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Meta-Analysis
. 2018 May 30;5(5):CD005188.
doi: 10.1002/14651858.CD005188.pub4.

Interventions to increase influenza vaccination rates of those 60 years and older in the community

Roger E Thomas  1 , Diane L Lorenzetti
Affiliations
Meta-Analysis

Interventions to increase influenza vaccination rates of those 60 years and older in the community

Roger E Thomas et al. Cochrane Database Syst Rev. .

Abstract

Background: The effectiveness of interventions to increase influenza vaccination uptake in people aged 60 years and older varies by country and participant characteristics. This review updates versions published in 2010 and 2014.

Objectives: To assess access, provider, system, and societal interventions to increase the uptake of influenza vaccination in people aged 60 years and older in the community.

Search methods: We searched CENTRAL, which includes the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE, Embase, CINAHL, and ERIC for this update, as well as WHO ICTRP and ClinicalTrials.gov for ongoing studies to 7 December 2017. We also searched the reference lists of included studies.

Selection criteria: Randomised controlled trials (RCTs) and cluster-randomised trials of interventions to increase influenza vaccination in people aged 60 years or older in the community.

Data collection and analysis: We used standard methodological procedures as specified by Cochrane.

Main results: We included three new RCTs for this update (total 61 RCTs; 1,055,337 participants). Trials involved people aged 60 years and older living in the community in high-income countries. Heterogeneity limited some meta-analyses. We assessed studies as at low risk of bias for randomisation (38%), allocation concealment (11%), blinding (44%), and selective reporting (100%). Half (51%) had missing data. We assessed the evidence as low-quality. We identified three levels of intervention intensity: low (e.g. postcards), medium (e.g. personalised phone calls), and high (e.g. home visits, facilitators).Increasing community demand (12 strategies, 41 trials, 53 study arms, 767,460 participants)One successful intervention that could be meta-analysed was client reminders or recalls by letter plus leaflet or postcard compared to reminder (odds ratio (OR) 1.11, 95% confidence interval (CI) 1.07 to 1.15; 3 studies; 64,200 participants). Successful interventions tested by single studies were patient outreach by retired teachers (OR 3.33, 95% CI 1.79 to 6.22); invitations by clinic receptionists (OR 2.72, 95% CI 1.55 to 4.76); nurses or pharmacists educating and nurses vaccinating patients (OR 152.95, 95% CI 9.39 to 2490.67); medical students counselling patients (OR 1.62, 95% CI 1.11 to 2.35); and multiple recall questionnaires (OR 1.13, 95% CI 1.03 to 1.24).Some interventions could not be meta-analysed due to significant heterogeneity: 17 studies tested simple reminders (11 with 95% CI entirely above unity); 16 tested personalised reminders (12 with 95% CI entirely above unity); two investigated customised compared to form letters (both 95% CI above unity); and four studies examined the impact of health risk appraisals (all had 95% CI above unity). One study of a lottery for free groceries was not effective.Enhancing vaccination access (6 strategies, 8 trials, 10 arms, 9353 participants)We meta-analysed results from two studies of home visits (OR 1.30, 95% CI 1.05 to 1.61) and two studies that tested free vaccine compared to patient payment for vaccine (OR 2.36, 95% CI 1.98 to 2.82). We were unable to conduct meta-analyses of two studies of home visits by nurses plus a physician care plan (both with 95% CI above unity) and two studies of free vaccine compared to no intervention (both with 95% CI above unity). One study of group visits (OR 27.2, 95% CI 1.60 to 463.3) was effective, and one study of home visits compared to safety interventions was not.Provider- or system-based interventions (11 strategies, 15 trials, 17 arms, 278,524 participants)One successful intervention that could be meta-analysed focused on payments to physicians (OR 2.22, 95% CI 1.77 to 2.77). Successful interventions tested by individual studies were: reminding physicians to vaccinate all patients (OR 2.47, 95% CI 1.53 to 3.99); posters in clinics presenting vaccination rates and encouraging competition between doctors (OR 2.03, 95% CI 1.86 to 2.22); and chart reviews and benchmarking to the rates achieved by the top 10% of physicians (OR 3.43, 95% CI 2.37 to 4.97).We were unable to meta-analyse four studies that looked at physician reminders (three studies with 95% CI above unity) and three studies of facilitator encouragement of vaccination (two studies with 95% CI above unity). Interventions that were not effective were: comparing letters on discharge from hospital to letters to general practitioners; posters plus postcards versus posters alone; educational reminders, academic detailing, and peer comparisons compared to mailed educational materials; educational outreach plus feedback to teams versus written feedback; and an intervention to increase staff vaccination rates.Interventions at the societal levelNo studies reported on societal-level interventions.Study funding sourcesStudies were funded by government health organisations (n = 33), foundations (n = 9), organisations that provided healthcare services in the studies (n = 3), and a pharmaceutical company offering free vaccines (n = 1). Fifteen studies did not report study funding sources.

Authors' conclusions: We identified interventions that demonstrated significant positive effects of low (postcards), medium (personalised phone calls), and high (home visits, facilitators) intensity that increase community demand for vaccination, enhance access, and improve provider/system response. The overall GRADE assessment of the evidence was moderate quality. Conclusions are unchanged from the 2014 review.

PubMed Disclaimer

Conflict of interest statement

Roger E Thomas: none known. Diane L Lorenzetti: none known.

Figures

1
1
Study flow diagram.
2
2
'Risk of bias' summary: review authors' judgments about each risk of bias item for each included study.
3
3
'Risk of bias' graph: review authors' judgments about each risk of bias item presented as percentages across all included studies.
4
4
Funnel plot of comparison: 1 Increasing community demand, outcome: 1.1 Client reminder and recall (postcard) compared to no intervention.
5
5
Funnel plot of comparison: 1 Increasing community demand, outcome: 1.2 Client reminder and recall (tailored letter or postcard or phone call) compared to no intervention.
See this image and copyright information in PMC

Update of

References

References to studies included in this review

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Hull 2002 {published and unpublished data}
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Humiston 2011 {published data only}
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Karuza 1995 {published data only}
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Kellerman 2000 {published data only}
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Kerse 1999 {published data only (unpublished sought but not used)}
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Kiefe 2001 {published and unpublished data}
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Kim 1999 {published data only}
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Maglione 2002b {published data only}
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Marrero 2006 {published and unpublished data}
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Moran 1996 {published data only}
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References to studies excluded from this review

Ahmed 2004 {published data only}
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Arthur 2001 {published data only}
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Bardenheier 2010 {published data only}
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Bardenheier 2011 {published data only}
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Belcher 1990 {published data only}
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Birchmeier 2002 {published data only}
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Bloom 1999 {published data only}
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Bou‐Mias 2006 {published data only}
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Brimberry 1988 {published data only}
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Clancy 2003 {published data only (unpublished sought but not used)}
    1. Clancy DE, Cope DW, Magruder KM, Huang P, Wolfman TE. Evaluating concordance to American Diabetes Association standards of care for type 2 diabetes through group visits in an uninsured or inadequately insured patient population. Diabetes Care 2003;26(7):2032‐6. - PubMed
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Cowan 1992 {published data only}
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Cowan 2006 {published data only}
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Dickey 1992 {published data only}
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Egido Polo 1989 {published data only}
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Frank 1985 {published data only}
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Gelfman 1986 {published data only}
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Grabenstein 1990 {published data only}
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Grabenstein 1992 {published data only}
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Hutchison 1991 {published data only}
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Nichol 1990 {published data only}
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Nichol 1992 {published data only}
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Nichol 1998 {published data only}
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Van Essen 1997 {published and unpublished data}
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Zimmerman 2003b {published and unpublished data}
    1. Zimmerman RK, Santibanez TA, Janosky JE, Fine MJ, Raymund M, Wilson SA, et al. What affects influenza vaccination rates among older patients? An analysis from inner‐city, suburban, rural, and Veterans Affairs practices. American Journal of Medicine 2003;114(1):31‐8. - PubMed
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References to studies awaiting assessment

Hurley 2017 {published data only (unpublished sought but not used)}
    1. Hurley LP, Beaty B, Lockhart S, Gurfinkel D, Breslin K, Dickinson M, et al. Centralized vaccine reminder/recall to improve adult vaccination rates at an urban safety net health system. Journal of General Internal Medicine 2017;32(Suppl 2):S135‐6.

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References to other published versions of this review

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