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

Seasonal influenza vaccination among people with diabetes: influence of patients' characteristics and healthcare use on behavioral changes

Annual seasonal influenza vaccination (SIV) is recommended for people with diabetes, but vaccine coverage remains low. We estimated the probabilities of stopping or starting SIV, their correlates, and the expected time spent in the vaccinated state over 10 seasons for different patient profiles. We set up a retrospective cohort study of patients with diabetes in 2006 (n = 16,026), identified in a representative sample of beneficiaries of the French National Health Insurance Fund. We followed them up over 10 seasons (2005/06–2015/16). We used a Markov model to estimate transition probabilities and a proportional hazards model to study covariates. Between two consecutive seasons, the probabilities of starting (0.17) or stopping (0.09) SIV were lower than those of remaining vaccinated (0.91) or unvaccinated (0.83). Men, older patients, those with type 1 diabetes, treated diabetes or more comorbidities, frequent contacts with doctors, and with any hospital stay for diabetes or influenza during the last year were more likely to start and/or less likely to stop SIV. The mean expected number of seasons with SIV uptake over 10 seasons (range: 2.6–7.9) was lowest for women <65 years with untreated diabetes and highest for men ≥65 years with type 1 diabetes. Contacts with doctors and some clinical events may play a key role in SIV adoption. Healthcare workers have a crucial role in reducing missed opportunities for SIV. The existence of empirical patient profiles with different patterns of SIV uptake should encourage their use of tailored educational approaches about SIV to address patients’ vaccine hesitancy.

Enhancing Immunization Rates in Two Urban Academic Primary Care Clinics: A Before and After Assessment

PURPOSE

Immunization rates in many cities in the United States remain suboptimal compared to Healthy People 2020 Goals and are lower than national averages. This study aimed to determine whether a lecture-based educational intervention targeted at nurses and medical assistants would improve vaccination rates.

METHODS

We conducted a quality improvement study in two urban academic family medicine clinics serving a predominantly Medicaid patient population as well as a sizable proportion of refugees. The intervention consisted of 3 lectures that were delivered to clinic nurses and medical assistants. Vaccinations in 1689 patients - 872 in the 3-month preintervention period, 817 in the 3-month postintervention period - were analyzed.

RESULTS

Following the educational intervention, a statistically significant increase was seen only in human papillomavirus vaccine immunization rates for 13-18-year-olds (from 90.7% [n=54] to 100% [n=45]; P=0.036). When the results were stratified by clinic, only 1 site showed statistically significant increases in: pneumococcal polysaccharide vaccine (23-valent) for high-risk 19-to-64-year-olds (from 36.4% [n=154] to 47.8% [n=136]; P=0.049); Haemophilus influenzae type B vaccine for 2-month-to-5-year-olds (from 91.1% [n=112] to 97.3% [n=111]; P=0.048); and meningococcal conjugate vaccine (quadrivalent) for 13-18-year olds (from 85.2% [n=27] to 100% [n=26]; P=0.042). No increases were seen for our study's refugee patient population (n=171), and a significant decrease of the second-dose measles, mumps, and rubella vaccine (P=0.036) occurred in this subcohort.

CONCLUSIONS

Ultimately, this quality improvement study demonstrated that educational interventions alone have a limited impact on increasing immunization rates.

Increasing Influenza and Pneumococcal Vaccination Uptake in Seniors Using Point-of-Care Informational Interventions in Primary Care in Singapore: A Pragmatic, Cluster-Randomized Crossover Trial

Objectives. To evaluate the effectiveness of point-of-care informational interventions in general practitioner clinics to improve influenza and pneumococcal vaccination uptake among elderly patients.Methods. We conducted a pragmatic, cluster-randomized crossover trial in 22 private general practitioner clinics in Singapore, from November 2017 to July 2018. We included all patients aged 65 years or older. Clinics were assigned to a 3-month intervention (flyers and posters encouraging vaccination) plus 1-month washout period, and a 4-month control period (usual care). Primary outcomes were differences in vaccination uptake rates between periods. Secondary outcomes were identification of other factors associated with vaccination uptake.Results. A total of 4378 and 4459 patients were included in the intervention and control periods, respectively. Both influenza (5.9% vs 4.8%; P = .047) and pneumococcal (5.7% vs 3.7%; P = .001) vaccination uptake rates were higher during the intervention period compared with the control period. On multilevel logistic regression analysis, follow-up for hypertension, diabetes mellitus, hyperlipidemia, or any combination of the 3 was associated with uptake of both vaccines.Conclusions. Point-of-care informational interventions likely contributed to increased influenza and pneumococcal vaccination uptake. Patients on follow-up for hypertension, diabetes mellitus, hyperlipidemia, or any combination of the 3 were more likely to receive influenza and pneumococcal vaccination and should be actively engaged by physicians.Trial Registration. ClinicalTrials.gov Identifier: NCT03445117.

Adjuvanted influenza vaccine for the Italian elderly in the 2018/19 season: an updated health technology assessment

BACKGROUND

The elderly, defined here as subjects aged ≥ 65 years, are among at-risk subjects for whom annual influenza vaccination is recommended. For the 2018/19 season, three vaccine types are available for the elderly in Italy: trivalent inactivated vaccine (TIV), adjuvanted TIV (aTIV) and quadrivalent inactivated vaccines (QIV). No health technology assessment (HTA) of seasonal influenza vaccination in the elderly has previously been conducted in Italy.

METHODS

An HTA was conducted in 2017 to analyze the burden of influenza illness, the characteristics, efficacy, safety and cost-effectiveness of available vaccines and the related organizational and ethical implications. This was then contextualized to the 2018/19 influenza season. Comprehensive literature reviews/analyses were performed and a static mathematical model developed in order to address the above issues.

RESULTS

In Italy, influenza is usually less common in the elderly than in other age-classes, but the burden of disease is the highest; >10% of infected elderly subjects develop complications, and about 90% of all influenza-related deaths occur in this age-class. All available vaccines are effective, safe and acceptable from an ethical standpoint. However, aTIV has proved more immunogenic and effective in the elderly. Furthermore, from the third payer's perspective, aTIV is highly cost-effective and cost-saving in comparison with TIV and QIV, respectively. Nevertheless, vaccination coverage needs to be improved.

CONCLUSIONS

According to this HTA, aTIV appeared the vaccine of choice in the elderly. HTA should be reapplied whenever new relevant data become available.

Trajectories of seasonal influenza vaccine uptake among French people with diabetes: a nationwide retrospective cohort study, 2006-2015

Background

Annual seasonal influenza vaccination (SIV) is recommended for people with diabetes, but their SIV rates remain far below public health targets. We aimed to identify temporal trajectories of SIV uptake over a 10-year period among French people with diabetes and describe their clinical characteristics.

Methods

We identified patients with diabetes in 2006 among a permanent, representative sample of beneficiaries of the French National Health Insurance Fund. We followed them up over 10 seasons (2005/06–2015/16), using SIV reimbursement claims and group-based trajectory modelling to identify SIV trajectories and to study sociodemographic, clinical, and healthcare utilization characteristics associated with the trajectories.

Results

We identified six trajectories. Of the 15,766 patients included in the model, 4344 (28%) belonged to the “continuously vaccinated” trajectory and 4728 (30%) to the “never vaccinated” one. Two other trajectories showed a “progressive decrease” (2832, 18%) or sharp “postpandemic decrease” (1627, 10%) in uptake. The last two trajectories (totalling 2235 patients, 14%) showed an early or delayed “increase” in uptake. Compared to “continuously vaccinated” patients, those in the “progressively decreasing” trajectory were older and those in all other trajectories were younger with fewer comorbidities at inclusion. Worsening diabetes and comorbidities during follow-up were associated with the “increasing” trajectories.

Conclusions

Most patients with diabetes had been continuously vaccinated or never vaccinated and thus had stable SIV behaviours. Others adopted or abandoned SIV. These behaviour shifts might be due to increasing age, health events, or contextual factors (e.g., controversies about vaccine safety or efficacy). Healthcare professionals and stakeholders should develop tailored strategies that take each group’s specificities into account.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7209-z) contains supplementary material, which is available to authorized users.

Strategies for Improving Influenza Vaccination Rates in Patients with Chronic Renal Disease

BACKGROUND

The influenza vaccination rate among older and chronically ill patients in Germany has declined in the past decade in spite of vaccination campaigns.

METHODS

The influenza vaccination rate among persons with chronic renal disease was studied with the aid of billing data from various Associations of Statutory Health Insurance Physicians (Kassenärztliche Vereinigungen, ASHIPs) in Germany. It was tested in a randomized controlled trial whether a written vaccination appeal, sent by physicians to patients, led to an increase in the vaccination rate. It was tested in a further such trial whether the vaccination rate among patients with renal disease could be improved by an appeal for vaccination that was sent by the ASHIPs to the treating nephrologists. Finally, it was also tested in a prospective interventional study whether the vaccination rate could be improved by an appeal for vaccination sent by a health- insurance carrier directly to the patients.

RESULTS

In 2012-2017, the vaccination rate among persons with chronically impaired renal function ranged from 41.1% to 46.9%; it ranged from 31.7% to 33.7% in kidney transplant recipients and from 42.7% to 44.7% in dialysis patients. An appeal for vaccination that was sent from physicians to patients raised the vaccination rate by 8.3% in the intervention group compared to the control group (p = 0.03; number needed to treat [NNT]: 13). On the other hand, an appeal for vaccination that was sent to the nephrologists lowered the vaccination rate by 0.8% in the intervention group compared to the control group. Finally, an appeal for vaccination that was sent by the health-insurance fund to the patients raised the vaccination rate by 3.2% (p<0.001; NNT: 32).

CONCLUSION

Fewer than half of all patients with chronic renal failure in Germany are vaccinated against influenza. The vaccination rate was found to be increased only after an appeal for vaccination that was sent directly to the patients. A letter sent to the treating physicians had no positive effect at all.

Explaining the Use of Social Network Sites as Seen by Older Adults: The Enjoyment Component of a Hedonic Information System

Previous studies suggest that older adults are living increasingly alone and without the company of their close relatives, which cause them depression problems and a detriment to their health and general wellbeing. The use of social network sites (SNS) allows them to reduce their isolation, improve their social participation, and increase their autonomy. Although the adoption of various information technologies by older adults has been studied, some assumptions still predominate, for example, that older adults use SNS only for utilitarian purposes. However, considering SNS as hedonic information systems, and in order to extend the theoretical explanation of the intention to use hedonic systems to their actual use, this study aims to determine the influence of perceived enjoyment, perceived usefulness, and perceived ease of use on the use of SNS by elders in Concepción, Chile. Two hundred fifty-three older adults participated in the cross-sectional study. The results indicate that perceived ease of use is the variable that has the greatest total effect in explaining the use of SNS and that by adding the perceived enjoyment construct, the explanatory power of the model increases significantly. Therefore, advancement in user acceptance models, especially in the use of SNS by elders, can be made by focusing on the type of system, hedonic or utilitarian.

Adult vaccination as part of a healthy lifestyle: moving from medical intervention to health promotion

As the global population ages, there is concern about the effect of an increased proportion of older individuals on the economic sustainability of healthcare systems and the social effects of an older society. Health authorities and advocacy groups in countries at the forefront of this trend are now developing strategies to ameliorate the social and financial effects of an ageing population. There is broad agreement that for both society and for the individuals, it is important to ensure that increasing lifespans are matched with increased "healthspans" - the number of years spent in good health. There is also growing consensus that vaccination is one of the tools that can play an important role in improving adult health - though currently vaccination coverage is often poor. This review focuses on two issues that consistently appear to be associated with under-vaccination: the low awareness of risk (and potential consequences) for vaccine-preventable diseases and a poor understanding of the value of improved vaccination coverage for adults. We suggest that understanding of vaccination as a health-promoting activity, rather than a medical intervention designed to prevent the spread of a specific pathogen - is a crucial step to improve vaccination uptake among adults (see Supplementary video abstract ). Key messages As populations age globally, we are seeing an increasing burden of vaccine-preventable disease in adults. Adult vaccination against some common diseases has been shown to dramatically improve health and quality of life for older people. Despite the attested benefits, vaccination coverage is almost always poor in adults, even in countries where access is free at point of care. In this article, we discuss what appears to a neglected issue in adult vaccination, that of personal autonomy. We argue that adult vaccination will only be successful if it respects individual autonomy and that this requires treating the choice to vaccinate as a public health issue akin to smoking cessation, exercise and healthy diet.

A Systematic Review of Studies of the STOPP/START 2015 and American Geriatric Society Beers 2015 Criteria in Patients ≥ 65 Years

BACKGROUND

Polypharmacy remains problematic for individuals ≥65.

OBJECTIVE

To summarise the percentages of patients meeting 2015 STOPP criteria for Potentially Inappropriate Prescriptions (PIPs), 2015 Beers criteria for Potentially Inappropriate Medications (PIMs), and START criteria Potential Prescribing Omissions (PPOs).

METHODS

Searches conducted on 2 January 2019 in Medline, Embase, and PubMed identified 562 studies and 62 studies were retained for review. Data were abstracted independently.

RESULTS

62 studies (n=1,854,698) included two RCTs and 60 non-randomised studies. For thirty STOPP/START studies (n=1,245,974) average percentages for ≥1 PIP weighted by study size were 42.8% for 1,242,010 community patients and 51.8% for 3,964 hospitalised patients. For nineteen Beers studies (n = 595,811) the average percentages for ≥1 PIM were 58% for 593,389 community patients and 55.5% for 2,422 hospitalised patients. For thirteen studies (n=12,913) assessing both STOPP/START and Beers criteria the average percentages for ≥1 STOPP PIP were 33.9% and Beers PIMs 46.8% for 8,238 community patients, and for ≥ 1 STOPP PIP were 42.4% and for ≥1 Beers PIM 60.5% for 4,675 hospitalised patients. Only ten studies assessed changes over time and eight found positive changes.

CONCLUSION

PIP/PIM/PPO rates are high in community and hospitalised patients in many countries. RCTs are needed for interventions to: reduce new/existing PIPs/PIMs/PPO prescriptions, reduce prescriptions causing adverse effects, and enable regulatory authorities to monitor and reduce inappropriate prescriptions in real time. Substantial differences between Beers and STOPP/START assessments need to be investigated whether they are due to the criteria, differential medication availability between countries, or data availability to assess the criteria.

Vaccination in England: a review of why business as usual is not enough to maintain coverage

BACKGROUND

The vaccine system in England underwent radical changes in 2013 following the implementation of the Health and Social Care Act. There have since been multi-year decreases in coverage of many vaccines. Healthcare professionals have reported finding the new system fragmented and challenging. This study aims to produce a logic model of the new system and evaluate the available evidence for interventions to improve coverage.

METHODS

We undertook qualitative document analysis to develop the logic model using process evaluation methods. We performed a systematic review by searching 12 databases with a broad search strategy to identify interventions studied in England conducted between 2006 and 2016 and evaluated their effectiveness. We then compared the evidence base to the logic model.

RESULTS

We analysed 83 documents and developed a logic model describing the core inputs, processes, activities, outputs, outcomes and impacts of the new vaccination system alongside the programmatic assumptions for each stage. Of 9,615 unique articles, we screened 624 abstracts, 45 full-text articles, and included 16 studies: 8 randomised controlled trials and 8 quasi-experimental studies. Four studies suggest that modifications to the contracting and incentive systems can increase coverage, but changes to other programme inputs (e.g. human or capital resources) were not evaluated. Four multi-component intervention studies modified activities and outputs from within a GP practice to increase coverage, but were part of campaigns or projects. Thus, many potentially modifiable factors relating to routine programme implementation remain unexplored. Reminder/recall systems are under-studied in England; incentive payments to adolescents may be effective; and only two studies evaluated carer information.

CONCLUSIONS

The evidence base for interventions to increase immunisation coverage in the new system in England are limited by a small number of studies and by significant risk of bias. Several areas important to primary care remain unexplored as targets for interventions, especially modification to organisational management.

A process evaluation of how the routine vaccination programme is implemented at GP practices in England

BACKGROUND

In recent years, the incidence of several pathogens of public health importance (measles, mumps, pertussis and rubella) has increased in Europe, leading to outbreaks. This has included England, where GP practices implement the vaccination programme based on government guidance. However, there has been no study of how implementation takes place, which makes it difficult to identify organisational variation and thus limits the ability to recommend interventions to improve coverage. The aim of this study is to undertake a comparative process evaluation of the implementation of the routine vaccination programme at GP practices in England.

METHODS

We recruited a sample of geographically and demographically diverse GP practices through a national research network and collected quantitative and qualitative data as part of a Time-Driven Activity-Based Costing analysis between May 2017 and February 2018. We conducted semi-structured interviews with practice staff involved in vaccination, who then completed an activity log for 2 weeks. Interviews were transcribed and coded using a framework method.

RESULTS

Nine practices completed data collection from diverse geographic and socio-economic contexts, and 52 clinical and non-clinical staff participated in 26 interviews. Information relating to 372 vaccination appointments (233 childhood and 139 adult appointments) was captured using activity logs. We have defined a 14-stage care delivery value chain and detailed process map for vaccination. Areas of greatest variation include the method of reminder and recall activities, structure of vaccination appointments and task allocation between staff groups. For childhood vaccination, mean appointment length was 15.9 min (range 9.0-22.0 min) and 10.9 min for adults (range 6.8-14.1 min). Non-clinical administrative activities comprised 59.7% total activity (range 48.4-67.0%). Appointment length and total time were not related to coverage, whereas capacity in terms of appointments per eligible patient may improve coverage. Administrative tasks had lower fidelity of implementation.

CONCLUSIONS

There is variation in how GP practices in England implement the delivery of the routine vaccination programme. Further work is required to evaluate capacity factors in a wider range of practices, alongside other contextual factors, including the working culture within practices.