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

  • Conclusions changed
  • Review
  • Intervention

Authors

  • Roger E Thomas,

    Corresponding author
    1. University of Calgary, Department of Family Medicine, Faculty of Medicine, Calgary, AB, Canada
    • Roger E Thomas, Department of Family Medicine, Faculty of Medicine, University of Calgary, UCMC, #1707-1632 14th Avenue, Calgary, AB, T2M 1N7, Canada. rthomas@ucalgary.ca.

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  • Diane L Lorenzetti

    1. Faculty of Medicine, University of Calgary, Department of Community Health Sciences, Calgary, AB, Canada
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Abstract

Background

The effectiveness of interventions to increase the uptake of influenza vaccination in people aged 60 and older is uncertain.

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.

Search methods

We searched CENTRAL (2014, Issue 5), MEDLINE (January 1950 to May week 3 2014), EMBASE (1980 to June 2014), AgeLine (1978 to 4 June 2014), ERIC (1965 to June 2014) and CINAHL (1982 to June 2014).

Selection criteria

Randomised controlled trials (RCTs) of interventions to increase influenza vaccination uptake in people aged 60 and older.

Data collection and analysis

Two review authors independently assessed study quality and extracted influenza vaccine uptake data.

Main results

This update identified 13 new RCTs; the review now includes a total of 57 RCTs with 896,531 participants. The trials included community-dwelling seniors in high-income countries. Heterogeneity limited meta-analysis. The percentage of trials with low risk of bias for each domain was as follows: randomisation (33%); allocation concealment (11%); blinding (44%); missing data (49%) and selective reporting (100%).

Increasing community demand (32 trials, 10 strategies)

The interventions with a statistically significant result were: three trials (n = 64,200) of letter plus leaflet/postcard compared to letter (odds ratio (OR) 1.11, 95% confidence interval (CI) 1.07 to 1.15); two trials (n = 614) of nurses/pharmacists educating plus vaccinating patients (OR 3.29, 95% CI 1.91 to 5.66); single trials of a phone call from a senior (n = 193) (OR 3.33, 95% CI 1.79 to 6.22), a telephone invitation versus clinic drop-in (n = 243) (OR 2.72, 95% CI 1.55 to 4.76), a free groceries lottery (n = 291) (OR 1.04, 95% CI 0.62 to 1.76) and nurses educating and vaccinating patients (n = 485) (OR 152.95, 95% CI 9.39 to 2490.67).

We did not pool the following trials due to considerable heterogeneity: postcard/letter/pamphlets (16 trials, n = 592,165); tailored communications (16 trials, n = 388,164); customised letter/phone-call (four trials, n = 82,465) and client-based appraisals (three trials, n = 4016), although several trials showed the interventions were effective.

Enhancing vaccination access (10 trials, six strategies)

The interventions with a statistically significant result were: two trials (n = 2112) of home visits compared to clinic invitation (OR 1.30, 95% CI 1.05 to 1.61); two trials (n = 2251) of free vaccine (OR 2.36, 95% CI 1.98 to 2.82) and one trial (n = 321) of patient group visits (OR 24.85, 95% CI 1.45 to 425.32). One trial (n = 350) of a home visit plus vaccine encouragement compared to a home visit plus safety advice was non-significant.

We did not pool the following trials due to considerable heterogeneity: nurse home visits (two trials, n = 2069) and free vaccine compared to no intervention (two trials, n = 2250).

Provider- or system-based interventions (17 trials, 11 strategies)

The interventions with a statistically significant result were: two trials (n = 2815) of paying physicians (OR 2.22, 95% CI 1.77 to 2.77); one trial (n = 316) of reminding physicians about all their patients (OR 2.47, 95% CI 1.53 to 3.99); one trial (n = 8376) of posters plus postcards (OR 2.03, 95% CI 1.86 to 2.22); one trial (n = 1360) of chart review/feedback (OR 3.43, 95% CI 2.37 to 4.97) and one trial (n = 27,580) of educational outreach/feedback (OR 0.77, 95% CI 0.72 to 0.81).

Trials of posters plus postcards versus posters (n = 5753), academic detailing (n = 1400) and increasing staff vaccination rates (n = 26,432) were non-significant.

We did not pool the following trials due to considerable heterogeneity: reminding physicians (four trials, n = 202,264) and practice facilitators (three trials, n = 2183), although several trials showed the interventions were effective.

Interventions at the societal level

We identified no RCTs of interventions at the societal level.

Authors' conclusions

There are interventions that are effective for increasing community demand for vaccination, enhancing access and improving provider/system response. Heterogeneity limited pooling of trials.

Plain language summary

Interventions to increase influenza (flu) vaccination uptake for people aged 60 and older

Many health authorities recommend influenza vaccination of older people. However, vaccination uptake in people aged 60 and older varies across countries, socioeconomic and health-risk groups. It is important to identify effective interventions to increase influenza vaccination uptake.

We included 57 randomised controlled trials (RCTs) with 896,531 participants (all were community-dwelling seniors in high-income countries). Thirty-six trials compared the intervention to a no-intervention control group. Of the 57 RCTs, 33% randomised participants using a method that produced a low risk of bias and 61% used a method with an unclear risk. For missing data, 49% of the RCTs had a low risk of bias and 39% had an unclear risk.

Included trials all focused on increasing influenza vaccination uptake and did not report adverse effects. Trials were varied and we needed to use caution when pooling results.

Increasing community demand for vaccination (32 trials, 10 strategies)

Effective interventions in this comparison were a letter plus leaflet/postcard compared to a letter, nurses/pharmacists educating plus vaccinating patients, a phone call from a senior, a telephone invitation rather than clinic drop-in, free groceries lottery, and nurses educating and vaccinating patients. We were unable to pool trials of postcard/letter/pamphlets, communications tailored to patients, a customised letter/phone-call or client-based appraisals, but several trials of these interventions showed they were effective.

Enhancing vaccination access (eight trials, six strategies)

Effective interventions in this comparison were: home visits compared to an invitation to attend clinic, offers of free vaccine (in USA) and patient group-visits to physicians. We were unable to pool trials of nurse home-visits or free vaccine compared to no intervention (USA).

Improving provision by providers or the healthcare system (17 trials, 11 strategies)

Effective interventions in this comparison were: paying physicians, reminding physicians about all patients, posters plus postcards, chart review/feedback and educational outreach/feedback.

Trials of posters plus postcards versus posters, academic detailing and increasing staff vaccination rates showed that these interventions were not effective.

We did not pool the following trials due to considerable heterogeneity: reminding physicians (four trials, n = 202,264) and practice facilitators, although several of these trials showed the interventions were effective.

We found no low risk of bias RCTs or cohort studies that studied whether these interventions reduce morbidity or hospitalisation of seniors.

Evidence is current to 4 June 2014.

Societal level: No RCTs

Laienverständliche Zusammenfassung

Interventionen zur Erhöhung der Impfrate gegen Influenza (Grippe) für Menschen im Alter von 60 Jahren und älter

Viele Gesundheitsbehörden empfehlen Grippeschutzimpfungen für ältere Menschen. Jedoch ist die Nachfrage nach Impfungen bei Menschen ab 60 Jahren sehr unterschiedlich je nach Land, sozioökonomischem Status und gesundheitlicher Risikogruppe. Es ist sehr wichtig, wirksame Maßnahmen zur Erhöhung der Impfraten gegen Grippe zu finden.

Insgesamt nahmen wir 57 randomisierte, kontrollierte Studien (RCTs) mit 896.531 Teilnehmern (allesamt im eigenen Haushalt lebende Senioren in einkommensstarken Ländern) in die Übersichtsarbeit auf. In 36 Studien wurde die Intervention mit einer Kontrollgruppe verglichen, in der keine Intervention erfolgte. Von insgesamt 57 RCTs wählten 33 % der Studien ihre Teilnehmer zufällig nach eine Methode aus, die nur ein geringes Verzerrungsrisiko birgt. Bei 61 % der Studien war das Verzerrungsrisiko unklar. Im Hinblick auf fehlende Daten wiesen 49 % aller RCTs ein nur geringes und 39 % ein unklares Risiko auf.

Alle eingeschlossenen Studien konzentrierten sich auf die Erhöhung der Impfraten gegen Grippe (Influenza) und keine berichtete von negativen Auswirkungen. Die Studien zeigten Unterschiede, weshalb wir beim Zusammenfassen der Ergebnisse Vorsicht walten lassen mussten.

Erhöhung der Nachfrage nach Schutzimpfungen in der Bevölkerung (32 Studien, 10 Strategien)

Zu den wirksamen Maßnahmen in dieser Vergleichskategorie gehörten ein Brief kombiniert mit einer Broschüre/Postkarte im Vergleich zu nur einem Brief, Krankenpfleger/Apotheker für die Aufklärung und die Impfung von Patienten, ein Telefonanruf von einer dienstälteren Person, eine telefonische Einladung anstelle eines Sprechstundenbesuchs, eine Lebensmittel-Verlosung sowie Pflegepersonal, das Patienten aufklärt und impft. Es war uns unmöglich, die Studien zu Postkarte/Brief/Broschüre, auf Patienten zugeschnittene Kommunikation, individualisierte Briefen/Telefonanrufe oder kundenspezifischen Beurteilungen zusammenzufassen, jedoch konnten einige Studien deren Wirksamkeit nachweisen.

Verbesserung des Zugangs zu Schutzimpfungen (8 Studien, 6 Strategien)

Zu den wirksamen Interventionen in dieser Vergleichskategorie gehörten Hausbesuche im Vergleich zu Einladungen in die Sprechstunde, Angebote für kostenlose Impfungen (in den USA) und Gruppenbesuche von Patienten bei Ärzten. Es war uns unmöglich, die Studien zu Hausbesuchen von Pflegepersonal oder kostenlosen Impfungen im Vergleich zu keiner Intervention (USA) zusammenzufassen.

Verbesserung der Versorgung durch Leistungserbringer oder das Gesundheitssystem (17 Studien, 11 Strategien)

Zu den wirksamen Interventionen in dieser Vergleichskategorie gehörten die Bezahlung von Ärzten, Ärzte an alle Patienten erinnern, Poster plus Postkarten, Durchsicht der Krankenakten/Feedback sowie Schulungsinitativen/Feedback.

Studien, die Poster plus Postkarten mit Postern allein verglichen, eine Schulung beinhalteten und die Impfraten des Personals steigern sollten, zeigten, dass diese Maßnahmen nicht wirksam waren.

In den folgenden Gruppen haben wir die Studien aufgrund starker Heterogenität nicht zusammengefasst: Erinnerung von Ärzten (vier Studien, n = 202.264) und Einsatz von Beratern in der Praxis (drei Studien, n = 2183), obwohl einige dieser Studien die Wirksamkeit der Maßnahmen nachweisen konnten.

Wir konnten keine RCTs oder Kohortenstudien mit geringem Verzerrungsrisiko finden, in denen untersucht wurde, ob diese Maßnahmen die Häufigkeit der Erkrankungen (Morbidität) oder die Zahl der Krankenhausaufenthalte von Senioren reduzierten.

Die Ergebnisse sind auf dem Stand vom 4. Juni 2014.

Gesellschaftliche Ebene: keine RCTs

Anmerkungen zur Übersetzung

Cochrane Schweiz