Interventions to improve influenza and pneumococcal vaccination rates among community-dwelling adults: a systematic review and meta-analysis

Abstract

Purpose: Influenza and pneumococcal vaccination rates remain below national targets. We systematically reviewed the effectiveness of quality improvement interventions for increasing the rates of influenza and pneumococcal vaccinations among community-dwelling adults.

Methods: We included randomized and nonrandomized studies with a concurrent control group. We estimated pooled odds ratios using random effects models, and used the Downs and Black tool to assess the quality of included studies.

Results: Most studies involved elderly primary care patients. Interventions were associated with improvements in the rates of any vaccination (111 comparisons in 77 studies, pooled odds ratio [OR] = 1.61, 95% CI, 1.49-1.75), and influenza (93 comparisons, 65 studies, OR = 1.46, 95% CI, 1.35-1.57) and pneumococcal (58 comparisons, 35 studies, OR = 2.01, 95% CI, 1.72-2.3) vaccinations. Interventions that appeared effective were patient financial incentives (influenza only), audit and feedback (influenza only), clinician reminders, clinician financial incentives (influenza only), team change, patient outreach, delivery site changes (influenza only), clinician education (pneumococcus only), and case management (pneumococcus only). Patient outreach was more effective if personal contact was involved. Team changes were more effective where nurses administered influenza vaccinations independently. Heterogeneity in some pooled odds ratios was high, however, and funnel plots showed signs of potential publication bias. Study quality varied but was not associated with outcomes.

Conclusions: Quality improvement interventions, especially those that assign vaccination responsibilities to nonphysician personnel or that activate patients through personal contact, can modestly improve vaccination rates in community-dwelling adults. To meet national policy targets, more-potent interventions should be developed and evaluated.

Figure 1.

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Figure 2.

Effect of quality improvement interventions on influenza vaccination rates. CQI = continuous quality improvement; OR = odds ratio. Note: Forest plot showing pooled odds ratios from random effects meta-analyses. Vaccination rates provided are crude estimates generated by summing patients among studies. Many studies contributing odds ratios for meta-analysis did not provide crude counts. ^a Pooled odds ratios from fewer than 3 comparisons are reported but considered insuffi cient for interpretation.

Figure 3.

Effect of quality improvement interventions on pneumococcal vaccination rates. CQI = continuous quality improvement; OR = odds ratio. Note: Forest plot showing pooled odds ratios from random effects meta-analyses. Vaccination rates provided are crude estimates generated by summing patients among studies. Many studies contributing odds ratios for meta-analysis did not provide crude counts. ^a Pooled odds ratios from fewer than 3 comparisons are reported, but considered insuffi cient for interpretation. No comparisons involving patient fi nancial incentives were available for meta-analysis.