Recommended care adherence: Improved by patient reminder letters but with potential attenuation by the healthcare process complexity

Zhou Zhang, Jason Fish

Research output: Contribution to journalArticlepeer-review

3 Scopus citations


Background American adults receive the recommended care just over half of the time for all recommended services. Many patient reminder strategies have attempted to increase the adherence rates for preventative and chronic disease management. However, there is a lack of data available in relation to adherence rates for symptom-specific recommended services and a lack of data identifying any contributions from the organisational structures to these adherence rates. Purpose To identify the efficacy and differences in patient reminder letter strategies on various categories of recommended services, as well as to analyse the relationship between a novel quantification of a healthcare system's process complexity with adherence rates. Design Retrospective cohort study analysing pilot data collected from an urban, academic healthcare provider utilising patient reminder letters. Participants Adults attending one academic medical centre's outpatient practice from 2008 to 2009. Intervention Two reminder letters sent chronologically if the recommended care was not completed in the appropriate time frame. Main measures Adherence rates of each recommended service at baseline, after first and second reminder letters, and non-adherence rates despite the reminder letter intervention. Process flow complexity was calculated as a composite score combining elements of fastest time to complete routine order, number of different steps in routine order, number of departments involved, and number of sites patients visit. Results Patient adherence rates increased for all the recommended services after the first reminder letter. Preventative and Chronic Disease Management recommendations demonstrated additional moderate increases after the second reminder letter. Referrals and Radiologogy and Diagnostic Testing (acute, symptom specific) and Labs (acute and nonacute) demonstrated additional minimal adherence rate increases after the second reminder letter. Comparison of the process flow complexity demonstrated an inverse relationship between process complexity and adherence rates, particularly for non-acute orders. Conclusions One reminder letter seemed to be sufficient for most recommended care. The complexity of the healthcare process may be an important predictive factor for patient adherence.

Original languageEnglish (US)
Pages (from-to)149-164
Number of pages16
JournalQuality in Primary Care
Issue number2
StatePublished - Jun 14 2012


  • Chronic disease
  • Patient adherence
  • Reminder letters

ASJC Scopus subject areas

  • Health Policy
  • Public Health, Environmental and Occupational Health


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