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QUESTION: In elderly patients aged 65–74 years who have not previously been recalled for influenza immunisation, is telephone appointing by receptionists effective for improving uptake of influenza immunisation?
3 general practices in London and Essex, UK.
1318 patients who were 65–74 years of age and registered at 1 of 3 general practices that serve a multi-ethnic, inner city population. Patients with chronic disease who had been previously recalled for influenza immunisation were excluded. Follow up was 100%.
1206 households (1318 patients, mean age 69 y, 55% women), which were grouped within each practice, were allocated to telephone appointing (intervention group, 605 households, 660 patients) or to the control group (601 households, 658 patients). Each household in the intervention group received ≤2 telephone contacts (made at different times during the day) by a receptionist who offered to make an appointment for influenza vaccination at a nurse run clinic. The study coincided with a letter and leaflet mailout to every general practice registered patient aged ≥65 years, which promoted influenza immunisation uptake, and a national television campaign promoting influenza immunisation.
Main outcome measure
Uptake of influenza immunisation.
Analysis was by intention to treat. Of the 605 households in the intervention group, 360 (59.5%) were contacted by telephone, 30 (5%) already had an appointment for influenza vaccination, 102 (17%) could not be contacted by telephone, and 113 (19%) had no telephone. A higher rate of uptake of influenza immunisation was seen among patients in the intervention group than in the control group (table).
In elderly patients aged 65–74 years who had not previously been recalled for influenza immunisation, telephone appointing by receptionists improved uptake of influenza immunisation.
Influenza is a common respiratory illness caused by influenza viruses. It occurs mainly in winter, has a sudden onset, and is characterised by fever, chills, myalgia, headache, cough, and sore throat. For most people, influenza is self limiting, although unpleasant. However, for those in high risk groups (eg, people who are elderly, immunosuppressed, or have chronic conditions, such as respiratory, cardiac, or renal disease, or diabetes), it can be life threatening. In the UK, annual mortality caused by influenza ranges from 3000–4000 deaths.1 However, this increases during epidemics. During the epidemic of 1989–90, 29 000 “flu related deaths” occurred in the UK.1
The influenza vaccine reduces infection, illness, hospital admissions, and deaths in older persons,2 who if vaccinated every year, have greater protection than those vaccinated for the first time.3 Increasing uptake of the influenza vaccine can potentially reduce the morbidity and mortality of influenza in high risk groups. In the UK, vaccination is usually delivered in general practices, typically by nurses. The UK Department of Health has set a target that 70% of people >65 years of age should be vaccinated.1
The studies by Arthur et al and Hull et al describe 2 methods that aim to increase uptake of the influenza vaccine: offering it as part of a health check (Arthur et al) or a telephone invitation from a practice receptionist (Hull et al). Both interventions showed increased uptake of the vaccine.
Neither study provided details on where clinics were held or if flexibility of timing was given to better suit patients. This information is important to the interpretation of the study by Hull et al, which addresses a multi-ethnic, transient, and therefore, hard to reach population. It would also be useful to know more about the health information that was provided by receptionists in the study by Hull et al and by the nurses in the study by Arthur et al. For example, were “scripts” used? How were the dangers of flu described?
The model used in the study by Arthur et al, where nurses included the flu vaccine within the health check, may not (as the authors suggest) be practical because it is costly in terms of nursing time. Practice nurses have a heavy workload during the autumn months, vaccinating large numbers of patients (eg, 2 nurses vaccinate about 60 patients/h in the author’s practice), and the population >65 years is increasing.
An economic analysis would help readers place the effects of these interventions into context. Practices in the UK receive an item of service payment for each vaccination given to persons >65 years. However, this cost will be offset by reduced visits to general practitioners, home visits, drugs, and hospital admissions, plus the advantage to patients of illness prevention.
A recent systematic review identified that organisational changes, such as separate clinics, deployment of non-medical staff (eg, nurses), patient financial incentives, and patient reminders are the most effective ways of improving uptake of adult immunisation and screening.4 Clearly, the interventions used in the studies by Arthur et al and Hull et al fit many of these criteria. A package of interventions is most likely to be effective for increasing uptake of vaccination.5 It would be interesting to see if the effects of the interventions evaluated here could be further improved by the incorporation of other strategies (eg, patient financial incentives).
These 2 interventions should be seen as part of a larger strategy to vaccinate vulnerable patients. Clinics need to be held at convenient times and be easily accessible. Mobile outreach or weekend clinics may be required. Publicity, ranging from media campaigns to personal letters to patients, needs to be appropriate and widely dispersed in simple language.
↵* Information provided by author.
For correspondence: Dr S A Hull, Department of General Practice and Primary Care, Medical Sciences Building, Queen Mary College, London, UK.
Source of funding: East London and Essex Network of Researchers.
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