Influenza-like illness and antimicrobial prescribing in Australian general practice from 2015 to 2017: a national longitudinal study using the MedicineInsight dataset

Respiratory syncytial virus vaccination strategies for older Canadian adults: a cost-utility analysis

BACKGROUND

Respiratory syncytial virus (RSV) vaccines could reduce disease burden and costs in older Canadian adults, but vaccination program cost-effectiveness is unknown. We evaluated the cost-effectiveness of different age cut-offs for RSV adult vaccination programs, with or without a focus on people with higher disease risk due to chronic medical conditions.

METHODS

We developed a static individual-based model of medically attended RSV disease to compare alternative age-, medical risk-, and age-plus medical risk-based vaccination policies. The model followed a multiage population of 100 000 people aged 50 years and older. Vaccine characteristics were based on RSV vaccines authorized in Canada as of May 2024, with vaccine protection assumed to last 2 years (or 3 years in scenario analyses). We calculated sequential incremental cost-effectiveness ratios in 2023 Canadian dollars per quality-adjusted life year (QALY) from the health-system and societal perspectives, discounted at 1.5%.

RESULTS

Although all vaccination strategies averted medically attended RSV disease, universal age-based strategies were not an efficient use of resources compared with medical risk-based strategies. Vaccinating adults aged 70 years and older with 1 or more chronic medical condition was the optimal strategy for a cost-effectiveness threshold of $50 000 per QALY. Results were sensitive to assumptions about vaccine price, but medical risk-based approaches remained optimal compared with age-based strategies, even when vaccine prices were low. Findings were robust to a range of alternative assumptions.

INTERPRETATION

Vaccination programs for RSV in some groups of older Canadians with underlying medical conditions are likely cost-effective. These findings can inform the design of vaccination programs.

Temporal trends in antibiotic prescribing and serious and nonserious infections in children presenting to general practice: a registry-based longitudinal cohort study of 162 507 individuals

BACKGROUND

It is crucial to understand the trends in paediatric antibiotic prescribing and serious and nonserious infections to improve antibiotic prescribing practices for children in ambulatory care.

OBJECTIVES

Assessing trends in paediatric antibiotic prescribing and infection incidence in general practice from 2002 to 2022.

METHODS

In this retrospective cohort study using INTEGO network data from 162 507 patients in Flanders (Belgium), we calculated antibiotic prescribing rates and proportions alongside incidence rates of serious and nonserious infections, stratified by age (0-1, 2-6, 7-12 years) and municipality. We performed autoregressive moving average time-series analyses and seasonality analyses.

RESULTS

From 2002 to 2022, antibiotic prescribing rate decreased significantly: 584/1000 person-years (PY) (95% CI 571-597) to 484/1000PY (95% CI 478-491); so did antibiotic overall prescribing proportion: 46.3% (95% CI 45.1-47.6) to 23.3% (95% CI 22.9-23.7) (59.3% amoxicillin and 17.8% broad spectrum). Prescribing proportions dropped significantly for nonserious (45.6% to 20.9%) and increased for serious infections (64.1% to 69.8%). Proportions significantly dropped for acute suppurative otitis media (74.7% to 64.1%), upper respiratory tract infections (44.9% to 16.6%), bronchitis/bronchiolitis (73.6% to 44.1%) and acute tonsillopharyngitis (59.5% to 21.7%), while significantly increasing for pneumonia (65.2% to 80.2%). Nonserious and serious infection incidence rates increased from 785/1000PY and 34.2/1000PY to 1223/1000PY and 64.1/1000PY, respectively. Blood and CRP testing proportions increased significantly.

CONCLUSIONS

Antibiotic prescribing in general practice for children declined from 2002 to 2022. Further targeted antibiotic stewardship initiatives are needed to reduce the use of broad-spectrum antibiotics and antibiotic prescribing for conditions such as otitis media and bronchitis/bronchiolitis.

Influenza presentations and use of neuraminidase inhibitors by Australian general practice registrars: a cross-sectional analysis from the ReCEnT study

OBJECTIVE

This study aims to establish prevalence and associations of (1) influenza and influenza-like illness (IILI) presentations to Australian general practice (GP) registrars (trainees) and (2) the use of neuraminidase inhibitors (NAIs) by GP registrars for new presentations of IILI, for the 10 years leading up to the COVID-19 pandemic in Australia (2010-2019).

DESIGN

This was a cross-sectional analysis of the Registrar Clinical Encounters in Training ongoing inception cohort study of the in-consultation experience and clinical behaviours of GP registrars. Data are collected by individual registrars three times (from 60 consecutive consultations each time) at 6 monthly intervals. Data include diagnoses/problems managed and medicines prescribed, along with multiple other variables. Univariate and multivariable logistic regression was used to establish associations of registrars seeing patients with IILI and of prescribing NAIs for IILI.

SETTING

Teaching practices within the Australian general practitioner specialist vocational training programme. Practices were located in five of the six Australian states (plus one territory).

PARTICIPANTS

GP registrars in each of their three compulsory 6-month GP training terms.

RESULTS

From 2010 to 2019, 0.2% of diagnoses/problems seen by registrars were IILI. 15.4% of new IILI presentations were prescribed an NAI. IILI diagnoses were less likely in younger (0-14) and older (65+) age groups, and more likely in an area of higher socioeconomic advantage. There was considerable variation in NAI prescribing between regions. There was no significant association of prescribing NAIs with age or Aboriginal and/or Torres Strait Islander patients.

CONCLUSIONS

IILI presentations were more likely among working-age adults and not among those groups at higher risk. Similarly, high-risk patient groups who would benefit most were not more likely to receive NAIs. The epidemiology and management of IILI has been distorted by the COVID-19 pandemic, but the burden of influenza in vulnerable populations must not be overlooked. Appropriately targeted antiviral therapy with NAIs influences outcomes for vulnerable patients. General practitioners manage the majority of IILI in Australia, and understanding GP IILI presentation and NAI prescribing patterns is a key first step to enabling sound and rational prescribing decisions for better patient outcomes.

General practice management of depression among patients with coronary heart disease in Australia

BACKGROUND

Incident depression is associated with coronary heart disease (CHD) and increased morbidity and mortality. Treatment of depression with antidepressants and psychotherapy can be beneficial for these patients to reduce the risk of further CHD events. Ongoing management of CHD and depression mainly occurs in the community, but little is known about the identification and care of patients with comorbid CHD and depression in general practice. This study explores the prescription of antidepressants for these patients by sociodemographic variables.

METHODS

This is an open cohort study with de-identified data based on electronic medical records of 880,900 regular patients aged 40 + years from a national general practice database in Australia (MedicineInsight). Data from 2011-2018 was used to classify patients as newly recorded CHD (CHD recorded in 2018 but not in previous years), previously recorded CHD (CHD recorded between 2011-2017) or no recorded history of CHD. Antidepressant prescribing in 2018 considered active ingredients and commercial brand names. The association between sociodemographic variables and antidepressant prescribing was tabulated according to the CHD status.

RESULTS

The proportion of current depression among patients with newly recorded CHD was 11.4% (95%CI 10.3-12.6), 10.5% among those with previously recorded CHD (95%CI 10.0-11.1) and 9.6% among those with no recorded history of CHD (95%CI 9.2-10.1). Antidepressant prescribing was slightly higher among those with newly recorded CHD (76.4%; 95%CI 72.1-80.6) than among those with previously recorded CHD (71.6%; 95%CI 69.9-73.2) or no history of CHD (69.5%; 95%CI 68.6-70.4). Among males with newly recorded CHD and depression, antidepressant prescribing was more frequent in major cities or inner regional areas (~ 81%) than in outer/remote Australia (66.6%; 95% CI 52.8-80.4%).

CONCLUSIONS

Although antidepressant prescribing was slightly greater in those with newly recorded CHD compared to those with depression alone, its clinical significance is uncertain. Much larger differences in prescribing were seen by geographic location and could be addressed by innovations in clinical practice.

Chronic diseases and variations in rates of antimicrobial use in the community: a population-based analysis of linked administrative data in Quebec, Canada, 2002-2017

BACKGROUND

Chronic diseases may increase risk of infection and complications from infections; fear of these risks may lower clinicians' tolerance threshold for the prescription of antimicrobials, thus increasing the risk of selecting resistant bacteria. We sought to describe rates of antimicrobial use in Quebec and measure the association between chronic diseases and utilization rates.

METHODS

Using the Quebec Integrated Chronic Disease Surveillance System, we analyzed data of people covered by the public drug insurance plan in 2002-2017. Based on delivered prescriptions, we described trends in antimicrobial use in the population, and per category of select chronic diseases (i.e., none, respiratory, cardiovascular, diabetes, mental disorder), according to age group (0-17 yr, 18-64 yr and ≥ 65 yr). We computed ratios of extended-to-narrow-spectrum antimicrobials in 2014-2017. We used robust Poisson regression to quantify the association between chronic diseases and rates of antimicrobial use among children and adults (≥ 18 yr).

RESULTS

Between 2002 and 2017, 4 231 724 prescriptions were received over 6 653 473 individual-years among children; 1 367 492 (20.6%) individual-years had at least 1 chronic disease. Among adults aged 18-64 years, 13 365 577 prescriptions were received over 24 935 592 individual-years; 9 533 493 (38.2%) individual-years had at least 1 chronic disease. Among adults 65 years or older, 11 689 365 prescriptions were received over 15 927 342 individual-years; 12 743 588 (80.0%) individual-years had least 1 chronic disease. Antimicrobial use decreased among children, remained stable among younger adults and increased among older adults. Trends were consistent across chronic disease categories in children and older adults. In 2014-2017, 19.9% of children, 39.1% of younger adults and 79.7% of older adults had at least 1 chronic disease. Claims for extended-spectrum antimicrobials were frequent in all age and chronic disease groups, relative to narrow-spectrum antimicrobials (ratios from 3.1:1 to 14.6:1). Antimicrobial use was higher among people with respiratory diseases (adults: relative rate [RR] 2.09, 95% confidence interval [CI] 2.07-2.10; children: RR 1.62, 95% CI 1.59-1.65), mental health diagnoses (adults: RR 1.48, 95% CI 1.46-1.49; children: RR 1.22, 95% 1.20-1.24), diabetes (adults: RR 1.40, 95% CI 1.28-1.41; children: RR 2.02, 95% CI 1.58-2.57) and cardiovascular diseases (adults: RR 1.31, 95% CI 1.30-1.32), compared with those with none of the studied chronic diseases.

INTERPRETATION

During the study period, large proportions of antimicrobial prescriptions were for people with chronic diseases, across the age spectrum. Interventions to reduce antimicrobial use should be tailored for these populations.

Chronic diseases and compliance with provincial guidelines for outpatient antibiotic prescription in cases of otitis media and respiratory infections: a population-based study of linked data in Quebec, Canada, 2010-2017

BACKGROUND

In Quebec, antibiotic use is higher among outpatients with chronic diseases. We sought to measure compliance with provincial guidelines for the treatment of otitis media and common respiratory infections, and to measure variations in compliance according to the presence of certain chronic diseases.

METHODS

We conducted a population-based study of linked data on antibiotic dispensing covered by the public drug insurance plan between April 2010 and March 2017. We included patients who had consulted a primary care physician within 2 days before being dispensed an antibiotic for an infection targeted by provincial guidelines, including bronchitis in patients with chronic obstructive pulmonary disease, otitis media, pharyngitis, pneumonia and sinusitis. We computed proportions of prescriptions compliant with guidelines (use of recommended antibiotic for children, and use of recommended antibiotic and dosage for adults) by age group (children or adults) and chronic disease (respiratory, cardiovascular, diabetes, mental disorder or none). We measured the impact of chronic diseases on compliance using robust Poisson regression.

RESULTS

We analyzed between 14 677 and 198 902 prescriptions for each infection under study. Compliance was greater than 87% among children, but was lower among children with asthma (proportion ratios between 0.97 and 1.00). In adults, the chosen antibiotic was compliant for at least 73% of prescriptions, except for pharyngitis (≤ 61%). Accounting for dosage lowered compliance to between 31% and 61%. Compliance was lower in the presence of chronic diseases (proportion ratios between 0.94 and 0.98).

INTERPRETATION

It is possible that prescribing noncompliant prescriptions was sometimes appropriate, but the high frequency of noncompliance suggests room for improvement. Given that variations associated with chronic diseases were small, disease-specific guidelines for antibiotic prescriptions are likely to have a limited impact on compliance.

Antimicrobial resistance (AMR) in COVID-19 patients: a systematic review and meta-analysis (November 2019-June 2021)

BACKGROUND

Pneumonia from SARS-CoV-2 is difficult to distinguish from other viral and bacterial etiologies. Broad-spectrum antimicrobials are frequently prescribed to patients hospitalized with COVID-19 which potentially acts as a catalyst for the development of antimicrobial resistance (AMR).

OBJECTIVES

We conducted a systematic review and meta-analysis during the first 18 months of the pandemic to quantify the prevalence and types of resistant co-infecting organisms in patients with COVID-19 and explore differences across hospital and geographic settings.

METHODS

We searched MEDLINE, Embase, Web of Science (BioSIS), and Scopus from November 1, 2019 to May 28, 2021 to identify relevant articles pertaining to resistant co-infections in patients with laboratory confirmed SARS-CoV-2. Patient- and study-level analyses were conducted. We calculated pooled prevalence estimates of co-infection with resistant bacterial or fungal organisms using random effects models. Stratified meta-analysis by hospital and geographic setting was also performed to elucidate any differences.

RESULTS

Of 1331 articles identified, 38 met inclusion criteria. A total of 1959 unique isolates were identified with 29% (569) resistant organisms identified. Co-infection with resistant bacterial or fungal organisms ranged from 0.2 to 100% among included studies. Pooled prevalence of co-infection with resistant bacterial and fungal organisms was 24% (95% CI 8-40%; n = 25 studies: I2 = 99%) and 0.3% (95% CI 0.1-0.6%; n = 8 studies: I2 = 78%), respectively. Among multi-drug resistant organisms, methicillin-resistant Staphylococcus aureus, carbapenem-resistant Acinetobacter baumannii, Klebsiella pneumoniae, Pseudomonas aeruginosa and multi-drug resistant Candida auris were most commonly reported. Stratified analyses found higher proportions of AMR outside of Europe and in ICU settings, though these results were not statistically significant. Patient-level analysis demonstrated > 50% (n = 58) mortality, whereby all but 6 patients were infected with a resistant organism.

CONCLUSIONS

During the first 18 months of the pandemic, AMR prevalence was high in COVID-19 patients and varied by hospital and geography although there was substantial heterogeneity. Given the variation in patient populations within these studies, clinical settings, practice patterns, and definitions of AMR, further research is warranted to quantify AMR in COVID-19 patients to improve surveillance programs, infection prevention and control practices and antimicrobial stewardship programs globally.

Risk Factors of Influenza-Associated Respiratory Illnesses Reported to a Sentinel Hospital of Lahore, Pakistan: 2015-2016

Epidemiological data about determinants of influenza A virus (IAV) in the Pakistani population is scarce. We aimed to conduct a prospective hospital-based active surveillance study from October 2015 to May 2016 to identify potential risk factors associated with IAV infection among patients with influenza-like illness (ILI) and severe acute respiratory illness (SARI). Surveillance was conducted in Lahore General Hospital, selected as a sentinel site in Lahore District, Pakistan. Nasal/throat samples were collected along with epidemiological and clinical data from enrolled patients. Real-time reverse-transcription polymerase chain reaction (rRT-PCR) was performed to identify IAV and its subtypes (H1N1pdm09, H3N2). Data were analyzed to determine risk factors and risk markers associated with IAV infections. A total of 311 suspected ILI and SARI cases were enrolled in the study, and among these 50 were IAV-positive. Of these 50 confirmed cases of IAV, 14 were subtyped as H1N1pdm09 and 15 were H3N2; the remaining 21 were untyped. A final multivariable model identified four independent risk factors/markers for IAV infection: exposure history to ILI patients within last 7 days and gender being male were identified as risk factors of IAV infection, while use of antibiotics prior to hospital consultation and presence of fever were identified as risk markers. We concluded that adopting nonpharmaceutical interventions like hand hygiene, masks, social distancing, and where possible, avoiding identified risk factors could decrease the risk of IAV infection and may prevent imminent outbreaks of IAV in the community.

Association Between the Use of Antibiotics, Antivirals, and Hospitalizations Among Patients With Laboratory-confirmed Influenza

BACKGROUND

Clinicians may prescribe antibiotics to influenza patients at high risk for bacterial complications. We explored the association between antibiotics, antivirals, and hospitalization among people with influenza.

METHODS

A retrospective cohort study of patients with confirmed influenza with encounters during January 2011-January 2019 was conducted using data from the Veterans Affairs Informatics and Computing Infrastructure (VINCI). We compared inpatient hospitalizations (all-cause and respiratory) within 30 days of influenza diagnosis between 4 patient cohorts: (1) no treatment (n = 4228); (2) antibiotic only (n = 671); (3) antiviral only (n = 6492); and (4) antibiotic plus antiviral (n = 1415). We estimated relative risk for hospitalization using Poisson generalized linear model and robust standard errors.

RESULTS

Among 12 806 influenza cases, most were white men (mean age, 57-60 years). Those with antivirals only, antibiotic plus antiviral, and antibiotics only all had a statistically significant lower risk of all-cause and respiratory hospitalization compared to those without treatment. Comparing the antibiotic plus antiviral cohort to those who were prescribed an antiviral alone, there was a 47% lower risk for respiratory hospitalization (relative risk, 0.53 [95% confidence interval, .31-.94]), and no other statistical differences were detected.

CONCLUSIONS

Those prescribed an antiviral, antibiotic, or both had a lower risk of hospitalization within 30 days compared to those without therapy. Furthermore, intervention with both an antibiotic and antiviral had a lower risk of respiratory hospitalization within 30 days compared to those with an antiviral alone. Importantly, the absolute magnitude of decreased risk with antibiotic plus antiviral therapy is small and must be interpreted within the context of the overall risk of antibiotic usage.

Trends in long-term opioid prescriptions for musculoskeletal conditions in Australian general practice: a national longitudinal study using MedicineInsight, 2012-2018

OBJECTIVE

Describe trends and patterns in long-term opioid prescriptions among adults with musculoskeletal conditions (MSK).

DESIGN

Interrupted time-series analysis based on an open cohort study.

SETTING

A representative sample of 402 Australian general practices contributing data to the MedicineInsight database.

PARTICIPANTS

811 174 patients aged 18+ years with an MSK diagnosis and three or more consultations in any two consecutive years between 2012 and 2018. Males represented 44.5% of the sample, 28.4% were 65+ years and 1.9% were Aboriginal or Torres Strait Islanders.

PRIMARY AND SECONDARY OUTCOME MEASURES

Annual prevalence and cumulative incidence (%) of long-term opioid prescribing (3+ prescriptions in 90 days) among patients with an MSK. Average duration of these episodes in each year between 2012 and 2018.

RESULTS

The prevalence of long-term opioid prescribing increased from 5.5% (95% CI 5.2 to 5.8) in 2012 to 9.1% (95% CI 8.8 to 9.7) in 2018 (annual change OR 1.09, 95% CI 1.08 to 1.09), but a slightly lower incidence was observed in 2018 (3.0% vs 3.6%-3.8% in other years; annual change OR 0.99, 95% CI 0.98 to 0.99). The incidence was between 37% and 52% higher among practices located in rural Australia or lower socioeconomic areas. Individual risk factors included increasing age (3.4 times higher among those aged 80+ years than the 18-34 years group in 2012, increasing to 4.8 times higher in 2018), identifying as Aboriginal or Torres Strait Islander (1.7-1.9 higher incidence than their peers), or living in disadvantaged areas (36%-57% more likely than among those living in wealthiest areas). Long-term opioid prescriptions lasted in average 287-301 days between 2012 and 2016, reducing to 229 days in 2017 and 140 days in 2018. A longer duration was observed in practices from more disadvantaged areas and females in all years, except in 2018.

CONCLUSIONS

The continued rise in the prevalence of long-term opioid prescribing is of concern, despite a recent reduction in the incidence and duration of opioid management.

Blood pressure control in Australian general practice: analysis using general practice records of 1.2 million patients from the MedicineInsight database

INTRODUCTION

Hypertension is mostly managed in primary care. This study investigated the prevalence of diagnosed hypertension in Australian general practice and whether hypertension control is influenced by sociodemographic characteristics, duration since diagnosis or prescription of antihypertensive medications.

METHODS

Cross-sectional study using a large national database of electronic medical records of patients attending general practice in 2017 (MedicineInsight).

RESULTS

Of 1.2 million 'regular' patients (one or more consultations per year in every year from 2015 to 2017), 39.8% had a diagnosis of hypertension (95% confidence interval 38.7-40.9). Of these, 85.3% had their blood pressure (BP) recorded in 2017, and 54.9% (95% confidence interval 54.2-55.5) had controlled hypertension (<140/90 mmHg). BP control was lower in females (54.1%) compared with males (55.7%) and in the oldest age group (52.0%), with no differences by socioeconomic status. Hypertension control was lower among 'regular' patients recently diagnosed (6-12 months = 48.6% controlled) relative to those more than 12 months since diagnosis (1-2 years = 53.6%; 3-5 years 55.5%; >5 years = 55.0%). Among recently diagnosed 'regular' patients, 59.2% had no record of being prescribed antihypertensive therapy in the last 6 months of the study, of which 44.3% had controlled hypertension. For those diagnosed more than 5 years ago, 37.4% had no record of being prescribed antihypertensive patients, and 56% had normal BP levels.

CONCLUSION

Although the prevalence of hypertension varied by socidemographics, there were no differences in BP assessment or control by socioeconomic status. Hypertension control remains a challenge in primary care, and electronic medical records provide an opportunity to assess hypertension management.

Influenza-like illness in Australia: A comparison of general practice surveillance system with electronic medical records

Surveillance systems are fundamental to detect infectious disease outbreaks and guide public health responses. We compared influenza-like illness (ILI) rates for 2015-2017 using data from the Australian Sentinel Practice Research Network (ASPREN) and electronic medical records from 550 general practices across Australia (MedicineInsight). There was a high correlation between both sources (r = .84-.95) and a consistent higher ILI rate in 2017. Both sources also showed higher ILI rates among women and patients aged 20-49 years. The use of routinely collected electronic medical records like those in MedicineInsight could be used to complement active influenza surveillance systems in Australia.

Pneumococcal vaccination uptake among patients aged 65 years or over in Australian general practice

In Australia, pneumococcal vaccine is provided free to all adults aged ≥65 years and Indigenous people aged 15–65 years, and is subsidized for non-Indigenous adults <65 years of age with risk factors. This study aimed to explore pneumococcal vaccination uptake in older patients attending 550 Australian general practices from 2010–2017 by patient sociodemographics, presence of comorbidities and practice characteristics. Study 1: a cross-sectional analysis of ‘active’ patients aged ≥65 years in each year was performed to calculate annual pneumococcal vaccination uptake. Study 2: a cohort of 58,589 ‘every year’ patients aged 60–65 years in 2010 was analyzed to identify the number of patients immunized during the study period. Logistic regression models assessed associations between vaccination, patient and practice characteristics. Annual pneumococcal vaccine uptake varied by patient’s age (65–74 or ≥75 years), presence of comorbidities and regularity of practice visits (range 36% to 76%), and it declined slowly from 2011–2016 amongst all groups. Cohort analyses showed that 69% of those aged 60–65 years in 2010 had a recorded pneumococcal vaccination by 2017 (peak age of vaccination = 66 years), and vaccination was more likely among those with comorbidities, ex-smokers and frequent attenders to practices. Findings demonstrate that the NPS MedicineInsight database provides estimates of vaccination uptake consistent with past surveys, reproducible every year and at low cost. It has the advantage of additional clinical information compared to the Australian Immunization Register. Whilst vaccination uptake was adequate among ‘every year’ patients, interventions are needed to improve pneumococcal vaccination for all older Australians.

Impact of funding influenza vaccination on coverage among Australian children: a national study using MedicineInsight, a large general practice database

Influenza contributes to morbidity and mortality worldwide. Children are at a higher risk of influenza-related complications and vaccination promotes direct protection and limits transmission. This study aimed to explore influenza vaccination coverage among children in Australian general practice from 2015 to 2018, and patterns in coverage before and after the implementation of state-funded immunization programs. Data from 196,520 'active' patients (3+ consultations in two consecutive years) aged <5 years from 542 Australian general practices were included (MedicineInsight database). Logistic regression models were used to identify associations between vaccination with patient and practice characteristics. The overall vaccination coverage increased more than five times from 2015 (3.9%) to 2018 (19.6%) and varied among states. Children attending practices located in the wealthiest areas were more likely to receive the vaccine and appeared to benefit most from the funding, as the increase in coverage from 2017 to 2018 was greater among them than those attending practices in the least advantaged areas (17 vs. 11 percentage points, respectively). This relationship was not evident when analyzing the patient's socioeconomic level. In conclusion, free influenza vaccinations increase coverage in at-risk populations. Promotional campaigns may be required to maintain higher coverage and target practices located in low-income areas.