), support health care visits (eg, having a list of medications and necessary health information in 1 app); (2) negative user experiences that captured technical difficulties (glitches, confusing app navigation, and poor interoperability), dosage schedule, and reminder setup inflexibility; and (3) desired functions and features related to optimization of information input, improvement of reminders, and upgrading app performance (better synchronization or backup of data and interoperability)., Conclusions: A large number of mobile phone medication adherence apps are currently available. The majority of apps have features representing a behavioral approach to intervention. Findings of the content analysis offer mostly positive feedback as well as insights into current limitations and improvements that could be addressed in current and future medication adherence apps., (©Jamie Yea Eun Park, Jenny Li, Alyssa Howren, Nicole Wen Tsao, Mary De Vera. Originally published in JMIR Mhealth and Uhealth (http://mhealth.jmir.org), 31.01.2019.)

Purpose: Summative evaluation forms assessing a student's clinical performance are often completed at the end of a clinical experience from a faculty preceptor. In our institution, despite the use of an electronic system, completion timeliness has been suboptimal potentially limiting our ability to monitor student progress. The aim of the present study was to determine if a student-centered approach to summative evaluation form collection at the end of a pediatrics clinical experience will enhance timeliness of completion for third year medical students at Pennsylvania State College of Medicine., Methods: This was a pre- and post-intervention educational quality improvement project focused on 156 (82 pre-intervention, 74 post-intervention) third year medical students at Pennsylvania State College of Medicinecompleting their four-week pediatric clerkship. Utilizing Research Electronic Data Capture (REDCap) informatics support, student-directed evaluation form solicitation was encouraged. Wilcoxon rank sum test was applied to compare pre-intervention (May 1, 2017 to March 2, 2018) and post-intervention (April 2, 2018 to December 21, 2018) percentages of forms completed before rotation midpoint., Results: Seven hundred and forty evaluation forms were submitted during the pre-intervention phase and five-hundred and seventeen were submitted during the post-intervention phase. Form completion percentage before rotation midpoint increased after implementation of student-directed solicitation (9.6% versus 39.7%, P<0.05)., Conclusion: Our clerkship relies on subjective summative evaluations to track student progress, employ improvement strategies, and determine criteria for advancement; however, our preceptors struggled with timely submission. Allowing students to direct the solicitation of evaluation forms enhanced the timeliness of completion at our institution and should be considered in clerkships with similar difficulties.

Background: Drug-drug interaction (DDI) alerts in electronic health records (EHRs) can help prevent adverse drug events, but such alerts are frequently overridden, raising concerns about their clinical usefulness and contribution to alert fatigue., Objective: To study the effect of conversion to a commercial EHR on DDI alert and acceptance rates., Design: Two before-and-after studies., Participants: 3277 clinicians who received a DDI alert in the outpatient setting., Intervention: Introduction of a new, commercial EHR and subsequent adjustment of DDI alerting criteria., Main Measures: Alert burden and proportion of alerts accepted., Key Results: Overall interruptive DDI alert burden increased by a factor of 6 from the legacy EHR to the commercial EHR. The acceptance rate for the most severe alerts fell from 100 to 8.4%, and from 29.3 to 7.5% for medium severity alerts (P < 0.001). After disabling the least severe alerts, total DDI alert burden fell by 50.5%, and acceptance of Tier 1 alerts rose from 9.1 to 12.7% (P < 0.01)., Conclusions: Changing from a highly tailored DDI alerting system to a more general one as part of an EHR conversion decreased acceptance of DDI alerts and increased alert burden on users. The decrease in acceptance rates cannot be fully explained by differences in the clinical knowledge base, nor can it be fully explained by alert fatigue associated with increased alert burden. Instead, workflow factors probably predominate, including timing of alerts in the prescribing process, lack of differentiation of more and less severe alerts, and features of how users interact with alerts.

Background: Methamphetamine (METH) use poses a barrier to antiretroviral therapy (ART) adherence. We evaluated the efficacy of the individualized texting for adherence building (iTAB) intervention among persons living with HIV (PLWH) who meet criteria for METH use disorder. We examined daily associations between ART adherence and text-reported METH use and depressed mood., Methods: We conducted a single site, 2-arm, 6-week, pilot randomized clinical trial comparing a personalized, bidirectional, text messaging system (iTAB; n = 50) to an active control condition (n = 25). All participants received adherence psychoeducation and daily texts assessing METH use and depressed mood. The iTAB group received personalized daily ART reminder texts. ART adherence was monitored using Medication Event Monitoring System (MEMS) caps., Results: Response rates to daily ART reminder texts were high (79%), with good concordance between MEMS-derived and text-reported ART adherence (p < .001). Intervention groups did not differ in MEMS-derived ART adherence (68% iTAB, 70% active control; p = .68); however, participants in the iTAB group had fewer METH use days (median 14.4 iTAB, 22.0 active control; p = .05). Text-reported METH use, but not depressed mood, was associated with poorer MEMS-derived ART adherence., Conclusions: High text response rates and good concordance between MEMS-derived and text-reported adherence suggests text messaging is a feasible intervention delivery approach that provides a valid indication of ART adherence. Reductions in METH use among iTAB participants suggest daily health reminders may help attenuate substance use. Further research is needed to substantiate daily text messaging as a harm reduction approach., (Copyright © 2018. Published by Elsevier B.V.)

Background: Non-attendance at outpatient clinics is common and costly., Aims: This study aimed to determine if sending SMS ('short message service' or text message) reminders to patients before appointments reduced non-attendance., Methods: We collected outpatient data at Ballyfermot and Lucan Community Adult Mental Health Service, Dublin, Ireland during 6-month periods (a) immediately prior to the introduction of SMS reminders for outpatient appointments; (b) immediately following the introduction of SMS reminders; and (c) two and a half years later., Results: In the 6-month period prior to SMS reminders, 2170 outpatient appointments were offered and there was a 22.2% non-attendance rate. In the 6-months following the introduction of SMS reminders, 2092 appointments were offered and the non-attendance rate fell to 13.9% (p < 0.001), with the lower non-attendance rate among those who did not receive SMS reminders (9.7%) rather than those who did (15.7%) (p = 0.0002). There were 98 appointment cancellations during this period (73% via SMS messaging). In the 6-month period two and a half years after the introduction of SMS reminders, 2474 appointments were offered and the non-attendance rate rose to 19.3%; this did not differ between those who received SMS reminders (19.3%) and those who did not (19.1%) (p = 0.38209) and was still lower than the rate prior to SMS reminders (p = 0.01321). During this period, 197 appointments were cancelled (75% via SMS messaging)., Conclusions: The chief value of SMS reminders lies not in reminding patients of appointments but in providing a convenient way to cancel them, thus allowing more appointments to be offered.

Background: Follow-up of tests pending at discharge (TPADs) is poor. We previously demonstrated a twofold increase in awareness of any TPAD by attendings and primary care physicians (PCPs) using an automated email intervention OBJECTIVE: To determine whether automated notification improves documented follow-up for actionable TPADs DESIGN: Cluster-randomized controlled trial SUBJECTS: Attendings and PCPs caring for adult patients discharged from general medicine and cardiology services with at least one actionable TPAD between June 2011 and May 2012 INTERVENTION: An automated system that notifies discharging attendings and network PCPs of finalized TPADs by email MAIN MEASURES: The primary outcome was the proportion of actionable TPADs with documented action determined by independent physician review of the electronic health record (EHR). Secondary outcomes included documented acknowledgment, 30-day readmissions, and adjusted median days to documented follow-up., Key Results: Of the 3378 TPADs sampled, 253 (7.5%) were determined to be actionable by physician review. Of these, 150 (123 patients discharged by 53 attendings) and 103 (90 patients discharged by 44 attendings) were assigned to intervention and usual care groups, respectively, and underwent chart review. The proportion of actionable TPADs with documented action was 60.7 vs. 56.3% (p = 0.82) in the intervention vs. usual care groups, similar for documented acknowledgment. The proportion of patients with actionable TPADs readmitted within 30 days was 22.8 vs. 31.1% in the intervention vs. usual care groups (p = 0.24). The adjusted median days [95% CI] to documented action was 9 [6.2, 11.8] vs. 14 [10.2, 17.8] (p = 0.04) in the intervention vs. usual care groups, similar for documented acknowledgment. In sub-group analysis, the intervention had greater impact on documented action for patients with network PCPs compared with usual care (70 vs. 50%, p = 0.03)., Conclusions: Automated notification of actionable TPADs shortened time to action but did not significantly improve documented follow-up, except for network-affiliated patients. The high proportion of actionable TPADs without any documented follow-up (~ 40%) represents an ongoing safety concern., Clinical Trials Identifier: NCT01153451.

Background and Objectives: Preventive care in general practice is fundamental to managing the Australian diabetes epidemic. Recommended preventive care is nonetheless underperformed. The aim of this pilot study was to demonstrate proof of concept that pre-consultation patient-directed reminders could improve preventive care in general practice., Method: Over two weeks, four general practices used a special software tool to generate reminder sheets listing recommended checks for a subset of patients with type 2 diabetes mellitus (T2DM). The sheets were given to patients before their consultations. The number of checks performed was compared for patients who did and did not receive reminders. General practitioners (GPs) were interviewed about the reminders and chronic disease management., Results: Patients who received reminders had more recommended checks performed than those who did not receive reminders. GPs found the reminders useful but suggested that broader system changes are required., Discussion: Pre-consultation patient-directed reminders could potentially be an effective tool to increase preventive care for patients with T2DM in general practice.

Objectives: Young children in resource-poor settings remain inadequately immunized. We evaluated the role of compliance-linked incentives versus mobile phone messaging to improve childhood immunizations., Methods: Children aged ≤24 months from a rural community in India were randomly assigned to either a control group or 1 of 2 study groups. A cloud-based, biometric-linked software platform was used for positive identification, record keeping for all groups, and delivery of automated mobile phone reminders with or without compliance-linked incentives (Indian rupee Rs30 or US dollar $0.50 of phone talk time) for the study groups. Immunization coverage was analyzed by using multivariable Poisson regression., Results: Between July 11, 2016, and July 20, 2017, 608 children were randomly assigned to the study groups. Five hundred and forty-nine (90.3%) children fulfilled eligibility criteria, with a median age of 5 months; 51.4% were girls, 83.6% of their mothers had no schooling, and they were in the study for a median duration of 292 days. Median immunization coverage at enrollment was 33% in all groups and increased to 41.7% (interquartile range [IQR]: 23.1%-69.2%), 40.1% (IQR: 30.8%-69.2%), and 50.0% (IQR: 30.8%-76.9%) by the end of the study in the control group, the group with mobile phone reminders, and the compliance-linked incentives group, respectively. The administration of compliance-linked incentives was independently associated with improvement in immunization coverage and a modest increase in timeliness of immunizations., Conclusions: Compliance-linked incentives are an important intervention for improving the coverage and timeliness of immunizations in young children in resource-poor settings., Competing Interests: POTENTIAL CONFLICT OF INTEREST: Dr Ajay K. Jain reports grants and personal fees from Alexion Pharmaceuticals outside the submitted work; the other authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2018 by the American Academy of Pediatrics.)

Purpose: To evaluate the feasibility and acceptability of a text messaging intervention to increase contraception among adolescent emergency department patients., Methods: A pilot randomized controlled trial of sexually active females aged 14-19 receiving 3 months of theory-based, unidirectional educational and motivational texts providing reproductive health information versus standardized discharge instructions. Blinded assessors measured contraception initiation via telephone follow-up and health record review at 3 months., Results: We randomized 100 eligible participants (predominantly aged 18-19, Hispanic, and with a primary provider); 88.0% had follow-up. In the intervention arm, 3/50 (6.0%) participants opted out, and 1,172/1,654 (70.9%) texts were successfully delivered; over 90% of message failures were from one mobile carrier. Most (36/41; 87.7%) in the intervention group liked and wanted future reproductive health messages. Contraception was initiated in 6/50 (12.0%) in the intervention arm and in 11/49 (22.4%) in the control arm., Conclusions: A pregnancy prevention texting intervention was feasible and acceptable among adolescent females in the emergency department setting., (Copyright © 2017 The Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Time-sensitive alerts are among the many types of clinical notifications delivered to physicians' secure InBaskets within commercial electronic health records (EHRs). A delayed alert review can impact patient safety and compromise care., Objective: To characterize factors associated with opening of non-interruptive time-sensitive alerts delivered into primary care provider (PCP) InBaskets., Design and Participants: We analyzed data for 799 automated alerts. Alerts highlighted actionable medication concerns for older patients post-hospital discharge (2010-2011). These were study-generated alerts sent 3 days post-discharge to InBaskets for 75 PCPs across a multisite healthcare system, and represent a subset of all urgent InBasket notifications., Main Measures: Using EHR access and audit logs to track alert opening, we performed bivariate and multivariate analyses calculating associations between patient characteristics, provider characteristics, contextual factors at the time of alert delivery (number of InBasket notifications, weekday), and alert opening within 24 h., Key Results: At the time of alert delivery, the PCPs had a median of 69 InBasket notifications and had received a median of 379.8 notifications (IQR 295.0, 492.0) over the prior 7 days. Of the 799 alerts, 47.1% were opened within 24 h. Patients with longer hospital stays (>4 days) were marginally more likely to have alerts opened (OR 1.48 [95% CI 1.00-2.19]). Alerts delivered to PCPs whose InBaskets had a higher number of notifications at the time of alert delivery were significantly less likely to be opened within 24 h (top quartile >157 notifications: OR 0.34 [95% CI 0.18-0.61]; reference bottom quartile ≤42). Alerts delivered on Saturdays were also less likely to be opened within 24 h (OR 0.18 [CI 0.08-0.39])., Conclusions: The number of total InBasket notifications and weekend delivery may impact the opening of time-sensitive EHR alerts. Further study is needed to support safe and effective approaches to care team management of InBasket notifications.

Objectives: To examine the effects of an educational meeting and subsequent computer reminders on the number of ordered laboratory tests., Methods: Using interrupted time series analysis we assessed whether trends in the number of laboratory tests ordered by rheumatologists between September 2012 and September 2015 at the Sint Maartenskliniek (the Netherlands) changed following an educational meeting (September 2013) and the introduction of computer reminders into the Computerised Physician Order Entry System (July 2014). The analyses were done for the set of tests on which both interventions had focussed (intervention tests; complement, cryoglobulins, immunoglobins, myeloma protein) and a set of control tests unrelated to the interventions (alanine transferase, anti-cyclic citrullinated peptide, C-reactive protein, creatine, haemoglobin, leukocytes, mean corpuscular volume, rheumatoid factor and thrombocytes)., Results: At the start of the study, 101 intervention tests and 7660 control tests were ordered per month by the rheumatologists. After the educational meeting, both the level and trend of ordered intervention and control tests did not change significantly. After implementation of the reminders, the level of ordered intervention tests decreased by 85.0 tests (95%-CI -133.3 to -36.8, p<0.01), the level of control tests did not change following the introduction of reminders., Conclusions: In summary, an educational meeting alone was not effective in decreasing the number of ordered intervention tests, but the combination with computer reminders did result in a large decrease of those tests. Therefore, we recommend using computer reminders in addition to education if reduction of inappropriate test use is aimed for.

Background: No-shows, or missed appointments, are a problem for many medical practices. They result in fragmented care and reduce access for all patients., Objective: To determine whether telephone reminder calls targeted to patients at high risk of no-show can reduce no-show rates., Design: Single-center randomized controlled trial., Participants: A total of 2247 primary care patients in a hospital-based primary care clinic at high risk of no-show (>15 % risk) for their appointment in 7 days., Intervention: Seven days prior to their appointment, intervention arm patients were placed in a calling queue to receive a reminder phone call from a patient service coordinator. Coordinators were trained to engage patients in concrete planning. All patients received an automated phone call (usual care)., Main Measures: Primary outcome was no-show rate. Secondary outcomes included arrival rate, cancellation rate, reschedule rate, time to cancellation, and change in revenue., Key Results: The no-show rate in the intervention arm (22.8 %) was significantly lower (absolute risk difference -6.4 %, p < 0.01, 95 % CI [-9.8 to -3.0 %]) than that in the control arm (29.2 %). Arrival, cancellation, and reschedule rates did not differ significantly. In the intervention arm, rescheduling and cancellations occurred further in advance of the appointment (mean difference, 0.35 days; 95 % CI [0.07-0.64]; p = 0.01). Reimbursement did not differ significantly., Conclusions: A phone call 7 days prior to an appointment led to a significant reduction in no-shows and increased reimbursement among patients at high risk of no-show. The use of targeted interventions may be of interest to practices taking on increased accountability for population health.

Poor adherence to medication can lead to negative health outcomes and increased financial burdens. We present a literature review on electronic medication reminders used for medication adherence in self care settings, to identify current and possible future trends. A structured PubMed search based on extracted MeSH terms provided a total of 45 publications which were identified as most relevant. Three main categories of electronic solutions were identified: mobile phone reminders, in-home electronic reminder devices, and portable reminder devices.

In this review article, we address issues related to using data from anesthesia information management systems (AIMS) to deliver near real-time alerts via AIMS workstation popups and/or alphanumeric pagers and post hoc reports via e-mail. We focus on reports and alerts for influencing the behavior of anesthesia providers (i.e., anesthesiologists, anesthesia residents, and nurse anesthetists). Multiple studies have shown that anesthesia clinical decision support (CDS) improves adherence to protocols and increases financial performance through facilitation of billing, regulatory, and compliance documentation; however, improved clinical outcomes have not been demonstrated. We inform developers and users of feedback systems about the multitude of concerns to consider during development and implementation of CDS to increase its effectiveness and to mitigate its potentially disruptive aspects. We discuss the timing and modalities used to deliver messages, implications of outlier-only versus individualized feedback, the need to consider possible unintended consequences of such feedback, regulations, sustainability, and portability among systems. We discuss statistical issues related to the appropriate evaluation of CDS efficacy. We provide a systematic review of the published literature (indexed in PubMed) of anesthesia CDS and offer 2 case studies of CDS interventions using AIMS data from our own institution illustrating the salient points. Because of the considerable expense and complexity of maintaining near real-time CDS systems, as compared with providing individual reports via e-mail after the fact, we suggest that if the same goal can be accomplished via delayed reporting versus immediate feedback, the former approach is preferable. Nevertheless, some processes require near real-time alerts to produce the desired improvement. Post hoc e-mail reporting from enterprise-wide electronic health record systems is straightforward and can be accomplished using system-independent pathways (e.g., via built-in e-mail support provided by the relational database management system). However, for some of these enterprise-wide systems, near real-time data access, necessary for CDS that generates concurrent alerts, has been challenging to implement.

Modern technological devices supporting coping and management for patients with diabetes are increasingly popular and could be important healthcare tools. This review aimed to evaluate patient satisfaction and perceptions regarding these devices, examples of which include short message service reminder systems, online educational programs, and clinician-patient electronic communication. Therapy devices such as continuous glucose monitors and continuous subcutaneous insulin infusion pumps are not included in this review. Embase, Psychinfo, Medline, CINAHL, and gray literature databases were searched for "diabetes mellitus," "technical device," "patient satisfaction," and their synonyms. This review was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement guidelines. The search produced 1,902 studies, 26 of which were included in the review: type 1 diabetes mellitus (eight studies), type 2 diabetes mellitus (nine studies), and both (nine studies). High satisfaction was seen with almost all devices and correlated strongly with ease of use and improved diabetes management. Satisfaction was not affected by participant age, and the effect of diabetes type was not assessed. Web devices were reported as easiest to use. Increased support was valued and resulted from devices facilitating interaction with healthcare professionals (HCPs) or peers. Technical difficulties were barriers to both use and satisfaction. Overall, patients enjoyed supplementing their usual therapy with these devices. Perceived support from HCPs or peers formed an important aspect of patient satisfaction and should be considered for future interventions.

Aims: To investigate short- and long-term effects of real-time monitoring medication use combined with short message service (SMS) reminders for missed doses on refill adherence to oral anti-diabetic medication., Methods: A randomized controlled trial with two intervention groups and one control group involving 161 participants with Type 2 diabetes with suboptimal adherence. For 6 months, participants in the SMS group (n = 56) were monitored and received SMS reminders if they missed their medication. Participants in the non-SMS group (n = 48) were only monitored. The control group (n = 57) was not exposed to any intervention. Primary outcome measure was refill adherence to oral anti-diabetic medication. Multi-level regression analyses were performed to examine intervention effects on adherence between and within groups after 1 and 2 years of follow-up., Results: At baseline, mean refill adherence was comparable between the groups. After 1 year, adherence in the SMS group was significantly higher than in the control group (79.5% vs. 64.5%; P < 0.001) and showed a significant improvement from baseline (+16.3%; P < 0.001). Mean adherence in the non-SMS group reached 73.1% (+7.3%; P < 0.05), but did not differ from the control group (P = 0.06). After 2 years, the improved adherence in the SMS group persisted and remained significantly higher than in the control group (80.4% vs. 68.4%; P < .01), contrary to the non-SMS group whose adherence approached baseline level again (65.5%)., Conclusions: This study shows the long-term effectiveness of real-time medication monitoring combined with SMS reminders in improving refill adherence. This new reminder system can strengthen the self-management of people with diabetes., (© 2014 The Authors. Diabetic Medicine © 2014 Diabetes UK.)

Objective: To assess primary care providers' current reminder/recall practices, preferences for collaboration with health departments in reminder/recall efforts, attitudes toward practice-based and population-based reminder/recall, and experiences with a population-based reminder/recall intervention., Methods: Providers responsible for making decisions about immunization delivery at all primary care practices that participate in the Colorado Immunization Information System were surveyed. Data collection was preceded by an intervention in which half of 14 counties received a population-based reminder/recall intervention conducted by the health department. Practice staff involved in immunization activities were then selected for semistructured telephone interviews that were based on the location of their practice within specified strata, including whether they were in the intervention counties, urban/rural location, and practice type., Results: A total of 282 (73.6%) of 383 of providers responded to the survey, and 253 who administered vaccines to children 19 to 35 months were retained; 82 staff members at 36 practices were interviewed. Providers' preferences for who should conduct reminder/recall were almost evenly split, with slightly more indicating that it should be conducted by the health department. Cost and feasibility issues were perceived barriers to conducting practice-based recall, particularly among urban practices. Support for population-based reminder/recall was highest among rural practices. Concern about perceived inaccuracies in immunization registry data was the major barrier to conducting population-based reminder/recall. The population-based intervention did not create an undue burden on practices., Conclusions: A collaborative approach to reminder/recall involving both providers and health departments is preferable for many providers and may be a viable solution to the barriers of practice-based reminder/recall., (Copyright © 2014 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

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.

Objective: To assess the effectiveness of reminder/recall (R/R) for immunizing adolescents in private pediatric practices and to describe the associated costs and revenues., Methods: We conducted a randomized controlled trial in 4 private pediatric practices in metropolitan Denver. In each practice, 400 adolescents aged 11 to 18 years who had not received 1 or more targeted vaccinations (tetanus-diphtheria-acellular pertussis, meningococcal conjugate, or first dose of human papillomavirus vaccine for female patients) were randomly selected and randomized to intervention (2 letters and 2 telephone calls) or control (usual care) groups. Primary outcomes were receipt of >1 targeted vaccines and receipt of all targeted vaccines 6 months postintervention. We calculated net additional revenue for each additional adolescent who received at least 1 targeted vaccine and for those who received all targeted vaccines., Results: Eight hundred adolescents were randomized to the intervention and 800 to the control group. Baseline rates of having already received tetanus-diphtheria-acellular pertussis, meningococcal conjugate, and first dose of human papillomavirus vaccine before R/R ranged from 33% to 54%. Postintervention, the intervention group had significantly higher proportions of receipt of at least 1 targeted vaccine (47.1% vs 34.6%, P < .0001) and receipt of all targeted vaccines (36.2% vs 25.2%, P < .0001) compared with the control group. Three practices had positive net revenues from R/R; 1 showed net losses., Conclusions: R/R was successful at increasing immunization rates in adolescents and effect sizes were comparable to those in younger children. Practices conducting R/R may benefit financially if they can generate additional well-child care visits and keep supply costs low.

Objective: To describe parents' experiences and preferences regarding the use of different communication modes for immunization reminder/recall messages., Methods: A cross-sectional, Internet-based survey of a nationally representative sample of parents of children 0 to 17 years of age was performed. Survey items included questions regarding previous receipt of reminder/recall notices; preferences for how to receive notices in the future; recentness of changes to home address, home telephone, cell phone, and e-mail information; child's usual site for immunization; and willingness to register cell phone numbers with the child's immunization provider to receive future cell phone or text messages about immunization., Results: Overall, 31% of parents had ever received an immunization reminder/recall notice, usually by mail. For future immunization messages, approximately one-third of parents preferred mail or calls to the home telephone, 16% preferred e-mail, and 8% preferred calls to a cell phone. More than one-half of parents had maintained the same home address, home telephone number, cell phone number, or e-mail address for the previous 3 years. More than one-half of parents were willing to register their cell phone numbers with their child's usual immunization provider., Conclusions: Although most parents continue to prefer the traditional modes for immunization reminder/recall messages, 1 in 4 preferred newer technologies, and parents' e-mail and cell phone information was surprisingly stable. More than one-half of the parents were willing to register their cell phone numbers for future immunization messaging via cell phone calls or text messages. Research and implementation efforts might benefit from focusing on this willing population.

Objective: We created a new diabetes foot examination clinical reminder to directly populate a foot risk registry and examined its accuracy versus administrative data., Methods: A pre- and post-test design assessed accuracy of coding foot risk and clinician acceptability. The intervention hospital's reminder was replaced with a dialogue tick box containing the International Diabetic Foot Classification System to populate risk using health factors., Results: There were no hospital agreement differences for each foot condition except diabetes and peripheral neuropathy, demonstrating higher agreement at the intervention hospital. There were no differences in service agreement adherence or consulting rates although both demonstrated significantly lower consulting rates at study end. The intervention hospital had a significantly lower patient cancellation rate (1% v. 5%, P=0.01) and better coding for grade 3 patients. The new reminder demonstrated high acceptability., Conclusions: The registry system resulted in improved discrimination of the highest foot risk. Further testing is recommended.

Objective: To evaluate a direct mail-out campaign to increase Pap screening rates in women who have not had a test in 48 months., Methods: Ninety thousand under-screened women were randomised to be mailed a 48-month reminder letter to have a Pap test (n=60,000), or not to be mailed a letter (n=30,000). Differences in Pap test rates were assessed by Kaplan-Meier survival analysis, by chi2 tests of significance between Pap test rates in letter versus no-letter groups, and by proportional hazards regression modelling of predictors of a Pap test with letter versus no-letter as the main study variable. T-tests were conducted on mean time to Pap test to assess whether time to Pap test was significantly different between the intervention and control groups., Results: After 90 days following each mail-out, Pap test rates in the letter group were significantly higher than in the non-letter group, by approximately two percentage points. After controlling for potential confounders, the hazard ratio of a Pap test within 90 days of a mail-out in the letter group was 1.5 compared with 1.0 in the no-letter group. Hazard ratios of having a Pap test within 90 days decreased significantly with time since last Pap test (p<0.0001); were significantly higher than 1.0 for most non-metropolitan areas of NSW compared with metropolitan areas; and increased significantly with age (p<0.0001). Pap test hazard ratios were not associated with socio-economic status of area of residence, but the hazard ratio was significantly higher than 1.0 if the reminder letter was sent after the Christmas/New Year break. No significant differences in mean time to Pap test were found between the letter and no-letter groups., Conclusions and Implications: Being sent a reminder letter is associated with higher Pap testing rates in under-screened women.

This article updates the author's earlier review of some of the major computer-based ambulatory information systems and the literature evaluating their costs, benefits, effect on quality of care, and physician acceptance. The evidence suggests that computer-based information systems can increase access to clinical information, improve physician performance, enhance quality of care, and facilitate outcomes research review. In addition to presenting health information networks and clinical decision support systems such as reminder systems, drug ordering systems, and medical care management systems, the article describes applications of telemedicine and Web-based systems. It also discusses barriers to the widespread use of computer-based ambulatory information systems.

Background: The NHS breast screening programme (NHSBSP) was established in 1987 to screen women aged 50-64 every three years to achieve a significant reduction in breast cancer mortality. Ensuring that women are re-invited every three years (that is, a three year screening round is in operation) is becoming increasingly difficult as pressure on the service rises. Coverage measures the proportion of eligible women receiving a screen in the previous three years and is currently used as an NHS performance indicator, while uptake measures the proportion of invited women who attend for screening. Data for 1996/1997 for the West Midlands NHSBSP show that, although uptake among 50-64 year olds was in excess of the 70% target at 78%, coverage was 10% below this at 68%. The discrepancy between coverage and uptake is likely to in part reflect "round slippage" in which women are re-invited at three years or more from their previous screen. To investigate the extent to which slippage is occurring in the region a technique for assessing round length independently of coverage was developed., Methods: Records for women receiving routine recall (incident) screens between 1994 and 1997 in the West Midlands NHSBSP were examined and the time between the most recent screen and the previous screen measured in months., Findings: Of 73,785 women screened in 1996/1997, 46.3% had a round length of under three years, although 74.9% had been re-screened within 38 months of the previous screen. Overall the regional programme was estimated to have a round slippage of approximately two months., Conclusions: The West Midlands NHSBSP operates to high standards in terms of uptake and cancer detection, but round slippage must be reduced. The lack of quantitative data with which to assess round length has hindered assessment in the past. The simple technique developed in this study will allow assessment of round length to be used routinely as the key quality assurance measure for the programme.