PREVENTION IN PEDIATRIC CARE Impact of Appointment Reminders on Vaccination Coverage at an Urban Clinic

Objective. To test if appointment reminders blinded to immunization status improve kept-appointment and vaccination coverage rates. Design. Controlled trial. Setting. Pediatric clinic serving a low-income community in New York City. Intervention. Children ages 4 through 18 months (n 5 1273) scheduled sequentially for clinic appointments were systematically assigned to 1 of 4 study groups: control (n 5 346); postcard (n 5 314); telephone call (n 5 307); and postcard and telephone call (n 5 306). Outcome Measures. Kept-appointment and vaccination coverage rates. Results. Children assigned to the postcard and telephone group were 1.75 times more likely to keep their appointments than controls (95% confidence interval [CI] 5 1.2, 2.5). Children who actually received the postcard and telephone reminders were 2.3 times more likely to keep an appointment than controls (95% CI 5 1.4, 3.7). Children who kept appointments were 2.3 times more likely to be up-to-date with their immunizations (95% CI 5 1.7, 3.2). The reminders selectively increased vaccination coverage for the subgroup of children who were not up-to-date before the appointment (x2 5 11.2). The cost of the reminders was $.67 for the postcard and $1.58 for the postcard and telephone. Assuming 5000 visits per year and $100 reimbursement per visit, the return on each dollar invested was $10 for the postcard and $7.28 for the postcard and telephone reminder. Conclusions. Appointment reminders blind to immunization status are a practical and cost-effective strategy to increase kept-appointment rates for all children, and, through this mechanism, reach and vaccinate children who are not up-to-date. Pediatrics 2000;106: 919–923; appointment reminder, vaccination coverage. ABBREVIATIONS. P, postcard; T, telephone call; PT, postcard or telephone call; OR, odds ratio; CI, confidence interval. Reminding parents that their children’s vaccinations are due or delayed is an effective strategy for increasing vaccination coverage.1–9 However, the logistic and financial barriers associated with creating office immunization tracking and reminder systems have deterred many providers from implementing such systems. By 1995, only 35% of pediatricians and 23% of family physicians were using a manual or a computer-based vaccination reminder/recall system.2 Providers more commonly have systems in place to remind parents of their child’s upcoming appointment. These appointment reminders are blind to the child’s immunization status and do not require a tracking system. Although appointment reminders are an efficient and cost-effective means of improving kept-appointment rates, few data show that they improve vaccination coverage of children at primary care practices.10–14 If children are vaccinated at well-child visits, then increasing keptappointment rates will increase immunization rates. The 2 studies examining the efficacy of appointment reminders for improving vaccination coverage have shown conflicting results. At a clinic in Cleveland with volunteer families, a computerizedappointment reminder and recall intervention increased infants’ kept-appointment rates and ontime immunization.15 In contrast, a randomized clinical trial conducted at a clinic in Rochester, New York, found mailed appointment reminders increased show rates for well-child visits but had no significant effect on immunization status.16 We conducted a controlled trial of appointment reminders blind to immunization status at a pediatric clinic in a low-income community in New York City. The study hypothesis was that appointment reminders improved kept-appointment and, through this mechanism, vaccination coverage rates. The study also evaluated the cost-benefit of the appointment reminders.