ABSTRACT
BACKGROUND: Vaccination coverage for influenza in the elderly remains low when the physician is the only person responsible for immunization. Integration of other health care workers may improve the coverage rate of at-risk groups.
OBJECTIVES: To estimate vaccination coverage rate by using a strategy based on the systematic intervention of a health care professional proposing vaccination before the doctor’s consultation, to evaluate the changes in coverage rates before and after introduction of this strategy, and to assess the feasibility of this intervention and the achieved coverage rate in family physician offices
STUDY DESIGN: Prospective study in a medical outpatient clinic and 5 family physician practices in Switzerland.
POPULATION: Participants consisted of all patients 65 years or older attending a medical outpatient clinic during the vaccination period in 1999 (n = 401), patients 65 years or older regularly followed at a medical outpatient clinic in 1998 and 1999 (n = 195), and patients 65 years or older presenting to 5 family physician offices in 1999 (n = 598).
OUTCOME MEASURED: Rates of vaccination coverage.
RESULTS: Among all participants, vaccination coverage rates in 1999 were 85% at the medical outpatient clinic and 83% in family physician offices. Among participants regularly followed at the medical outpatient clinic, vaccination coverage increased from 48% in 1998 to 76% in 1999. Rates of refusal were 9% at the medical outpatient clinic and 14% in the family physician offices.
CONCLUSIONS: The systematic intervention of a health care professional to suggest vaccination before the doctor’s visit is an effective measure to achieve high coverage rate. Such a strategy also improves outpatient clinic or private practice efficiency by reducing pressures on physicians.
Annual influenza vaccination is recommended for all persons 65 years and older.1-3 Unfortunately, coverage rate remains low. In Switzerland during the winter season of 1998-1999, estimated vaccination coverage was only 8% in the general population.4 In institutionalized elderly patients, coverage was 37% in the same study. In 1994, the rate estimated from a telephonic survey was only 36% in elderly patients in Geneva.5 Since then, an active promotional campaign among the public led to a coverage rate among persons older than 65 years of about 60% (L. Toscani, personal communication 2000), a rate that approaches that in the United States (67%).6
Apart from making the general population or the target groups aware of the importance of the vaccination to prevent influenza complications, a strategy commonly used to improve coverage consists of training the physicians. However, their knowledge about vaccination does not always explain their behavior; although doctors know that vaccines are efficacious and are convinced that they should offer vaccination to all at-risk patients, they do not propose it to all eligible patients.7 Reimbursement of vaccines, as done since 1996 in Switzerland, does not seem to increase vaccination rates.8
At the Medical Outpatient Clinic, University of Lausanne, we recorded the influenza vaccination coverage rate of patients 65 years and older who were followed regularly in 1997, after an intensive education of physicians including a state-of-the-art lecture and interactive seminars; the same was done in 1998, but letters also were sent to all patients who did not have an appointment during the vaccination period. The vaccination coverage increased from 39% in 1997 to 47% in 1998, presumably because of the reminder letter.9 This rate was still unsatisfactory. We postulated that the main reason for low rate of influenza vaccination coverage of elderly patients was the physicians’ omission to propose the vaccination rather than the patients’ refusal. To test this hypothesis and to improve the coverage at the same time, we introduced at the medical outpatient clinic a strategy coupling a systematic intervention of a medical person allowed to do injections (medical student) with the existing educational program and reminder letters. A similar method (except for the reminder letters) was applied in 5 general practices, with the receptionists providing the information and the paramedical staff performing the vaccination.
The specific objectives were (1) to estimate vaccination coverage rate by using a strategy based on the systematic intervention of a health care professional proposing vaccination before the doctor’s consultation, (2) to evaluate the changes in coverage rates before and after introduction of the strategy, and (3) to assess the feasibility of this intervention and the achieved coverage rate in family physicians’ offices.
Methods
The protocol was approved by the ethical committee of the Department of Internal Medicine, University Hospital, Lausanne. Table 1 summarizes the study profile, populations, strategy applied, and outcome measures that are described below. The study took place in the Medical Outpatient Clinic, University of Lausanne, which provides medical care to the general population (attendees are biased toward young people, refugees, foreigners, and elderly individuals with low incomes); and in 1 rural general practice office (Orbe) and 2 urban general practice offices (Neuchâtel), with 5 physicians.