Ten-year durability and success of an organized program to increase influenza and pneumococcal vaccination rates among high-risk adults. Improving Physician Coverage of Pneumococcal Vaccine: A Randomized Trial of a Telephone Intervention A comparison of adverse effects of two influenza vaccines, and the influence on subsequent uptake. Influenza and pneumococcal vaccination in long term care facilities in two regions of Quebec. A computerized reminder system to increase the use of preventive care for hospitalized patients. Opportunities not missed--systematic influenza and pneumococcal immunization in a public inner-city emergency department. 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? Impact of physician reminders on the use of influenza vaccinations: a randomized trial. A Randomized Study of Tracking With Outreach and Provider Prompting to Improve Immunization Coverage and Primary Care Increasing influenza and pneumococcal immunization rates: a randomized controlled study of a senior center-based intervention. An in-home preventive assessment program for independent older adults: a randomized controlled trial. Achieving the national health objective for influenza immunization: success of an institution-wide vaccination program. Standing orders for influenza vaccination increased vaccination rates in inpatient settings compared with community rates. The Effect of an Education and Feedback Intervention on Group‐Model and Network‐Model Health Maintenance Organization Physician Prescribing Behavior Mass mailings have little effect on utilization of influenza vaccine among Medicare beneficiaries. Early results from the Northland immunisation register. Public health in managed care: a randomized controlled trial of the effectiveness of postcard reminders. Influenza Vaccination Coverage Rates in 5 European Countries: a Population-Based Cross-Sectional Analysis of the Seasons 02/03, 03/04 and 04/05 Effect of a fact sheet reminder on performance of the periodic health examination: a randomized controlled trial. The Effect Of Microcomputer-Generated Reminders On Influenza Vaccination Rates In A University-Based Family Practice Center Effect of preventive home visits by a nurse on the outcomes of frail elderly people in the community: a randomized controlled trial.
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 Improved pneumococcal vaccine ( PPV ) immunization for seniors is a national goal of the Medicare program . This study examined whether adding a simple telephone follow-up to an existing mailed physician performance feedback under the Medicare program would increase the impact on billed pneumococcal immunizations . Medicare fee-for-service cl aims data were used to select New York primary care physicians with high volume ( n = 732 ) or African-American serving ( n = 329 ) practice s. All practice s received mailed feedback on their 1999 Medicare practice specific PPV coverage rates , along with educational material s and offers of assistance . Practice s were also r and omized to receive telephone calls directing attention to the mailing and further promoting improvements in PPV coverage or no active follow-up . Physicians r and omized to telephone follow-up showed significantly higher rates of practice specific PPV coverage in 2000 than those receiving the routine mailing only , and 27 % vs. 17 % ( p = 0.01 ) of high volume physicians and 34 % vs. 22 % ( p = .052 ) of African American serving physicians achieved at least a 5 % increase in their cumulative PPV cl aims coverage . This study concludes that telephone follow-up is an effective and straightforward method to enhance the impact of practice specific feedback to promote improvements in Medicare PPV immunization . However , improved methods may be needed to induce a large percentage of physicians to change In a study comparing the side effects of two  influenza vaccines  in a health centre vaccination programme involving patients in ; at risk ' groups , no significant difference was found between the vaccines used or the method of administration . The majority of side effects were minor , but as many as 35 per cent of the study group reported some systemic upset after vaccination . A follow-up study a year later showed that the incidence of side effects did not appear to influence the uptake of revaccination OBJECTIVES To evaluate the use of influenza and pneumococcal vaccines  in long term care facilities . DESIGN Cross-sectional survey in a r and om sample of 30 facilities in two regions of Quebec . Information was collected from the general manager or the chief of nursing , all consultant physicians and a r and om sample of 20 residents in each facility . RESULTS Twenty-nine centres agreed to participate . The mean influenza vaccination rate was 70 % , and was not influenced by differences in the types of facilities or the organization of the programs for immunization . The main obstacle to influenza vaccination reported by physicians was nonacceptance by a significant proportion of residents . Of the residents who did not initially request influenza vaccine , only 64 % accepted  vaccination  when it was offered . The vast majority of residents were satisfied with the information they had received and the respect shown for their freedom of choice . Forty per cent of residents were unfit to provide a valid consent and the vaccination rate was 76 % in this group . Only one-third of the physicians regularly obtained authorization from a relative or the legal guardian before prescribing vaccination for incompetent residents . None of the facilities studied had an effective program for pneumococcal vaccination , only 43 % of the physicians reported any use of pneumococcal vaccine  and 98 % of residents had never heard of the vaccine . CONCLUSIONS The national objective of 95 % coverage with influenza vaccine  will be difficult to achieve in long term care facilities , mainly because a minority of residents are not likely to be convinced of the benefit of immunization . Much remains to be done to promote and administer pneumococcal vaccine in this setting BACKGROUND Although they are effective in outpatient setting s , computerized reminders have not been proved to increase preventive care in inpatient setting s. METHODS We conducted a r and omized , controlled trial to determine the effects of computerized reminders on the rates at which four preventive therapies were ordered for in patients . During an 18-month study period , a computerized system processed on-line information for all 6371 patients admitted to a general-medicine service ( for a total of 10,065 hospitalizations ) , generating preventive care reminders as appropriate . Physicians who were in the intervention group viewed these reminders when they were using a computerized order-entry system for in patients . RESULTS The reminder system identified 3416 patients ( 53.6 percent ) as eligible for preventive measures that had not been ordered by the admitting physician . For patients with at least one indication , computerized reminders result ed in higher adjusted ordering rates for pneumococcal vaccination ( 35.8 percent of the patients in the intervention group vs. 0.8 percent of those in the control group , P<0.001 ) ,  influenza vaccination ( 51.4 percent vs. 1.0 percent , P < 0.001 ) , prophylactic heparin ( 32.2 percent vs. 18.9 percent , P<0.001 ) , and prophylactic aspirin at discharge ( 36.4 percent vs. 27.6 percent , P<0.001 ) . CONCLUSIONS A majority of hospitalized patients in this study were eligible for preventive measures , and computerized reminders significantly increased the rate of delivery of such therapies OBJECTIVE To demonstrate the feasibility of systematic influenza and pneumococcal vaccination in a busy Emergency Department ( ED ) . SETTING A public , inner-city hospital with an annual adult ED census of 120,000 . 93 % of patients are people of color . 78 % deny having either government or private insurance . Only 28 % of patients report having a primary care provider . Only 15 % present with complaints requiring immediate evaluation by a physician . METHODS Two uncontrolled demonstration projects were conducted during two periods , from 10/21/96 through 12/2/96 , ( during the influenza immunization season ) and from 5/27/97 to 7/26/97 . During project one , nurses were given st and ing orders that all non-urgent patients meeting CDC recommended criteria were to be offered immunization against influenza and /or pneumococcus at triage . The date of immunization was entered into unused fields in the computerized patient registration system , making it available system-wide , to all providers having access to billing system terminals . From 11/4 through 11/18 , an extra ' immunization nurse ' was assigned to test for improvement in immunization figures . A time/motion study of the time required for each immunization was conducted using a convenience sample of eight nurses over all three shifts . During project two , responsibility for carrying out st and ing orders for immunization was transferred to the patient 's nurses in the treatment area , and all high-risk patients were made eligible for immunization . An immunization card was issued to the patient at the time of each immunization . A monetary incentive to nurses was used to encourage completion of tracking forms . Computer record-keeping was continued . RESULTS Both projects required intense supervision to ensure performance . Despite initial resistance , and extreme variation in individual performance , many nurses and physicians became supportive of ED immunization during the two projects . During project one , 2631 patients were screened , and 789 high-risk patients were identified . 1238 patients were immunized against influenza and 374 against pneumococcus . Immunizations per shift per nurse varied from 0 to 24 . Median time for immunization was 4 min ( range 2 - 10 ) . The addition of an extra nurse at triage did not improve performance . During period two , 1907 patients were screened , 1532 high-risk patients were identified , and 1179 patients were immunized against pneumococcus . CONCLUSION Systematic ED immunization of high-risk adults is feasible even in a busy public ED setting 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 analyze the impact of mailed physician reminders to immunize their patients . DESIGN R and omized trial involving Washington State physiatrists participating in the Medicare program . In 1997 , all physiatrists in the state were separated into solo or group practice . Solo physicians and group practice s were then separately r and omized to receive 4 monthly reminders to have their patients immunized . In 1998 , the intervention and control groups were switched . SETTING The state of Washington . PATIENTS A total of 4300 Medicare out patients seen in Washington State in 1997 and 4025 patients in 1998 . INTERVENTION Repeated mailer . MAIN OUTCOME MEASURE By using multivariate analysis , Medicare billing data was analyzed to determine the impact of the physician reminders on influenza vaccination rates . RESULTS Among solo practitioners , patients whose physiatrist received the reminder letters in 1998 were 34 % more likely ( adjusted relative risk [ RR ] = 1.34 ; 95 % confidence interval [CI],.96 - 1.88 ) to have a vaccination billing . Among group practitioners , those patients whose physiatrist received the reminder letters in 1997 were 26 % more likely ( RR = 1.26 ; 95 % CI,.98 - 1.60 ) to have a vaccination billing . These differences , however , were not statistically significant . The adjusted RRs for the remaining intervention groups , solo practitioners in 1997 ( RR = .89 ; 95 % CI,.63 - 1.26 ) , and group practitioners in 1998 ( RR = 1.00 ; 95 % CI,.73 - 1.36 ) , revealed no increase in vaccination billings for patients whose physiatrist received the intervention . CONCLUSIONS Repeated physician reminders did not increase the vaccination rate of Washington State Medicare patients who were seen by physiatrists in 1997 and 1998 . These results were consistent whether the physiatrists were in solo or group practice . Other methods should be considered to improve the primary care delivered to this Medicare population Objective . To compare and measure the effects and cost-effectiveness of two interventions design ed to raise immunization rates . Setting s. Nine primary care sites serving impoverished and middle-class children . Subjects . Complete birth cohorts ( ages 0 to 12 months ; n = 3015 ) from these sites . Interventions . Two 18-month duration interventions : 1 ) tracking with outreach [ tracking/outreach ] to bring underimmunized children to their primary care provider office , and 2 ) a primary care provider office policy change to identify and reduce missed immunization opportunities ( prompting ) . Design . R and omized , controlled trial , r and omizing within sites using a two-by-two factorial design . Subjects were allocated to one of four study groups : control , prompting only , tracking/outreach only , and combined prompting with tracking/outreach . Outcomes were obtained by blinded chart abstract ion . Measures . Immunization status for age ; number of days of delay in immunization ; primary care utilization ; and rates of screening for occult disease . Results . Out of 3015 subjects , 274 subjects ( 9 % ) transferred out of the participating sites or had incomplete charts and were excluded . The 2741 ( 91 % ) remaining subjects were assessed . At baseline , study groups did not differ in age , gender , insurance type , or immunization status . Of the remaining subjects , 63 % received Medicaid . Final series-complete immunization coverage levels were : control , 74 % ; prompting-only , 76 % ; tracking/outreach-only 95 % ; and combined tracking/outreach with prompting , 95 % . Analysis of variance showed that : 1 ) tracking/outreach increased immunization rates 20 percentage points ; 2 ) tracking/outreach decreased mean immunization delay 63 days ; 3 ) tracking/outreach increased mean health supervision visits 0.44 visits per child ; 4 ) tracking/outreach increased mean anemia screening 0.17 screenings per child and mean lead screenings 0.12 screenings per child ; 5 ) impact of tracking/outreach was greatest for uninsured and impoverished patients ; and 6 ) the prompting intervention had no impact on the studied outcomes , and its failure was caused by inconsistent use of prompts and failure to vaccinate ill children when prompted . Using tracking/outreach , the cost per additional child fully immunized was $ 474 . Each $ 1000 spent on the tracking/outreach intervention result ed in : 2.1 additional fully vaccinated children and 668 fewer child-days of delayed immunization ; 4.6 additional health supervision visits and 5.9 additional other visits to the primary care provider ; and 1.8 additional anemia screenings and 1.3 additional lead screenings . Conclusions . Outreach directed toward children not up-to- date on immunizations improves not only immunization status , but also health supervision visit attendance and screening rates . The cost per additional child immunized was high , but should be interpreted in view of the spillover benefits that accompanied improved immunization . Effective means to improve coverage by reducing missed immunization opportunities still need to be identified . immunization , primary care , r and omized , controlled trial , missed immunization opportunities , outreach BACKGROUND Immunizations decrease morbidity from influenza and pneumococcal infections . Immunization levels remain below desired levels despite clinic-based and public education efforts . This paper describes a r and omized , controlled trial of a senior center-based program , which used peer-to-peer outreach to increase pneumococcal and influenza immunization rates among an urban senior population . METHODS Seniors were r and omized to intervention or control groups . The intervention group received educational brochures mailed with reply cards to report immunization status , telephone calls from senior volunteers to unimmunized participants , and computerized immunization tracking .  Immunization rates were obtained before and after the intervention by self-report . RESULTS Among participants without prior pneumococcal immunization , the pneumococcal immunization rate among the intervention group ( 52.0 % ; 95 % CI = 46.6%-57.4 % ) was significantly higher than that of the control group ( 30.9 % ; 95 % CI = 26.6%-35.2 % ) ( rate ratio = 1.68 ; 95 % CI = 1.40 - 2.03 ) . Among those without influenza immunization in the prior year , significantly more ( 50.0 % ; 95 % CI = 40.0%-60.0 % ) were immunized against influenza in the intervention group than in the control group ( 23.0 % ; 95 % CI = 15.2%-33.3 % ) ( rate ratio = 2.17 ; 95 % CI = 1.42 - 3.31 ) . Among those with influenza immunization in the prior year , the rate ratio was 1.04 ( 95 % CI = 1.01 - 1.07 ) . CONCLUSIONS The intervention increased both influenza and pneumococcal immunization rates to high levels , suggesting that further progress in increasing adult immunization coverage is possible OBJECTIVE To evaluate the effectiveness of in-home geriatric assessment s as a means of providing preventive health care and improving health and functional status of community-living elderly veterans . DESIGN R and omized controlled trial with 1-year follow-up . SETTING Home visits performed in a suburb of Los Angeles . PARTICIPANTS Community-living veterans 70 years and older not currently receiving health care at the Sepulveda VA Medical Center ( n = 131 intervention ; 123 controls ) . INTERVENTION A home visit by a physician 's assistant or nurse , to screen for medical , functional and psychosocial problems , followed by a letter describing findings and recommendations , and follow-up visits by trained volunteers at 4-month intervals for 1 year . Controls received only telephone interviews at 4-month intervals to collect outcome data . MEASUREMENTS Compliance with recommendations was studied for the intervention group . Outcome comparisons between the two groups included : mortality , medication usage , functional status , immunization rates , and nursing home and hospital utilization . MAIN RESULTS A mean of four new or suboptimally treated problems was identified for intervention subjects . Subjects complied with 76 % of recommendations to see a physician or initiate a specific health practice . At 12-month follow-up , intervention subjects had significantly increased their immunization rates ( P < 0.001 ) and had a significantly increased likelihood of having a primary care physician ( P < 0.05 ) . Twelve-month functional status ( IADL ) scores were significantly higher for intervention subjects than for controls ; intervention subjects maintained their functional status , while controls experienced significant decline during the follow-up year ( P < 0.05 ) . Non-prescription drug use increased significantly among controls , but not among intervention subjects ( P < 0.05 ) . CONCLUSIONS A brief geriatric screening assessment performed in the home can detect unrecognized and treatable problems , even among relatively healthy older adults . The use of trained volunteers is a feasible strategy for providing health education and follow-up contacts . These results support the concept that preventive gerontological approaches can help maintain important aspects of health and function 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 BACKGROUND Hospitalization of older adults during the period of influenza vaccination in the fall of each year presents a barrier to immunization against influenza . This study evaluates a program using st and ing orders for influenza vaccination to increase vaccination rates among hospitalized older adults and to determine the effect of vaccination on readmission rates for influenza-like illness . METHODS An influenza vaccination program using a st and ing order policy was implemented to vaccinate all consenting persons 65 years and older prior to hospital discharge . This was a prospect i ve , single center , cohort study in a tertiary care university teaching hospital during an 8-week vaccination period in the fall of 1994 and follow-up during the subsequent influenza season . The vaccination status of each patient was recorded as no vaccination , vaccination received in hospital , or vaccination in the community prior to or after the hospitalization . Hospital vaccination rates were compared with the rate of vaccination of older adults in the community . During the subsequent influenza season , the number of subjects reporting symptoms of influenza-like illness ( ILI ) or who were readmitted to hospital with influenza-related illness was compared in an analysis of vaccinated versus unvaccinated subjects . RESULTS Seven hundred and sixty-one patients were interviewed , and 332 of these individuals had been vaccinated in the community prior to their hospital admission . Of the remaining 429 unvaccinated patients who were eligible for vaccination in the study , 171 were vaccinated in our immunization program , eight were vaccinated in the community after discharge , and 244 were not vaccinated . We were able to increase the absolute vaccination rate by 22 % , when compared with community rates , with our immunization program . The number of subjects with ILI symptoms or readmission to hospital was too small to compare the vaccinated to the unvaccinated group in the study . CONCLUSIONS An inpatient influenza immunization program using a st and ing order policy was able to target a particularly high-risk subset of persons 65 years and over who might otherwise have not received influenza vaccination & NA ; The authors evaluated the effect of an educational and feedback intervention on H2‐blocker prescribing patterns and determined , if such effects differed for network‐ versus group‐model health maintenance organization ( HMO ) physicians and in academic versus nonacademic setting s. Physicians were r and omized to receive an educational memor and um alone or combined with feedback regarding their individual prescribing behavior . The memo suggested preferred use of an H2‐blocker ( cimetidine ) that would be less expensive to the HMO . Prescribing was monitored during the 6 months before and after the intervention . The study was undertaken at the primary care practice s of a mixed group‐ and network‐model university‐affiliated HMO . Thirty group‐model ( at two academic and four nonacademic sites ) and 33 network‐model ( all in full‐time private practice ) primary care physicians participated in the study . The analysis utilized weighted and unweighted analysis of covariance of the change in physicians ' cimetidine‐prescribing rates between the baseline and study periods . A significant response to the intervention was noted among academic and nonacademic group‐model HMO physicians , but not among network physicians ( adjusted mean absolute prescribing changes of + 9.9 % and + 8.9 % versus ‐2.8 % , P = .02 ) . There was no difference in prescribing change based on ITYPE of intervention ( education versus feedback ) . The authors conclude that a simple passive educational intervention can be effective at changing group‐model HMO physician behavior BACKGROUND We review ed published and unpublished studies of mass mailings design ed to increase utilization of  influenza vaccine  among Medicare beneficiaries . METHODS Search of computerized indexes for published studies and the Medicare Peer Review Organization Health Care Quality Improvement Project data base for unpublished studies . Study selection criteria were : use of a controlled trial design and use of mass mailings direct  to Medicare beneficiaries to increase receipt of influenza vaccinations .  Study selection and data extraction were performed in duplicate by physician review ers with consensus resolution . RESULTS Six controlled trials of mass mailings were identified . One study , published in the Morbidity and Mortality Weekly Report ( MMWR ) , reported a modest but statistically significant improvement in influenza vaccination rates among patients who received a letter relative to those who did not . This study was cited as justification for mail interventions performed in five subsequent studies , none of which reported clinical ly meaningful results . None of these five studies was published . CONCLUSIONS Mass mailings have at best had clinical ly trivial effects on increasing influenza vaccination among Medicare beneficiaries . Publication bias has contributed to continued use of a relatively ineffective intervention A controlled trial to determine the effects of introducing a central ised , computerised immunisation register  commenced in Northl and in May 1985 . All infants born since 1 January 1985 have been registered on the Health Department 's mainframe computer and assigned to either control or test groups . This birth information has been used to study two interventions aim ed at increasing immunisation levels in the experimental group . The first involves sending to general practitioners lists of infants due for immunisation , and the second sending immunisation reminder cards to parents . Results show significant differences in immunisation levels between test group infants and comparable controls : an 18.2 % increase for the six week immunisation , a 16.7 % increase for the three month immunisation , and a 4.7 % increase for the five month immunisation . A user survey has shown a high degree of acceptance by GPs and practice nurses . The pilot scheme will continue through 1986 , and will be used over this period to improve acceptability to users and assist in planning a possible national computerised immunisation information system OBJECTIVES This study evaluated the effectiveness of an annual public health intervention in a managed care setting . METHODS Managed care organization members 65 years and older who received influenza immunization in 1996 were r and omized to an intervention group ( mailed a postcard reminder to receive an influenza vaccination in 1997 ) or a control group ( no postcard ) .  Vaccination rates for both groups were assessed monthly . RESULTS Members receiving the intervention were no more likely to be immunized ( 78.6 % ) than members of the control group ( 77.2 % , P = .222 ) . Members were vaccinated at the same pace regardless of vaccination history and postcard intervention status . CONCLUSIONS Postcard reminders were not an effective intervention among seniors who had been vaccinated the previous year Introduction : Influenza continues to be a considerable health problem in Europe .  Vaccination is the only preventive measure , reducing mortality and morbidity of influenza in all age groups Objectives : The objective of this survey was to assess and compare the level of influenza vaccination coverage during three consecutive influenza seasons ( 02/03 , 03/04 , 04/05 ) in the five European countries United Kingdom , France , Italy , Germany and Spain , underst and the driving forces and barriers to vaccination now and 3 years ago and determine vaccination intentions for the following winter . Methods : We conducted a r and om-sampling , telephone-based household survey among non-institutionalized individuals representative of the population aged 14 and over . The surveys used the same question naire for all three seasons . The data were subsequently pooled . Four target groups were determined for analysis : ( 1 ) persons aged 65 and over ; ( 2 ) people working in the medical field ; ( 3 ) persons suffering from chronic illness and ( 4 ) a group composed of persons aged 65 and over or working in the medical field or suffering from a chronic illness . Results : The overall sample consisted of 28,021 people . The  influenza vaccination coverage rate increased from 21.0 % in season 02/03 to 23.6 % in season 03/04 and then to 23.7 % in season 04/05 . The differences between the seasons are statistically significant ( p = 0.01 ) . The highest rate over all countries and seasons had Germany in season 04/05 with 26.5 % , Spain had in season 02/03 with 19.3 % the lowest rate totally . The coverage rate in the target group composed of person 's aged 65 and over or working in the medical field or suffering from a chronic illness was 49.7 % in season 02–04 and 50.0 % in season 04/05 . The driving forces and barriers to vaccination did not change over the years . The most frequent reasons for being vaccinated given by vaccines were : influenza , considered to be a serious illness which people wanted to avoid , having received advise from the family doctor or nurse to be vaccinated and not wanting to infect family and friends . Reasons for not being vaccinated mentioned by people who have never been vaccinated were : not expecting to catch influenza , not having considered vaccination before and not having received a recommendation from the family doctor to be vaccinated . Options encouraging influenza vaccination are : recommendation by the family doctor or nurse , more available information on the vaccine regarding efficacy and tolerance and more information available about the disease . The adjusted odds ratio of receiving  influenza vaccine  varied between 2.5 in Germany and 6.3 in the United Kingdom in any risk group . Conclusion : The vaccination coverage rate increased from the first season ( 21.0 % ) to the third season ( 23.7 % ) by 2.6 % . The family doctor is the most important source of encouragement for people to be vaccinated against influenza . It seems that the public would be more likely to be vaccinated if they had more information on the efficacy and tolerance of the vaccine , as well as the disease . We therefore suggest that family doctors be better informed on influenza vaccine and the disease itself , so that they can actively inform their patients on these topics Physicians ' performance of the periodic health examination is often incomplete . Performance rates may be low because physicians forget recommendations for specific periodic health examination components at the time of the patient encounter . We studied the effect of providing information about seven periodic health examination actions ( cervical Pap smear , mammography , fecal occult blood testing , serum cholesterol level , and influenza , pneumococcal , and diphtheria-tetanus immunizations ) on first-year medical residents ' performance of these actions over a three-month period . We r and omly selected 16 residents to receive periodic health examination recommendations  , plus data supporting each recommendation , on their outpatient charts at the patient encounter . Thirteen residents who did not receive this information served as controls . Experimental and control groups achieved similar knowledge scores ( 0.53 versus 0.47 , P = .48 ) and attitude scores ( 0.73 versus .078 , P = .19 ) for preventive care measures on pre study testing . The experimental group performed 10.5 % of indicated periodic health examination actions , whereas the control group performed 5.8 % of indicated actions ( P = NS ) . These results suggest no clinical ly meaningful improvement in performance of periodic health examination actions , even when periodic health examination guidelines were available at the time of the physician-patient encounter 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 Timely recognition and prevention of health problems among elderly people have been shown to improve their health . In this r and omized controlled trial the authors examined the impact of preventive home visits by a nurse compared with usual care on the outcomes of frail elderly people living in the community . METHODS A screening question naire identified eligible participants ( those aged 70 years or more at risk of sudden deterioration in health ) . Those r and omly assigned to the visiting nurse group were assessed and followed up in their homes for 14 months . The primary outcome measure was the combined rate of deaths and admissions to an institution , and the secondary outcome measure the rate of health services utilization , during the 14 months ; these rates were determined through a medical chart audit by a research nurse who was blind to group allocation . RESULTS The question naire was mailed to 415 elderly people , of whom 369 ( 88.9 % ) responded . Of these , 198 ( 53.7 % ) were eligible , and 142 consented to participate and were r and omly assigned to either the visiting nurse group ( 73 ) or the usual care group ( 69 ) . The combined rate of deaths and admissions to an institution was 10.0 % in the visiting nurse group and 5.8 % in the usual care group ( p = 0.52 ) . The rate of health services utilization did not differ significantly between the 2 groups . Influenza and pneumonia vaccination rates were significantly higher in the visiting nurse group ( 90.1 % and 81.9 % ) than in the usual care group ( 53.0 % and 0 % ) ( p < 0.001 ) . INTERPRETATION The trial failed to show any effect of a visiting nurse other than vastly improved vaccination coverage
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 up date s 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 .