Ten-year durability and success of an organized program to increase influenza and pneumococcal vaccination rates among high-risk adults. Influenza Vaccination Programs for Elderly Persons: Cost-Effectiveness in a Health Maintenance Organization Guiding individual decisions: a randomized, controlled trial of decision analysis. Increased use of pneumococcal vaccination in a medicine clinic following initiation of a quality assessment monitor. Achieving compliance with influenza immunization of medical house staff and students. A randomized controlled trial. Two decades after vaccine license: hepatitis B immunization and infection among young men who have sex with men. Increasing influenza immunization among high-risk patients: education or financial incentive? Adult immunization: the medical record design as a facilitator for physician compliance. Vaccination of high-risk patients for influenza. A comparison of telephone and mail reminder methods. Influenza immunization in a managed care organization Use of a low-literacy patient education tool to enhance pneumococcal vaccination rates. A randomized controlled trial. Progress toward the elimination of hepatitis B virus transmission among health care workers in the United States. Achieving the national health objective for influenza immunization: success of an institution-wide vaccination program. A Reappraisal of Hepatitis B Virus Vaccination Strategies Using Cost-Effectiveness Analysis Evaluation of office-based intervention to improve prevention counseling for patients at risk for sexually acquired hepatitis B virus infection. Hepatitis B-WARE Study Group. Effectiveness of a co-ordinated nation-wide programme to improve influenza immunisation rates in The Netherlands. Interpandemic influenza in the Houston area, 1974-76. Improving general practice care of patients with asthma or chronic obstructive pulmonary disease: evaluation of a quality system. Do postcard reminders improve influenza compliance? A prospective trial of different postcard "cues". Effects of computer reminders for influenza vaccination on morbidity during influenza epidemics. Pneumococcal vaccine in the hospital. Improved use and implications for high-risk patients. Understanding and enhancing compliance with the second dose of hepatitis B vaccine: a cohort analysis and a randomized controlled trial. The Effect Of Microcomputer-Generated Reminders On Influenza Vaccination Rates In A University-Based Family Practice Center The protective efficacy of polyvalent pneumococcal polysaccharide vaccine. Control of occupational hepatitis B among healthcare workers in the Czech Republic, 1982 to 1995. Randomized controlled study of customized preventive medicine reminder letters in a community practice.
PURPOSE Influenza and pneumococcal vaccines are underused . Systems approaches that incorporate administrative and organizational strategies are more successful than education of providers for improving vaccination rates . Little has been published on the long-term success and durability of such efforts . METHODS We performed a 10-year time-series study to examine the durability and success of an ongoing , multifaceted , institution-wide influenza and pneumococcal vaccination program . The program was first implemented at the Minneapolis Department of Veterans Affairs ( VA ) Medical Center in 1987 - 88 following the demonstration that a clinic-based st and ing order policy was much more successful than provider education for improving vaccine delivery . The program ensures that vaccine is offered to all high-risk patients followed up at the medical center , promotes convenient access for patients , and facilitates efficient administration of vaccine . Specific elements include an annual mailing to patients , st and ing orders for nurses , walk-in clinics , and the use of st and ardized , preprinted documentation forms . Initially the program targeted high-risk out patients for influenza vaccination .  It was extended to include in patients in 1989 - 90 .  Pneumococcal vaccinations were added to the program in 1994 - 95 . Vaccination rates are estimated each year from surveys mailed to r and omly selected patients , and vaccine utilization is monitored through pharmacy logs . RESULTS The survey response rates have exceeded 75 % each year .  Influenza vaccination rates for all high-risk patients followed up at the medical center have increased from 58 % following the 1987 - 88 vaccination season to 84 % in 1996 - 97 ( P < 0.001 ) . Pneumococcal vaccination rates have also increased from 34 % in 1994 - 95 to 63 % in 1996 - 97 ( P < 0.001 ) . Vaccination rates are similar for in patients and out patients , but rates for high-risk patients < 65 years of age remain lower than for the elderly : 69 % versus 89 % for influenza , 1996 - 97 ( P < 0.001 ) ; 52 % versus 66 % for pneumococcal , 1996 - 97 ( P = 0.05 ) . For elderly patients followed up at the medical center , influenza ( 89 % versus 67 % , P < 0.0001 ) and pneumococcal ( 66 % versus 43 % , P < 0.0001 ) vaccination rates significantly exceeded those for the state of Minnesota in 1996 - 97 . The annual number of influenza vaccine doses dispensed has increased from 10,000 in 1987 - 88 to more than 22,000 in 1996 - 97 ; and more than 13,000 doses of pneumococcal vaccine have been administered from 1994 - 95 through 1996 - 97 . CONCLUSION This simple , multifaceted program that incorporates administrative and organizational strategies to enhance influenza and pneumococcal vaccination rates has been highly durable and successful over a 10-year peroid . Similar strategies if implemented in other setting s may enhance vaccination rates for the millions of high-risk patients who have yet to be immunized Annual influenza vaccination of elderly and chronically ill persons has been a long-st and ing recommendation of the U.S. Public Health Service [ 1 , 2 ] . Recent studies have documented the health benefits of annual influenza vaccination [ 3 - 10 ] , but despite the exhortations of the Surgeon General and the clear evidence of vaccine efficacy , many persons in high-risk groups fail to receive the recommended vaccinations [ 11 , 12 ] . Because of the low level of compliance with the U.S. Public Health Service influenza vaccination guidelines [ 13 ] , the Centers for Disease Control and Prevention ( CDC ) have proposed new strategies to increase the proportion of high-risk persons who are immunized [ 14 ] . One such strategy is to promote assessment s of the net financial costs to health maintenance organizations of operational vaccine delivery programs . Successful demonstrations of net financial benefit should encourage managers of organized medical care programs and health insurance companies to advocate improved vaccine delivery . Methods General Methods Setting The study was done at Kaiser Permanente , Northwest Region , a prepaid group practice health maintenance organization ( HMO ) that includes 20 % of the Portl and , Oregon-Vancouver , Washington , St and ard Metropolitan Statistic Area population . Members receive almost all of their medical care from the health plan , and each contact they make with the HMO is recorded in a single , central ized chart . Epidemic Periods Epidemic periods were defined as periods during which influenza viruses circulated persistently in Oregon according to influenza virus isolation date s reported by the Oregon State Virology Laboratory . The eight epidemic periods defined using this approach are shown in Table 1 . The study period for the nonepidemic 1981 - 1982 reference period was defined by averaging the months and days of the epidemic periods . The number of  specimens tested ranged from 118 in 1981 - 1982 to 652 in 1988 - 1989 . Table 1 . Influenza Epidemic Periods and Study Sample s Influenza viruses were isolated from only 9 of 118 specimens ( 8 % ) tested in the 1981 - 1982 nonepidemic reference period ; B viruses were isolated from two specimens obtained in late April . During the epidemic study periods , influenza viruses were typically isolated from 25 % of specimens , isolations were sustained , and isolation frequency distributions described epidemic curves . Participants Participants included in a study period were Kaiser Permanente members 65 years of age or older , each with at least 1 month of eligibility during that period and during the September-December vaccination period . These members represent almost all elderly persons enrolled in the HMO . High-risk participants were defined as those who had had medical care contacts for chronic pulmonary ( ICDA [ International Classification of Diseases , Adapted ] codes 9:491 - 493.9 , 496 , 500 - 505 , 506.4 , 508.1 , 510 - 516 , 714.8 ) , cardiovascular ( 112.81 , 130.3 , 393 - 398 , 401.0 , 402 - 405 , 410 - 414 , 416 , 420 - 429 , 430 - 438 , 440.1 , 785.2-.3 ) , metabolic ( 250 - 250.9 , 571 - 571.9 ) , renal ( 274.10 , 580 - 583.9 , 585 , 587 - 588.0 ) , or malignant ( 140 - 208.9 ) conditions . These risk factors for influenza-related complications are defined by the CDC 's Advisory Committee for Immunization Practice s. Data Sources An  automated inpatient data base was used to identify all hospitalizations for pneumonia and influenza during the nine study periods . This data base contains discharge diagnoses and records of inpatient procedures and is the source of the discharge summaries . The outpatient data base contains outpatient diagnoses and records of procedures for a continuously up date d research sample composed of 5 % of elderly health plan members . Each month , a r and om 5 % sample of all new elderly Kaiser Permanente subscriber units is added to the cumulative pool of enrollees whose records are abstract ed . Automated outpatient diagnoses were available through 1987 . Medical record abstract ions were the source of outpatient diagnoses for the first quarter of 1988 . Inpatient high-risk discharge diagnoses made during the 3 years before the study period were obtained from the inpatient data base . Outpatient high-risk diagnoses made during the year before the study period were obtained from the outpatient data base and by chart abstract ion . Influenza and pneumococcal vaccination status was abstract ed from the medical records for pneumonia and influenza cases that were not in the 5 % research sample .  Automated vaccination data through 1987 were available for cases and controls in the research sample . Medical record abstract ions were the source of 1988 - 1989 vaccination data for all study participants . Participants receiving influenza vaccine after the start of epidemics were classified as unvaccinated . Case-Control Assessment of Vaccine Effectiveness Population -based , casecontrol design s were used to estimate influenza vaccine effectiveness in preventing medically attended episodes of pneumonia and influenza . To exclude pneumonias that were unlikely to be influenza related , we included only persons with pneumonia and influenza who were admitted to medical services . Because we based participant selection on discharge diagnoses , participants with both hospital- and community-acquired pneumonia and influenza were included . Pneumonia and Influenza Cases and Controls Participants who were hospitalized with pneumonia and influenza during the study period , who were eligible Kaiser Permanente members , and who had a pneumonia and influenza ICDA-9 code ( 480 - 483,485,486,487 ) listed as a discharge diagnosis were included as cases of hospitalized pneumonia and influenza . Controls were members of the 5 % research sample who met the study eligibility criteria and who were not hospitalized with pneumonia or influenza during the given period . Pneumonia and influenza deaths during a study period were defined as hospitalized patients with pneumonia and influenza who died in the hospital . Controls were members of the 5 % research sample who were not pneumonia and influenza hospital deaths during that period . Outpatient pneumonia and influenza cases included members of the 5 % research sample who had an outpatient episode of pneumonia and influenza with no inpatient component during the given study period . Controls were members of the 5 % research sample who did not have an outpatient episode of pneumonia and influenza during the given period . Cases and controls were group matched for high-risk status . Logistic regressions were used to adjust influenza vaccine effects on occurrence of pneumonia and influenza episodes for differences in age , sex , months of HMO eligibility , and pneumococcal vaccine status . Vaccine Effectiveness Relative risks for pneumonia and influenza episodes in unvaccinated and vaccinated population s were estimated by the adjusted exposure ( unvaccinated ) odds ratios . The effectiveness of influenza vaccine  in preventing pneumonia and influenza episodes was computed from the estimated relative risk as effectiveness = 1-(1/relative risk ) . Pneumonia and Influenza Episodes Prevented The population -based , casecontrol design allowed unbiased estimation of the total number of participants vaccinated and of the pneumonia and influenza episode rates among unvaccinated participants . The product of these estimates multiplied by the vaccine effectiveness is the estimated number of pneumonia and influenza episodes prevented by influenza vaccination : pneumonia and influenza episodes prevented = ( number of participants vaccinated)(effectiveness of vaccination)(pneumonia and influenza episode rate among unvaccinated participants ) . Statistical Methods The units of analysis for period-specific vaccine effectiveness analyses were persons . A case for a given period had an episode of pneumonia or influenza during that period . A control for a given period did not have an episode of pneumonia or influenza during that period . The same person could appear as a case in more than one period . Person-periods were the units of analysis for aggregate analyses . A person contributed a person-period of observation to each period when study criteria were met . Some members of the 5 % research sample were controls in some periods and cases in other periods . Study participants not in the 5 % research sample could only contribute person-periods as hospitalized cases . Risks for pneumonia and influenza episodes during high-risk and nonhigh-risk person-periods are separately modeled as logistic functions of influenza vaccine status , pneumococcal vaccine status , age , sex , and length of observation time . The SAS logistic procedure was used to estimate odds ratios and confidence intervals for model variables . The Hosmer-Lemeshow statistic was used to assess the goodness of fit of logistic models . Cost Analysis Methods Medical Care Costs of Pneumonia and Influenza Episodes Costs of providing inpatient care for pneumonia and influenza episodes were obtained from Kaiser Permanente accounting systems for the various patient care cost centers .  Costs of providing outpatient care were estimated from the 5 % research sample , using relative value units included in the outpatient data base and unit costs for accounting cost centers . Cost of Vaccine Delivery Costs of the vaccine delivery program were estimated by a micro-costing approach and included overhead costs . The purchase cost of vaccine was obtained from administrative records and included all vaccines used and wastage . Distribution costs were allocated based on the proportion of direct drug costs represented by influenza vaccine . Two methods of promoting the vaccination program were identified : an article in the member newsletter and referrals by nurses , generally by the telephone advice nurse . Time estimates were obtained from interviews with providers , and labor costs per hour were obtained from Kaiser Permanente administrative records . Cost-Effectiveness Ratios Three cost-effectiveness measures were computed : cost per prevented episode of In early 1983 , all 1,280 faculty and resident physicians at one hospital who were eligible to be vaccinated against hepatitis B  were divided r and omly into three groups : Group 1 physicians received general information about the risks and benefits of alternative vaccine decisions ; Group 2 physicians were additionally invited to provide personal information for an individualized decision analysis ( 12.6 percent responded ) ; and Group 3  physicians  , who served as controls , were not contacted . In one year 's follow-up , 20 percent of physicians were screened for hepatitis B antibody or vaccinated . More Group 2 physicians whose decision analyses recommended screening or vaccination took these actions ( 39 percent ) than any other group . Group assignment remained significantly associated with vaccine decisions after analyzing results by the " intention to treat " principle , and after adjusting for training status , exposure to blood and blood products , and pre- study intentions about the vaccine . Despite the low overall vaccine acceptance rate , it is concluded that individualized decision analysis can influence the clinical decisions taken by knowledgeable and interested patients OBJECTIVES To determine the use of pneumococcal vaccination in a general medicine ambulatory clinic and the effect of a quality assessment monitor on use . DESIGN A prospect i ve 8-month ( October 1990 through May 1991 ) survey and 8-month ( October 1989 through May 1990 ) retrospective survey of use of pneumococcal vaccination in the clinic . SETTING A general medicine clinic where patients are seen for their first internal medicine clinic visit at The University of Iowa Hospitals and Clinics , Iowa City , Iowa . PATIENTS One thous and sixty adult patients who presented to the clinic during the study interval . INTERVENTIONS The use of the form constituted an intervention . RESULTS Use of pneumococcal vaccination  was increased more than 5 times over the baseline level following implementation of the quality assessment monitor . CONCLUSIONS Underuse of pneumococcal vaccination occurred in this general medicine clinic , and the introduction of a quality assessment monitor constituted an intervention that significantly increased the use of pneumococcal vaccination OBJECTIVE To determine the optimal method to increase influenza immunization rates of medical house staff and students . DESIGN Prospect i ve r and omized trial and cross-sectional survey . STUDY GROUP Four hundred forty-two internal medicine , obstetrics-gynecology , and general surgery residents and junior medical students . MEASUREMENTS The four interventions employed were ( 1 ) an educational memor and um outlining vaccine indications sent to all study group members , ( 2 ) a personal letter mailed to a r and om sample of half of the remaining unimmunized persons , ( 3 ) a telephone call to half of the unimmunized letter recipients , and ( 4 ) vaccine offered directly to the remaining unimmunized persons in clinics and conferences . In addition , a question naire was administered to all persons requesting or offered vaccine . MAIN RESULTS During the 3 weeks after the memor and um , 87 ( 20 % ) of 442 persons were immunized . Five weeks after the letter , 61 ( 34 % ) of persons receiving a letter and 30 ( 17 % ) of the no-letter controls ( P = .0005 ) had been immunized . After the telephone call , there was a statistically insignificant trend toward increased compliance . In clinics and conferences , 90 % of persons reached were immunized and 10 % refused , largely extinguishing the effect of prior interventions . At completion of the study , 275 ( 62 % ) of 442 participants were immunized , 29 ( 7 % ) refused , and 138 ( 31 % ) were not reached . Question naire results revealed that only 32 % had ever been previously immunized against influenza , yet 70 % stated that they had worked despite having influenzalike symptoms . CONCLUSION A high rate of immunization of house staff and medical students can be achieved most effectively by offering vaccine in clinics and conferences . Continued education about influenza immunization is necessary for physicians and medical students OBJECTIVES This study investigated hepatitis B immunization  coverage and the extent of hepatitis B virus ( HBV ) infection among young men who have sex with men ( MSM ) , a group for whom hepatitis B vaccine has been recommended since 1982 . METHODS We analyzed data from 3432 MSM , aged 15 to 22 years , r and omly sample d at 194 gay-identified venues in 7 US metropolitan areas from 1994 through 1998 . Participants were interviewed , counseled , and tested for serologic markers of HBV infection . RESULTS Immunization coverage was 9 % and the prevalence of markers of HBV infection was 11 % . HBV infection ranged from 2 % among 15-year-olds to 17 % among 22-year-olds . Among participants susceptible to HBV infection , 96 % used a regular source of health care or accessed the health care system for HIV or sexually transmitted disease testing . CONCLUSIONS Despite the availability of an effective vaccine for nearly 2 decades , our findings suggest that few adolescent and young adult MSM in the United States are vaccinated against hepatitis B. Health care providers should intensify their efforts to identify and vaccinate young MSM who are susceptible to HBV PURPOSE To determine whether an educational brochure or a lottery-type incentive increases influenza immunization rates . PATIENTS AND METHODS In a prospect i ve , single-blind factorial design r and omized trial at an urban community health center , all high-risk patients ( n = 797 ) seen in the preceding 18 months were r and omly assigned to one of four groups : a control group ; a group mailed a large print , illustrated educational brochure emphasizing factors important to patients in making a decision about influenza immunization ; a group mailed a lottery-type incentive announcing that all patients receiving influenza immunization  would be eligible for grocery gift certificates ; and a group mailed both educational brochure and incentive . Immunization was free , available without an appointment , and recorded by a computerized tracking system . RESULTS The group mailed the brochure was more likely to be immunized than control ( odds ratio [ OR ] = 2.29 , 95 % confidence interval [ CI ] 1.45 to 3.61 ) , as was the group mailed the incentive ( OR = 1.68 , 95 % CI 1.05 to 2.68 ) , but there was no difference between the group mailed both interventions and the control group . The effectiveness of the brochure was more striking for individuals who had not accepted immunization in the prior year ( OR = 4.21 , 95 % CI 2.48 to 7.14 ) , suggesting a true educational effect rather than simply a reminder . CONCLUSION In this community health center setting , an illustrated educational brochure increased influenza immunization among high-risk patients , a lottery-type incentive was much less effective , and both together was not effective A three-year prospect i ve chart audit of a family practice residency program was performed to measure  physician compliance  in following the recommendations of an  adult immunization program .  Despite curriculum changes , performance self-evaluation , and reminders by faculty members to residents about the need for adult immunization , physician compliance was poor in the second year of the study . It was thought that components of the medical record might be improved to facilitate physician compliance in the adult immunization program . At the beginning of the third year of the audit , tetanus and pneumococcal vaccines were preprinted on the health maintenance inventory ( HMI ) , but influenza was not . The chart design also was changed to put the HMI in a more prominent place . In the third year of the audit , physician compliance with tetanus and pneumococcus immunization improved significantly . The results of the chart review suggest that physician compliance with adult immunization programs can be improved with appropriate chart design During the 1984 - 1985 influenza season two study groups were used to compare telephone and letter reminder methods with a control group that received no reminder to determine which was the most effective strategy to increase influenza vaccination rates among the high-risk patient population of a university-based family practice . Seven hundred eighty-seven high-risk patients were r and omly assigned to one of the three study groups : a mailed-reminder group , a telephone-reminder group , and a control group .  Vaccination rates for both reminder methods were significantly higher than for the control group ( P less than .02 ) , and if successfully contacted , the telephone-reminder group had a significantly better vaccination rate than the mailed-reminder group ( P less than .05 ) . If successful telephone contact can be made , this reminder method is more effective than a letter reminder to increase influenza vaccination rates among high-risk patients Abstract OBJECTIVE : To compare the effects of different types of computer-generated , mailed reminders on the rate of influenza immunization and to analyze the relative cost-effectiveness of the reminders . DESIGN : R and omized controlled trial . SETTING : Multispeciality group practice . PATIENTS : We studied 24,743 high-risk adult patients aligned with a primary care physician . INTERVENTION : Patients were r and omized to one of four interventions : ( 1 ) no reminder , which served as control ; ( 2 ) a generic postcard ; ( 3 ) a personalized postcard from their physician ; and ( 4 ) a personalized letter from their physician , tailored to their health risk . MEASUREMENTS : The immunization rate was measured using billing data . A telephone survey was conducted in a subgroup of patients to measure reactions to the mailed reminders . To evaluate the cost-effectiveness , a model was constructed that integrated the observed effect of the interventions with published data on the effect of immunization on future inpatient health care costs . MAIN RESULTS : All three of the reminders studied increased the influenza vaccination rate when compared with the control group . The vaccination rate was 40.6 % in the control group , 43.5 % in the generic postcard group , 44.7 % in the personalized postcard group , and 45.2 % in the tailored letter group . The rates of immunization increased as the intensity of the intervention increased ( p < .0001 ) . Seventy-eight percent of patients in the letter group deemed the intervention useful , and 86 % reported that they would like to get reminders in the future . The cost-effectiveness analysis estimated that in a nonepidemic year , the net savings per 100 reminders sent would be $ 659 for the personalized postcard intervention and $ 735 for the tailored letter intervention . When these net cost-savings rates were each applied to the entire high-risk cohort of 24,743 patients , the estimated total net savings was $ 162,940 for the postcard and $ 181,858 for the tailored letter . CONCLUSIONS : Although the absolute increase in immunization rates with the use of reminders appeared small , the increases translated into substantial cost savings when applied to a large high-risk population . Personalized reminders were somewhat more effective in increasing immunization , and personalized letters tailored to the patients ’ condition were deemed useful and important by the individuals who received them and had a beneficial indirect effect on patient satisfaction CONTEXT Pneumococcal immunization rates for elderly and high-risk patients are only one third to one half the target rate of 60 % established by the US Public Health Service . Limited or marginal literacy , which affects nearly 100 million Americans , especially the elderly , may contribute to these low rates of immunization . OBJECTIVE To determine whether the use of a simple , low-literacy educational tool enhances patient-physician dialogue about pneumococcal vaccination and increases rates of immunization . DESIGN A r and omized controlled trial conducted between May and June of 1998 . SETTING Ambulatory care clinic of a 900-bed public teaching hospital serving a predominantly indigent , low-literate , African American , inner-city population . PARTICIPANTS Of 433 patients who presented for routine primary care , had vaccine indications ( age > or = 65 years or chronic disease ) , and had not been previously vaccinated , 221 were r and omly assigned to the intervention group and 212 to the control group .  Of the total patient population ( mean age , 63 years ) , 280 ( 64.7 % ) had less than a high school education , 401 ( 92.6 % ) were African American , and 300 ( 69.3 % ) were female . INTERVENTION One-page , low-literacy ( below fifth- grade level ) educational h and out encouraging patients to " ask your doctor about the pneumonia shot " vs a control group ( 1 -page , low-literacy educational h and out conveying information about nutrition ) . MAIN OUTCOME MEASURES Vaccination rates ( documented by chart audit ) of patients who received pneumococcal vaccination and rates of patients who self-reported having discussed vaccination with their physicians . RESULTS Patients in the intervention group were 4 times more likely to have discussed the pneumococcal vaccine with their physicians than patients in the control group ( 87/221 [ 39.4 % ] vs 21/212 [ 9.9 % ] ; relative risk [ RR ] , 3.97 [ 95 % confidence interval [ CI ] , 2.71 - 5.83 ] ) , and were more than 5 times as likely to have received the pneumococcal vaccine than the control group ( 44/221 [ 19.9 % ] vs 8/212 [ 3.8 % ] ; RR , 5.28 [ 95 % CI , 2.80 - 9.93 ] ) . In a multivariate analysis controlling for race , sex , education , insurance status , age , level of physician training , health status , and vaccine indication , only assignment to the intervention group was statistically significantly related to the probability of being immunized or discussing the issue with their physicians ( P<.001 for both trends ) . CONCLUSIONS A simple , low-literacy educational tool increased pneumococcal vaccination rates and patient-physician discussion s about the vaccine in an elderly , low-literate , indigent , minority population BACKGROUND Hepatitis B virus ( HBV ) infection is a well-recognized occupational risk for health care workers ( HCWs ) .  Vaccination coverage , disease trends , and the need for booster doses after hepatitis B vaccination of adults have been the subject of intense study during the 15 years of the vaccine 's availability . METHODS Vaccination coverage of HCWs was determined from a review of medical records on a sample of employees from 113 r and omly selected hospitals . The number of HBV infections among HCWs and the general US population for 1983 through 1995 was estimated from national surveillance data . Studies on long-term protection after hepatitis B vaccination of adults were review ed . RESULTS A total of 2837 employee medical records were review ed ; 2532 employees ( 90 % ) were eligible to receive hepatitis B vaccine  , and 66.5 % of them ( 95 % confidence interval , 61.9%-70.9 % ) had received 3 doses of hepatitis B vaccine .  Vaccination coverage was highest ( 75 % ) for personnel with frequent exposure to infectious body fluids ( phlebotomists , laboratory personnel , and nursing staff ) and lowest ( 45 % ) for employees at low risk for exposure ( dietary and clerical staff ) . The number of HBV infections among HCWs declined from 17,000 in 1983 to 400 in 1995 . The 95 % decline in incidence observed among HCWs is 1.5-fold greater than the reduction in incidence in the general US population . Studies on long-term protection demonstrate that vaccine-induced protection persists at least 11 years even when titers of antibody to hepatitis B surface antigen decline below detectable levels . CONCLUSIONS Although a high percentage of HCWs have been fully vaccinated with hepatitis B vaccine , efforts need to be made to improve this coverage . There has been a dramatic decrease in the number of HBV infections among HCWs who are now at lower risk of HBV infection than the general US population . Vaccine-induced protection persists at least 11 years and booster doses are not needed at this time for adults who have responded to vaccination PURPOSE To enhance influenza vaccination rates for high-risk out patients at the Department of Veterans Affairs Medical Center ( VAMC ) in Minneapolis , Minnesota , an institution-wide immunization program was implemented during 1987 . PATIENTS AND METHODS The program consisted of : ( 1 ) a hospital policy allowing nurses to vaccinate without a signed physician 's order ; ( 2 ) stamped reminders on all clinic progress notes ; ( 3 ) a 2-week walk-in flu shot clinic ; ( 4 ) influenza vaccination " stations " in the busiest clinic areas ; and ( 5 ) a mailing to all out patients . Risk characteristics and vaccination rates for patients were estimated from a vali date d self-administered postcard question naire mailed to 500 r and omly selected out patients . For comparison , 500 patients were surveyed from each of three other Midwestern VAMCs without similar programs . RESULTS Overall , 70.6 % of Minneapolis patients were high-risk and 58.3 % of them were vaccinated . In contrast , 69.9 % of patients at the comparison medical centers were high-risk , but only 29.9 % of them were vaccinated . CONCLUSION The Minneapolis VAMC influenza vaccination program was highly successful and may serve as a useful model for achieving the national health objective for influenza immunization Hepatitis B virus ( HBV ) is the world 's most common blood-borne viral infection , chronically infecting more than 200 million people worldwide [ 1 ] . It is responsible for substantial morbidity and mortality and is a leading cause of hepatocellular carcinoma . Approximately 300 000 Americans are infected with HBV each year , an annual incidence rate of 11.5/10 000 population [ 2 , 3 ] . Serologic evidence of previous infection is found in 4.8 % of the U.S. population [ 4 ] . Each year approximately 4000 persons in the United States die of HBV-related cirrhosis and about 800 people die of HBV-related hepatocellular carcinoma [ 3 , 5 , 6 ] . The goal of our study was to determine the clinical and economic impact of alternative HBV vaccination strategies for selected U.S. population s. This analysis up date s the earlier work of Mulley and colleagues [ 7 ] by incorporating more recent data on incidence of HBV infection , cost of acute disease and chronic sequelae , and safety and effectiveness of HBV vaccine  , by focusing on a broader range of population s , and by modeling a longer period . A safe and effective vaccine to prevent HBV infection was introduced in the United States in 1981 . Nonetheless , the overall incidence of HBV infection increased 14.5 % between 1981 and 1987 [ 2 , 3 ] , especially in selected high-risk groups [ 8 ] ( 77 % increase between 1981 and 1988 among injection drug abusers ) . The clear relationship between HBV infection and primary hepatocellular carcinoma indicates that HBV vaccine is the first effective anti-cancer vaccine [ 6 ] . However , the vaccine is not administered to most high-risk people ( fewer than 50 % of high-risk health care workers have received a complete HBV vaccination series ) [ 3 , 9 , 10 ] . Acute HBV infection manifests itself clinical ly along a spectrum from asymptomatic , sub clinical infection through fatal fulminant hepatitis [ 1 , 5 , 11 ] . More than 50 % of HBV infections in adolescents and adults in the United States are asymptomatic [ 2 , 9 , 12 , 13 ] . Others exhibit a variety of nonspecific viral symptoms ; one quarter become ill with jaundice [ 3 ] . More than 10 000 people with acute HBV infection are hospitalized annually [ 3 ] . About 250 die each year of fulminant infection [ 3 ] . Both asymptomatic and nonfulminant symptomatic HBV infection are similarly associated with chronic forms of infection , which , in turn , may lead to cirrhosis and hepatocellular carcinoma [ 1 , 5 , 6 , 11 , 14 - 16 ] . The epidemiology of HBV infection varies greatly by geography and sociodemographic factors [ 1 - 4 , 17 ] . Population s at greatest risk include those with multiple sex partners , sexually active male homosexuals , injection drug abusers , family members of HBV carriers , newborn children of actively infected mothers , medical personnel who are exposed to blood and blood products , immigrants from HBV endemic areas , and sexual partners of members of high-risk groups [ 3 ] . Epidemiologic studies have documented serologic evidence of HBV infection in as many as 50 % of members of high-risk groups [ 2 , 3 , 18 ] . This combination of increasing incidence , exp and ing high-risk population s , and failure to deliver the vaccine to those at highest risk warrants a re-evaluation of current HBV vaccine policy . The Centers for Disease Control ( CDC ) has recommended universal vaccination of newborns and of high-risk adolescents [ 19 ] . The Occupational Safety and Health Administration ( OSHA ) has issued guidelines requiring HBV vaccination for all at-risk health care workers [ 20 ] . Others have proposed more limited vaccination strategies [ 21 ] . Methods Structure of the Model : Basic Decision Tree We used decision analysis to model clinical and economic consequences of alternative approaches to prevention and management of HBV infection . We focused on number and costs of cases prevented , deaths prevented , and years of life saved [ 22 ] . The decision model examined three different HBV management strategies ( no vaccination , universal vaccination , and screen and vaccinate ) in four different U.S. cohorts : 1 ) newborns ; 2 ) adolescents at age 10 ; 3 ) a high-risk adult population with HBV infection incidence of 5 % per annum ; and , 4 ) the general adult population ( 12 to 50 years old ) . In addition , we examined a mixed population strategy of screening all pregnant women before or during labor for evidence of active HBV infection ( HBsAg ) , administering HBV vaccine and hepatitis B immune globulin ( HBIG ) to the newborns of mothers who test positive , and then vaccinating all children at age 10 and again 10 years later . Each analysis followed a cohort of 10 000 individuals for three consecutive 10-year periods , because probabilities of infection or sequelae change over time . Cyclical Markov modeling could have been used , but its complexity makes presentation more difficult to underst and , and accuracy is not importantly improved . The decision model used in this analysis was developed after a critical review of the literature , with input from five HBV experts to ensure accuracy and validity . The basic decision tree ( Figure 1 ) incorporated the sensitivity and specificity of screening tests for previous or current HBV infection , estimates of compliance with vaccine administration , the probability of protection if vaccine is administered , the probability of exposure to HBV , and the probability of acute infection after exposure to HBV . All strategies assume that some individuals will be protected from HBV by virtue of previous infection . The terminal branches that end with no hepatitis B infection identify persons who remain uninfected with HBV at the end of the period . They enter the model again at the same starting point as everyone else ( no previous HBV infection ) for up to two additional consecutive 10-year periods . The terminal branches of the basic tree that end with hepatitis B infection lead to a subtree Figure 2 that reflects the distribution of types of acute disease and the probability of long-term sequelae of HBV infection . Figure 1 . Structure of basic adult decision tree for first 10-year period . Figure 2 . Structure of the decision tree for persons who contract hepatitis B virus . Data Sources We obtained the data used in the model from three sources . First , we critically review ed the medical literature and found probability estimates of incidence and prevalence , clinical course and patient management of HBV infection and its sequelae in the community ; safety and efficacy of HBV vaccine ; and compliance with the administration of HBV vaccines  . Second , using a modified Delphi technique , an expert panel review ed these estimates , reconciled conflicting data , and provided consensus estimates for probabilities , events , patient management in the community , and outcomes for which reliable data were unavailable in the medical literature . Third , we obtained data on costs from actual private insurer payments , adjusted for expected patient out-of-pocket expenditures . Screening Strategies We used two screening strategies . First , the antibody to hepatitis B surface antigen ( anti-HBsAg ) was used in the adult population s to screen for previous infection to identify those individuals who were protected from recurrent infection and who , therefore , did not require vaccination . Second , HBV surface antigen ( HBsAg ) was used to screen mothers for active infection to identify newborns at high risk for HBV infection who would benefit from HBV vaccine and HBIG [ 22 , 23 ] . Compliance and Vaccine Effectiveness Table 1 shows the input values for screening tests , vaccine compliance , and vaccine effectiveness used for the base case analysis . We assumed 100 % compliance with maternal screening for HBV before or at the time of delivery . For other groups , we assumed compliance with screening to be 20 % greater than the probability that they would comply with at least the first dose of vaccine . The literature and expert panel suggested a 50 % compliance rate with the full series of three vaccinations ( 0 , 1 , and 6 months ) among adults and adolescents , with lower compliance rates among high-risk population s and higher compliance rates among newborns because of accessibility in the hospital for the first dose of vaccine . People who did not comply with any of the initial series of vaccinations were assumed not to comply with any subsequent vaccine booster doses . Table 1 . Base Case Input Values ( Per Person ) * Efficacy for full and partial vaccination series were estimated from r and omized and historical clinical trials ( Table 1 ) [ 7 , 17 , 23 - 34 ] . Antibody titers decrease over time after vaccination [ 26 , 35 - 38 ] . Although epidemiologic studies do not indicate that such decreases in titers result in reduced protection against HBV infection , such studies have been limited to 7 or fewer years after vaccination [ 38 ] . The CDC currently does not recommend administration of vaccine boosters but is following population s of immunized patients to determine if such boosters will be required . The base case model we report here assumed that vaccine efficacy persisted for 10 years , after which a single booster dose was required to provide continuing protection against HBV infection for an additional 10 years , a conservative assumption that biases the model against the cost-effectiveness of all vaccination strategies . Among those who responded to the vaccine by developing protective antibodies , we made counterbalancing assumptions : no decrease in protection from HBV vaccine before 10 years but no protection after 10 years unless a booster is administered . We assumed that HBV vaccine did not incur any side effects that required medical care [ 26 , 27 ] and that persons infected with HBV despite vaccination followed the same clinical course as those never vaccinated . Newborns of mothers who tested positive for active hepatitis B infection ( HBsAg+ ) were assumed to be treated with HBIG plus HBV vaccine . These infants also underwent serologic testing at 1 year of age and those with low antibody titers ( 10 % of neonates receiving a full primary series of HBV The aim of this study was to determine the effectiveness of tools to identify and counsel patients at risk for sexually transmitted hepatitis B virus infection . Physicians were r and omly assigned to either an intervention group or a control group . The intervention group was provided with material s intended to encourage patients to return for counseling and to guide counseling concerning prevention of hepatitis B virus infection . Baseline data on 457 patients at risk for hepatitis B virus infection showed that 7 % had received prevention counseling and 2 % had begun hepatitis B vaccination . Counseling was least likely to occur in obstetric-gynecologic practice s , among uninsured patients , and among patients whose only risk factor was a diagnosis of a sexually transmitted disease . After a 6-month intervention period 26 % of the intervention group patients and 7 % of the control group patients had been counseled ( P < .01 ) . Vaccination was more likely among intervention group patients ( 8 % vs < 1 % ; P < .001 ) . The use of tools to identify and counsel patients at risk for sexually transmitted hepatitis B virus infection result ed in increased office-based prevention activities OBJECTIVE To assess t he effectiveness of a nation-widemultifaceted intervention programme involving general practitioners ( GPs ) on influenza immunisation practice . DESIGN Pragmatic before-after trial using pre- and post-measurement question naires . SETTING AND SUBJECTS R and om sample of Dutch general practice s. INTERVENTION During a 2.5-year period ( 1995 - 1997 ) a variety of methods was implemented to enhance  physician adoption of the immunisation guideline , including employment of facilitators , information-based methods , small-group consensus meetings , individual instructions and introduction of supportive computer software . MAIN OUTCOME MEASURES Influenza immunisation practice and influenza vaccine uptake . RESULTS In 988 practice s all influenza vaccination characteristics markedly improved from 1995 to 1997 . The most significant changes were found in computerised marking of high-risk patients ( from 54 % to 82 % of practice s ) , computerised selection ( 41 % to 77 % ) and sending personal reminders ( 40 % to 77 % ) . Vaccine uptake increased from 9 % to 16 % of the practice population ( 78 % increase , p < 0.001 ) . Uptake was most prominent in urban and single-h and ed practice s and in those with more patients insured through the National Health Service , low GP workload and low baseline uptake . CONCLUSION Our data suggest that a co-ordinated approach involving primary care physicians can succeed in enlarging the public health impact of a population -based preventive measure Prospect i ve virologic surveillance has defined two influenza epidemics representing the fifth and sixth outbreaks attributed to H3N2 viruses since the prototype , A/Hong Kong/68 ( ( H3N2 ) , emerged in 1968 . The 1975 epidemic was caused by influenza A/Port Chalmers and yielded an estimated attack rate of 9 per cent ; the second , attributed to influenza A/Victoria , produced an explosive outbreak , with an estimated attack rate of 18 per cent in 1976 . The highest morbidity occurred in preschool children , with an estimated attack rate of over 30 per cent . During the early stages of both epidemics there was a predominance of cases among school-aged  children , and school absenteeism peaked earlier than other nonvirologic indexes . These observations support the concept of rapid dissemination of influenza among schoolchildren and suggest that control of epidemic influenza might be facilitated by prophylaxis for that age group and other accessible , healthy population CONTEXT During the past decade , several guidelines on the management of chronic obstructive pulmonary disease and asthma have been developed . However , strategies for implementing these guidelines have not been systematic ally evaluated . OBJECTIVE To test a quality system intended to improve general practitioners ' compliance with recently established guidelines . DESIGN Before-after study with concurrent controls . UNIT OF ANALYSIS : 19 general medical practice s in the Netherl and s ( 14 intervention practice s and 5 control practice s ) . INTERVENTION A quality system with five components : identification of barriers , documentation , education , feedback , and peer review . PATIENTS Out patients 16 to 70 years of age with asthma or chronic obstructive pulmonary disease . MEASUREMENTS The number of consultations for respiratory symptom monitoring , measurement of peak expiratory flow rate , prescription of anti-inflammatory agents , monitoring of medication compliance and inhalation technique , and influenza vaccination .  RESULTS The percentage of patients who had two or more consultations per year increased significantly in the intervention practice s ( median , 27 % of patients before the intervention vs 82 % of patients after the intervention ; P < 0.01 ) , as did the percentage of patients who had at least one measurement of peak expiratory flow rate ( median , 10 % of patients before the intervention vs 84 % of patients after the intervention ; P < 0.01 ) . The percentage of patients who received a prescription for anti-inflammatory agents did not increase significantly . No significant changes were seen in the control practice s. Physicians in the intervention practice s were more likely to monitor medication compliance and inhalation technique . No difference was found in frequency of influenza vaccination . CONCLUSION The quality system improved guideline compliance in some areas but not in others A r and omized trial of various postcard reminder " cues " was performed to improve underst and ing of health-related behavior and to find better strategies for improving influenza vaccination compliance . Data were gathered on 283 high-risk patients ( 92 per cent response rate ) who received : 1 ) a " neutral " cue simply announcing the availability of vaccine ;  2 ) a " Health-Belief-Model " card written to take advantage of the association between certain health beliefs and vaccination behavior ; 3 )  a " personal " card signed by the patient 's physician ; or 4 )  no postcard . The highest rate of vaccination occurred among recipients of the Health-Belief-Model postcard ( 51.5 per cent vs. 20.2 per cent for control , p less than 0.001 ) . Linear logistic regression analysis found that age , prior vaccination history and experimental group had a significant effect on likelihood of being vaccinated . After adjusting for age and prior vaccination experience , the vaccination rate was found to be significantly higher for persons receiving the Health-Belief-Model postcard compared with persons receiving no postcard or a neutral postcard . We conclude that reminder postcards emphasizing elements of the health belief model may help increase vaccination rates To study the effects of computer-generated reminders for influenza vaccination of patients at high risk of pulmonary disease during the winter , we selected 4555 such patients from a population of 15,000 adults who participated in a three-year r and omized trial of preventive-care reminders . The physicians who received the reminders vaccinated eligible patients twice as often as did the control physicians ( P = 0.0001 ) . There was a linear increase in the incidence of influenza in our area during the three winters under study ( from 1000 to 33,451 to 71,075 cases per year ) , and we modeled the percentage of patients with hospitalizations , emergency room visits with chest radiography , and blood gas determinations as a logistic function of this increase . The difference in linear trends between the patients in the intervention group ( whose physicians received reminders ) and those in the control group was significant for emergency room visits ( P less than 0.05 ) , hospitalizations ( P less than 0.01 ) , and blood gas determinations ( P less than 0.001 ) . The most likely explanation for the difference is the greater use of influenza vaccine in the intervention group A r and omized trial of a program to improve pneumococcal immunization was undertaken . Also studied were the prevalence of high-risk conditions for serious pneumococcal disease among hospital admissions and prior hospitalization of patients with pneumococcal bacteremia . During two successive winters , 56 % of 1,062 medical patients were identified by admission diagnosis or age as having a high-risk condition . None had received prior vaccination . During the trial period , identifying c and i date s for vaccination increased immunization from two ( 2.1 % ) of 95 to ten ( 10.4 % ) of 96 in year 1 and from two ( 2.1 % ) of 96 to 19 ( 20 % ) of 95 in year 2 . Among adults with pneumococcal bacteremia , 33 ( 54 % ) of 61 , including 32 ( 64 % ) of 50 with high-risk conditions , had documentation of prior hospitalization within five years . A hospital-based program can increase pneumococcal  immunization rates and would be directed at patients in whom serious pneumococcal disease is likely to develop OBJECTIVE To determine the predictors and extent of noncompliance with a second dose of hepatitis B vaccine and the effectiveness of a compliance enhancement strategy . DESIGN Cohort analysis and r and omized clinical trial . SUBJECTS A total of 256 consecutive adults attending a sexually transmitted diseases clinic from October 1992 to July 1993 who were seronegative for hepatitis B virus and agreed to receive hepatitis B vaccination . SETTING Hamilton , Ont . INTERVENTION Subjects were followed up for 4 months . Those who did not return for the second dose of vaccine by 6 weeks after the first ( 2 weeks overdue ) were r and omly assigned to the enhanced intervention group ( telephone and mail reminders ) or the regular intervention group ( mail reminder only ) . Subjects were considered noncompliant if they did not return for the second dose by 4 months after the first . RESULTS The risk of not returning for the second dose of vaccine within 4 months after the first was strongly and linearly associated with level of education ( p = 0.004 ) . The noncompliance rate among those with less than a grade 10 education was 50 % , grade 10 - 13 education 34 % , some college education 15 % and some university education 9 % . In the r and omized controlled trial the enhanced intervention group had twice the compliance rate of the regular intervention group ( 48 % v. 25 % ; p = 0.008 ) . Subjects with no post secondary education were highly responsive to the enhanced intervention ( relative risk 2.1 ; p = 0.02 ) compared with those with a higher level of education ( relative risk 1.0 ; p = 1.0 ) . CONCLUSION Hepatitis B vaccine recipients with lower educational levels are at increased risk of noncompliance with the second dose of vaccine but are highly responsive to telephone reminders Less than 20 percent of elderly and other high-risk persons targeted for annual influenza vaccination are immunized each year . In most busy practice setting s , it is difficult for primary care physicians to identify every patient in need of preventive health interventions . The purpose of this study was to assess the effect of microcomputer-generated reminders on  influenza vaccination rates  in a university-based family practice center . The practice uses an interactive encounter form system from which up date d clinical information is routinely entered into a cumulative data base . During a 2-month period , 686 patients were identified in the data base as eligible to receive influenza vaccine according to accepted criteria . Practice physicians ( n = 32 ) were stratified by level of training and r and omized to one of three groups , thereby receiving printed reminders on the encounter forms of all , none , or half of their eligible patients . Patients of physicians who always received reminders were more likely to receive influenza vaccine  during the study period than patients of the never-reminded physicians ( 51 percent versus 30 percent , P < 0.001 ) . Patients whose physicians received reminders for only half their patients had an intermediate likelihood of receiving a vaccination if a reminder was printed ( 38 percent ) but were less likely than the patients of never-reminded physicians to receive the vaccine if no reminder was printed ( 20 percent , P < 0.001 ) . This study suggests that physicians learn to depend on reminders for preventive health activities and that reminders are most effective when they are provided at every patient encounter BACKGROUND Although the protective efficacy of pneumococcal polysaccharide vaccine has been demonstrated in r and omized trials in young African gold miners , there has been controversy about its efficacy in older Americans at risk for serious pneumococcal infections . To assess the vaccine 's protective efficacy against invasive pneumococcal infections , we conducted a hospital-based case-control study of the efficacy of pneumococcal vaccine in adults with a condition recognized to be an indication for receiving the vaccine . METHODS From 1984 to 1990 , adults in whom Streptococcus pneumoniae was isolated from any normally sterile site were identified by prospect i ve surveillance in the microbiology laboratories of 11 large hospitals ; those with an indication for pneumococcal vaccine were enrolled as case patients . For each case patient , one control was matched according to age , underlying illness , and site of hospitalization . We contacted all providers of medical care to ascertain each subject 's history of immunization with pneumococcal vaccine . Isolates of S. pneumoniae were serotyped by an investigator unaware of the subject 's vaccination history . RESULTS Thirteen percent of the 1,054 case patients and 20 percent of the 1,054 matched controls had received pneumococcal vaccine ( P less than 0.001 ) . When vaccine was given in either its 14-valent or its 23-valent form , its aggregate protective efficacy ( calculated as a percentage : 1 minus the odds ratio of having been vaccinated times 100 ) against infections caused by the serotypes represented in the vaccine was 56 percent ( 95 percent confidence interval , 42 percent to 67 percent ; P less than 0.00001 ) for all 983 patients infected with a serotype represented in the vaccine , 61 percent for a subgroup of 808 immunocompetent patients ( 95 percent confidence interval , 47 percent to 72 percent ; P less than 0.00001 ) , and 21 percent for a subgroup of 175 immunocompromised patients ( 95 percent confidence interval , -55 percent to 60 percent ; P = 0.48 ) . The vaccine was not efficacious against infections caused by serotypes not represented in the vaccine ( protective efficacy , -73 percent ; 95 percent confidence interval , -263 percent to 18 percent ; P = 0.15 ) . CONCLUSIONS Polyvalent pneumococcal vaccine is efficacious in preventing invasive pneumococcal infections in immunocompetent patients with indications for its administration . This vaccine should be used more widely Occupational hepatitis B remains a threat to healthcare workers ( HCWs ) worldwide , even with availability of an effective vaccine . Despite limited re sources for public health , the Czech Republic instituted a m and atory vaccination program for HCWs in 1983 . Annual incidence rates of acute hepatitis B were followed prospect ively through 1995 . Despite giving vaccine intradermally from 1983 to 1989 and intramuscularly as half dose from 1990 to 1995 , rates of occupational hepatitis B decreased dramatically , from 177 cases per 100,000 workers in 1982 ( before program initiated ) to 17 cases per 100,000 in 1995 . Among high-risk workers , the effect was even more dramatic ( from 587 to 23 per 100,000 ) . We conclude that strong public-health leadership led to control of occupational hepatitis B among HCWs in the Czech Republic , despite limited re sources that precluded administering full-dose intramuscular vaccine for much of the program . Application of a similar program should be considered for other countries in regions that currently do not have a hepatitis B vaccination program OBJECTIVE To test the effectiveness of customized , family-oriented reminder letters in activating patients to seek appropriate preventive services . DESIGN R and omized clinical trial . One group received computer-generated , customized letters explaining recommended preventive procedures for each family member . A second group received a form letter listing recommendations for all preventive procedures for all age and sex groups . A third group ( control group ) received no letters .  SETTING A private medical centre , without university affiliation , in rural Quebec . PARTICIPANTS From 8770 patients who met study criteria , 719 families were r and omly selected . Data were available for 1971 of 1998 patients in these families . MAIN OUTCOME MEASURES The Family Received Index is the proportion of all procedures for which a family was overdue that they received . The Family End-of- study Up-to- date Index is the proportion of procedures for which the family was eligible and for which they were up-to- date at the end of the study . RESULTS The Family Received Index for families mailed customized letters was more than double the index for patients not mailed letters ( Kruskal-Wallis P = .0139 ) . Comparison of the Family End-of- study Up-to- date indices also demonstrated that families of patients sent customized letters were more likely to be up-to- date than families not sent letters ( Kruskal-Wallis P = .0054 ) . No statistically significant difference appeared between the number of preventive measures received by the control group and the form-letter group . CONCLUSIONS This study demonstrates a clinical ly small but statistically significant value to customizing reminder letters
nfluenza , pneumococcal infections , and hepatitis B , three vaccine-preventable diseases , cause significant morbidity and mortality in the United States .
ates of morbidity and mortality are higher among dults with certain medical conditions , occupational xposures , or risk behaviors .
Vaccination coverage rates n these target population s remain low and below ational health objectives .
Using methods previously developed for the Guide to ommunity Preventive Services for review s of universally ecommended vaccines ( those that should be adminisered to all people in a given age group ) , we conducted ystematic review s to evaluate the evidence on effectiveess of 11 interventions to improve vaccination coverge in targeted population s ( those with risk factors that ake them particularly susceptible to a disease ) .