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

Thomas RE and Lorenzetti DL. (2018)

Cochrane Database of Systematic Reviews - 10.1002/14651858

Evidence Categories

  • Care setting: Primary care
  • Population group: Older adults
  • Intervention: Other Intervention
  • Intervention: Patient incentives
  • Intervention: Provider incentives
  • Intervention: Reminder/recall (provider)
  • Intervention: Reminder/recall (patient)
  • Intervention: Health literacy
  • Intervention: Provider education
  • Intervention: Improving access
  • Outcome: Uptake of vaccinations

Type of Evidence

Systematic Review

Aims

"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."

Findings

The authors state:

"We included 3 new RCTs for this update (total 61 RCTs; 1,055,337 participants). Trials involved people aged 60 years and older living in the community in high‐income countries. Heterogeneity limited some meta‐analyses. We assessed studies as at low risk of bias for randomisation (38%), allocation concealment (11%), blinding (44%), and selective reporting (100%). Half (51%) had missing data. We assessed the evidence as low‐quality. We identified three levels of intervention intensity: low (e.g. postcards), medium (e.g. personalised phone calls), and high (e.g. home visits, facilitators).

Increasing community demand (12 strategies, 41 trials, 53 study arms, 767,460 participants)

One successful intervention that could be meta‐analysed was client reminders or recalls by letter plus leaflet or postcard compared to reminder (odds ratio (OR) 1.11, 95% confidence interval (CI) 1.07 to 1.15; 3 studies; 64,200 participants). Successful interventions tested by single studies were patient outreach by retired teachers (OR 3.33, 95% CI 1.79 to 6.22); invitations by clinic receptionists (OR 2.72, 95% CI 1.55 to 4.76); nurses or pharmacists educating and nurses vaccinating patients (OR 152.95, 95% CI 9.39 to 2490.67); medical students counselling patients (OR 1.62, 95% CI 1.11 to 2.35); and multiple recall questionnaires (OR 1.13, 95% CI 1.03 to 1.24).

Some interventions could not be meta‐analysed due to significant heterogeneity: 17 studies tested simple reminders (the 95% CI was entirely above unity in 11 trials implying all 11 interventions increased vaccination rates); 16 tested personalised reminders (the 95% CI was entirely above unity in 12 trials implying all 12 interventions increased vaccination rates ); 2 investigated customised compared to form letters (the 95% CI was above unity in both trials implying both interventions increased vaccination rates); and 4 studies examined the impact of health risk appraisals (the 95% CI was above unity in all 4 trials implying all 4 interventions increased vaccination rates). One study of a lottery for free groceries was not effective.

Enhancing vaccination access (6 strategies, 8 trials, 10 arms, 9353 participants)

We meta‐analysed results from 2 studies of home visits (OR 1.30, 95% CI 1.05 to 1.61), and 2 studies that tested free vaccine compared to patient payment for vaccine (OR 2.36, 95% CI 1.98 to 2.82). We were unable to conduct meta‐analyses of 2 studies of home visits by nurses plus a physician care plan (the 95% CI was entirely above unity in both trials implying both interventions increased vaccination rates) and 2 studies of free vaccine compared to no intervention (the 95% CI was entirely above unity in both trials implying both interventions increased vaccination rates). One study of group visits (OR 27.2, 95% CI 1.60 to 463.3) was effective, and 1 study of home visits compared to safety interventions was not.

Provider‐ or system‐based interventions (11 strategies, 15 trials, 17 arms, 278,524 participants)

One successful intervention that could be meta‐analysed focused on payments to physicians (OR 2.22, 95% CI 1.77 to 2.77). Successful interventions tested by individual studies were: reminding physicians to vaccinate all patients (OR 2.47, 95% CI 1.53 to 3.99); posters in clinics presenting vaccination rates and encouraging competition between doctors (OR 2.03, 95% CI 1.86 to 2.22); and chart reviews and benchmarking to the rates achieved by the top 10% of physicians (OR 3.43, 95% CI 2.37 to 4.97).

We were unable to meta‐analyse 4 studies that looked at physician reminders (the 95% CI was entirely above unity in 3 trials implying all 3 interventions increased vaccination rates) and 3 studies of facilitator encouragement of vaccination (the 95% CI was entirely above unity in 2 trials implying both interventions increased vaccination rates). Interventions that were not effective were: comparing letters on discharge from hospital to letters to general practitioners; posters plus postcards versus posters alone; educational reminders, academic detailing, and peer comparisons compared to mailed educational materials; educational outreach plus feedback to teams versus written feedback; and an intervention to increase staff vaccination rates."

Conclusions

The authors state:

"We identified interventions that demonstrated significant positive effects of low (postcards), medium (personalised phone calls), and high (home visits, facilitators) intensity that increase community demand for vaccination, enhance access, and improve provider/system response. The overall GRADE assessment of the evidence was moderate quality. Conclusions are unchanged from the 2014 review."