How to develop a program to increase influenza vaccine uptake among workers in health care settings? A national survey of physician practices regarding influenza vaccine Components of variance and intraclass correlations for the design of community-based surveys and intervention studies: data from the Health Survey for England 1994. Multi-Level Intervention to Prevent Influenza Infections in Older Low Income and Minority Adults Increasing influenza immunization among high-risk patients: education or financial incentive? A target-based model for increasing influenza immunizations in private practice The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. A randomised intervention study to examine the effect on immunisation coverage of making influenza vaccine available at no cost. [The impact of postal invitations and user fee on influenza vaccination among the elderly. A randomized controlled trial in general practice]. Cluster trials in implementation research: estimation of intracluster correlation coefficients and sample size. Improving influenza vaccination rates in the workplace: a randomized trial. Generalist and subspecialist physicians' knowledge, attitudes, and practices regarding influenza and pneumococcal vaccinations for elderly and other high-risk patients: a nationwide survey. Effect of the frequency of delivery of reminders and an influenza tool kit on increasing influenza vaccination rates among adults with high-risk conditions. Changing practices in the use of pneumococcal vaccine. Patient Education Strategies to Improve Pneumococcal Vaccination Rates: Randomized Trial
Background Apart from direct protection and reduced productivity loss during epidemics , the main reason to immunize healthcare workers ( HCWs ) against influenza is to provide indirect protection of frail patients through reduced transmission in healthcare setting s. Because the vaccine uptake among HCWs remains far below the health objectives , systematic programs are needed to take full advantage of such vaccination . In an earlier report , we showed a mean 9 % increase of vaccine uptake among HCWs in nursing homes that implemented a systematic program compared with control homes , with higher rates in those homes that implemented more program elements . Here , we report in detail the process of the development of the implementation program to enable research ers and practitioners to develop intervention programs tailored to their setting . Methods We applied the intervention mapping ( IM ) method to develop a theory- and evidence -based intervention program to change vaccination behaviour among HCWs in nursing homes . Results After a comprehensive needs assessment , we were able to specify proximal program objectives and selected methods and strategies for inducing behavioural change . By consensus , we decided on planning of three main program components , i.e. , an outreach visit to all nursing homes , plenary information meetings , and the appointment of a program coordinator -- preferably a physician -- in each home . Finally , we planned program adoption , implementation , and evaluation . Conclusion The IM methodology result ed in a systematic , comprehensive , and transparent procedure of program development . A potentially effective intervention program to change influenza vaccination behaviour among HCWs was developed , and its impact was assessed in a clustered r and omised controlled trial Abstract OBJECTIVE : To characterize U.S. physicians ’ practice s regarding  influenza vaccine , particularly regarding the capacity to identify high-risk patients , the use of reminder systems , and the typical period of administration of vaccine . DESIGN : Cross-sectional mail survey administered in October and November 2000 . PARTICIPANTS : National r and om sample of internists and family physicians ( N=1,606 ) . RESULTS : Response rate was 60 % . Family physicians are significantly more likely than internists to administer influenza vaccine in their practice s ( 82 % vs 76 % ; P<.05 ) . Eighty percent of physicians typically administer influenza vaccine for 3 to 5 months , but only 27 % continue administering vaccine after the typical national peak of influenza activity . Only one half of physicians said their practice s are able to generate lists of patients with chronic illnesses at high risk for complications of influenza , and only one quarter had used mail or telephone reminder systems to contact high-risk patients . Physicians working in a physician network ( including managed care organizations ) are more than twice as likely to use reminders as physicians in other practice setting s ( odds ratio , 2.04 ; 95 % confidence interval , 1.17 to 3.55 ) . CONCLUSIONS : Over three quarters of U.S. internists and family physicians routinely administer influenza vaccine , but few continue immunization efforts past the typical national peak of influenza activity . Many physicians may be limited by their practice data systems ’ capacity to identify high-risk patients . Despite the known effectiveness and cost-effectiveness of reminder systems , few physicians use reminders for influenza vaccination efforts . These findings raise concerns about meeting domestic influenza vaccination goals —especially for individuals with chronic illness and during periods of delayed vaccine availability— and the possibility of increased morbidity and mortality attributable to influenza as a result The authors estimated components of variance and intraclass correlation coefficients ( ICCs ) to aid in the design of complex surveys and community intervention studies by analyzing data from the Health Survey for Engl and 1994 . This cross-sectional survey of English adults included data on a range of lifestyle risk factors and health outcomes . For the survey , households were sample d in 720 postal code sectors nested within 177 district health authorities and 14 regional health authorities . Study subjects were adults aged 16 years or more .  ICCs and components of variance were estimated from a nested r and om-effects analysis of variance . Results are presented at the district health authority , postal code sector , and household levels . Between-cluster variation was evident at each level of clustering . In these data , ICCs were inversely related to cluster size , but design effects could be substantial when the cluster size was large . Most ICCs were below 0.01 at the district health authority level , and they were mostly below 0.05 at the postal code sector level . At the household level , many ICCs were in the range of 0.0 - 0.3 . These data may provide useful information for the design of epidemiologic studies in which the units sample d or allocated range in size from households to large administrative areas In this paper we describe a successful multi-level participatory intervention grounded in principles of individual and group empowerment , and guided by social construction theory . The intervention addressed known and persistent inequities in influenza vaccination among African American and Latino older adults , and associated infections , hospitalizations and mortality . It was design ed to increase resident ability to make informed decisions about vaccination , and to build internal and external infrastructure to support sustainability over time . The intervention brought a group of social scientists , vaccine research ers , geriatricians , public health nurses , elder services providers and advocates together with senior housing management and activist African American and Latino residents living in public senior housing in a small east coast city . Two buildings of equal size and similar ethnic composition were r and omized as intervention and control buildings . Pre and post intervention surveys were conducted in both buildings , measuring knowledge , attitudes and peer norms . Processes and outcomes were documented at four levels : Influenza Strategic Alliance ( macro and exo levels ) , building management ( meso level ) , building resident committee ( meso level ) and individual residents . The Influenza Strategic Alliance ( I.S.A. ) provided ongoing re sources , information and vaccine ; the building management provided economic and other in-kind re sources and supported residents to continue flu clinics in the building . The V.I.P. Resident Committee conducted flu campaigns with flu clinics in English and Spanish . The vaccination rate in the intervention building at post test exceeded the study goal of 70 % and showed a significant improvement over the control building . The intervention achieved desired outcomes at all four levels and result ed in a significant increase in influenza vaccination , and improvements in pro-vaccination knowledge , beliefs , and underst and ing of health consequences 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 Objective : To measure the impact of a population -based tracking system on influenza immunization rates . Design : Thirteen practice s with 45 physicians were r and omized to a control and two intervention groups . Setting : Private practice s. Patients : All patients aged 65 years and over who were seen in participating physicians ’ practice s within the preceding two years . Intervention : In both intervention groups influenza immunization rates for physicians were recorded weekly as cumulative percentages of their target population s , using a specially prepared poster . In addition , postcard reminders were sent to all the patients in one of the intervention groups . Measurements and main results : Immunization rates in the two intervention groups were 30 % higher than in the control group ; the control group immunized 50 % ( 2,405/4,772 ) of its target population , while the poster and poster/postcard groups immunized 66 % ( 1,420/2,149 ) and 67 % ( 2,427/3,604 ) , respectively . Conclusion : A population -based strategy that monitors performance can significantly improve rates of influenza immunization in private practice OBJECTIVE : To test the feasibility of creating a valid and reliable checklist with the following features : appropriate for assessing both r and omised and non-r and omised studies ; provision of both an overall score for study quality and a profile of scores not only for the quality of reporting , internal validity ( bias and confounding ) and power , but also for external validity . DESIGN : A pilot version was first developed , based on epidemiological principles , review s , and existing checklists for r and omised studies . Face and content validity were assessed by three experienced review ers and reliability was determined using two raters assessing 10 r and omised and 10 non-r and omised studies . Using different raters , the checklist was revised and tested for internal consistency ( Kuder-Richardson 20 ) , test-retest and inter-rater reliability ( Spearman correlation coefficient and sign rank test ; kappa statistics ) , criterion validity , and respondent burden . MAIN RESULTS : The performance of the checklist improved considerably after revision of a pilot version . The Quality Index had high internal consistency ( KR-20 : 0.89 ) as did the subscales apart from external validity ( KR-20 : 0.54 ) . Test-retest ( r 0.88 ) and inter-rater ( r 0.75 ) reliability of the Quality Index were good . Reliability of the subscales varied from good ( bias ) to poor ( external validity ) . The Quality Index correlated highly with an existing , established instrument for assessing r and omised studies ( r 0.90 ) . There was little difference between its performance with non-r and omised and with r and omised studies . Raters took about 20 minutes to assess each paper ( range 10 to 45 minutes ) . CONCLUSIONS : This study has shown that it is feasible to develop a checklist that can be used to assess the method ological quality not only of r and omised controlled trials but also non-r and omised studies . It has also shown that it is possible to produce a checklist that provides a profile of the paper , alerting review ers to its particular method ological strengths and weaknesses . Further work is required to improve the checklist and the training of raters in the assessment of external validity AIMS This study aims to assess the effects of two interventions on influenza vaccination coverage : a simple organisational strategy , and making the vaccine available free . METHODS Sixteen general practitioners in the Auckl and region were r and omly selected to participate . Patients over 65 years of these general practitioners were r and omly allocated to control , letter of invitation for a flu vaccine , or offer of a free flu vaccine . Administration of a flu vaccine for each person in the study was documented in each general practitioner surgery . Vaccine coverage for each of the three groups was measured . RESULTS Results were available for 15 of the 16 participating general practitioners , a total of 2791 subjects .  Immunisation coverage rates for control , letter of invitation and vaccine at no cost , were 17 % , 27 % and 45 % respectively . Statistical analysis , allowing for the cluster method used to obtain subjects , showed risk ratios of 1.55 and 2.65 for the two interventions , with p values of < 0.00001 . CONCLUSIONS A potential source of bias in this study is underreporting of administration of vaccine to people in group 1 . Notwithst and ing this potential bias , both interventions were highly effective at increasing the uptake of influenza vaccine in the elderly population . General practitioners should be recommended to routinely invite patients over 65 years to have a flu vaccine . Given the commitment of the Ministry of Health to the vaccination against influenza of people over 65 , this study would suggest that serious consideration should be given to making the vaccine available at no cost to this age group Influenza epidemics are accompanied by considerable excess morbidity and mortality especially among the elderly and the chronically ill . In the influenza season 1995 a controlled , r and omized trial was carried out to examine the impact of postal invitations and user fee on  influenza vaccination rates .  Five hundred and eighty-five patients aged 65 years or older participated . They were all recognized by their general practitioner ( GP ) to be in the risk group to whom influenza vaccination is recommended . One third were invited to free influenza vaccination . Another third received postal invitations to influenza vaccination paying the usual fee ( $ 40-$60 US ) . The last third served as a control group , being vaccinated on their own request and paying the usual fee . In the control group 25 % ( 19 - 31 % , 95 % confidence interval ) of the patients were vaccinated , compared to 49 % ( 42 - 56 % ) in the group which received a postal reminder and paid the usual fee , and 72 % ( 65 - 78 % ) in the group invited to be vaccinated free of charge The cluster r and omized trial  with a concurrent economic evaluation is considered the gold st and ard evaluative design for the conduct of implementation research evaluating different strategies to promote the transfer of research findings into clinical practice . This has implication s for the planning of such studies , as information is needed on the effects of clustering on both effectiveness and efficiency outcomes . This paper describes the design considerations specific to implementation research studies , focusing particularly on the estimation of sample size requirements and on the need for reliable information on intracluster correlation coefficients for both effectiveness and efficiency outcomes BACKGROUND To minimize absenteeism result ing from influenza , employers frequently offer on-site  influenza vaccination to employees . Yet the level of uptake of vaccine is low among working adults . This study was design ed to increase workplace influenza vaccination rates by offering both a choice of intranasal ( LAIV ) and injectable ( TIV ) influenza vaccines to eligible employees , and an incentive for being vaccinated , and by increasing awareness of the vaccine clinic . DESIGN This study used a stratified r and omized cluster trial . SETTING / PARTICIPANTS A total of 12,222 employees in 53 U.S. companies with previous influenza vaccine clinics were examined . INTERVENTIONS Control sites advertised and offered vaccine clinics as previously done . Choice sites offered LAIV or TIV and maintained their previous advertising level but promoted the choice of vaccines . Choice Plus sites increased advertising and promoted and offered a choice of vaccines and a nominal incentive . MAIN OUTCOME MEASURES These included vaccination rates among eligible employees . Hierarchic linear modeling ( HLM ) was used to determine factors associated with vaccination . RESULTS The overall vaccination rate increased from 39 % in 2007 - 2008 to 46 % in 2008 - 2009 ( p<0.001 ) . The difference in vaccination rates for LAIV was 6.5 % for Choice versus Control and 9.9 % for Choice Plus versus Control ( both p<0.001 ) . Rates of TIV increased by 15.9 percentage points in the Choice Plus arm versus Control for workers aged > or = 50 years ( p=0.024 ) . Rates of TIV did not change in workers aged 18 - 49 years in either intervention arm or in workers aged > or = 50 years in the Choice arm . In HLM analyses , factors significantly associated with increased vaccination were older age , female gender , previous company vaccination rate , and the Choice Plus intervention . CONCLUSIONS An incentive for vaccination , an intensified advertising campaign , and offering a choice of influenza vaccines improved vaccination rates in the workplace BACKGROUND Influenza and pneumococcal vaccination rates remain too low . This survey assessed generalist and subspecialist physicians ' knowledge , attitudes , and practice s regarding influenza and pneumococcal vaccinations for high-risk patients . METHODS A self-administered question naire was mailed to 6000 physicians r and omly selected from a national data base . RESULTS After 3 mailings , 1874 physicians ( 32 % ) of the 5858 eligible responded . Although most physicians thought that it was very important for their high-risk patients be current on influenza and pneumococcal vaccinations , only 86 % and 75 % of generalists and subspecialists , respectively , very strongly recommended influenza vaccinations to their elderly patients and only 81 % and 64 % , respectively , very strongly recommended pneumococcal vaccinations to their elderly patients ( P<.001 for both ) . After multivariate logistic regression , factors significantly associated with strongly recommending vaccinations to elderly patients in the influenza and pneumococcal vaccination models included female sex of provider , the provider having received an influenza vaccination , the provider 's beliefs about vaccine effectiveness and cost-effectiveness , a patient 's risk for illness , and ease of targeting patients . In addition , generalists were more likely than subspecialists to strongly recommend pneumococcal vaccinations to their patients . Patient reminders , special clinics , and st and ing orders were each used by fewer than 30 % of respondents , although generalists were more likely than subspecialists to use such strategies . CONCLUSIONS Nontrivial proportions of generalist and subspecialist physicians fail to strongly recommend influenza and pneumococcal vaccinations  to their elderly and high-risk patients . Other effective strategies for promoting vaccine delivery are also used relatively infrequently . These findings suggest areas for improvement if vaccination rates are to reach national goals OBJECTIVE To evaluate the incremental effect of a second client reminder postcard or an influenza tool kit targeted toward employers on increasing influenza vaccination rates among adults age < 65 years at high risk for complications from influenza illness . METHODS In this demonstration study , enrollees of 3 managed care organizations ( n = 8881 ) were r and omized at the employer level into 4 arms : 1 postcard , 2 postcards , 1 postcard + tool kit , and 2 postcards + tool kit . The postcards and tool kits were mailed during the fall of 2001 , and their effect on influenza vaccination rates was assessed through a survey . RESULTS Compared with a single postcard , 2 postcards increased vaccination rates by 4 percentage points ( adjusted relative risk = 1.05 ; P < .05 ) among persons aged 50 to 64 years but did not have any effect among younger adults . Older adults had a greater burden of disease and reported more favorable knowledge and attitudes toward the influenza vaccine . The influenza tool kit did not appear to have any incremental effect on vaccination rates . CONCLUSIONS Our findings underscore the necessity of evaluating the effectiveness of interventions in different population subgroups and of identifying factors that modify the effectiveness of interventions . Rigorous assessment of intervention effectiveness in managed care setting s will enable decision makers to optimize use of scarce healthcare dollars for improving the health and well-being of enrollees BACKGROUND AND OBJECTIVES An important issue facing primary care practice s is how to best improve preventive services to patients . We sought to determine if an intervention design ed by a continuous quality improvement ( CQI ) process ( reminder sticker and patient education sign in each examining room ) or a patient education intervention ( sign only ) could increase the rate of pneumococcal vaccination . METHODS These two interventions were administered over a 6-month period in a controlled , prospect i ve study design in a family practice residency program clinic . The study targeted patients ages 65 and older and patients ages 2 - 64 with diabetes mellitus who had never received the pneumococcal vaccine . The main outcome measure was the vaccination rate in the targeted population . RESULTS A total of 1,647 patient encounters involving 778 patients were documented during the study period . Overall , the reminder and sign module had higher percentages of pneumococcal vaccination in this target population ( 20 % versus 11 % for sign only , versus 7 % control ) . Chi-square analysis revealed a statistically significant difference for this group , compared with placebo , but not for the sign-only group . CONCLUSIONS An intervention design ed from a CQI process to impact the office patterns of primary care physicians can produce measurable changes in pneumococcal vaccination rates Background The pneumococcal vaccine is widely underused . Patient education is one mechanism not widely explored for increasing vaccination rates . Objective To evaluate the effects of a culturally appropriate patient education videotape on pneumococcal vaccination rates among the clinic population of an inner-city public hospital . Methods R and omized , controlled trial comparing ( 1 ) a videotapebrochure group who both viewed the videotape and received a lowliteracy brochure , ( 2 ) a videotape only group , and ( 3 ) a control group . Results Of 2,962 charts review ed , 558 patients were r and omized . The study population was 94 % black , 73 % female , and elderly ( mean age 63.0 years ) and 64 % had less than a high school education . Patients in the videotape-brochure group were 2.5 ( 1.8 , 3.5 95 % CI ) times more likely to discuss the vaccine with their physician ( p < .001 ) and 3.5 ( 1.9 , 6.5 95 % CI ) times more likely to receive the vaccine ( p < .001 ) than the control group . The videotape-brochure group was 1.6 ( 1.2 , 2.1 95 % CI ) times more likely to discuss the vaccine ( p < .001 ) and 2.3 ( 1.4 , 3.8 95 % CI ) times more likely to receive the vaccine ( p = .002 ) than the video only group . Patients in the video only group were 1.6 ( 1.1 , 2.3 95 % CI ) times more likely to discuss the vaccine with their physician than the control group ( p = .041 ) but were not more likely to receive the vaccine . Conclusion A culturally appropriate videotape along with a lowliteracy brochure significantly increased pneumococcal vaccination rates and physician-patient discussion about the vaccine . These significant outcomes were not observed with use of videotape alone and were likely attributable to the effect of the brochure . We recommend that patient education initiatives to increase vaccination rates not focus solely on audiovisual media
PURPOSE Influenza and pneumococcal vaccination rates remain below national targets .
We systematic ally review ed the effectiveness of quality improvement interventions for increasing the rates of influenza and pneumococcal vaccinations among community-dwelling adults .