To our knowledge, this is the first time that such an active strategy has been reported and applied in family physicians’ offices. The implementation in private practices documents its feasibility and effectiveness in those settings. The consistent coverage rates obtained in the medical outpatient clinic and the general practices (85% and 83%, respectively) confirmed the usefulness of the strategy, whatever the patient population and the medical staff involved. One may argue that patients had little choice between accepting or actively refusing the vaccination. We hope that the quality of information provided to the elderly, the possibility for them to ask specific questions that come to mind, and even to delay the decision until they can discuss the decision further with the doctor balances the potential enforcement.
The main disadvantage of our strategy is the need for an additional person in the outpatient clinic. The direct cost of an extra person in public service can be justified if it decreases the indirect costs for society, which is the case for influenza vaccination.12 More pragmatically, at the institutional level, the additional income generated by the increase of vaccine sales outweighed the salary of the medical student (about US$100/day for a total of 40 days, ie, 20 working days for 2 months). The implementation in the family physicians’ offices showed that such a procedure can work in a small setting without additional staff. Counseling about vaccination represents an additional task for the paramedical personnel, but it certainly provides more credit to the overall work and improves the therapeutic network. Also, because the vaccination has to be proposed, the time for discussion has to be taken by whoever is the most willing to do the job.
Some doctors may feel that this strategy excludes them from important duties. We must face the reality that physicians often do not accomplish their tasks properly. With our procedure, they remain informed about the vaccination status of their patients and maintain their important role in counseling patients who cannot decide about the vaccination or when problems arise.
One can argue that the increase in vaccination coverage rate was due, at least in part, to external factors such as media propaganda, and that the new strategy played only a marginal role. Of course, we cannot exclude such an influence, but it certainly unlikely was to be the cause of a 58% increase in coverage rate; indeed, no particular campaign was launched in 1999 and no change in coverage rate between 1998 and 1999 was observed in a similar institution in the same area. We chose to use historical controls because we were convinced that the new strategy would dramatically improve vaccination in the elderly and felt therefore that it was unethical not to offer this procedure to all our patients. Moreover, the main interest of the study was to investigate the maximum coverage rate that could be expected with a very active intervention and to estimate precisely the rate of true refusals, so that defined objectives in terms of coverage rates can be set in similar institutions.
The new strategy assessed in this study is in line with the recommendations of the Advisory Committee on Immunization Practices, published in March 2000, that promoted the use of standing orders to improve adult vaccination delivery.18 Evidence of effectiveness of such programs is increasing. They could be adapted to other preventive measures to improve delivery of those services, and they could be used to improve outpatient clinic efficiency by reducing pressures on physicians.
Acknowledgments
We thank M. Cheseaux and S. Martin, the medical students responsible for providing vaccine information and delivery and data entry, the resident-physicians at medical outpatient clinic, and the nurses and receptionists in the medical outpatient clinic and the family physicians’ practices.