Study populations
To estimate vaccination coverage rate after implementing the new strategy in the medical outpatient clinic (objective 1), we included all patients 65 years and older attending the 1999 vaccination period (401 patients). To evaluate the changes in coverage rates before and after the introduction of the strategy (objective 2), we included patients 65 years and older who were followed regularly at medical outpatient clinic in 1998 and 1999 (195 patients). To assess the feasibility of this intervention and the achieved coverage rate in family physicians’ offices, we included all patients 65 years and older attending family physicians’ offices in 1999 (598 patients).
Medical outpatient clinic procedures
Pre-intervention season (1998). During the vaccination period (mid-October to mid-December), all patients 65 years and older presented to the receptionist and then waited until they were seen by a first to fifth-year resident physician who proposed the vaccination during the consultation. The injection was then done by a nurse. Alternatively, anyone could go straight to the nurse (walk-in clinic) and ask for an influenza shot, which was done after checking that there was no contraindication (egg allergy, fever during the past 2 days, or use of anticoagulants, in which case subcutaneous injection was performed). To check that all patients regularly followed at the medical outpatient clinic had made contact during the vaccination period, an independent registrar in mid-November reviewed all files of patients 65 years and older. For those regularly followed, he checked whether an appointment had been made; if not, a reminder letter was sent to the patient.
Intervention season (1999). During the vaccination period, all patients 65 years and older were told by the receptionist that a medical student would propose an influenza vaccination before seeing the doctor. The medical student informed the patients about influenza complications and prevention by vaccination, and asked them whether they had been vaccinated in the previous year. The patient then had to decide whether to be vaccinated immediately, discuss the vaccination with the doctor first, or refuse the vaccination. In case of refusal, the reason was investigated. The patient who agreed to the vaccination received the injection from the medical student and a label was attached to the patient’s file to inform the doctor about the vaccination status. The same procedure performed in 1998 was applied for the reminder letter
General practice procedures
During the intervention season only (1999), the receptionist at the admission desk proposed influenza vaccination to all patients 65 years and older and the paramedical staff promptly performed the injection, if the patient agreed. The same information and questionnaires were applied in the family physician’s offices and the medical outpatient clinic.
Outcomes
Several outcomes were predefined: (1) vaccination coverage rate of all patients 65 years and older who attended the medical outpatient clinic spontaneously or on appointment during the 1999 vaccination period; (2) vaccination coverage rate of patients 65 years and older regularly followed (excluding those coming only once without a follow-up) at the medical outpatient clinic in 1998 and 1999 (all were contacted by a reminder letter, if not seen during vaccination period); (3) vaccination coverage rate of all patients 65 years and older who attended the family physicians’ offices during the 1999 vaccination period; and (4) reasons for nonvaccination among those interviewed.
Data management and analysis
The data were entered immediately into Epi Info 6.0 and analyzed with SPSS 7.5. Testing for differences between the 1998 and 1999 rates in the medical outpatient clinic was done with chi-square tests.
Results
Rate of vaccination coverage at the medical outpatient clinic during the intervention period
A total of 401 patients 65 years and older came to the outpatient clinic during the vaccination period in 1999. The median age was 74 years (range, 65-97 years) and most patients were male (56%). Table 2 shows that 85% (341/401) accepted the vaccination at the medical outpatient clinic. Of those, 52% were advised by the medical student before consultation, 26% came spontaneously to the nurse for influenza vaccination, and 19% came with advice from their physicians. The rate of refusal was 9% (see Table 2 for details).
Changes in rates of vaccination coverage of patients regularly followed at the medical outpatient clinic in 1998 and 1999
In 1998, 195 patients 65 years and older regularly followed at the medical outpatient clinic were monitored.9 A reminder letter was sent to patients who did not have an appointment during the vaccination period (73/195 patients). About one fifth (15/73) came for vaccination after the reminder letter. Overall, 48% (93/195) were vaccinated in 1998.