In 1999, 325 of 401 patients 65 years and older were regularly followed by a resident-physician. The larger number in 1999 (when compared 195 patients in 1998) was due to the fact that, in 1998, only those who followed in 1997 were monitored. Among the 325 patients, 268 came to the office during the vaccination period; 57 persons regularly followed did not have an appointment during the vaccination period and were sent a reminder letter. Overall, 76% of patients regularly followed (246/325) were vaccinated in 1999. Of those, 65% were advised by the medical student. The rate of refusal was 11%. Only 2 patients in the targeted population were missed during the target period, and 2 patients had medical contraindications for vaccination. Thus, the new strategy led to a relative increase of 58% for vaccination coverage (from 48% to 76%; P < .0001, Yates correction).
Rate of vaccination coverage in family physicians’ offices in 1999
A total of 598 patients 65 years and older attended their family physicians’ offices during the vaccination period. The median age was 74 years (range, 65-99 years) and most were female (62%). Eighty-three percent accepted the vaccination at the family physicians’ offices, 3% wished to be vaccinated somewhere else, and 14% refused.
Reasons for nonvaccination
The rates of refusal were 14% in the family physician’s offices and 9% in the medical outpatient clinic. Reasons for nonvaccination in the medical outpatient clinic were obtaining the influenza vaccination elsewhere (5%) and medical contraindications (1%; Table 2).
Discussion
Our study demonstrated that the systematic intervention of a paramedical person before the doctor’s consultation can lead to a considerable improvement in vaccination coverage in an ambulatory setting. A 58% relative increase (from 48% to 76%) over 1 year in the same institution has never been achieved. This suggested that failure of the physician to propose vaccination is an important reason for low vaccination coverage of high-risk patients in teaching institutions, where physician turnover is high. Thanks to our organizational strategy, we reached an 85% vaccination coverage among all outpatient attendees, which far surpassed that achieved by an ongoing educational program or alternative strategies such as reminder letters.
Until now, the highest coverage ever reported in Europe in persons 65 years and older was 82% in a study in Finland, where the investigators used an age-based strategy, with free vaccines and personnel-mailed reminders.10 Even when efficacious11 and cost effective,12 these strategies are insufficiently used.4 Other means to improve vaccination coverage such as centralized planning identification through computerized enrollment files at central registry and immunization clinics have improved vaccination coverage rates to almost 80% among chronically ill seniors in the United States.13
Two American studies showed that approaches incorporating administrative and organizational measures were more successful in improving vaccination rates than the education of providers. A pilot study14 and a 10-year follow-up15 done in the Minneapolis Department of Veterans Affairs Medical Center used a strategy including annual educational and publicity mailing to patients, walk-in clinics for vaccine administration, standing orders for nurses, and use of standardized patient information and medical record documentation forms. The follow-up study showed a remarkable improvement in the coverage rate, which reached 92% in 1996-1997 in specific groups. Another study done in the University Department of Emergency Medicine of Chicago that used standing orders for nurses at triage was only partly successful, with 47% coverage.16
Our study adds to the knowledge gathered in the United States, where administrative and organizational strategies (standing orders for nurses) improved vaccination coverage significantly.14-16 These studies were conducted in a different population sample, including hospitalized patients and other high-risk groups, which is quite different from the situation in general practice. Comparing vaccination coverage rates between different studies is always hazardous because of differences in inclusion criteria and reporting biases. The highest vaccination coverage ever achieved was 92%, but the method used for the rate estimation was a mailed survey where vaccinated persons may have been more likely to respond than nonvaccinated ones.15 The investigators exported their program from a teaching hospital to a community outpatient setting, with an increase in coverage from 56% to 72% in 1 clinic and no significant increase in the other clinic, which shows that several factors should be considered when a new strategy is implemented (staff, motivation, etc).17 The relatively low coverage (47%) reached in another study conducted in an emergency department was due in part to the fact that the nurse dedicated to providing vaccination was diverted from the preventive task of caring for patients when the workload increased. In addition, only one fourth of the emergency attendees was screened.16