Interventions to improve influenza and pneumococcal vaccination rates among community-dwelling adults: a systematic review and meta-analysis

Missed opportunities for pneumococcal vaccinations in high-risk and older adults in the United States

Pneumococcal vaccination rates remain sub-optimal in high-risk adult populations. This analysis quantified "missed opportunities," defined as number of healthcare encounters in unvaccinated patients who are recommended to be vaccinated. The 2015 National Health Interview Survey was used to assess vaccination status from adults 18-64 with risk factor and adults ≥65 years-old. In older adults, there was a mean of 5.15 (95% CI: 4.90-5.39) healthcare visits that could be opportunities for pneumococcal vaccination. In adults 18-64 years at high risk, there was a mean of 4.83 (95% CI: 4.66-4.99). Healthcare providers should take advantage of patient interactions to increase vaccination rates.

Factors associated with pneumococcal vaccination in 2040 people with type 2 diabetes: A cross-sectional study

AIMS

Pneumococcal vaccination is recommended in diabetes because of the high risk for invasive pneumococcal disease and mortality; however, vaccination rates are below recommended targets. This study was conducted to identify possible reasons behind the low rate of vaccine uptake.

METHODS

We examined baseline information from the Alberta Caring for Diabetes study, a prospective cohort study of 2040 adults with type 2 diabetes. Patients were recruited between December 2011 and December 2013. The baseline survey collected information on a wide range of socio-demographic characteristics, disease and management information, as well as health status measurements and health service utilization. Multivariable logistic regression analyses were conducted to identify factors associated with self-reported pneumococcal vaccination status.

RESULTS

Mean age was 64 (SD 11) years, 45% were women, mean duration of diabetes was 12 (SD 10) years, and 1090 (53%) were vaccinated. Age≥65 years (adjusted odds ratio [aOR] 2.52; 95% CI: 1.98-3.20), respiratory disease (aOR 1.50; 95% CI: 1.17-1.93), and cancer (aOR 1.45; 95% CI: 1.08-1.94) were independently associated with pneumococcal vaccination. In addition, women, retirees, people with diabetes≥10 years, people using antihypertensive medications or insulin, and those who had their HbA_1c, kidney function, or their weight or waist circumference measured by a healthcare professional in the past year were more likely to have been vaccinated.

CONCLUSION

Based on this information, future programs aimed at people aged<65 years old, men, those who are currently working, those recently diagnosed with diabetes, and those with few comorbidities could have the most potential for improving pneumococcal vaccine uptake in people with diabetes.

Reporting quality of systematic reviews of interventions aimed at improving vaccination coverage: compliance with PRISMA guidelines

Systematic reviews have become increasingly important for informing clinical practice and policy; however, little is known about the reporting characteristics and quality of SRs of interventions to improve immunization coverage in different settings. The aim of this study was to assess the reporting quality of systematic reviews of interventions aimed at improving vaccination coverage using the recommended Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guideline.PubMed and Cochrane Library were searched to identify SRs of interventions to improve immunization coverage, indexed up to May 2016. Two authors independently screened the search output, assessed study eligibility, and extracted data from eligible SRs using a 27-item data collection form derived from PRISMA. Discrepancies in reviews assessments were resolved by discussion and consensus.A total of 57 reviews were included in this study with a mean percentage of applicable PRISMA items that were met across all studies of 66% (range 19-100%) and median compliance of 70%. 39 out of the 57 reviews were published after the release of the PRISMA statement in 2009. Highest compliance was observed in items related to the "description of rational", "description of eligibility criteria", "synthesis of results" and "provision of a general interpretation of the results" (items #3, #6, #14 and #26, respectively). Compliance was poorest in the items "describing summary of evidence" (item 24, 19%), "describing indication of review protocol and registration" (item 5, 26%) and "describing results of risk of bias across studies (item 22, 33%).The overall reporting quality of systematic reviews of interventions to improve vaccination coverage requires significant improvement. There remains a need for additional research targeted at addressing potential barriers to compliance and strategies to improve compliance with PRISMA guideline.

Disparities in uptake of 13-valent pneumococcal conjugate vaccine among older adults in the United States

BACKGROUND

In September 2014, 13-valent pneumococcal conjugate vaccine (PCV13) was universally recommended for all US adults aged ≥65 years. Adult PCV13 coverage, including whether disparities in uptake exist, however, is not well-described.

METHODS

We used a monthly series of cross-sectional analyses of administrative medical and prescription claims data collected by IQVIA and linked to sociodemographic data collected by Experian to estimate overall and subpopulation-level uptake of PCV13 among US adults aged ≥65 years.

RESULTS

Among adults aged ≥65 years, 43.3% received PCV13 by the end of November 2017. Race/ethnicity, annual household income, education status, and neighborhood urbanicity were strongly related to PCV13 uptake among adults aged ≥65 years. Lower uptake of PCV13 was observed for non-Hispanic black (36.3%) and Hispanic (30.0%) adults (vs 45.6% for non-Hispanic whites, P < .01), the poor (30.7% vs 54.2% among lowest vs highest income deciles, P < .01), adults with low educational status (33.0% vs 49.0% among those without high school education vs college educated, P < .01), and those living in rural communities (22.9%) or urban/inner-city (33.8%) areas (vs 45.8% in suburban areas, P < .01).

CONCLUSIONS

PCV13 uptake among adults aged ≥65 occurred rapidly in the three years after universal recommendation in September 2014. Yet, poor and minority communities, rural and urban/inner-city areas, and communities with low educational attainment had substantially lower PCV13 coverage. These same populations are at increased risk of pneumococcal disease. In order to maximize the benefits of pneumococcal vaccination, further targeted and tailored interventions to increase PCV13 uptake in these underserved populations are still necessary.

Promoting Influenza Vaccination Among an ACA Health Plan Subscriber Population: A Randomized Trial

PURPOSE

To assess the effectiveness of an intervention to promote influenza vaccination among members of an Affordable Care Act (ACA) insurance plan.

DESIGN

Randomized controlled trial.

SETTING

Messages were delivered by a community-based, nonprofit health insurance provider to its members in Central Texas.

PARTICIPANTS

Adult subscribers for whom either a phone number or an e-mail address was available (n = 25 649).

INTERVENTION

Participants were randomly assigned to be sent (1) no messages, (2) messages encouraging influenza vaccination via e-mails and texts, and (3) messages encouraging influenza vaccination through e-mails, texts, and postal mail. Messages were sent between September 12, 2017 and November 17, 2017.

MEASURES

Influenza vaccination was determined using medical and pharmacy claims.

ANALYSIS

Rate differences and 95% confidence intervals between each exposure condition were calculated for the overall population and by subgroups.

RESULTS

The vaccination rate by December 31, 2017 was 16.9%. Those sent both electronic messages and postal mail were significantly more likely to be vaccinated than those who were not sent messages (rate difference: 2.5%; 95% confidence interval [CI]: 1.4-3.6) and those who were sent electronic messages only (rate difference: 1.6%; 95% CI: 0.5-2.8).

CONCLUSION

A combination of messages delivered via text, e-mail, and postal mail generated a modest but significant positive effect on influenza vaccine rates in an ACA plan population. The postal mail component was essential for achieving this effect.

Improving the Combination Pneumococcal Vaccination Rate in Systemic Lupus Erythematosus Patients at an Adult Rheumatology Practice

OBJECTIVE

The risk of developing invasive pneumococcal infection is 13 times higher in patients with systemic lupus erythematosus (SLE) in comparison with the general population. The US Centers for Disease Control and Prevention anticipates a US$7.6 million medical cost reduction by providing pneumococcal vaccination. The objective of this study was to improve the rate of combination pneumococcal vaccination (pneumococcal polysaccharide vaccine 23 + pneumococcal conjugate vaccine 13) in patients with SLE in our adult academic rheumatology practice.

METHODS

With the use of physician- and staff-based surveys, we analyzed the underlying barriers in providing vaccination. We then planned a multifaceted intervention including pre-visit planning, day-of-visit planning, weekly review, and monthly feedback.

RESULTS

Our project is one of the few studies planned to improve combination pneumococcal vaccination rates in adult patients with SLE and we report an impressive improvement from 10% baseline rate to 59% vaccination rate by the end of the study period. This highlights the role of planning an intervention with an integrated workflow and the importance of sharing performance data, which leads to high compliance among team members.

CONCLUSION

The significant improvement in combination vaccination rate in eligible patients with SLE and the additional rise of vaccine rates seen in other eligible patients in the practice draws attention to the high adaptiveness of the intervention resulting in a true practice change. Our quality project design can serve as a model that can be adapted by other specialty clinics to achieve higher vaccination standards.

The impact of pharmacy-based immunization services on the likelihood of immunization in the United States

OBJECTIVES

A major policy to increase immunization rates against infectious diseases in the United States has included pharmacy-based immunization services. We aimed to determine the impact of pharmacy-based immunization services on the likelihood of adult influenza and pneumococcal immunization.

DESIGN

National individual-level immunization data were merged with pharmacy-level data on the availability of immunization services for 8466 pharmacies from a national pharmacy chain. County-level variation in availability of vaccines from 2006 to 2010 was used to characterize exposure to immunization services. We used a longitudinal logistic regression model to estimate the impact of pharmacy-based immunization services on the outcomes of interest.

SETTING AND PARTICIPANTS

We conducted the main analysis in the U.S. adult population. We conducted subgroup analyses of high-risk populations, including people 65 years of age or older.

OUTCOME MEASURES

Odds of being immunized for influenza or pneumococcal disease after exposure to the service compared with before the service while controlling for existing trends in immunization rate growth and other confounders.

RESULTS

Each additional year of exposure to pharmacy-based immunization services was associated with a 1.023 (CI 1.012-1.034) greater odds of reporting an influenza immunization and a 1.016 (CI 1.006-1.027) greater odds of reporting a pneumococcal immunization. Five years after national implementation, we estimate that 6.2 million additional influenza immunizations and 3.5 million additional pneumococcal immunizations are attributable to pharmacy-delivered immunization services each year. Subgroup analyses further indicate that the policy increased the odds of immunization for both diseases over time among adults 65 years of age or older (influenza odds ratio [OR] 1.025, CI 1.013-1.038; and pneumococcal OR 1.026, CI 1.010-1.042).

CONCLUSION

Pharmacy-based immunization services increased the likelihood of immunization for influenza and pneumococcal diseases, resulting in millions of additional immunizations in the United States.

Interventions to increase influenza vaccination rates of those 60 years and older in the community

BACKGROUND

The effectiveness of interventions to increase influenza vaccination uptake in people aged 60 years and older varies by country and participant characteristics. This review updates versions published in 2010 and 2014.

OBJECTIVES

To assess access, provider, system, and societal interventions to increase the uptake of influenza vaccination in people aged 60 years and older in the community.

SEARCH METHODS

We searched CENTRAL, which includes the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE, Embase, CINAHL, and ERIC for this update, as well as WHO ICTRP and ClinicalTrials.gov for ongoing studies to 7 December 2017. We also searched the reference lists of included studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and cluster-randomised trials of interventions to increase influenza vaccination in people aged 60 years or older in the community.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as specified by Cochrane.

MAIN RESULTS

We included three new RCTs for this update (total 61 RCTs; 1,055,337 participants). Trials involved people aged 60 years and older living in the community in high-income countries. Heterogeneity limited some meta-analyses. We assessed studies as at low risk of bias for randomisation (38%), allocation concealment (11%), blinding (44%), and selective reporting (100%). Half (51%) had missing data. We assessed the evidence as low-quality. We identified three levels of intervention intensity: low (e.g. postcards), medium (e.g. personalised phone calls), and high (e.g. home visits, facilitators).Increasing community demand (12 strategies, 41 trials, 53 study arms, 767,460 participants)One successful intervention that could be meta-analysed was client reminders or recalls by letter plus leaflet or postcard compared to reminder (odds ratio (OR) 1.11, 95% confidence interval (CI) 1.07 to 1.15; 3 studies; 64,200 participants). Successful interventions tested by single studies were patient outreach by retired teachers (OR 3.33, 95% CI 1.79 to 6.22); invitations by clinic receptionists (OR 2.72, 95% CI 1.55 to 4.76); nurses or pharmacists educating and nurses vaccinating patients (OR 152.95, 95% CI 9.39 to 2490.67); medical students counselling patients (OR 1.62, 95% CI 1.11 to 2.35); and multiple recall questionnaires (OR 1.13, 95% CI 1.03 to 1.24).Some interventions could not be meta-analysed due to significant heterogeneity: 17 studies tested simple reminders (11 with 95% CI entirely above unity); 16 tested personalised reminders (12 with 95% CI entirely above unity); two investigated customised compared to form letters (both 95% CI above unity); and four studies examined the impact of health risk appraisals (all had 95% CI above unity). One study of a lottery for free groceries was not effective.Enhancing vaccination access (6 strategies, 8 trials, 10 arms, 9353 participants)We meta-analysed results from two studies of home visits (OR 1.30, 95% CI 1.05 to 1.61) and two studies that tested free vaccine compared to patient payment for vaccine (OR 2.36, 95% CI 1.98 to 2.82). We were unable to conduct meta-analyses of two studies of home visits by nurses plus a physician care plan (both with 95% CI above unity) and two studies of free vaccine compared to no intervention (both with 95% CI above unity). One study of group visits (OR 27.2, 95% CI 1.60 to 463.3) was effective, and one study of home visits compared to safety interventions was not.Provider- or system-based interventions (11 strategies, 15 trials, 17 arms, 278,524 participants)One successful intervention that could be meta-analysed focused on payments to physicians (OR 2.22, 95% CI 1.77 to 2.77). Successful interventions tested by individual studies were: reminding physicians to vaccinate all patients (OR 2.47, 95% CI 1.53 to 3.99); posters in clinics presenting vaccination rates and encouraging competition between doctors (OR 2.03, 95% CI 1.86 to 2.22); and chart reviews and benchmarking to the rates achieved by the top 10% of physicians (OR 3.43, 95% CI 2.37 to 4.97).We were unable to meta-analyse four studies that looked at physician reminders (three studies with 95% CI above unity) and three studies of facilitator encouragement of vaccination (two studies with 95% CI above unity). Interventions that were not effective were: comparing letters on discharge from hospital to letters to general practitioners; posters plus postcards versus posters alone; educational reminders, academic detailing, and peer comparisons compared to mailed educational materials; educational outreach plus feedback to teams versus written feedback; and an intervention to increase staff vaccination rates.Interventions at the societal levelNo studies reported on societal-level interventions.Study funding sourcesStudies were funded by government health organisations (n = 33), foundations (n = 9), organisations that provided healthcare services in the studies (n = 3), and a pharmaceutical company offering free vaccines (n = 1). Fifteen studies did not report study funding sources.

AUTHORS' CONCLUSIONS

We identified interventions that demonstrated significant positive effects of low (postcards), medium (personalised phone calls), and high (home visits, facilitators) intensity that increase community demand for vaccination, enhance access, and improve provider/system response. The overall GRADE assessment of the evidence was moderate quality. Conclusions are unchanged from the 2014 review.

Reducing Missed Opportunities for Influenza Vaccination in Patients with Rheumatoid Arthritis: Evaluation of a Multisystem Intervention

OBJECTIVE

To assess a multimodal intervention for reducing missed opportunities for outpatient influenza vaccination in individuals with rheumatoid arthritis (RA).

METHODS

Patients with RA were enrolled from a single center and each rheumatology outpatient visit was tracked for missed opportunities for influenza vaccination, defined as a visit in which an unvaccinated patient without contraindications remained unvaccinated or lacked documentation of vaccine recommendation in the electronic medical record (EMR). Providers then received a multimodal intervention consisting of an education session, EMR alerts, and weekly provider-specific e-mail reminders. Missed opportunities before and after the intervention were compared, and the determinants of missed opportunities were analyzed.

RESULTS

A total of 228 patients with RA were enrolled (904 preintervention visits) and 197 returned for at least 1 postintervention visit (721 postintervention visits). The preintervention frequency of any missed opportunities for influenza vaccination was 47%. This was reduced to 23% postintervention (p < 0.001). Among those vaccinated, the relative hazard for influenza vaccination post- versus preintervention period was 1.24 (p = 0.038). Younger age, less frequent office visits, higher erythrocyte sedimentation rate, and negative attitudes about vaccines were each independently associated with missed opportunities preintervention. Postintervention, these factors were no longer associated with missed opportunities; however, the intervention was not as effective in non-Hispanic black patients, non-English speakers, those residing outside of the New York City metropolitan area, and those reporting prior adverse reactions to vaccines.

CONCLUSION

Improved uptake of influenza vaccination in patients with RA is possible using a multimodal approach. Certain subgroups may need a more potent intervention for equivalent efficacy.

The relative burden of community-acquired pneumonia hospitalizations in older adults: a retrospective observational study in the United States

Background

The risk of community-acquired pneumonia (CAP) increases with age and significantly impacts morbidity and mortality in the elderly population. The burden of illness and cost of preventing CAP has not been compared to other serious diseases.

Methods

This retrospective analysis used claims data from 2014 to 2015 and compared hospitalizations for CAP, myocardial infarction (MI), stroke, and osteoporotic fractures (OF) in adults aged ≥65 years enrolled in a Medicare Advantage insurance plan. Individuals who had not already been hospitalized for one of these conditions and did not have evidence of long-term care were included in the study. Hospitalizations for each condition were described by length of stay, readmissions, mortality, and total costs. Preventive measures included vaccinations for CAP and medications for MI, stroke, and OF.

Results

A total of 1,949,352 individuals were included in the cohort. In 2015, the rate of CAP-related hospitalizations was the highest at 846.7 per 100,000 person-years compared to 405 for MI, 278.9 for stroke, and 343.9 for OF. Vaccination costs for CAP were $40.2 million including $14.1 million for pneumococcal and $26.1 million for influenza vaccines. The cost of preventive medications for MI and stroke reached over $661 million and OF totaled $169 million.

Conclusions

Although CAP has a higher burden of hospitalization and total costs than MI, stroke, and OF in the elderly population, prevention efforts were disproportionately smaller for CAP. Prioritization of CAP prevention is needed to substantially reduce the burden of CAP.

Improving pneumococcal vaccine uptake in veterans with chronic lymphocytic leukemia through a virtual clinic

Through a "virtual clinic," we used the electronic medical record to identify and intervene upon patients with chronic lymphocytic leukemia (cll) who were not current for pneumococcal vaccines. Within 180 days, 100/160 patients (62%) received the recommended pneumococcal vaccine. A virtual clinic may improve vaccination rates among high-risk patient populations.

The role of timeliness in the cost-effectiveness of older adult vaccination: A case study of pneumococcal conjugate vaccine in Australia

While the impact of the timeliness of vaccine administration has been well-studied for childhood vaccinations, there has been little detailed quantitative analysis on the potential impact of the timeliness of vaccinations in older adults. The aim of this study was to explore the impact of implementing more realistic observed uptake distributions, taking into the account reduced vaccine efficacy but higher pneumococcal disease burden with increasing age beyond 65 years. A multi-cohort Markov model was constructed to evaluate the cost-effectiveness of a pneumococcal (PCV13) immunisation program in Australia, assuming two different uptake modelling approaches. The approach using an estimate of observed uptake was compared with a scenario in which the total cumulative uptake was delivered at the recommended age of vaccination. We found these two approaches produced different results both in terms of cases prevented and cost-effectiveness. The impact of the non-timely uptake in adult programs may sometimes have positive and other times negative effects, depending on several factors including the age-specific disease rates and the duration of vaccine protection. Our study highlights the importance of using realistic assumptions around uptake (including non-timely vaccination) when estimating the impact of vaccination in adults.

UNderstanding uptake of Immunisations in TravellIng aNd Gypsy communities (UNITING): a qualitative interview study

BACKGROUND

Gypsies, Travellers and Roma (referred to as Travellers) are less likely to access health services, including immunisation. To improve immunisation rates, we need to understand what helps and hinders individuals in these communities in taking up immunisations.

AIMS

(1) Investigate the barriers to and facilitators of acceptability and uptake of immunisations among six Traveller communities across four UK cities; and (2) identify possible interventions to increase uptake of immunisations in these Traveller communities that could be tested in a subsequent feasibility study.

METHODS

Three-phase qualitative study underpinned by the social ecological model. Phase 1: interviews with 174 Travellers from six communities: Romanian Roma (Bristol); English Gypsy/Irish Traveller (Bristol); English Gypsy (York); Romanian/Slovakian Roma (Glasgow); Scottish Showpeople (Glasgow); and Irish Traveller (London). Focus on childhood and adult vaccines. Phase 2: interviews with 39 service providers. Data were analysed using the framework approach. Interventions were identified using a modified intervention mapping approach. Phase 3: 51 Travellers and 25 service providers attended workshops and produced a prioritised list of potentially acceptable and feasible interventions.

RESULTS

There were many common accounts of barriers and facilitators across communities, particularly across the English-speaking communities. Scottish Showpeople were the most similar to the general population. Roma communities experienced additional barriers of language and being in a new country. Men, women and service providers described similar barriers and facilitators. There was widespread acceptance of childhood and adult immunisation, with current parents perceived as more positive than their elders. A minority of English-speaking Travellers worried about multiple/combined childhood vaccines, adult flu and whooping cough. Cultural concerns about vaccines offered during pregnancy and about human papillomavirus were most evident in the Bristol English Gypsy/Irish Traveller community. Language, literacy, discrimination, poor school attendance, poverty and housing were identified by Travellers and service providers as barriers for some. Trustful relationships with health professionals were important and continuity of care was valued. A few English-speaking Travellers described problems of booking and attending for immunisation. Service providers tailored their approach to Travellers, particularly the Roma. Funding cuts, NHS reforms and poor monitoring challenged their work. Five 'top-priority' interventions were agreed across communities and service providers to improve the immunisation among Travellers who are housed or settled on an authorised site: (1) cultural competence training for health professionals and frontline staff; (2) identification of Travellers in health records to tailor support and monitor uptake; (3) provision of a named frontline person in general practitioner practices to provide respectful and supportive service; (4) flexible and diverse systems for booking appointments, recall and reminders; and (5) protected funding for health visitors specialising in Traveller health, including immunisation.

LIMITATIONS

No Travellers living on the roadside or on unofficial encampments were interviewed. We should exert caution in generalising to these groups.

FUTURE WORK

To include development, implementation and evaluation of a national policy plan (and practice guidance plan) to promote the uptake of immunisation among Traveller communities.

STUDY REGISTRATION

Current Controlled Trials ISRCTN20019630 and UK Clinical Research Network Portfolio number 15182.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 72. See the NIHR Journals Library website for further project information.

The Cost of Interventions to Increase Influenza Vaccination: A Systematic Review

CONTEXT

Influenza vaccination rates remain below Healthy People 2020 goals. This project sought to systematically review economic evaluations of healthcare-based quality improvement interventions for improving influenza vaccination uptake among general populations and healthcare workers.

EVIDENCE ACQUISITION

The databases MEDLINE, Econlit, Centre for Reviews & Dissemination, Greylit, and Worldcat were searched in July 2016 for papers published from January 2004 to July 2016. Eligible studies evaluated efforts by bodies within the healthcare system to encourage influenza vaccination by means of an organizational or structural change. For each study, program costs per enrollee and per additional enrollee vaccinated were derived (excluding vaccine costs, standardized to 2017 U.S. dollars). Complete economic evaluations were examined when available.

EVIDENCE SYNTHESIS

Of 2,350 records, 18 articles were eligible and described 29 unique interventions. Most interventions improved vaccine uptake. Among 23 interventions in general populations, the median program cost was $3.27 (interquartile range, $0.82-$11.53) per enrollee and $50.78 (interquartile range, $27.85-$124.84) per additional enrollee vaccinated. Among ten complete economic evaluations in general populations, three studies reported net cost savings, four reported costs <$50,000 per quality-adjusted life year, and three reported costs <$60,000 per life saved. Among six interventions in healthcare workers, the median program cost was $8.09 (interquartile range, $5.03-$10.31) per worker enrolled and $125.24 (interquartile range, $96.06-$171.38) per additional worker vaccinated (there were no complete economic analyses).

CONCLUSIONS

Quality improvement interventions for influenza vaccination involve per-enrollee costs that are similar to the cost of the vaccine itself ($11.78-$36.08/dose). Based on limited available evidence in general populations, quality improvement interventions may be cost saving to cost effective for the health system.

Factors influencing on influenza vaccination and its trends of coverage in patients with diabetes in Korea: A population-based cross-sectional study

BACKGROUND

Influenza infection is a contagious disease and annual influenza vaccination is recommended to the patients with chronic diseases. Although diabetes is an indication for influenza vaccination, the global rate of influenza vaccination is insufficient. Therefore, our study aimed to elucidate influenza vaccination statuses among patients with diabetes and the related factors in Korea.

METHODS

A total of 32,268 subjects (4,540 with and 27,728 without diabetes) from the Korea National Health and Nutrition Examination Survey III-VI (2005-2015) were included. Socioeconomic factors and health-related factors were analyses for the relation of influenza vaccination by Student's t-test, the chi-squared test and a multivariate logistic regression analysis.

RESULTS

The influenza vaccination coverage rates were 50.0% in the diabetes mellitus (DM) group and 38.2% in the non-DM group. The trends in influenza vaccination rates during KNHANES III-VI were not significant in each group (P trend  =  0.24 in the DM group, 0.30 in the non-DM group). Socioeconomic (older age, female sex, higher family income, and medical aid insurance) and health-related factors (lack of risky alcohol consumption, obesity, and recent health check-ups) were associated with influenza vaccination among patients with DM.

CONCLUSIONS

The rate of influenza vaccination among patients with diabetes is insufficient in Korea. More efforts are needed to increase the influenza vaccination rates among vulnerable at-risk populations.

Randomized Controlled Trial of Text Message Reminders for Increasing Influenza Vaccination

PURPOSE

Seasonal influenza vaccine is recommended and funded for groups at higher risk of serious infection, but uptake is suboptimal. We conducted a randomized controlled trial of short message service (SMS) reminders for influenza vaccination.

METHODS

Six weeks after seasonal influenza vaccinations began, we identified high-risk patients who had a mobile telephone number on record at 10 practices in Western Australia. Thirty-two percent of the selected patients had already been vaccinated in the current year and were ineligible. Of the remaining 12,354 eligible patients at each practice one-half were randomly assigned to receive a vaccination reminder by SMS (intervention) and the rest received no SMS (control). Approximately 3 months after the SMS was sent (the study period), vaccination data were extracted from the patients' electronic medical records. Log-binomial regression models were used to calculate the relative risk (RR) of vaccination between the intervention and control group.

RESULTS

Twelve-percent (769 of 6,177) of the intervention group and 9% (548 of 6,177) of the control group were vaccinated during the study period, a 39% relative increase attributable to the SMS (RR = 1.39; 95% CI, 1.26-1.54). For every 29 SMSs sent, costing $3.48, 1 additional high-risk patient was immunized. The greatest effect was observed for children younger than 5 years, whose parents were more than twice as likely to have their child vaccinated if they received a SMS reminder (RR = 2.43; 95% CI, 1.79-3.29).

CONCLUSION

We found SMS reminders to be a modestly effective, low-cost means to increase seasonal influenza vaccine coverage among high-risk patients.

Using the 4 Pillars to increase vaccination among high-risk adults: who benefits?

OBJECTIVES

To compare changes in vaccination rates (pneumococcal polysaccharide vaccine [PPSV]; tetanus, diphtheria, and pertussis [Tdap] vaccine; and influenza vaccine) among high-risk adults following an intervention (June 1, 2013, to January 31, 2015) that used the 4 Pillars Practice Transformation Program (4 Pillars Program).

STUDY DESIGN

Post hoc analysis of data from a randomized controlled cluster trial.

METHODS

Eighteen primary care practices received staff education, guidance for using the 4 Pillars Program, and support for a practice immunization champion. Paired t tests were used to compare vaccination rates separately for those with diabetes, chronic lung or chronic heart disease, or other high-risk conditions. Student's t tests were used to compare vaccination rates across high-risk conditions. Generalized estimating equation modeling was used to determine the likelihood of vaccination.

RESULTS

Based on International Classification of Diseases, Ninth Revision, Clinical Modification codes, 4737 patients aged 18 to 64 years were identified as having diabetes (n = 1999), chronic heart disease (n = 658), chronic lung disease (n = 1682), or another high-risk condition (n = 764). PPSV uptake increased by 12.2 percentage points (PP), Tdap vaccination increased by 11.4 PP, and influenza vaccination increased by 4.8 PP. In regression analyses, patients with diabetes (odds ratio [OR], 2.2; 95% CI, 1.80-2.73), chronic lung disease (OR, 1.50; 95% CI, 1.21-1.87), or chronic heart disease (OR, 1.32; 95% CI, 1.02-1.71) were more likely to receive PPSV than those without the respective high-risk condition. Those with diabetes (OR, 1.14; 95% CI, 1.01-1.28) or chronic lung disease (OR, 1.14; 95% CI, 1.01-1.30) were more likely to receive an influenza vaccine than those without the respective condition. The likelihood of Tdap vaccination was not significantly associated with any of the chronic conditions tested.

CONCLUSIONS

An intervention including the 4 Pillars Program was associated with significant increases in vaccination of high-risk adults. However, the overall uptake of recommended vaccines for those with high-risk conditions remained below national goals.

A formative research-guided educational intervention to improve the knowledge and attitudes of seniors towards influenza and pneumococcal vaccinations

BACKGROUND

Adult influenza and pneumococcal vaccination rates in Singapore are low, and factors influencing knowledge and attitudes of seniors towards influenza, pneumonia and their respective vaccines are not well-known. Our study aims to understand the barriers and facilitators towards getting influenza and pneumococcal vaccinations among seniors in Singapore, and subsequently inform the conduct of a relevant community-based educational intervention, as well as evaluate the intervention outcomes.

METHODS

We performed a mixed methods study with two components: Firstly, formative research was conducted among community-dwelling seniors, using focus group discussions (FGDs), to understand their knowledge and attitudes towards influenza, pneumonia and their respective vaccines. Next, a quantitative study was conducted to evaluate knowledge of seniors and the effectiveness of an educational intervention.

RESULTS

Four FGDs were organised with 32 participants, who were predominantly female, of lower educational background, and residing in government rental flats. Participants had varying levels of knowledge and many misconceptions about influenza, pneumonia and their respective vaccinations, with concerns about side effects and vaccine effectiveness. The formative research results were used to inform a community-based educational intervention for seniors. Our subsequent evaluation included 604 elderly participants, mainly from lower educational and socio-economic strata, who initially demonstrated poor knowledge scores (median score 5 out of 9, IQR 4-5). Following our intervention, median knowledge score improved to 7 (IQR 6-8) (p < .0001). Significant improvements in knowledge scores were observed across genders, age strata, education levels, and housing types.

DISCUSSION

Our formative research identified knowledge gaps among community-dwelling seniors which affected their attitudes towards vaccination uptake. Key findings were taken into consideration when implementing the educational intervention. Our community-based intervention was effective in improving knowledge and attitudes, and could be used as a cue to action for short-term behaviour changes.

Impact of patient education on influenza vaccine uptake among community-dwelling elderly: a randomized controlled trial

This randomized controlled trial aimed to test the effectiveness of brief face-to-face patient education in increasing influenza vaccination rate among elderly in the community. Recruitment and intervention were conducted at two general outpatient clinics in Hong Kong. 529 eligible patients were randomly assigned to intervention or control group with 1:1 allocation ratio. Patients in the intervention group received 3-min one-on-one verbal education by medical students and a pamphlet regarding influenza vaccination. Neither verbal health education nor pamphlet was given to the control group. Intention-to-treat analysis showed significantly higher vaccination rate in the intervention group compared with the control group (33.6 versus 25.0%) and the adjusted relative risk was 1.34 (95% CI 1.04-1.72; P = 0.021). Hence, brief face-to-face patient education was effective in increasing influenza vaccine uptake rate of community-dwelling elderly patients. Participants who were undecided whether to receive vaccination seemed to demonstrate larger beneficial effect (RR = 7.84; 95% CI 1.06-57.76) compared with patients who were certain of either receiving (RR = 1.16; 95% CI 0.90-1.48) or not receiving (RR = 2.18; 95% CI 0.68-6.99) the vaccine. The study also revealed that patients' intention for vaccination may not translate into action, reasons for which should be explored in future research.

Factors that influence influenza vaccination rates among the elderly: nurses' perspectives

AIMS

To explore which factors nurses perceive to help and hinder influenza vaccination rates among the elderly.

BACKGROUND

Influenza-related illnesses and deaths have disproportionately high prevalence among the elderly. Vaccination is an effective tool to prevent complications.

METHODS

Semistructured interviews were conducted with nurses focusing on barriers, facilitators and health care providers' roles in influencing patients to be vaccinated. Interviews were recorded, transcribed and thematically analysed.

RESULTS

Nurses identified that the prevalent barriers were fear of the vaccine's side effects, feelings of good health and technical considerations. Facilitators included ease of access and encouragement from health providers, media and social networks. The health care team was influential in raising vaccination rates through direct recommendation, providing concrete information or leading by example.

CONCLUSIONS

The health care team can influence patients to vaccinate. Investments in training nurses in the knowledge and skills needed to educate patients, and providing nurses with the necessary resources to engage patients in these discussions may be beneficial. Nurse managers can be instrumental in enhancing nurses' roles and actions to increase influenza vaccination rates among the elderly.

IMPLICATIONS FOR NURSING MANAGEMENT

It is essential to reinforce the nurses' role in promoting vaccination among seniors. Given that nurses are the largest number of health professionals, their potential outreach to large numbers of people is strong.

Significance of electronic health records: A comparative study of vaccination rates in patients with sickle cell disease

OBJECTIVE

In this study, we investigated the influence of electronic health records (EHR) and electronic vaccination schedule applications on the vaccination status of patients who were admitted to our Center for the treatment of sickle cell disease (SCD).

METHODS

The vaccination status against influenza and pneumococcus infection was determined in 93 patients who were admitted to the hematology outpatient clinic, Baskent University Adana Hospital from April 2004 to March 2009. The vaccination status was then re-evaluated following establishment of EHR and electronic vaccination schedules in 2012.

RESULTS

Of the 93 patients with SCD 21.5% (n = 20) were vaccinated against pneumococcus and 21.5% (n = 20) were regularly vaccinated against influenza. When the vaccination rates of 59 of 93 patients who presented for their regular control examinations were analyzed following establishment of EHR and vaccination schedules in 2012, these rates were 49.2% (n = 29) and 50.8% (n = 30) for influenza and pneumococcus, respectively, after EHR; there were 23.7% (n = 14) and 20.3% (n = 12), respectively, before EHR. A statistically significant difference was found between the vaccination rates before and after EHR (p < 0.05).

CONCLUSION

Although viral and bacterial infections are life-threatening health problems in patients with SCD, the vaccination rates were low in high-risk patients. However, these rates increased after application of electronic vaccination schedules.

Mailed outreach and facilitated test ordering to promote cholesterol screening in community health centers: A randomized trial

RATIONALE, AIMS, AND OBJECTIVES

Lipid screening is central to cardiovascular risk assessment. We sought to determine whether a simple mailed outreach message and facilitated test ordering increase cholesterol screening among federally qualified community health center patients with no recent cholesterol screening test performed.

METHODS

Using a patient-randomized controlled trial, we examined the effects of delivering a simple mailed outreach intervention promoting cholesterol testing and facilitated test ordering (without requiring an office visit). Participants were adult patients 50 to 75 years old, with no diagnosed cardiovascular disease or diabetes, and no cholesterol test within 5 years who had received care from community health centers in Illinois and Arizona. The intervention took place in 2014 and was powered to detect a 10% increase in screening due to the intervention.

RESULTS

Participants' (n = 480) mean age was 57.5 years, 51.0% were male, and 43.8% were smokers. There was no significant difference between groups in the primary study outcome-completion of total cholesterol and high-density lipoprotein cholesterol tests or complete lipid panel within 3 months; 32 participants (13.3%) in intervention group versus 26 (10.8%) in control group met the primary outcome, with absolute difference of 2.5 percentage points (95% confidence interval -6.6 to 11.6).

CONCLUSIONS

This outreach intervention promoting cholesterol screening was ineffective. Interventions that attempt to minimize barriers to cholesterol screening on multiple fronts and that are more compelling to patients are needed.

Development and evaluation of a patient education video promoting pneumococcal vaccination

OBJECTIVE

This study aimed to develop and refine a patient education video about pneumococcal polysaccharide vaccination (PPSV23) and to assess patient perceptions regarding video content and receipt of video during a clinic visit.

METHODS

Focus groups were conducted to obtain patient feedback on a brief video focusing on personal susceptibility to pneumonia and highlighting the importance of both childhood and adult vaccines. Subsequently, interviews were conducted with patients ages 65 and 66 who were shown the revised video at an office visit. We assessed attitudes toward the video and perceptions about its presentation at the point of care. Participants responded to open-ended items as well as Likert-type items with responses from 1 (strongly disagree) to 5 (strongly agree).

RESULTS

Focus group participants (n=26) had positive reactions to the video, but suggested reducing the intensity of messages about pneumonia severity. Participants (n=73) shown the revised video during a clinic visit perceived it to be easy to understand (M=4.83, SD=0.58) and informative (M=4.8, SD=0.75).

CONCLUSION

Target audience feedback helped refine a video promoting PPSV23 vaccination; the video was well received by patients.

PRACTICE IMPLICATIONS

This video may be an effective educational tool to increase rates of PPSV23 vaccination.

Behavior change interventions and policies influencing primary healthcare professionals' practice-an overview of reviews

BACKGROUND

There is a plethora of interventions and policies aimed at changing practice habits of primary healthcare professionals, but it is unclear which are the most appropriate, sustainable, and effective. We aimed to evaluate the evidence on behavior change interventions and policies directed at healthcare professionals working in primary healthcare centers.

METHODS

Study design: overview of reviews.

DATA SOURCE

MEDLINE (Ovid), Embase (Ovid), The Cochrane Library (Wiley), CINAHL (EbscoHost), and grey literature (January 2005 to July 2015).

STUDY SELECTION

two reviewers independently, and in duplicate, identified systematic reviews, overviews of reviews, scoping reviews, rapid reviews, and relevant health technology reports published in full-text in the English language.

DATA EXTRACTION AND SYNTHESIS

two reviewers extracted data pertaining to the types of reviews, study designs, number of studies, demographics of the professionals enrolled, interventions, outcomes, and authors' conclusions for the included studies. We evaluated the methodological quality of the included studies using the AMSTAR scale. For the comparative evaluation, we classified interventions according to the behavior change wheel (Michie et al.).

RESULTS

Of 2771 citations retrieved, we included 138 reviews representing 3502 individual studies. The majority of systematic reviews (91%) investigated behavior and practice changes among family physicians. Interactive and multifaceted continuous medical education programs, training with audit and feedback, and clinical decision support systems were found to be beneficial in improving knowledge, optimizing screening rate and prescriptions, enhancing patient outcomes, and reducing adverse events. Collaborative team-based policies involving primarily family physicians, nurses, and pharmacists were found to be most effective. Available evidence on environmental restructuring and modeling was found to be effective in improving collaboration and adherence to treatment guidelines. Limited evidence on nurse-led care approaches were found to be as effective as general practitioners in patient satisfaction in settings like asthma, cardiovascular, and diabetes clinics, although this needs further evaluation. Evidence does not support the use of financial incentives to family physicians, especially for long-term behavior change.

CONCLUSIONS

Behavior change interventions including education, training, and enablement in the context of collaborative team-based approaches are effective to change practice of primary healthcare professionals. Environmental restructuring approaches including nurse-led care and modeling need further evaluation. Financial incentives to family physicians do not influence long-term practice change.

Using the 4 Pillars Practice Transformation Program to Increase Pneumococcal Immunizations for Older Adults: A Cluster-Randomized Trial

OBJECTIVES

To test the effectiveness of a step-by step, evidence-based guide, the 4 Pillars Practice Transformation Program, to increase adult pneumococcal vaccination.

DESIGN

Randomized controlled cluster trial (RCCT) in Year 1 (June 1, 2013 to May 31, 2014) and pre-post study in Year 2 (June 1, 2014 to January 31, 2015) with data analyzed in 2016. Baseline year was June 1, 2012, to May 31, 2013. Demographic and vaccination data were derived from deidentified electronic medical record extractions.

SETTING

Primary care practices (n = 25) stratified according to metropolitan area (Houston, Pittsburgh), location (rural, urban, suburban), and type (family medicine, internal medicine), randomized to receive the intervention in Year 1 (n = 13) or Year 2 (n = 12).

PARTICIPANTS

Individuals aged 65 and older at baseline (N = 18,107; mean age 74.2; 60.7% female, 16.5% non-white, 15.7% Hispanic).

INTERVENTION

The 4 Pillars Program, provider education, and one-on-one coaching of practice-based immunization champions. Outcome measures were 23-valent pneumococcal polysaccharide vaccine (PPSV) and pneumococcal conjugate vaccine (PCV) vaccination rates and percentage point (PP) changes in vaccination rates.

RESULTS

In the Year 1 RCCT, PPSV vaccination rates increased significantly in all intervention and control groups, with average increases ranging from 6.5 to 8.7 PP (P < .001). The intervention was not related to greater likelihood of PPSV vaccination. In the Year 2 pre-post study, the likelihood of PPSV and PCV vaccination was significantly higher in the active intervention sites than the maintenance sites in Pittsburgh but not in Houston.

CONCLUSION

In a RCCT, PPSV vaccination rates increased in the intervention and control groups in Year 1. In a pre-post study, private primary care practices actively participating in the 4 Pillars Practice Transformation Program improved PPSV and PCV uptake significantly more than practices that were in the maintenance phase of the study.

Factors associated with pneumococcal polysaccharide vaccination of the elderly in Spain: A cross-sectional study

Vaccination of the elderly is an important factor in limiting the impact of pneumonia in the community. The aim of this study was to investigate the factors associated with pneumococcal polysaccharide vaccination in patients aged ≥ 65 years hospitalized for causes unrelated to pneumonia, acute respiratory disease, or influenza-like illness in Spain. We made a cross-sectional study during 2013-2014. A bivariate analysis was performed comparing vaccinated and unvaccinated patients, taking into account sociodemographic variables and risk medical conditions. A multivariate analysis was performed using multilevel regression models. 921 patients were included; 403 (43.8%) had received the pneumococcal vaccine (394 received the polysaccharide vaccine). Visiting the general practitioner ≥ 3 times during the last year (OR = 1.79; 95% CI 1.25-2.57); having received the influenza vaccination in the 2013-14 season (OR = 2.57; 95% CI 1.72-3.84) or in any of the 3 previous seasons (OR = 11.70; 95% CI 7.42-18.45) were associated with receiving the pneumococcal polysaccharide vaccine. Pneumococcal vaccination coverage of hospitalized elderly people is low. The elderly need to be targeted about pneumococcal vaccination and activities that encourage healthcare workers to proactively propose vaccination might be useful. Educational campaigns aimed at the elderly could also help to increase vaccination coverages and reduce the burden of pneumococcal disease in the community.

Surveillance for Certain Health Behaviors, Chronic Diseases, and Conditions, Access to Health Care, and Use of Preventive Health Services Among States and Selected Local Areas - Behavioral Risk Factor Surveillance System, United States, 2012

PROBLEM

Chronic diseases (e.g., heart diseases, cancer, chronic lower respiratory disease, stroke, diabetes, and arthritis) and unintentional injuries are the leading causes of morbidity and mortality in the United States. Behavioral risk factors (e.g., tobacco use, poor diet, physical inactivity, excessive alcohol consumption, failure to use seat belts, and insufficient sleep) are linked to the leading causes of death. Modifying these behavioral risk factors and using preventive health services (e.g., cancer screenings and influenza and pneumococcal vaccination of adults aged ≥65 years) can substantially reduce morbidity and mortality in the U.S.

POPULATION

Continuous monitoring of these health-risk behaviors, chronic conditions, and use of preventive services are essential to the development of health promotion strategies, intervention programs, and health policies at the state, city, and county level.

REPORTING PERIOD

January-December 2012.

DESCRIPTION OF THE SYSTEM

The Behavioral Risk Factor Surveillance System (BRFSS) is an ongoing, state-based, random-digit-dialed landline- and cellular-telephone survey of noninstitutionalized adults aged ≥18 years residing in the United States. BRFSS collects data on health-risk behaviors, chronic diseases and conditions, access to health care, and use of preventive health services related to the leading causes of death and disability. This report presents results for all 50 states, the District of Columbia, participating U.S. territories that include the Commonwealth of Puerto Rico (Puerto Rico) and Guam, 187 Metropolitan/Micropolitan Statistical Areas (MMSAs), and 210 counties (n = 475,687 survey respondents) for the year 2012.

RESULTS

In 2012, the estimated prevalence of health-risk behaviors, chronic diseases or conditions, access to health care, and use of preventive health services substantially varied by state and territory, MMSA, and county. The following portion of the abstract lists a summary of results by selected BRFSS measures. Each set of proportions refers to the range of estimated prevalence for health-risk behaviors, chronic diseases or conditions, and use of preventive health care services among geographical units, as reported by survey respondents. Adults with good or better health: 64.0%-88.3% for states and territories, 62.7%-90.5% for MMSAs, and 68.1%-92.4% for counties. Adults aged 18-64 years with health care coverage: 64.2%-93.1% for states and territories, 35.4%- 93.7% for MMSAs, and 35.4%-96.7% for counties. Adults who received a routine physical checkup during the preceding 12 months: 55.7%-80.1% for states and territories, 50.6%-85.0% for MMSAs, and 52.4%-85.0% for counties. An influenza vaccination received during the preceding 12 months among adults aged ≥65 years: 26.3%-70.1% for states and territories, 20.8%-77.8% for MMSAs, and 24.1%-77.6% for counties. Ever received pneumococcal vaccination among adults aged ≥65 years: 22.2%-76.2% for states and territories, 15.3%-83.4% for MMSAs, and 25.8%-85.2% for counties. Adults who had a dental visit in the past year: 53.7%-76.2% for states and territories, and 44.8%-81.7% for MMSAs and counties. Adults aged ≥65 years who have lost all of their natural teeth from tooth decay or gum disease: 7.0%-33.7% for states and territories, 5.8%-39.6% for MMSAs, and 5.8%-37.1% for counties. Adults aged 50-75 years who received a colorectal cancer screening on the basis of the U.S. Preventive Services Task Force recommendation: 40.0%-76.4% for states and territories, 47.1%-80.7% for MMSAs, and 47.0%-81.0% for counties. Women aged 21-65 years who had a Papanicolaou test during the preceding 3 years: 68.5% to 89.6% for states and territories, 70.3% to 92.8% for MMSAs, and 65.7%-94.6% for counties. Women aged 50-74 years who had a mammogram during the preceding 2 years: 66.5%- 89.7% for states and territories, 61.1%-91.5% for MMSAs, and 61.8%-91.6% for counties. Current cigarette smoking among adults: 10.6%-28.3% for states and territories, 5.1%-30.1% for MMSAs, and 5.1%-28.3% for counties. Binge drinking among adults during the preceding month: 10.2%-25.2% for states and territories, 6.2%-28.1% for MMSAs, and 6.2%-29.5% for counties. Heavy drinking among adults during the preceding month: 3.5%-8.5% for states and territories, 2.0%-11.0% for MMSAs, and 1.9%-11.0% for counties. Adults who reported no leisure-time physical activity: 16.3%-42.4% for states and territories, 9.2%-47.3% for MMSAs, and 9.2%-39.0% for counties. Self- reported seat belt use: 62.0%-93.7% for states and territories, 54.1%-97.1% for MMSAs, and 50.1%-97.4% for counties. Adults who were obese: 20.5%-34.7% for states and territories, 14.8%-44.5% for MMSAs and counties. Adults with diagnosed diabetes: 7.0%-16.4% for states and territories, 3.4%-17.4% for MMSAs, and 3.1%-17.4% for counties. Adults who ever had any type of cancer: 3.0%-13.7% for states and territories, 3.8%-19.2% for MMSAs, and 4.5%-19.2% for counties. Adults with current asthma: 5.8%-11.1% for states and territories, 3.1%-15.0% for MMSAs, and 3.1%-15.7% for counties. Adults with some form of arthritis: 15.6%-36.4% for states and territories, 16.8%-45.8% for MMSAs, and 14.8%-35.9% for counties. Adults having had a depressive disorder: 9.0%-23.5% for states and territories, 9.2%-28.3% for MMSAs, and 8.5%-28.4% for counties. Adults aged ≥45 years who have had coronary heart disease: 7.4%-19.0% for states and territories, 6.1%-23.3% for MMSAs, and 6.1%-20.6% for counties. Adults aged ≥45 years who have had a stroke: 3.1%-7.3% for states and territories, 2.1%-9.3% for MMSAs, and 1.5%-9.3% for counties. Adults with limited activities because of physical, mental, or emotional problems: 15.0%-28.6% for states and territories, 12.0%-31.7% for MMSAs, and 11.3%-31.7% for counties. Adults using special equipment because of any health problem: 4.8%-11.6% for states and territories, 4.0%-14.7% for MMSAs, and 2.8%-13.6% for counties.

INTERPRETATION

This report underscores the need for continuous surveillance of health-risk behaviors, chronic diseases or conditions, health care access, and use of preventive care services at state and local levels. It will help to identify high-risk populations and to evaluate public health intervention programs and policies designed to reduce morbidity and mortality from chronic disease and injury.

PUBLIC HEALTH ACTION

State and local health departments and agencies can continue to use BRFSS data to identify populations at high risk for unhealthy behaviors and chronic diseases or conditions, lack of health care access, and inadequate use of preventive care services. Additionally, states can use the data to design, implement, monitor, and evaluate public health programs and policies at state and local levels.

Diffusion of Pharmacy-Based Influenza Vaccination Over Time in the United States

OBJECTIVES

To examine pharmacy-based influenza vaccination using diffusion of innovation theory.

METHODS

We used 1993 to 2013 Behavioral Risk Factor Surveillance System data to generate weighted prevalence rates of influenza vaccination, stratified by age (18-64 years vs ≥ 65 years) and state of residence. The diffusion of innovation theory adopter categories were residents of states allowing pharmacist vaccination before 1996 ("innovator/early adopters"), between 1996 and 1998 ("early majority"), between 1999 and 2004 ("late majority"), and in 2007 or later ("laggards").

RESULTS

For adults aged 18 to 64 years, vaccination rates were similar before the innovation (1993), diverged as the innovation reached the majority (2003), and were significantly lower for laggard states by 2013. Younger adults' vaccination rates steadily increased from 12% to 16% in 1993 to 29% to 36% in 2013. For older adults, there was no significant difference in vaccination rates between adopter categories in any year and no advantage associated with adoption category.

CONCLUSIONS

Key features of pharmacy-based vaccination, including relative advantage and compatibility, are most relevant to younger adults; different interventions are warranted for older adults.

A brief educational intervention increases providers' human papillomavirus vaccine knowledge

Recommendation by a healthcare provider is critical to increase human papillomavirus (HPV) vaccine uptake in the US. However, current deficits in providers' knowledge of HPV and its vaccine are not fully understood and interventions to amend knowledge gaps are untested. To determine whether attending a structured presentation could increase provider knowledge of the HPV vaccine, we assessed knowledge levels of physicians, non-physician healthcare workers, and medical students before and after attending a 30-minute lecture held between October 2012 and June 2014. Paired t-test and McNemar's test were used to compare knowledge scores and the proportion of correct responses for each question, respectively. Multiple linear regression analyses were performed to examine correlates of baseline knowledge and change in knowledge scores post-intervention. A total of 427 participants, including 75 physicians, 208 medical students, and 144 nurses or other healthcare workers, attended one of 16 presentations and responded to both pre-test and post-test surveys. Baseline knowledge was low among all groups, with scores higher among older participants and physicians/medical students. On average, knowledge scores significantly improved from 8 to 15 after the presentation (maximum possible score 16) (P < .001), irrespective of specialty, race/ethnicity, gender, and age. Although lower at baseline, knowledge scores of younger participants and non-physician healthcare workers (e.g., nurses, physician assistants (PAs), nursing students) improved the most of all groups. We conclude that a brief, structured presentation increased HPV knowledge among a variety of healthcare workers, even when their baseline knowledge was low.

Influenza vaccination competence of nurses in France: A survey in nursing schools

Since 2008, French nurses have been allowed to vaccinate against influenza without medical prescription. Our survey aimed at assessing nursing students' knowledge and perception of this prerogative. Among 213 responders, 61% were aware of this matter, and 47.5% were familiar with its requirements. Most (75.6%) were positive about it. Influenza vaccination without medical prescription is well-known and validated by nursing students. This new competence may improve vaccination coverage.

A Virtual Clinic Improves Pneumococcal Vaccination for Asplenic Veterans at High Risk for Pneumococcal Disease

We developed a "virtual clinic" to improve pneumococcal vaccination among asplenic adults. Using an electronic medical record, we identified patients, assessed their vaccination status, entered orders, and notified patients and providers. Within 180 days, 38 of 76 patients (50%) received a pneumococcal vaccination. A virtual clinic may optimize vaccinations among high-risk patients.

Interventions to increase the uptake of seasonal influenza vaccination among pregnant women: A systematic review

BACKGROUND

Pregnant women and their infants under 6 months of age infected with influenza have a high risk of serious morbidity and mortality. Influenza vaccine during pregnancy offers 3-for-1 benefits to pregnant women, fetuses and newborn infants. Current vaccination uptake rates during pregnancy, however, are often lower than other high-risk groups and the general population.

METHODS

We systematically reviewed evidence on the effectiveness of interventions to improve influenza vaccination coverage in pregnant women. Risk differences (RDs) were calculated from the included studies.

RESULTS

Eleven studies were included in the review, of which four were randomized controlled trials (RCTs). Three cohort studies assessed provider-focused interventions while four RCTs and one cohort study evaluated pregnant women-focused interventions. Two cohort studies and a prospective intervention study assessed the effectiveness of bundled interventions. No study solely assessed the effectiveness of interventions to enhance access to influenza vaccination. One moderate quality RCT showed that an influenza pamphlet, with or without a verbalized benefit statement, improved the vaccination rate (RD=0.26; RD=0.39). The other reviewed RCTs showed discordant results, with RDs ranging from -0.15 to 0.03. Although all observational studies significantly improved vaccination rates (RDs ranged from 0.03 to 0.44), the quality of the evidence varied.

CONCLUSIONS

There is a lack of effective interventions to increase the influenza vaccination rate in pregnant women. Based on the existing research, we recommend that clinicians provide influenza pamphlets to pregnant women with a verbalized statement about the benefits of influenza vaccine to newborns. Further high-quality RCTs are needed to develop successful maternal influenza vaccination programs. Increased clarity in reporting the content of interventions would help to improve the comparability and generalizability of the published studies.

Stagnating Low Influenza Vaccine Coverage Rates in the Polish Elderly Population in 2008-2013

Although annual vaccination is the most effective way of preventing the disease and its severe outcomes, influenza vaccine coverage rates have always been at suboptimal levels in Poland. A retrospective analysis was conducted on influenza vaccine coverage rates among patients older than 65 years at local and national levels. Influenza vaccine coverage rates among the elderly in the capital city of Warsaw ranged from 20.5% in 2013 to 31.5% in 2010 and these rates were higher than those reported at the national level (from 7.6% in 2012 to 11.3% in 2009). At a local level the proportion of vaccines given to the elderly compared to all vaccinated individuals varied from 40 to 52% which was comparable to the proportions reported at the national level (37-48.5%). 69% of the elderly were only vaccinated once during the observation period, and only 0.5% of them repeated the vaccination in each subsequent year. The chance of being vaccinated against influenza more than once was statistically higher among women than men (OR 4.9; 95% CI 4.2-5.8). Influenza vaccine coverage rates are low at both local and national levels and ought to be improved in Poland in future.

Improving Influenza and Pneumococcal Vaccination Rates in Ambulatory Specialty Practices

Background. Influenza and pneumococcal vaccinations are recommended for elderly and high-risk patients; however, rates of adherence are low. We sought to implement influenza and pneumococcal vaccine initiatives in 4 different ambulatory specialty practices, using 3 unique approaches.

Methods. Four specialties with high-risk patient populations were selected for intervention: allergy (asthma), infectious disease (ID) (human immunodeficiency virus), pulmonary (chronic lung disease), and rheumatology (immunocompromised). Allergy and ID focused on influenza vaccination, and pulmonary and rheumatology focused on pneumococcal vaccination. We used 3 strategies for quality improvement: physician reminders, patient letters, and a nurse-driven model. Physicians were provided their performance data on a monthly basis and presented trended data on a quarterly basis at staff meetings.

Results. All 4 specialties developed processes for improving vaccination rates with all showing some increase. Higher rates were achieved with pneumococcal vaccine than influenza. Pneumococcal vaccine rates showed steady improvement from year to year while influenza vaccine rates remained relatively constant. Allergy's influenza rate was 59% in 2011 and 64% in the 2014 flu season. Infectious disease influenza rates moved from 74% in the 2011 flu season to 86% for the 2014 season. Pneumococcal vaccine in pulmonary patients' rate was 52% at the start of intervention in February 2009 and 79% as of January 2015. Rheumatology rates rose from 50% in February 2009 to 87% in January 2015.

Conclusions. Integrated routine workflow and performance data sharing can effectively engage specialists and staff in vaccine adherence improvement. Influenza vaccination may require other approaches to achieve the rates seen with pneumococcal vaccine.

Estimated Human and Economic Burden of Four Major Adult Vaccine-Preventable Diseases in the United States, 2013

Low uptake of routinely recommended adult immunizations is a public health concern. Using data from the peer-reviewed literature, government disease-surveillance programs, and the US Census, we developed a customizable model to estimate human and economic burden caused by four major adult vaccine-preventable diseases (VPD) in 2013 in the United States, and for each US state individually. To estimate the number of cases for each adult VPD for a given population, we multiplied age-specific incidence rates obtained from the literature by age-specific 2013 Census population data. We then multiplied the estimated number of cases for a given population by age-specific, estimated medical and indirect (non-medical) costs per case. Adult VPDs examined were: (1) influenza, (2) pneumococcal disease (both invasive disease and pneumonia), (3) herpes zoster (shingles), and (4) pertussis (whooping cough). Sensitivity analyses simulated the impact of various epidemiological scenarios on the total estimated economic burden. Estimated US annual cost for the four adult VPDs was $26.5 billion (B) among adults aged 50 years and older, $15.3B (58 %) of which was attributable to those 65 and older. Among adults 50 and older, influenza, pneumococcal disease, herpes zoster, and pertussis made up $16.0B (60 %), $5.1B (19 %), $5.0B (19 %), and $0.4B (2 %) of the cost, respectively. Among those 65 and older, they made up $8.3B (54 %), $3.8B (25 %), $3.0B (20 %), and 0.2B (1 %) of the cost, respectively. Most (80-85 %) pneumococcal costs stemmed from nonbacteremic pneumococcal pneumonia (NPP). Cost attributable to adult VPD in the United States is substantial. Broadening adult immunization efforts beyond influenza only may help reduce the economic burden of adult VPD, and a pneumococcal vaccination effort, primarily focused on reducing NPP, may constitute a logical starting place. Sensitivity analyses revealed that a pandemic influenza season or change in size of the US elderly population could increase these costs dramatically.

The effect of various types of patients' reminders on the uptake of pneumococcal vaccine in adults: A randomized controlled trial

BACKGROUND

Invasive pneumococcal disease is one of the most important vaccine-preventable diseases threatening the adult community due to missed opportunities for vaccination. This study compares the effect of three different types of patient reminder system on adulthood Streptococcus pneumoniae immunization in a primary care setting.

METHODS

The study targeted patients aged 40 and older eligible for pneumococcal vaccine, but did not receive it yet (89.5% of 3072 patients) based on their electronic medical records in a family medicine center in Beirut. The sample population was randomized using an automated computer randomization system into six equal groups, receiving short phone calls, short text messaging system (sms-text) or e-mails each with or without patient education. Each group received three identical reminders spaced by a period of four weeks. Documentation of vaccine administration was then added to the longitudinal electronic patient record. The primary outcome was the vaccine administration rate in the clinics.

RESULTS

Of the eligible patients due for the pneumococcal 23-polyvalent vaccine, 1380 who had mobile phone numbers and e-mails were randomized into six equal intervention groups. The various reminders increased vaccination rate to 14.9%: 16.5% of the short phone calls group, 7.2% of the sms-text group and 5.7% of the e-mail group took the vaccine. The vaccination rate was independent of the age, associated education message and the predisposing condition.

CONCLUSION

Use of electronic text reminders via e-mails and mobile phones seems to be a feasible and sustainable model to increase pneumococcal vaccination rates in a primary care center.

The role of community pharmacy-based vaccination in the USA: current practice and future directions

Community pharmacy-based provision of immunizations in the USA has become commonplace in the last few decades, with success in increasing rates of immunizations. Community pharmacy-based vaccination services are provided by pharmacists educated in the practice of immunization delivery and provide a convenient and accessible option for receiving immunizations. The pharmacist’s role in immunization practice has been described as serving in the roles of educator, facilitator, and immunizer. With a majority of pharmacist-provided vaccinations occurring in the community pharmacy setting, there are many examples of community pharmacists serving in these immunization roles with successful outcomes. Different community pharmacies employ a number of different models and workflow practices that usually consist of a year-round in-house service staffed by their own immunizing pharmacist. Challenges that currently exist in this setting are variability in scopes of immunization practice for pharmacists across states, inconsistent reimbursement mechanisms, and barriers in technology. Many of these challenges can be alleviated by continual education; working with legislators, state boards of pharmacy, stakeholders, and payers to standardize laws; and reimbursement design. Other challenges that may need to be addressed are improvements in communication and continuity of care between community pharmacists and the patient centered medical home.

Vaccination in Older Adults in Singapore: A Summary of Recent Literature

Singaporeans are living longer and not having enough babies to replace themselves, with projected 20% of the population aged 65 years and above by 2030. These worrying trends can exert significant pressure on Singapore's economy and society. Health-resource utilisations are increasing as our population ages, with increase in hospitalisations, emergency room visits and consumption of pharmaceutical drugs. Interventions such as vaccinations in older people are well-studied approaches to prevent infections and the related complications. The Advisory Committee on Immunization Practice (ACIP) by the US Centers for Disease Control and Prevention (CDC) recommends routine immunisation against influenza, tetanus, pneumococcal pneumonia as well as herpes zoster infections in all people aged 65 years and above. The administrations of other vaccines (meningococcal, hepatitis A and B, varicella and Haemophilus influenzae type b) are recommended only in older people with certain risk factors. Despite the benefits of vaccination in older people, the data in the West shows that the rate of vaccination in this age group remains lower than targets recommended by the World Health Organisation (WHO). The main barriers to vaccinations exist in the healthcare system, health care providers, patients and caregivers. Interventions are warranted to increase awareness among physicians, to engage the involvement of the pharmacist/nurse to provide standing orders and reduction in cost of vaccination; this potentially improves vaccination uptake to protect our increasing elderly population.

Characteristics and health behaviors of diabetic patients receiving influenza vaccination

OBJECTIVE

Epidemiological research has posited a 'healthy user' bias in patients receiving influenza vaccination; thus we sought to evaluate potential healthy-user attributes and their associations with influenza vaccination.

RESEARCH DESIGN & METHODS

Between 2011 and 2013, adults with type 2 diabetes were enrolled in a prospective cohort in Alberta, Canada. Information collected included sociodemographics, diabetes-related data (e.g., duration, complications), health behaviors (e.g., smoking status), functional health status, and satisfaction with healthcare. Data were collected by a mailed, self-administered survey. Multivariable logistic regression analyses were used to identify potential healthy-user attributes independently associated with influenza vaccination.

RESULTS

From a cohort of 2040 patients, 1287 (63%) reported receiving the influenza vaccine in the previous year. Average age of the cohort was 64 years (standard deviation 11) and 55% were male. In multivariable analysis, attributes independently associated with influenza vaccination included receiving preventive medications: aspirin (64% vs 44%; adjusted odds ratio, aOR 1.65, 95% CI 1.34-2.04); blood pressure medications (76% vs 56%; aOR 1.36, 95% CI 1.07-1.71); and cholesterol-lowering medications (74% vs 53%; aOR 1.50, 95% CI 1.19-1.89), as well as having a healthcare professional check feet for lesions (47% vs 31%; aOR 1.39, 95% CI 1.12-1.74). Additional covariates independently associated with influenza vaccination included: age over 65 years, respiratory disease, the number of additional comorbidities, and higher ratings of healthcare experience.

CONCLUSION

Vaccinated diabetic patients exhibit many postulated attributes of 'healthy users', which has implications for the interpretation of epidemiological studies of influenza vaccine effectiveness, as well as targeting future vaccination campaigns.

Practice-level quality improvement interventions in primary care: a review of systematic reviews

AIM

To present an overview of effective interventions for quality improvement in primary care at the practice level utilising existing systematic reviews.

BACKGROUND

Quality improvement in primary care involves a range of approaches from the system-level to patient-level improvement. One key setting in which quality improvement needs to occur is at the level of the basic unit of primary care--the individual general practice. Therefore, there is a need for practitioners to have access to an overview of the effectiveness of quality improvement interventions available in this setting.

METHODS

DESIGN

A tertiary evidence synthesis was conducted (a review of systematic reviews). A systematic approach was used to identify and summarise published literature relevant to understanding primary-care quality improvement at the practice level. Quality assessment was via the Critical Appraisal Skills Programme tool for systematic reviews, with data extraction identifying evidence of effect for the examined interventions.

SCOPE

Included reviews had to be relevant to quality improvement at the practice level and relevant to the UK primary-care context. Reviews were excluded if describing system-level interventions.

OUTCOME MEASURES

A range of measures across care structure, process and outcomes were defined and interpreted across the quality improvement interventions.

FINDINGS

Audit and feedback, computerised advice, point-of-care reminders, practice facilitation, educational outreach and processes for patient review and follow-up all demonstrated evidence of a quality improvement effect. Evidence of an improvement effect was higher where baseline performance was low and was particularly demonstrated across process measures and measures related to prescribing. Evidence was not sufficient to suggest that multifaceted approaches were more effective than single interventions.

CONCLUSION

Evidence exists for a range of quality improvement interventions at the primary-care practice level. More research is required to determine the use and impact of quality improvement interventions using theoretical frameworks and cost-effectiveness analysis.