Current issues of ACP Journal Club are published in Annals of Internal Medicine

Quality Improvement

Reminders increased preventive procedures in family practice

ACP J Club. 1992 Mar-April;116:63. doi:10.7326/ACPJC-1992-116-2-063

Source Citation

Rosser WW, McDowell I, Newell C. Use of reminders for preventive procedures in family medicine. Can Med Assoc J. 1991 Oct 1;145: 807-12, 814.



To compare 3 different reminder systems for increasing the performance of 5 preventive maneuvers in primary care.


A 4-group, randomized (by family), controlled trial of 1 year duration.


A Canadian university hospital-based family medical center.


5883 noninstitutionalized patients aged ≥ 15 years who, by attending within the previous 18 months or by self-report, were members of the study practice.


Neither group 1 (control) patients nor their physicians received reminders; when patients from group 2 (physician reminder) visited the office, their encounter forms included computer-generated physician reminders. Groups 3 and 4 patients were contacted for overdue maneuvers. Patients from group 3 (telephone reminder) were contacted by phone (up to 5 attempts, during working hours), informed of an overdue maneuver for any family member, and asked to keep a specific appointment; patients from group 4 (letter reminder) were notified by mail and asked to comply, with noncompliers reminded 21 days later.

Main outcome measures

Patient records (or written confirmation if performed elsewhere) documented annual performance of influenza vaccination for those ≥ 65 years of age; blood pressure measurement for those ≥ 18 years; smoking assessment for those ≥ 15 years; Papanicolaou testing for sexually active women 18 to 35 years; and decennial tetanus toxoid boosters for those ≥ 18 years.

Main results

Among group 1 (control) patients, 14% of the required maneuvers were carried out during the study year. 34% of the maneuvers were completed in group 2 (physician reminder) patients (P vs group 1 < 0.01; 60% were completed in the 52% of group 2 patients who visited the practice). 42% were completed in group 3 (telephone reminder) patients (P vs group 2 < 0.05; 66% were contacted and over half of those not contacted had obsolete numbers). 42% were completed in group 4 (letter reminder) patients (P vs group 2 < 0.05; 14% of letters could not be delivered, and 65% of families required a reminder). More complex maneuvers were not less likely to be done. The cost (to the practice) per procedure performed in excess to the group 1 (control) rate was least for group 2 and most for group 3.


Reminder systems increased the delivery of preventive maneuvers in family practice. Active reminders were more effective than passive reminders.

Sources of funding: Department of National Health and Welfare and Ontario Ministry of Health.

Address for article reprint: Dr. W.W. Rosser, Department of Family and Community Medicine, University of Toronto, 444 Yonge Street, Toronto, Ontario M5B 2H4, Canada.


This interesting study reaffirms the positive effect of computer-based reminders on practice patterns in general and on preventive care in particular. The authors have gone beyond many previous studies by comparing the effect of reminders to the physician, which the authors call passive reminders, with both telephone and mail reminders to the patients, which they call active reminders. On the surface the latter reminders appear to be more effective. But this advantage is exaggerated by the under-reporting of the procedures completed by the physicians (observations of a sample of physician-patient interactions taken through a one-way mirror revealed 15% of the procedures "performed" were not recorded) and by an inflated estimate of the number of patients who "belong" to the practice.

The authors report that patient reminders are more expensive than physician reminders, then speculate about ways to reduce these costs. However, their cost estimate excluded the patient's costs for an extra medical visit: transportation, time, and, in many countries, visit charges. These costs are the major reason that the Canadian and U.S. task forces on preventive care prefer case findings at regular visits to special call-ups for preventive procedures (1).

Because of their extra cost to the patients and the practice, patient reminders have no role as a primary means of increasing preventive care. Practitioners should organize their patient records so that they support routine initiation of pending preventive procedures whenever patients visit. The appropriate role of reminders is to "mop up"—that is, to pick up the patients who did not spontaneously visit their physician during the preventive window of opportunity.

Clement J. McDonald, MD
Regenstrief Health CenterIndianapolis, Indiana, USA

Clement J. McDonald, MD
Regenstrief Health Center
Indianapolis, Indiana, USA


1. Spitzer WO, Mann KV. The public's health is too important to be left to public health workers. A commentary on Guide to Clinical Preventive Services. Ann Intern Med. 1989;111:939-42.