Phone Reminders Research Articles

Effect of mobile telephone reminders on treatment outcome in HIV: evidence from a randomised controlled trial in India

Objective To assess whether customised mobile phone reminders would improve adherence to therapy and thus decrease virological failure among HIV infected patients starting antiretroviral treatment (ART).Design Randomised controlled trial among...

42 * The primary care atrial fibrillation (PCAF) service: consultant-led anticoagulation assessment clinics in the primary care setting increase the uptake of anticoagulation therapy in AF patients at high-risk of stroke

Introduction: AF confers a 5-6% annual risk of stroke, though this can be significantly reduced by appropriate thromboembolic prophylaxis. However, NICE has estimated that 46% of patients that should be anticoagulated are not. This may be in part due to GP and patient concerns over anticoagulation and lack of awareness of recently-released novel oral anticoagulants (NOACs). We present outcomes from an innovative Consultant-led anticoagulation assessment service: the Primary Care AF (PCAF) service. Methods: The PCAF pathway involves 4 phases. Phase 1 : for each enrolled GP practice, the “true” AF register is established by identifying patients with AF not already on the register. Phase 2 : High-risk patients (CHA2DS2-VASc score ≥1) who either are not on anticoagulation or are on warfarin but with a sub-optimal TTR are identified. Phase 3 : Identified patients are invited for review by letter, with phone reminders 1 week and 1 day prior. Phase 4 : PCAF clinics are delivered within the patients' GP practice by a Consultant Cardiologist or Stroke Physician. Where appropriate, anticoagulation is prescribed in accordance with NICE/local formulary guidelines. Results: 42 GP practices have been enrolled to date, covering a population of 284,945 (AF prevalence 2.0%). After clarifying the AF registers ( Phase 1 ), 5426 high-risk patients were identified, of whom 2398 (44.2%) were not on anticoagulation ( Phase 2 ). After case note reviews to exclude patients in whom AF had resolved or there was a contra-indication to anticoagulation, 1169 high-risk patients not on anticoagulation were invited for review ( Phase 3 ). 1014 patients (87%) attended, of whom 761 (75.0%) had AF and eligibility for anticoagulation confirmed ( Phase 4 ). 745 (97.9%) of these patients agreed to commence anticoagulation (43.0% warfarin, 57.0% NOAC). Taking into account all exclusions, the rate of anticoagulation in eligible patients increased from 76.8% (3028 of 3944) to 95.7% (3773 of 3944) following PCAF service intervention. In addition, 261 of 3028 patients on warfarin (8.6%) had a sub-optimal TTR, of whom 211 (80.8%) attended for review. 137 patients (64.9%) were advised to continue with warfarin after a review of compliance and recent INRs; 74 (35.1%) were offered a NOAC, with 67 (90.5%) agreeing to switch. Based on a NNT with warfarin for 1 year to prevent 1 stroke in a mixed primary/secondary prevention group of 25 from NICE/DoH analyses, 29.8 strokes have been prevented in the 745 high-risk patients not previously on anticoagulation. With the addition of patients with a sub-optimal TTR who have now switched to a NOAC, it can be estimated that >30 strokes have been prevented amongst the 42 GP practices. Conclusion: By bridging the primary/secondary care boundary, Consultant-led anticoagulation clinics in GP practices via the PCAF service have proven to be highly effective in identifying AF patients at high risk of stroke, optimising their treatment and preventing strokes.

An Education- and Telephone-Based Intervention to Improve Follow-up to Vision Care in Patients With Diabetes: A Prospective, Single-Blinded, Randomized Trial.

The aim was to evaluate the effectiveness of a multipronged intervention on diabetic dilated fundus examination (DFE) adherence. In a prospective trial, 521 patients with diabetes who were due for follow-up DFEs were randomized to usual care or the intervention group. Usual care received a form letter reminder to schedule and an automated reminder phone call prior to their appointment. Intervention participants received an educational brochure about diabetic eye disease and a personalized letter reminder to schedule. A research assistant called intervention participants to help schedule the appointment, and they received a reminder letter and an automated phone call prior to the scheduled visit. Patients in the intervention group were significantly more likely to schedule (63% vs 40%; P < .0001) and complete their appointment (48% vs 30%; P < .0001) compared with usual care. A multipronged intervention, including an educational mailing and telephone assistance with scheduling an appointment, significantly improved diabetic DFE adherence.

Feasibility and preliminary efficacy of a web-based smoking cessation intervention for HIV-infected smokers: a randomized controlled trial.

To evaluate the feasibility and preliminary efficacy of a Web-based tobacco treatment for persons living with HIV (PLWH). Prospective, randomized controlled trial. HIV-care center in the Bronx, New York. Eligibility criteria included HIV infection, current tobacco usage, interest in quitting, and access to a computer with internet. One hundred thirty-eight subjects enrolled, and 134 completed the study. Positively Smoke Free on the Web (PSFW), an 8-session, 7-week targeted tobacco treatment program for PLWH, was compared with standard care (brief advice to quit and self-help brochure). All subjects were offered nicotine patches. The main feasibility outcomes were number of sessions logged into, number of Web pages visited, number of interactive clicks, and total time logged in. The main efficacy outcome was biochemically verified, 7-day point prevalence abstinence 3 months after intervention. PSFW subjects logged into a mean of 5.5 of 8 sessions and 26.2 of 41 pages. They executed a mean of 10 interactive clicks during a mean total of 59.8 minutes logged in. Most required reminder phone calls to complete the sessions. Educational level, anxiety score, and home access of the Web site were associated with Web site usage. Ten percent of the PSFW group vs. 4.3% of controls achieved the abstinence end point. Among those who completed all 8 sessions, 17.9% were abstinent, and among women completers, 30.8% were abstinent. Web-based treatment is a feasible strategy for PLWH smokers, and preliminary findings suggest therapeutic efficacy.

The potential for health-related uses of mobile phones and internet with homeless veterans: results from a multisite survey.

Addressing the health needs of homeless veterans is a priority in the United States, and, although information technologies can potentially improve access to and engagement in care, little is known about this population's use of information technologies or their willingness to use technologies to communicate with healthcare providers and systems. This study fills this gap through a survey of homeless veterans' use of information technologies and their attitudes about using these technologies to assist with accessing needed healthcare services. Among the 106 homeless veterans surveyed, 89% had a mobile phone (one-third were smartphones), and 76% used the Internet. Among those with a mobile phone, 71% used text messaging. Nearly all respondents (93%) were interested in receiving mobile phone reminders (text message or phone call) about upcoming medical appointments, and a similar proportion (88%) wanted mobile phone outreach asking if they would like to schedule an appointment if they had not been seen by a health provider in over a year. In addition, respondents already used these technologies for information and communication related to health, housing, and jobs. These findings suggest new avenues for communication and health interventions for hard-to-reach homeless veterans.

Analysis of three strategies to increase screening coverage for cervical cancer in the general population of women aged 60 to 70years: the CRICERVA study.

BackgroundCervical cancer is a frequently diagnosed cancer in women worldwide. Despite having easy preventive and therapeutic approaches, it is an important cause of mortality among women.MethodsThe CRICERVA study is a cluster clinical trial which assigned one of three interventions to the target population registered in Cerdanyola, Barcelona. Among the 5,707 resident women aged 60 to 70 years in the study area, women with no record of cervical cytology over the last three years were selected. The study included four arms: three interventions all including a pre-assigned date for screening visit and i) personalized invitation letter; ii) adding to i) an informative leaflet; and, iii) in addition to ii) a personalized appointment reminder phone call, and iv) no specific action taken (control group). Participants were offered a personal interview about social-demographic characteristics and about screening attitudes. Cervical cytology and HPV DNA test (HC2) were offered as screening tests. In the case of screening positive in any of these tests, the women were followed up until a full diagnosis could be obtained. The effect size of each study arm was estimated as the absolute gain in coverage between the original coverage and the final coverage.ResultsFrom the intervention groups (4,775 women), we identified 3,616 who were not appropriately screened, of which 2,560 women answered the trial call and 1,376 were amenable to screening. HPV was tested in 920 women and cervical cytology in all 1,376. Overall, there was an absolute gain in coverage of 28.8% in the intervention groups compared to 6% in the control group. Coverage increased from 51.2% to 76.0% in strategy i); from 47.4% to 79.0% in strategy ii) and from 44.5% to 74.6% in strategy iii). Lack of information about the relevance of screening was the most important factor for not attending the screening program.ConclusionsThe study confirms that actively contacting women and including a date for a screening visit, notably increased participation in the screening program. Efforts to improve health education in preventative activities are warranted.Trial registrationClinical Trials.gov Identifier NCT01373723. Registered 14 June 2011.

Évaluation de l’efficacité de la tamsulosine pour améliorer la tolérance des sondes urétérales JJ. Étude prospective multicentrique randomisée

We evaluated the use of tamsulosine versus placebo for management of ureteral stent discomfort. This prospective and randomized study was realized in the Department of Urology of three university hospital. The participation was proposed at all patient having indication to receive an ureteral stent except for cancer. The evaluation of the tolerance used two validate questionnaires: Ureteral Stent Symptom Questionnaire (USSQ) and IPSS completed by each patient the day of the insertion, next day, one week later and the day before and after the removal. The main assessment criterion was the question "global quality of life" one week after the stent insertion. Seventy-nine patients were randomized between June, 2010 and October, 2012. Despite phone reminders only 38 (48.1%) were complete questionnaires. Out of 39, 18 patients in the tamsulosine group and out of 40, 20 in the phloroglucinol group. The majority of the patients (92%) were included for stone disease. There is not significant difference between the 2 groups using the USSQ and IPSS at day+1, day+7, pre-ablation and day+1 ablation. A significant improvement of the scores was noted to day+1 by the ablation of the JJ in 2 groups. Our study did not show superiority of tamsulosine versus placebo in the improvement of the tolerance of ureteral stent. 2.

Consequences and determinants of poor nutrition in children aged 0-3 years, and public health interventions that may improve dietary intake: a general review

Purpose – The purpose of this paper is to review the evidence base for effective public health interventions which aim to improve the diet of children aged zero to three years. Design/methodology/approach – General review. Findings – Key approaches and components of effective interventions include: repeated tasting, parental modelling, use of rewards, moderate restriction of “unhealthy” foods alongside an increase in portion sizes of fruits and vegetables, culturally appropriate messages, culturally acceptable health care provider, sufficient intensity of intervention, and an intervention which targets parental self-efficacy and modelling. Interventions which provide home visits (rather than require visits to a GP surgery or local community centre) financial incentives and/or mobile phone reminders may increase retention, particularly for some individuals. Recruiting mothers into programmes whilst they are pregnant may improve recruitment and retention rates. Originality/value – Allows for key public health interventions, approaches and components to be explored and identified. This will ensure that there is guidance to inform the development of new interventions for this age group and more importantly recommend that those components which are most successful be incorporated in policy and practice.

Effect of mobile phone reminders on follow-up medical care of children exposed to or infected with HIV in Cameroon (MORE CARE): a multicentre, single-blind, factorial, randomised controlled trial

Missed scheduled HIV appointments lead to increased mortality, resistance to antiretroviral therapy, and suboptimum virological response. We aimed to assess whether reminders sent to carers by text message, mobile phone call, or concomitant text message and mobile phone call increase attendance at medical appointments for HIV care in a population of children infected with or exposed to HIV in Cameroon. We also aimed to ascertain the most cost-effective method of mobile-phone-based reminder. MORE CARE was a multicentre, single-blind, factorial, randomised controlled trial in urban, semi-urban, and rural settings in Cameroon. Carers of children who were infected with or had been exposed to HIV were randomly assigned electronically in blocks of four and allocated (1:1:1:1) sequentially to receive a text message and a call, a text message only, a call only, or no reminder (control). Investigators were masked to group assignment. Text messages were sent and calls made 2 or 3 days before a scheduled follow-up appointment. The primary outcomes were efficacy (the proportion of patients attending a previously scheduled appointment) and efficiency (attendance/[measures of staff working time × cost of the reminders]), as a measure of cost-effectiveness. The primary analysis was by intention to treat. This study is registered with the Pan African Clinical Trials Register, number PACTR201304000528276. The study took place between Jan 28 and May 24, 2013. We randomly assigned 242 adult-child (carer-patient) pairs into four groups: text message plus call (n=61), call (n=60), text message (n=60), and control (n=61). 54 participants (89%) in the text message plus call group, 51 (85%) in the call group, 45 (75%) in the text message group, and 31 (51%) in the control group attended their scheduled appointment. Compared with control, the odds ratios for improvement in the primary efficacy outcome were 7·5 (95% CI 2·9-19·0; p<0·0001) for text message plus call, 5·5 (2·3-13·1; p=0·0002) for call, and 2·9 (1·3-6·3; p=0·012) for text message. No significant differences were seen in comparisons of the three intervention groups with each other, and there was no synergism between text messages and calls. For the primary efficiency outcome, the mean difference for text message versus text message plus call was 1·5 (95% CI 0·7 to 2·4; p=0·002), for call versus text message plus call was 1·2 (0·7 to 1·6; p<0·0001), and for call versus text message was 0·4 (-1·3 to 0·6; p=0·47). Mobile-phone-based reminders of scheduled HIV appointments for carers of paediatric patients in low-resource settings can increase attendance. The most effective method of reminder was text message plus phone call, but text messaging alone was the most efficient (ie, cost-effective) method. No external funding.

Mobile phone reminders for paediatric HIV follow-up care

Mobile phone reminders for paediatric HIV follow-up care

Optimizing strategies to improve interprofessional practice for veterans, part 1.

IntroductionInterprofessional patient care is a well-recognized path that health care systems are striving toward. The Veteran’s Affairs (VA) system initiated interprofessional practice (IPP) models with their Geriatric Evaluation and Management (GEM) programs. GEM programs incorporate a range of specialties, including but not limited to, medicine, nursing, social work, physical therapy and pharmacy, to collaboratively evaluate veterans. Despite being a valuable resource, they are now faced with significant cut-backs, including closures. The primary goal of this project was to assess how the GEM model could be optimized at the Pittsburgh, Pennsylvania VA to allow for the sustainability of this important IPP assessment. Part 1 of the study evaluated the IPP process using program, patient, and family surveys. Part 2 examined how well the geriatrician matched patients to specialists in the GEM model. This paper describes Part 1 of our study.MethodsThree strategies were used: 1) a national GEM program survey; 2) a veteran/family satisfaction survey; and 3) an absentee assessment.ResultsTwenty-six of 92 programs responded to the GEM IPP survey. Six strategies were shared to optimize IPP models throughout the country. Of the 34 satisfaction surveys, 80% stated the GEM clinic was beneficial, 79% stated their concerns were addressed, and 100% would recommend GEM to their friends. Of the 24 absentee assessments, the top three reasons for missing the appointments were transportation, medical illnesses, and not knowing/remembering about the appointment. Absentee rate diminished from 41% to 19% after instituting a reminder phone call policy.DiscussionMaintaining the sustainability of IPP programs is crucial for the health of our veterans. This project uncovered tools to improve the GEM IPP model for our veterans that can be incorporated nationally. Despite the lengthy nature of IPP models, patients and families appreciated the thoroughness, requested transportation and food, and responded well to reminder phone calls. A keen eye on these issues and concomitant medical complexity needs to be observed when planning IPP models to ensure sustainability.

Monitoring Microbicide Gel Use with Real-Time Notification of the Container’s Opening Events: Results of the CAPRISA Wisebag Study

Accurate estimation of the effectiveness of a microbicide for HIV prevention requires valid measurement of adherence to product use. A microbicide gel applicator container (Wisebag), fitted with cell phone technology to transmit opening events and text message reminders, was developed to monitor each opening event of the container as a proxy for gel use and adherence. Ten women were enrolled in a pilot study and followed for up to 4 months. Wisebag opening (WBO) dates and times were recorded and correlated with self-reported sex acts and gel applicator returns. During the 33 monthly follow-up visits, 47.8 % (77/161) of the recorded number of WBO events were concordant with the number of empty (used) applicators returned. The discrepancies were likely due to removal of more than one applicator during a single opening event. When the date and time of the WBO event data was assessed in relation to three different self-report adherence measures, agreement was fairly modest. The Wisebag was found to be acceptable as a storage container and the cell phone reminders generated were useful in supporting the dosing strategy. We recommend that the Wisebag be considered for larger scale and lengthier testing in microbicide trials.

Tumeurs germinales du testiculeet expositions précoces aux pesticides: étude pilote TESTEPERA

BackgroundTesticular germ cell tumors (TGCT) represent the most frequent cancer in men aged between 15 and 45 years. Current hypotheses are focusing on environmental exposures occurring during prenatal periods. However, very few studies have explored intra-uterine environmental exposure related to TGCT. MethodsTESTEPERA is a pilot case-control study aiming to determine the effectiveness of different recruitment approaches in the French context and to verify our ability to collect relevant data on their prenatal periods. ResultsBetween 2011 and 2012, 150 male subjects were contacted in the Rhône-Alpes region (58 cases from a cancer center and 92 controls from a regional maternity). Participation rate varied from 33% for cases diagnosed in 2008 vs 68% for cases diagnosed in 2010. Participation rate of controls varied depending on modalities of contact (13% for face-to-face recruitment; 0% for contact by phone only; 50% for face-to-face contact with phone reminder). Data collection allowed precise job identification and geolocation of subjects’ addresses. Precision of geolocation was dependent upon the level of urbanization (p<0.001) but not on the time period (p=0.52). ConclusionOur results support the feasibility of a case-control study focusing on the relation between TGCT and environmental pesticide exposures during early and later life.

Increasing Colorectal Cancer Screening in an Overdue Population: Participation and Cost Impacts of Adding Telephone Calls to a FIT Mailing Program

Many people who live in rural areas face distance barriers to colonoscopy. Our previous study demonstrated the utility of mailing fecal immunochemical tests (FIT) to average risk patients overdue for colorectal cancer (CRC screening). The aims of this study were to determine if introductory and reminder telephone calls would increase the proportion of returned FITs as well as to compare costs. Average risk patients overdue for CRC screening received a high intensity intervention (HII), which included an introductory telephone call to see if they were interested in taking a FIT prior to mailing the test out and reminder phone calls if the FIT was not returned. This HII group was compared to our previous low intensity intervention (LII) where a FIT was mailed to a similar group of veterans with no telephone contact. While a higher proportion of eligible respondents returned FITs in the LII (92 vs. 45 %), there was a much higher proportion of FITs returned out of those mailed in the HII (85 vs. 14 %). The fewer wasted FITs in the HII led to it having lower cost per FIT returned ($27.43 vs. $44.86). Given that either intervention is a feasible approach for patients overdue for CRC screening, health care providers should consider offering FITs using a home-based mailing program along with other evidence-based CRC screening options to average risk patients. Factors such as location, patient population, FIT cost and reimbursement, and personnel costs need to be considered when deciding the most effective way to implement FIT screening.

Health plan starts P4P program for community pharmacies

Health plan starts P4P program for community pharmacies

Mobile phones to support adherence to antiretroviral therapy: what would it cost the Indian National AIDS Control Programme?

IntroductionAdherence to antiretroviral treatment (ART) is critical to maintaining health and good clinical outcomes in people living with HIV/AIDS. To address poor treatment adherence, low-cost interventions using mobile communication technology are being studied. While there are some studies that show an effect of mobile phone reminders on adherence to ART, none has reported on the costs of such reminders for national AIDS programmes. This paper aims to study the costs of mobile phone reminder strategies (mHealth interventions) to support adherence in the context of India's National AIDS Control Program (NACP).MethodsThe study was undertaken at two tertiary level teaching hospitals that implement the NACP in Karnataka state, South India. Costs for a mobile phone reminder application to support adherence, implemented at these sites (i.e. weekly calls, messages or both) were studied. Costs were collected based on the concept of avoidable costs specific to the application. The costs that were assessed were one-time costs and recurrent costs that included fixed and variable costs. A sequential procedure for costing was used. Costs were calculated at national-programme level, individual ART-centre level and individual patient level from the NACP's perspective. The assessed costs were pooled to obtain an annual cost per patient. The type of application, number of ART centres and number of patients on ART were varied in a sensitivity analysis of costs.ResultsThe Indian NACP would incur a cost of between 79 and 110 INR (USD 1.27–1.77) per patient per year, based on the type of reminder, the number of patients on ART and the number of functioning ART centres. The total programme costs for a scale-up of the mHealth intervention to reach the one million patients expected to be on treatment by 2017 is estimated to be 0.36% of the total five-year national-programme budget.ConclusionsThe cost of the mHealth intervention for ART-adherence support in the context of the Indian NACP is low and is facilitated by the low cost of mobile communication in the country. Extending the use of mobile communication applications beyond adherence support under the national programme could be done relatively inexpensively.

Examining strategies to improve accelerometer compliance for individuals living with schizophrenia.

This study examined the feasibility and effect of 2 investigator-based and 2 participant-based strategies on accelerometer wear time in individuals living with schizophrenia in order to improve accelerometry compliance. Four adults with schizophrenia were asked to wear an accelerometer for 1 week during the baseline, intervention, and follow-up phases of a study that evaluated exercise counseling. To encourage participants to wear their accelerometers, investigators modeled proper accelerometer use, provided verbal and written instructions, and placed reminder phone calls. Participants were also given wear time logs and reminder magnets. All participants wore their accelerometers for the required amount of time during the study. Researchers should use multiple techniques to help ensure compliance. Research is needed to identify the most effective combination of strategies for this population.

Perceived Value of Pharmacist Interns in a Culturally Adapted Community Program

Objective: A study was conducted to determine program participants’ perception of fourth year pharmacist interns in a culturally adapted community program focused on improving medication adherence. Methods: Students participated in translation, recruitment, pre- and post- program screening, and reminder phone calls to program enrollees. An 8 question survey using a likert scale was developed and administered to participants at the end of the program. Results: There was a 100% “Always” report in three questions that inquired about the pharmacist interns’ contribution to the participants’ learning, and the program participants “Always” felt like their time was well spent with the pharmacist interns. Conclusion: Patients perceived the involvement of pharmacist interns in the implementation of a culturally adapted community program as positive.

Perceptions of HIV infected patients on the use of cell phone as a tool to support their antiretroviral adherence; a cross-sectional study in a large referral hospital in Kenya

BackgroundClinical trials were conducted to assess the feasibility of using a cell phone text messaging-based system to follow up Human Immunodeficiency Virus (HIV) infected patients on antiretroviral (ARTs) and assess for improved adherence to their medication. However there is need to evaluate the perceptions of the HIV infected patients towards the use of these cell phones in an effort to better aid in the clinical management of their HIV infection. The objective of this study was therefore to determine the perceptions of HIV infected patients on the use of cell phone text messaging as a tool to support adherence to their ART medication.MethodsA cross sectional survey was conducted among patients receiving Highly Active Anti-Retroviral Therapy (HAART) at the Kenyatta National Hospital Comprehensive Care Clinic in Nairobi between May and July, 2011. Pre-tested questionnaires were used to collect the socio-demographic and perceptions data. The recruitment of the participants was done using the random probability sampling method and statistical analysis of data performed using Statistical Package for Social Sciences (SPSS) version 16.0.ResultsA total of 500 HIV infected patients (Male-107, Female-307) aged 19-72 years were interviewed. The majority of individuals (99%) had access to cell phones and 99% of the HIV infected patients interviewed supported the idea of cell phone use in management of their HIV infection. A large proportion (46%) claimed that they needed cell phone access for medical advice and guidance on factors that hinder their adherence to medication and only 3% of them needed it as a reminder to take their drugs. The majority (72%) preferred calling the healthcare provider with their own phones for convenience and confidential purposes with only 0.4% preferring to be called or texted by the health care provider. Most (94%), especially the older patients, had no problem with their confidentiality being infringed in the process of the conversation as per the bivariate analysis results.ConclusionCell phone communications are acceptable and in fact preferable over cell phone reminders.

Capsule Commentary on Fortuna et al., Get Screened: A Randomized Trial of the Incremental Benefits of Reminders, Recall, and Outreach on Cancer Screening

Fortuna et al.1 assess and compare the effectiveness of phone, mail, and personal reminders as methods to improve rates of breast and colorectal cancer screening in an underserved population. Compared to reminder letters alone, cancer screening rates were increased with the addition of reminders at the point of care or a personalized phone call. However, no benefit was shown with the addition of an automated phone call to a reminder letter, compared to the letter alone. This study is well-written, well-designed, and shows promising findings. Unfortunately, this study might lack relevance for the practice environments of many, perhaps most, physicians currently practicing in the United States, in which electronic medical records (EMRs) are widely available and capable of ever-wider functionality. A survey done in 2011–2012 showed that greater than 40 % of physicians are currently using EMRs.2 Of course, the authors made extensive use of EMRs in their study in retrieving patient data and ascertaining their screening status. However, today’s EMRs make possible automated reminders to both physicians and patients regarding their screening.3 This issue affects the generalizability of the study results. If we accept the results that letter+autodial+prompt and letter+personal call are better than letter alone (note that these first two options do not appear statistically different, though they are not compared explicitly), then we must ask what the equivalent to “letter+autodial+[paper] prompt” is in current EMRs. Is a computer prompt of equivalent effectiveness to a paper prompt? What about a prompt delivered in real time to the provider, so that the prompt can be personally delivered during the visit? Another point to raise is the choice of American Cancer Society (ACS) cancer-screening guidelines. It is unclear which screening guidelines are most widely followed by physicians (if indeed any guidelines, as a set, are consistently followed at all,4) but clearly there are several competing possibilities, including United States Preventive Services Task Force (USPSTF) guidelines. A separate analysis to determine the sensitivity of the results to guidelines might be useful. This study serves as evidence that reminders work. The next step is to implement such reminders according to the most current practice environments.