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CochraneDatabaseof SystematicReviews

Interventions to increase influenza vaccinationrates ofthose

60years and older inthecommunity(Review)

Thomas RE,LorenzettiDL

Thomas RE, Lorenzetti DL.

Interventions to increase influenza vaccination ratesof those 60years and older in thecommunity.

CochraneDatabaseof SystematicReviews 2018, Issue5. Art. No.: CD005188.

DOI: 10.1002/14651858.CD005188.pub4.

www.cochranelibrary.com

Interventions to increase influenza vaccinationrates ofthose 60years andolder inthecommunity(Review)

http://www.cochranelibrary.com

T A B L E O F C O N T E N T S

1HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4SUMMARY OF FINDINGS FOR THE MAIN COMPARISON . . . . . . . . . . . . . . . . . . .

8BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

9OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

10METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

13RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Figure 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Figure 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Figure 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Figure 4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Figure 5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

27ADDITIONAL SUMMARY OF FINDINGS . . . . . . . . . . . . . . . . . . . . . . . . . .

32DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

34AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

36ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

36REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

58CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

162DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Analysis 1.1. Comparison 1 Increasing community demand, Outcome 1 Client reminder and recall (postcard) compared to

no intervention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165

Analysis 1.2. Comparison 1 Increasing community demand, Outcome 2 Client reminder and recall (tailored letter or

postcard or phone call) compared to no intervention. . . . . . . . . . . . . . . . . . . . . 166

Analysis 1.3. Comparison 1 Increasing community demand, Outcome 3 Client reminder and recall (letter + leaflet or

postcard) compared to letter. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167

Analysis 1.4. Comparison 1 Increasing community demand, Outcome 4 Client reminder and recall (customised letter or

phone call) compared to form letter. . . . . . . . . . . . . . . . . . . . . . . . . . . 168

Analysis 1.5. Comparison 1 Increasing community demand, Outcome 5 Client reminder and recall (telephone call from

retired teacher plus educational brochure) compared to usual publicity. . . . . . . . . . . . . . . 168

Analysis 1.6. Comparison 1 Increasing community demand, Outcome 6 Client reminder and recall (telephone invitation)

compared to invitation to patient when “dropped in” to clinic. . . . . . . . . . . . . . . . . . 169

Analysis 1.7. Comparison 1 Increasing community demand, Outcome 7 Brochure + lottery for free groceries compared to

no intervention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170

Analysis 1.8. Comparison 1 Increasing community demand, Outcome 8 Questionnaires to clients about attitudes. . 170

Analysis 1.9. Comparison 1 Increasing community demand, Outcome 9 Client-based education (health risk appraisal)

compared to no intervention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171

Analysis 1.10. Comparison 1 Increasing community demand, Outcome 10 Client-based education (nurses or pharmacists

educated and nurses vaccinated patients) compared to no intervention. . . . . . . . . . . . . . . 172

Analysis 1.11. Comparison 1 Increasing community demand, Outcome 11 Client-based education (nurses educated and

vaccinated patients) compared to nurses educated patients. . . . . . . . . . . . . . . . . . . 172

Analysis 1.12. Comparison 1 Increasing community demand, Outcome 12 Face-to-face 3-minute conversation compared

to no intervention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173

Analysis 2.1. Comparison 2 Enhancing vaccination access, Outcome 1 Group visits of patients to physician and nurse

compared to usual care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174

Analysis 2.2. Comparison 2 Enhancing vaccination access, Outcome 2 Home visit compared to invitation to attend

influenza vaccination clinic. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174

Analysis 2.3. Comparison 2 Enhancing vaccination access, Outcome 3 Home visit with encouragement to receive influenza

vaccination, compared to home visit with safety intervention. . . . . . . . . . . . . . . . . . 175

iInterventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Analysis 2.4. Comparison 2 Enhancing vaccination access, Outcome 4 Home visit by nurse or group sessions with

encouragement to receive influenza vaccination, plus care plan developed with physician, compared to no

intervention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176

Analysis 2.5. Comparison 2 Enhancing vaccination access, Outcome 5 Free influenza vaccine compared to invitation to be

vaccinated but patient pays. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176

Analysis 2.6. Comparison 2 Enhancing vaccination access, Outcome 6 Free influenza vaccine compared to no

intervention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177

Analysis 3.1. Comparison 3 Provider- or system-based intervention, Outcome 1 Reminder (to physician) compared to no

reminder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178

Analysis 3.2. Comparison 3 Provider- or system-based intervention, Outcome 2 Reminder to physician about all patients

compared to reminder about half patients. . . . . . . . . . . . . . . . . . . . . . . . . 178

Analysis 3.3. Comparison 3 Provider- or system-based intervention, Outcome 3 Reminder (to hospital staff to vaccinate

patient) compared to letter to GP on day of discharge. . . . . . . . . . . . . . . . . . . . . 179

Analysis 3.4. Comparison 3 Provider- or system-based intervention, Outcome 4 Posters in clinic displaying influenza

vaccination rates to encourage doctors to compete, plus postcards to patients, compared to no intervention. . 180

Analysis 3.5. Comparison 3 Provider- or system-based intervention, Outcome 5 Posters in clinic displaying influenza

vaccination rates to encourage doctors to compete, plus postcards to patients, compared to posters displaying

vaccination rates. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180

Analysis 3.6. Comparison 3 Provider- or system-based intervention, Outcome 6 Facilitator encouragement of prevention

manoeuvres including influenza vaccination compared to no intervention. . . . . . . . . . . . . . 181

Analysis 3.7. Comparison 3 Provider- or system-based intervention, Outcome 7 Educational reminders, academic detailing,

and peer comparisons to physicians compared to mailed educational materials. . . . . . . . . . . . 182

Analysis 3.8. Comparison 3 Provider- or system-based intervention, Outcome 8 Chart review and feedback to physician

plus benchmarking to vaccination rates achieved by top 10% of physicians, compared to chart review and feedback. 182

Analysis 3.9. Comparison 3 Provider- or system-based intervention, Outcome 9 Educational outreach + feedback to

practice teams versus written feedback to practice teams. . . . . . . . . . . . . . . . . . . . 183

Analysis 3.10. Comparison 3 Provider- or system-based intervention, Outcome 10 Payment to physicians versus no

payment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184

Analysis 3.11. Comparison 3 Provider- or system-based intervention, Outcome 11 Intervention to increase staff influenza

vaccination rate versus no intervention. . . . . . . . . . . . . . . . . . . . . . . . . . 184

185ADDITIONAL TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

189APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

195FEEDBACK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

197WHAT’S NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

197HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

198CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

198DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

198SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

199DIFFERENCES BETWEEN PROTOCOL AND REVIEW . . . . . . . . . . . . . . . . . . . . .

199INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

iiInterventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

[Intervention Review]

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

Roger E Thomas1 , Diane L Lorenzetti2

1Department of Family Medicine, Faculty of Medicine, University of Calgary, Calgary, Canada. 2Department of Community Health

Sciences, Faculty of Medicine, University of Calgary, Calgary, Canada

Contact address: Roger E Thomas, Department of Family Medicine, Faculty of Medicine, University of Calgary, Health Sciences

Centre, 3330 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada. [email protected].

Editorial group: Cochrane Acute Respiratory Infections Group.

Publication status and date: Edited (no change to conclusions), published in Issue 7, 2018.

Citation: Thomas RE, Lorenzetti DL. Interventions to increase influenza vaccination rates of those 60 years and older in the community.

Cochrane Database of Systematic Reviews 2018, Issue 5. Art. No.: CD005188. DOI: 10.1002/14651858.CD005188.pub4.

A B S T R A C T

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 reference lists of included studies.

Selection criteria

Randomised controlled trials (RCTs) and cluster-RCTs 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 3 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)

1Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

mailto:[email protected]

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 (the 95% CI was

entirely above unity in 11 trials implying all 11 interventions increased vaccination rates); 16 tested personalised reminders (the 95% CI

was entirely above unity in 12 trials implying all 12 interventions increased vaccination rates ); 2 investigated customised compared to

form letters (the 95% CI was above unity in both trials implying both interventions increased vaccination rates); and 4 studies examined

the impact of health risk appraisals (the 95% CI was above unity in all 4 trials implying all 4 interventions increased vaccination rates).

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 2 studies of home visits (OR 1.30, 95% CI 1.05 to 1.61), and 2 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 2 studies of home visits by

nurses plus a physician care plan (the 95% CI was entirely above unity in both trials implying both interventions increased vaccination

rates) and 2 studies of free vaccine compared to no intervention (the 95% CI was entirely above unity in both trials implying both

interventions increased vaccination rates). One study of group visits (OR 27.2, 95% CI 1.60 to 463.3) was effective, and 1 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 4 studies that looked at physician reminders (the 95% CI was entirely above unity in 3 trials implying

all 3 interventions increased vaccination rates) and 3 studies of facilitator encouragement of vaccination (the 95% CI was entirely

above unity in 2 trials implying both interventions increased vaccination rates). 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 level

No studies reported on societal-level interventions.

Study funding sources

Studies 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.

P L A I N L A N G U A G E S U M M A R Y

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

Review question

2Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Does increasing demand, vaccination access, and provider activity increase influenza vaccination rates in people aged 60 years and older

living in the community?

Background

Vaccination rates vary across countries and socioeconomic and health risk groups.

Search date

The evidence is current to 7 December 2017.

Study characteristics

We included three new trials (15,993 participants) for this update; the review now includes a total of 61 trials with 1,055,337 participants.

All participants were aged 60 years or older, living in the community.

Study funding sources

Government health organisations funded 33 studies; foundations funded 9 studies; organisations that provided healthcare services in

the studies funded 3 studies; and a pharmaceutical company offering free vaccines funded 1 study. Fifteen studies did not report any

funding source.

Key results

Increasing community demand for vaccination (12 strategies, 41 trials, 767,460 participants)

Effective interventions consisted of reminders/recalls using letters and leaflets, and nurses or pharmacists educating and nurses vaccinating

patients. Individual effective studies consisted of client outreach by retired teachers, receptionists, nurses, and medical students.

It was not possible to combine some interventions for analysis as they were too varied: 17 studies of simple reminders (11 with significant

results); 16 studies of personalised reminders (12 with significant results); two studies of customised letters versus form letters (both

with significant results); and four studies of health risk appraisals plus vaccination recommendations (all with significant results).

Improving vaccination access (6 strategies, 8 trials, 9353 participants)

Effective interventions consisted of home visits, client group clinic visits, and free vaccine offers.

Improving provision by providers or the healthcare system (11 strategies, 15 trials, 278,524 participants)

Effective interventions that could be combined for analysis included physician payment, physician reminders, clinic posters encouraging

physician competition, and chart reviews plus benchmarking to rates of the top 10% of physicians. We could not analyse some groups of

interventions: physician reminders (four studies, two of which were effective) and facilitator vaccination encouragement (three studies,

two of which were effective).

Individual studies that were not effective consisted of posters plus postcards versus posters alone, educational reminders to physicians

compared to mailed educational materials, educational outreach plus feedback to teams versus written feedback, and increasing staff

vaccination rates.

No studies measured if interventions reduced illness or hospital admissions or reported societal-level interventions.

Quality of the evidence

Overall, we assessed the included studies as at moderate risk of bias. The overall GRADE assessment of the evidence was high to

moderate quality.

3Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

S U M M A R Y O F F I N D I N G S F O R T H E M A I N C O M P A R I S O N [Explanation]

Increasing community demand compared to no intervention or another intervention for increasing influenza vaccination uptake

Patient or population: people aged 60 years and older living in the community

Setting: the community

Intervention: increasing community demand

Comparison: no intervention or another intervention

Outcomes Anticipated absolute effects* (95%CI) Relative effect

(95%CI)

of participants

(studies)

Certainty of the evi-

dence

(GRADE)

Comments

Comparator Intervention

Client reminder and re-

call (postcard) com-

pared to no intervention

Study population - 402,367

(17 RCTs)

⊕⊕⊕⊕

HIGH

We could not pool the

data due to heterogene-

ity (I² = 97%). The 95%

CI of 11/ 17 trials was

above unity, implying

that all these interven-

tions increased vacci-

nation rates

153 per 1000 182 per 1000

(163 to 203)

Client reminder and re-

call (tailored letter or

postcard or phone call)

compared to no inter-

vention

Study population - 195,964

(16 RCTs)

⊕⊕⊕⊕

HIGH

We could not pool the

data due to heterogene-

ity (I² = 99%). The 95%

CI of 12/ 16 trials was

above unity, implying

that all these interven-

tions increased vacci-

nation rates

105 per 1000 185 per 1000

(155 to 220)

Client reminder and re-

call (letter + leaflet or

postcard) compared to

letter

Study population OR 1.11

(1.07 to 1.15)

64,200

(3 RCTs)

⊕⊕⊕⊕

HIGH

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208 per 1000 225 per 1000

(219 to 231)

Client reminder and re-

call (customised letter

or phone call) com-

pared to form letter

Study population - 82,465

(4 RCTs)

⊕⊕⊕⊕

HIGH

We could not pool the

data due to heterogene-

ity (I² = 96%). The

95% CI of 2/ 4 RCTs

was above unity, im-

plying that these 2 tri-

als increased vaccina-

tion rates

133 per 1000 160 per 1000

(120 to 209)

Client re-

minder and recall (tele-

phone call from retired

teacher plus educa-

tional brochure) com-

pared to usual publicity

Study population OR 3.33

(1.79 to 6.22)

193

(1 RCT)

⊕⊕⊕⊕

HIGH

231 per 1000 500 per 1000

(349 to 651)

Client reminder and re-

call (telephone invita-

tion) compared to invi-

tation to patient when

‘‘dropped in’’ to clinic

Study population OR 2.72

(1.55 to 4.76)

243

(1 RCT)

⊕⊕⊕©

MODERATE 1

220 per 1000 433 per 1000

(304 to 572)

Brochure + lottery for

free groceries com-

pared to no intervention

Study population OR 1.04

(0.62 to 1.76)

291

(1 RCT)

⊕⊕⊕⊕

HIGH

254 per 1000 261 per 1000

(174 to 374)

Questionnaires to

clients about attitudes

Study population OR 1.13

(1.03 to 1.24)

13,809

(1 RCT)

⊕⊕⊕⊕

HIGH

750 per 1000 773 per 1000

(756 to 788)

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(health risk appraisal)

compared to no inter-

vention

Study population - 6300

(4 RCTs)

⊕⊕⊕⊕

HIGH

We could not pool the

data due to heterogene-

ity (I² = 96%). The 95%

CI of all 4 trials was

above unity, implying

that all 4 increased vac-

cination rates

291 per 1000 582 per 1000

(388 to 754)

Client-based education

(nurses or pharma-

cists educated and

nurses vaccinated par-

ticipants) compared to

no intervention

Study population OR 3.29

(1.91 to 5.66)

614

(2 RCTs)

⊕⊕⊕⊕

HIGH

90 per 1000 246 per 1000

(159 to 360)

Client-based education

(nurses ed-

ucated and vaccinated

participants) compared

to nurses educated par-

ticipants

Study population OR 152.95

(9.39 to 2490.67)

485

(1 RCT)

⊕⊕⊕⊕

HIGH

0 per 1000 0 per 1000

(0 to 0)

Face-to-

face 3-minute conver-

sation compared to no

intervention

Study population OR 1.62

(1.11 to 2.35)

529

(1 RCT)

⊕⊕⊕©

MODERATE 2

254 per 1000 355 per 1000

(274 to 444)

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its

95% CI).

CI: confidence interval; OR: odds ratio; RCT: randomised controlled trial

GRADEWorkingGroup grades of evidence

High certainty: We are very confident that the true effect lies close to that of the estimate of the effect.

Moderate certainty: We are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is

substantially different.

Lowcertainty: Our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect.

Very low certainty: We have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect

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B A C K G R O U N D

Description of the condition

The key issue is whether influenza vaccination in people aged 60

years and older is effective.

A 2018 Cochrane Review of vaccines to prevent influenza in

older adults concluded that there was insufficient high-quality evi-

dence of the effectiveness of vaccines in this population (Demicheli

2018). One randomised controlled trial (RCT) showed benefits

against influenza symptoms but was underpowered to detect ef-

fects on complications (1348 participants). Other data sets were

not randomised and were deemed likely to contain biases. A 2017

systematic review compared high-dose influenza vaccine (60 µg

haemagglutinin/strain) to standard-dose influenza vaccine (15 µg

haemagglutinin/strain). In two trials, those who received the high-

dose vaccine had higher geometric mean titres and seroprotection

rates after vaccination and significantly less risk of developing lab-

oratory-confirmed influenza infections (risk ratio 0.76, 95% con-

fidence interval 0.65 to 0.90; 41,141 participants; I² statistic 0%).

There were no serious adverse events in either group (Wilkinson

2017). A Cochrane Review that explored the extent to which vac-

cinating healthcare workers reduced instances of influenza among

older adults living in institutions concluded that there was insuf-

ficient evidence of the effectiveness of this intervention (Thomas

2016).

There were two purposes in updating this review: (1) when in-

fluenza vaccines likely to be more effective than the current ones

are tested, our assessment of the literature on maximising vaccine

uptake can be used to optimise those RCTs; and (2) when more ef-

fective vaccines become available, our review provides assessments

of a wide range of methods to increase vaccine uptake for those

aged 60 years and older.

Globally, there is a very wide range of influenza vaccine uptake in

people aged 60 years and older.

The Organisation for Economic Co-operation and Development

(OECD) estimated influenza vaccination rates for those aged 65

years and older in 25 OECD member countries for 2015 (range

82% to 2%) (OECD 2016). Only seven countries had rates above

60%: South Korea (82%), the UK (71%), the USA (69%), New

Zealand (68%), the Netherlands (67%), Israel (66%), and Canada

(62%). Rates were surprisingly low for Scandinavia and Germany:

Sweden (49%), Finland (43%), Denmark (42%), Iceland (40%),

Germany (37%), Norway (28%). Rates were very low for East-

ern Europe: Hungary (21%), Lithuania (20%), Slovak Republic

(13%), Slovenia (10%), Latvia (3%), and Estonia (2%) (OECD

2016). The Centers for Disease Control and Prevention (CDC)

estimated the rate for 2016 to 2017 for the USA at 65% (CDC

2017). While these rates appear low, studies have shown that self re-

ports of vaccination status are inherently unreliable. Zimmerman

2003a investigated the reliability of self report by comparing the

self reported vaccination status of 919 individuals aged 66 years or

older against medical records. While 80% reported receiving in-

fluenza vaccination, an audit of medical records found that receipt

of vaccination was only documented in 51% of participants’ med-

ical records. MacDonald 1999 surveyed 500 randomly selected

outpatients in Veterans Affairs clinics in Minneapolis, USA. These

researchers reported that in 92% of cases, self report of vaccination

status in people aged 65 years or older mirrored chart documen-

tation.

A variety of factors may determine the likelihood of older adults

receiving influenza vaccination (Kamal 2003). In a retrospective,

random national sample of the data from the 1999 Behavioral

Risk Factor Surveillance System survey of the CDC (USA) the av-

erage influenza vaccination rate was 66.7%. Variations were found

among Caucasian (understood to be white) (68.3%) and African-

American (52.9%), unemployed (61.8%), employed (57.4%), and

retired (68.3%) people; those with annual household income less

than USD 15,000 (58.4%); and those earning USD 50,000 or

more (69.6%). Not surprisingly, the greatest difference was be-

tween those with health insurance (67.1%) and those without

(46.4%).

Regardless, the Advisory Committee on Immunization Practices

of the US Public Health Service recommended vaccination of peo-

ple aged 65 years and older (Grohskopf 2014). In light of de-

clining antibody levels in this age group, the Committee stated:

“Although delaying vaccination might permit greater immunity

later in the season, deferral might result in missed opportunities

to vaccinate and difficulties in vaccinating a population within

a limited time” (Grohskopf 2014). “The Committee concluded

that vaccination programs should balance maximizing likelihood

of persistence of vaccine-induced protection through the season

with avoiding missed opportunities to vaccinate or vaccinating af-

ter influenza virus circulation begins” (Grohskopf 2014).

Description of the intervention

There is a need to determine which interventions are most effective

at increasing vaccine uptake in adults aged 60 years and older.

Studies have identified patient, administrative, healthcare worker,

and societal factors that affect influenza vaccination uptake in

older people. The Community Preventive Services Task Force in

the USA has classified interventions to increase vaccination uptake

into three types: increasing community demand, enhancing access,

and provider or system based (CDC 2018). To make this review

more relevant for readers, we adopted this classification model,

amending the model to also include societal interventions.

Interventions to increase community demand

Interventions to increase community demand include increasing

perceptions among people aged 60 years and older that they are

susceptible to influenza; increasing belief that vaccination is ef-

fective; and appropriately decreasing concern about side effects.

8Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Methods of contacting people aged 60 years and older have in-

cluded postcards, letters, tailored letters, pamphlets, patient edu-

cation (Herman 1994), telephone campaigns (Hull 2002), finan-

cial incentives (Moran 1996), and recruiting people aged 60 years

and older to advocate for vaccination of peers (Krieger 2000).

Other studies have explored the cost-effectiveness of different ways

of encouraging vaccination, such as reminder letters followed by

phone calls (Frank 1985). While some studies have concluded that

there is a need to overcome perceived barriers to vaccination by

physicians and healthcare consumers (De Wals 1996), others have

queried whether there is a ceiling effect with respect to the number

of individuals who will respond to such cues (Ganguly 1995).

Interventions to enhance access

Interventions to enhance access include providing more clinics,

better clinic hours, offering vaccination during existing home vis-

its (Dalby 2000; Fabacher 1994), arranging home visits specifi-

cally to provide vaccination (Dixon-Woods 2004), and decreasing

economic barriers by making vaccinations freely available, or at a

low cost. Other initiatives may include decreasing administrative

barriers for staff such as enabling annual standing vaccine orders

(Lawson 2000), and transferring responsibility for administering

vaccines to other staff (e.g. from physicians to nurses).

Provider- or system-based interventions

Some studies have demonstrated that recommendations from

healthcare workers can promote vaccine acceptance among older

adults (Ashby-Hughes 1999; Nichol 1996; Nichol 2001; Shefer

1999). Other studies have reported on the positive impact of pa-

tient educational campaigns delivered by healthcare workers such

as pharmacists (Ginson 2000; Grabenstein 1992).

Interventions that can specifically target healthcare workers in-

clude providing information to alter personal beliefs and attitudes

about the susceptibility of their patients and themselves to in-

fluenza; informing healthcare workers of the effectiveness and sa-

fety of vaccines; and implementing strategies to increase motiva-

tion and willingness to vaccinate patients (Ballada 1994). Other

interventions that can alter behaviour include promoting vaccina-

tion history taking and documentation (Buffington 1991); iden-

tifying high-risk patients (Wrenn 1994); generating physician re-

minders (Baker 1998; Chambers 1991; Chan 2002; Clayton 1999;

Cowan 1992; Dexter 2001; Kelterman 2000); and organising and

participating in educational campaigns targeting healthcare work-

ers (Calkins 1995; Herman 1994; Karuza 1995).

Societal interventions

We added a fourth category to the three CDC categories: interven-

tions on a societal level, or administrative frameworks and cam-

paigns that target specific communities or societies (Bennett 1994;

Hak 2000; Nichol 1990; Remmen 2002). These include govern-

ment policies and mandated programmes, such as moving from

risk-based to age-based targeting for vaccination programmes (De

Wals 1996), remuneration to healthcare workers for increasing

vaccination uptake, or meeting specific targets (Ives 1994). Cur-

rently, the USA, in addition to recommending immunisation for

people at high risk of complications from influenza, or those who

live with people at high risk of complications, explicitly recom-

mends vaccination for people aged 50 years or older (Fiore 2009).

Germany, Austria, Hungary, and the Spanish autonomous region

of Catalonia recommend vaccination for those aged 60 years and

older (ECDC 2017).

How the intervention might work

Each of the four types of interventions is designed to change pre-

disposing or enabling factors at the level of patient, provider, or

system.

Why it is important to do this review

Cochrane Reviews have been published that assess the effects of

influenza vaccines for healthy adults (Demicheli 2014), people af-

fected by chronic obstructive pulmonary disease, Poole 2006, and

asthma, Cates 2013; and to prevent cardiovascular disease (Clar

2015). However, there had been no Cochrane Review assessing in-

terventions to increase influenza vaccination in older people in the

community before the publication of this review (Thomas 2010;

Thomas 2014). The systematic review by Kohlhammer 2007 of

surveys to ascertain vaccination rates among those aged 65 years

and older combined data from surveys of small areas with some

national telephone surveys. The review by Shojania 2010 was lim-

ited to point-of-care computer reminders to physicians and iden-

tified six studies on vaccination. While Lau 2012 made an exten-

sive search of English language studies and used the Downs-Black

measure of study quality, the validity and reliability of this tool has

not been demonstrated (Downs 1998). Furthermore, Lau 2012

pooled RCTs and studies of other designs together, and pooled

some studies with high I² statistic measures of heterogeneity.

An accurate assessment of the effectiveness of interventions to in-

crease influenza vaccination uptake in those aged 60 years and

older in the community, and the costs and benefits of these inter-

ventions, is essential to inform rational choice regarding the evi-

dence for universal recommendations to vaccinate older people in

the community. A separate review needs to be undertaken of those

living in institutions or temporarily accommodated in institutions

(such as emergency departments or hospitals).

O B J E C T I V E S

9Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

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.

M E T H O D S

Criteria for considering studies for this review

Types of studies

Randomised controlled trials (RCTs) or cluster-RCTs of interven-

tions to increase influenza vaccination uptake in those aged 60

years and older in the community, with recording of influenza

vaccination status either through clinic records or billing data, or

local or national vaccination registers were eligible for inclusion.

We included studies with either individual or group data.

We excluded studies without a case definition, retrospective de-

signs based only on individual recall of disease, or studies com-

paring different types of vaccines or different schedules or doses

without a control group.

Types of participants

Those aged 60 years or older living in the community. We also in-

cluded studies focused on interventions targeting healthcare work-

ers involved in the provision of vaccination to this population;

these include physicians, nurses, pharmacists, and administrators.

To ensure comparability with other Cochrane Reviews on in-

fluenza vaccination, we used the same age groupings (up to 60

years and aged 60 years and older). We used data for those aged

65 years or older if they were the only data presented in a study

and we were unable to obtain data for those aged 60 years or older

from the authors.

Types of interventions

Any intervention to increase uptake of influenza vaccination in

those aged 60 years or older, in any dose, preparation, or time

schedule, compared to another intervention or no intervention.

We assessed the following types of interventions separately.

1. To increase community demand, e.g. interventions to

increase people’s perceptions of their susceptibility to influenza,

the effectiveness of vaccination, and decrease concerns about side

effects, using postcards, letters, brochures, telephone calls,

computer reminders, educational campaigns, media campaigns,

vaccination campaigns, incentives for patients or client-held

records.

2. To enhance access, e.g. more clinics, more available clinic

hours, home visits, fewer administrative barriers, standing annual

vaccine orders, free vaccine or vaccine at reduced out-of-pocket

cost in the administrative area studied, or transfer of

responsibility to other staff groups (e.g. from physicians to

nurses), home visits, or increasing the effectiveness of vaccination

activities through quality improvement activities.

3. Provider or system based, e.g. to increase healthcare

workers’ beliefs that older people are susceptible to influenza and

that vaccination is effective and safe for themselves and their

patients; to increase healthcare worker professional behaviours

such as the frequency of taking a vaccination history,

documenting vaccination, and identifying high-risk patients;

organising reminders, reminders during annual physical

examinations, and organising and participating in educational

campaigns or meetings for healthcare workers.

4. Societal interventions, e.g. administrative frameworks or

decisions that differ between societies or regions of societies and

that affect vaccination uptake, such as increased remuneration to

healthcare workers for increasing vaccination uptake.

Types of outcome measures

We evaluated the effects of interventions on both immediate and

long-term changes in influenza vaccination uptake. The most im-

portant predictor of being vaccinated against influenza is being

vaccinated the previous year; therefore we ascertained baseline rates

in the year prior to the intervention. We excluded studies reporting

only serological outcomes if they did not include and report on an

intervention to increase vaccination uptake as well as an outcome

of actual vaccination uptake. We excluded studies that ascertained

outcomes only by self report.

Primary outcomes

Uptake of vaccination against influenza in those aged 60 years or

older.

Secondary outcomes

None.

Search methods for identification of studies

Electronic searches

We searched the Cochrane Central Register of Controlled Trials

(CENTRAL; 2017, Issue 11) (accessed 7 December 2017), which

includes the Cochrane Acute Respiratory Infections Group’s Spe-

cialised Register, MEDLINE (Ovid), Embase (Elsevier), CINAHL

(Cumulative Index to Nursing and Allied Health Literature) (EB-

SCO), and ERIC (Educational Resources Information Center)

(ProQuest) all from June 2014 to 7 December 2017 for this up-

date.

10Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

We searched MEDLINE and CENTRAL using the search strategy

described in Appendix 1. We combined the MEDLINE search

with the Cochrane Highly Sensitive Search Strategy for identify-

ing randomised trials in MEDLINE: sensitivity-maximising ver-

sion (2008 revision); Ovid format (Lefebvre 2011). We adapted

the MEDLINE search strategy to search Embase (Appendix 2),

CINAHL (Appendix 3), and ERIC (Appendix 4). See Appendix 5

for previous search details. We applied no language or publication

restrictions.

Searching other resources

We searched the World Health Organization (WHO) Interna-

tional Clinical Trials Registry Platform ( ICTRP) ( www.who.int/

ictrp) (Appendix 6) and ClinicalTrials.gov ( clinicaltrials.gov)

(Appendix 7) for completed and ongoing trials (latest search 7

December 2017). We also scanned the reference lists of included

studies, followed up every reference in the reviews and systematic

reviews, and contacted first or corresponding authors of relevant

studies to identify further published or unpublished trials.

Data collection and analysis

Selection of studies

Two review authors (RET, DLL) independently assessed all ab-

stracts for study design, reporting of influenza vaccination uptake

for those aged 60 years or older in the community and an inter-

vention to increase vaccination uptake. Two review authors (RET,

DLL) then independently assessed the full text of studies that ap-

peared eligible for inclusion.

Data extraction and management

Two review authors (RET, DLL) independently entered the fol-

lowing data on data abstraction sheets.

1. Methods (purpose, design, duration of study, interval

between intervention and when outcome was measured, power

computation, statistics).

2. Participants (country, setting, eligible participants and

health status, age, gender).

3. Interventions (intervention 1, intervention 2, control).

4. Outcomes (outcome measured, time points from the study

that are considered in the review or measured or reported in the

study, percentage vaccinated).

5. Funding.

Assessment of risk of bias in included studies

Two review authors (RET, DLL) independently assessed risk of

bias for each study using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011).

We resolved any disagreements by discussion. We assessed the risk

of bias according to the following domains.

1. Random sequence generation.

2. Allocation concealment.

3. Blinding of participants and personnel.

4. Blinding of outcome assessment.

5. Incomplete outcome data.

6. Selective outcome reporting.

7. Other bias.

We graded each potential source of bias as high, low, or unclear

and provided quotes from the study report together with a jus-

tification for our judgement in the ’Risk of bias’ table. We sum-

marised the ’Risk of bias’ judgements across different studies for

each of the domains listed. Where necessary, we considered blind-

ing separately for different key outcomes. Where information on

risk of bias related to unpublished data or correspondence with a

trialist, we noted this in the ’Risk of bias’ table.

When considering treatment effects, we took into account the risk

of bias for studies that contributed to that outcome.

Assessment of bias in conducting the systematic

review

We conducted this review update according to the published pro-

tocol and reported deviations from it in the Differences between

protocol and review section.

Measures of treatment effect

We entered outcome data for each study into data tables in Review

Manager 5 to calculate treatment effects (Review Manager 2014).

We used odds ratios for dichotomous outcomes.

We conducted meta-analyses only where this was meaningful, that

is where the treatments, participants, and the underlying clinical

question were sufficiently similar for pooling.

Unit of analysis issues

The Cochrane Handbook for Systematic Reviews of Interventions identifies five particular biases to consider in cluster-randomised

trials (Higgins 2011):

1. recruitment bias when individuals are recruited to the trial

after the clusters have been randomised;

2. “chance baseline imbalance between the randomized

groups, in terms of either the clusters or the individuals.

Although not a form of bias as such, the risk of baseline

differences can be reduced by using stratified or pair-matched

randomization of clusters. Reporting of the baseline

comparability of clusters, or statistical adjustment for baseline

characteristics, can help reduce concern about the effects of

baseline imbalance.”;

3. loss of clusters and missing outcomes for individuals within

clusters;

11Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

http://www.who.int/ictrp

http://clinicaltrials.gov/

4. “not taking the clustering into account ... Such analyses

create a ’unit of analysis error’ and produce over-precise results

(the standard error of the estimated intervention effect is too

small) and P values that are too small. They do not lead to biased

estimates of effect. However, if they remain uncorrected, they

will receive too much weight in a meta-analysis”; and

5. if there is “a herd effect in the cluster-randomized trials ...

such contamination would lead to underestimates of effect.

Thus, if an intervention effect is still demonstrated despite

contamination in those trials that were not cluster-randomized, a

confident conclusion about the presence of an effect can be

drawn. However, the size of the effect is likely to be

underestimated. Contamination and herd effects may be

different for different types of cluster.”

The solution is to correct each cluster-randomised trial by its in-

traclass correlation coefficient (ICC), but the Cochrane Handbook for Systematic Reviews of Interventions comments that “In fact this is seldom available in published reports. A common approach is to

use external estimates obtained from similar studies.” We searched

for relevant ICCs in similar studies and planned to correct for

clustering effects if possible (Higgins 2011).

Dealing with missing data

We contacted investigators or study sponsors to verify key study

characteristics and to obtain missing numerical outcome and ’Risk

of bias’ data (e.g. when a study was available only as an abstract).

Where requested data were not forthcoming, and missing data

could introduce bias, we explored the impact of excluding these

studies from the overall assessment of results by a sensitivity anal-

ysis.

Where numerical outcome data were missing, such as standard de-

viations or correlation coefficients, and we were unable to obtain

these data from the study authors, we calculated these data from

other available statistics such as P values according to the meth-

ods described in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011).

Assessment of heterogeneity

We assessed data for heterogeneity in each intervention category

and used the Chi² test to examine heterogeneity between studies

and the I² statistic to assess variability in estimates of effect due

to heterogeneity. We planned to perform a meta-analysis if the

I² statistic was less than 70% for groups of studies with a similar

intervention. We planned to use strategies for meta-regression (by

quality and by sample size) for the interventions that had more

than five RCTs.

Assessment of reporting biases

We constructed funnel plots (plots of the effect estimate from each

study against the sample size or effect standard error) to assess

the potential for bias related to the size of the trials, which could

indicate possible publication bias. We constructed funnel plots

for interventions with five or more RCTs because plots for fewer

RCTs would be hard to interpret.

Data synthesis

We used the numbers of vaccinated and unvaccinated individuals

from all included RCTs and cluster-randomised trials to synthe-

sise the data as odds ratios (ORs) employing the random-effects

model. We performed meta-analysis on groups of RCTs where ex-

posure, populations, and outcomes were homogenous, and where

the I² statistic was less than 70%. We classified interventions ac-

cording to CDC norms as: (1) interventions designed to increase

community demand for vaccinations; (2) enhance access to vacci-

nation services; (3) provider- or system-level interventions, or (4)

societal interventions (CDC 2018).

GRADE and ’Summary of findings’ table

We created three ’Summary of findings’ tables for three compar-

isons: interventions to increase community demand, interventions

to enhance access, and provider- or system-based interventions,

using the outcome of an increased influenza vaccination rate com-

pared to the previous year. We used the five GRADE considera-

tions (study limitations, consistency of effect, imprecision, indi-

rectness, and publication bias) to assess the certainty of evidence

as it related to the studies that contributed data to the meta-anal-

yses for the prespecified outcomes (Atkins 2004). We used meth-

ods and recommendations described in Section 8.5 and Chap-

ter 12 of the Cochrane Handbook for Systematic Reviews of Inter- ventions (Higgins 2011), employing GRADEpro GDT software (GRADEpro GDT 2014). We justified all decisions to downgrade

the quality of studies in footnotes, and made comments to aid

readers’ understanding of the review where necessary.

Subgroup analysis and investigation of heterogeneity

We analysed the included studies according to the three different

strategies used by study authors: increasing community demand,

enhancing vaccination access, and provider- or system-based in-

terventions. We pooled studies with similar interventions for each

of these three groups.

Sensitivity analysis

We carried out sensitivity analyses if interventions were tested by

five or more trials. We removed studies with the highest risk of bias,

serially, and then examined whether the heterogeneity decreased

to a level to permit meta-analysis (less than 70%). If heterogeneity

remained above 70%, we removed the smallest studies, serially,

and then examined whether the heterogeneity decreased to a level

to permit meta-analysis (less than 70%).

12Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

R E S U L T S

Description of studies

Results of the search

The searches for this update identified 1497 records. After de-

duplication of records and assessment of titles and abstracts, we

obtained six full-text studies for assessment. We included three

new studies for this update. This updated review includes a total

of 61 study reports involving 1,055,337 participants. See Figure

13Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Figure 1. Study flow diagram.

14Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Included studies

We included three new trials for a total of 61 included RCTs

(Conner 2017; Leung 2017; Stuck 2015). Studies were conducted

in 12 countries: the USA (n = 36), Canada (n = 7), Australia (n

= 4), the UK (n = 4), Spain (n = 3), and one each in Denmark,

Germany, Hong Kong, Israel, New Zealand, Puerto Rico, and

Switzerland. See Characteristics of included studies.

Design

Of the 61 included studies, 36 were RCTs and 25 were cluster-

randomised trials.

Sample sizes

There was a wide range of study sizes: the smallest study involved

45 participants (Buffington 1991), and the three largest each in-

volved more than 100,000 participants (Berg 2008; CDC 1995b

(Montana); Maglione 2002b).

Setting

All included studies were conducted in primary care settings (one

assessed preparations for discharge back to the community and

compared reminders to hospital staff to a letter to the general

practitioner (GP) on patient discharge back to the community).

Participants

All participants lived in the community and were aged 60 years

and older. All healthcare workers were from primary care settings

(with the exception of MacIntyre 2003, in which hospital workers

either reminded hospital staff or sent a reminder letter to the GP).

Interventions

The 61 included studies had 80 intervention arms. Of these, 53

arms tested interventions to encourage participants to obtain in-

fluenza vaccination (n = 767,460); 10 arms aimed to improve

health system access for participants to obtain vaccine (n = 9353);

and 17 arms encouraged physicians or health systems to increase

vaccination rates for participants (n = 278,524). Fifty-three in-

tervention arms encouraged participants to obtain vaccination; of

these, 45 arms used reminder and recall methods, and eight used

education techniques for participants. The studies included 10 in-

tervention arms that encouraged improved health system access:

one tested group visits to clinics; five investigated home visits; and

four offered free vaccines. Of the studies that encouraged improved

physician or health systems to increase vaccination rates, 11 arms

used reminders, three used education, two paid physicians, and

one encouraged health clinic staff to be vaccinated.

Outcomes

Influenza vaccination rates. No studies reported adverse effects.

Funding

Studies 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.

Excluded studies

We excluded a total of 352 studies from this review, three in this

most recent update. We excluded studies for the following reasons:

not RCT or cluster-randomised trial (n = 286; two new studies

excluded in this update); did not report separate outcome data for

people aged 60 years or older (n = 27; one new excluded study in

this update); did not report influenza outcomes data (n = 20); or

the population of interest did not include people aged 60 years or

older (n = 19). We independently reviewed all non-randomised

studies and determined that insufficient data were available to en-

able an evaluation of the potential effects of known and unknown

confounders on risk of bias. We did not include the data from these

studies in our analysis. See Characteristics of excluded studies and

Table 1.

Studies awaiting classification

Hurley 2017 randomised 5332 adults aged 65 years or older to

centralised reminder and recall for influenza vaccination, or usual

care. A conference abstract has been published, and full publication

has yet to be published. Attempts to contact the study authors have

so far been unsuccessful. We will assess this study for inclusion in

a future update of this review.

Risk of bias in included studies

See Figure 2 and Figure 3.

15Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Figure 2. ’Risk of bias’ summary: review authors’ judgments about each risk of bias item for each included

study.

16Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Figure 3. ’Risk of bias’ graph: review authors’ judgments about each risk of bias item presented as

percentages across all included studies.

Allocation

We assessed 23 trials as at low risk of bias, 35 trials as at unclear risk

of bias, and three trials as at high risk of bias. We assessed seven

trials as at low risk of bias for concealment of sequence allocation,

and 54 trials as at unclear risk of bias. Three trials were at high

risk for randomisation bias (Beck 1997; Kellerman 2000; Lukasik

1987). In Beck 1997, 113 participants did not receive the baseline

Senior Health Questionnaire, and the study authors did not state

if participants were randomly assigned. Lukasik 1987 reported

that “After a random start participants were alternately assigned to

each group,” and Kellerman 2000 used “alternate randomisation

of alphabetised households.”

With respect to allocation concealment, only seven trials described

their method of allocation concealment and were assessed as at low

risk of bias (Conner 2017; Dalby 2000; Garcia-Aymerich 2007;

Hogg 2008; Karuza 1995; Kerse 1999; MacIntyre 2003). The

trial authors of the remaining studies did not include an allocation

concealment statement.

Blinding

We assessed 27 included trials as at low risk of bias, 30 as at unclear

risk of bias, and four as at high risk of bias for this domain. Stud-

ies that reported independent verification of vaccination status

from databases, or after the trial from databases, were at lower risk

of detection bias, especially if the databases were independently

maintained by government or health organisation agencies. Of the

27 trials assessed as at low risk of bias, the vaccination outcomes

were measured through computerised databases in 17 studies; six

stated that healthcare workers were blinded; two that participants

were blinded; and eight that those who abstracted data from charts

were blinded. The numbers add up to more than 27 because some

studies stated more than one method of blinding.

We assessed four studies as at high risk of bias for this domain.

Leung 2017 stated that the study was unblinded and that the

medical student investigators delivered the intervention. Lukasik

1987 stated that “patients would be told, whether by telephone or

in the office, that the vaccine was available, and that they would

be given a shot if they wished.” Nexøe 1997 stated that “Ran-

domisation was blinded for the GPs. However, GPs were paid the

equivalent of USD 36 for each patient vaccinated without patient

fee.” Spaulding 1991 stated that “Physicians in the Department of

Family Practice were aware that a study was in progress and that

some of their participants might receive postcards about influenza

immunisation. Vaccine was offered to all eligible participants on a

walk-in basis. Patients who presented for immunisation read and

signed an informed consent document.” The authors of this study

did not report if physicians performed the vaccinations.

Incomplete outcome data

Thirty-one trials (51%) were at low risk and 23 trials (38%) at un-

clear risk of bias for incomplete outcome data. Seven trials (11%)

were at high risk of bias for this domain. In Barnas 1989, there was

15% dropout after randomisation and it was not stated if dropout

differed between groups. In Beck 1997, there were 48 (30%) drop-

17Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

outs from the intervention group and 21 (13%) from the con-

trol group, and the dropouts were not equivalent in composition.

In Clayton 1999 the authors reported: “Because the sensitivity of

administrative data is somewhat limited (estimated to be 62.4%,

according to Kaiser Permanente Northeast Division studies), the

vaccination rates presented are underestimates of the true rates.” In

Garcia-Aymerich 2007, only 21 of 44 integrated-care patients and

41 of 69 conventional-care patients were assessed after 12 months,

and whether the dropouts differed was not assessed. In Kiefe 2001,

13 of 48 physicians and their patients in the intervention group

with benchmarking and 14 of 49 in the comparison group with-

out benchmarking dropped out; a personal communication from

author Dr C Kiefe stated: “It was not possible to review records

for physicians who no longer wished to participate or were lost

to follow-up.” In Kim 1999, outcomes for the 7 physicians who

dropped out and their 128 participants, and a further 299 partici-

pants because their physician left the medical group, were not pre-

sented, and there was no ascertainment if the dropouts differed.

In the group of 239 patients sent a letter in McDowell 1986, only

2 were returned, but in the phone group the nurse was able to

contact only 177 of 208 (85%); in the personal contact group the

intervention was delivered to 201 of 218 (92%); and the authors

stated: “8 weeks after the study ended we called random samples

of patients from each study group who had apparently not been

vaccinated to estimate the extent of underreporting.” (Of the 97

contacted, the percentages unaware of the programme, refusing

vaccination, and undecided varied between the intervention and

control groups.)

Selective reporting

All 61 trials reported the results of all of their planned interventions

to increase vaccination rates, and also reported the number of

dropouts and thus were free of selective reporting.

Other potential sources of bias

We constructed funnel plots for interventions where there were

five or more RCTs. There were only two such groups: reminders

to participants and tailored reminders to participants. The funnel

plots did not show evidence of publication bias (Figure 4; Figure

5).

Figure 4. Funnel plot of comparison: 1 Increasing community demand, outcome: 1.1 Client reminder and

recall (postcard) compared to no intervention.

18Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Figure 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.

Unit of analysis issues

Of the 61 included studies, 25 were cluster-randomised trials; in 13

of these, the study authors corrected the cluster effect statistically (

Abramson 2011; Berg 2008; Chan 2002; Dapp 2011; Hogg 1998;

Hull 2002; Kerse 1999; Kiefe 2001; Kim 1999; Kouides 1998;

Lemelin 2001; Satterthwaite 1997; Siriwardena 2002).

Cluster-randomised trials with clustering effects controlled

for in the analysis (n = 13)

Five cluster-randomised trials were randomised by physicians.

Chan 2002 corrected randomisation by physician by general linear

mixed models. Dapp 2011 corrected randomisation by physician

by generalised estimating equations. Kiefe 2001 corrected nesting

of participants’ data within physicians by controlling for baseline

performance and by generalised linear models (but 27 of 97 physi-

cians were lost to follow-up). Kim 1999 corrected randomisation

by physician (to receive either ongoing education, academic detail-

ing and feedback, or ongoing education) by mixed-model analysis

of variance (ANOVA), with participants’ data nested within physi-

cians. Although the study authors did not explicitly say that the

effects of clustering were assessed, the analysis likely accomplished

this result. Kouides 1998 randomised physicians to the interven-

tion (additional remuneration for influenza vaccination uptake of

70% or above, with each physician’s individual vaccination uptake

displayed on posters in clinics, or to usual remuneration). Baseline

differences were controlled for by linear regression equations by

practices with seven potential confounders.

Three cluster-randomised trials were randomised by practice. In

Lemelin 2001, randomisation by practice was corrected by gen-

eral linear model repeated-measures ANOVA. Satterthwaite 1997

corrected for clustering using the Rao-Scott method. Siriwardena

2002 corrected randomisation of practices to educational out-

reach, audit and feedback compared to audit and feedback as fol-

lows: “Because the target of the intervention and therefore the unit

of randomisation was the practice, cluster-randomised methodol-

ogy was used” (p. 736). Siriwardena 2002 used Egret and SPSS

programs for analysis and “Poisson regression was used to detect

significant differences between intervention and control groups in

vaccination uptake change, using population at risk as an offset

and taking account of the stratification” (p. 737). The ICCs were

not provided, but the study authors stated that they took the clus-

tered design into account (Siriwardena 2002).

In one cluster-randomised trial, randomisation was conducted by

19Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

the clinic. In Abramson 2011, randomisation by clinics was cor-

rected with the Rao-Scott procedure in computing odds ratios

with an ICC of 0.015.

In four cluster-randomised trials, randomisation was done by

household. Hull 2002 and Kerse 1999 corrected randomisation

by household within practices by adjusting for clustering by gen-

eralised linear models, and Berg 2008 by using the ’proc genmod’

command repeated option in SAS. Hogg 1998 randomised par-

ticipants; subsequently, participants’ entire families were included

in the groups to which the participants were assigned. The lack of

group baseline equivalence in age, family size, and number of pro-

cedures was corrected for in the analysis, thus groups were made

equivalent (there were no data on the percentage of letters not

delivered). This was a cluster-randomised trial to increase the up-

take of several health interventions, and the authors corrected for

differences in the numbers achieved before randomisation.

Interaction among participants or among health team members

was an explicit part of the research design in these cluster-ran-

domised trials. For example, in Lemelin 2001 and Hogg 2008 fa-

cilitators visited practices and worked with practice team members

to encourage increased uptake; in Kerse 1999, the intervention

was an educational programme for GPs.

Cluster-randomised trials with clustering effects not

controlled for in the analysis (n = 12)

While the solution is to correct each cluster-randomised trial by

its ICC, the Cochrane Handbook for Systematic Reviews of Interven- tions comments that “In fact this is seldom available in published reports. A common approach is to use external estimates obtained

from similar studies” (Higgins 2011). We were not able to find

ICCs relevant to this group of studies.

Four trials were randomised by practice, three by physician, two

by household, and three by place of residence.

Randomisation by practice

In Buffington 1991, for 13 private group practices, 45 physicians

were randomised to two interventions: a poster in the physician’s

office displaying the number of influenza vaccinations they had

given, or poster plus reminder postcards sent to all patients. The

control group received no intervention. There were no data on

whether the physicians or the patients in these practices were sim-

ilar. Personal communication from Dr Marc LaForce described

the interest among the control group physicians and competition

between physicians (LaForce 2017 [pers comm]). Hogg 2008 ran-

domised solo or group practices to either intervention (27 prac-

tices) or control (27 practices), and two nurses with master’s de-

grees were assigned (one to 13 and the other to 14 intervention

practices). The control group had 58.7% female physicians per

practice (intervention had 33.2%), and 59.2% had practice nurses

(intervention had 51.8%). Practices were similar in numbers of

physicians per practice, hours booked/week, date of physician’s

graduation from medical school, and scores on the pre-interven-

tion preventive performance index. Clusters could differ by num-

bers of patients, physicians, or the availability of an intervention

nurse. Outcomes were summarised at the practice level. Karuza

1995 randomised 13 group practices to either receive an inter-

vention of a group discussion to adopt and implement a CDC

influenza vaccination guideline, or to no intervention (control

group). The intervention physicians had more visits per patient

during the influenza vaccination season (2.1 versus 1.6, P < 0.05)

and more arthritis patients (21% versus 11%, P < 0.05), but were

otherwise similar. There were no outcome differences between the

13 practice groups, so data were analysed for the 51 physicians as

a group. Eleven per cent of charts were not available for review at

study end. Outcomes were analysed at the physician level. There

was opportunity for interaction between participants, physicians,

and team members. Morrissey 1995 randomised participants to re-

ceive a nursing intervention within practices from nurses or physi-

cian assistants.

Randomisation by physician

Chambers 1991 randomised internal medicine residents into three

groups (all their patients received a reminder, or half their patients

received a reminder, or none of their patients received a reminder).

There were baseline group differences in patient age, risk level, and

number of visits. Regression analyses were run to assess the effects

of these differences, but these were not corrected for in the over-

all results. From a list of all primary care physicians in Louisiana,

Kumar 1999 randomly selected 750 to the intervention group.

Physicians in the intervention group were provided with a list-

ing of their Medicare patient pool immunisation rate and missed

opportunities, and “were encouraged to evaluate ways in which

their practices might improve upon the baseline immunisation sta-

tus and were offered assistance in designing quality improvement

projects to effect such a change. The information provided to the

physicians included computed uptake for all selected physicians

which allowed them to compare their uptake with those of other

physicians.” Nexøe 1997 randomised 13 solo physicians for their

patients to receive a postcard inviting them to receive free influenza

vaccination, or a postcard to receive vaccine at their own cost, or

to no postcard. There were no data on whether the practices or

physicians were similar.

Randomisation by household

Clayton 1999 randomised households to receive postcard re-

minders. The groups were equivalent at baseline on age, gender,

and state of residence; there was no information on the percent-

age of postcards not received. While not part of the study de-

sign, 8% of participants also received a reminder call from their

20Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

GP. Kellerman 2000 randomised households to receive reminder

phone calls; there were no data on group baseline equivalence, and

only 66% of phone calls were successful.

Randomisation by place of residence

CDC 1995a (Wyoming) and CDC 1995b (Montana) randomised

regions (composed of zip code aggregates) in two states to receive

reminder letters. There were no data on baseline equivalence or the

percentage of letters not received. McCaul 2002 stated: “First, we

randomly assigned counties to either the reminder-letter (n = 17),

action-letter (n = 12), or no letter (n = 20) conditions. Within the

reminder-letter counties we then randomly assigned individuals

within each county to either the reminder-only, reminder plus

positive frame, or reminder plus negative frame conditions. Within

the action letter counties, all individuals received the same letter

from their county public health offices.” (p. 625). The study design

was thus clustered, but incorporated random individual allocation

within the reminder letter group. There were no data on group

baseline equivalence and there was a 6% non-participation rate

mostly due to returned letters.

Conclusions about the cluster-randomised trials not corrected

by the study authors for clustering effects

For the cluster-randomised trials randomised by practice or physi-

cian to intervention or control, there may be discussions between

some team members; some physician participants may differ in

level of motivation, organisation, and persuasiveness; and the pa-

tients may speak to each other in the waiting room before mak-

ing a decision about vaccination. Those studies where the physi-

cian was designated as the focus of the intervention (and not just

a way of administratively reaching patients) may be expected to

have the strongest clustering effects. Hogg 2008 noted that the

practices and the physicians were similar, and Karuza 1995 that

the physicians were similar. Kouides 1998 controlled for baseline

differences by regression equations.

Clustering within households should have an effect only if the

household members had different attitudes to vaccination or re-

ceiving interventions.

For the studies that randomised by place of residence (states in the

USA), there were no data on baseline equivalence, but it is highly

unlikely there were conversations between potential participants.

Differences between groups could arise only from differences in

socioeconomic status or culture that affect willingness to receive

vaccination or interventions.

As none of these cluster-randomised trials stated ICCs, and there

are no standard ICCs published for this type of intervention, we

were unable to correct for clustering in those cluster-randomised

trials where the study authors had not corrected for clustering.

The only ICC reported was in a study by Abramson 2011 (who

noted an ICC of 0.015), but the intervention was vaccinating staff

and physicians (with the hope that this would increase physicians’

motivation to vaccinate patients) with no intervention to vaccinate

patients.

The limited number of these cluster-randomised trials and the

variability of the method of randomisation (by practice, physician,

household, or geographic area) meant that we did not have any

ICCs from other studies with which to correct for clustering.

We did not find any cluster-randomised trials where individuals

joined clusters after randomisation.

RCTs randomising individual participants (n = 36)

We included 36 RCTs presenting individual participant data that

did not involve clustering.

Some studies initially appeared to be cluster-randomised trials but

were not. In McDowell 1986, although families were selected, only

one patient was selected per family and then randomised. In Frank

2004, individual participants were randomised by the last digit

of their family medical record number to intervention (physicians

received automatic electronic reminders for 12 preventive care

interventions) or control. In this study, groups were equivalent at

baseline, but physicians were not blinded to group of allocation. In

Beck 1997, the intervention group received visits to their physician

and nurse at the clinic in groups (average size eight) for:

1. a 15-minute warm up and socialisation event, with

information presented on specific disease processes;

2. a 15-minute break for socialisation, followed by a nurse

checking blood pressure, immunisation status, immediate needs

and arranging for a visit with the patient’s physician;

3. 15 minutes of questions and answers and a planned next

visit; or

4. a 30-minute visit with their physician.

While it was expected that intervention patients would socialise

and exchange information with one another, randomisation was

by individual patient. In Maglione 2002a, Maglione 2002b,

Maglione 2002c, and Maglione 2002d, the intervention was de-

livered to individuals, but it was not stated whether randomisation

was by region within states. In CDC 1995a (Wyoming) and CDC

1995b (Montana), individuals were randomised within specific

regions of the two states.

Availability of baseline influenza vaccination rates

The key predictor of influenza vaccination is whether the con-

sumer received vaccination in the previous year. We therefore ini-

tially conducted separate analyses for RCTs that reported base-

line influenza vaccination uptake for both treatment and control

groups for the year prior to the intervention, and for RCTs with

no baseline data (Appendix 8).

Table 2 shows that for the 28 RCTs with data for the previous

year uptake, the difference in vaccination uptake in the treatment

21Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

and control groups was 0% to 2% in 18 RCTs, 3% to 4% in

seven RCTs, and 5% or more in three RCTs. Randomisation had

thus been relatively effective in producing intervention and con-

trol groups with similar uptake of influenza vaccination in the year

prior to the intervention. We therefore decided that it would be

appropriate to analyse the studies with and without baseline in-

fluenza uptake together.

Effects of interventions

See: Summary of findings for the main comparison

Increasing community demand compared to no intervention or

another intervention for increasing influenza vaccination uptake;

Summary of findings 2 Enhancing vaccination access compared

to no intervention or another intervention for increasing influenza

vaccination uptake; Summary of findings 3 Provider- or system-

based interventions compared to no intervention or another

intervention for increasing influenza vaccination uptake

The primary outcome was uptake of vaccination against influenza

in those aged 60 years or older. The outcome measure for all

interventions was any change in the percentage of participants

who received influenza vaccination.

1. Interventions to increase community demand

To increase community demand, 41 trials with 53 arms tested 12

intervention strategies with 767,460 participants. Forty-five arms

tested methods of client reminder and recall, and eight focused

on client education. For this group of interventions, a successful

intervention that could be meta-analysed was client reminders or

recalls by letter or leaflet. Succesful interventions tested by sin-

gle studies were patient outreach by retired teachers; invitations

by clinic receptionists; nurses educating and vaccinating patients;

medical students counselling patients; and multiple recall ques-

tionnaires. Some interventions could not be meta-analysed due to

significant heterogeneity: 17 studies testing simple reminders, 16

testing personalised reminders, two studies of customised letters

compared to form letters, and four studies of health risk appraisals

leading to a recommendation for vaccination. One study of a lot-

tery for free groceries was found not to be effective.

Client reminders and recall

Reminder postcard

Seventeen RCTs assessed the simplest kind of intervention, that

is a patient reminder postcard compared to no intervention

(intervention (n = 125,801); control (n = 276,566)) (Baker

1998; Barnas 1989; Berg 2008; CDC 1995a (Wyoming); CDC

1995b (Montana); Clayton 1999; Hogg 1998; Maglione 2002a;

Maglione 2002b; Maglione 2002c; McCaul 2002; Minor 2010;

Moran 1992; Moran 1995; Moran 1996; Puech 1998). There was

marked heterogeneity (Chi² = 535.169, P < 0.001; I² = 97%),

and data could not be pooled (Analysis 1.1; Figure 5). The 95%

confidence interval (CI) of 11/17 trials was above unity, implying

that all these interventions increased vaccination rates: Baker 1998

(odds ratio (OR) 1.15, 95% CI 1.06 to 1.26); Boca 2012 (OR

1.20, 95% CI 1.02 to 1.41); Maglione 2002a (OR 1.42, 95% CI

1.13 to 1.80); Maglione 2002b (OR 1.05, 95% CI 1.00 to 1.11);

Maglione 2002c (OR 1.14, 95% CI 1.00 to 1.08); McCaul 2002

(OR 1.33, 95% CI 1.21 to 1.47); CDC 1995a (Wyoming) (OR

1.91, 95% CI 1.81 to 2.02); CDC 1995b (Montana) (OR 1.51,

95% CI 1.42 to 1.61); Minor 2010 (OR 1.82, 95% CI 1.00 to

3.30); Moran 1996 (OR 2.05, 95% CI 1.23 to 3.41); and Puech

1998 (OR 3.75, 95% CI 1.87 to 7.56). There were insufficient

studies in each ’Risk of bias’ category with an appropriate I² statis-

tic to permit sensitivity analyses by ’Risk of bias’ category.

Letter, postcard, or phone call

Sixteen RCTs assessed letters, postcards, or phone calls person-

alised to the participant’s health status compared to no interven-

tion (intervention (n = 65,005); control (n = 130,959)) (Baker

1998; CDC 1995a (Wyoming); CDC 1995b (Montana); Díaz

Grávalos 1999; Dietrich 1989; Hogg 1998; Hull 2002; Humiston

2011; Kellerman 2000; McCaul 2002; McDowell 1986; Minor

2010; Mullooly 1987; Roca 2012; Smith 1999; Spaulding 1991).

There was marked heterogeneity (Chi² = 539.90, P < 0.001; I²

= 99%), and data could not be pooled (Analysis 1.2). The 95%

CI of 12/16 trials was above unity, implying that all these inter-

ventions increased vaccination rates: Baker 1998 (OR 1.22, 95%

CI 1.13 to 1.31); Díaz Grávalos 1999 (OR 6.92, 95% CI 3.07 to

15.64); Hull 2002 (OR 1.27, 95% CI 1.02 to 1.58); Humiston

2011 (OR 6.25, 95% CI 5.41 to 7.22); McCaul 2002 (OR 1.61,

95% CI 1.49 to 1.74); CDC 1995a (Wyoming) (OR 1.79, 95%

CI 1.69 to 1.90); CDC 1995b (Montana) (OR 2.07, 95% CI 1.45

to 2.20); Minor 2010 (OR 2.18, 95% CI 1.13 to 4.18); Mullooly

1987 (OR 1.48, 95% CI 1.24 to 1.76); Roca 2012 (OR 6.33,

95% CI 2.84 to 14.14); Smith 1999 (OR 1.24, 95% CI 1.14

to 1.35); and Spaulding 1991 (OR 3.29, 95% CI 1.82 to 5.96).

There were insufficient studies in each ’Risk of bias’ category with

an appropriate I² statistic to permit sensitivity analyses by ’Risk of

bias’ category.

Reminder letter + leaflet or postcard versus a reminder letter

only

Three trials compared a reminder letter plus leaflet (or postcard)

to a letter (intervention (n = 32,112); control (n = 32,088)) (OR

1.11, 95% CI 1.07 to 1.15; P < 0.001; I² = 0%; Analysis 1.3)

(Maglione 2002b; Maglione 2002d; Nuttall 2003).

Letter or phone call versus form letter

22Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Four trials compared a customised letter or phone call to a form

letter (intervention (n = 39,798); control (n = 42,667)) (Analysis

1.4) (CDC 1995a (Wyoming); CDC 1995b (Montana); Hogg

1998; Minor 2010). There was marked heterogeneity (Chi² =

74.39, P < 0.001; I² = 96%), and data could not be pooled. The

95% CI of two trials was above unity, implying that both these

interventions increased vaccination rates: Minor 2010 (OR 1.93,

95% CI 1.02 to 3.64) and CDC 1995b (Montana) (OR 1.37,

95% CI 1.27 to 1.48). We assessed all four trials as at unclear risk

of bias for randomisation; two trials were at low risk and two at

unclear risk for attrition bias. We were thus unable to perform a

sensitivity analysis.

Telephone calls to clients

Telephone calls to clients are much more time intensive, requir-

ing contacting the consumer (sometimes with multiple attempts),

presenting information, and arranging an appointment.

Krieger 2000 (intervention (n = 102); control (n = 91)) compared

a telephone call from a retired teacher plus an educational brochure

to usual publicity (OR 3.33, 95% CI 1.79 to 6.22; P < 0.001;

Analysis 1.5). However, for participants who had been vaccinated

the previous year, vaccination uptake in the intervention group

declined from 100% to 98.5%, and in the control group from

100% to 94.7%, a non-significant difference.

Lukasik 1987 (intervention (n = 120); control (n = 123)) compared

telephone vaccination invitations versus an invitation made when

participants dropped into the clinic (OR 2.72, 95% CI 1.55 to

4.76; P = 0.001; Analysis 1.6).

Lottery for free groceries

This was the most unusual intervention. Moran 1996 (interven-

tion (n = 153); control (n = 138)) compared a brochure plus a

lottery for free groceries to no intervention (OR 1.04, 95% CI

0.62 to 1.76; P = 0.88; Analysis 1.7).

Questionnaires seeking intentions

Conner 2017 (intervention (n = 3100); control (n = 3200)) in a

comprehensive RCT compared six different questionnaires to mo-

tivate individuals to attend for influenza vaccination. One ques-

tionnaire was a simple enquiry about intention to attend for vac-

cination. A second questionnaire asked about regret if the partic-

ipant did not attend. A third questionnaire asked about benefits

(four questions: would benefit both me and people I know; I’d

feel good about myself; responsible thing to do; will protect the

health of people I care about). For each of these three questionnaire

groups there was a parallel group that received the same questions

plus a sticky note (“Please take a few minutes to complete this

for us. Thank you”). There were minimal and non-significant dif-

ferences in vaccination rates among these three question groups,

and when grouped together the average vaccination rate was 2.8%

higher than control (414 additional vaccinees). The OR was 1.13

(95% CI 1.03 to 1.24; P = 0.0078; Analysis 1.8).

Client-based education and vaccination

Health risk appraisal

Four trials (intervention (n = 3100); control (n = 3200)) compared

a health risk appraisal plus an offer of influenza vaccination to no

intervention (Garcia-Aymerich 2007; Ives 1994; Morrissey 1995;

Stuck 2015). There was significant heterogeneity (Chi² = 77.76;

P < 0.001; I² = 96%), hence data could not be pooled for analysis

(Analysis 1.9). The 95% CI was above unity in all four trials,

implying all four trials increased vaccination rates: Díaz Grávalos

1999 (OR 7.03, 95% CI 3.01 to 16.39); Ives 1994 (OR 2.17,

95% CI 1.70 to 2.77); Morrissey 1995 (OR 8.09, 95% CI 5.41

to 12.09); and Stuck 2015 (OR 1.33, 95% CI 1.12 to 1.58).

Client-based education; vaccination provided by nurses

Two RCTs (intervention (n = 293); control (n = 321)) compared

nurses or pharmacists educating participants about influenza vac-

cination and nurses vaccinating participants with no intervention

(Herman 1994; Marrero 2006). The OR was 3.29 (95% CI 1.91

to 5.66; P < 0.001). Heterogeneity was low (Chi² = 1.12, P = 0.27;

I² = 18%; Analysis 1.10). Herman 1994 (intervention (n = 243);

control (n = 242)) also compared nurses educating and vaccinat-

ing participants to only educating participants and found the vac-

cination uptake in the intervention group increased 23.8% and

declined in the education-only group by 2.1% (P = 0.001). The

OR was 152.95 (95% CI 9.39 to 2490.67; P = 0.001; Analysis

1.11).

Face-to-face three-minute presentation

Leung 2017 (intervention (n = 265); control (n = 264)) investi-

gated three-minute face-to-face presentations by medical students

with a two further minutes for questions; the OR was 1.62 (95%

CI 1.11 to 2.35; P = 0.01; Analysis 1.12).

2. Interventions to enhance vaccination access

To increase community vaccination access, eight trials with 10

arms tested six strategies with 9353 participants. One arm assessed

the effect of visits by groups of participants to primary health care.

Five assessed home visits, and four free vaccines. We could meta-

analyse the following interventions: home visits and free vaccine

compared to patient payment for vaccine. We were unable to meta-

analyse some interventions due to significant heterogeneity: home

visits by nurses plus a physician care plan (CI above unity) and

free vaccines compared to no intervention. One study of group

23Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

visits was effective, and one of a home visit compared to a safety

intervention was not.

Group visits to physicians and nurses

Beck 1997 (intervention (n = 160); control (n = 161)) compared

visits by groups of participants to a physician and nurse to usual

care by a physician. The OR was 27.19 (95% CI 1.60 to 463.25;

P = 0.02). The uptake in the intervention group increased from

74% in the previous year to 81%, and declined from 72% to 64%

in the control group. This decline could not be entered in the

dichotomous data entry table, and the result would be stronger if

the decline could be recorded (Analysis 2.1).

Home visits

Arthur 2002 compared a home visit with an offer of influenza

vaccination to a letter inviting participants to attend a vaccination

clinic. The OR was 1.28 (95% CI 1.03 to 1.58). Nuttall 2003

compared a home visit with an offer of influenza vaccination to

usual care. Their combined total was intervention (n = 710 par-

ticipants); control (n = 1402). The pooled OR was 1.30 (95% CI

1.05 to 1.61; P = 0.01), with low heterogeneity (Chi² = 0.86, P =

0.35; I² = 0%; Analysis 2.2).

Black 1993 (intervention (n = 198); control (n = 152)) compared

home visits that included an encouragement to receive influenza

vaccination to home visits with a safety intervention. The OR was

0.98 (95% CI 0.64 to 1.50; P = 0.92; Analysis 2.3). Black 1993

noted: “Another 45 clients had been assigned to the influenza

group but did not receive the promotion because the public health

nurse found that they had already been administered influenza

vaccine. These 45 participants and those who were missed (n =

9) were included in the analysis in their originally allocated group

(an ”intention to treat“ analysis); thus a total sample of 359 was

analysed.” (p. 1752). However, Black 1993 did not report the

distribution of these 45 between the intervention and the control

groups, and an uneven distribution could positively or negatively

affect the apparent effect of the intervention.

Two trials assessed the effects of a home visit by a nurse with en-

couragement to receive influenza vaccination (combined interven-

tion (n = 647); control (n = 1422)) (Dalby 2000; Dapp 2011).

There was marked heterogeneity (Chi² = 10.99, P = 0.001; I² =

91%), and data could not be pooled (Analysis 2.4). The Dapp

2011 study was much larger (574 intervention, 1353 control group

participants), with a complex intervention (health risk appraisal,

individualised recommendations, health information, reinforce-

ment by home visit or group sessions). The OR was 1.68 (95%

CI 1.37 to 2.07; P < 0.001). Dalby 2000, a small study with 73

participants in the intervention and 69 in the control group, also

employed a complex intervention (home visits with encourage-

ment to receive influenza vaccination plus a care plan developed

with a physician). The OR was 1.84 (95% CI 1.51 to 2.25; P <

0.001; Analysis 2.4). The group was unusual in being older (av-

erage age 78 years) and included women who had been widowed,

hospitalised, or experienced a degree of functional loss in the pre-

vious six months. Although the study scored a low risk of bias for

randomisation, there was a marked gender imbalance, with 71%

female in the experimental group and 62% in the control group.

Free influenza vaccination

Two RCTs (combined intervention (n = 1125); control (n = 1125))

compared an offer of free influenza vaccination to an invitation to

be vaccinated but the participant paid (Nexøe 1997; Satterthwaite

1997). The OR was 2.36 (95% CI 1.98 to 2.82; P < 0.001).

Heterogeneity was low (Chi² = 0.42, P = 0.52; I² = 0%; Analysis

2.5).

The same two RCTs compared an offer of free vaccination to no

intervention. However, we were unable to pool the trials due to

high heterogeneity (Chi² = 6.72, P = 0.010; I² = 85%). Individu-

ally, Nexøe 1997 found an OR of 7.80 (95% CI 4.97 to 12.24; P

< 0.001) and Satterthwaite 1997 an OR of 4.03 (95% CI 3.25 to

4.99; P < 0.001; Analysis 2.6).

3. Provider- or system-based interventions

To increase provider- or system-based provision, 15 trials with

17 arms tested 11 intervention strategies incorporating a total of

278,524 participants. Eleven arms assessed reminders to physi-

cians; three assessed education and feedback to physicians; two

payment to physicians; and one vaccinating clinic staff. One suc-

cessful intervention we could meta-analyse was payment to physi-

cians. Successful interventions tested by individual studies were:

reminding physicians to vaccinate all patients compared to re-

minding approximately half of the patients; posters in clinics pre-

senting vaccination rates and encouraging competition between

doctors; and chart review and benchmarking to the rates achieved

by the top 10% of physicians. We were unable to meta-analyse

reminders to physicians and facilitator encouragement of vacci-

nation. Interventions that were not effective were: letters to GPs

upon discharge from hospital; posters plus postcards versus posters

alone; educational reminders; academic detailing and peer com-

parisons compared to mailed educational materials; educational

outreach plus feedback to teams versus written feedback; and in-

creasing staff vaccination rates.

Reminders to physicians

Four trials (intervention (n = 71,845); control (n = 130,419))

compared a reminder to physicians to no intervention (Chambers

1991; Chan 2002; Frank 2004; Kumar 1999). There was marked

heterogeneity (Chi² = 30.66; P < 0.001; I² = 90%), and the trials

could not be pooled (Analysis 3.1). Kumar 1999 (OR 1.18, 95%

CI 1.13 to 1.23) and both arms of Chamber’s trial had their 95%

CI above unity. In Chamber’s main trial the OR was 2.30 (95%

24Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

CI 1.49 to 3.54), and in another arm which compared 198 partic-

ipants in the intervention group (reminder to physicians about all

their patients) and 118 in the control group (reminder to physi-

cians about half of their patients) the OR was 2.47 (95% CI 1.53

to 3.99; P = 0.001) (Chambers 1991), (Analysis 3.2). Two tri-

als had a 95% CI which included unity: Frank 2004 (OR 1.22;

95%CI 0.87, 1.70) and Chan 2002 (OR 1.07, 95% CI 0.98 to

1.17). We assessed three trials as at low risk of bias and one as at

unclear risk of bias for both randomisation and attrition, thus a

sensitivity analysis was not feasible.

MacIntyre 2003, a very small study (intervention (n = 17); control

(n = 27)), compared a reminder to hospital staff to vaccinate the

participants to a reminder letter to the participants’ GP on the day

of discharge. The OR was 1.70 (95% CI 0.51 to 5.70; P = 0.39;

Analysis 3.3).

Posters in clinics as a reminder to physicians, participants,

and staff

Buffington 1991 (intervention (n = 3604); control (n = 4772))

compared displaying posters in clinics with the influenza vaccina-

tion uptake by individual physicians (to encourage physicians to

compete) plus postcards to participants, to no intervention. The

OR was 2.03 (95% CI 1.86 to 2.22; P < 0.001; Analysis 3.4).

The same RCT (intervention (n = 3604); control (n = 2149))

compared posters in clinics displaying vaccination uptake and also

sending postcards to participants, to posters in clinics displaying

vaccination uptake. The OR was 1.06 (95% CI 0.95 to 1.19; P =

0.32; Analysis 3.5).

Facilitator encouragement of prevention manoeuvres

Three RCTs (combined intervention (n = 1013); control (n =

1170)) compared facilitator encouragement to perform prevention

manoeuvres, including influenza vaccination, to no intervention

(Hogg 2008; Karuza 1995; Kerse 1999). Heterogeneity was high

(Chi² = 34.74, P < 0.001; I² = 94%), and the studies could not

be pooled (Analysis 3.6). However, Hogg 2008 found an OR of

2.11 (95% CI 1.27 to 3.49; P = 0.001), and Karuza 1995 an

OR of 292.81 (95% CI 18.16 to 4721.62; P ≤ 0.001) (the high

upper 95% CI was due to the fact that there was no change in

the vaccination rate in the control group). Hogg 2008 did not

obtain baseline influenza vaccination data from the previous year.

Lemelin 2001 did not present numbers of participants aged 65

or older and so could not be included in the meta-analysis, but

the increase in vaccination uptake in the intervention group was

18.7% and 4.0% in the control (P = 0.01).

Physician education and feedback

Kim 1999 (intervention (n = 706); control (n = 694)) compared

educational reminders, academic detailing, and peer comparisons

to other physicians, to mailed educational materials. The OR was

1.13 (95% CI 0.80 to 1.58; P = 0.50; Analysis 3.7).

Kiefe 2001 (intervention (n = 678); control (n = 682)) compared

chart review and feedback to physicians plus benchmarking to the

vaccination uptake achieved by the top 10% of physicians, to chart

review and feedback. The OR was 3.43 (95% CI 2.37 to 4.97; P

< 0.001; Analysis 3.8).

Siriwardena 2002 (intervention (n = 13,633); control (n =

13,947)) found that educational outreach and feedback to practice

teams was less effective than written feedback to practice teams.

The OR was 0.77 (95% CI 0.72 to 0.81; P < 0.001; Analysis 3.9).

Payment to physicians for influenza vaccinations

Ives 1994 and Kouides 1998 (combined intervention (n = 1559);

control (n = 1256)) compared capitated payments to payment

per vaccination. The OR was 2.22 (95% CI 1.77 to 2.77; P <

0.001), with minimal heterogeneity (Chi² = 0.23, P = 0.63; I² =

0%; Analysis 3.10).

Interventions to increase staff influenza uptake

Abramson 2011 encouraged primary care physicians to receive in-

fluenza vaccination, hoping that would encourage them to vacci-

nate their patients. The physicians in the intervention group cared

for 11,325 patients, and those in the control group 15,097 pa-

tients. For vaccination of patients the OR was 1.04 (95% CI 0.97

to 1.12; P = 0.24; Analysis 3.11).

4. Societal interventions

We included no RCTs conducted at the societal level.

Joseph 2005 assessed the effects of the change in influenza vac-

cination policy in the UK from a purely risk-based policy to one

that stated that age itself is a risk, because of the increasing risks

from influenza with age, and also because age is associated with

risk factors that may be unknown to older people. In 1998 it was

recommended that those aged 75 years or older should be offered

influenza vaccination, and in 2000 it was recommended for those

aged 65 or over. For those aged 65 to 74 years, uptake rose from

34.6% (1989 to 1990) to 55.8% (1999 to 2000), 65.8% (2000

to 2001), and 72.1% (2003 to 2004), showing a higher uptake

after the introduction of the 2000 policy to vaccinate those aged

65 years or over.

A study of 795 general practices in England found that, for pa-

tients 65 and older, vaccination rates increased 7% if a personal

invitation was sent; a lead staff member led the campaign and pro-

duced a practice report; and the campaign continued until the UK

Quality and Outcomes Framework targets were met. If a lead staff

member searched the practice information technology framework

25Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

for candidates for vaccination, there was a 4% increase in vacci-

nation rates (Dexter 2012).

McGovern 2008 performed a serial cross-sectional study of the

recording of coronary heart disease-related health indicators and

medications in 301 general practices in Scotland. Before the con-

tract on 31 March 2004, 3.7% of participants over the age of 16

years had a computer record of coronary heart disease; post con-

tract on 31 March 2005 this was 4.9%. Of these, 57.4% had re-

ceived influenza vaccination before and 85.5% after the contract,

although the data do not differentiate those aged up to 60 years

and those aged 60 years and older.

Siriwardena 2003b reported on the impact of a clinical governance

aim of immunising 60% of participants aged 65 years and older

against influenza in 2000 in the West Lincolnshire Primary Care

Trust. All 39 practices in this geographic area signed a clinical

governance contract to participate and agreed to a practice audit

(compulsory audit for coronary heart disease and voluntary audit

for influenza vaccination). Practices that completed agreements

also received additional payments. The baseline audit was con-

ducted in May 2000, and the audit was repeated in April 2001.

Changes in vaccination uptake were calculated for the 24 practices

that completed the audit cycle, and uptakes were compared using

paired t-tests. There was a mean improvement of 24% (95% CI

19.7 to 28.4; P < 0.001) in vaccination uptake in participants aged

65 years or over (mean at baseline 48.9%, at follow-up 73.0%).

Jansen 2008 noted that in the Netherlands before the 1996 to 1997

respiratory season influenza vaccination was only recommended

for individuals with high-risk medical conditions, and then ex-

tended to all those aged 65 years or older. Uptake for those aged

65 years or older increased from 30% in 1991 to 45% in 1995

and 87% in 2002.

Remmen 2002 studied variations in influenza vaccination uptake

in a group practice physically located in Belgium but near the

Netherlands border, which included participants from both Bel-

gium and the Netherlands. Participants shared the same language

and socioeconomic characteristics but were provided with services

related to their country of residence. Since the year 2000 in both

countries vaccination has been recommended for people aged 65

years or older, as well as for others with health conditions that

place them at high risk of influenza complications. In Belgium,

approximately 75% of the cost of obtaining a vaccine from a phar-

macy and having it administered by a physician is covered by in-

surance. In contrast, in the Netherlands, vaccination is obtained

from physicians’ offices, with no direct cost to the patient. Among

those aged 65 years or older, 64.3% of Belgian compared to 77.5%

of Dutch participants were immunised in 2000 to 2001.

Two reports evaluated the effect of including influenza vaccination

as a USA Medicare B benefit from 1988 to 1992 for 2 million

individuals aged 65 years or older at intervention sites statewide

in 10 states and at selected sites in another 10 states. Shalala 1993

assessed the impact on influenza vaccination by telephone sur-

veys. Rates in telephone surveys were higher than claims by physi-

cians, implying some individuals did not have Medicare pay for

their flu shot. Vaccination rates in the surveys rose from 34% in

1988 to 1989 to 50% in 1991 to 1992. Schmitz 1993a indicated

that extensive publicity campaigns and mail out of an informa-

tive and persuasive letter had accompanied the implementation of

this demonstration project. Over the period of the demonstration,

vaccination uptake increased in both intervention and demonstra-

tion areas. For those aged 65 to 74 years, the difference in cover-

age between intervention and comparison groups increased from

+3% for 1988 to 1989 to +8% for 1989 to 1990 and to +12% for

1990 to 1991. For those aged 75 to 84 years, the differences were

+1%, +4%, and +12%, respectively. Among those aged 85 years

or older, the respective differences were -5%, -5%, and +12%.

Frick 2004 assessed the effect of including influenza vaccination

as a Medicare benefit by using data from the Women’s Health and

Aging Study for 12 zip (postal) codes in Baltimore and interviewed

71% of the 1409 eligible females. However, uptake increased in

the two years before the introduction of Medicare, and uptake

thereafter decreased for African-American people, and dipped then

slightly increased for Caucasian (understood to be white) females.

Jha 2003 assessed the effects of the US Department of Veterans Af-

fairs’ 1995 re-engineering initiative, which implemented quality-

of-care indicators and compared vaccination uptake of Veterans

Affairs patients to that of patients in the Medicare fee-for-service

system. Influenza vaccination uptake for those aged 65 years or

older in the Veterans Affairs system increased from 28% in 1994

to 1995 before re-engineering to 78% in 2000. Uptake was 71%

in 1997 to 1999 (compared to 66% for Medicare) and 78% in

2000 (compared to 71% for Medicare 2000 to 2001). There was

no assessment of the differences in population characteristics or

medical resources of the two systems.

The 2001 Japanese immunisation law subsidised routine influenza

vaccinations for those aged 65 years or older or those aged 60 years

or older with specific health conditions (Ohkusa 2005). Copay-

ments are determined by each local government every year, and

excess costs beyond co payments are subsidised by central and lo-

cal governments and paid directly to the medical institutions that

provide vaccinations. Ohkusa 2005 compared the amount of the

copayment provided by local government in 12 large cities to the

influenza immunisation uptake. Vaccination uptake increased in

2002 to 2003 compared to the 2001 to 2002 season, and the mag-

nitude of the association was negatively related to the amount of

the copayment.

These interventions on the societal level were the most challeng-

ing to evaluate because of unknown biases due to secular trends of

increasing influenza vaccination rates in most societies; multiple

and often unknown co-interventions in the form of, for example,

newspaper and magazine articles and alerts; and initiatives by or-

ganisations on many levels from individual practices to regional

campaigns. Overall, these societal interventions correlate with in-

creases in influenza vaccination rates.

26Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

A D D I T I O N A L S U M M A R Y O F F I N D I N G S [Explanation]

Enhancing vaccination access compared to no intervention or another intervention for increasing influenza vaccination uptake

Patient or population: people aged 60 years and older living in the community

Setting: the community

Intervention: enhancing vaccination access

Comparison: no intervention or another intervention

Outcomes Anticipated absolute effects* (95%CI) Relative effect

(95%CI)

of participants

(studies)

Certainty of the evi-

dence

(GRADE)

Comments

Comparator Intervention

Group visits of par-

ticipants to physician

and nurse compared to

usual care

Study population OR 27.19

(1.60 to 463.25)

321

(1 RCT)

⊕⊕⊕©

MODERATE 1

0 per 1000 0 per 1000

(0 to 0)

Home visit compared

to invitation to at-

tend influenza vaccina-

tion clinic

Study population OR 1.30

(1.05 to 1.61)

2112

(2 RCTs)

⊕⊕⊕⊕

HIGH

213 per 1000 260 per 1000

(221 to 303)

Home visit with en-

couragement to receive

influenza vaccination

compared to home visit

with safety intervention

Study population OR 0.98

(0.64 to 1.50)

350

(1 RCT)

⊕⊕⊕⊕

HIGH

566 per 1000 561 per 1000

(455 to 662)

Home visit by nurse

or group sessions with

encouragement to re-

ceive influenza vacci-

nation plus care plan

developed with physi-

cian compared to no in-

tervention

Study population - 2069

(2 RCTs)

⊕⊕⊕⊕

HIGH

We could not pool the

data due to heterogene-

ity (I² = 91%). The

95% CI for both trials

was above unity, imply-

ing that both interven-

tions increased vacci-

nation rates2 7

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http://www.thecochranelibrary.com/view/0/SummaryFindings.html

566 per 1000 706 per 1000

(663 to 746)

Free influenza vaccine

compared to invitation

to be vaccinated but pa-

tient pays

Study population OR 2.36

(1.98 to 2.82)

2251

(2 RCTs)

⊕⊕⊕⊕

HIGH

304 per 1000 507 per 1000

(463 to 552)

Free influenza vaccine

compared to no inter-

vention

Study population - 2250

(2 RCTs)

⊕⊕⊕⊕

HIGH

We could not pool the

data due to heterogene-

ity (I² = 85%). The

95% CI for both trials

was above unity, imply-

ing that both interven-

tions increased vacci-

nation rates

184 per 1000 550 per 1000

(391 to 700)

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its

95% CI).

CI: confidence interval; OR: odds ratio; RCT: randomised controlled trial

GRADEWorkingGroup grades of evidence

High certainty: We are very confident that the true effect lies close to that of the estimate of the effect.

Moderate certainty: We are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is

substantially different.

Lowcertainty: Our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect.

Very low certainty: We have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect

1High risk for randomisation and incomplete data.

2 8

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Provider- or system-based interventions compared to no intervention or another intervention for increasing influenza vaccination uptake

Patient or population: people aged 60 years and older living in the community

Setting: the community

Intervention: provider- or system-based interventions

Comparison: no intervention or another intervention

Outcomes Anticipated absolute effects* (95%CI) Relative effect

(95%CI)

of participants

(studies)

Certainty of the evi-

dence

(GRADE)

Comments

Comparator Intervention

Reminder (to physician)

compared to no re-

minder

Study population - 202,264

(4 RCTs)

⊕⊕⊕⊕

HIGH

We could not pool the

data due to heterogene-

ity (I² = 90%). The 95%

CI for 3/ 4 trials was

above unity, implying

that these 3 interven-

tions increased vacci-

nation rates

46 per 1000 56 per 1000

(42 to 72)

Reminder to physician

about all participants

compared to reminder

about half of partici-

pants

Study population OR 2.47

(1.53 to 3.99)

316

(1 RCT)

⊕⊕⊕⊕

HIGH

314 per 1000 530 per 1000

(411 to 646)

Reminder (to hospital

staff to vaccinate pa-

tient) compared to re-

minder letter to GP on

day of discharge

Study population OR 1.70

(0.51 to 5.70)

(1 RCT)

⊕⊕⊕⊕

HIGH

500 per 1000 630 per 1000

(338 to 851)

Posters in clinic dis-

playing influenza vacci-

nation rates to encour-

age doctors to compete

Study population OR 2.03

(1.86 to 2.22)

8376

(1 RCT)

⊕⊕⊕⊕

HIGH

2 9

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plus postcards to par-

ticipants compared to

no intervention 504 per 1000 673 per 1000

(654 to 693)

Posters in clinic dis-

playing influenza vacci-

nation rates to encour-

age doctors to compete

plus postcards to par-

ticipants compared to

posters alone

Study population OR 1.06

(0.95 to 1.19)

5753

(1 RCT)

⊕⊕⊕⊕

HIGH

661 per 1000 674 per 1000

(649 to 699)

Facilitator encourage-

ment of prevention

manoeuvres including

influenza vaccination

compared to no inter-

vention

Study population - 2183

(3 RCTs)

⊕⊕⊕©

MODERATE 1 We could not pool the

data due to heterogene-

ity (I² = 94%). The

95% CI for 3/ 4 trials

was above unity, imply-

ing that the 3 interven-

tions increased vacci-

nation rates

154 per 1000 500 per 1000

(92 to 907)

Educational reminders,

academic detailing,and

peer comparisons to

physicians compared

to mailed educational

materials

Study population OR 1.13

(0.80 to 1.58)

1400

(1 RCT)

⊕⊕⊕©

MODERATE 2

99 per 1000 111 per 1000

(81 to 149)

Chart review and feed-

back to physician plus

benchmarking to vac-

cination rates achieved

by top 10% of physi-

cians compared to

chart review and feed-

back

Study population OR 3.43

(2.37 to 4.97)

1360

(1 RCT)

⊕⊕⊕©

MODERATE 3

3 0

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60 per 1000 180 per 1000

(132 to 241)

Educational outreach

plus feedback to prac-

tice teams versus writ-

ten feedback to prac-

tice teams

Study population OR 0.77

(0.72 to 0.81)

27,580

(1 RCT)

⊕⊕⊕⊕

HIGH

254 per 1000 208 per 1000

(197 to 216)

Payment to physicians

versus no payment

Study population OR 2.22

(1.77 to 2.77)

2815

(2 RCTs)

⊕⊕⊕⊕

HIGH

100 per 1000 198 per 1000

(165 to 236)

Intervention to increase

staff influenza vaccina-

tion rate versus no in-

tervention

Study population OR 1.04

(0.97 to 1.12)

26,432

(1 RCT)

⊕⊕⊕⊕

HIGH

137 per 1000 142 per 1000

(133 to 151)

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its

95% CI).

CI: confidence interval; OR: odds ratio; RCT: randomised controlled trial

GRADEWorkingGroup grades of evidence

High certainty: We are very confident that the true effect lies close to that of the estimate of the effect.

Moderate certainty: We are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is

substantially different.

Lowcertainty: Our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect.

Very low certainty: We have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect

1One trial at high risk for incomplete data. 2High risk for incomplete data. 3High risk for incomplete data.

3 1

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D I S C U S S I O N

Of the 61 included RCTs, 31 were published in 1999 or earlier, and

30 in 2000 or later. However, there were few studies in which the

research work was undertaken during or after the avian influenza

and H1N1 or H2N3 scares. These events changed the level of

concern of both the public and the health professions, with many

interventions at international, societal, and regional levels, and

significant media coverage in the form of nightly news bulletins

on the radio, TV, and in the press. There is thus the question

of whether all of the current body of evidence is relevant during

pandemic scares and whether it remains relevant during routine

influenza seasons.

Researchers have tested a wide range of interventions relevant to

increasing community demand for influenza vaccination, increas-

ing access, and provider- and system-based interventions. We as-

sessed 37% of included studies as at low risk of bias for sequence

generation; 20% as at low risk for allocation concealment bias;

45% as at low risk of blinding bias; 52% as at low risk for attri-

tion bias; and no studies as at risk of selective reporting bias. The

overall GRADE assessment of the evidence was high to moderate

quality.

For the letter, postcard, and phone call interventions, there was

marked heterogeneity; although most individual trials reported

significant results, a meta-analysis was not possible for many in-

terventions. The wide variety of interventions that could not be

logically pooled together reduced the power of this systematic re-

view in drawing conclusions.

Summary of main results

We included 61 RCTs of interventions to increase vaccination

rates in people aged 60 years and older. We categorised interven-

tions into three types: reminders to and education of clients to

be vaccinated; interventions to increase access to vaccination; and

provider- or system-based interventions. Some studies reported on

multiple interventions and contributed to more than one type of

intervention group. We did not identify any RCTs that evaluated

societal-level interventions.

The most frequent intervention was client reminders and educa-

tion (41 trials with a total of 766,931 participants), followed by

provider- or system-based interventions (15 trials with 278,524

participants), and interventions to increase access to vaccination

(8 trials with 9353 participants). Some studies contributed data

to test more than one intervention. Of the 80 study arms, 54 had

95% CIs entirely above unity implying all these interventions in-

creased vaccination rates, but heterogeneity limited meta-analysis.

Reminders to and education of clients to be

vaccinated

We included three studies of client reminder and recall by letter

plus leaflet in a meta-analysis (OR 1.11, 95% CI 1.07 to 1.15)

and two studies of nurses educating and vaccinating patients (OR

3.29, 95% CI 1.91 to 5.66).

Study heterogeneity prevented us from meta-analysing four groups

of studies, but within each group there were studies with their

95% CI entirely above unity, implying the interventions were suc-

cessful. Seventeen RCTs tested simple reminders, and 11 studies

had 95% CIs entirely above unity implying all 11 interventions

increased vaccination rates. Sixteen studies tested personalised re-

minders, and 12 had 95% CIs entirely above unity implying all

12 interventions increased vaccination rates. Two RCTs of cus-

tomised letters compared to form letter could not be pooled, but

both had their 95% CIs above unity implying both interventions

increased vaccination rates. Four RCTs of health risk appraisals

leading to a recommendation for vaccination could not be pooled,

but all had their 95% CI above unity implying all 4 interventions

increased vaccination rates.

Six individual studies of interventions were all effective at increas-

ing vaccination rates: patient outreach by retired teachers (OR

3.33, 95% CI 1.79 to 6.22); invitation by clinic receptionists (OR

2.72, 95% CI 1.55 to 4.76); nurses educating and 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 dif-

ferent types of questionnaire for recall (OR 1.13, 95% CI 1.03

to 1.24). A study of a lottery for free groceries was not effective

(Summary of findings for the main comparison).

Interventions to increase access to vaccination

We meta-analysed results of two studies of home visits (OR 1.30,

95% CI 1.05 to 1.61) and two studies of free vaccine compared

to a user pays model (OR 2.36, 95% CI 1.98 to 2.82).

We were unable to meta-analyse two studies of home visits by

nurses plus a physician care plan, but both had 95% CIs above

unity implying both interventions increased vaccination rates, and

two studies of free vaccine provision compared to no intervention,

both of which had their 95% CI above unity implying both in-

terventions increased vaccination rates.

One RCT of group visits (OR 27.2, 95% CI 1.60 to 463.3) was

effective, and one of a home visit compared to a safety intervention

was not effective (Summary of findings 2).

Provider- or system-based interventions

We meta-analysed results of two studies investigating payment to

physicians (OR 2.22, 95% CI 1.77 to 2.77).

We were unable to meta-analyse four studies of reminders to physi-

cians, two of which had their 95% CIs above unity implying both

interventions increased vaccination rates, and three studies of facil-

itator encouragement of vaccination, of which two had their 95%

CI above unity implying both interventions increased vaccination

rates.

32Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

A study investigating reminders to physicians to vaccinate all pa-

tients compared to reminding about half of patients (OR 1.70,

95% CI 1.53 to 3.99); a study of posters in clinics of vaccination

rates encouraging doctors to compete (OR 2.03, 95% CI 1.86

to 2.22); and a study of chart review and benchmarking to rates

achieved by the top 10% of physicians (OR 3.43, 95% CI 2.37

to 4.97) were effective. Studies comparing letters on discharge

from hospital to letters to GPs; posters + postcard versus posters;

educational reminders + academic detailing + peer comparisons

compared to mailed educational materials; educational outreach

+ feedback to teams versus written feedback; and an intervention

to increase staff vaccination rates were not effective (Summary of

findings 3).

Sensitivity analyses for the studies of increasing community demand, enhancing vaccination access, and provider- or system-based interventions

We assessed data for heterogeneity in each category and subcate-

gory of interventions, and used the Chi² test to examine hetero-

geneity between studies and the I² statistic to assess variability in

estimates of effect due to heterogeneity. We carried out sensitivity

analyses by serially removing studies with the highest risk of bias,

and then serially removed the smallest RCTs for each group of in-

terventions that included more than five RCTs. These changes did

not decrease heterogeneity to a level that permitted meta-analysis

(less than 70%).

No studies reported adverse effects.

Interventions on the societal level

We included no RCTs at the societal level. Identifying the roles

of policy changes about vaccination, educational interventions,

media discussions, and societal trends in affecting vaccination up-

take is difficult. Interventions on the societal level are the most

challenging to evaluate, due to unknown biases relating to secu-

lar trends of increasing influenza vaccination rates in most soci-

eties, multiple and often unknown co-interventions in the forms

of stimuli such as newspaper and magazine articles, and alerts and

initiatives by organisations on many levels from individual prac-

tices to regional campaigns. Overall, these societal interventions

are correlated with increases in influenza vaccination rates.

Overall completeness and applicability of evidence

We included 61 RCTs, of which 36 (60%) were from the USA,

seven were from Canada, four each were from Australia and the

UK, three were from Spain, and one each was from Denmark,

Germany, Hong Kong, Israel, New Zealand, Puerto Rico, and

Switzerland. The majority of studies therefore reflect medical and

financial structures in the USA.

Interventions were tested comprehensively for effect in three parts

of the healthcare system: participants, healthcare providers (physi-

cians, nurses, and pharmacists), and local or state healthcare sys-

tems, but not in overall societal healthcare systems.

However, a key problem is measuring the completeness of the as-

sessment of influenza vaccination because it was possible for par-

ticipants to receive vaccination at walk-in clinics and during cam-

paigns instead of from their regular clinics. Some studies did not

perform independent verification of the accuracy and complete-

ness of clinic records or financial billing.

We excluded non-randomised designs because we were unable to

assess the completeness of known confounders.

Studies were funded by government health organisations and foun-

dations or organisations that provided health care. In one study,

free vaccine was provided by a manufacturer, and 15 studies did

not report funding sources.

Quality of the evidence

Of the 61 included studies, 32 were published before 2000, which

may affect both the rigour of study design and data analysis. Fur-

thermore, few studies were published after the 2002-2004 SARS

epidemic.

For randomisation, 23 (38%) trials were at low risk of bias; 35

(57%) were at unclear risk of bias; and three (5%) were at high

risk of bias. We assessed trials as at unclear risk of bias usually

because the description was limited to statements such as “were

randomised.” For concealment of allocation, seven studies (11%)

were at low risk and 54 (89%) at unclear risk of bias because no

statement was present in the text. For blinding, 27 (44%) trials

were at low risk of bias; 30 (49%) were at unclear risk of bias; and

four (7%) were at high risk of bias. For incomplete outcome data,

31 (51%) trials were at low risk of bias; 23 (38%) were at unclear

risk of bias; and seven (11%) were at high risk of bias. All 61 trials

(100%) were at low risk of bias for selective reporting.

Influenza vaccination uptake was recorded using computers or

ascertained from computerised records or review of clinic records

in 57 RCTs; by two research assistants through phone calls or

home visits in Black 1993; from records during the vaccination

campaign in Díaz Grávalos 1999; from hospital records or phone

calls and letters to GPs in MacIntyre 2003; and from the records

of the pharmacy where the RCT was conducted in Marrero 2006.

All 61 trials were thus free of selective reporting.

The overall GRADE assessment of the evidence was moderate

quality.

Potential biases in the review process

33Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

All stages in the review process were accomplished independently,

with data checking by the other review author. This Cochrane

Review was unfunded, and we included articles only in languages

the review authors could read (English, French, German, Italian,

Portuguese, and Spanish) or for which the English language ab-

stract provided sufficient information. This focus on specific lan-

guages and possible exclusion of studies in other languages may

have biased the results of this review. Unfortunately, we were un-

able to obtain data for two studies originating from South Korea

(Lee 2003; Song 2000). The findings from these studies may have

altered the findings reported and conclusions reached through this

review.

Agreements and disagreements with other studies or reviews

We adopted the three intervention categories applied by the Com-

munity Preventive Services Task Force in the USA published in

the Guide to Community Preventive Services for this review (CDC 2018). These are: increasing community demand for vaccinations;

enhancing access to vaccination services; and provider- or system-

based interventions.

The CDC 2018 review synthesised results across age groups (chil-

dren, adults, and elders) and included studies of influenza vaccine

among elders. The CDC 2018 review recommended combining

one or more interventions to increase community demand with

at least one provider- or system-based intervention, and one or

more interventions to enhance access. The strategies for increas-

ing community demand that were recommended included the

use of client reminder/recall and multi component interventions

that included education and enhancing access through home visits

and reductions in out-of-pocket costs. Recommended provider- or

system-based interventions included reminder/recall systems for

providers, assessment and feedback of vaccination information to

providers, and the use of standing orders. Our review by contrast

focused exclusively on influenza uptake among older adults.

Two previous Cochrane Reviews also investigated interventions

to change health professionals’ behaviour and addressed interven-

tions to increase adult influenza vaccination uptake (Ivers 2012;

Jacobson 2005; Krishna 2002). While our review does include

some studies identified in previous reviews (Buffington 1991;

Kiefe 2001; Kim 1999; Lukasik 1987; McDowell 1986; Puech

1998; Siriwardena 2002), we excluded other studies where the in-

tervention was not aimed at increasing influenza vaccination up-

take; individuals aged 60 years or older were not the focus of the

research; or outcomes for those aged 60 years or older could not

be identified separately. The conclusions reached in this review

were therefore based on a set of studies that are distinct from those

included in prior reviews.

Similarly, while Lau 2012 undertook a comprehensive search of

randomised and non-randomised studies of interventions to in-

crease influenza and pneumococcal vaccination rates, unlike our

review this review excluded all non-English language studies.

A U T H O R S ’ C O N C L U S I O N S

Implications for practice

Effectiveness of influenza vaccine in people aged 60

years and older

The key issue was to address the effectiveness of influenza vaccine

for people aged 60 years and older. The first author of this review

(RE Thomas) is also the first author of the Cochrane Review on

influenza vaccination of healthcare workers who care for those 60

years and older in institutions (Thomas 2016), and an author on

the Cochrane Review on influenza vaccination for those 60 years

and older (Demicheli 2018). To avoid selective quotation, we have

presented the authors’ conclusions of both reviews as follows.

Influenza vaccination of healthcare workers in institutions

caring for those 60 years and older

“The four cluster-randomised controlled trials (RCTs) contribut-

ing outcome data to our review are at high risk of bias and

pooled data have not shown convincing evidence of benefit on the

outcomes of direct interest, namely laboratory-proven influenza

(low quality evidence), lower respiratory tract infections (moderate

quality evidence), admissions to hospital (low quality evidence),

and deaths from lower respiratory tract illness or from all causes

(very low quality evidence). Where meta-analysis was possible the

95% confidence interval (CI) in each case has not excluded little

or no effect of vaccination programmes. We conclude that there

is an absence of high quality evidence that vaccinating healthcare

workers against influenza protects people aged 60 years or older in

their care on influenza-specific outcomes. There is little evidence

to justify medical care and public health practitioners mandating

influenza vaccination for healthcare workers who care for the el-

derly in long-term care institutions (LTCIs).” (Thomas 2016).

Influenza vaccination of those 60 years and older

Implications for practice

“Healthy older adults receiving the influenza vaccine may be at

lower risk of influenza (from 6% to 2.4%, low-certainty evidence)

and are probably at lower risk of influenza-like illness (ILI) (from

6% to 3.5%, moderate-certainty evidence) compared with those

who do not receive a vaccination over the course of a single in-

fluenza season. Our uncertainty in the effect on influenza reflects

34Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

a lack of information about how the diagnosis was confirmed in

the studies and judgements of high or unclear risk of bias.

”The findings of our review indicate that implementing vaccina-

tion programmes for elderly people may lead to reductions in in-

fluenza and ILI, but randomised studies to date have provided

insufficient data on complications. Very few deaths occurred in

the trials, and no data on hospitalisation were reported. No cases

of pneumonia occurred in one study that reported this outcome.

The sparse nature of the data overall may reflect the low risk of de-

veloping complications in the healthy population of interest and

low rates of ILI and influenza in the trials. Vaccination probably

increases fever from 1.6% to 2.5% (moderate-certainty evidence)

and may increase nausea from 2.4% to 4.2%, but for both of

these harms the confidence interval is wide. Similar effects were

observed for headache, general malaise, and upper respiratory tract

symptoms. Sore arm and swelling occurred more frequently with

vaccination.

“Policymakers considering funding vaccine programmes and in-

dividuals contemplating vaccination should take into account the

likely benefits in terms of the reductions in the risk of influenza

and ILI (3.5% and 2.5%, respectively), uncertainty over compli-

cations, and possible increases in harms.” (Demicheli 2018).

Implications for research

“Investment in the development of better vaccines than are cur-

rently available should be linked to better knowledge of the causes

and patterns of ILI in different communities. The additional ef-

fects of vaccinating carers in reducing transmission in nursing

homes should be assessed. The effect of vaccination of high-risk

groups should also be further assessed.

Until such time as the role of vaccines for preventing complications

of influenza in the elderly is clarified, more comprehensive and

effective strategies for the control of acute respiratory infections

should be investigated. These should include several preventive

interventions that take into account the multi-agent nature of ILI

and its context (such as personal hygiene and adequate food, water,

and sanitation).

When a new vaccination or preventive technology becomes

available, an adequately powered, publicly funded, high-quality

placebo-controlled trial run over several seasons should be under-

taken. New insights on the role of viruses and other agents in the

genesis of influenza and ILI are also needed.” (Demicheli 2018).

Interventions to increase influenza vaccination rates

in people aged 60 years and older in the community

This Cochrane Review also advocates for a publicly funded ran-

domised controlled trial (RCT) of more effective vaccines. Our

conclusions on how to increase vaccine uptake when these become

available are as follows.

The 61 included RCTs investigated a wide variety of interven-

tions that varied in approach, intensity, and cost. Although there

is evidence that low- (e.g. postcards), medium- (e.g. personalised

phone calls), and high-intensity (e.g. home visits or facilitators in

practices) interventions are effective in increasing community de-

mand for vaccination, the extent, cost, and resource implications

associated with the interventions vary. For instance, while facilita-

tion and home visits were found to be effective, these approaches

are likely to be more costly than other interventions. In contrast,

although reminders are the least intensive intervention, they may

vary in the extent to which they can effect changes in vaccination

uptake. Although we found a variety of interventions to be highly

effective at increasing vaccination uptake, individual healthcare

practitioners will wish to assess the local resource implications of

each strategy and select those that best meet their capacity and

needs.

The population served and the healthcare system will affect the

barriers to vaccination, motivations to implement vaccination, the

resources made available, and the effectiveness of interventions. It

is thus difficult to compare studies carried out in different coun-

tries or areas. Differences due to the healthcare system will occur

by socioeconomic area (e.g. suburban populations where many

people regularly see their own general practitioner), by distance

from any healthcare facility (e.g. rural areas), or by transient work

situations (e.g. agricultural or mining communities).

Implications for research

Although this Cochrane Review includes a number of RCTs as-

sessing the effectiveness of interventions to increase vaccination

uptake among seniors, further research exploring the effective-

ness of these approaches is needed. Although patient-, provider-

, and system-based interventions may effect changes in vaccina-

tion uptake, additional research is needed to determine how best

to target these interventions to specific populations, such as peo-

ple with complex, chronic health conditions, and encourage all

stakeholders to actively engage in these initiatives. For example,

while generic reminders to health staff may result in increases in

numbers of patients who are vaccinated, reminders that include

comprehensive lists of specific patients requiring vaccination may

be more effective at targeting those who are least likely to request

vaccination. Furthermore, people of all ages communicate via text

messaging and social media. Research is also needed to investigate

the effectiveness of these non-traditional modes of communica-

tion on vaccination uptake among seniors.

We found no evidence of the effectiveness of societal-level RCT

interventions to increase vaccination. This represents a significant

gap in the literature. Future studies that focus on community- and

national-level strategies to encourage vaccination of unvaccinated

individuals with no ongoing source of primary care are needed

to inform the development and implementation of approaches to

vaccination that target entire populations.

35Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

A C K N O W L E D G E M E N T S

We thank Janine Morrison, Emily Medd, and Wendy Spragins for

retrieving full-text articles for the first edition of this review. We

thank Vicky Debold, Amy Zelmer, Ann Mayo, Tony Arthur, Mark

Jones, and Matthew Thompson for comments on the draft review.

We thank Dr Margaret Russell for her excellent and invaluable

organisational and critical work on the first edition of this review.

We thank Tony Arthur, Janet Wale, Conor Teljeur, and Matthew

Thompson for comments on the 2014 update. Thanks to David

Honeyman for the 2017 literature search.

For previous versions of this review, Roger E Thomas planned the

review design, assessed articles for inclusion, entered data, per-

formed the analyses, and wrote the text. Diane Lorenzetti designed

and executed the search strategy, assessed articles for inclusion,

entered data, and approved the text. Margaret Russell assessed ar-

ticles for inclusion, entered data, and approved the text.

R E F E R E N C E S

References to studies included in this review

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Thomas RE [pers comm]. Baseline vaccination rates. AM

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Beck 1997 {published data only}

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G, et al. A randomized controlled trial of group outpatient

visits for chronically ill older HMO members: The

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Black 1993 {published and unpublished data}

Black M [pers comm]. Request for community prevalence

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2008. ∗ Black ME, Ploeg J, Walter SD, Hutchinson BG, Scott

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Centers for Disease Control and Prevention. McMahon

JW, Hillman JR, McInerney M, Kileen MJ, Christensen

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beneficiaries - Montana and Wyoming, 1994. Morbidity

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Centers for Disease Control and Prevention. McMahon

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a randomized trial. Archives of Physical Medicine and

Rehabilitation 2002;83(3):371–5.

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Jackson C, et al. Varying cognitive targets and response

rates to enhance the question behaviour effect: an 8-

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C, Howard M. Effect of preventive home visits by a nurse

on the outcomes of frail elderly people in the community: a

randomized controlled trial. Canadian Medical Association Journal 2000;162(4):497–500.

Howard M [pers comm]. Baseline vaccination rates, and

study risk of bias. RE Thomas 5 September 2017.

Dapp 2011 {published data only}

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design, participants, interventions, results, and study risk of

bias. RE Thomas 1 April 2013.

Dapp U, Anders J, von Renteln-Kruse W, Meier-

Baumgartner HP. Active health promotion in old age:

methodology of a preventive intervention programme

provided by an interdisciplinary health advisory team for

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2011;66A(5):591–8.

Díaz Grávalos 1999 {published data only}

Díaz Grávalos GJ, Palmeiro FG, Vazquez Fernandez LA,

Casado Gorriz I, Fernandez Bernardez MA, Sobrado

Palomares JR. Annual influenza vaccination. Causes of non-

compliance among patients aged over 65 years [Vacunación

antigripal anual: causa de incumplimiento en mayores

de 65 años]. Medifam - Revisita de Medicina Familiar y

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Dietrich 1989 {published data only}

Dietrich AJ, Duhamel M. Improving geriatric preventive

care through a patient-held checklist. Family Medicine

1989;21(3):195–8.

Frank 2004 {published and unpublished data}

Frank O [pers comm]. Baseline vaccination rates, results

and study risk of bias. RE Thomas 23 August 2008. ∗ Frank O, Litt J, Beilby J. Opportunistic electronic

reminders. Improving performance of preventive care in

general practice. Australian Family Physician 2004;33(1-2): 87–90.

Garcia-Aymerich 2007 {published data only}

Garcia-Aymerich J, Hernandez C, Alonso A, Casas A,

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care intervention on risk factors of COPD readmission.

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randomized cohort study. Journal of the American Geriatrics

Society 1994;42(11):1154–9.

Hogg 1998 {published data only (unpublished sought but not used)}

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G. Randomized controlled study of customized preventive

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Canadian Family Physician 1998;44:81–8.

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controlled trial of telephone appointing in general practice.

British Journal of General Practice 2002;52(482):712–6.

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Ives D [pers comm]. Baseline vaccination rates, results and

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Kiefe 2001 {published and unpublished data}

Kiefe CI [pers comm]. Baseline vaccination rates, results

and study risk of bias. RE Thomas 22 December 2008. ∗ Kiefe CI, Allison JJ, Williams OD, Person SD, Weaver

MT, Weissman NW. Improving quality improvement

using achievable benchmarks for physician feedback: a

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Weingarten SR. Physician education and report cards: do

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tailored multifaceted approach to changing family physician

practice patterns and improving preventive care. Canadian

Medical Association Journal 2001;164(6):757–63.

Leung 2017 {published data only}

Leung KC, Mui C, Chiu WY, Ng YY, Chen MHY, Ho

PH, et al. Impact of patient education on influenza vaccine

uptake among community-dwelling elderly: a randomized

controlled trial. Education Research 2017;32(5):455–64. DOI: 10.1093/her/cyx053

Lukasik 1987 {published data only}

Lukasik MH, Pratt G. The telephone: an overlooked

technology for prevention in family medicine. Canadian

Family Physician 1987;33:1997–2001.

MacIntyre 2003 {published and unpublished data} ∗ MacIntyre CR, Kainer MA, Brown GV. A randomised,

clinical trial comparing the effectiveness of hospital and

community-based reminder systems for increasing uptake of

influenza and pneumococcal vaccine in hospitalised patients

aged 65 years and over. Gerontology 2003;49(1):33–40.

MacIntyre R [pers comm]. Baseline vaccination rates,

results and study risk of bias. RE Thomas 9 September

2008.

Maglione 2002a {published data only}

Maglione MA, Stone EG, Shekelle PG. Mass mailings

have little effect on utilization of influenza vaccine among

Medicare beneficiaries. American Journal of Preventive Medicine 2002;23(1):43–6.

Maglione 2002b {published data only}

Maglione MA, Stone EG, Shekelle PG. Mass mailings

have little effect on utilization of influenza vaccine among

Medicare beneficiaries. American Journal of Preventive Medicine 2002;23(1):43–6.

Maglione 2002c {published data only}

Maglione MA, Stone EG, Shekelle PG. Mass mailings

have little effect on utilization of influenza vaccine among

Medicare beneficiaries. American Journal of Preventive Medicine 2002;23(1):43–6.

Maglione 2002d {published data only}

Maglione MA, Stone EG, Shekelle PG. Mass mailings

have little effect on utilization of influenza vaccine among

Medicare beneficiaries. American Journal of Preventive Medicine 2002;23(1):43–6.

Marrero 2006 {published and unpublished data}

Marrero W [pers comm]. Baseline vaccination rates. RE

Thomas 26 September 2008. ∗ Marrero W, Hernandez L, Garcia R, Gutierrez LM.

Immunization program against influenza for adults 65 years

or older at a community pharmacy in Puerto Rico. Puerto Rico Health Sciences Journal 2006;25(1):35–42.

McCaul 2002 {published and unpublished data}

McCaul KD [pers comm]. Baseline vaccination rates,

results and study risk of bias. RE Thomas 21 August 2008. ∗ McCaul KD, Johnson RJ, Rothman AJ. The effects of

framing and action instructions on whether older adults

obtain flu shots. Health Psychology 2002;21(6):624–8.

McDowell 1986 {published data only}

McDowell I, Newell C, Rosser W. A follow-up study of

patients advised to obtain influenza immunizations. Family Medicine 1990;22(4):303–6. ∗ McDowell I, Newell C, Rosser W. Comparison of three

methods of recalling patients for influenza vaccination.

Canadian Medical Association Journal 1986;135(9):991–7.

38Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Minor 2010 {published data only (unpublished sought but not used)}

Minor D [pers comm]. Baseline vaccination rates, results

and study risk of bias. RE Thomas 5 April 2013. ∗ Minor DS, Eubanks JT, Butler KR Jr, Wofford MR,

Penman D, Replogle WH. Improving influenza vaccination

rates by targeting individuals not seeking early seasonal

vaccination. American Journal of Medicine 2010;123(11):

1031–5.

Moran 1992 {published and unpublished data}

Moran WP [pers comm]. Baseline vaccination rates, results

and study risk of bias. RE Thomas 1 September 2008. ∗ Moran WP, Nelson K, Wofford JL, Velez R. Computer-

generated mailed reminders for influenza immunization: a

clinical trial. Journal of General Internal Medicine 1992;7 (5):535–7.

Moran 1995 {published data only}

Moran WP, Wofford JL, Velez R. Assessment of influenza

immunization of community elderly: illustrating the need

for community level health information. Carolina Health Services Review 1995;3:21–9.

Moran 1996 {published data only}

Moran WP, Nelson K, Wofford JL, Velez R, Case LD.

Increasing influenza immunization among high-risk

patients: education or financial incentive?. American Journal

of Medicine 1996;101(6):612–20.

Morrissey 1995 {published data only}

Morrissey JP, Harris RP, Kincade-Norburn J, McLaughlin C,

Garrett JM, Jackman AM, et al. Medicare reimbursement

for preventive care: changes in performance of services,

quality of life, and health care costs. Journal of the American Geriatric Society 1995;33(4):315–31.

Mullooly 1987 {published data only}

Mullooly JP. Increasing influenza vaccination among high-

risk elderly: a randomized controlled trial of a mail cue in

an HMO setting. American Journal of Public Health 1987; 77(5):626–7.

Nexøe 1997 {published data only}

Nexøe J, Kragstrup J, Ronne T. Impact of postal invitations

and user fee on influenza vaccination rates among the

elderly. A randomized controlled trial in general practice.

Scandinavian Journal of Primary Health Care 1997;15(2): 109–12.

Nuttall 2003 {published data only}

Nuttall D. The influence of health professionals on the

uptake of the influenza immunization. British Journal of Community Nursing 2003;8(9):391–6.

Puech 1998 {published data only}

Puech M, Ward J, Lajoie V. Postcard reminders from GPs

for influenza vaccine: are they more effective than an ad hoc

approach?. Australian and New Zealand Journal of Public Health 1998;22(2):254–6.

Roca 2012 {published data only}

Roca B, Herrero E, Resino E, Torres V, Penades M, Andreu

C. Impact of education program on influenza vaccination

rates in Spain. American Journal of Managed Care 2012;18

(12):e446–52.

Satterthwaite 1997 {published data only}

Satterthwaite P. A randomised intervention study to

examine the effect on immunisation coverage of making

influenza vaccine available at no cost. New Zealand Medical Journal 1997;110(1038):58–60.

Siriwardena 2002 {published data only}

Siriwardena AN, Rashid A, Johnson MR, Dewey ME.

Cluster randomised controlled trial of an educational

outreach visit to improve influenza and pneumococcal

immunisation rates in primary care. British Journal of General Practice 2002;52(482):735–40.

Smith 1999 {published data only}

Smith DM, Zhou XH, Weinberger M, Smith F,

McDonald RC. Mailed reminders for area-wide influenza

immunization: a randomized controlled trial. Journal of the American Geriatric Society 1999;47(1):1–5.

Spaulding 1991 {published data only}

Spaulding SA, Kugler JP. Influenza immunization: the

impact of notifying patients of high-risk status. Journal of Family Practice 1991;33(5):495–8.

Stuck 2015 {published data only}

Stuck AE, Moser A, Mort U, Wirz U, Wyser J, Gillmann

G, et al. Effect of health risk assessment and counselling on

health behaviour and survival in older people: a pragmatic

randomised trial. PLoS Medicine 2015;12(10):e1001889. DOI: 10.1371/journal.pmed.1001889

References to studies excluded from this review

Ahmed 2004 {published data only}

Ahmed F, Friedman C, Franks A, Latts LM, Nugent EW,

France EK, et al. Effect of the frequency of delivery of

reminders and an influenza tool kit on increasing influenza

vaccination rates among adults with high-risk conditions.

American Journal of Managed Care 2004;10:698–702.

Alemi 1996 {published data only}

Alemi F, Alemagno SA, Goldhagen J, Ash L, Finkelstein

B, Lavin A, et al. Computer reminders improve on-time

immunization rates. Medical Care 1996;34(Suppl 10):

45–51.

Alexy 1998 {published data only}

Alexy BB, Elnitsky C. Rural mobile health unit: outcomes.

Public Health Nursing 1998;15(1):3–11.

Allsup 2004 {published data only}

Allsup S, Haycox A, Regan M, Gosney M. Is influenza

vaccination cost effective for healthy people between ages 65

and 74 years? A randomised controlled trial. Vaccine 2004; 23:639–45.

Anderson 1979 {published data only}

Anderson C, Martin H. Effectiveness of patient recall

system on immunization rates for influenza. Journal of

Family Practice 1979;9(4):727–30.

Armstrong 1999 {published data only}

Armstrong K, Berlin M, Schwartz JS, Propert K, Ubel

PA. Educational content and the effectiveness of influenza

39Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

vaccination reminders. Journal of General Internal Medicine

1999;14(11):695–8.

Arthur 2001 {published data only}

Arthur AJ. The effect of health assessments by practice

nurses on uptake of influenza vaccination among older

people in the UK. Journal of Clinical Nursing 2001;10(5):

716–7.

Bakare 2007 {published data only}

Bakare M, Shrivastava R, Jeevanantham V, Navaneethan

SD. Impact of two different models on influenza and

pneumococcal vaccination in hospitalized patients. Southern

Medical Journal 2007;100(2):140–4.

Balagué 1993 {published data only}

Balagué GL, Ruiz Martinez MC, Mercade Mercade MA.

The evaluation of an influenza vaccination campaign in a

health sector. Atencion Primaria 1993;11(4):202.

Baldo 1999 {published data only}

Baldo V, Menegon T, Buoro S, Scalici C, Vesco A, Peale S, et

al. Vaccination against influenza in the elderly. Experience

with adjuvant vaccines [Vaccinazione antinfluenzale in

anziani. Esperienza con vaccini adiuvati]. Annali di Igiene 1999;11:369–73.

Bardenheier 2005 {published data only}

Bardenheier BH, Shefer A, McKibben L, Roberts H, Rhew

D, Bratzler D. Factors predictive of increased influenza

and pneumococcal vaccination coverage in long-term care

facilities: the CMS-CDC Standing Orders Program Project.

Journal of the American Medical Directors Association 2005;6

(5):291–9.

Bardenheier 2010 {published data only}

Bardenheier BH, Shefer AM, Remsburg RE, Marsteller

JA. Are standing order programs associated with influenza

vaccination? - NNHS, 2004. Journal of the American Medical Directors Association 2010;11:654–61.

Bardenheier 2011 {published data only}

Bardenheier B, Shefer A, Ahmed F, Remsburg R, Rowland

Hogue CJ, Gravenstein S. Do vaccination strategies

implemented in nursing homes narrow the racial gap in

receipt of influenza vaccinations in the United States?.

Journal of the American Geriatric Society 2011;59:687–93.

Barker 1999 {published data only}

Barker WH, Bennett NM, LaForce FM, Waltz EC, Weiner

LB. “McFlu”. The Monroe County, New York, Medicare

vaccine demonstration. American Journal of Preventive Medicine 1999;16(Suppl 3):118–27.

Barton 1990 {published data only}

Barton MB, Schoenbaum SC. Improving influenza

vaccination performance in an HMO setting: the use

of computer-generated reminders and peer comparison

feedback. American Journal of Public Health 1990;80(5):

534–6.

Beardsworth 2004 {published data only}

Beardsworth A, Maxim R, Bertrand T. The power of

coalition - improving Rhode Island’s adult immunization

rate - the Ocean State Adult Immunization Coalition.

Medicine & Health, Rhode Island 2004;87(3):72–4.

Becker 1989 {published data only}

Becker DM, Gomez EB, Kaiser DL, Yoshihasi A, Hodge

RH Jr. Improving preventive care at a medical clinic:

how can the patient help?. American Journal of Preventive Medicine 1989;5(6):353–9.

Bekker 2003 {published data only}

Bekker HL, Gough D, Williams M. Attendance choices

about the influenza immunization programme: evidence

for targeting patients’ beliefs. Psychology Health & Medicine

2003;8(3):279–88.

Belcher 1990 {published data only}

Belcher DW. Implementing preventive services. Success and

failure in an outpatient trial. Archives of Internal Medicine 1990;150(12):2533–41.

Bennett 1994 {published data only}

Bennett NM, Lewis B, Doniger AS, Bell K, Kouides

R, LaForce FM, et al. A coordinated, community-wide

program in Monroe County, New York, to increase

influenza immunization rates in the elderly. Archives of

Internal Medicine 1994;154:1741–5.

Berg 2004 {published data only (unpublished sought but not used)}

Berg GD, Thomas E, Silverstein S, Neel CL, Mireles

M. Reducing medical service utilization by encouraging

vaccines: randomized controlled trial. American Journal of

Preventive Medicine 2004;27(4):284–8.

Berg 2005 {published data only}

Berg GD, Fleegler E, van Vonno CJ, Thomas E. A matched-

cohort study of health services utilization for a heart failure

disease management program. Disease Management 2005;8 (1):35–41.

Birchmeier 2002 {published data only}

Birchmeier M, Favrat B, Pecoud A, Abetel G, Karly M,

Landry P, et al. Improving influenza vaccination rates in the

elderly. Journal of Family Practice 2002;51(10):856.

Bloom 1988 {published data only}

Bloom HG, Bloom JS, Krasnoff L, Frank AD. Increased

utilization of influenza and pneumococcal vaccines in an

elderly hospitalized population. Journal of the American

Geriatrics Society 1988;36(10):897–901.

Bloom 1999 {published data only}

Bloom HG, Wheeler DA, Linn J. A managed care

organization’s attempt to increase influenza and

pneumococcal immunizations for older adults in an acute

care setting. Journal of the American Geriatrics Society 1999;

47(1):106–10.

Bond 2011 {published data only}

Bond TC, Patel PR, Krisher J, Sauls L, Deans J, Strott

K, et al. A group-randomized evaluation of a quality

improvement intervention to improve influenza vaccination

rates in dialysis centers. American Journal of Kidney Disease 2011;57(2):283–90.

Bou-Mias 2006 {published data only}

Bou-Mias C, Zwart-Salmeron M, Calvet-Freixas E, Bunuel-

Alvarez JC. Telephone recruitment for flu vaccination.

Atencion Primaria 2006;37(3):176–7.

40Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Bovier 2001 {published data only}

Bovier PA, Chamot E, Gallacchi MB, Loutan L. Importance

of patients’ perceptions and general practitioners’

recommendations in understanding missed opportunities

for immunisations in Swiss adults. Vaccine 2001;19(32):

4760–7.

Brady 1988 {published data only}

Brady WJ, Hissa DC, McConnell M, Wones RG. Should

physicians perform their own quality assurance audits?.

Journal of General Internal Medicine 1988;3(6):560–5.

Breen 2003 {published data only}

Breen D. Pneumococcal vaccination programme in over 65s

and at-risk groups: the Dumfries and Galloway experience.

Communicable Disease & Public Health 2003;6(3):228–30.

Brimberry 1988 {published data only}

Brimberry R. Vaccination of high-risk patients for influenza.

A comparison of telephone and mail reminder methods.

Journal of Family Practice 1988;26(4):397–400.

Browngoehl 1997 {published data only}

Browngoehl K, Kennedy K, Krotki K, Mainzer H.

Increasing immunization: a Medicaid managed care model.

Pediatrics 1997;99:E4.

Buchner 1987 {published and unpublished data}

Buchner D [pers comm]. Baseline vaccination rates,

verification letters were received, study risk of bias. RE

Thomas 21 August 2008. ∗ Buchner DM, Larson EB, White RF. Influenza vaccination

in community elderly. A controlled trial of postcard

reminders. Journal of the American Geriatrics Society 1987; 35(8):755–60.

Burns 2005 {published data only}

Burns VE, Ring C, Carroll D. Factors influencing influenza

vaccination uptake in an elderly, community-based sample.

Vaccine 2005;23(27):3604–8.

Call 2005 {published data only}

Call SA, Vollenweider MA, Hornung CA, Simel DL,

McKinney WP. Does this patient have influenza?. JAMA

2005;293(8):987–97.

Cardozo 1998 {published data only}

Cardozo LJ, Steinberg J, Lepczyk MB, Binnus-Emerick L,

Cardozo YM, Aranha AN. Delivery of preventive healthcare

to older African-American patients: a performance

comparison from two practice models. American Journal of Managed Care 1998;4(6):809–16.

Carey 1991 {published data only}

Carey TS, Levis D, Pickard CG, Bernstein J. Development

of a model quality-of-care assessment program for adult

preventive care in rural medical practices. Quality Review Bulletin 1991;17(2):54–9.

Carman 2000 {published data only}

Carman WF, Elder AG, Wallace LA, McAulay K, Walker

A, Murray GD, et al. Effects of influenza vaccination of

health-care workers on mortality of elderly people in long-

term care: a randomised controlled trial. Lancet 2000;355

(9198):93–7.

Carter 1986 {published data only}

Carter WB, Beach LR, Inui TS. The flu shot study:

using multiattribute utility theory to design a vaccination

intervention. Organizational Behavior & Human Decision Processes 1986;38(3):378–91.

CDC 2003 {published data only}

Centers for Disease Control and Prevention. Facilitating

influenza and pneumococcal vaccination through standing

order programs. Morbidity and Mortality Weekly Report

2003;52(4):68–9.

Chami 2012 {published data only}

Chami K, Gavazzi G, Bar-Hen A, Carrat F, de Wazière B,

Lejeune B, et al. A short-term multicomponent infection

control program in nursing homes: a cluster randomized

controlled trial. Journal of the American Association of

Medical Directors 2012;13:569.e9–e17.

Chan 1999 {published data only (unpublished sought but not used)}

Chan L [pers comm]. Baseline vaccination rates, study risk

of bias. RE Thomas 3 November 2008. ∗ Chan L, Doctor JN, MacLehose RF, Lawson H, Rosenblatt

RA, Baldwin L, et al. Do Medicare patients with disabilities

receive preventive services? A population-based study.

Archives of Physical Medicine & Rehabilitation 1999;80(6): 642–6.

Charles 1994 {published data only}

Charles J, Lewis J. Requiring elderly patients to give signed

consent for influenza vaccine. Does it affect acceptance?.

Canadian Family Physician 1994;40:474–7.

Chen 2007 {published data only}

Chen JY, Fox SA, Cantrell CH, Stockdale SE, Kagawa-

Singer M. Health disparities and prevention: racial/ethnic

barriers to flu vaccinations. Journal of Community Health 2007;32(1):5–20.

Cheney 1987 {published data only}

Cheney C, Ramsdell JW. Effect of medical records’

checklists on implementation of periodic health measures.

American Journal of Medicine 1987;83(1):129–36.

Chi 2006 {published data only}

Chi RC, Reiber GE, Neuzil KM. Influenza and

pneumococcal vaccination in older veterans: results from

the behavioral risk factor surveillance system. Journal of the American Geriatrics Society 2006;54(2):217–23.

Chodroff 1990 {published data only}

Chodroff CH. Cancer screening and immunization quality

assurance using a personal computer. Quality Review Bulletin 1990;16(8):279–87.

Christenson 2001 {published data only}

Christenson B, Lundbergh P, Hedlund J, Ortqvisit A.

Effects of a large-scale intervention with influenza and

23-valent pneumococcal vaccines in adults aged 65 years

or older: a prospective study. Lancet 2001;357(9261): 1008–11.

Clancy 2003 {published data only (unpublished sought but not used)}

Clancy DE, Cope DW, Magruder KM, Huang P, Wolfman

TE. Evaluating concordance to American Diabetes

41Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

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.

Cohen 1982 {published data only}

Cohen DI, Littenberg B, Wetzel C, Neuhauser D.

Improving physician compliance with preventive medicine

guidelines. Medical Care 1982;20(10):1040–5.

Cohen 2004 {published data only}

Cohen D, Cicco-Bloom B, Strickland PO, Headley A,

Orzano J, Levine J, et al. Opportunistic approaches

for delivering preventive care in illness visits. Preventive

Medicine 2004;38(5):565–73.

Colombo 2005 {published data only}

Colombo GL, Serra G, Morlotti L, Fara GM. The

role of economic evaluation for the implementation of

vaccination strategies [Ruolo della valutazione economica

nell’implementazione di strategie vaccinali]. Annali di Igiene 2005;17(6):479–90.

Correa-de-Araujo 2006 {published data only}

Correa-de-Araujo R, McDermott K, Moy E. Gender

differences across racial and ethnic groups in the quality of

care for diabetes. Women’s Health Issues 2006;16(2):56–65.

Costa 1994 {published data only}

Costa TX, Rodriguez AA, Perez PN, Begines CM, Cabello

Ortega RC, Romero GA. Influenza vaccination in high-risk

groups. Role of the nursing staff. Atencion Primaria 1994; 13(5):256–8.

Cowan 1992 {published data only}

Cowan JA, Heckerling PS, Parker JB. Effect of a fact

sheet reminder on performance of the periodic health

examination: a randomized controlled trial. American Journal of Preventive Medicine 1992;8:104–9.

Cowan 2006 {published data only}

Cowan AE, Winston CA, Davis MM, Wortley PM, Clark

SJ. Influenza vaccination status and influenza-related

perspectives and practices among US physicians. American

Journal of Infection Control 2006;34(4):164–9.

Crawford 2005 {published data only}

Crawford AG, Sikirica V, Goldfarb N, Popiel RG, Patel

M, Wang C, et al. Interactive voice response reminder

effects on preventive service utilization. American Journal of

Medical Quality 2005;20(6):329–36.

Crawford 2011 {published data only}

Crawford VLS, O’Hanlon A, McGee H. The effect

of patient characteristics upon uptake of the influenza

vaccination: a study comparing community-based older

adults in two healthcare systems. Age and Aging 2011;40: 35–41.

Crouse 1994 {published data only}

Crouse BJ, Nichol K, Peterson DC, Grimm MB. Hospital-

based strategies for improving influenza vaccination rates.

Journal of Family Practice 1994;38(3):258–61.

Curry 2006 {published data only}

Curry E, Kerr N, Yang J, Briggs S. Influenza immunisation

rate for 2005 and factors associated with receiving this

vaccine in patients aged 65 years and over admitted to a

general medical ward at Auckland City Hospital. New Zealand Medical Journal 2006;119(1243):U2254.

Daniels 2007 {published data only}

Daniels NA, Juarbe T, Moreno-John G, Perez-Stable EJ.

Effectiveness of adult vaccination programs in faith-based

organizations. Ethnicity and Disease 2007;17(1):S1.

Dannetun 2003 {published data only}

Dannetun E, Tegnell A, Normann B, Garpenholt O,

Giesecke J. Influenza vaccine coverage and reasons for non-

vaccination in a sample of people above 65 years of age,

in Sweden, 1998-2000. Scandinavian Journal of Infectious

Diseases 2003;35(6-7):389–93.

Davidse 1995 {published data only}

Davidse W, Perenboom RJ. Increase of degree of vaccination

against influenza in at-risk patients by directed primary care

invitation. Nederlands Tijdschrift Voor Geneeskunde 1995; 139(42):2149–52.

Davidson 1984 {published data only}

Davidson RA, Fletcher SW, Retchin S, Duh S. A

nurse-initiated reminder system for the periodic health

examination. Implementation and evaluation. Archives of Internal Medicine 1984;144(11):2167–70.

Davis 2005 {published data only}

Davis MM, Halasyamani LK, Sneller V-P, Bishop KR,

Clark SJ. Provider response to different formats of the adult

immunization schedule. American Journal of Preventive

Medicine 2005;29(1):34–40.

Denis 1996 {published data only}

Denis B, Lambrechts T, Lambeau JL, Soetens G.

Immunization against influenza among elderly in general

practice. Louvain Medical 1996;115(1):12–9.

Desbiens 2005 {published data only}

Desbiens NA. A 5-year experience with influenza prevention

and containment in a program of all-inclusive care for

elderly adults. American Journal of Infection Control 2005;

33(4):238–42.

De Wals 1989 {published data only}

De Wals P, Vienne A, Lemaire G, Tamigniau P, Demolin

A, Hecquet P, et al. Acceptability of vaccination against

influenza. Revue Medicale de Bruxelles 1989;10(1-2):49–52.

De Wals 1996 {published data only}

De Wals P, Carbonneau M, Payette H, Niyonsenga T.

Influenza and pneumococcal vaccination in long term care

facilities in two regions of Quebec. Canadian Journal of

Infectious Diseases 1996;7(5):296–300.

Dexter 2001 {published data only}

Dexter PR, Perkins S, Overhage JM, Maharry K, Kohler

RB, McDonald CJ. A computerized reminder system to

increase the use of preventive care for hospitalized patients.

New England Journal of Medicine 2001;345(13):965–70.

Dickey 1990 {published data only}

Dickey LL, Petitti D. Assessment of a patient-held

minirecord for adult health maintenance. Journal of Family

Practice 1990;31(4):431–8.

42Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Dickey 1992 {published data only}

Dickey LL, Petitti D. A patient-held minirecord to promote

adult preventive care. Journal of Family Practice 1992;34(4):

457–63.

Dickey 1993 {published data only}

Dickey LL. Promoting preventive care with patient-held

minirecords: a review. Patient Education & Counseling

1993;20(1):37–47.

Dini 1996 {published data only}

Dini EF, Chaney M, Moolenaar RL, LeBaron CW.

Information as intervention: how Georgia used vaccination

coverage data to double public sector vaccination coverage

in seven years. Journal of Public Health Management Practice

1996;2(1):45–9.

Donato 2007 {published data only}

Donato AA, Motz LM, Wilson G, Lloyd BJ. Efficacy of

multiple influenza vaccine delivery systems in a single

facility. Infection Control & Hospital Epidemiology 2007;28 (2):219–21.

Douglas 1990 {published data only}

Douglas KC, Rush DR, O’Dell M, Monroe A, Ausmus

M. Adult immunization in a network of family practice

residency programs. Journal of Family Practice 1990;31(5): 513–20.

Earle 2003 {published data only}

Earle CC, Burstein HJ, Winer EP, Weeks JC. Quality of

non-breast cancer health maintenance among elderly breast

cancer survivors. Journal of Clinical Oncology 2003;21(8):

1447–51.

Egido Polo 1989 {published data only}

Egido Polo A, Abat Dinarés X, Marimon Amenos MR,

Andujar Gallo A, Albiol Perelló M. Influenza vaccination:

evaluation of an integrated program in a basic urban health

area. Atencion Primaria 1989;6(8):578–82.

Etkind 1996 {published data only}

Etkind P, Simon M, Shannon S, Bottum C, Goldstein R,

Werner B, et al. The impact of the Medicare Influenza

Demonstration Project on influenza vaccination in a county

in Massachusetts, 1988-1992. Journal of Community Health

1996;21(3):199–209.

Evans 2003 {published data only}

Evans MR, Watson PA. Why do older people not get

immunised against influenza? A community survey. Vaccine

2003;21(19-20):2421–7.

Fairbrother 1999 {published data only}

Fairbrother G, Hanson KL, Friedman S, Butts GC. The

impact of physician bonuses, enhanced fees, and feedback

on childhood immunization coverage rates. American Journal of Public Health 1999;89(2):171–5.

Fedson 1989 {published data only}

Fedson DS. Prevention and control of influenza in

institutional settings. Hospital Practice 1989;24(9A):87–94.

Fedson 1994 {published data only}

Fedson DS. Influenza and pneumococcal vaccination of the

elderly: newer vaccines and prospects for clinical benefits at

the margin. Preventive Medicine 1994;23(5):751–5.

Fedson 1996 {published data only}

Fedson DS. Evaluating the impact of influenza vaccination:

a North American perspective. Pharmacoeconomics 1996;9

(Suppl 3):54–61.

Fernández Silvela 1994 {published data only}

Fernández Silvela A, Lindoso López T, Valencia Barrera

S, Alvarez Otero S, Alvarez Mazariegos JA. Influenza

vaccination campaigns. A comparative evaluation

[Campanas de vacunacion antigripal. Evaluacion

comparativa]. Revisita de Enfermeria 1994;17(191-2):13–8.

Ferrante 2010 {published data only}

Ferrante JM, Balasubramanian BA, Hudson SV, Crabtree

BF. Principles of the patient-centered medical home and

preventive services delivery. Annals of Family Medicine 2010;8:108–16.

Fiebach 1991 {published data only}

Fiebach NH, Viscoli CM. Patient acceptance of influenza

vaccination. American Journal of Medicine 1991;91(4):

393–400.

Fishbein 2006a {published data only}

Fishbein DB, Fontanesi J, Kopald D, Stevenson J, Bennett

NM, Stryker DW, et al. Why do not patients receive

influenza vaccine in December and January?. Vaccine 2006; 24(6):798–802.

Fishbein 2006b {published data only}

Fishbein DB, Willis BC, Cassidy WM, Marioneaux D,

Winston CA. A comprehensive patient assessment and

physician reminder tool for adult immunization: effect on

vaccine administration. Vaccine 2006;25:3971–83.

Fisher 2003 {published data only}

Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas

FL, Pinder EL. The implications of regional variations

in Medicare spending. Part 1: the content, quality, and

accessibility of care. Annals of Internal Medicine 2003;138 (4):273–87.

Fitzner 2001 {published data only}

Fitzner KA, Shortridge KF, McGhee SM, Hedley AJ. Cost-

effectiveness study on influenza prevention in Hong Kong.

Health Policy 2001;56(3):215–34.

Fitzpatrick 2004 {published data only}

Fitzpatrick F, Harrington P, Mahony D. The “silver-haired”

general medical services patient. Clinical activity of the

non-means tested over-70’s during their first six months.

Irish Medical Journal 2004;97(4):111–4.

Flach 2004 {published data only}

Flach SD, McCoy KD, Vaughn TE, Ward MM, Boots

Miller BJ, Doebbeling BN. Does patient-centered care

improve provision of preventive services?. Journal of General Internal Medicine 2004;19(10):1019–26.

Fontanesi 2004 {published data only}

Fontanesi J, Shefer AM, Fishbein DB, Bennett NM,

De Guire M, Kopald D, et al. Operational conditions

affecting the vaccination of older adults. American Journal

of Preventive Medicine 2004;26(4):265–70.

43Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Fowles 1998 {published data only}

Fowles JB, Beebe TJ. Failure to immunize the elderly: a

systems problem or a statement of personal values?. Joint

Commission Journal on Quality Improvement 1998;24(12): 704–10.

Frame 1994 {published data only}

Frame PS, Zimmer JG, Werth PL, Hall WJ, Eberly SW.

Computer-based vs manual health maintenance tracking.

A controlled trial. Archives of Family Medicine 1994;3(7): 581–8.

Francisco 2006 {published data only}

Francisco PM, Donalisio MR, Barros MB, Cesar CL,

Carandina L, Goldbaum M. Factors associated with

vaccination against influenza in the elderly. Pan American

Journal of Public Health 2006;19(4):259–64.

Frank 1985 {published data only}

Frank JW, Henderson M, McMurray L. Influenza

vaccination in the elderly: 1. Determinants of acceptance.

Canadian Medical Association Journal 1985;132(4):371–5.

Frick 2004 {published data only}

Frick KD, Scanlon DP, Bandeen-Roche K, Kasper JD,

Simonsick EM, Sullivan EM. Influenza vaccination by race

among disabled community dwelling older women. Journal

of Health Care for the Poor & Underserved 2004;15(2): 220–36.

Furey 2001 {published data only}

Furey A, Robinson E, Young Y. Improving influenza

immunisation coverage in 2000-2001: a baseline survey,

review of the evidence and sharing of best practice.

Communicable Disease & Public Health 2001;4(3):183–7.

Galasso 1977 {published data only}

Galasso GJ, Tyeryar FJ, La M Jr. Overview of clinical trials

of influenza vaccines, 1976. Journal of Infectious Diseases

1977;136(Suppl):425–8.

Ganguly 1989 {published data only}

Ganguly R, Cameron D. Factors affecting immunization

rate in a cohort of elderly veterans: a retrospective pilot

study of influenza vaccine compliance. Vaccine 1989;7(5): 462–4.

Ganguly 1995 {published data only}

Ganguly R, Webster TB. Influenza vaccination in the

elderly. Journal of Investigational Allergology & Clinical

Immunology 1995;5(2):73–7.

Gannon 2012 {published data only}

Gannon M, Qaseem A, Snooks Q, Snow V. Improving

adult immunization practices using a team approach in the

primary care setting. American Journal of Public Health 102; 7:e46–52.

Garrett 2005 {published data only}

Garrett DG, Bluml BM. Patient self-management program

for diabetes: first-year clinical, humanistic, and economic

outcomes. Journal of the American Pharmacists Association

2005;45(2):130–7.

Gauthey 1999 {published data only}

Gauthey L, Toscani L, Chamot E, Larequi T, Robert CF.

Influenza vaccination coverage in the geriatric population of

the State of Geneva, Switzerland. European Journal of Public

Health 1999;9(1):36–40.

Gelfman 1986 {published data only}

Gelfman DM, Witherspoon JM, Buchsbaum DG, Centor

RM. Short-term results of an immunization compliance

program. Virginia Medical 1986;113(9):532–4.

Gerace 1988 {published data only}

Gerace TM, Sangster JF. Influenza vaccination: a

comparison of two outreach strategies. Family Medicine

1988;20(1):43–5.

Giles 2003 {published data only}

Giles SG. A home based health check combined with

influenza vaccination improved uptake of influenza

vaccination in people >/= 75 years of age. Evidence-Based Nursing 2003;6:52–3.

Gill 2000 {published data only}

Gill JM, Saldarriaga AM. The impact of a computerized

physician reminder and a mailed patient reminder on

influenza immunizations for older patients. Delaware

Medical Journal 2000;72(10):425–30.

Gill 2005 {published data only}

Gill JM, Fagan HB, Townsend B, Mainous AG 3rd. Impact

of providing a medical home to the uninsured: evaluation

of a statewide program. Journal of Health Care for the Poor

& Underserved 2005;16(3):515–35.

Goebel 2005 {published data only}

Goebel LJ, Neitch SM, Mufson MA. Standing orders in an

ambulatory setting increases influenza vaccine usage in older

people. Journal of the American Geriatrics Society 2005;53 (6):1008–10.

Grabenstein 1990 {published data only}

Grabenstein JD, Smith LJ, Watson RR, Summers RJ.

Immunization outreach using individual need assessments

of adults at an army hospital. Public Health Reports 1990;

105(3):311–6.

Grabenstein 1992 {published data only}

Grabenstein JD, Hartzema AG, Guess HA, Johnston WP,

Rittenhouse BE. Community pharmacists as immunization

advocates. Cost-effectiveness of a cue to influenza

vaccination. Medical Care 1992;30(6):503–13.

Grabenstein 2001 {published data only}

Grabenstein JD, Guess HA, Hartzema AG, Koch

GG, Konrad TR. Effect of vaccination by community

pharmacists among adult prescription recipients. Medical

Care 2001;39(4):340–8.

Granollers 1993 {published data only}

Granollers Mercarder S, Pont RA. Nurse care in primary

health care: diagnosis and follow-up of health problems

[Cuidados de enfermeria en atencion primaria: diagnostico

y seguimiento de problemas de salud]. Atencion Primaria

1993;11(2):64–8.

Green 2003 {published data only}

Green CA, Polen MR, Brody KK. Depression, functional

status, treatment for psychiatric problems, and the health-

44Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

related practices of elderly HMO members. American

Journal of Health Promotion 2003;17(4):269–75.

Greene 2001 {published data only}

Greene J, Blustein J, Laflamme KA. Use of preventive care

services, beneficiary characteristics, and Medicare HMO

performance. Health Care Financing Review 2001;22(4): 141–53.

Groll 2006 {published data only}

Groll DL, Thomson DJ. Incidence of influenza in Ontario

following the Universal Influenza Immunization Campaign.

Vaccine 2006;24(24):5245–50.

Gutiérrez 2005 {published data only}

Gutiérrez JP, Bertozzi SM. Influenza vaccination in the

elderly population in Mexico: economic considerations

[Vacunacion contra influenza para adultos mayores en

Mexico: consideraciones economicas]. Salud Publica de

Mexico 2005;47(3):234–9.

Gutschi 1998 {published data only}

Gutschi LM, Vaillancourt R. Effect of pharmacist

interventions on pneumococcal and influenza vaccination

rates: a seamless care approach. Canadian Pharmaceutical Journal 1998;131(8):32–8.

Hahn 1990 {published data only}

Hahn DL, Berger MG. Implementation of a systematic

health maintenance protocol in a private practice. Journal of

Family Practice 1990;31(5):492–502.

Halliday 2003 {published data only}

Halliday L, Thomson JA, Roberts L, Bowen S, Mead C.

Influenza vaccination of staff in aged care facilities in the

ACT: how can we improve the uptake of influenza vaccine?.

Australian and New Zealand Journal of Public Health 2003;

27(1):70.

Hanna 2001 {published data only}

Hanna JN, Young DM, Brookes DL, Dostie BG, Murphy

DM. The initial coverage and impact of the pneumococcal

and influenza vaccination program for at-risk indigenous

adults in Far North Queensland. Australian and New

Zealand Journal of Public Health 2001;25(6):543–6.

Hannah 2005 {published data only}

Hannah KL, Schade CP, Cochran R, Brehm JG. Promoting

influenza and pneumococcal immunization in older adults.

Joint Commission Journal on Quality & Patient Safety 2005; 31(5):286–93.

Harari 2008 {published data only}

Harari D, Iliffe S, Kharicha K, Egger M, Gillman G, von

Renteln-Kruse W, et al. Promotion of health in older

people: a randomised controlled trial of health risk appraisal

in British general practice. Age and Ageing 2008;37:565-71.

Harbarth 1998 {published data only}

Harbarth S, Siegrist C, Schira J, Wunderli W, Pittet

D. Influenza immunization: improving compliance

of healthcare workers. Infection Control and Hospital

Epidemiology 1998;19:337-42.

Harris 1990 {published data only}

Harris RP, O’Malley MS, Fletcher SW, Knight BP.

Prompting physicians for preventive procedures: a five-year

study of manual and computer reminders. American Journal of Preventive Medicine 1990;6(3):145–52.

Harris 2006 {published data only}

Harris LM, Chin NP, Fiscella K, Humiston S. Barrier to

pneumococcal and influenza vaccinations in Black elderly

communities: mistrust. Journal of the National Medical Association 2006;98(10):1678–84.

Hedlund 2003 {published data only}

Hedlund J, Christenson B, Lundbergh P, Ortqvisit A.

Effects of a large-scale intervention with influenza and 23-

valent pneumococcal vaccines in elderly people: a 1-year

follow-up. Vaccine 2003;21(25-6):3906–11.

Henk 1975 {published data only}

Henk M, Froom J. Outreach by primary-care physicians.

JAMA 1975;233(3):256–9.

Hermiz 2002 {published data only}

Hermiz O, Comino E, Marks G, Daffurn K, Wilson S,

Harris M. Randomised controlled trial of home based care

of patients with chronic obstructive pulmonary disease.

BMJ 2002;325(7370):938.

Herrett 2016 {published data only}

Herrett E, Williamson E, van Staa T, Ranopa M, Free C,

Chadborn T, et al. Text messaging reminders for influenza

vaccine in primary care: a cluster randomised controlled

trial (TXT4FLUJAB). BMJ Open 2016;6(2):e010069. DOI: 10.1136/bmjopen-2015-010069

Hirdes 2006 {published data only}

Hirdes JP, Dalby DM, Knight SR, Iain CG, Bernabei R,

Morris JN, et al. Predictors of influenza immunization

among home care clients in Ontario. Canadian Journal of Public Health 2006;97(4):335–9.

Hoey 1982 {published data only}

Hoey JR, McCallum HP, Lepage EM. Expanding the nurse’s

role to improve preventive service in an outpatient clinic.

Canadian Medical Association Journal 1982;127(1):27–8.

Honkanen 1996 {published data only}

Honkanen PO, Keistinen T, Kivela SL. Factors associated

with influenza vaccination coverage among the elderly: role

of health care personnel. Public Health 1996;110(3):163–8.

Honkanen 1997 {published data only}

Honkanen PO, Keistinen T, Kivela SL. The impact of

vaccination strategy and methods of information on

influenza and pneumococcal vaccination coverage in the

elderly population. Vaccine 1997;15(3):317–20.

Honkanen 2006 {published data only}

Honkanen P, Laara E, Pyhala R, Kivela SL, Helena MP.

Comparison of two vaccination programmes in preventing

influenza-related hospitalization among the elderly during

two consecutive seasons. Scandinavian Journal of Infectious

Diseases 2006;38(6-7):506–11.

45Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Humair 2002 {published data only}

Humair J-P, Buchs CR, Stalder H. Promoting influenza

vaccination of elderly patients in primary care. Family

Practice 2002;19(4):383–9.

Hutchinson 1995 {published data only}

Hutchinson HL, Norman LA. Compliance with influenza

immunization: a survey of high-risk patients at a family

medicine clinic. Journal of the American Board of Family

Practice 1995;8:448-51.

Hutchison 1991 {published data only}

Hutchison BG, Shannon HS. Effect of repeated annual

reminder letters on influenza immunization among elderly

patients. Journal of Family Practice 1991;33(2):187–9.

Hutt 2010 {published data only}

Hutt E, Radcliff TA, Oman KS, Fink R, Ruscin M, Linnebur

S, et al. Impact of NHAP guideline implementation

intervention on staff and resident vaccination rates. Journal

of the American Medical Directors Association 2010;11: 365–70. ∗ Hutt E, Ruscin M, Linnebur SA, Fish DN, Oman KS,

Fink RM, et al. A multifaceted intervention to implement

guidelines did not affect hospitalization rates for nursing-

home acquired pneumonia. Journal of the American Medical

Directors Association 2011;12:499–507.

Jacobs 2001 {published data only}

Jacobs EA, Lauderdale DS, Meltzer D, Shorey JM, Levinson

W, Thisted RA. Impact of interpreter services on delivery of

health care to limited-English-proficient patients. Journal of

General Internal Medicine 2001;16(7):468–74.

Jain 1998 {published data only}

Jain S, Avins AL, Mendelson T. Preventive health services

and access to care for male veterans compared with their

spouses. Western Journal of Medicine 1998;168(6):499–503.

Jans 2000 {published data only}

Jans MP, Schellevis FG, Van Hensbergen W, van Eijk JT.

Improving general practice care of patients with asthma

or chronic obstructive pulmonary disease: evaluation of a

quality system. Effective Clinical Practice 2000;3(1):16–24.

Jefferson 1996 {published data only}

Jefferson T, Demicheli V. Economic evaluation of influenza

vaccination and economic modelling. Can results be

pooled?. Pharmacoeconomics 1996;9(Suppl 3):67–72.

Jiménez-Garcia 2007 {published data only}

Jiménez-Garcia R, Rinez-Fernandez MC, Hernandez-

Barrera V, Garcia-Carballo MM, de Miguel AG, Carrasco-

Garrido P. Compliance with influenza and pneumococcal

vaccination among patients with chronic obstructive

pulmonary disease consulting their medical practitioners in

Catalonia, Spain. Journal of Infection 2007;54(1):65–74.

Jin 2003 {published data only}

Jin Y, Carriere KC, Predy G, Johnson DH, Marrie TJ. The

association between influenza immunization coverage rates

and hospitalization for community-acquired pneumonia in

Alberta. Canadian Journal of Public Health 2003;94(5):

341–5.

Johnson 2005 {published data only}

Johnson EA, Webb WL, McDowall JM, Chasson LL, Oser

CS, Grandpre JR, et al. A field-based approach to support

improved diabetes care in rural states. Preventing Chronic Disease 2005;2(4):1–9.

Kassam 2001 {published data only}

Kassam R, Farris KB, Burback L, Volume CI, Cox CE,

Cave A. Pharmaceutical care research and education

project: pharmacists’ interventions. Journal of the American Pharmaceutical Association 2001;41(3):401–10.

Kelly 1988 {published data only}

Kelly SD. The impact of a microcomputer on a general

practice immunisation clinic. Practitioner 1988;232(1443):

197, 200-1.

Kemper 1993 {published data only}

Kemper KJ, Goldberg H. Do computer-generated reminder

letters improve the rate of influenza immunization in an

urban pediatric clinic?. American Journal of Diseases of Children 1993;147(7):717–8.

Kendal 1985 {published data only}

Kendal AP, Patriarca PA, Arden NH. Policies and outcomes

for control of influenza among the elderly in the USA.

Vaccine 1985;3(3):274–6.

Kennedy 1994 {published data only}

Kennedy KM, Browngoehl K. A “high-tech,” “soft-touch”

immunization program for members of a Medicaid managed

care organization. HMO Practice 1994;8(3):115-20, 21.

Kern 1990 {published data only}

Kern DE, Harris WL, Boekeloo BO, Barker LR, Hogeland

P. Use of an outpatient medical record audit to achieve

educational objectives: changes in residents’ performances

over six years. Journal of General Internal Medicine 1990;5

(3):218–24.

Klachko 1989 {published data only}

Klachko DM, Wright DL, Gardner DW. Effect of a

microcomputer-based registry on adult immunizations.

Journal of Family Practice 1989;29(2):169–72.

Knoell 1991 {published data only}

Knoell KR, Leeds AL. Influenza vaccination program for

elderly outpatients. American Journal of Hospital Pharmacy 1991;48(2):256–9.

Korn 1988 {published data only}

Korn JE, Schlossberg LA, Rich EC. Improved preventive

care following an intervention during an ambulatory care

rotation: carryover to a second setting. Journal of General Internal Medicine 1988;3(2):156–60.

Kosiak 2006 {published data only}

Kosiak B, Sangl J, Correa-de-Araujo R. Quality of health

care for older women: what do we know?. Women’s Health

Issues 2006;16(2):89–99.

Kunze 1998 {published data only}

Kunze M. The contribution of social medicine to

vaccination in Austria. Wiener Medizinische Wochenschrift

1998;148(8-9):191–7.

46Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Kwong 2006 {published data only}

Kwong JC, Sambell C, Johansen H, Stukel TA, Manuel

DG. The effect of universal influenza immunization on

vaccination rates in Ontario. Health Reports 2006;17(2): 31–40.

Kyaw 2002 {published data only}

Kyaw MH, Wayne B, Chalmers J, Jones IG, Campbell H.

Influenza and pneumococcal vaccine distribution and use

in primary care and hospital settings in Scotland: coverage,

practice and policies. Epidemiology & Infection 2002;128

(3):445–55.

Landis 1995 {published data only}

Landis S, Scarbrough ML. Using a vaccine manager to

enhance in-hospital vaccine administration. Journal of Family Practice 1995;41(4):364–9.

Landon 2004 {published data only}

Landon BE, Zaslavsky AM, Bernard SL, Cioffi MJ, Cleary

PD. Comparison of performance of traditional Medicare vs

Medicare managed care. JAMA 2004;291(14):1744–52.

Larson 1979 {published data only}

Larson EB, Olsen E, Cole W, Shortell S. The relationship

of health beliefs and a postcard reminder to influenza

vaccination. Journal of Family Practice 1979;8(6):1207–11.

Larson 1982 {published and unpublished data}

Larson EB, Bergman J, Heidrich F, Alvin BL, Schneeweiss

R. Do postcard reminders improve influenza compliance? A

prospective trial of different postcard “cues”. Medical Care

1982;20(6):639–48.

Lau 2006 {published data only}

Lau JTF, Yang X, Tsui HY, Kim JH. Prevalence of influenza

vaccination and associated factors among community-

dwelling Hong Kong residents of age 65 or above. Vaccine

2006;24(26):5526–34.

Lawson 2000 {published data only}

Lawson F, Baker V, Au D, McElhaney JE. Standing orders

for influenza vaccination increased vaccination rates in

inpatient settings compared with community rates. Journals

of Gerontology Series A-Biological Sciences & Medical Sciences 2000;55(9):522–6.

Lazorik 2001 {published data only}

Lazorik D. The role of emergency nurses in the prevention

and control of influenza and pneumococcal disease. Journal

of Emergency Nursing 2001;27(5):454–60.

LeBaron 1997 {published data only}

LeBaron CW, Chaney M, Baughman AL, Dini EF, Maes

E, Dietz V, et al. Impact of measurement and feedback on

vaccination coverage in public clinics, 1988-1994. JAMA

1997;277(8):631–5.

Lee 2003 {published data only (unpublished sought but not used)}

Lee SS. Is the use of physician reminder sticker on medical

records effective for improving the rate of recommending

influenza vaccination?. Korean Academy of Family Medicine

2003;24(8):715–20.

Lees 2005 {published data only}

Lees KA, Wortley PM, Coughlin SS. Comparison of

racial/ethnic disparities in adult immunization and cancer

screening. American Journal of Preventive Medicine 2005;29

(5):404–11.

Leirer 1989 {published data only}

Leirer VO, Morrow DG, Pariante G, Doksum T. Increasing

influenza vaccination adherence through voice mail. Journal

of the American Geriatrics Society 1989;37(12):1147–50.

Leirer 1991 {published data only}

Leirer VO, Morrow DG, Tanke ED, Pariante GM. Elders’

nonadherence: its assessment and medication reminding by

voice mail. Gerontologist 1991;31(4):514–20.

Levy 1996 {published data only}

Levy E. French economic evaluations of influenza and

influenza vaccination. Pharmacoeconomics 1996;9(Suppl 3): 62–6.

Lieberman 2003 {published data only}

Lieberman D, Lieberman D. Management of respiratory

infections in the elderly. Expert Review of Antiinfective

Therapy 2003;1(3):505–16.

Lindley 2006 {published data only}

Lindley MC, Wortley PM, Winston CA, Bardenheier

BH. The role of attitudes in understanding disparities in

adult influenza vaccination. American Journal of Preventive Medicine 2006;31(4):281–5.

Loeser 1983 {published data only}

Loeser H, Zvagulis I, Hercz L, Pless IB. The organization

and evaluation of a computer-assisted, centralized

immunization registry. American Journal of Public Health

1983;73(11):1298–301.

Lu 2005 {published data only}

Lu P-J, Singleton JA, Rangel MC, Wortley PM, Bridges

CB. Influenza vaccination trends among adults 65 years or

older in the United States, 1989-2002. Archives of Internal

Medicine 2005;165(16):1849–56.

Lynd 2005 {published data only}

Lynd LD, Goeree R, O’Brien BJ. Antiviral agents for

influenza: a comparison of cost-effectiveness data.

Pharmacoeconomics 2005;23(11):1083–106.

Macdonald 1985 {published data only}

Macdonald H, Roder D. The planning, implementation

and evaluation of an immunization promotion campaign in

South Australia. Hygiene 1985;4(2):13–7.

Maciosek 2006 {published data only}

Maciosek MV, Solberg LI, Coffield AB, Edwards NM,

Goodman MJ. Influenza vaccination health impact and cost

effectiveness among adults aged 50 to 64 and 65 and older.

American Journal of Preventive Medicine 2006;31(1):72–9.

Madlon-Kay 1987 {published data only}

Madlon-Kay DJ. Improving the periodic health

examination: use of a screening flow chart for patients and

physicians. Journal of Family Practice 1987;25(5):470–3.

Mair 1974 {published data only}

Mair HJ, Sansome DA, Tillett HE. A controlled trial of

inactivated monovalent influenza A vaccines in general

practice. Journal of Hygiene 1974;73(2):317–27.

47Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Malmvall 2007 {published data only}

Malmvall BE, Franzen I, Abom PE, Hugosson MB. The

rate of influenza immunization to people aged 65 years

and older was increased from 45% to 70% by a primary

health care-based multiprofessional approach. Quality

Management in Health Care 2007;16(1):51–9.

Mandel 1985 {published data only}

Mandel I, Franks P, Dickinson J. Improving physician

compliance with preventive medicine guidelines. Journal of Family Practice 1985;21(3):223–4.

Mangione 2006 {published data only}

Mangione CM, Gerzoff RB, Williamson DF, Steers WN,

Kerr EA, Brown AF, et al. The association between quality

of care and the intensity of diabetes disease management

programs. Annals of Internal Medicine 2006;145(2):107–16.

Mangtani 2006 {published data only}

Mangtani P, Breeze E, Stirling S, Hanciles S, Kovats S,

Fletcher A. Cross-sectional survey of older peoples’ views

related to influenza vaccine uptake. BMC Public Health

2006;6:249.

Margolis 1988 {published data only}

Margolis KL, Lofgren RP, Korn JE. Organizational strategies

to improve influenza vaccine delivery. A standing order in a

general medicine clinic. Archives of Internal Medicine 1988;

148(10):2205–7.

Margolis 1992 {published data only}

Margolis KL, Nichol KL, Wuorenma J, Von Sternberg TL.

Exporting a successful influenza vaccination program from

a teaching hospital to a community outpatient setting.

Journal of the American Geriatrics Society 1992;40(10): 1021–3.

Marra 2011 {published data only}

Marra F, Marra C, Kaczorowski J, Gastonguay L. Pharmacy-

based immunization in rural communities strategy (PhICS):

interim results. Canadian Pharmacists Journal 2011;14(5):

e17.

Marsteller 2006 {published data only}

Marsteller JA, Tiggle R, Remsburg R, Shefer A, Bardenheier

B. Influenza immunization in nursing homes: who does not

get immunized and whose status is unknown?. Infection

Control & Hospital Epidemiology 2006;27(4):388–96.

Martinen 2004 {published data only}

Martinen M, Freundl M. Managing congestive heart failure

in long-term care. Journal of Gerontological Nursing 2004; 30(12):5–12.

Mayo 2004 {published data only}

Mayo AM, Cobler S. Flu vaccines and patient decision

making: what we need to know. Journal of the American

Academy of Nurse Practitioners 2004;16(9):402–10.

McArthur 1999 {published data only}

McArthur MA, Simor AE, Campbell B, McGeer

A. Influenza vaccination in long-term-care facilities:

structuring programs for success. Infection Control and

Hospital Epidemiology 1999;20(7):499–503.

McDonald 1984 {published data only}

McDonald CJ, Hui SL, Smith DM, Tierney WM, Cohen

SJ, Weinberger M, et al. Reminders to physicians from

an introspective computer medical record. A two-year

randomized trial. Annals of Internal Medicine 1984;100(1):

130–8.

McDonald 1992 {published data only (unpublished sought but not

used)}

McDonald CJ, Hui SL, Tierney WM. Effects of computer

reminders for influenza vaccination on morbidity during

influenza epidemics. MD Computing: Computers in Medical Practice 1992;9(5):304–12.

McKinney 1989 {published data only}

McKinney WP, Barnas GP. Influenza immunization in the

elderly: knowledge and attitudes do not explain physician

behavior. American Journal of Public Health 1989;79(10): 1422.

McLeod 2001 {published data only}

McLeod L, Lau WW. Decreasing influenza impact in

lodges: 1997-2000 Calgary Regional Health Authority.

Canadian Journal of Public Health [Revue Canadienne de Santé Publique] 2001;92(4):291–4.

Merkel 1994 {published data only}

Merkel PA, Caputo GC. Evaluation of a simple office-based

strategy for increasing influenza vaccine administration and

the effect of differing reimbursement plans on the patient

acceptance rate. Journal of General Internal Medicine 1994;9

(12):679–83.

Métrailler 2003 {published data only}

Métrailler A, Emery G, Zuber A, Robyr M, Mabillard F,

Dolt G, et al. Can we improve the general and nutritional

management of elderly individuals living at a medical-social

facility? A team work [Peut–on améliorer la prise en charge

generale et nutritionnelle des personnes âgées vivant en

etablissement médico–social? Un travail d’equipe]. Revue Medicale de la Suisse Romande 2003;123(3):197–200.

Milman 2005 {published data only}

Milman U, Ben-Moshe S, Hermoni D. The role of the

patient care team in elderly people decision on influenza

vaccination. Patient Education & Counseling 2005;58(2): 203–8.

Mody 2005 {published data only}

Mody L, Langa KM, Saint S, Bradley SF. Preventing

infections in nursing homes: a survey of infection control

practices in southeast Michigan. American Journal of Infection Control 2005;33(8):489–92.

Morrow 1995 {published data only}

Morrow RW, Gooding AD, Clark C. Improving physicians’

preventive health care behavior through peer review and

financial incentives. Archives of Family Medicine 1995;4(2): 165–9.

Mosesso 2003 {published data only}

Mosesso VN Jr, Packer CR, McMahon J, Auble TE, Paris

PM. Influenza immunizations provided by EMS agencies:

the MEDICVAX Project. Prehospital Emergency Care 2003;

7(1):74–8.

48Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Mukamel 2001 {published data only}

Mukamel DB, Gold HT, Bennett NM. Cost utility of

public clinics to increase pneumococcal vaccines in the

elderly. American Journal of Preventive Medicine 2001;21(1): 29–34.

Mulet Pons 1995 {published data only}

Mulet Pons MJ, Sarrión Ferre MT, Barea Montoro A,

Marin Rueda N, Blanquer Grégori JJ, Melchor Penella

MA. Evaluation of the completion of influenza vaccination

[Evaluacion del cumplimiento de la vacunacion antigripal].

Atención Primaria 1995;16(7):423–7.

Müller 2005 {published data only}

Müller D, Szucs TD. Coverage rates of influenza vaccine

in Italy during the 2002/3 and 2003/04 seasons: a cross-

sectional study. Annali di Igiene 2005;17(4):351–63.

Murphy 1996 {published data only}

Murphy AW, Harrington M, Bury G, O’Doherty K,

O’Kelly F, Smith M, et al. Impact of a collaborative

immunisation programme in an inner city practice. Irish Medical Journal 1996;89(6):220–1.

Nakatani 2002 {published data only}

Nakatani H, Sano T, Iuchi T. Development of vaccination

policy in Japan: current issues and policy directions. Journal of Infectious Diseases 2002;55(4):101–11.

Ndiaye 2005 {published data only}

Ndiaye SM, Hopkins DP, Shefer AM, Hinman AR, Briss

PA, Rodewald L, et al. Interventions to improve influenza,

pneumococcal polysaccharide, and hepatitis B vaccination

coverage among high-risk adults: a systematic review.

American Journal of Preventive Medicine 2005;28(Suppl 5):

248–79.

Nichol 1990 {published data only}

Nichol KL, Korn JE, Margolis KL, Poland GA, Petzel RA,

Lofgren RP. Achieving the national health objective for

influenza immunization: success of an institution-wide

vaccination program. American Journal of Medicine 1990; 89(2):156–60.

Nichol 1992 {published data only}

Nichol KL, Lofgren RP, Gapinski J. Influenza vaccination.

Knowledge, attitudes, and behavior among high-risk

outpatients. Archives of Internal Medicine 1992;152(1):

106–10.

Nichol 1998 {published data only}

Nichol KL. Ten-year durability and success of an

organized program to increase influenza and pneumococcal

vaccination rates among high-risk adults. American Journal of Medicine 1998;105(5):385–92.

Nichol 2006 {published data only}

Nichol K, Nordin J, Mullooly J. Influence of clinical

outcome and outcome period definitions on estimates

of absolute clinical and economic benefits of influenza

vaccination in community dwelling elderly persons. Vaccine 2006;24(10):1562–8.

Nicoleau 2001 {published data only}

Nicoleau A, Nicoleau CA, Balzora JD, Oboh A, Siddiqui N,

Rosenberg C. Elderly African-Americans and the influenza

vaccine: the impact of the primary care physician. Journal of

the American Medical Directors Association 2001;2(2):56–9.

Nowalk 2004a {published data only}

Nowalk MP, Zimmerman RK, Feghali J. Missed

opportunities for adult immunization in diverse primary

care office settings. Vaccine 2004;22(25-6):3457–63.

Nowalk 2004b {published data only}

Nowalk MP, Zimmerman RK, Shen S, Jewell IK, Raymund

M. Barriers to pneumococcal and influenza vaccination in

older community-dwelling adults. Journal of the American

Geriatrics Society 2004;52(1):25–30.

Nowalk 2004c {published data only}

Nowalk MP, Bardella IJ, Zimmerman RK, Shen S. The

physician’s office: can it influence adult immunization rates?

. American Journal of Managed Care 2004;10(1):13–9.

Nowalk 2008 {published data only}

Nowalk MP, Zimmerman RK, Lin CJ, Raymund M,

Tabbarah M, Wilson SA, et al. Raising adult vaccination

rates over 4 years among racially diverse patients at inner-

city health centers. Journal of the American Geriatrics Society 2008;56(7):1177–82.

Nowalk 2012 {published data only}

Nowalk MP, Nutini J, Raymund M, Ahmed F, Albert SM,

Zimmerman RK. Evaluation of a toolkit to introduce

standing orders for influenza and pneumococcal vaccination

in adults: a multimodal pilot project. Vaccine 2012;30(41): 5978–82. PUBMED: 22835736]

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Nowalk MP, Nolan BA, Nutini J, Ahmed F, Albert

SM, Susick M, et al. Success of the 4 pillars toolkit

for influenza and pneumococcal vaccination in adults.

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23777396]

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O’Connor AM, Pennie RA, Dales RE. Framing effects

on expectations, decisions, and side effects experienced:

the case of influenza immunization. Journal of Clinical Epidemiology 1996;49(11):1271–6.

O’Connor 1998 {published data only}

O’Connor PJ, Desai J, Rush WA, Cherney LM, Solberg LI,

Bishop DB. Is having a regular provider of diabetes care

related to intensity of care and glycemic control?. Journal of Family Practice 1998;47(4):290–7.

O’Malley 2006 {published data only}

O’Malley AS, Forrest CB. Immunization disparities in

older Americans: determinants and future research needs.

American Journal of Preventive Medicine 2006;31(2):150–8.

O’Reilly 2002 {published data only}

O’Reilly D, Gormley G, Gilliland A, Cuene-Grandidier

H, Rafferty C, Reilly P, et al. Influenza vaccinations in

Northern Ireland: are older patients missing out?. Age and Ageing 2002;31(5):385–90.

Ohmit 1995 {published data only}

Ohmit SE, Furumoto-Dawson A, Monto AS, Fasano N.

Influenza vaccine use among an elderly population in a

49Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

community intervention. American Journal of Preventive

Medicine 1995;11(4):271–6.

Ompad 2006 {published data only}

Ompad DC, Galea S, Vlahov D. Distribution of influenza

vaccine to high-risk groups. Epidemiologic Reviews 2006;28:

54–70.

Ornstein 1991 {published data only}

Ornstein SM, Garr DR, Jenkins RG, Rust PF, Arnon A.

Computer-generated physician and patient reminders.

Tools to improve population adherence to selected

preventive services. Journal of Family Practice 1991;32(1): 82–90.

Overhage 1996 {published data only}

Overhage JM, Tierney WM, McDonald CJ. Computer

reminders to implement preventive care guidelines for

hospitalized patients. Archives of Internal Medicine 1996; 156:1551–6.

Padiyara 2011 {published data only}

Padiyara RS, D’Souza JJ, Rihani RS. Clinical pharmacist

intervention and the proportion of diabetes patients

attaining prevention objectives in a multispecialty medical

group. Journal of Managed Care Pharmacy 2011;17(6): 456–62.

Parchman 2004 {published data only}

Parchman ML, Burge SK. The patient-physician

relationship, primary care attributes, and preventive services.

Family Medicine 2004;36(1):22–7.

Parry 2004 {published data only}

Parry MF, Grant B, Iton A, Parry PD, Baranowsky D.

Influenza vaccination: a collaborative effort to improve the

health of the community. Infection Control and Hospital Epidemiology 2004;25(11):929–32.

Pasquarella 2003 {published data only}

Pasquarella A, Perria C, D’Amato M, Billi P, Marceca

M, Volpe E, et al. Management of vaccination practices

in adults: the influenza vaccination campaign in Lazio

region, Italy [Modelli organizzativi di profilassi vaccinale

nell’adulto: l’esperienza della campagna di vaccinazione

antinfluenzale nella regione Lazio]. Annali di Igiene 2003; 15(6):871–9.

Patel 2004 {published data only}

Patel PH, Welsh C, Foggs MB. Improved asthma outcomes

using a coordinated care approach in a large medical group.

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Patel 2006 {published data only}

Patel MS, Davis MM. Could a federal program to promote

influenza vaccination among elders be cost-effective?.

Preventive Medicine 2006;42(3):240–6.

Patriarca 1985 {published data only}

Patriarca PA, Weber JA, Meissner MK, Stricof RL, Dateno

B, Braun JE, et al. Use of influenza vaccine in nursing

homes. Journal of the American Geriatrics Society 1985;33

(7):463–6.

Payaprom 2011 {published data only}

Payaprom Y, Alabaster E, Bennett P, Tantipong H. Using

the health action process approach and implementation

intentions to increase flu vaccine uptake in high risk Thai

individuals: a controlled before-after trial. Health Psychology 2011;30(4):492–500.

Pearson 2005 {published data only}

Pearson E, Lang E, Colacone A, Farooki N, Afilalo M.

Successful implementation of a combined pneumococcal

and influenza vaccination program in a Canadian emergency

department. Canadian Journal of Emergency Medical Care

2005;7(6):371–7.

Piedra 1995 {published data only}

Piedra PA. Influenza virus pneumonia: pathogenesis,

treatment, and prevention. Seminars in Respiratory Infections 1995;10(4):216–23.

Pleis 2002 {published data only}

Pleis JR, Gentleman JF. Using the National Health

Interview Survey: time trends in influenza vaccinations

among targeted adults. Effective Clinical Practice 2002;5 (Suppl 3):E3.

Ploeg 1994 {published data only}

Ploeg J, Black ME, Hutchison BG, Walter SD, Scott EA,

Chambers LW. Personal, home and community safety

promotion with community-dwelling elderly persons:

response to a public health nurse intervention. Canadian

Journal of Public Health 1994;85(3):188–91.

Postma 2005 {published data only}

Postma MJ, Jansema P, Scheijbeler HW, van Genugten ML.

Scenarios on costs and savings of influenza treatment and

prevention for Dutch healthy working adults. Vaccine 2005;

23(46-7):5365–71.

Prati 2012 {published data only}

Prati G, Pietrantoni L, Zani B. Influenza vaccination: the

persuasiveness of messages among people aged 65 years and

older. Health Communication 2012;27:413–20.

Puig-Barberà 1999 {published data only}

Puig-Barberà J, Ors-Zarzoso P, Vilches Peña C, Lloria Paes

F. Impact of various strategies on the rates of flu vaccination

in the elderly [Impacto de distintas estrategias en las tasas

de vacunación antigripal en ancianos]. Atención Primaria 1999;23(6):339–45.

Quinley 2004 {published data only}

Quinley JC, Shih A. Improving physician coverage of

pneumococcal vaccine: a randomized trial of a telephone

intervention. Journal of Community Health 2004;29(2): 103–15.

Rantz 2001 {published data only}

Rantz MJ, Popejoy L, Petroski GF, Madsden RW, Mehr

DR, Zwygart-Stauffacher M, et al. Randomized clinical trial

of quality improvement interventions in nursing homes.

Gerontologist 2001;41(4):525–38.

Reichert 2001 {published data only}

Reichert TA, Sugaya N, Fedson DS, Glezen WP, Simonsen

L, Tashiro M. The Japanese experience with vaccinating

schoolchildren against influenza. New England Journal of

Medicine 2001;344(12):889–96.

50Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Resnick 2001 {published data only}

Resnick B. Promoting health in older adults: a four-year

analysis. Journal of the American Academic Nurse 2001;13

(1):23–33.

Ressel 2003 {published data only}

Ressel GW, Advisory Committee on Immunization

Practices. ACIP releases 2003 guidelines on the prevention

and control of influenza. American Family Physician 2003;

68(7):1426–30.

Retchin 1991 {published data only}

Retchin SM, Preston J. Effects of cost containment on the

care of elderly diabetics. Archives of Internal Medicine 1991;

151(11):2244–8.

Rimple 2006 {published data only}

Rimple D, Weiss SJ, Brett M, Ernst AA. An emergency

department-based vaccination program: overcoming the

barriers for adults at high risk for vaccine-preventable

diseases. Academic Emergency Medicine 2006;13(9):922–30.

Robare 2011 {published data only}

Robare JF, Bayles CM, Newman AB, Williams K, Milas C,

Boudreau R, et al. The “10 Keys” to Healthy Aging: 24-

month follow-up results from an innovative community-

based prevention program. Health Education & Behavior 2011;38(4):379–88.

Rodewald 1999 {published data only}

Rodewald L, Szilagyi P, Humiston S, Barth R, Kraus R,

Raubertas R. A randomized study of tracking with outreach

and provider prompting to improve immunization coverage

and primary care. Pediatrics 1999;103(1):31–8.

Rodriguez 1993 {published data only}

Rodriguez RM, Baraff LJ. Emergency department

immunization of the elderly with pneumococcal and

influenza vaccines. Annals of Emergency Medicine 1993;22 (11):1729–32.

Rodriguez-Rodriguez 2006 {published data only}

Rodriguez-Rodriguez MI, Gatón Del Amo M, Robles-

Marinas V, Rubio-Dominguez J. Factors determining flu

vaccination in the over-65s [Factores determinantes de

vacunación antigripal en mayores de 65 años]. Atención

Primaria 2006;37(7):381–5.

Roffey 1998 {published data only}

Roffey VE. Vaccination of health care workers working in

geriatric long term care hospitals reduced patient mortality.

Evidence-Based Nursing 1998;1:18.

Russell 2000 {published data only}

Russell ML, Maxwell CJ. The prevalence and correlates

of influenza vaccination among a home care population.

Canadian Journal of Public Health 2000;91(6):441–4.

Rust 1999 {published data only}

Rust CT, Sisk FA, Kuo AR, Smith J, Miller R, Sullivan KM.

Impact of resident feedback on immunization outcomes.

Archives of Pediatrics & Adolescent Medicine 1999;153(11): 1165–9.

Ryan 1984 {published data only}

Ryan MP, MacLeod AF. A comparison of adverse effects of

two influenza vaccines, and the influence on subsequent

uptake. Journal of the Royal College of General Practitioners

1984;34(265):442–4.

Sambamoorthi 2005 {published data only}

Sambamoorthi U, Findley PA. Who are the elderly who

never receive influenza immunization?. Preventive Medicine

2005;40(4):469–78.

Sansom 2003 {published data only}

Sansom S, Rudy E, Strine T, Douglas W. Hepatitis A and B

vaccination in a sexually transmitted disease clinic for men

who have sex with men. Sexually Transmitted Diseases 2003;

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Sarnoff 1998 {published data only}

Sarnoff R, Rundall T. Meta-analysis of effectiveness of

interventions to increase influenza immunization rates

among high-risk population groups. Medical Care Research & Review 1998;55(4):432–56.

Schectman 1995 {published data only}

Schectman JM, Kanwal NK, Schroth WS, Elinsky EG. The

effect of an education and feedback intervention on group-

model and network-model health maintenance organisation

physician prescribing behavior. Medical Care 1995;33: 139–44.

Schensul 2009 {published data only}

Schensul JJ, Radda K, Coman E, Vazquez E. Multi-

level intervention to prevent influenza infections in older

low income and minority adults. American Journal of Community Psychology 2009;43(3-4):313–29.

Schluter 1999 {published data only}

Schluter WW, Ralston DL, Delaney RJ, Sauaia A, Dunn

TR. Increasing influenza and pneumococcal vaccination

and tuberculosis screening among residents of Colorado

long-term care facilities. Evaluation & the Health Professions

1999;22(4):466–83.

Schmitz 1993a {published data only}

Schmitz R, Schwartz A. The Medicare influenza vaccine

cost-effectiveness study nursing home survey. International

Congress Series; options for the control of influenza International Congress Series: 1019 1993;1:123–6.

Schmitz 1993b {published data only}

Schmitz RJ, Schwartz AM. Medicare coverage, vaccine

promotion and rates of influenza vaccination among the

Medicare population: 1998-1991. International Congress

Series; options for the control of influenza International Congress Series: 1019. Elsevier Science Publishers B.V.;

Elsevier Science Publishing Co., Inc 1993;1:115–22.

Schneider 2001 {published data only}

Schneider EC, Cleary PD, Zaslavsky AM, Epstein AM.

Racial disparity in influenza vaccination: does managed

care narrow the gap between African Americans and whites?

. JAMA 2001;286(12):1455–60.

Schreiner 1988 {published data only}

Schreiner DT, Petrus ER, Rettie CS, Kluge RM. Improving

compliance with preventive medicine procedures in a house

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51Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Schwartz 2006 {published data only}

Schwartz KL, Neale AV, Northrup J, Monsur J, Patel

DA, Tobar R Jr, et al. Racial similarities in response to

standardized offer of influenza vaccination: a MetroNet

study. Journal of General Internal Medicine 2006;21(4):

346–51.

Schwarz 2005 {published data only}

Schwarz Chavarri H, Ortuno Lopez JL, Lattur Vilchez A,

Pedrera Carbonell V, Orozco Beltran D, Gil Guillen V. Flu

vaccination in primary care: analysis of the process and

proposals for increasing coverage [Vacunación antigripal en

atención primaria: análisis del proceso y propuestas para

aumentar las tasas de cobertura]. Atención Primaria 2005;

36(7):390–6.

Scott 1996 {published data only}

Scott WG, Scott HM. Economic evaluation of vaccination

against influenza in New Zealand. Pharmacoeconomics 1996;9(1):51–60.

Setia 1985 {published data only}

Setia U, Serventi I, Lorenz P. Factors affecting the use of

influenza vaccine in the institutionalized elderly. Journal of

the American Geriatrics Society 1985;33(12):856–8.

Shah 2006 {published data only}

Shah MN, Clarkson L, Lerner EB, Fairbanks RJ, McCann

R, Schneider SM. An emergency medical services program

to promote the health of older adults. Journal of the

American Geriatrics Society 2006;54:956–62.

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Shahrabani S, Benzion U. The effects of socioeconomic

factors on the decision to be vaccinated: the case of flu shot

vaccination. Israel Medical Association Journal 2006;8(9):

630–4.

Shank 1989 {published data only}

Shank JC, Powell T, Llewelyn J. A five-year demonstration

project associated with improvement in physician health

maintenance behavior. Family Medicine 1989;21(4):273–8.

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Shenson D, Bolen J, Adams M, Seeff L, Blackman D.

Are older adults up-to-date with cancer screening and

vaccinations?. Preventing Chronic Disease 2005;2(3):A04.

Shenson 2007 {published data only}

Shenson D, Bolen J, Adams M. Receipt of preventive

services by elders based on composite measures, 1997-2004.

American Journal of Preventive Medicine 2007;32(1):11–8.

Shenson 2011 {published data only}

Shenson D, Adams M, Bolen J, Anderson L. Routine

checkups don’t ensure that seniors get preventive services.

Journal of Family Practice 2011;60(1):E1–10.

Shugarman 2006 {published data only}

Shugarman LR, Hales C, Setodji CM, Bardenheier B, Lynn

J. The influence of staff and resident immunization rates on

influenza-like illness outbreaks in nursing homes. Journal of

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Siebers 1985 {published data only}

Siebers M, Hunt V. Increasing the pneumococcal

vaccination rate of elderly patients in a general internal

medicine clinic. Journal of the American Geriatrics Society 1985;33(3):175–8.

Simor 2002 {published data only}

Simor AE. Influenza outbreaks in long-term-care facilities:

how can we do better?. Infection Control and Hospital Epidemiology 2002;23(10):564–7.

Siriwardena 2003a {published data only}

Siriwardena AN, Rashid A, Johnson M, Hazelwood

L, Wilburn T. Improving influenza and pneumococcal

vaccination uptake in high-risk groups in Lincolnshire:

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Slobodkin 1998 {published data only}

Slobodkin D, Kitlas J, Zielske P. Opportunities not missed -

systematic influenza and pneumococcal immunization in a

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Soljak 1987 {published data only}

Soljak M, Handford S. Early results from the Northland

immunisation register. New Zealand Medical Journal 1987; 100(822):244–6.

Song 2000 {published data only (unpublished sought but not used)}

Russell M [pers comm]. Baseline vaccination rates, results

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and postcard reminders for the influenza vaccination: a

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in a tertiary care hospital. Korean Journal of Preventive Medicine 2000;33(1):109–16.

Song YM [pers comm]. Baseline vaccination rates, results

and study risk of bias. RE Thomas 16 February 2009; 20

November 2017.

Stancliff 2000 {published data only}

Stancliff S, Salomon N, Perlman DC, Russell PC. Provision

of influenza and pneumococcal vaccines to injection drug

users at a syringe exchange. Journal of Substance Abuse and Treatment 2000;18(3):263–5.

Stehr-Green 1993 {published data only}

Stehr-Green P, Dini E, Lindegren M, Patriarca P. Evaluation

of telephoned computer-generated reminders to improve

immunization coverage at inner-city clinics. Public Health

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Stenqvist K, Hellvin MA, Hellke P, Hoglund D, von

Sydow H. Influenza work on the regional level in Sweden:

an integrated program for vaccination of risk groups,

surveillance and pandemic planning which focuses on the

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Steyer 2004 {published data only}

Steyer TE, Ragucci KR, Pearson WS, Mainous AG 3rd. The

role of pharmacists in the delivery of influenza vaccinations.

Vaccine 2004;22(8):1001–6.

52Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Stott 1998 {published data only}

Stott DJ, Murray GD, Elder A, Carman WB. Influenza

vaccination of health care workers in long-term care protects

elderly patients. Age and Ageing 1998;27(Suppl 2):45–6.

Straits-Troster 2006 {published data only}

Straits-Troster KA, Kahwati LC, Kinsinger LS, Orelien

J, Burdick MB, Yevich SJ. Racial/ethnic differences in

influenza vaccination in the Veterans Affairs Healthcare

System. American Journal of Preventive Medicine 2006;31

(5):375–82.

Stuart 1969 {published data only}

Stuart WH, Dull HB, Newton LH, McQueen JL, Schiff

ER. Evaluation of monovalent influenza vaccine in a

retirement community during the epidemic of 1965-66.

JAMA 1969;209(2):232–8.

Sylvan 2003 {published data only}

Sylvan S, Eriksson G, Berglund K, Pauksen K, Bergqvisit S.

Low vaccine coverage rate for influenza and pneumococcal

vaccination in an elderly population in Uppsala County,

Sweden. Interscience Conference on Antimicrobial Agents

and Chemotherapy. 2003; Vol. 43:Abstract no. G-884.

Szilagyi 1992 {published data only}

Szilagyi P, Rodewald L, Savageau J, Yoos L, Doane C.

Improving influenza immunization vaccination rates in

children with asthma: a test of a computerized reminder

system and an analysis of factors predicting vaccination.

Pediatrics 1992;90(6):871–5.

Szilagyi 2005 {published data only}

Szilagyi PG, Shone LP, Barth R, Kouides RW, Long C,

Humiston SG, et al. Physician practices and attitudes

regarding adult immunizations. Preventive Medicine 2005; 40(2):152–61.

Szilagyi 2006 {published data only}

Szilagyi PG, Schaffer S, Barth R, Shone LP, Humiston

SG, Ambrose S, et al. Effect of telephone reminder/recall

on adolescent immunization and preventive visits: results

from a randomized clinical trial. Archives of Pediatrics and Adolescent Medicine 2006;160:157–63.

Szucs 2006 {published data only}

Szucs TD, Wahle K, Muller D. Influenza vaccination in

Germany. A population-based cross-sectional analysis of

three seasons between 2002 and 2005 [Grippeimpfung

in Deutschland. Eine bevolkerungsbezongene

Querschnittsanalyse der derie Influenzasasons von 2002 bis

2005]. Medizinische Klinik 2006;10(7):537–45.

Tabbarah 2005 {published data only}

Tabbarah M, Zimmerman RK, Nowalk MP, Janosky JE,

Troy JA, Raymund M, et al. What predicts influenza

vaccination status in older Americans over several years?

. Journal of the American Geriatrics Society 2005;53(8): 1354–9.

Tacken 2002 {published data only}

Tacken M, Braspenning J, Spreeuwenberg P, van den

Hoogen H, van Essen G, de Bakker D, et al. Patient

characteristics determine differences in the influenza

vaccination rate more so than practice features. Preventive

Medicine 2002;35(4):401–6.

Tape 1993 {published data only}

Tape TG, Campbell JR. Computerized medical records and

preventive health care: success depends on many factors.

American Journal of Medicine 1993;94(6):619–25.

Terrell-Perica 2001 {published data only}

Terrell-Perica SM, Effler PV, Houck PM, Lee L, Crosthwaite

GH. The effect of a combined influenza/pneumococcal

immunization reminder letter. American Journal of

Preventive Medicine 2001;21(4):256–60.

Tierney 2005 {published data only}

Tierney WM, Overhage JM, Murray MD, Harris LE, Zhou

X-H, Eckert GJ, et al. Can computer-generated evidence-

based care suggestions enhance evidence-based management

of asthma and chronic obstructive pulmonary disease? A

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Tollestrup 1991 {published data only}

Tollestrup K, Hubbard B. Evaluation of a follow-up system

in a county health department’s immunization clinic.

American Journal of Preventive Medicine 1991;7(1):24–8.

Toscani 2003 {published data only}

Toscani L, Gauthey L, Robert CF. The information network

of senior citizens in Geneva, Switzerland, and progress in

flu vaccination coverage between 1991 and 2000. Vaccine

2003;21(5-6):393–8.

Traeger 2006 {published data only}

Traeger M, Thompson A, Dickson E, Provencio A. Bridging

disparity: a multidisciplinary approach for influenza

vaccination in an American Indian community. American

Journal of Public Health 2006;96(5):921–5.

Trick 2009 {published data only}

Trick WE, Das K, Gerard MN, Charles-Damte M, Murphy

G, Benson I, et al. Clinical trial of standing-orders strategies

to increase the inpatient influenza vaccination rate. Infection Control and Hospital Epidemiology 2009;30(1):86–8.

Tucker 1987 {published data only}

Tucker JB, DeSimone JP. Patient response to mail cues

recommending influenza vaccine. Family Medicine 1987;19 (3):209–12.

Turner 1989 {published data only}

Turner BJ, Day SC, Borenstein B. A controlled trial to

improve delivery of preventive care: physician or patient

reminders. Journal of General Internal Medicine 1989;4:

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Turner 1990 {published data only}

Turner RC, Waivers LE, O’Brien K. The effect of patient-

carried reminder cards on the performance of health

maintenance measures. Archives of Internal Medicine 1990; 150:645–7.

Turner 2003 {published data only}

Turner D, Wailoo A, Nicholson K, Cooper N, Sutton

A, Abrams K. Systematic review and economic decision

modelling for the prevention and treatment of influenza A

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Tymchuk 1991 {published data only}

Tymchuk AJ, Ouslander JG. Informed consent: does

position of information have an effect upon what

elderly people in long-term care remember?. Educational Gerontology 1991;17(1):11–9.

Usami 2009 {published data only}

Usami T, Hashiguchi M, Kouhara T, Ishii A, Nagata

T, Mochizuki M. Impact of community pharmacists

advocating immunization on influenza vaccination rates

among the elderly. Yakugaku Zasshi 2009;129(9):1063–8.

Van Amburgh 2001 {published data only}

Van Amburgh JA, Waite NM, Hobson EH, Migden H.

Improved influenza vaccination rates in a rural population as

a result of a pharmacist-managed immunization campaign.

Pharmacotherapy 2001;21(9):1115–22.

Van den Hooven 2006 {published data only}

Van den Hooven E, Hoes A, Nichol K, Hak E. Influence

of design and analytical factors on confounding in non-

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Van Essen GA, Kuyvenhoven MM, de Melker RA.

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∗ Indicates the major publication for the study

58Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

C H A R A C T E R I S T I C S O F S T U D I E S

Characteristics of included studies [ordered by study ID]

Abramson 2011

Methods Purpose: to compare influenza vaccination uptake of those aged ≥ 65 years attending

primary care clinics that received an intervention to increase staff influenza vaccination

uptake, or control (no staff intervention). No influenza intervention for participants

Design: cluster RCT (intervention provided to staff in 13 intervention clinics and not

provided in 14 control clinics)

Duration of study: HMO data extracted for 2007 to 2008 (intervention year) and

previous year (2006 to 2007)

Interval between intervention and when outcome was measured: 2007 to 2008 (inter-

vention year) (no further details)

Country: Israel

Setting: 27 primary care community clinics

Power computation: based on 2006-2007 imputed ICC = 0.019, for the sample of

participants in 2007 to 2008 ≥ 65, alpha = 0.05, power = 80% for increase in vaccination

uptake from 50% to 58%, and power of 90% for increase in vaccination uptake to 60%

for the healthcare workers, based on previous year staff vaccination uptake, predicted

156 healthcare workers required in each of intervention and control groups for power =

90% to detect relative increase in staff immunisation from 30% to 50%, with alpha =

0.05

Statistics: ORs and 95% CI corrected for clustering, logistic regression

Participants Inclusion criteria

Eligible participants: (health status); all healthcare workers in the 13 intervention clinics;

all participants aged ≥ 65 years in 13 intervention and 14 control clinics

Age: ≥ 65 years; staff were all 344 physicians, nurses, pharmacists, administrative, and

ancillary staff with direct patient contact

Gender: 58% female

Interventions Intervention 1: intervention to increase staff influenza vaccination uptake in the

Jerusalem area

Control: no staff intervention

Co-interventions: none

Outcomes Outcome measured: % aged ≥ 65 years influenza vaccination (intervention clinics 2006

to 2007 average influenza vaccination uptake 58.1% (43.4% 2006 to 2007); control 56.

7% (44.7%). Data are from Table 1, text provides different percentages

Time points reported in the study: 2007 to 2008 was intervention year (time points not

stated)

Notes Funding: none stated

Risk of bias

Bias Authors’ judgement Support for judgement

59Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Abramson 2011 (Continued)

Random sequence generation (selection

bias)

Unclear risk Clinics randomly selected for staff inter-

vention (method not stated)

Allocation concealment (selection bias) Unclear risk No statement

Blinding (performance bias and detection

bias)

All outcomes

Unclear risk No statement

Incomplete outcome data (attrition bias)

All outcomes

Low risk Baseline 11,755 in 13 intervention clinics;

420 (3.6%) excluded as died or left clinics

or moved to sheltered accomodation before

end of intervention period; 15,660 in 14

control clinics, 503 (3.2%) excluded

Selective reporting (reporting bias) Low risk No selective reporting

Arthur 2002

Methods Purpose: to compare the effect of offering home health checks to appointments in a

vaccination clinic on increasing influenza vaccination uptake

Design: randomised 1/3 participants to receive 30-minute health check and offer of

influenza vaccine at home, and 2/3 to receive personal letter to attend vaccination clinic

in surgery

Duration of study: October to 4 December 2000

Interval between intervention and when outcome was measured: letters mailed October

2000; health checks undertaken 2 October to 4 December 2000

Power computation: 99% power at alpha = 0.05 for uptake of 64% in health check

group compared to 50% in personal letter group

Statistics: Chi² to analyse difference in uptake between trial arms; ITT

Participants Country: UK

Setting: 34 general practice physicians in Leicestershire

Eligible participants: (health status) all 2052 participants aged >= 75 years living in

community

Age: ≥ 75 years

Gender: 60% female

Interventions Intervention 1: health check at home

Intervention 2: invitation to attend vaccination clinic

Outcomes Outcome measured: % influenza vaccination; how receipt of vaccine was recorded is not

stated, but as this is a single practice; the sole purpose of this intervention was influenza

vaccination; and vaccination clinics and home visits are by practice nurses, it can be

expected to be complete

Time points from the study considered in the review or measured or reported in the

study: 2 October to 4 December 2000

% vaccinated by 31 December 2000

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

Arthur 2002 (Continued)

Notes Funding: Melton, Rutland and Harborough Primary Care Group, Leicestershire Health

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection

bias)

Low risk SAS data analysis program assigned codes.

Allocation concealment (selection bias) Unclear risk No statement

Blinding (performance bias and detection

bias)

All outcomes

Unclear risk No statement

Incomplete outcome data (attrition bias)

All outcomes

Low risk Of 2408 participants, 356 in nursing home

or sheltered accomodation; of 680 ran-

domised to health check, 468 received

health check and 680 followed up; of 1372

randomised to personal letter, 66 received

flu vaccine at home and 1372 followed up

Selective reporting (reporting bias) Low risk No selective reporting

Baker 1998

Methods Purpose: to compare generic postcard recommending immunisation, personalised post-

card from physician, personalised letter from physician tailored to health risk, and no

intervention

Design: participants randomised to 3 interventions and 1 control group

Duration of study: reminders posted 3rd week of September 1995; date of end of study

not stated

Interval between intervention and when outcome was measured: not stated

Power computation: not performed

Statistics: percentages, ORs and 95% CIs

Participants Country: USA

Setting: Henry Ford multispecialty clinics, southeast Michigan

Eligible participants: high risk adult patients were defined as having asthma, diabetes,

end-stage renal disease, sickle cell disease, ischaemic cardiomyopathy, or nephrotic syn-

drome); of these participants aged ≥ 65 years were included

Age: ≥ 65 years

Gender: 57.7% female

Interventions Intervention 1: generic postcard recommending immunisation

Intervention 2: personalised postcard from physician

Intervention 3: personalised letter from physician tailored to health risk

Control: no intervention

61Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Baker 1998 (Continued)

Co-interventions: walk-in influenza clinics October; printed materials based on Health

Beliefs Model; toll-free telephone line

Outcomes Outcome measured: % influenza vaccination

Time points from the study considered in the review or measured or reported in the

study: computer-generated reminders sent last week of September 1995, date of end of

study not stated

% vaccinated by: not stated

Notes Funding: not stated

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection

bias)

Unclear risk “randomised into one of four groups” (no

method stated)

Allocation concealment (selection bias) Unclear risk No statement

Blinding (performance bias and detection

bias)

All outcomes

Low risk No statement, but computerised billing

data

Incomplete outcome data (attrition bias)

All outcomes

Unclear risk Cohort = 24,743, aged ≥ 65 years = 17,

598; aged < 65 years with chronic condi-

tion = 10,573; aged ≥ 65 years with chronic

condition = 3431, so there is overlap and

those aged < 65 years and aged ≥ 65 years

total 28,171, 3428 more than the cohort.

We were unable to contact the authors after

numerous e-mail attempts including col-

leagues and organisations

Selective reporting (reporting bias) Low risk No selective reporting

Barnas 1989

Methods Purpose: to compare pre-appointment postcard with message encouraging influenza

vaccination to pre-appointment card with no message

Design: RCT, participants randomised

Duration of study: “fall of 1986”

Interval between intervention and when outcome was measured: not stated

Power computation: not performed

Statistics: Chi², probabilities

62Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Barnas 1989 (Continued)

Participants Country: USA

Setting: primary care clinic, Milwaukee County Medical Complex

Eligible participants: (health status): 988 participants aged ≥ 65 years were randomised,

and of the 840 (85%) who kept their appointments and were seen at the clinic, 406

received the message and 434 did not.

Age: ≥ 65 years

Gender: not stated

Interventions Intervention 1: pre-appointment postcard with message encouraging influenza vaccina-

tion

Control: pre-appointment card with no message

Outcomes Outcome measured: % vaccinated

Time points from the study considered in the review or measured or reported in the

study: “Fall of 1986”

% vaccinated by: not stated

Notes Funding: not stated

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection

bias)

Unclear risk “All 988 participants ... were randomised .

..” (no method stated)

Allocation concealment (selection bias) Unclear risk No statement

Blinding (performance bias and detection

bias)

All outcomes

Low risk No statement; computerised billing data

Incomplete outcome data (attrition bias)

All outcomes

High risk “988 participants ≥ 65 ... were ran-

domised, ... of the 840 (85%) who kept

their appointments and were seen at the

clinic 406 received the message and 434 did

not.” Computerised billing data

Selective reporting (reporting bias) Low risk No selective reporting

63Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Beck 1997

Methods Purpose: to compare group visits of chronically ill older participants to a physician to

usual care

Design: RCT; individual participants randomised

Duration of study: 1 year

Interval between intervention and when outcome was measured: not stated

Power computation: not performed

Statistics: Chi² for dichotomous data, ANOVA for continuous data; not ITT

Participants Country: USA

Setting: 1 office of Colorado Permanente Medical Care Program, a group HMO in

Denver

Eligible participants: (health status) people 65 years or older with a chronic illness based

on chart review (heart, lung, or joint disease or diabetes) or high health utilisation in past

12 months (1 or more outpatient visits/month or 1 or more calls to nurse or physician

per 2 months); 68% arthritis, 62% hypertension, 30% heart disease, 31% liver disease,

15% cancer, 15% diabetes

Age: average: intervention 72, usual care 75 (P = 0.008)

Gender: intervention 69%, control 64% female (ns). Baseline N: 419 contacted, of

whom 300 returned questionnaires (of whom 77 said not interested, 3 termination from

programme, 4 transfers to another clinic, 9 lack of transport, 3 died, 2 low utilisers, 1

home bound). Then 113 additional participants added. Randomised to (1) group visits

(160, of whom 20 no-shows, 19 dropouts, 2 no transport, 5 deaths, 1 skilled nursing

facility, 1 transferred clinic) and (2) usual care (161, of whom 9 deaths, 7 belonged to

Kaiser Permanente, 2 skilled nursing facility, 3 transferred clinic)

Interventions Intervention group 1: visits to physician and nurse at clinic in groups average size 8, for

(a) 15-minute warmup and socialisation with information on specific disease processes;

(b) 15-minute break for socialisation, and nurse checked blood pressure, immunisation

status, immediate needs, and arranged visit with physician; (c) 15 minutes of questions

and answers, and planned next visit; (d) 30 minutes for visit to physician

Control: usual visits to physician

Outcomes Outcome measured: % vaccinated

Time points from the study considered in the review or measured or reported in the

study: not stated

% vaccinated by: date not stated

Notes Funding: Garfield Memorial Fund, Research and Development Fund Kaiser Health

Plan of Colorado data from administrative databases and chart review used to measure

vaccination uptake.

No intended or unintended co-interventions recorded.

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection

bias)

High risk 113 participants added, but did not receive

the baseline Senior Health Questionnaire,

and not stated if randomly assigned; groups

64Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Beck 1997 (Continued)

were equivalent at baseline in important

characteristics related to the outcome ex-

cept age (P = 0.008)

Allocation concealment (selection bias) Unclear risk No statement

Blinding (performance bias and detection

bias)

All outcomes

Low risk Data were obtained from administrative

databases and chart review to measure vac-

cination uptake

Incomplete outcome data (attrition bias)

All outcomes

High risk In intervention group, participants at-

tended an average of 6.62 group visits (55%

of those scheduled), and no process anal-

ysis whether active involvement/participa-

tion by individual participants in group ac-

tivities

48 dropouts from intervention group

(30%) and 21 (13%) from control, not

equivalent in composition: intervention

(20 no-shows, 19 dropouts, 5 deaths, 2 no

transport, 1 transferred to nursing home,

1 transferred clinic); control (9 deaths, 2

transferred to nursing home, 3 transferred

clinic, 7 other)

Influenza vaccination rate in control de-

creased from 72% in previous year to 64%

1 year after intervention, and in experimen-

tal group increased from 74% in previous

year to 81%. The better result in the ex-

perimental group could be due in part to

attrition of less interested participants

Selective reporting (reporting bias) Low risk No selective reporting

65Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Berg 2008

Methods Purpose: to test hypotheses that mailed advice to receive an influenza vaccine or to

call a telephonic nurse service would reduce condition-related inpatient bed days and

emergency department visit

Design: RCT

Duration of study: 5 months

Interval between intervention and when outcome was measured: not stated

Power computation: no information provided

Statistics: unit of study is household, not individual. Clustered analyses were done,

including for differences in vaccination uptake using Chi² statistics generated by the

’proc genmod’ command using the ’repeated’ option in SAS to account for the clustering

effect on variance.

Data are presented in such a way that the reader can do a comparison of the influenza

vaccination uptake between groups as a secondary analysis, but the trial was not explicitly

designed to test the effects of the interventions on influenza vaccination uptake

Participants Country: USA

Setting: subscribers (households) and their dependents over the age of 65 years enrolled

in the Blue Cross & Blue Shield Government-wide Service Benefit Plan in the states

of Oklahoma, Rhode Island, Kentucky, California, Arizona, Utah, and Colorado in

October 2002. Subscribers were current or retired federal employees.

Eligible participants: (health status): no data provided on health status; however, the

’participants’ are actually ’households’.

Age: 65 years or older

Gender: 60% female

Interventions Intervention 1: postal cue encouraging influenza vaccination (N = 26,474 people)

Intervention 2: postal cue to call a nurse advice service if symptoms consistent with

influenza-like illness developed (26,846 people)

Control: no postal cues sent (81,453 people)

Outcomes Outcome measured: claims made to the insurance providers for inpatient bed days,

emergency department visits, physician evaluation and management visits and other

outpatient visits for selected respiratory or congestive heart failure ICD-9-CM code

diagnoses claims. Physician evaluation and management visits were examined using

clinical procedural terminology codes

However, although not a primary outcome planned for this study, data were obtained

for influenza vaccination uptake, which are presented in Tables 2 and 3 in the form of

rates calculated as (number of events/N in sample) x 10,000

Notes Funding: Blue Cross Blue Shield Association, McKesson Corporation

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection

bias)

Low risk “Households in all states had an equal prob-

ability of assignment into the intervention

group.” “The simple randomisation code

was developed by using a computer ran-

66Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Berg 2008 (Continued)

dom number generator between the values

of 0 and 1 so that the control group was 3

times as large as the intervention group.”

Allocation concealment (selection bias) Unclear risk No statement

Blinding (performance bias and detection

bias)

All outcomes

Low risk No statement; outcome data based on

billing claims

Incomplete outcome data (attrition bias)

All outcomes

Unclear risk Attrition of participants not addressed:

“Because the mailings were sent out in bulk,

no information was available on undeliver-

able pieces.”

Unable to assess incomplete data points for

participants. “Influenza vaccinations often

are given in settings that do not generate

claims, thus limiting the reliability of evi-

dence of influenza vaccinations as seen via

administrative claims.”

Analysis of whether differential attrition

could affect outcomes was not performed.

The study was not designed to evaluate up-

take of influenza vaccination as a primary

outcome, and because it is possible that par-

ticipants might have received influenza vac-

cination from a source that did not result

in a claim being made to the insurers from

which the outcomes were ascertained, there

is likely underestimation of the influenza

vaccination uptake for all 3 study groups.

However, one might argue that one would

not necessarily a priori expect to see system-

atic difference in utilisation of uncaptured

sources of influenza vaccination between

these groups unless there was differential

dropout between the groups over time. No

information was presented on people who

might have dropped out because of death

during the study or on those who might

have lost their insurance benefits during the

study period. This is a threat to the validity

of both the cardinal outcomes and the anal-

ysis of secondary outcomes we performed

Selective reporting (reporting bias) Low risk No selective reporting

67Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Black 1993

Methods Purpose: to compare effects on influenza vaccination uptake of a home visit including

an intervention promoting influenza vaccination to a home visit with an intervention

promoting safety

Design: RCT

Duration of study: not stated

Interval between intervention and when outcome was measured: not stated

Power computation: post hoc power computation showed 80% power α = 0.05 to detect

50% difference.

Statistics: percentages; multiple logistic regression

Participants Country: Canada

Setting: Hamilton, Ontario

Eligible participants: (health status): 1011 clients aged ≥ 65 years referred to public

health nurses in Hamilton

Age: 78 years

Gender: 71% female in influenza intervention group, 62% female in safety intervention

Interventions Intervention 1: home visit including an intervention promoting influenza vaccination

Intervention 2: home visit including an intervention promoting safety

Control: no control group

E-mail from author: “our high rates post intervention in the intervention and control

groups may have been due to attention bias, although we tried to minimize it in the

’safety’ group by asking the PHNs to avoid discussing immunization history with safety

group subjects. However, at that time the province and federal governments had become

more active with media campaigns and that too could explain the high rates in both

groups.”

Outcomes Outcome measured: % influenza vaccination

Time points from the study considered in the review or measured or reported in the

study: not stated

% vaccinated by: not stated

Notes Funding: Ontario Ministry of Health

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection

bias)

Unclear risk “were randomly assigned” (no method

stated)

Allocation concealment (selection bias) Unclear risk No statement

Blinding (performance bias and detection

bias)

All outcomes

Low risk No statement, however “outcome data were

obtained through telephone interview (or

home visit) by two research assistants who

were unaware of group membership.”

68Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Black 1993 (Continued)

Incomplete outcome data (attrition bias)

All outcomes

Low risk 589 of 1011 eligible clients excluded be-

cause of cognitive impairment or not ac-

tive clients, and 57 declined; 157 received

influenza vaccination promotion and 148

safety promotion; 45 clients assigned to in-

fluenza vaccination promotion group had

already received influenza vaccine and were

included in influenza vaccination promo-

tion group for ITT analysis.

Outcome data collected by 2 research as-

sistants either through phone calls or home

visits

Selective reporting (reporting bias) Low risk No selective reporting

Boca 2012

Methods Letter describing clinical manifestations and complications of influenza, effectiveness

of vaccine sent to intervention group; control group received no intervention; power

computation assessed 1187 required in each group to find difference of 5% in vaccination

rates, P = 0.05, power = 0.80; vaccination assessed from computer records

Participants 2402 participants ≥ 60 years in a health centre in Castellón, Valencia, Spain

Interventions Letter mailed to homes of participants in intervention group

Outcomes Vaccination rates in 2009 seasonal vaccination campaign

Notes Of those vaccinated in 2009, 501 (52.7%) received the letter and 449 (47.3%) did not

(P = 0.01); vaccination in 2008 was highly correlated with vaccination in 2009 (P < 0.

0001)

Funding: Spanish VACH Cohort and the ISCIII-RETIC (RD06/006)

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection

bias)

Low risk Computer random number generator

Allocation concealment (selection bias) Unclear risk Not stated

Blinding (performance bias and detection

bias)

All outcomes

Low risk Healthcare workers caring for participants

blinded, participants not blinded

Incomplete outcome data (attrition bias)

All outcomes

Low risk No letters returned undelivered.

69Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Boca 2012 (Continued)

Selective reporting (reporting bias) Low risk No selective reporting

Buffington 1991

Methods Purpose: to compare displaying clinic and individual physician influenza vaccination

uptake on posters plus postcard reminders to participants, to displaying clinic and indi-

vidual physician influenza vaccination uptake on posters, to no intervention

Design: RCT, clinics as unit of randomisation

Duration of study: 23 September to 30 December 1989

Interval between intervention and when outcome was measured: from 23 September to

30 December 1989

Power computation: not performed

Statistics: not stated; probabilities reported

Participants Country: USA

Setting: 45 physicians in 3 offices associated with Genesee Hospital, Rochester, NY

Eligible participants: (health status): aged ≥ 65 years

Age: ≥ 65 years

Gender: not stated

Interventions Intervention 1: display of clinic and individual physician influenza vaccination uptake

on posters plus postcard reminders to participants

Intervention 2: display of clinic and individual physician influenza vaccination uptake

on posters

Control: no intervention

E-mail from author: “What was interesting was the competition that evolved in those

physicians that used the target model. Physicians using the target model did compare

their progress with other physician’s results. The whole effort generated a pretty positive

attitude toward getting the elderly immunized against influenza.”

Outcomes Outcome measured: % influenza vaccination

Time points from the study considered in the review or measured or reported in the

study: 23 September to 30 December 1989

% vaccinated by: 30 December

Notes Funding: Medicare Influenza Demonstration Project sponsored by US Health Care

Finance Administration

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection

bias)

Unclear risk “Practices were stratified according to size

and randomised.” (no statement about

method)

Allocation concealment (selection bias) Unclear risk No statement

70Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Buffington 1991 (Continued)

Blinding (performance bias and detection

bias)

All outcomes

Low risk No statement, but influenza vaccination

uptake from computerised billing codes, or

line listing of vaccinees in practices that

were not computerised

Incomplete outcome data (attrition bias)

All outcomes

Low risk 2149 in Group 2 (poster), 3604 in Group 3

(poster and postcard) and 4772 in Group 1

(control), but no statement as to how many

letters returned undelivered; influenza vac-

cination uptake from computerised billing

codes, or line listing of vaccinees in prac-

tices that were not computerised

Selective reporting (reporting bias) Low risk No selective reporting

CDC 1995a (Wyoming)

Methods Purpose: to compare an individual letter plus an informational brochure about influenza

vaccination to a form letter plus brochure to no intervention in Montana and Wyoming

Design: RCT; Montana was divided into 24 geographic regions, and Wyoming into 16

by zip codes, with 4 regions randomly assigned from each to intervention.

Duration of study: 3 months

Interval between intervention and when outcome was measured: brochure or letter

mailed to Medicare beneficiaries 23 to 30 September 1994; vaccination uptake assessed

1 October to 31 December 1994 and compared to 1993 vaccination uptake rates

Power computation: not performed

Statistics: logistic regression to examine relationship of letter plus brochure and influenza

vaccination; Egret statistical software to adjust for confounding variables

Participants Total number: Montana: personalised letter 19,850, form letter 21,250, no letter 150,

000; Wyoming same numbers

Setting: all Medicare beneficiaries in Montana and Wyoming

Diagnostic criteria: % receiving influenza vaccination recorded as influenza vaccination

claims submitted to Health Care Financing Administration (Medicare pays for influenza

vaccination for all those enrolled in Medicare Part B, and 96% of those ≥ 65 years in

the USA are enrolled in Medicare Part B)

Gender: not stated

Age: ≥ 65 years

Country: USA

Comorbidity not stated. Sociodemographics not stated. Ethnicity not stated. Date of

study 1994

Interventions Intervention 1: individual letter plus an informational brochure about influenza vacci-

nation

Intervention 2: form letter plus brochure

Control: no intervention

Integrity of intervention not stated.

71Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

CDC 1995a (Wyoming) (Continued)

Outcomes Outcome measured: % vaccinated

Time points from the study considered in the review or measured or reported in the study:

influenza vaccination claims October 1 through 31 December 1994, and compared to

vaccination uptake 1 October to 31 December 1993

% vaccinated by: 31 December 1984

Note: numbers in CDC 1995a (Wyoming) and CDC 1995b (Montana) differ from those

in Maglione 2002a. We adopted the numbers in Maglione 2002a because the authors

reported extracting data independently in duplicate, comparing them, and resolving

discrepancies

Notes Funding: Montana-Wyoming Foundation for Medical Care

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection

bias)

Unclear risk “The two states were divided into 40 geo-

graphic regions defined by zip code aggre-

gates (24 in Montana, 16 in Wyoming); in

each state four regions were randomly se-

lected as intervention sites.”

Allocation concealment (selection bias) Unclear risk No statement

Blinding (performance bias and detection

bias)

All outcomes

Unclear risk No statement

Incomplete outcome data (attrition bias)

All outcomes

Low risk Influenza vaccination data are collected by

Medicare as billing claims

Selective reporting (reporting bias) Low risk No selective reporting

CDC 1995b (Montana)

Methods Data are for Wyoming. See McMahon 1995b

Participants See McMahon 1995b

Interventions See McMahon 1995b

Outcomes See McMahon 1995b

Notes -

Risk of bias

72Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

CDC 1995b (Montana) (Continued)

Bias Authors’ judgement Support for judgement

Random sequence generation (selection

bias)

Unclear risk “The two states were divided into 40 geo-

graphic regions defined by zip code aggre-

gates (24 in Montana, 16 in Wyoming); in

each state four regions were randomly se-

lected as intervention sites.”

Allocation concealment (selection bias) Unclear risk No statement

Blinding (performance bias and detection

bias)

All outcomes

Unclear risk No statement

Incomplete outcome data (attrition bias)

All outcomes

Low risk Influenza vaccination data are collected by

Medicare as billing claims; 96% of those

≥ 65 years are covered by Medicare Part

B, which processes all billing claims for in-

fluenza vaccination

Selective reporting (reporting bias) Low risk No selective reporting

Chambers 1991

Methods Purpose: to compare reminders to internal medicine residents to give influenza vaccina-

tion for all, half, or none of their patients

Design: RCT, resident physicians randomised

Duration of study: 2 months

Interval between intervention and when outcome was measured: 1 October to 30 Novem-

ber 1987

Power computation: not performed

Statistics: Chi², multiple logistic regression

Participants Country: USA

Setting: Family Practice Center of Thomas Jefferson University, Philadelphia

Eligible participants: (health status); all patients aged ≥ 65 years

Age: ≥ 65 years

Gender: 74% female

Interventions Intervention 1: reminders to internal medicine residents to give influenza vaccination

for all of their patients

Intervention 2: reminders to internal medicine residents to give influenza vaccination

for half of their patients

Control: no reminders

Outcomes Outcome measured: % influenza vaccination

Time points from the study considered in the review or measured or reported in the

study: 1 October to 30 November 1987

73Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Chambers 1991 (Continued)

% vaccinated by: 30 November 1987

Notes Funding: not stated

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection

bias)

Low risk “All physicians in the practice were strati-

fied based on level of training and randomly

assigned to one of three groups via a com-

puterised randomization program”

Allocation concealment (selection bias) Unclear risk No statement

Blinding (performance bias and detection

bias)

All outcomes

Low risk No statement, but influenza vaccinations

were recorded by computerised billing sys-

tem

Incomplete outcome data (attrition bias)

All outcomes

Unclear risk 2493 eligible patients, of whom 864 vis-

ited clinic during 2-month study period;

of these 168 excluded (had already received

influenza vaccine or saw several physicians)

, 24 made drop-in visits, leaving 686 for

randomisation, of whom 464 aged ≥ 65

years; average 10% had received influenza

vaccination previous year

Selective reporting (reporting bias) Low risk No selective reporting

Chan 2002

Methods Purpose: comparison of 4 reminders monthly to physiatrists to offer influenza vaccination

compared to no reminders

Design: RCT; intervention and control groups switched in 1998

Duration of study: intervention administered “during influenza season.”

Interval between intervention and when outcome was measured: all Medicare claims for

influenza vaccination in 1997 and 1998

Power computation: not performed

Statistics: t-tests; random-effects log-binomial model and generalised programmed linear

mixed model to estimate risk ratio of vaccination, controlling for patient age, gender

and number of claims

Participants Country: USA

Setting: physiatrists (rehabilitation physicians) in Washington state and their patients

Eligible participants: (health status) 105 physiatrists in Washington state in 1996 with

4300 patients aged ≥ 65 years in 1997 and 4025 in 1998; exclusions: any patient seen

by more than 1 physiatrist (n = 1065); 1 physiatrist who received intervention in both

74Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Chan 2002 (Continued)

1997 and 1998 and was excluded in 1998; 5 physiatrists who did not submit Medicare

claims in 1997

Age: 1997: 70.2 years; 1998: 69.5 years

Gender: 60% female

Interventions Intervention 1: in 1997 the solo practitioners were randomised to receive either 4 re-

minders or none; group practices were also randomised to receive 4 reminders or none;

in 1998 within each practice group intervention and control groups were switched.

Control: no reminders in alternate years

Outcomes Outcome measured: % vaccinated

Time points from the study considered in the review or measured or reported in the

study: all Medicare claims for influenza vaccination in 1997 and 1998

% vaccinated by 31 December 1998

Notes Funding: Health Care Financing Administration

We entered the vaccination uptake in the control groups in 1997 as the baseline prior

year uptake for the intervention group in 1998; the 1998 trial was a cross-over of the

1997 participants

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection

bias)

Low risk “We performed a randomised crossover

trial ...” E-mail from author: “This project

was done through Medicare’s Division of

Clinic Standards and Quality as a quality

improvement project. I think that we went

to a table of random numbers assigned each

provider a random number. The even num-

bers got one arm, the odd number got the

other arm”

Allocation concealment (selection bias) Unclear risk No statement

Blinding (performance bias and detection

bias)

All outcomes

Low risk E-mail from author: “Staff were blinded

to the allocation.” Outcome was influenza

Medicare claims

Incomplete outcome data (attrition bias)

All outcomes

Low risk Data reported for all 1997 and 1998 par-

ticipants.

Selective reporting (reporting bias) Low risk No selective reporting

75Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Clayton 1999

Methods Purpose: to compare educational materials plus postcard to educational materials to

encourage influenza vaccination

Design: RCT, households randomised

Duration of study: October to December 1997

Interval between intervention and when outcome was measured: October to December

1997

Power computation: 99% power to detect 5% difference

Statistics: binomial test for differences in proportions; Chi² for association between

demographic variables and group assignment

Participants Country: USA

Setting: Kaiser Permanente Northeast

Eligible participants: (health status): 10,700 aged ≥ 65 years

Age: 73.5 years

Sex: 57% female

Interventions Participants with a record of influenza vaccination the previous year (n = 5278)

Intervention 1: mailed educational materials plus reminder postcard (N = 2631)

Intervention 2: mailed educational materials (N = 2647)

Participants with no record of influenza vaccination previous year (n = 5422)

Intervention 1: mailed educational materials plus reminder postcard (N = 5422)

No control group

Outcomes Outcome measured: % influenza vaccination

Time points from the study considered in the review or measured or reported in the

study: October to December 1997

% vaccinated by: December 1997

Notes Funding: Kaiser Permanente

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection

bias)

Unclear risk “... half were randomly selected to re-

ceive the postcard reminder in addition to

the standard member educational materi-

als (intervention group), and the other half

did not receive a postcard (control group).

”

Allocation concealment (selection bias) Unclear risk No statement

Blinding (performance bias and detection

bias)

All outcomes

Low risk “... the vaccination rates were estimated

through administrative data.”

Incomplete outcome data (attrition bias)

All outcomes

High risk “Because the sensitivity of administrative

data is somewhat limited (estimated to be

76Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Clayton 1999 (Continued)

62.4%, according to Kaiser Permanente

Northeast Division studies), the vaccina-

tion rates presented are underestimates of

the true rates.”

Selective reporting (reporting bias) Low risk No selective reporting

Conner 2017

Methods Purpose: to assess the impact of question-behaviour effect (QBE) surveys on influenza

vaccination behaviour in older adults

Design: RCT

Power computation: “Using the effect size (d ¼ 0.13) from Conner et al. (2011) study

of the QBE and influenza vaccination, G*Power indicated that 1539 participants per

condition would provide 95% power to detect a significant effect at an alpha of 0.05

using a two-tailed test.”

Statistics: “multilevel modelling analyses (using random effects, the Bernoulli model,

and centring predictor variables around the group mean) that controlled for the fact that

participants were clustered within one of seven General Practices examined the impact

of condition on rates of vaccination controlling for any differences across conditions. For

each predictor we report unstandardized coefficients, standard errors, odds ratios and

95% confidence intervals (based on the population-average model).”

Participants All participants aged 65 years or over in 1 of 7 general practices in northern England who

were eligible for an influenza vaccine but had not taken part in a “centralized influenza

vaccination invitation scheme in Fall/Autumn 2012).”

Interventions Participants in control condition 1 (no questionnaire) did not receive a questionnaire.

Participants in control condition 2 (demographics questionnaire) received a question-

naire tapping whether they had children, their occupation, marital status, and ethnic

origin. Participants in the other 6 conditions received questionnaires tapping the same

demographic questions plus questions about influenza vaccination: intention + attitude

questions (both conditions 3 and 4); anticipated regret + intention + attitude questions

(both conditions 5 and 6); beneficence + intention + attitude questions (both conditions

7 and 8). Conditions 4, 6, and 8 additionally had a sticky note attached to the front that

included a message (“Please take a few minutes to complete this for us. Thank you!”)

printed in blue on a yellow (72 72 mm) sticky note but with the message appearing to

be handwritten

Outcomes 1. Receipt of a demographic questionnaire had no effect on vaccination rates as compared

with control (those who did not receive a questionnaire) (B = 0.058, standard error = 0.

081, P = 0.50, OR = 1.06, 95% CI = 0.87, 1.29)

2. Vaccination rates were higher among participants who received a vaccination ques-

tionnaire (B = 0.160, P = 0.04)

3. Neither cognitive target manipulation (intention + attitude questions vs intention +

attitude + anticipated regret questions vs intention + attitude + beneficence questions)

nor presence vs absence of a sticky note influenced vaccination rates

83.4% had received a previous influenza vaccination. The vaccination rates for the 8

groups were:

77Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Conner 2017 (Continued)

(a) control group 1 (no questionnaire) 74.7%; control group 2 (demographics question-

naire) 75.7%;

(b) intention to attend for a flu shot group 1 (“I intend to attend for a flu shot”) 76.8%;

intention group 2 (with sticky note “Please take a few minutes to complete this for us.

Thank you!”) 77.4%;

feel regret”; “I would later wish I had”) 77.2%; regret + intention group 2 (with sticky

note) 78.1%;

(d) intention + regret + beneficence group 1 72.2%; group 2 (with sticky note) 77.1%

Notes Funding: UK Economic and Social Research Council

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection

bias)

Low risk “Patients were randomized individually to

one of eight conditions by the second au-

thor using a random number generator but

were not blinded to condition (presence or

type of survey administered)”

Allocation concealment (selection bias) Low risk “Patients were randomized individually to

one of eight conditions by the second au-

thor using a random number generator but

were not blinded to condition (presence or

type of survey administered)”

Blinding (performance bias and detection

bias)

All outcomes

Unclear risk No statement

Incomplete outcome data (attrition bias)

All outcomes

Unclear risk A total of 15 participants were excluded

(12 not randomised, 3 no vaccination data)

, resulting in a final sample of 13,803 (there

were no significant differences between the

2 groups on sex, age, or previous influenza

vaccination)

Selective reporting (reporting bias) Low risk No selective reporting

78Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Dalby 2000

Methods Purpose: to compare encouragement by visiting nurse to receive influenza vaccination

to no intervention

Design: RCT

Duration of study: 14 months

Interval between intervention and when outcome was measured: within 14 months of

study

Power computation: α = 0.05, β = 0.8, difference = 15%, requires n = 128

Statistics: Chi², Fisher’s exact; Student’s t-test, Mann-Whitney U test

Participants Country: Canada

Setting: practices of 2 physicians in Stoney Creek, Ontario

Eligible participants: (health status): individuals ≥ 70 years and functional impairment

or admission to hospital or bereavement in past 6 months

Age: ≥ 70 years, average 78.5 years

Gender: 71% female in nurse group, 62% in control

Interventions Intervention 1: encouragement by visiting nurse during comprehensive assessments to

receive influenza vaccination, care plan developed with physician

Control: no intervention

Outcomes Outcome measured: % influenza vaccination

Time points from the study considered in the review or measured or reported in the

study: 14 months, dates not stated

% vaccinated by: not stated

Notes Funding: Ontario Ministry of Health

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection

bias)

Low risk “Eligible participants were randomly as-

signed ... by a research assistant not affili-

ated with the HSO using a random number

table. The randomization schedule was de-

veloped by another research assistant, who

was not involved in the randomization pro-

cess.”

Allocation concealment (selection bias) Low risk “The randomizations schedule was kept

within the Health Services Delivery Re-

search Unit of the St. Joseph’s Community

Health centre throughout the trial.”

Blinding (performance bias and detection

bias)

All outcomes

Unclear risk No statement

79Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Dalby 2000 (Continued)

Incomplete outcome data (attrition bias)

All outcomes

Low risk “... a research nurse conducted a detailed

audit of all participants’ medical records”

Selective reporting (reporting bias) Low risk No selective reporting

Dapp 2011

Methods Purpose: to assess the effects of health risk appraisal, personal reinforcement, and quality

circles for older people to improve preventive care and health behaviour

Design: RCT (participants of solo GPs individually randomly assigned by computer to

intervention or control). The 21 solo GPs were allocated to 3 clusters of GPs matched

by age, gender, and qualification

Duration of study: recruitment over a 9-month period. Follow-up at 1 year (duration of

intervention not stated)

Interval between intervention and when outcome was measured: follow-up at 1 year

(duration from end of intervention not stated)

Power computation: 763 required in intervention and 1525 in control to detect 30%

difference in preventive care or health behaviour, alpha = 0.05, power = 80%, assuming

20% preventive behaviour in controls and 20% dropout

Statistics: generalised estimating equations; for missing data multiple imputations

Participants Country: Germany

Setting: 21 solo GP practices in Hamburg

Eligible participants: (health status): 500 GP practices in Hamburg, of which 21 agreed

to participate; each practice provided completed list of those ≥ 60 years, and “eligibles”

from practices who returned brief questionnaire and consent form were randomised

(total number of eligibles not stated); 2580 patients of 14 general practitioners who

returned questionnaires were randomised and 746 who were not randomised were placed

in a “concurrent comparison” group

Age: average 72 years

Gender: 62% female

Interventions Intervention (n = 878): health risk appraisal, individualised recommendations, health

information, reinforcement by home visit or group sessions

Control (n = 1702): usual care (but their GPs had received the training how to care for

the intervention group participants but did not implement it with their patients)

Comparison group (n = 746): “usual care;” (patients were placed in this group if their

GPs had not received training Co-interventions: none

Outcomes Outcome measured: % influenza vaccination (and 8 other preventive care outcomes and

6 health behaviours)

Time points reported in the study: follow-up 1 year, time from end of intervention to

follow-up not stated

Notes Funding: European Union; Swiss Federal Education and Science Ministry; Bundesmin-

isterium für Familie, Senioren, Frauen und Jugend, Berlin; Max and Ingeburg Herz

Stiftung, Hambung; Robert Bosch Stiftung, Stuttgart

80Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Dapp 2011 (Continued)

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection

bias)

Low risk Computer based at independent cen-

tre (participants individually randomised

within solo GP practices, GPs were allo-

cated 7 to intervention, 7 to control, and 7

to “concurrent comparison” group)

Allocation concealment (selection bias) Unclear risk No statement

Blinding (performance bias and detection

bias)

All outcomes

Unclear risk Blinding not possible, as treating GPs re-

ceived summary statements about partici-

pants as part of intervention

Incomplete outcome data (attrition bias)

All outcomes

Unclear risk Total eligibles not stated; 2580 baseline

in RCT (878 intervention, 1702 control),

baseline characteristics similar, 746 in “con-

current comparison” group; at 1-year fol-

low-up 587 (67%) and 1376 (81%) in con-

trol group returned questionnaire; no dif-

ferential attrition analysis of losses from

groups

Selective reporting (reporting bias) Low risk No selective reporting

Dietrich 1989

Methods Purpose: to compare effects of reminder letters and checklists to obtain influenza vacci-

nation to no intervention

Design: RCT, participants randomised

Duration of study: enrolment during 3 months in “fall of 1984”

Interval between intervention and when outcome was measured: 12 months before and

after randomisation

Power computation: not performed

Statistics: t-tests; Chi²

Participants Country: USA

Setting: community practice in New England with 5 family physicians and 1 internist

Eligible participants: (health status) aged ≥ 65 years with office visits during 3-month

enrolment period in 1984; exclusions: no telephone, transient, blind, demented, termi-

nally ill; 156 potential participants, 31 not eligible; 117 returned baseline questionnaire;

2 died and 1 moved during study

Age: 74 years

Gender: 68% female

81Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Dietrich 1989 (Continued)

Interventions Intervention: mailed personal prevention checklists, letters encouraging use of checklists

to keep track of preventive health care

Control: no intervention

Outcomes Outcome measured: % vaccinated

Time points from the study considered in the review or measured or reported in the

study: 12 months before and after randomisation

% vaccinated by 12 months after randomisation

Notes Funding: American Academy of Family Physicians and US Public Health Service

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection

bias)

Unclear risk “participants were assigned randomly” (no

statement about method)

Allocation concealment (selection bias) Unclear risk No statement

Blinding (performance bias and detection

bias)

All outcomes

Low risk No statement, chart audit for vaccinations

(not stated who performed chart audit, but

was retrospective), and questionnaires for

vaccination received elsewhere

Incomplete outcome data (attrition bias)

All outcomes

Low risk All 114 recruited participants were fol-

lowed to the end of the study; chart au-

dit for vaccinations, and questionnaires for

vaccination received elsewhere

Selective reporting (reporting bias) Low risk No selective reporting

Díaz Grávalos 1999

Methods Purpose: to compare personalised postcard to encourage influenza vaccination to no

intervention

Design: RCT, participants randomised

Duration of study: 1 October to 4 December 1998

Interval between intervention and when outcome was measured: 1 October to 4 De-

cember 1998

Power computation: P1 = 0.05; P2 = 0.15, α = 0.05, β = 0.90, requires n = 152

Statistics: RRs, 95% CIs

Participants Country: Spain

Setting: San Cristovo de Cea, Ourense

Eligible participants: (health status): residents aged ≥ 65 years (n = 640) who had not

been vaccinated after 50 days (3/4 of the duration of the influenza vaccination campaign)

had elapsed, and were randomly assigned to receive a reminder postcard (n = 162) or no

82Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Díaz Grávalos 1999 (Continued)

intervention (n = 478).

Age: ≥ 65 years, average 76.5 years

Gender: 58.6% female

Interventions Intervention: personalised postcard to encourage influenza vaccination

Control: no intervention

Outcomes Outcome measured: % influenza vaccination

Time points from the study considered in the review or measured or reported in the

study: 1 October to 4 December 1998

% vaccinated by: 4 December 1998

Notes Funding: not stated

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection

bias)

Low risk randomised number table using EPIDAT

Allocation concealment (selection bias) Unclear risk No statement

Blinding (performance bias and detection

bias)

All outcomes

Unclear risk No statement

Incomplete outcome data (attrition bias)

All outcomes

Unclear risk No statement on how many of the 162 were

assessed at the end of the study. No differ-

ences by gender or age between vaccinees

in intervention and control groups

Selective reporting (reporting bias) Low risk No selective reporting

83Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Frank 2004

Methods Purpose: comparison of opportunistic on-screen reminders to physicians about preven-

tive care compared to no reminders

Design: RCT

Duration of study: 9 March 1998 to 8 March 1999

Interval between intervention and when outcome was measured: between 9 March 1998

and 8 March 1999

Power computation: not performed

Statistics: univariate binomial regression with GEE; ITT analysis

(Very helpful e-mail from Dr Frank, 23 August 2008: ”Our study looked at whether

each opportunity to provide a preventive service in a consultation was taken. This is a

different way of looking at the question from the more usual approach of asking what

proportion of participants who had attended during the influenza immunization season

had received the vaccine by the end of the season (in other words, efficacy), or from

asking what proportion of participants of the practice had received the vaccine by the

end of the season (effectiveness).

“We were interested in what happened in each consultation in which influenza vaccina-

tion was indicated and due for the patient. We were able to do this very data-intensive

exercise only because we set out to use a practice that kept all clinical and billing data

electronically and because I custom wrote software to analyse the practice’s electronic

data automatically. To my knowledge, this study is unique in its intensive automated

analysis of each consultation.

”The GPs actually performed slightly worse when reminded to give influenza vaccine.

We don’t know why this occurred, but it may be because the rate of giving influenza

vaccine to participants 65 years and over in Australia was already quite high, possibly

making our reminders redundant

“In our approach, we were not interested in numbers of participants, but in the number

of opportunities that arose in consultations for the participants who did attend. Our

approach to examining the question of opportunistic performance of preventive services

is almost unique, in that we looked closely at every opportunity that arose, and did not

take a snapshot of the practice population at one point in time, which is what almost all

other studies have done. In retrospect, it would have been useful to collect data about

efficacy so that we could compare our results more easily with those other studies.”)

Participants Country: Australia

Setting: urban practice with 10 GPs

Eligible participants: (health status): 10,507 for all reminder activities, of whom 1847

were ≥ 65 years and eligible for the influenza intervention

Age: ≥ 65 years

Gender: 57% female

Interventions Intervention: computer-generated reminder

Control: no intervention

Outcomes Outcome measured: % influenza vaccination

Time points from the study considered in the review or measured or reported in the

study: 9 March 1998 to 30 June 1998 (these dates are from e-mail from author)

% vaccinated by: 30 June 1998

Notes Funding: not stated (PhD thesis)

84Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Frank 2004 (Continued)

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection

bias)

Low risk All quotes are from e-mail from author 18

August 2008: “Randomization of partic-

ipants was automated. Patients were ran-

domised by the last digit of their family’s

five digit number within the practice. Fam-

ily numbers had been allocated sequentially

by the practice’s computer system without

regard to any characteristics of the patient

or the family. We were satisfied that this

method was not likely to cause any bias in

the randomization.”

Allocation concealment (selection bias) Unclear risk “Allocation was not concealed. However,

I believe that in the daily rush of seeing

participants, most of the GPs were unlikely

to have had time or energy to look at the

patient’s family number in order to work

out to which group the patient had been

randomised.”

Blinding (performance bias and detection

bias)

All outcomes

Unclear risk “Blinding, in the sense of blinding the in-

vestigators, was not necessary because the

judgement of whether a preventive activity

(including the administration of influenza

vaccine) had been performed was made by

searching the practice’s electronic clinical

record automatically”;

“Vaccinations were recorded by the doctors

in their clinical record system’s immuniza-

tion module which used coded data entry

to make the entries consistent and therefore

machine-searchable. If our search found

a record of influenza vaccine being given

between 9th March (the start of our trial)

and the end of June (the end of the useful

immunization season), this was counted as

influenza immunisation having been per-

formed”

Incomplete outcome data (attrition bias)

All outcomes

Low risk “We analysed all data by intention to treat.

All participants who were enrolled and ran-

domised (both of which occurred automat-

ically at their first visit during the trial) were

included in the analyses.”

85Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Frank 2004 (Continued)

Selective reporting (reporting bias) Low risk No selective reporting

Garcia-Aymerich 2007

Methods Purpose: evaluate the effects of an integrated care intervention on outcomes of partici-

pants with COPD

Design: RCT; participants randomised

Duration: 1 year

Power computation: not performed

Statistics: “Results are expressed as mean (SD), median (P25-P75), or as number (per-

centage) in the corresponding categories. To assess the possibility of selection bias, com-

parisons of baseline characteristics between UC [usual care] and IC [integrated care],

both for the followed-up and for the lost subjects were performed using independent t-

tests, Kruskal-Wallis test or the Chi-square test”

Participants Country: Spain

Setting: Barcelona tertiary hospital

Participants: 113 people with COPD discharged from hospital

Age: average 73 years

Gender: 84% male

Interventions Intervention group received:

1. “a comprehensive assessment of the patient at discharge ... by a specialized nurse”;

2. a 2-hour education session focusing on disease education, treatment, self management,

social support, and call centre support;

3. tailored treatment plan, home visit by specialised nurse and primary care team within

72 hours after discharge and follow-up phone calls at 3 and 9 months to reinforce self

management strategies, and online access to a specialised nurse.

Control group received usual care.

Participants in intervention and control groups were assessed via a questionnaire

Outcomes No significant difference in influenza vaccination uptake between intervention and con-

trol (90% versus 78%, P = 0.442)

Notes Funding: European Union Linkcare eTEN C517435; Marato de TV3; Comissionat per

a Universitats i Recerca de la Generalitat de Catalunya (SGR-00386) and Red Respira-

ISCIII-RTIC-03/11 and Red Telemedicina ISCIII-RTIC-03/117; Instituto de Salud

Carlos III (CP05/00118), Ministry of Health, Spain; European Union CHRONIC (IST-

1999/12158)

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection

bias)

Low risk “randomly assigned”; “blindly assigned (1:

2 ratio) using computer generated random

numbers either to integrated care (IC) or

to usual care (UC).”

86Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Garcia-Aymerich 2007 (Continued)

Allocation concealment (selection bias) Low risk “blindly assigned (1:2 ratio) using com-

puter generated random numbers either to

integrated care (IC) or to usual care (UC).

”

Blinding (performance bias and detection

bias)

All outcomes

Low risk “blindly assigned (1:2 ratio) using com-

puter generated random numbers either to

integrated care (IC) or to usual care (UC).

”

Incomplete outcome data (attrition bias)

All outcomes

High risk 21/44 integrated-care participants and 41/

69 conventional-care participants assessed

at 12 months; “subjects who were lost for

the present analysis had a higher number

of COPD admissions in the previous year

and in the follow-up year, and they were

using long-term oxygen therapy in a higher

proportion than those subjects who partic-

ipated in the 12 months assessment.” (no

differential analysis by group)

Selective reporting (reporting bias) Low risk No selective reporting

Herman 1994

Methods Purpose: to compare patient education before the participants were seen by the physician,

to patient education and vaccination by nurses before the participants were seen by the

physician, to no intervention

Design: RCT

Duration of study: 1 October 1989 to 31 March 1990

Interval between intervention and when outcome was measured: 1 October 1989 to 31

January 1990

Power computation: not performed

Statistics: Chi²; ANOVA; logistic regression controlling for prior baseline vaccination

status, age, race, gender, high-risk comorbidity, and physicians’ level of training

Participants Country: USA

Setting: Metro-Health Medical Center, teaching hospital of Case Western Reserve Uni-

versity

Participants: (health status) 1202 participants ≥ 65 years seen during 1988/9 and 1989/

90 influenza seasons, of whom 756 were seen during both seasons

Age: 74 years

Gender: 69% female

Interventions Intervention 1 “patient education group”: educational materials (background papers,

guidelines, lectures) plus nurses educated patients with National Institute on Aging ’Shots

for Safety’ and material on influenza vaccination from Ohio Department of Health

Intervention 2 “prevention team group”: same as intervention 1, but nurses were allowed

87Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Herman 1994 (Continued)

to vaccinate patients before they were seen by doctor and maintained health maintenance

flow sheet for each patient

Control: no intervention for patients

Co-interventions: physicians and nurse practitioners in all 3 groups received educational

materials and opportunities to attend lectures

Outcomes Outcome measured: % vaccinated, by billing data, researcher chart review, health main-

tenance flow sheets

Time points from the study considered in the review or measured or reported in the

study: 1 October 1989 to 31 January 1990

% vaccinated by: 31 January 1990

Notes Funding: Case Western Reserve University Teaching Nursing Home Program

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection

bias)

Unclear risk “The three ... practices were assigned ran-

domly” (no statement about method)

Allocation concealment (selection bias) Unclear risk No statement

Blinding (performance bias and detection

bias)

All outcomes

Low risk Daily billing forms were reviewed by

trained research assistant

Incomplete outcome data (attrition bias)

All outcomes

Low risk All 1202 participants analysed.

Selective reporting (reporting bias) Low risk No selective reporting

Hogg 1998

Methods Purpose: to compare customised letters recommending preventive procedures, to form

letters, to no intervention

Design: RCT; participants randomised, then entire family included in the intervention

group to which the individual patient had been randomised

Duration of study: letters sent September 1990 to March 1991; data collected months

after letters sent.

Interval between intervention and when outcome was measured: 6 months

Power computation: the smallest increase to be detected was for Pap smears, so sample

powered with α = 0.05, β = 0.8 (% difference to be detected not stated), with allowance

for participants who would leave the practice.

Statistics: Chi², ANOVA, Kruskal-Wallis one-way ANOVA

88Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Hogg 1998 (Continued)

Participants Country: Canada

Setting: Wakefield Family Medicine Centre, western Quebec

Eligible participants: (health status): 8770 families, from whom 719 families were ran-

domly selected; “The random selection of the study sample was applied to individual

patient registration numbers in the medical record software system.”

Age: ≥ 65 years

Gender: not stated separately for those aged ≥ 65 years

Interventions Intervention 1: customised letters recommending preventive procedures

Intervention 2: form letters recommending preventive procedures

Control: no intervention

Outcomes Outcome measured: % influenza vaccination

Time points from the study considered in the review or measured or reported in the

study: letters sent September 1990 to March 1991; data collected months after letters

sent

% vaccinated by: September 1991

Notes Funding: National Health Research & Development Program, Health Canada

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection

bias)

Unclear risk “The study used a randomised controlled

trial design.”; “Once an individual was se-

lected, his or her entire family was ran-

domly assigned to one of the three arms of

the study.” (method not stated)

Allocation concealment (selection bias) Unclear risk No statement

Blinding (performance bias and detection

bias)

All outcomes

High risk “The study was not blinded in that physi-

cians could be aware that a patient was

a member of a family in the study if the

patient mentioned that the family had re-

ceived a letter.”

Incomplete outcome data (attrition bias)

All outcomes

Unclear risk 682 randomised to no letter, 676 to form

letter, and 613 to customised letter; final

comparison among groups (Table 2) lists

249, 245, 192; initial randomisation re-

sulted in unevenly sized groups with fewer

in the control group

Selective reporting (reporting bias) Low risk No selective reporting

89Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Hogg 2008

Methods Purpose: to compare a comprehensive preventive intervention programme to no inter-

vention

Design: cluster-RCT, match-paired; “The unit of randomization and analysis was the

practice; the unit of observation was the patient.”

Duration of study: 11.5 months

Interval between intervention and when outcome was measured: “The intervention

lasted 11.5 months.”; “Data were collected ... up to 2 months after the intervention.”

Power computation: 24 practices were needed to detect a mean difference of 0.07 in

the primary outcome between intervention and control groups (“The delta selected (0.

07) approximates the 10% change in care frequently associated with care improvement

interventions”), SD = 0.083, α = 0.05, β = 0.83, and 27 practices were recruited to allow

for 15% attrition.

Statistics: Chi², paired t-tests

Participants Country: Canada

Setting: 2 letters and brochure to 351 primary care practices in eastern Ontario; 54

practices participated

Eligible participants: (health status): aged ≥ 65 years

Age: ≥ 65 years

Gender: not stated

Interventions Intervention: comprehensive preventive intervention programme; facilitators were as-

signed 13 to 14 practices whom they visited monthly, average duration of visit 46 min-

utes; facilitators encouraged 26 preventive manoeuvres; with baseline audit, feedback,

and consensus building, and periodic follow-up and consensus building

Control: no intervention

Outcomes Outcome measured: % influenza vaccination for each practice

Time points from the study considered in the review or measured or reported in the

study: “The intervention lasted 11.5 months.”; “Data were collected ... up to 2 months

after the intervention.”

% vaccinated by: “up to 2 months after the intervention”

Notes Funding: Canadian Institutes of Health Research

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection

bias)

Low risk “Practices were matched on solo versus

group practice, presence of nursing staff

and location (rural or urban) and each pair

member was randomly assigned using the

Statistical Analysis software package.”

Allocation concealment (selection bias) Low risk “The allocation sequence was kept locked

and unavailable to the administrative staff

until the time of assignment.”

90Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Hogg 2008 (Continued)

Blinding (performance bias and detection

bias)

All outcomes

Low risk “Physicians and facilitators were blinded to

the actual manoeuvres that would be in-

cluded in the preventive performance in-

dex.”

Incomplete outcome data (attrition bias)

All outcomes

Low risk 54 practices randomised, data from 54

analysed (27 intervention, 27 control prac-

tices)

Selective reporting (reporting bias) Low risk No selective reporting

Hull 2002

Methods Purpose: to compare phone call by receptionist to attend influenza vaccination clinic to

no intervention

Design: RCT

Duration of study: 25 September to 6 October 2000

Interval between intervention and when outcome was measured: data on influenza vac-

cination status was submitted mid-December 2000.

Power computation: for α = 0.05, β = 0.8, would require 384 participants to show

increase in vaccination uptake from 40% to 50%.

Statistics: Chi², ITT, generalised linear models for clustered data

Participants Country: UK

Setting: 3 general practices in East London and Essex

Eligible participants: (health status): 1820 participants 65 to 74 years not previously in

an influenza vaccination recall system; exclusions: asthma, diabetes, COPD, IHD, renal

disease

Age: 69 years

Gender: 54% female

Interventions Intervention: phone call by receptionist to attend influenza vaccination clinic

Control: no intervention

Co-interventions: East London and City Health Authority sent letter to every patient

aged ≥ 65 years asking them to contact GP for influenza vaccination; national campaign

September promoting influenza vaccination

Outcomes Outcome measured: % influenza vaccination

Time points from the study considered in the review or measured or reported in the

study: 25 September to 6 October 2000

% vaccinated by: 6 October 2001

Notes Funding: ELENoR infrastructure grant

Risk of bias

Bias Authors’ judgement Support for judgement

91Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Hull 2002 (Continued)

Random sequence generation (selection

bias)

Low risk “... households, which were randomised to

either the control or intervention group by

the study co-ordinator using a computer

program (STATA)”

Allocation concealment (selection bias) Unclear risk “... households, which were randomised to

either the control or intervention group by

the study co-ordinator using a computer

program (STATA)” (unclear if, once ran-

domised, study co-ordinator referred back

to randomisation lists)

Blinding (performance bias and detection

bias)

All outcomes

Low risk “Nurses who undertook the vaccination

clinics were unaware of the household allo-

cation to control or intervention group.”

Incomplete outcome data (attrition bias)

All outcomes

Low risk E-mail from author: “We did an intention

to treat analysis, all households in the orig-

inal randomisation were included in the

analysis.”

Selective reporting (reporting bias) Low risk No selective reporting

Humiston 2011

Methods Purpose: to compare tracking patient influenza vaccination uptake, providing reminders,

patient recall, and outreach to participants to standard care in each of 7 clinics

Design: RCT; individual seniors were randomised within each clinic to intervention or

control

Duration of study: 29 September to 13 October 2004 (depending on arrival of influenza

vaccine) to 22 January 2004

Interval between intervention and when outcome was measured: 15 weeks

Power computation: 170 participants/group to demonstrate 15% difference in vaccina-

tion uptake (control rate = 50%), P < 0.05, power 0.80, 2-tailed; as interest was also

to collect data across multiple sites and ethnic groups, more participants were enrolled

than required by power computation

Statistics: Chi², Fisher’s exact, logistic regression; intention-to-treat

Participants Country: USA

Setting: 7 clinics in Rochester, NY

Eligible participants: (health status): 2004 (control), 1748 (intervention); 50% white,

33% African-American, 10% Hispanic, 7% other

Age: average 74.2 years

Gender: 62% female

Interventions Intervention: outreach workers in each of 7 clinics tracked patient influenza vaccination

uptake, provided reminders, recalled participants, recalled and phoned participants

Control: standard routine for each clinic

92Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Humiston 2011 (Continued)

Co-interventions: none

Outcomes Outcome measured: % influenza vaccination

Time points reported in the study: from 29 September to 13 October 2004 (depending

on arrival of influenza vaccine) to 22 January 2004

Notes Funding: Centers for Disease Control and Prevention National Immunization Program

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection

bias)

Low risk “individual seniors within PCCs to inter-

vention or standard-of-care control groups”

according to whether last digit of Social Se-

curity number odd or even

Allocation concealment (selection bias) Unclear risk No statement

Blinding (performance bias and detection

bias)

All outcomes

Unclear risk Blinding not possible due to recalls and

prompts.

Incomplete outcome data (attrition bias)

All outcomes

Unclear risk 3752 eligibles randomised (participants

who died during the trial were analysed

as randomised). However: “Each outreach

worker was responsible for tracking ap-

proximately 900 to 1,000 eligible patients”

(which implies for 7 clinics total eligibles =

6300 to 7000)

Selective reporting (reporting bias) Low risk No selective reporting

Ives 1994

Methods Purpose: to compare offer of free influenza vaccination in capitated care groups, to fee-

for-service care groups, to no offer

Design: RCT; participants randomised

Duration of study: 1 May to 31 December 1989

Interval between intervention and when outcome was measured: April 1991 to March

1992

Power computation: not provided

Statistics: Chi²; logistic regression controlling for age, gender, marital status, education,

insurance, and intervention group

Participants Country: USA

Setting: community-dwelling Medicare beneficiaries 65 to 79 years in rural Pennsylvania

Eligible participants: (health status) 3884 enrolled in demonstration project, of whom

93Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Ives 1994 (Continued)

3606 (92.8%) completed follow-up telephone interview; study population was then

limited to those interviewed between April 1991 and March 1992 = 1989 community-

dwelling Medicare beneficiaries 65 to 79 years. Exclusions: institutionalised, non-ambu-

latory, life-threatening diagnosis of cancer in previous 5 years

Age: 65 to 79 years

Gender: not stated

Interventions Intervention 1: those participating in capitated payment group; after health risk appraisal

interview randomly assigned to offer of no-cost influenza immunisation

Intervention 2: those participating in fee-for-service group; after health risk appraisal

interview randomly assigned to offer of no-cost influenza immunisation; physicians only

paid if they received and submitted payment voucher from participants

Control: given their health risk appraisals but not offered immunisation

Received this helpful e-mail from Dr Diane Ives: “Regarding the issues of bias, this

was a community based demonstration project to see if Medicare beneficiaries would

use prevention programs if offered at no cost. Everyone enrolled in Medicare Part B

was potentially eligible and contacted to invite participation. Due to the nature of the

programs, it was impossible to blind the providers or participants. However, subjects

were randomly assigned to one of the 3 comparison groups (hospital based, physician

based and control/no free services), with the exception that spouse pairs were assigned

to the same group for feasibility of both using the services. The 2 references below detail

the characteristics of people who came into the program based on various recruitment

methods, and also describe those who did not participate. We found people who partic-

ipated had more disease history and risk factors, people who were contacted but refused

to participate were the healthiest and possibly refused because they felt they did not have

the risk factors targeted by the interventions, and those unable to be reached had highest

levels of disease based on Medicare claims data and may have been too ill to participate

Ives DG, Kuller LH, Schulz R, Traven ND, Lave JR. Comparison of recruitment strate-

gies and associated disease prevalence for health promotion in rural elderly. Preventive Medicine 1992;21:582-591 Ives DG, Traven ND, Kuller LH, Schulz R. Selection bias and non response to health

promotion in older adults. Epidemiology 1994;5:456-461.”

Outcomes Outcome measured: % vaccinated, measured by self report and by completed flu vouchers

for payment to physician by Medicare

Time points from the study considered in the review or measured or reported in the

study: April 1991 to March 1992

% vaccinated by March 1992 (2.5 years after study had begun, 1.5 years after offer of

influenza vaccine)

Notes Funding: Health Care Financing Administration

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection

bias)

Unclear risk “... participants were randomly assigned”

(no statement about method)

94Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Ives 1994 (Continued)

Allocation concealment (selection bias) Unclear risk No statement

Blinding (performance bias and detection

bias)

All outcomes

Unclear risk Measured by self report, but also by com-

pleted flu vouchers for payment to physi-

cian by Medicare

Incomplete outcome data (attrition bias)

All outcomes

Low risk All 1989 participants enrolled were anal-

ysed.

Selective reporting (reporting bias) Low risk No selective reporting

Karuza 1995

Methods Purpose: to compare focus groups of physicians discussing adoption of influenza guide-

line for participants ≥ 65 years to focus groups of physicians about an unrelated topic

Design: RCT, practices as the unit of randomisation

Duration of study: 4 months

Interval between intervention and when outcome was measured: 4 months

Power computation: not performed

Statistics: ANOVA for differences in uptake between study arms

Participants Country: USA

Setting: HMO in Buffalo, NY

Eligible participants: (health status) 13 practices in prepaid HMO in Buffalo, NY; all

physicians volunteered to participate; 8 physicians dropped out due to sickness or reas-

signment, and 6 physicians were omitted as they did not have 5 eligible participants

Age: participants were aged ≥ 65 years, not institutionalised

Gender: 63.5% female

Interventions Intervention 1: physician focus group with expert presenting guideline of immunisation

practices of the Advisory Committee of the Centers for Disease Control and Prevention,

including discussion with facilitator, with a plan that intervention practices would de-

velop their own methods such as reminder letters to participants or reminders on charts

Intervention 2: focus group on non-influenza topic (steroid use and GI bleeding)

Control: none

Outcomes Outcome measured: % influenza vaccination

Time points from the study considered in the review or measured or reported in the

study: pre-intervention base uptake measured 1 October 1990 through 31 January 1991;

intervention uptake measured during vaccination season 1 October 1991 to 31 January

1992

% vaccinated by 31 January 1992

Notes Funding: US Bureau of Health Professions, US Health Resources and Services Admin-

istration, and Agency for Health Care Policy and Research, US Public Health Service

Risk of bias

95Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Karuza 1995 (Continued)

Bias Authors’ judgement Support for judgement

Random sequence generation (selection

bias)

Unclear risk “Thirteen group practices and their pri-

mary care physicians (mean size, 5) were as-

signed randomly to intervention or control

arms.”

Allocation concealment (selection bias) Low risk “The vaccination data were obtained

through prechart and postchart reviews

conducted at these sites by trained outside

reviewers.”

Blinding (performance bias and detection

bias)

All outcomes

Low risk “The vaccination data were obtained

through prechart and postchart reviews

conducted at these sites by trained outside

reviewers.”

Incomplete outcome data (attrition bias)

All outcomes

Unclear risk “Active participants who were not seen dur-

ing the influenza vaccination season were

counted as not receiving the vaccine.”; “.

.. 10% of the charts were reviewed again

by a different reviewer. For the key mea-

sures the inter-judge reliability of the chart

review was better than 98% agreement.”;

“Because of expected patient attrition (e.g.

mortality, moving out of town, and chang-

ing physicians) and clerical error, an aver-

age of 11% of the charts was unavailable at

the post chart review per physician.”

Selective reporting (reporting bias) Low risk No selective reporting

Kellerman 2000

Methods Purpose: to compare a phone call reminder about influenza vaccination to no intervention

Design: RCT; participants randomised

Duration of study: 23 September to 23 October 1996

Interval between intervention and when outcome was measured: 1 month

Power computation: not performed

Statistics: percentages, probabilities

Participants Country: USA

Setting: Smoky Hill Family Practice Center, Salina, Kansas

Eligible participants: (health status): all 475 individuals aged ≥ 65 years were sent a

postcard reminder, eligibles were those who did not respond; exclusions: those resident

in nursing homes

Age: ≥ 65 years

Gender: not stated

96Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Kellerman 2000 (Continued)

Interventions All 475 individuals aged ≥ 65 years were sent a postcard reminding them about influenza

vaccination; non-respondents were then randomised to either:

1. intervention: 1 to 2 phone calls; or

2. control: no intervention.

Outcomes Outcome measured: % influenza vaccination

Time points from the study considered in the review or measured or reported in the

study: 23 September to 23 October 1996

% vaccinated by: 23 October 1996

Notes Funding: no funding

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection

bias)

High risk Alternate randomisation of alphabetised

households

Allocation concealment (selection bias) Unclear risk No statement

Blinding (performance bias and detection

bias)

All outcomes

Unclear risk No statement

Incomplete outcome data (attrition bias)

All outcomes

Unclear risk Vaccination uptake for the whole prac-

tice for the 2 preceding years is provided,

but not for the intervention and control

groups. Not stated how immunisation data

were recorded or whether the practice was

computerised (however, participants were

all aged ≥ 65 years and thus Medicare bene-

ficiaries, so there was an incentive to record

data to obtain payment)

“For the purposes of this study, only im-

munizations administered at the Family

Practice Center were considered in assess-

ing the study’s outcome. During the tele-

phone intervention, Family Practice Center

staff recorded any patient comments about

prior immunization for that season or sub-

sequent intentions for immunization.”

Selective reporting (reporting bias) Low risk No selective reporting

97Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Kerse 1999

Methods Purpose: to compare an educational programme for GPs about social and physical ac-

tivity, prescribing and vaccination practices for elderly participants with audit, to no

intervention

Design: RCT; general practices were unit of allocation

Duration of study: November 1995 to April 1997

Interval between intervention and when outcome was measured: November 1995 to

April 1997

Power computation: website stated 93 participants needed in each group to detect 20%

change with α = 0.05, β = 0.8, allowing for clustering.

Statistics: ITT. “We adjusted for the effect of clustered design with a cross sectional time

series iterative programed least squares regression.”

Participants Country: Australia

Setting: 42 GPs in Melbourne

Eligible participants: (health status) a number was assigned to 398 GPs in metropolitan

Melbourne, then 193 with no computerised recall system were randomly selected for

influenza vaccination; exclusions from the 193 were: 6 were not contactable; 25 moved

or had died; 28 had partners already enrolled in trial; 25 worked < 12 hours/week; 7

were retiring; 13 had no elderly participants or participants who did not speak English;

and 7 had computerised recall systems. 42 of 82 eligibles were then enrolled, and using

random number table average 397 charts were reviewed per practitioner, and 10 elderly

participants identified per practitioner; 267 (64%) of invited participants participated.

Age: ≥ 65 years

Gender: 54% female

Interventions Intervention: educational programme in 5 stages for GPs about social and physical

activity, prescribing and vaccination practices for elderly participants

Control: no intervention

Outcomes Outcome measured: % influenza vaccination

Time points from the study considered in the review or measured or reported in the

study: November 1995 to February 1996 and at 1-year follow-up (December 1996 to

April 1997)

% vaccinated by: April 1997

E-mail from Dr Kerse indicated data on baseline influenza uptake for the year before the

intervention would be supplied, but further e-mail not received

Notes Funding: Victoria Health Promotion Foundation; doctoral scholarship for Dr Kerse

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection

bias)

Low risk “An independent research assistant at a dis-

tant site used computer randomisation to

allocate general practitioners to interven-

tion or control group and this was con-

cealed until the interview began.”

98Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Kerse 1999 (Continued)

Allocation concealment (selection bias) Low risk “An independent research assistant at a dis-

tant site used computer randomization to

allocate general practitioners to interven-

tion or control group and this was con-

cealed until the interview began.”

Blinding (performance bias and detection

bias)

All outcomes

Low risk “Interviewers evaluating outcomes were

blinded to the intervention group of partic-

ipants and general practitioners at all times,

and participants were unaware of the group

allocation of their general practitioner.”

Incomplete outcome data (attrition bias)

All outcomes

Unclear risk In Table 1, 135 participants are listed in

the intervention group (but only 120 are

listed as either “yes” or “no” for influenza

vaccination) and 132 in the control (but

only 112 listed “yes” or “no” for influenza

vaccination status).

“Influenza vaccination rates increased by

almost 10% in both groups” (but no num-

bers for these outcomes are cited)

After 1 year, 34 participants could not be

followed up; they were correctly counted in

the groups to which they were randomised

in an ITT analysis.

Immunisation data ascertained by chart re-

view (all practices were deliberately selected

as being not computerised)

Selective reporting (reporting bias) Low risk No selective reporting

99Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Kiefe 2001

Methods Purpose: to compare a multimodal improvement intervention with chart review and

feedback to physicians, to the same intervention plus feedback about the performance

of the top 10% of physicians

Design: RCT, physicians randomly assigned; 20 records for each physician randomly

assessed at baseline and a different set of 20 records at follow-up

Duration of study: baseline was performance of physicians 1 January 1994 through 30

June 1995; intervention during 1996; follow-up through 30 June 1998.

Interval between intervention and when outcome was measured: 1 January 1997 to 30

June 1998

Power computation: (e-mail from author Dr C Kiefe: “We did perform an a priori power computation to have at least 80% power to detect an effect on at least one of

the indicators. Because the study was positive, this became meaningless and we did not

include this is the paper.”)

Statistics: t-tests; generalised linear models with nesting of participants within physicians

and controlling for baseline performance (no adjustments for patient characteristics as

“each quality measure specified a group of participants who were ideal candidates for

intervention”)

Participants Country: USA

Setting: 561 eligible physicians in Alabama

Eligible participants: (health status) random sample of 97 Alabama fee-for-service physi-

cians (of whom 70 completed the study; the 27 who did not complete the study practised

in a different environment, or were retired or deceased) from a group of 561 Alabama

family physicians, internists, and endocrinologists. The 70 physicians had 2978 diabetic

participants. Exclusions were: end-stage renal disease, in a skilled nursing home, dead

at baseline. (E-mail from author Dr C Kiefe: “Community physicians who were partic-

ipating in CMS (then [Alabama Health Quality Assurance Foundation] HCFA) Am-

bulatory Care Quality Improvement Project (ACQIP). The analyses were at the patient

level, because the outcomes were measured at the patient level. Patients were Medicare

beneficiaries with diabetes.”)

Age: average 76 years

Gender: not stated (“We have archived the original data and we could find the exact %

female, but it would be fairly burdensome. I seem to remember that this older Medicare

population had about 75% women”)

Interventions Intervention 1: Ambulatory Care Quality Improvement Project; physicians given per-

formance feedback on diabetes care, then quality improvement (n = 49 physicians, 14

lost to follow-up)

Intervention 2: same as intervention 1 + achievable benchmark based on performance

of top 10% of physicians being assessed (n = 48 physicians, 13 lost to follow-up)

No control group

Outcomes Outcome measured: % influenza vaccination

Time points from the study considered in the review or measured or reported in the

study: baseline was performance of physicians 1 January 1994 through 30 June 1995;

intervention during 1996; follow-up 1 January 1997 to 30 June 1998.

% vaccinated by: 20 June 1998

Notes Funding: Agency for Healthcare Research and Quality

100Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Kiefe 2001 (Continued)

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection

bias)

Unclear risk “... this group-randomized trial” (E-mail

from author Dr C Kiefe: “We randomised

the physicians and then reviewed the medi-

cal records of their participants to ascertain

whether flu vaccine was documented.”)

Allocation concealment (selection bias) Unclear risk No statement

Blinding (performance bias and detection

bias)

All outcomes

Unclear risk No statement, but vaccination status as-

sessed by chart review using pilot-tested

protocol

Incomplete outcome data (attrition bias)

All outcomes

High risk 97 physicians randomised; intervention

group (48 received ACQIP + achievable

benchmarks, 13 lost to follow-up); control

(49 received ACQIP, 14 lost to follow-up).

Outcomes for physicians who did not com-

plete study not presented. (E-mail from au-

thor Dr C Kiefe: “It was not possible to re-

view records for physicians who no longer

wished to participate or were lost to follow-

up.”)

Selective reporting (reporting bias) Low risk No selective reporting

Kim 1999

Methods Purpose: to compare the effect of providing education, peer-comparison feedback, and

academic detailing to physicians with providing education to physicians, on the number

of preventive services and the % of participants to which they were offered

Design: RCT, physicians randomised to the 2 interventions

Duration of study: 2.5 years

Interval between intervention and when outcome was measured: February 1992 to

February 1994

Power computation: not performed

Statistics: mixed-model ANOVA, participants nested within physicians

Participants Country: USA

Setting: Kaiser Permanente Woodland Hills HMO San Fernando Valley, California

Eligible participants: (health status) 48 family physicians, internists, and subspecialists

providing primary care for at least 60 participants (of whom 7 dropped out, leaving 41)

; 9233 participants were 65 to 75 years and eligible; surveys mailed to a random sample

of 3249, of whom 2237 completed baseline and follow-up surveys, 299 then excluded

as their physician left the group, sample = 1810 participants

101Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Kim 1999 (Continued)

Age: average 73 years

Gender: participants 50% female

Interventions Intervention 1: mailed educational materials about 7 preventive care services

Intervention 2: same as intervention 1 + anonymous 15 minutes academic detailing and

peer-comparison feedback from pharmacist at beginning of study and 6 and 12 months

later

Control: no control group

Outcomes Outcome measured: % vaccinated; measured by chart review and patient survey (23%

to 26% overestimation by participants compared to chart review)

Time points from the study considered in the review or measured or reported in the

study: surveys of participants January to May 1992, and December 1995 to January

1996

Vaccinated by: January 1996

Notes Funding: Sidney Garfield Memorial Fund, S Kaiser Permanente

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection

bias)

Unclear risk “... physicians were randomly assigned” (no

statement about method)

Allocation concealment (selection bias) Unclear risk No statement

Blinding (performance bias and detection

bias)

All outcomes

Low risk No statement, but chart review by 4 trained

personnel using standardised forms, inter-

rater reliability = 100%

Incomplete outcome data (attrition bias)

All outcomes

High risk 48 physicians randomised to intervention

(comprehensive education) or control (ed-

ucation), and 2337 participants completed

both baseline and follow-up surveys, but

outcomes for the 7 physicians who dropped

out and their 128 participants, and a fur-

ther 299 participants because their physi-

cian left the medical group, are not pre-

sented; final outcome data are presented for

only 1810 participants

Selective reporting (reporting bias) Low risk No selective reporting

102Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Kouides 1998

Methods Purpose: to assess the effect of financial incentives to physicians for influenza vaccinations

on achieving vaccination targets

Design: RCT, physician practices randomised

Duration of study: September 1991 to 1 January 1992

Interval between intervention and when outcome was measured: September 1991 to 1

January 1992

Power computation: not performed

Statistics: t-tests for normally distributed continuous variables; Wilcoxon rank sum tests

for non-parametric variables; Chi², Fisher’s exact test for discrete variables; multiple

linear regression, controlling for number of elderly participants in the practice, type of

practice, per cent immunised in baseline year 1990, routine use of phone calls, postcards

or flowcharts as reminders for preventive services, and total number of visits by study

personnel to the practice

Participants Country: USA

Setting: Medicare Influenza Demonstration Project, Monroe County, NY

Eligible participants: (health status) 54 practices. Exclusions were physicians who pro-

vided care to < 50 participants, did not participate in Medicare Influenza Demonstration

Project, or had participated in a previous study.

Age: ≥ 65 years

Gender: not stated

Interventions Intervention: physicians received free influenza vaccine and were paid the standard USD

8.00 fee per vaccination from the Medicare Demonsration Project, and they were asked

to enter cumulative weekly vaccinations on an office poster (target population = all

active non-nursing home participants with office visits 1991 or 1992). If they achieved

70% vaccination coverage, they received an additional USD 0.80 per vaccination for

vaccinations given in their office, and if they achieved 85% coverage they received an

additional USD 1.60 per vaccination.

Control: no intervention

Co-interventions: extensive community media campaign, beneficiary letters to all Medi-

care recipients, extended schedule for public vaccination clinics (Kouides 1993 describes

a non-randomised study comparing patient vaccination uptake for physicians admitting

to 2 hospitals, which could have had an effect on Kouides’ RCT study)

Outcomes Outcome measured: % vaccinated

Time points from the study considered in the review or measured or reported in the

study: September 1991 to 1 January 1992

% vaccinated by: 1 January 1992

Notes Funding: Medicare Influenza Demonstration Project, Monroe County, NY

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection

bias)

Unclear risk “All physicians ... were randomised.” (no

statement about method)

103Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Kouides 1998 (Continued)

Allocation concealment (selection bias) Unclear risk No statement

Blinding (performance bias and detection

bias)

All outcomes

Low risk No statement, but vaccination status mea-

sured by Medicare billing

Incomplete outcome data (attrition bias)

All outcomes

Low risk Intention-to-treat with intervention group

n = 21,196 and control group n = 17,608

Selective reporting (reporting bias) Low risk No selective reporting

Krieger 2000

Methods Purpose: to assess the effect of peer-to-peer telephone outreach by seniors to increase

vaccination uptake

Design: RCT, seniors randomised

Duration of study: baseline survey September 1996; intervention 3rd week of October

1996 for 6 weeks; follow-up survey March 1997

Interval between intervention and when outcome was measured: intervention 3rd week

of October 1996 for 6 weeks; follow-up survey March 1997

Power computation: “We estimated that 1000 participants divided into 2 groups of equal

size would provide at least 80% power to detect a 25% difference in the proportions

of subjects receiving a recommended immunization, given control-group immunization

uptake ranging from 40%-80% and a 5 0.05. Analyses included only the 1083 partici-

pants who completed both surveys.”

Statistics: “The chi-square (with Yates correction), t test, analysis of variance, and

Wilcoxon matched-pairs signed-rank and rank-sum procedures were used to test for

differences between groups, and McNemar test was used for assessing baseline to follow-

up differences within groups.”

Participants Country: USA

Setting: Seattle Partners for Healthy Communities Seattle Senior Immunization Project

Eligible participants: (health status) recruited from senior centre and a marketing database

of seniors in 5 contiguous zip codes; 5512 invited, of whom 1246 (23%) completed

baseline survey; 163 (13%) dropped out

Age: average 75 years

Gender: intervention 42.8% female; control 47.8% female

Interventions Intervention: mailed educational brochure, senior volunteers called 25 participants using

script (4 hours training), follow-up phone call, plus same interventions as control

Control: usual senior centre and community immunisation newspaper articles, health

fair, pamphlets, posters, media announcements, mailed letter from regional Medicare

office to 10% of seniors, vaccine available at senior centre

Outcomes Outcome measured: % vaccinated, self report by survey (medical records were not audited

because seniors obtained influenza vaccination from several locations)

Time points from the study considered in the review or measured or reported in the

study: baseline survey September 1996; intervention 3rd week of October 1996 for 6

104Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Krieger 2000 (Continued)

weeks; follow-up survey March 1997

% vaccinated by: March 1997

Notes Funding: Centers for Disease Control and Prevention

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection

bias)

Low risk “... systematic allocation of alternate re-

spondents to either control or intervention”

Allocation concealment (selection bias) Unclear risk No statement

Blinding (performance bias and detection

bias)

All outcomes

Unclear risk “Volunteers ... made a follow-up contact

to ascertain whether immunization(s) were

received.”

Incomplete outcome data (attrition bias)

All outcomes

Low risk 163 (13%) lost to follow-up, similar

proportions in intervention and control

groups; “computerized registry to track the

contact and immunization status of each

subject”

Selective reporting (reporting bias) Low risk No selective reporting

Kumar 1999

Methods Purpose: to assess the effect of a physician-targeted intervention to increase influenza

vaccination uptake among seniors

Design: RCT, physicians randomised

Duration of study: 1 September to 31 December 1997

Power computation: none provided

Statistics: percentage of total Medicare beneficiaries immunised

Participants Country: USA

Setting: Louisiana physician offices

Participants: non-HMO Medicare providers. 750 physicians assigned to intervention

group; 1167 assigned to control group.

Age: participants aged > = 65 years

Gender: not reported

Interventions Intervention group received a “... cover letter and their Medicare patient pool influenza

immunization and missed opportunity indicator uptake in October 1997” and “... were

encouraged to evaluate ways in which their practices might improve upon the base-

line immunization status and were offered assistance in designing quality improvement

projects to effect such a change. The information provided to the physicians included

computed rates for all selected physicians which allowed them to compare their rates

105Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Kumar 1999 (Continued)

with rates of other physicians.” The control group did not receive any educational or

other materials

Outcomes % influenza vaccination

Although the influenza vaccination uptake increased from 1996 to 1997 in both the

intervention group (4.21% versus 5.23%) and the control group (3.74% versus 4.5%),

the intervention group uptake increased significantly more (P = 0.03) than the control

group uptake

Notes Funding: US Health Care Financing Administration, Department of Health and Human

Services

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection

bias)

Unclear risk “Randomly selected ’intervention group’

of physicians (n = 750)” and “... another

group of physicians, with similar character-

istics, was also randomly selected and des-

ignated as the ’control group’ (n = 1,167).

” (no statement about method of randomi-

sation)

Allocation concealment (selection bias) Unclear risk No statement

Blinding (performance bias and detection

bias)

All outcomes

Low risk No statement, but outcomes ascertained

from Medicare Part B claims

Incomplete outcome data (attrition bias)

All outcomes

Low risk Identified all Louisiana Medicare-certified

providers; analysed 1996 and 1997 Medi-

care Part B claims files for influenza vacci-

nations

Selective reporting (reporting bias) Low risk No selective reporting

106Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Lemelin 2001

Methods Purpose: to compare the effect of facilitators using 7 intervention strategies to encourage

8 recommended and to discourage 5 not-recommended preventive care manoeuvres,

compared to no intervention

Design: RCT, practices as unit of randomisation

Duration of study: 18 months

Interval between intervention and when outcome was measured: 18 months after last

patient visit

Power computation: 40 practices needed to detect mean difference of 0.09 in preventive

performance index used in this study between intervention and control groups with α

= 0.05, power = 80%

Statistics: “Cross tabulations using Chi² test and Fisher’s exact test were used to examine

categorical data and compare groups. We used Student’s t-test for independent groups

for comparisons of continuous data. To test for significant differences in end points be-

tween the intervention and control groups, we analysed end points using GLE repeated-

measures ANOVA, where end points measured at baseline and follow-up were treated

as within-subject factors ... and the intervention group was the between-subjects factor

... Significant interaction effects were further analysed with a least-significant-difference

post-hoc test to evaluate mean differences. We used a GLE ANOVA to test for differences

between the study groups in preventive performance index.”

Participants Country: Canada

Setting: health service organisations in Ontario

Eligible participants: (health status): 100 health service organisations, of which 46 were

recruited and 45 remained in study

Age: Canadian Task Force on Preventive Care recommended age of ≥ 65 years

Gender: 53.6% female

Interventions Intervention: facilitators used 7 strategies (audit and ongoing feedback, consensus build-

ing, opinion leaders and networking, academic detailing and education materials, re-

minder systems, patient-mediated activities, and patient education materials) to increase

uptake of 8 preventive care manoeuvres recommended by the Canadian Task Force on

Preventive Care and to discourage 5 that were not recommended.

Control: no intervention

Outcomes Outcome measured: % vaccinated

Time points from the study considered in the review or measured or reported in the

study: intervention July 1997 to December 1998

% vaccinated by: 31 December 1998

E-mail from Dr Bill Hogg: “Unfortunately the paper does not report the age break down

of the participants in the intervention and control groups (only the average age) and

so the information cannot be derived from the paper. I would have to go back to trial

data to produce the numbers requested. I’m on sabbatical and away from home so can’t

manage this.”

Notes Funding: Ontario Ministry of Health

Risk of bias

Bias Authors’ judgement Support for judgement

107Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Lemelin 2001 (Continued)

Random sequence generation (selection

bias)

Unclear risk “The primary care practice (1 to 6 doctors)

was the unit of randomization and the unit

of analysis.” (no statement of method)

Allocation concealment (selection bias) Unclear risk No statement

Blinding (performance bias and detection

bias)

All outcomes

Low risk “The chart auditors were blinded as to the

status of the practices and assessment of

outcomes.”

Incomplete outcome data (attrition bias)

All outcomes

Unclear risk For the performance of preventive manoeu-

vres: “The concordance between auditors

was 85.4% (kappa = 0.71) at baseline and

84.4% (kappa = 0.69) at follow-up.”

Selective reporting (reporting bias) Low risk No selective reporting

Leung 2017

Methods Purpose: to compare influenza vaccination rates after 3-minute conversation, with no-

intervention control

Design: RCT

Duration of study: 19 to 30 October 2015

Interval between intervention and when outcome was measured: 9 days

Power computation: 524 participants required to detect 20% difference in vaccination

rate with significance level of 0.05 and 80% power

Statistics: Mantel-Haenszel test

Participants 529 participants in outpatient departments of 2 Hong Kong hospitals, October 2015

Interventions 3-minute face-to-face scripted presentation (influenza prevalence, transmission, symp-

toms, and complications; efficacy and adverse effects of vaccine), then 2 minutes for

questions; no-intervention control

Outcomes Influenza vaccination rate 9 days after intervention group received the intervention

Notes The influenza vaccination rate “in past 2 years” was 130 (49%) and 129 (49%) in

control group, i.e. much higher than current outcome in intervention (94 vaccinated)

and control (67 vaccinated)

Funding: School of Public Health, Li Ka Shing Faculty of Medicine, University of Hong

Kong

Risk of bias

Bias Authors’ judgement Support for judgement

108Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Leung 2017 (Continued)

Random sequence generation (selection

bias)

Low risk Sealed envelope (www.

sealedenvelope.com); investigators called a

contact independent of research to obtain

allocation for each individual

Allocation concealment (selection bias) Unclear risk Not stated

Blinding (performance bias and detection

bias)

All outcomes

High risk States that study was unblinded; the inves-

tigators presented the intervention to the

participants

Incomplete outcome data (attrition bias)

All outcomes

Low risk 7276 eligibles, 529 randomised, vaccina-

tion report retrieved for 529, intention-to-

treat

Selective reporting (reporting bias) Low risk No selective reporting

Lukasik 1987

Methods Purpose: to compare phone invitations to receive influenza vaccination to a statement

of vaccine availability when participants “dropped in” to the clinic

Design: RCT

Duration of study: mid-September to December 1985

Interval between intervention and when outcome was measured: 0 to 3.5 months

Power computation: not performed

Statistics: not stated, appears to be comparison of percentages

Participants Country: Canada

Setting: University Family Medicine clinic in London, Ontario

Eligible participants: (health status): participants aged ≥ 65 years

Age: ≥ 65 years, average not stated

Gender: not stated

Interventions Intervention 1: phone call to participants to inform them that influenza vaccine was

available and that they could receive it during a regular visit or a vaccine clinic

Intervention 2: invitation to receive influenza vaccine during “drop-in” visit to clinic

Control: historical data from 1983 and 1984 (not used in this review as they are historical

controls with no information about secular trends)

Outcomes Outcome measured: % vaccinated

Time points from the study considered in the review or measured or reported in the

study: mid-September to December 1985 (date in December not stated)

% vaccinated by: December 1985 (date not stated)

Notes Funding: no funding stated

Risk of bias

109Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Lukasik 1987 (Continued)

Bias Authors’ judgement Support for judgement

Random sequence generation (selection

bias)

High risk “After a random start participants were al-

ternately assigned to each group, though re-

lated participants and those living in a sin-

gle household were kept in the same group.

”

Allocation concealment (selection bias) Unclear risk No statement

Blinding (performance bias and detection

bias)

All outcomes

High risk “A brightly coloured sticker was applied to

the charts of the entire study population as

a reminder to the health-care team that the

study was under way and that they were ex-

pected to promote the flu vaccine.”; “The

patients would be told, whether by tele-

phone or in the office, that the vaccine was

available, and that they would be given a

shot if they wished.”

Incomplete outcome data (attrition bias)

All outcomes

Low risk “The analysis was done with participants

in their originally assigned groups ... an in-

tention to treat analysis.”

Vaccination ascertained by chart review by

research collaborators, outcomes for all 243

participants were tracked

Selective reporting (reporting bias) Low risk No selective reporting

MacIntyre 2003

Methods Purpose: for hospitalised participants aged ≥ 65 years, to compare an alert system for

hospital staff to vaccinate them against influenza and a reminder letter sent to their GP

on the day of their discharge

Design: RCT, individuals randomised

Duration of study: for participants admitted May to September 1998

Interval between intervention and when outcome was measured: day of discharge (arm

A) or 1 month and 3 months after discharge (arm B)

Power computation: 100 required for 10% difference in vaccination with 95% confi-

dence and 80% power

Statistics: odds ratios

Participants Country: Australia

Setting: Royal Melbourne Hospital

Eligible participants: (health status): 606 participants aged ≥ 65 years admitted to a

Melbourne hospital, of whom 238 already vaccinated, 35 vaccination history not verified,

88 unable to obtain consent, and 113 refused, leaving 131 consented

Age: 74 years

110Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

MacIntyre 2003 (Continued)

Gender: 56% female

Interventions Intervention 1: reminder in chart and face-to-face reminder to nursing and medical staff

Intervention 2: reminder to GP on day of discharge

Control: no control group

Outcomes Outcome measured: % vaccinated

Time points from the study considered in the review or measured or reported in the

study: from admission (May to September 1998) up to day of discharge for hospital arm

and up to 3 months after discharge for GP arm

% vaccinated by day of discharge for hospital arm and 3 months after discharge for GP

arm

Notes Funding: Department of Human Services, Victoria

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection

bias)

Low risk “... research nurse picked a sealed envelope

from a randomization box”

Allocation concealment (selection bias) Low risk “... research nurse picked a sealed envelope

from a randomization box” (so likely re-

searchers not aware of allocation)

Blinding (performance bias and detection

bias)

All outcomes

Unclear risk No statement

Incomplete outcome data (attrition bias)

All outcomes

Low risk 244 eligibles, 131 consented; all those who

consented followed through to randomi-

sation and receipt of vaccine. Vaccination

for those vaccinated in hospital arm ascer-

tained by discharge records, and for those

in GP arm by phone call then letter to GP

Selective reporting (reporting bias) Low risk No selective reporting

111Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Maglione 2002a

Methods Purpose: to report the findings of four unpublished studies of RCTs to increase vacci-

nation rates in Health Care Quality Improvement Projects (HCQIP). For the purposes

of this Cochrane review we have labelled them Maglione 2002a (comparison of a letter

and brochure to no intervention in Minnesota); Maglione 2002b (four groups: letter;

postcard; letter plus postcard; no intervention in New Jersey; Maglione 2002c (compar-

ison of a postcard compared to no intervention in Utah-Nevada), and Maglione 2002d

(comparison of a letter followed by a separate mailing of a postcard to no intervention

in Washington state)

[N.B.: 2 published reports of the HCQIP database in Wyoming and Montana are re-

ported separately in this Cochrane review as (CDC 1995a (Wyoming); CDC 1995b

(Montana).

Design: RCT; Peer Review Organizations in US states are required to conduct quality

improvement projects and report results as part of the Health Care Quality Improvement

Project (HCQIP). Maglione 2002a searched for unpublished reports about Minnesota,

Utah-Nevada, New Jersey, and Washington state. Maglione and co-authors indepen-

dently abstracted the number and characteristics of participants and the setting, loca-

tion and target of intervention. 2 authors independently abstracted data, and resolved

discrepancies by consensus.

Duration of study: not stated

Interval between intervention and when outcome was measured: not stated. All 4 un-

published RCTs were reported as being performed in 1996.

Power computation: not performed

Statistics: percentages

Participants Total number: Minnesota (letter plus brochure 2924, no intervention 3343); Utah-

Nevada (postcard 25,000, no intervention 50,437); Washington state (letter plus post-

card 16,082, no intervention 16,057); New Jersey (letter 16,000, postcard 16,001, letter

plus postcard 16,000, no intervention 16,001)

Setting: Minnesota, Utah-Nevada, Washington state, New Jersey, all Medicare Part B

beneficiaries

Diagnostic criteria: % receiving influenza vaccination, validated by HCFA billing claims

Gender: not stated

Age: ≥ 65 years

Country: USA

Comorbidity not stated. Sociodemographics not stated. Ethnicity not stated. Date of

studies 1996

Interventions Minnesota: Intervention: letter and brochure; control (no intervention)

New Jersey: Intervention 1: letter; intervention 2: postcard; intervention 3: letter and

postcard; control (no intervention)

Utah-Nevada: intervention: postcard; control (no intervention)

Washington State: Intervention: letter and later mailing of a postcard; control (no inter-

vention)

Integrity of intervention:

Minnesota: letter and brochure sent to statewide sample of 5,000 elderly Medicare

beneficiaries prior to 1995 influenza season. Only 2924 could be matched to the Medicare

claims file and of these 50.3% received influenza vaccination

New Jersey: randomly selected beneficiaries at risk of serious risk of influenza complica-

tions were randomised to interventions or control. No statement on rates of reception

112Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Maglione 2002a (Continued)

of interventions

Utah-Nevada: 5000 beneficiaries who had been vaccinated and 25,000 who had not

in 1995 were randomised to receive a postcard reminder (estimated 82% received the

postcard) or no intervention

Washington State: beneficiaries who did not receive influenza vaccination in 1995 were

randomised to the two interventions or control. No statement about rates of reception

of the interventions

Outcomes Outcome measured: % vaccinated as measured by HCFA billing claims

Time points from the study considered in the review or measured or reported in the

study: 1996

% vaccinated during 1996

Notes Funding: Center for Medicare and Medicaid Services, US Department of Health and

Human Services

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection

bias)

Unclear risk Described only as “RCT”

Allocation concealment (selection bias) Unclear risk No statement

Blinding (performance bias and detection

bias)

All outcomes

Unclear risk No statement

Incomplete outcome data (attrition bias)

All outcomes

Low risk 96% of those aged ≥ 65 years are covered by

Medicare Part B, which processes all billing

claims for influenza vaccination

Selective reporting (reporting bias) Low risk No selective reporting

Maglione 2002b

Methods Data are reported for New Jersey. For details see Maglione 2002a

Participants See Maglione 2002a

Interventions See Maglione 2002a

Outcomes See Maglione 2002a

Notes See Maglione 2002a

Risk of bias

113Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Maglione 2002b (Continued)

Bias Authors’ judgement Support for judgement

Random sequence generation (selection

bias)

Unclear risk Described only as “RCT”

Allocation concealment (selection bias) Unclear risk No statement

Blinding (performance bias and detection

bias)

All outcomes

Unclear risk No statement

Incomplete outcome data (attrition bias)

All outcomes

Low risk 96% of those aged ≥ 65 years are covered by

Medicare Part B, which processes all billing

claims for influenza vaccination

Selective reporting (reporting bias) Low risk No selective reporting

Maglione 2002c

Methods Data are reported for Utah-Nevada. For details see Maglione 2002a

Participants See Maglione 2002a

Interventions See Maglione 2002a

Outcomes See Maglione 2002a

Notes See Maglione 2002a

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection

bias)

Unclear risk Described only as “RCT”

Allocation concealment (selection bias) Unclear risk No statement

Blinding (performance bias and detection

bias)

All outcomes

Unclear risk No statement

Incomplete outcome data (attrition bias)

All outcomes

Low risk 96% of those aged ≥ 65 years are covered by

Medicare Part B, which processes all billing

claims for influenza vaccination

Selective reporting (reporting bias) Low risk No selective reporting

114Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Maglione 2002d

Methods Data are reported for Washington state. For details see Maglione 2002a

Participants See Maglione 2002a

Interventions See Maglione 2002a

Outcomes See Maglione 2002a

Notes See Maglione 2002a

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection

bias)

Unclear risk Described only as “RCT”

Allocation concealment (selection bias) Unclear risk No statement

Blinding (performance bias and detection

bias)

All outcomes

Unclear risk No statement

Incomplete outcome data (attrition bias)

All outcomes

Low risk 96% of those aged ≥ 65 years are covered by

Medicare Part B, which processes all billing

claims for influenza vaccination

Selective reporting (reporting bias) Low risk No selective reporting

Marrero 2006

Methods Purpose: to compare an educational session about influenza and vaccination clinic in a

pharmacy to “usual care” (no intervention)

Design: RCT

Duration of study: 12 months

Interval between intervention and when outcome was measured: 12 months

Power computation: not performed

Statistics: percentages, ANOVA

Participants Country: Puerto Rico

Setting: pharmacy in San Lorenzo

Eligible participants: (health status): pharmacy customers ≥ 65 years who visited phar-

macy June or July 2000

Age: ≥ 65 years

Gender: 62% female

Interventions Intervention: offer of educational session about influenza and to attend vaccination clinic

Control: no intervention

115Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Marrero 2006 (Continued)

Outcomes Outcome measured: % influenza vaccination

Time points from the study considered in the review or measured or reported in the

study: 12 months

% vaccinated by: 12 months from intervention

Notes Funding: not stated

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection

bias)

Unclear risk “randomised allocation to intervention or

control”

Allocation concealment (selection bias) Unclear risk No statement

Blinding (performance bias and detection

bias)

All outcomes

Unclear risk No statement

Incomplete outcome data (attrition bias)

All outcomes

Unclear risk 46/50 from intervention and 37/50 from

control group received vaccination at 3

months; clinical results from 42/50 from

intervention and 31/50 from control group

assessed after 12 months (no differential at-

trition analysis)

Selective reporting (reporting bias) Low risk No selective reporting

McCaul 2002

Methods Purpose: to compare letter informing participants of importance of flu shot to reminder

letter stating date and time of clinic

Design: RCT, clustered by counties

Duration of study: not reported

Interval between intervention and when outcome was measured: not stated

Power computation: not performed

Statistics: t-tests

Participants Country: USA

Setting: 29 North Dakota counties

Eligible participants: (health status): 6730 male and 9107 female Medicare recipients

who had not submitted Medicare reimbursement requests for flu shots the previous year.

Age: ≥ 65 years

Gender: 57.5% female

116Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

McCaul 2002 (Continued)

Interventions Intervention 1: card reminding recipients of advantages of flu shots

Intervention 2: letter reminding recipients of advantages of flu shots and stating time,

date, and place of flu shot clinics

Control: no intervention

Outcomes Outcome measured: % vaccinated

Time points from the study considered in the review or measured or reported in the

study: not stated

% vaccinated by: not stated

Notes Funding: US Health Care Financing Administration

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection

bias)

Unclear risk “we randomly assigned counties to either

the reminder letter (n = 17), action-let-

ter (n = 12), or no-letter (n = 20) con-

ditions. Within the reminder-letter coun-

ties, we then randomly assigned individ-

uals within each county to either the re-

minder-only, reminder plus positive frame,

or reminder plus negative frame condi-

tions. Within the action-letter counties, all

individuals received the same action letter”

(no statement about method of randomi-

sation)

Allocation concealment (selection bias) Unclear risk No statement

Blinding (performance bias and detection

bias)

All outcomes

Low risk No statement about blinding, but assess-

ment based on Medicare reimbursement

claims

Incomplete outcome data (attrition bias)

All outcomes

Low risk E-mail from author states “... subject loss

was 6%, most of which was letters being

returned.”

Selective reporting (reporting bias) Low risk No selective reporting

117Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

McDowell 1986

Methods Purpose: to compare reminders to patients to receive influenza vaccination by telephone

reminder by their family physician, telephone reminder by nurse, or by letter

Design: cluster-RCT, participants randomised by family

Duration of study: 23 October to 31 December 1984

Interval between intervention and when outcome was measured: 23 October to 31

December 1984

Power computation: sample sizes offered power to detect 10% to 15% difference in

proportions (alpha not stated)

Statistics: Chi²

Participants Country: Canada

Setting: Ottawa Civic Hospital Family Practice Clinics

Eligible participants: (health status): 13,345 eligible participants, of whom 1420 aged ≥

65 years; 2 physicians refused to participate, leaving 939 participants; 113 patients had

been vaccinated before the trial and were excluded, leaving 201 available for a personal

reminder to patients by their family physician, 208 for a phone call by nurse, 239 for a

letter, and 215 in a control group

Age: ≥ 65 years

Gender: not stated

Intervention group 1 (physician reminder): 1122 families, 1471 people

Intervention group 2 (telephone reminder): 1104 families, 1468 people

Intervention group 3 (letter reminder): 1168 families, 1541 people

Control group: 1056 families, 1403 eligible participants

Exclusions: not clear

Interventions Intervention 1 (reminder to patients by their family physician): a computer-generated

reminder was included on the routinely printed encounter form before any visit to the

office to remind the physician of outstanding preventive procedures their patients needed.

Intervention 2 (telephone reminder): the practice nurse attempted to contact the family,

making a maximum of 5 calls during working hours, and completed an action form

for each listed patient. Once contact was made, the nurse advised the patient about the

indicated procedures and then attempted to arrange for them to be performed. The

person answering the telephone was asked to relay the message to other family members.

Intervention 3 (letter reminder): computer-generated letter, signed by their physician

and nurse, describing the procedures that were overdue for each member of the family

and the importance of having them performed. After 21 days a second reminder was

sent out to non-respondents.

Control: no action was taken to remind the physicians or the participants that a procedure

was overdue. Non-randomised control group: the participants of 2 doctors who refused

were not randomised and were treated as a second control group to assess the effects of

the increased preventive activity in the practices.

In the 1990 article in Family Medicine, McDowell provided baseline vaccination data for 1984, the year before the 2-year intervention in 1985 and 1986, and grouped the letter,

nurse, and physician reminders into 1 treatment group compared to a control. We have

followed this reporting of the results in the final publication in their series

Outcomes Outcome measured: % vaccinated by 31 December 1984, recorded in clinic computer

Time points from the study considered in the review or measured or reported in the

study: intervention 23 October 1984 to 31 December 1984, vaccine receipt assessed

until 31 December 1984

118Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

McDowell 1986 (Continued)

% vaccinated by: 31 December 1984

Intervention 1 (physician reminder): 766/1471 people visited the practice in the study

year; 22.9% of group were vaccinated, but the denominator for this proportion is not

stated (i.e. cannot tell if it was 766 people versus 1471 people versus 1122 families).

Intervention 2 (telephone reminder): 1104 of the 1468 families assigned to telephone

reminder required a reminder for 1 or more interventions; 684 families were actually

contacted. 37% of group were vaccinated, but denominator for proportion not stated (i.e.

cannot tell if it was 1104 families versus 684 families versus 1468 people that constituted

the 1104 families versus unknown number of people in the 684 families actually reached)

Intervention 3 (letter reminder): 164 of 1442 people sent letters had letters returned as

undeliverable. 35.2% were vaccinated, but cannot tell which denominator was used (i.

e. 1442 versus 978 people).

Control: 9.8% “of study group” were vaccinated. Not stated if the denominator is families

or individual people

Notes Funding: Department of National Health and Welfare, Ontario Ministry of Health,

Career Health Scientist Award to Dr McDowell; follow-up in 1985 showed no difference

between intervention and control groups (McDowell 1990)

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection

bias)

Unclear risk “... participants were randomly allocated by

family”

Allocation concealment (selection bias) Unclear risk No statement

Blinding (performance bias and detection

bias)

All outcomes

Unclear risk No statement about blinding, but vaccina-

tions recorded in clinic computer

Incomplete outcome data (attrition bias)

All outcomes

High risk In the group in which the family physician

invited the patient to be vaccinated this in-

tervention was delivered to 201/218 (92%)

. In the letter group, 239 letters were sent

and only 2 returned. In the phone group

the nurses were able to contact 177/208

(85%);

Intervention 1: 766/1471 people visited

the practice in the study year; 22.9% of

group vaccinated, but the denominator for

this proportion is not stated (cannot tell if

it was 766 people versus 1471 people ver-

sus 1122 families).

Intervention 2: 1104 of the 1468 families

assigned to telephone reminder required a

reminder for 1 or more interventions, and

119Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

McDowell 1986 (Continued)

684 families were actually contacted; 37%

of group were vaccinated, but denominator

for proportion not stated (cannot tell if it

was 1104 families versus 684 families ver-

sus 1468 people that constituted the 1104

families versus unknown number of people

in the 684 families actually reached).

Intervention 3: 164 of 1442 people sent

letters had letters returned as undeliver-

able; 35.2% were vaccinated, but cannot

tell which denominator was used (1442

versus 978 people).

Control: 9.8% “of study group” were vac-

cinated. Not stated if the denominator is

families or individual people

“8 weeks after the study ended we called

random samples of patients from each

study group who had apparently not been

vaccinated to estimate the extent of under-

reporting.”

Selective reporting (reporting bias) Low risk No selective reporting

Minor 2010

Methods Purpose: increase influenza vaccination uptake by phone versus mail reminders

Design: RCT of attendees at hypertension clinic to phone, mail, or control

Duration of study: mid-November to “the following spring”

Interval between intervention and when outcome was measured: intervention began

after mid-November, follow-up “in the following Spring.”

Power computation: not performed

Statistics: %s; ORs and 95% CIs

Participants Country: USA

Setting: University of Mississippi Hypertension Clinic

Eligible participants: (health status): 257 aged > 65 years

Age: 257 > 65 years

Gender: 62% female for whole sample aged < 50 years to > 65 years

Interventions Intervention 1: letter plus CDC Influenza Vaccine Information Statement

Intervention 2: phone call with same information

Control: standard clinic practice

Co-interventions: none

Outcomes Outcome measured: % influenza vaccination

Time points reported in the study: “Mid November”; “following Spring”

Notes Funding: none stated

120Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Minor 2010 (Continued)

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection

bias)

Unclear risk “... randomly assigned”

Allocation concealment (selection bias) Unclear risk No statement

Blinding (performance bias and detection

bias)

All outcomes

Unclear risk No statement

Incomplete outcome data (attrition bias)

All outcomes

Unclear risk 1712 eligibles had clinic visit in preceding

15 months; 341 had received influenza vac-

cination, 487 not contactable after 5 at-

tempts; sample = 884, of whom 257 aged

> 65 years

Selective reporting (reporting bias) Low risk No selective reporting

Moran 1992

Methods Purpose: to compare 1 and 2 reminder letters offering free influenza vaccine to no

intervention

Design: RCT, participants randomised

Duration of study: mid-October

Interval between intervention and when outcome was measured: not reported

Power computation: “Sample size was sufficient to detect a 20% change in immunization

(40% to 60%) with 80% power at ? = 0.05.”

Statistics: percentages

Participants Country: USA

Setting: urban community health centre (location not stated, but first author was located

in Winston-Salem, NC)

Eligible participants: (health status): “High-risk participants seen at an urban community

health center.” (eligible number not stated)

Age: ≥ 65 years

Gender: 61% female

Interventions Intervention 1: 1 letter offering free influenza vaccine

Intervention 2: 2 letters offering free influenza vaccine

Control: no intervention

Outcomes Outcome measured: % influenza vaccination

Time points from the study considered in the review or measured or reported in the

study: first letter sent mid-October 1990, second letter (to intervention group receiving

2 letters) sent 1 month later.

121Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Moran 1992 (Continued)

Vaccinated by: not stated

Notes Funding: US National Research Service Award, National Institute on Aging

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection

bias)

Unclear risk “A randomised, single-blind, controlled

trial ...”

Allocation concealment (selection bias) Unclear risk No statement

Blinding (performance bias and detection

bias)

All outcomes

Unclear risk “single-blind”, but does not state if it was

participants or researchers blinded; data en-

tered on computer clinical tracking pro-

gram

Incomplete outcome data (attrition bias)

All outcomes

Low risk Participants randomised to intervention

group 1 (n = 135) and intervention group

2 (n = 138) and 136 to control, of whom

66, 68, and 68 were aged ≥ 65 years; vac-

cination status of all participants reported;

immunisation reported in clinic computers

Selective reporting (reporting bias) Low risk No selective reporting

Moran 1995

Methods Purpose: to compare the effect of a mailed educational brochure on influenza vaccination

uptake compared to no intervention

Design: RCT, participants as unit of randomisation

Duration of study: 4 months

Interval between intervention and when outcome was measured: “The educational

brochures were mailed to the intervention group when the influenza vaccine became

available at the beginning of October.” (year not stated)

Power computation: 900 participants required to detect 20% difference if baseline rate

20%, 90% power, α = 0.05.

Statistics: not stated (probabilities computed)

Participants Country: USA

Setting: general internal medicine and gerontology service, Wake Forest University,

North Carolina

Eligible participants: (health status): 1583, then residents of long-term care facilities

excluded, leaving 1251, of whom 900 were randomised to treatment and control groups

Age: ≥ 65 years, average 76 years

Gender: 65.4% female

122Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Moran 1995 (Continued)

Interventions Intervention: mailed brochure encouraging influenza vaccination

Control: no intervention

Outcomes Outcome measured: % vaccinated

Time points from the study considered in the review or measured or reported in the

study: October to following January (year not stated)

% vaccinated by: January following intervention in October

Notes Funding: National Institute on Aging

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection

bias)

Unclear risk “... two random samples of 450 were se-

lected for the intervention and control

groups.”

Allocation concealment (selection bias) Unclear risk No statement

Blinding (performance bias and detection

bias)

All outcomes

Unclear risk No statement, vaccination status entered in

computer clinical tracking program

Incomplete outcome data (attrition bias)

All outcomes

Unclear risk Clinic immunisation and financial logs

showed 80 participants in intervention and

71 in control group received influenza vac-

cination; 666/900 responded to the post-

card survey, and a total of 218 in interven-

tion and 213 in control group said they had

been vaccinated in clinic and elsewhere

Selective reporting (reporting bias) Low risk No selective reporting

Moran 1996

Methods Purpose: “To determine whether an educational brochure or a lottery-type incentive

increases influenza immunization rates.”

Design: RCT, participants randomised

Duration of study: 3 months

Power computation: not reported

Statistics: Chi², Wilcoxon, logistic regression, odds ratios with CI, percentage partici-

pants receiving influenza vaccination in 4 groups

Participants Country: USA

Setting: urban community health centre

Participants: “All high-risk ambulatory patients seen at the community health centre

within the preceding 18 months”

123Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Moran 1996 (Continued)

Age: > 18 to 99 years of age, mean age 66 (n = 797)

Gender: male and female

Interventions Participants were randomly assigned to 1 of 4 groups: control (n = 202), mailed educa-

tional brochure (n = 198), mailed lottery incentive wherein participants who obtained

an influenza vaccination would be eligible to win 1 of 3 grocery gift certificates (n = 198)

, and a mailed combined educational brochure and lottery incentive (n = 199)

Outcomes Odds ratio of participants in the 4 groups obtaining an influenza vaccination. Odds

ratio for participants in the brochure group obtaining influenza immunisation when

compared with the control (OR 2.29, 95% CI 1.45 to 3.61), odds ratio for incentive

group compared with control (OR 1.68, 95% CI 1.05 to 2.68). “Immunization for

the group mailed both interventions was not significantly different from control (OR =

1.41, 95% confidence interval CI 0.88-2.27). For the subset of individuals for whom

prior immunization status was known, the impact of the educational brochure was even

more significant (OR = 4.21, 95% CI 2.48 to 7.14), but the groups mailed incentive or

both interventions were not significantly different.” For those aged 65+ years, the study

reports on the percentage in each group that received vaccination: 25% control, 41%

brochure, 30% incentive, 24% brochure and incentive

Notes National Research Service Award, US National Institute on Aging

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection

bias)

Unclear risk “High-risk patients were randomly allo-

cated to one of four groups.” (no statement

about method of randomisation)

Allocation concealment (selection bias) Unclear risk No statement

Blinding (performance bias and detection

bias)

All outcomes

Unclear risk No statement

Incomplete outcome data (attrition bias)

All outcomes

Low risk “... all high-risk patients (n = 797) seen in

the preceding 18 months” were reported in

the final outcome (Table II)

Selective reporting (reporting bias) Low risk No selective reporting

124Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Morrissey 1995

Methods Purpose: to evaluate the effects of a free package of preventive healthcare services, in-

cluding influenza vaccinations, on the health outcomes of seniors

Design: RCT, participants randomised within practices

Duration: 2 years

Power computation: all eligible participants at the practices were evaluated for study

inclusion

Statistics: Chi², analysis of covariance and regression analysis

Participants Country: USA

Setting: 10 primary care practices in 13 locations in central North Carolina

Participants: 1914 participants (954 intervention, 960 control)

Age: >= 65 years

Gender: 61.1% women

Interventions “The health promotion service package contained a set of procedures and nursing inter-

ventions that address important risk factors and premature mortality, institutionaliza-

tion, and increased disability for older people. Health promotion sessions, in this demon-

stration were conducted in physician offices using an individual counseling strategy that

involved the nurse/physician assistant and patient in mutual planning ...” Practices were

sent monthly reminders by research team to schedule intervention participants for pre-

ventive care and health promotion care services. Nurses were provided with training

in administering the services. The control group received the usual preventive services

offered by their practice at the usual costs

Outcomes Medical chart audits were performed on 3 heterogeneous practices (231 intervention

participants and 224 controls) to determine whether or not there was an increase in

the number of preventive care procedures performed in the intervention group. The

percentage of participants who received the Fluvax vaccine during the 1st year of the

study increased in the intervention group as compared to the control after randomisation

(72% versus 52%, P < 0.001)

Notes US Health Care Financing Administration

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection

bias)

Unclear risk “... randomised by strata into intervention

or control” (no statement about method)

Allocation concealment (selection bias) Unclear risk No statement

Blinding (performance bias and detection

bias)

All outcomes

Low risk “Although contamination of the control

group is sometimes a concern with such

a design, it was not an issue here for

two reasons: first, the financial intervention

involved full Medicare reimbursement to

physicians for preventive-care and health

promotion packages only for those patients

125Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Morrissey 1995 (Continued)

randomised to the intervention group; and

second, the office system intervention was

in effect only for patients receiving the in-

tervention group. The control group was

not identified to the practice, there was no

prompting, no form, and no special preven-

tive visit for the control-group patients”;

“Patients were informed of their random

assignment only after they came into the

practice for the interview”

Incomplete outcome data (attrition bias)

All outcomes

Unclear risk Of the 1914 participants recruited: “... it

was not feasible to conduct chart reviews

in every practice, so we chose three diverse

groups: a three-physician family practice ..

. a ten-physician community health center,

a six physician suburban internal medicine

practice ...”; “Of 458 patients eligible for

chart audit, charts were located and re-

viewed for 455 (231 intervention, 224 con-

trol)”

Selective reporting (reporting bias) Low risk No selective reporting

Mullooly 1987

Methods Purpose: to compare personalised letter with no intervention

Design: RCT, individuals randomised

Duration of study: interval between intervention and when outcome was measured:

“Kaiser Permanente ... operates seasonal influenza clinics.”

Power computation: not performed

Statistics: percentages

Participants Country: USA

Setting: Kaiser Permanente Northeast Region HMO in Portland, Oregon/Vancouver

and Washington metropolitan area

Eligible participants: (health status): ≥ 65 years, discharged alive from hospital October

1983 to September 1984 with diagnoses of cardiovascular, pulmonary, renal, metabolic/

nutritional, neurologic, or malignant diseases

Age: ≥ 65 years

Gender: intervention 48.1% female; control 52.7% female

Interventions Intervention 1: personalised recommendation to obtain influenza vaccination, and in-

formation about where and when to obtain vaccination

Control: no intervention

Outcomes Outcome measured: % influenza vaccination

Time points from the study considered in the review or measured or reported in the

study: not stated: “Kaiser Permanente ... operates seasonal influenza clinics.”

126Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Mullooly 1987 (Continued)

% vaccinated by: not stated

Notes Funding: not stated; we e-mailed the author for influenza vaccination uptake in the year

before the intervention but received no reply

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection

bias)

Low risk “The study group population was ran-

domised into intervention and control

groups based on a pseudo random digit of

the individual membership ID number.”

Allocation concealment (selection bias) Unclear risk No statement

Blinding (performance bias and detection

bias)

All outcomes

Unclear risk No statement: “Medical records were retro-

spectively reviewed at the end of the study

period to ascertain whether subjects had re-

ceived influenza vaccine”

Incomplete outcome data (attrition bias)

All outcomes

Unclear risk “Medical records were retrospectively re-

viewed at the end of the study period to

ascertain whether subjects had received in-

fluenza vaccine ...”

Selective reporting (reporting bias) Low risk No selective reporting

Nexøe 1997

Methods Purpose: to compare offer of free influenza vaccination to postal reminder with fee for

vaccination paid by the participants

Design: RCT

Duration of study: 25 September to 15 December 1995

Interval between intervention and when outcome was measured: not clear

Power computation: no information provided

Statistics: Chi² statistic for proportions, 2-way analysis of variance at alpha = 0.05.

No adjustments were made for within-practice clustering or for prior-year influenza

vaccination status

Participants Country: Denmark

Setting: 13 solo general practices in the counties of Funene and Vejle, 25 September to

15 December 1995. Eligible practices had not sent mailed reminders to participants in

previous years and were required to have at least 45 elderly participants aged 65 years or

older with a medical indication for influenza vaccination.

Eligible participants (health status): 585 people. These included 45 participants from

the practice of each GP who were aged over 65 years and with a medical indication for

influenza vaccination (treated for chronic pulmonary or cardiovascular disorder; acquired

127Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Nexøe 1997 (Continued)

or congenital immunodeficiency, other chronic disease such that the doctor perceived

the person to be at increased risk for influenza-related complications or nursing home

resident).

Age: all aged over 65 years, no age distribution provided

Sex: no data presented

Interventions Intervention 1: free influenza vaccination (15 from each practice, i.e. 1/3 of participants

from each practice)

Intervention 2: invitation for influenza vaccination but requirement to pay the usual GP

fee (USD 40 to 60) (15 from each practice, i.e. 1/3 of participants from each practice)

Control: no invitation, vaccinated only at their own request (15 from each practice, i.e.

1/3 of participants from each practice)

Outcomes Outcome measured: % vaccinated within each group as “registered”

Time points from the study considered in the review or measured or reported in the

study: registration occurred from 25 September to 15 December 1995.

% vaccinated by 15 December 1995

Notes Participants were randomised within each practice.

Explicit definition of “registered” not provided; the context of the phrase suggests that

this was by chart audit or records review.

In the control group 83% of the participants had been vaccinated in the previous year.

Overall, 25% of all participants had been vaccinated in the prior year (only aggregated

data across all practices provided). Authors do not provide practice-specific denomina-

tors, only practice-specific numerators for outcomes.

Funding: Danish Research Foundation for General Practice

Fees for vaccination and vaccine were paid for by the State Serum Institute

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection

bias)

Unclear risk No information provided.

Allocation concealment (selection bias) Unclear risk Insufficient information provided.

Blinding (performance bias and detection

bias)

All outcomes

Unclear risk Randomisation was blinded for the GPs.

However, GPs were paid the equivalent of

USD 36 for each patient vaccinated with-

out patient fee

Incomplete outcome data (attrition bias)

All outcomes

Unclear risk Attrition of participants: no explicit state-

ment as to follow-up

Incomplete data points for participants

No analysis if differential attrition could

affect outcomes

Given that data were obtained from the GP

records, they would appear to be complete,

128Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Nexøe 1997 (Continued)

although there is no explicit statement of

records audit being done. Completeness of

ascertainment would be best for the free-

vaccination group, as it is stated that “the

GP’s were paid for each patient vaccinated

without patient fee.”

Selective reporting (reporting bias) Low risk No selective reporting

Nuttall 2003

Methods Purpose: test hypothesis that an invitation letter to attend GP for influenza immunisation

plus home visit to discuss influenza vaccination is more likely to increase influenza vaccine

uptake than an invitation letter to attend GP for immunisation alone, or invitation letter

plus pamphlet promoting influenza immunisation

Design: RCT: eligible participants were stratified by age (< 72 years, 72 years or older to

ensure equal numbers of each age group within each intervention group). Participants

within each age group were randomly allocated into 3 groups. A total of 30 people were

allocated to each intervention.

Interval between intervention and when outcome was measured: not explicitly stated

except for the statements: “the intervention was to be completed the start of the influenza

immunisation programme at the GP surgery,” and that health records were audited

“following completion of the influenza immunization program.”

Power computation: not done

Statistics: simple comparison of proportions immunised across groups (ITT)

Participants Country: UK

Setting: a single GP practice in East Lancashire

Eligible participants (health status): 90 participants aged 65 to 90 years registered to the

practice who had failed to attend for the influenza immunisation in the prior year (i.e.

2000 to 2001 campaign (N = 393) who agreed to participate, were not confused, did

not have egg allergy (i.e. 90 participants))

Age: 50% were aged 65 to 72 years, 50% were aged over 72 years.

Gender: no information provided

Interventions Intervention 1: invitation letter to attend GP for influenza immunisation plus leaflet

promoting influenza vaccination

Intervention 2: letter plus home visit

Control: letter alone

Outcomes Outcome measured: % vaccinated based upon audit of health records

Time points from the study considered in the review or measured or reported in the

study: research project started following ethical approval (received 2 August 2001) and

was completed by June 2002.

% vaccinated by: not explicitly stated

Notes No source of funding mentioned.

Author comments that a smaller proportion of those immunised at outcome had re-

129Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Nuttall 2003 (Continued)

ceived a prior vaccination, but a larger proportion of those immunised at outcome had

a qualifying health condition at baseline.

90 participants were eligible and consented of 393 who had failed to attend for the

influenza immunisation in the prior year

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection

bias)

Unclear risk The 90 respondents were divided in half by

age (< 72 years, 72 years or older). The par-

ticipants in each age group were allocated

into the 3 intervention groups, using the

stratified randomisation technique

Allocation concealment (selection bias) Unclear risk No information provided.

Blinding (performance bias and detection

bias)

All outcomes

Unclear risk No information provided.

Incomplete outcome data (attrition bias)

All outcomes

Low risk Attrition of participants? Implied to be

none, not explicitly stated

Incomplete data points for participants?

Analysis if differential attrition could affect

outcomes? No information provided.

Vaccination data assessed by chart review

(RCT was of a single practice)

Selective reporting (reporting bias) Low risk No selective reporting

Puech 1998

Methods Purpose: to determine if a single postcard reminder for people aged 65 years or older

would improve influenza vaccination uptake in a 3-partner general practice

Design: RCT

Duration of study: 1 April to 31 July 1996

Interval between intervention and when outcome was measured: postcard mailed on 1

April 1996. Outcomes ascertained “end of July 1996”, 4 months later.

Power computation: study power to detect a difference of 20% in immunisation rates at

0.05 (2-sided): 61% for males, 81% for females

Statistics: randomisation was done within sex strata, analysis controlled (logistic regres-

sion) for 1995 immunisation status and study factor but did not control for proximity

to practice. Separate regressions done for males and females

130Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Puech 1998 (Continued)

Participants Country: Australia

Site: Leichhardt General Practice (a 3-partner practice) in suburban Sydney, Australia

Eligible participants: 325 people aged 65 years or older identified from a computerised

age-sex-disease registry maintained by the general practice who had made at least 3 visits

to the practice, 1 of which had to have occurred in the 2 years prior to study

Age:

65 to 69 years: 86/325 (26.5%)

70 to 74 years: 78/325 (24.0%)

75 to 79 years: 58/325 (17.8%)

80 to 84 years: 62/325 (19.1%)

85 years or older: 41/325 (12.6%)

Gender: 38.5% male, 61.5% female

Exclusions:

1. Nursing home residents were excluded as not on the computerised register

2. Flu vaccination received prior to 1 April 1996

3. Participants who had left practice, gone to a nursing home, or died since most recent

update of the practice register

4. Those known to be allergic to egg protein

5. Known by practice to object to flu vaccination, or having severe or terminal illness,

dementia, or unstable psychiatric conditions

Interventions Intervention: postcard mailed 1 April 1996 reminding participants to attend the practice

for an influenza vaccination before the end of the month and providing information on

disease and vaccine, vaccine availability, and vaccine cost

Control: usual care: “ad hoc approach” co-interventions: “influenced by news coverage

of outbreaks, media campaigns by vaccine manufacturers, opportunistic reminders and

secular events”

Outcomes Outcome measured: % vaccinated in 1996 (end of July) as validated by chart review

Time points from the study considered in the review or measured or reported in the

study: postcards mailed to intervention group on 1 April 1996. Practice records reviewed

for documentation of receiving vaccination at the end of July 1996

Notes Chart review of practice: assessor blind to participant group allocation; required docu-

mentation in chart that vaccination, not just prescription for vaccine actually provided.

However, no information provided as to whether or not chart review would have cap-

tured any vaccinations obtained from outside of the practice.

Funding: no information provided.

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection

bias)

Low risk Participants stratified by sex, then com-

puter-generated random numbers; how-

ever, for married couples once identified as

married, both randomly allocated to same

intervention

131Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Puech 1998 (Continued)

Allocation concealment (selection bias) Unclear risk Insufficient information

Blinding (performance bias and detection

bias)

All outcomes

Low risk General practitioners were blind to allo-

cation, but no information provided on

methods of blinding. Person who assessed

outcome was blind to the participant group

allocation

Incomplete outcome data (attrition bias)

All outcomes

Unclear risk Outcomes were ascertained from patient

chart, and participants were considered im-

munised if either immunisation was doc-

umented in patient record OR a prescrip-

tion given for flu vaccine but no record of

the actual vaccination in the notes. No in-

formation provided on loss to follow-up,

thus it is possible that participants recorded

as not vaccinated might in theory have re-

ceived vaccination from another practice

Selective reporting (reporting bias) Low risk No selective reporting

Roca 2012

Methods Purpose: to assess the effects of a mail-out education campaign on influenza vaccination

uptake among seniors

Design: RCT

Duration: 1 week in September 2009

Power computation: “On the basis of the percentage of participants vaccinated in 2008

and results of previous studies, we calculated that a sample size of 1187 participants in

each group was needed to find a vaccination rate difference of at least 5% between the

EPG and the NPG (42.5% and 37.5% respectively) with a level of significance of P = .

05 and a power of 80%”

Statistics: t-tests, Mann-Whitney U, Wilcoxon, Kruskal-Wallis, regression analysis

Participants Country: Spain

Setting: a health centre in Castellon, Spain

Participants: 2402 participants in family practices of 13 physicians

Age: >= 60 years old

Gender: 55.7% female

Interventions A personalised letter was sent to participants in the intervention group providing them

with information about influenza and answers to common questions/concerns with

respect to the influenza vaccine. The control group did not receive any letter

Outcomes Although there was an increase in vaccination uptake for both groups as compared with

the previous year, there was a greater increase in the intervention group as compared

with the control (9.4% versus 1.6% increase, P < 0.01)

132Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Roca 2012 (Continued)

Notes Spanish VACH Cohort and the ISCIII-RETIC (RD06/006)

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection

bias)

Low risk “We used a computer random number gen-

erator and a 1:1 ratio to randomly assign

participants to 1 of 2 groups”

Allocation concealment (selection bias) Unclear risk No statement

Blinding (performance bias and detection

bias)

All outcomes

Low risk “The study was open for participants but

blinded for the healthcare workers respon-

sible for caring for the patients.”

Incomplete outcome data (attrition bias)

All outcomes

Low risk All 2402 participants recruited were fol-

lowed through the 2009 vaccination season

Selective reporting (reporting bias) Low risk No selective reporting

Satterthwaite 1997

Methods Purpose: to compare effect of personalised invitation recommending a visit to doctor to

receive a flu vaccination where patient was required to pay for vaccination, to personalised

invitation recommending a visit to doctor to receive a flu vaccination at no charge, to

no intervention on influenza immunisation uptake

Design: RCT

Duration of study: not stated

Interval between intervention and when outcome was measured: not stated

Power computation: not stated

Statistics: Chi² statistic of significance adjusted for design effect of within-practice clus-

tering. Design effect for contrast of intervention 1 versus control was 1.09. Design effect

of contrast for intervention 2 versus control was 4.05

Participants Country: New Zealand

Setting: 31 active general practitioners in the Auckland region randomly selected from

the cervical screening program were invited to participate. Eligible practitioners were

able to generate a list of names and addresses of all patients over 65 years of age; normally

provided influenza vaccine to patients; worked at least 8/10 full-time equivalent; and did

not currently have in place a postal reminder system for influenza vaccination for patients

over 65 years. 8 doctors were not eligible; 7 were eligible but did not wish to participate;

and 16 were eligible and participated. Within each practice, up to 210 patients were

randomly allocated to interventions.

Eligible participants: (health status) 2791 people aged over 65 years

Age: within each practice, participants aged over 65 years. Age distribution of participants

not stated.

133Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Satterthwaite 1997 (Continued)

Gender: sex distribution of participants not stated.

No information provided on exclusion of participants.

Interventions Intervention 1 (N = 931): personalised invitation sent to people (mail) recommending

that they visit their general practitioner to receive a flu vaccination. Those who accepted

the invitation would have had to pay about NZD 20 for vaccination.

Intervention 2 (N = 930): personalised invitation sent to people recommending that

they visit their general practitioner to receive a flu vaccination at no charge

Control (N = 930): no intervention. These people would have had to pay about NZD

20 for vaccination

Outcomes Outcome measured: % participants vaccinated after intervention as recorded by practice

staff, validated by authors only for participants who received intervention 2

Time points from the study considered in the review or measured or reported in the

study: no information provided

Notes No information provided on year study was done. Internal evidence in the article suggests

prior to February 1997. Authors note that in 1997 flu season, government policy will

change to make influenza vaccination free for people over 65 years of age.

No information provided on vaccination status in the prior year.

Data are not presented by practice.

Funding: vaccine provided at no cost by Rhone Poulenc and distributed to practitioners

by Ebos Group

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection

bias)

Unclear risk “The patients were randomly allocated”

(no method stated)

Allocation concealment (selection bias) Unclear risk No information provided.

Blinding (performance bias and detection

bias)

All outcomes

Unclear risk No information provided.

Incomplete outcome data (attrition bias)

All outcomes

Unclear risk 931 in group 1 (invitation letter), 930 in

group 2 (free vaccine letter), and 930 in

group 3 (control); no data on attrition

Selective reporting (reporting bias) Low risk No selective reporting

134Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Siriwardena 2002

Methods Purpose: to compare the effect of an educational outreach visit to primary healthcare

teams to written feedback on influenza and pneumococcal vaccination uptake

Design: stratified cluster-RCT

Duration of study: 8 months

Interval between intervention and when outcome was measured: 6 months

Power computation: based on vaccination rate per practice as primary outcome. Sample

size was based upon attainment of an increase in vaccination uptake of 20%. To detect

a difference between control rates and the desired targets of at least 1 SD, the Student’s

t-test with power 0.8 and size 0.05 would require 17 practices per group or 9 per group

to detect an effect of 1.5 SDs with same power.

Statistics: Poisson regression using population at risk as an offset and taking account

of the stratification. Rates were expressed as mean vaccination rates, odds ratios and

confidence intervals

Participants Country: UK

Setting: 20 primary care practices in the West Lincolnshire Primary Care Trust and the

10 from the Trent Focus Collaborative Research Network

Eligible participants: (health status) 30 practices had patients aged 65 years or older or

who had coronary heart disease, diabetes, or splenectomy on their registers. A total of

27,580 participants aged 65 years or older were included in the 30 practices.

Age: no information provided on age distribution of participants in practices.

Gender: no information provided on sex distribution of participants in practices

Interventions Intervention: 1-hour educational outreach visit (based on principles of academic detail-

ing) to practice teams delivered by 1 member of the research team that included feedback

of practice vaccination uptake in relation to other practices in the study and national

targets

Control: written feedback on vaccination uptake of practice compared with other par-

ticipating practices

Outcomes Outcome measured: mean vaccination uptake (adjusted for initial level and stratification)

based upon practice records, for:

• participants aged 65 years or older;

• participants with coronary heart disease;

• participants with diabetes;

• participants with splenectomy.

Time points from the study considered in the review or measured or reported in the

study: baseline data collection began in August 2000. Interventions delivered at the start

of the annual influenza vaccination campaign of October 2000. Outcomes ascertained

6 months after the educational outreach visit, i.e. 8 months after baseline data collection

Notes Baseline data collection was in August 2000 and was done by practice staff.

The unit of cluster was the practice. However, due to ceiling effects (capacity to increase

immunisation uptake depends on baseline, possibly easier to increase from low baseline)

, practices were stratified on baseline uptake of influenza vaccination for diabetics, as

this was previously shown to be correlated with risk group. Within strata, practices were

randomly allocated to intervention or control.

20/39 practices in the West Lincolnshire Primary Trust participated as did 10/50 from

the Trent Focus Collaborative Research Network.

Participating and non-participating practices were similar in number of partners, list

135Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Siriwardena 2002 (Continued)

size, whether or not they were dispensing practices, and rurally.

Funding: Trent Focus and West Lincolnshire Primary Care Trust

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection

bias)

Unclear risk “Fifteen practices were randomised to in-

tervention and 15 to the control group af-

ter stratifying for baseline vaccination rate.

”

Allocation concealment (selection bias) Unclear risk No information provided.

Blinding (performance bias and detection

bias)

All outcomes

Unclear risk Not possible with this design

Incomplete outcome data (attrition bias)

All outcomes

Unclear risk 13,633 in intervention group and 13,947

in control group, but no data on attri-

tion; vaccination status assessed from clinic

records

Selective reporting (reporting bias) Low risk No selective reporting

Smith 1999

Methods Purpose: to determine the effectiveness of mailed reminders on influenza vaccination

uptake

Design: RCT

Duration of study: 3 months

Interval between intervention and when outcome was measured: first measurement was

made on 9 February 1996 (minimum 8+ weeks after intervention).

Power computation: not discussed

Statistics: logistic regression analysis adjusting for age, gender, residency in medium- or

low- compared to high-population density counties. In sensitivity analysis, the logistic

regression had data from both immunisation data and survey results with chronic disease

variables

Participants Country: USA

Setting: 10 counties in Indiana

Eligible participants: 9011 people (4508 intervention group, 4503 control group) reg-

istered in the Medicare eligibility file who were age 65 years or older, had no evidence of

having died, had an allowable charge in the prior year, who were not residents of nursing

homes and were not members of an HMO who lived in 1 of 10 eligible counties were

randomly selected for the study in 1995.

Intervention group: 4508 eligible participants

Control group: 4503 eligible participants

Age: 65 years or older; mean age of control group was 75.4 years, for intervention group

136Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Smith 1999 (Continued)

75.5 years

Gender: 61.9% female (control group), 61.2% female (intervention group)

Exclusions: those who were found to reside in a nursing home, who had an invalid

address, who were dead, or who refused to participate (intervention group: 497; control

group: 492)

Interventions Intervention: a reminder letter adapted from the Health Belief Model that advised that

costs were covered by Medicare, provided a state board of health phone number for

those without access to physicians plus information about influenza vaccination. Letter

was signed by the principal investigator, the state health commissioner, and the medical

director of Medicare for Indiana.

Control: no letters were sent.

Outcomes Outcome measured: N, % vaccinated against influenza (self report by postal survey or by

having a claim filed for immunisation between 1 October 1995 and 31 January 1996).

Self reported immunisation was validated by survey (99.6% agreement between survey

and Medicare claims for influenza vaccination).

Time points from the study considered in the review or measured or reported in the

study: letter was sent on 3 November 1995 and a reminder (same letter) sent again on

22 December 1995

Notes The eligible counties were selected by multistage random sampling from the 56 Indiana

counties that did not abut state borders: the county with highest population density

of elders, 4 counties randomly selected with a medium density of elders (19.6/square

miles), and 5 counties with low population density of elders (random number generator)

. The reason for exclusion of border counties was that residents of those counties were

perceived to be more likely to use out-of-state health services, which would reduce ability

to track outcomes.

Intensive follow-up was done to ascertain outcomes: non-responders to the 9 February

1996 postal survey were sent a second survey 16 April 1996 and 14 July 1996. A sample

of those who did not respond after the 14 July mail-out and who did not submit a claim

for influenza immunisation or were not identified in mortality files were telephoned to

determine immunisation status. Interviewers were blind to intervention assignment.

Funding: no information provided.

No data on vaccination prior to 1995 were collected or reported

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection

bias)

Unclear risk Random selection was by a random num-

ber generator; ? “... and then randomised

within county to control and intervention

groups.” No explicit statement that ran-

dom allocation used a random number

generator

Allocation concealment (selection bias) Unclear risk No information provided.

137Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Smith 1999 (Continued)

Blinding (performance bias and detection

bias)

All outcomes

Low risk In follow-ups, telephone interviewers were

blinded to intervention; no information

provided as to blinding for postal surveys

or Medicare claims. However, it is unlikely

that contamination could have occurred

Incomplete outcome data (attrition bias)

All outcomes

Unclear risk 10,000 Medicare beneficiaries randomly

selected; 5000 randomised to intervention

and 5000 to control; 4503 eligibles in con-

trol, 4508 eligibles in intervention group;

3487 in control group responded to sur-

vey or filed claim, and 3454 in intervention

group responded to survey or filed claim

(no differential attrition analysis)

Selective reporting (reporting bias) Low risk No selective reporting

Spaulding 1991

Methods Purpose: to compare the effect of a postcard reminder sent to high-risk participants to

usual care (no postcard) on influenza immunisation uptake

Design: RCT

Duration of study: 6 months

Time: 1983/1984 influenza season

Outcome measured: % vaccinated against influenza for the 1983 to 1984 season by sex,

rank of military sponsor, and age group (including those aged > 64 years)

Interval between intervention and when outcome was measured: 6 months were allowed

for people to be vaccinated, and it is clear that the intervention antedated the measure-

ment of outcome.

Power computation: no information provided

Statistics: Chi² statistic to compare proportions vaccinated in each group. Multivariate

analysis using Mantel-Haenszel Chi² statistic and Mantel-Haenszel adjusted risk ratio.

Within-family clustering was not addressed

Participants Country: USA

Setting: Department of Family Practice at Madigan Army Medical Center, Ft Lewis,

Washington

Eligible participants: 1068 military retirees or the family members of active or retired

members of the military who had 1 or more high-risk diagnoses for influenza complica-

tions according to the US Immunization Practices Advisory Committee criteria of 1983

Age: people of all ages

0 to 20 years: 153 (71 intervention; 82 control)

21 to 40 years: 130 (63 intervention; 70 control)

41 to 64 years: 289 (269 intervention; 289 control)

65 years or older: 224 (116 intervention; 108 control)

Sex: males 56.3%, females 43.7%

Males: 573 (519 intervention; 549 control)

Females: 496 (257 intervention group; 238 control)

138Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Spaulding 1991 (Continued)

Exclusions: people who did not have a high-risk health condition

Interventions Intervention: 519 participants in intervention group were mailed a reminder postcard

advising them that their physician had determined that they were at high risk of com-

plications should they catch the flu and strongly urging them to come to the Family

Practice Clinic for intervention. Postcard sent 2 weeks before availability of the influenza

vaccine used during the 1983/84 season.

Control: 549 participants who received routine care, were not sent a postcard

Outcomes Outcome measured: % receiving influenza vaccine based on office records of being

vaccinated

Time points from the study considered in the review or measured or reported in the

study: from time postcard sent 2 weeks before vaccine availability to 6 months after

vaccine became available

Intervention: postcard sent 2 weeks before availability of the influenza vaccine used

during the 1983/84 season.

% vaccinated by 6 months after the influenza vaccine used in the 1983/1984 season

became available

Notes Potential participants were assigned a code number that included 2 digits to identify if

they were members of the same family. These data were not used in analysis (i.e. within-

family clustering was not addressed in the data analysis).

There was no cost to patient for influenza immunisation.

No data are provided on influenza vaccination prior year.

Funding: no information provided.

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection

bias)

Low risk Individuals were assigned to intervention

or control group by a table of random num-

bers

Allocation concealment (selection bias) Unclear risk No information provided.

Blinding (performance bias and detection

bias)

All outcomes

High risk Physicians in the Department of Family

Practice were aware that a study was in

progress and that some of their patients

might receive postcards about influenza im-

munisation. Vaccine was offered to all el-

igible participants on a walk-in basis. Par-

ticipants who presented for immunisation

read and signed an informed consent doc-

ument.

It is not stated if the physicians were those

who performed the vaccinations. However,

participants might have told their vaccina-

tor whether or not they had received a post-

139Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Spaulding 1991 (Continued)

card

Incomplete outcome data (attrition bias)

All outcomes

Unclear risk No information provided on attrition or in-

complete data points. No analysis whether

differential attrition could affect results;

vaccination status assessed from records at

US Army Medical Center

Selective reporting (reporting bias) Low risk No selective reporting

Stuck 2015

Methods Purpose: to compare the effect of a health risk assessment compared to usual care to

improve (1) primary outcomes: unfavourable health behaviours, health and social im-

pairments and risk factors (including influenza vaccination) at 2-year follow-up, and (2)

secondary outcome: all-cause mortality at 8 year follow-up.

Design: RCT

Duration of study: 2 and 8 year follow-ups

Time: November 2000 to January 2002

Outcome measured relevant to this review: % vaccinated against influenza in 2001

Interval between intervention and when outcome was measured: only defined as “in-

fluenza vaccination in past 1 year”

Power computation: to demonstrate a 1.3 fold increase in positive health behaviours or

preventive care use with 80% power and a significance level of 0.05, assuming a dropout

rate of 20%, 1000 participants in each group were required. For a 1:2 randomisation

(intervention to control) 732 individuals were required in the intervention and 1464 in

the control group

Statistics: Intention to treat analysis, imputation methods for handling missing data,

generalised estimating equations with an underlying equicorrelation structure

Participants Individuals ≥ 65 in 19 primary care practices in Solothurn, Switzerland

Interventions European PRO-AGE Health Risk Assessment (11 preventive care recommendations)

November 2000 to January 2002; nurses and counsellors used a manual, and nurses

visited participants at home at baseline and every 6 months and contacted them by phone

at 3 months; control group received usual care from primary care practitioner

Outcomes At 2 years’ assessment of 6 outcomes: measurement of blood pressure, cholesterol, glucose,

faecal occult blood, influenza (65.8% intervention, 59.2% usual care) and pneumococcal

vaccination; at 8 years all-cause and cause-specific mortality

Notes Exclusions: needing assistance with basic activities of daily living, Mini Mental State score

≤ 24, terminal disease, or inability to speak German; power computation assessed needed

1000 in each group to demonstrate 1.3 fold increase in positive health behaviour or

preventive care use with alpha 0.05 and power = 80%, assuming control group prevalence

= 20% and dropouts = 20%; due to resource constraints randomisation changed to 1:2

ratio, and needed 732 in intervention and 1464 in control; ITT analysis

No funding; data provided by Swiss Federal Statistical Office

140Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Stuck 2015 (Continued)

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection

bias)

Low risk Computer-generated random number gen-

erator

Allocation concealment (selection bias) Unclear risk No statement

Blinding (performance bias and detection

bias)

All outcomes

Low risk Data extractors abstracted data from pri-

mary care practice records and were blinded

Incomplete outcome data (attrition bias)

All outcomes

Low risk In intervention group, 779 of 874 ran-

domised participants had 2-year outcome

data and 874/874 8-year outcome data; in

control group these numbers were 1238/

1410 and 1410/1410, respectively. Inten-

tion-to-treat analysis with multiple impu-

tation for missing values

Selective reporting (reporting bias) Low risk No selective reporting

ANOVA: analysis of variance

CDC: Centers for Disease Control and Prevention

CI: confidence interval

COPD: chronic obstructive pulmonary disease

GI: gastrointestinal

GLE ANOVA: general linear model repeated-measures analysis of variance

GP: general practitioner

HCFA: Health Care Financing Administration

HMO: health maintenance organisation

ICC: intraclass correlation

ICD-9-CM: International Classification of Diseases 9th Revision Clinical Modification

IHD: ischaemic heart disease

ITT: intention-to-treat

ns: non-significant

OR: odds ratio

RCT: randomised controlled trial

RR: risk ratio

SD: standard deviation

141Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Characteristics of excluded studies [ordered by study ID]

Study Reason for exclusion

Ahmed 2004 RCT; intervention to increase influenza vaccination rates, but cannot separate outcomes for 60 to 64

years from 18 to 64 years. E-mail from Dr Faruque Ahmed on 3 April 2013: “We generated a random

number for each employer using the RANUNI function in SAS. We randomised to the study arms

based on the random number using defined cut-offs. I am not sure whether we still have the data.”

Alemi 1996 Not RCT; children

Alexy 1998 Not RCT; intervention to increase influenza vaccination rate and influenza vaccination rate outcomes;

prospective cohort without control group (and those who participated through either the mobile health

unit or a home visit received the same level of intervention, thus no comparison could be made for

different levels of intervention)

Allsup 2004 RCT; however, focus was invitation from practices to participate in an RCT. Once invitees agreed to

participate they were randomised to receive either influenza vaccination or placebo, but there was no

control group that did not receive an invitation to participate. The primary focus of analysis was the

occurrence of GP-assessed pneumonia or ILI

Anderson 1979 Not RCT, survey of subsample asked about swine flu

Armstrong 1999 Not RCT; 8596 community-dwelling residents who received care at University of Pennsylvania primary

care site; reminder postcard to receive influenza vaccination mailed to random sample of 5000; brochure

mailed to 390 of remaining 3596; no baseline data; excluded as cannot assess secular trend in rest of

population

Arthur 2001 Not RCT; offer of health assessment, but no control group

Bakare 2007 Not RCT; retrospective survey of physician- and nurse-initiated influenza vaccination in acute care

hospital

Balagué 1993 Not RCT; survey of vaccination rates

Baldo 1999 RCT; no intervention to increase vaccination rates

Bardenheier 2005 Not RCT

Bardenheier 2010 Not RCT; survey of vaccination policies and influenza vaccination rates

Bardenheier 2011 Not RCT, survey of vaccination policies and influenza vaccination rates

Barker 1999 Not RCT; cohort comparing Monroe Country and Onondaga County, NY; no data on comparability

of cohorts; Bennett 1994 and Kouides 1993 also describe this non-RCT

Barton 1990 Not RCT; an intervention to increase influenza vaccination rates was used. For HMO in Boston 1983-4

= baseline rates as historical control; 1984 postcard reminders for high-risk individuals aged < 65 years;

1985 chart reminders for those aged > 65 years plus feedback to service chiefs; 1986 chart reminders plus

142Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

(Continued)

feedback to service chiefs plus feedback to physicians plus lists of unimmunised participants; excluded

as historical controls; excluded as cannot assess secular trend in rest of population

Beardsworth 2004 Not RCT; coalition helped family physicians purchase influenza vaccine, educational pamphlets and

provided a hotline

Becker 1989 Not RCT, 40 to 60 years of age; preventive care reminders

Bekker 2003 Not RCT, survey of attitudes of those aged ≥ 65 years to influenza vaccination

Belcher 1990 RCT; interventions to increase influenza rates: comparing education and feedback to physicians, patient

education, and a health promotion clinic; no baseline influenza vaccination rates; data for those aged

≥ 60 years not available separately. We e-mailed the author for data for those aged ≥ 60 years, but

received no response

Bennett 1994 Not RCT, intervention to increase influenza vaccination rates: community-wide demonstration project

in Monroe County, New York, to enrol all Medicare B enrollees those aged ≥ 65 years to increase

influenza vaccination rates

Berg 2004 RCT; intervention to increase influenza vaccination rates: informational sheet; publication does not

state baseline data or data for those aged < 60 years and aged ≥ 60 years separately. We e-mailed the

trial authors for data but received no reply

Berg 2005 Not RCT, matched participants randomly assigned from geographic regions; 78% of participants aged

< 65 years

Birchmeier 2002 Not RCT, residents offered influenza vaccination to participants in clinic

Bloom 1988 Not RCT, participants aged ≥ 65 years; intervention to increase influenza vaccination rates

Bloom 1999 Not RCT; for those participants aged ≥ 65 years, a fax was sent to family physician requesting they

administer influenza and pneumococcal vaccines

Bond 2011 RCT; cannot identify outcomes for those aged ≥ 65 years

Bou-Mias 2006 Not RCT; individuals aged 60 to 64 years in urban health centre in Spain; non-random allocation to

receive phone call about influenza vaccination or no call; no baseline rates for year before intervention

Bovier 2001 Not RCT; survey of attitudes of those aged ≥ 65 years to influenza vaccination

Brady 1988 RCT; cannot separate results for those aged < 60 years and those aged ≥ 60 years

Breen 2003 Not RCT; pneumococcal vaccination campaign

Brimberry 1988 RCT; article states no baseline influenza vaccination rates available; vaccination rates not separately

available for those aged ≥ 60 years

Browngoehl 1997 Not RCT, children

143Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

(Continued)

Buchner 1987 RCT; intervention to increase influenza vaccination; participants aged ≥ 65 years, but self report of

influenza vaccination by questionnaire

Burns 2005 Not RCT, survey of attitudes to vaccination

Call 2005 Not RCT, no intervention to increase influenza vaccination; article describes the clinical diagnosis of

ILI

Cardozo 1998 Not RCT, article is a retrospective chart review

Carey 1991 Not RCT; audit of 13 preventive manoeuvres including influenza vaccination

Carman 2000 RCT, but no intervention to increase vaccination in elderly (1 group of long-term care hospitals had

an “opt in” policy for influenza vaccination and another group an “opt out” policy); focus was on

vaccinating healthcare workers

Carter 1986 RCT; design of brochure to promote influenza vaccination; unable to contact author for more baseline

and outcome numbers and percentages for those aged ≥ 60 years; self report of influenza vaccination

CDC 2003 Not RCT, article is a note about policy change by Centers for Medicare and Medicaid to remove

requirement for physician signature on orders for influenza vaccination

Chami 2012 RCT in nursing homes to use hygienic measures to reduce infections; no influenza vaccine intervention

Chan 1999 Not RCT, no intervention to increase vaccination rates. Article is a survey of influenza vaccination rates

of female Medicare beneficiaries

Charles 1994 Not RCT; participants at Sunnybrook Health Science Centre Family Practice Unit, Toronto; 4 physician

teams divided into 2 groups and “patients of two of the four teams were designated as subjects and

patients of the remaining two were designated as controls,” then “simple random selection of patients

from the roster of each team physician to participate in the study.” (Participants aged ≥ 65 years.)

Chen 2007 Not RCT, no intervention to increase vaccination rates. Article is a telephone survey of attitudes to

influenza vaccination

Cheney 1987 RCT; intervention to increase influenza vaccination rates: internal medicine residents were randomised

to receive preventive care checklists; no baseline pre-intervention influenza vaccination rates; no num-

bers for outcomes, only graphical presentation on small graphs, so cannot assess numbers. We e-mailed

the authors for numbers for outcomes but did not receive a reply

Chi 2006 Not RCT, no intervention to increase vaccination rates. Article is a telephone survey of factors influ-

encing influenza vaccination

Chodroff 1990 Not RCT; 1986 historical controls; 1986 to 1990 residents given preventive care checklists

Christenson 2001 Not RCT; intervention to increase influenza vaccination rates: all individuals in Stockholm County

aged ≥ 65 years (n = 259,627) invited to participate in influenza plus pneumococcal vaccination

campaign; 100,242 received vaccine; focus on effectiveness of vaccination in reducing hospitalisation

144Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

(Continued)

and pneumonia

Clancy 2003 RCT; publication does not provide separate data for those aged < 60 years and aged ≥ 60 years, or

baseline influenza vaccination data for year prior to intervention; unable to locate author

Cohen 1982 RCT; no baseline data for influenza vaccination rates; influenza rates for participants aged ≥ 60 years

not available separately

Cohen 2004 Not RCT, article is an observational study of how physicians offer vaccination during consultations

Colombo 2005 Not RCT, article is an economic analysis of vaccination strategies

Correa-de-Araujo 2006 Not RCT, secondary analysis of differences in immunisation rates by ethnic group in Medical Expen-

diture Panel Survey; no intervention to increase vaccination rates

Costa 1994 Not RCT, article is a prospective cross-over without control; results for those aged ≥ 60 years not

available

Cowan 1992 RCT; 16 residents in intervention, 13 in control group; no data that residents or participants groups

similar; retrospective chart review of 107 charts (62 intervention, 45 control), also random sample of

charts seen by first-year residents (different residents from current sample) previous year

Cowan 2006 Not RCT, no intervention to increase vaccination rates. Article is about attitudes to vaccination among

healthcare workers

Crawford 2005 Not RCT; participants in a managed care organisation in “the eastern United States.” For breast

cancer screening, cervical cancer screening, or influenza vaccination (aged ≥ 65 years) interactive voice

reminders were sent; no data on secular trends; baseline data for year before intervention available

Crawford 2011 Not RCT, no intervention; survey of patient characteristics of those aged ≥ 65 years accepting influenza

vaccination

Crouse 1994 Not RCT; 6 community hospitals in northern Minnesota assessed 3 strategies to increase influenza

vaccination rates: standing orders, physician chart reminders, physician education; excluded as cannot

assess secular trend in rest of population

Curry 2006 Not RCT, survey of factors associated with influenza vaccination; no intervention to increase vaccination

rates

Daniels 2007 RCT; intervention to increase influenza vaccination rates: onsite adult vaccination in churches; abstract

states participants aged ≥ 65 years, but Table 1 states mean age is 65 years with SD = + or -14, so

clearly includes participants younger than 60 years

Dannetun 2003 Not RCT, survey of reasons for not being vaccinated by seniors in Linköping, Sweden; no intervention

to increase vaccination rates

Davidse 1995 Not RCT; GPs selected participants in Brabant for vaccination; cannot separate those aged ≥ 60 years,

no publication by this author since 1995 in MEDLINE to obtain e-mail address

145Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

(Continued)

Davidson 1984 Not RCT; intervention to increase influenza vaccination rates: university-based internal medicine prac-

tice in North Carolina; 50% sample selected 1 July 1979 to 30 June 1980 to receive nurse reminder

for influenza vaccination, then another 50% sample selected 1 January to 31 December 1981; 50%

not selected in each period served as controls; not stated what overlap occurred between intervention

groups in the 2 periods or controls in the 2 periods; excluded as cannot assess secular trend in rest of

population

Davis 2005 Not RCT, focus groups with physicians about barriers to influenza vaccination

De Wals 1989 Not RCT; intervention to increase vaccination rates: participants of GPs in Braine-le-Château, Belgium;

1984 baseline; 1985 information campaign by GPs; 1986 information campaign by posters, newspaper

editorials, and lectures for retired individuals; excluded as cannot assess secular trend in rest of population

De Wals 1996 Not RCT; survey of influenza vaccination rates in long-term care facilities in Quebec

Denis 1996 Not RCT; intervention in Charleroi, Belgium, to increase influenza vaccination rates in those aged ≥

65 years

Desbiens 2005 Not RCT; observational study of All-Inclusive Care for the Elderly programme in Chattanooga, Ten-

nessee

Dexter 2001 RCT; intervention to increase influenza vaccination rates in hospitalised patients; cannot separate those

aged ≥ 60 years

Dickey 1990 Not RCT, survey of US family physicians about interest in using patient-held health passport preventive

care checklist

Dickey 1992 Not RCT. Health Passport preventive care checklists used for preventive services in university family

medicine clinic, but key table listing preventive services is omitted from article

Dickey 1993 Not RCT, literature review of paediatric and adult patient-held preventive healthcare cards

Dini 1996 Not RCT, no intervention to increase vaccination rates and not appropriate age group (audit of child-

hood vaccinations in Georgia, USA)

Donato 2007 Not RCT; intervention to increase vaccination rates: 650-bed community hospital in Pennsylvania;

2002 nurses screened participants for influenza vaccination, put reminder stickers on front of chart and

orders in chart for physician to sign; 2003 nurses screened participants and standing order for influenza

vaccination before discharge; 2004 same as 2003 plus Grand Rounds and nursing education sessions

on each unit; excluded as cannot assess secular trend in rest of population

Douglas 1990 Not RCT; no intervention to increase influenza vaccination rates. Retrospective audit in Kansas City

family medicine residency programme clinics

Earle 2003 Not RCT; survey of participants with colorectal cancer in SEER (US National Cancer Institute Survival,

Epidemiology, and End Results) programme and factors associated with vaccination; average age 79

years; no baseline data for year before case-control study; no control

146Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

(Continued)

Egido Polo 1989 Not RCT, data for those aged ≥ 60 years not available; e-mail for author not available

Etkind 1996 Not RCT; in Essex County, Massachusetts, letters sent to all healthcare providers, press releases, news-

paper articles, radio and TV announcements, lectures at senior centres, influenza vaccination clinic

schedules sent to all community and elder organisations, Grand Rounds at each Essex County hospital;

in Worcester County “usual care”; excluded as not RCT, geographical areas may not be comparable

Evans 2003 Not RCT, no intervention to increase vaccination rates. Survey of reasons for not being vaccinated

against influenza

Fairbrother 1999 Not RCT, childhood vaccinations

Fedson 1989 Not RCT, no intervention to increase vaccination rates (guidelines for influenza vaccination in insti-

tutional settings)

Fedson 1994 Not RCT, no intervention to increase vaccination rates (article presenting guidelines for prevention

and control of influenza in hospitals and hospital staff )

Fedson 1996 Not RCT, no intervention to increase vaccination rates (review of effectiveness of influenza vaccine)

Fernández Silvela 1994 Not RCT; no baseline data

Ferrante 2010 Not RCT, cross-sectional data from RCT on colon cancer screening; 23% received influenza vaccination,

but no report of comparison to control group

Fiebach 1991 Not RCT, survey of reasons for accepting or refusing influenza vaccination

Fishbein 2006a Not RCT, observational study of missed opportunities for influenza vaccination

Fishbein 2006b Not RCT, average age 46 to 48; cannot separate outcomes for those aged ≥ 65 years; no reply to e-

mail to author

Fisher 2003 Not RCT, cross-sectional analysis of spending patterns in Medicare regions and influenza vaccination

rates; no intervention to increase vaccination rates in elderly

Fitzner 2001 Not RCT, theoretical model of cost-effectiveness of influenza vaccination in Hong Kong

Fitzpatrick 2004 Not RCT; retrospective case-control; no intervention to increase vaccination rates in elderly

Flach 2004 Not RCT, secondary analysis of survey of relationship of patient-centred care and vaccination rates in

Veterans Administration Hospitals

Fontanesi 2004 Not RCT, analysis of workflow observations of care of participants ≥ 50 in convenience sample of 16

ambulatory care settings in San Diego, California and Rochester, New York; development of model of 7

critical organisational, temporal, and clinical activities that predicted 93% of influenza immunisations

147Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

(Continued)

Fowles 1998 Not RCT; survey of influenza vaccination rates in seniors in HMO in Minneapolis-St Paul comparing

staff, multispecialty or primary care practices

Frame 1994 RCT; 10 preventive items; no influenza vaccination data

Francisco 2006 Not RCT, survey of reasons for not receiving influenza vaccination among those aged ≥ 60 years in

Sao Paulo, Brazil

Frank 1985 Not RCT; cohort, no control; reminder letters and phone calls for influenza vaccination

Frick 2004 Not RCT, analysis of changes in influenza vaccination rates by race in USA among disabled seniors

Furey 2001 Not RCT; feedback to GPs on influenza vaccination rates in those aged ≥ 75 years in Merton Sutton

and Wandsworth Health Authority, UK

Galasso 1977 Not RCT, review of clinical trials of influenza vaccination 1976

Ganguly 1989 Not RCT, survey of reasons for acceptance/refusal of vaccination

Ganguly 1995 Not RCT, survey of vaccination status of veterans in a nursing home

Gannon 2012 Not RCT, team intervention to improve multiple vaccination rates; no data on secular trends

Garrett 2005 Not RCT; pre-post cohort; study of employed workers, i.e. those aged < 65 years; ages not stated

Gauthey 1999 Not RCT, survey of influenza vaccination rates and motivations for receiving influenza vaccine among

those aged ≥ 65 years in the State of Geneva in Switzerland

Gelfman 1986 Not RCT, before-and-after 1-group study; physicians were not prompted to offer influenza and pneu-

mococcal vaccinations to high-risk participants at the beginning of the influenza season, then later in

the influenza season were prompted by reminders placed on charts at the Medical College of Virginia

Gerace 1988 Not RCT, comparison of letter in 1985 and phone call in 1986

Giles 2003 Not RCT. Summary of articles by Arthur 2002 and Hull 2002

Gill 2000 Not RCT; Christiana Care Foulk Road Family Medicine Center, Delaware, USA; 1997 baseline rates;

1998 reminder to nurse and physician during visit; excluded as cannot assess secular trend in rest of

population

Gill 2005 Not RCT; retrospective cohort; impact of “Providing a Medical Home to the Uninsured” in Delaware,

USA; cannot separately identify those aged ≥ 60 years

Goebel 2005 Not RCT; retrospective chart review of physicians who used standing orders and those who did not

Grabenstein 1990 Not RCT, survey of vaccination status at Walter Reed Army Hospital

148Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

(Continued)

Grabenstein 1992 Not RCT, cost-effectiveness model of pharmacists advocating and providing influenza vaccine

Grabenstein 2001 Not RCT; survey of influenza vaccination in Washington state (where pharmacists can give influenza

vaccinations) and Oregon (where they cannot)

Granollers 1993 Not RCT; participants not aged ≥ 60 years; nursing staff preventive care interventions

Green 2003 Not RCT, survey of the relationship of functional status, depression, and treatment for psychiatric

problems to rates of influenza vaccination in those aged ≥ 65 years in the Kaiser Permanente Northeast

HMO

Greene 2001 Not RCT, survey of uptake of preventive care

Groll 2006 Not RCT; study of Universal Influenza Campaign in Ontario; data for those aged ≥ 60 years not

available separately

Gutiérrez 2005 Not RCT, economic evaluation of influenza vaccination for those aged ≥ 65 years in Mexico

Gutschi 1998 RCT; intervention to increase influenza rates; no vaccination rates for year before intervention; cannot

separate rates for those aged ≥ 60 years

Hahn 1990 Not RCT; use of a health maintenance protocol in a family practice clinic; no influenza intervention

or outcomes

Halliday 2003 Not RCT, survey of 19 residential care facilities in Australian Capital Territory on staff vaccination

Hanna 2001 Not RCT; survey of pneumococcal and influenza vaccine rates in indigenous population in New

Zealand, and monitoring after local physicians were encouraged to offer vaccination; no information

on secular trends; cannot separate outcomes for those aged ≥ 60 years

Hannah 2005 Not RCT, intervention programme in West Virginia; no patient outcome data

Harari 2008 RCT; influenza vaccination only recorded for year before study (Table 3)

Harbarth 1998 Not RCT (concurrent comparison group)

Harris 1990 Not RCT, retrospective chart review; North Carolina Memorial Hospital Department of Medicine

Polyclinic Practice; time series: 1979 to 1980 no prompts; 1981 nursing prompt; 1984 computer

prompt; excluded as cannot assess secular trend in rest of population; cannot assess numbers in target

groups from Figure 2

Harris 2006 Not RCT; 249 participants with COPD recently discharged from hospital in Adelaide, Australia, for

COPD intervention group (received Cochrane Collaboration systematic review summaries related to

COPD) and control groups allocated to separate geographical areas; author sent PhD dissertation, and

we were able to verify it was not an RCT

149Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

(Continued)

Hedlund 2003 Not RCT; study of influenza and pneumococcal vaccination campaign for individuals aged ≥ 65 years

in Stockholm County, Sweden, 1998; no control group; baseline data for year before intervention not

available

Henk 1975 Not RCT; cohort, no control; age lists used to identify participants for influenza vaccination

Hermiz 2002 RCT; no intervention to increase influenza vaccination; no statement as to whether vaccinated partic-

ipants had received vaccination before or after intervention

Herrett 2016 RCT of text messages to at-risk participants for influenza vaccination. However, age groups are 18 to

34, 35 to 50, and 51 to 64, and cannot separate outcomes for those 60 and older

Hirdes 2006 Not RCT, survey of predictors of vaccination in Ontario nursing homes

Hoey 1982 Not RCT; intervention to increase vaccination rates: nurses offered influenza vaccination to half par-

ticipants seen in morning clinics, and participants were vaccinated by physicians in afternoon clinics;

participants aged ≥ 60 years cannot be identified

Honkanen 1996 Not RCT, survey of knowledge about influenza vaccination

Honkanen 1997 Not RCT; for 3 administrative areas in Finland: Admin Area A: risk of disease-based influenza vaccina-

tion programme; Admin Area B: age-based vaccination programme offered Autumn 1993 and 1994;

Admin Area C: age-based vaccination programme offered 1992 to 1994; areas not necessarily identical

Honkanen 2006 Not RCT; northern Finland; 14 municipalities risk of disease-based intervention x 2 years; 29 munici-

palities: age-based intervention x 2 years. 12 municipalities cross-over from disease-based intervention

in 1992 to age-based intervention in 1993; excluded as not RCT; geographical areas may not be com-

parable

Humair 2002 Not RCT; primary care clinic of Department of Community Medicine, Geneva University Hospital;

1995 baseline; 1996 leaflets and posters at reception desk and waiting areas, walk-in immunisation

clinic, 1.5-hour training workshop on influenza for physicians, computer reports every 2 weeks to

residents on vaccination performance compared to other residents; reminder stickers for records of

high-risk participants; excluded as cannot assess secular trend in rest of population

Hutchinson 1995 Not RCT; survey of influenza vaccination in clinic participants

Hutchison 1991 Not RCT; historical control 1982 to 1983; reminder letter 1987 to 1988

Hutt 2010 Not RCT, quasi-experimental mixed methods; cohort (8 nursing homes in Denver; no data on com-

parability of 8 non-intervention nursing homes in Missouri and Kansas); survey of implementation of

guidelines on nursing home-acquired pneumonia and hospitalisation; data on influenza vaccination

rates 2004 to 2007

Jacobs 2001 Not RCT; retrospective chart review of use and non-use of interpreters for clinical and preventive

services

Jain 1998 Not RCT, survey; no intervention to increase influenza vaccination

150Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

(Continued)

Jans 2000 Not RCT, cohort of 14 medical practices with 16 physicians implementing 8 guidelines for care of

COPD and asthma, compared to 5 control practices with 5 physicians “located in the same region” (non-

comparable intervention and control groups: practices differed P = 0.04 in “troublesome symptoms”

and P < 0.01 in type of disease (COPD versus asthma))

Jefferson 1996 Not RCT, economic evaluation of influenza vaccination

Jiménez-Garcia 2007 Not RCT, survey of influenza vaccination rates of people with COPD in Catalonia

Jin 2003 Not RCT, secondary analysis of Alberta administrative data for influenza vaccination rates for those

aged ≥ 65 years

Johnson 2005 C-RCT; no outcome data for influenza

Kassam 2001 C-RCT; cannot separate outcomes for influenza vaccination from pneumococcal vaccination

Kelly 1988 Not RCT; children

Kemper 1993 RCT; children

Kendal 1985 Not RCT, survey of vaccination rates in nursing homes in the USA

Kennedy 1994 Not RCT; tracking system for paediatric vaccinations in a Medicaid managed care organisation

Kern 1990 Not RCT; preventive care audit by faculty of charts of participants seen by internal medicine residents;

influenza vaccine outcomes not available separately for those aged ≥ 65 years

Klachko 1989 Not RCT; survey of influenza vaccination rates in diabetic clinic; data not available separately for those

aged ≥ 60 years

Knoell 1991 Not RCT; General Internal Medicine Group Practices at the University of California at San Fran-

cisco; 1987 to 1988 baseline; 1989 pharmacist presented 3 in-services to nursing staff about influenza

vaccination, participants aged > 65 years received information sheet in clinic, campaign to provide

vaccination with or without a visit; excluded as cannot assess secular trend in rest of population

Korn 1988 Not RCT; preventive medicine checklist placed on charts, including influenza for those aged ≥ 65

years; faculty audit of charts of 15 internal medicine residents exposed to intervention and 13 who had

not been; no assessment if residents were similar; no data on secular trends in practice

Kosiak 2006 Not RCT, secondary analysis of influenza vaccination rates for those aged ≥ 65 years in 2004 National

Healthcare Quality Report and National Healthcare Disparities Report

Kunze 1998 Not RCT. Editorial; no intervention to increase vaccination rates

Kwong 2006 Not RCT, secondary analysis of influenza vaccination rates in 1996 to 1997 National Population Health

Survey of Canada and Population Health Survey of Canada 2000 to 2001 and 2003, including those

aged ≥ 65 years

151Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

(Continued)

Kyaw 2002 Not RCT, survey of influenza vaccination rates and vaccination policies in 53 general practices in

Scotland 1993 to 1999

Landis 1995 Not RCT; vaccine manager to increase use of 4 vaccines; no data on influenza vaccination

Landon 2004 Not RCT, secondary analysis of Centers for Medicare & Medicaid Services data on influenza vaccination

rates for those aged ≥ 65

Larson 1979 Not RCT; reminder letter to those aged ≥ 65 years and high-risk patients at the University of Washington

family medicine centre; cannot separate outcomes for those aged ≥ 65 years from high-risk participants

Larson 1982 RCT; intervention to increase influenza vaccination rates: postcard reminders; correspondence from

author was neither able to provide precise baseline influenza vaccination rates before intervention (Dr

Larson estimated them from a survey with a 75% response rate at 50%), nor provide data separately

for those aged ≥ 60 years; self report of vaccination

Lau 2006 Not RCT, telephone survey of influenza vaccination rates among residents of Hong Kong for those

aged ≥ 65 years

Lawson 2000 Not RCT; standing orders for influenza vaccination; no control group (community rate used as control

rate, no details on characteristics of community group)

Lazorik 2001 Not RCT; no intervention to increase vaccination rates; article summarising preventive care options

LeBaron 1997 Not RCT; annual measurement and feedback programme; children

Lee 2003 Requested needed additional computations from author but no reply

Lees 2005 Not RCT, secondary analysis of 2000 US National Health Interview on influenza vaccination rates

Leirer 1989 Not RCT; intervention to increase influenza vaccination rates: 321 older people who attended com-

munity-supported lunch program at a senior citizen centre (location not stated, authors’ professional

address is Stanford, California); 64 individuals ≥ 65 “randomly selected” from those who attended

≥ 1 per week, and 257 “randomly selected” from those attending less frequently; (however 64 + 257

= 321, leaving no degrees of freedom, so the second sample could not have been randomly selected);

frequency of attendance does not control for potential confounders; no baseline data

Leirer 1991 Not RCT; no influenza outcomes, n = only 16

Levy 1996 Not RCT, French economic evaluations of influenza vaccination

Lieberman 2003 Not RCT; no intervention to increase vaccination rates. Discussion article about managing respiratory

infections

Lindley 2006 Not RCT, telephone survey of Medicare beneficiaries about vaccination rates

Loeser 1983 Not RCT; report of computerised vaccination register for children in Montreal; no influenza outcomes

152Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

(Continued)

Lu 2005 Not RCT, secondary analysis of 1989 to 2002 US National Health Interview Surveys for influenza

vaccination rates in those aged ≥ 65 years, and factors predicting vaccination

Lynd 2005 Not RCT, article about antivirals for influenza

Macdonald 1985 Not RCT; mass campaign; children

Maciosek 2006 Not RCT, literature review of cost-effectiveness of influenza vaccination

Madlon-Kay 1987 Not RCT; audit of 8 preventive care items, but influenza not audited as seasonal administration

Mair 1974 RCT with outcomes of antigenicity and reactogenicity. No intervention to increase vaccination rates

Malmvall 2007 Not RCT; intervention to increase influenza vaccination rates: inhabitants aged ≥ 65 years in Jönköping

County, Sweden; 1999 to 2001 baseline; 90% of GPs informed of vaccination campaign 2002; educa-

tion meetings encouraging senior practice nurses to vaccinate seniors each year 2002 to 2005; cannot

assess secular trend in rest of population

Mandel 1985 Not RCT; audit of 9 preventive care items, but influenza not included

Mangione 2006 Not RCT; secondary analysis of influenza vaccination status of random sample of 8661 participants

with diabetes in 7 US health plans 2000 to 2001, and description of physician reminders, performance

feedback, and structured care management

Mangtani 2006 Not RCT, survey of attitudes to influenza vaccination of 844 community-dwelling individuals ≥ 75

in the UK 2004 Medical Research Council Trial of Assessment and Management of Older People in

the Community

Margolis 1988 Not RCT; Veterans Affairs clinic in Minneapolis with participants in 3 subspecialty clinics as historical

controls

Margolis 1992 Not RCT; informational mailing to participants; standing vaccination orders; vaccination reminders

on daily patient lists; walk-in vaccination visits; no numbers from control clinic; comparator is 2 clinics

“similar location”

Marra 2011 RCT with random allocation of 12 communities in British Columbia to an intervention for pharmacists

to offer influenza vaccination and 13 control communities, but no data on vaccination rates in control

communities

Marsteller 2006 Not RCT, secondary analysis of the Canadian 1999 National Nursing Home Survey of the influenza

vaccination status of a random sample of 73,350 individuals aged ≥ 65 years in 1423 nursing facilities

Martinen 2004 Not RCT; cohort; no control; managing congestive heart failure in long-term care

Mayo 2004 RCT. No intervention to increase vaccination rates. Study of perceived barriers for hospital participants

to receiving influenza vaccination

153Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

(Continued)

McArthur 1999 Not RCT. Survey of factors affecting vaccination rates in all 1520 Canadian long-term care facilities in

1991

McDonald 1984 RCT; intervention to increase influenza vaccination rates: residents randomly allocated to receive com-

puter analyses of patient charts with care reminders including CDC recommendations for influenza

vaccination; influenza outcomes; no pre-intervention baseline data

McDonald 1992 RCT; intervention to increase influenza vaccination rates: computer-generated influenza vaccination

reminders; publication does not provide separate data for those aged < 60 years and ≥ 60 years, or

baseline influenza vaccination data for year prior to intervention; unable to locate author

McKinney 1989 Not RCT; survey of factors related to physician ordering of influenza vaccination in the Primary Care

Clinic at Milwaukee County Medical Complex

McLeod 2001 Not RCT, analysis of influenza outbreaks in seniors’ lodges in Calgary 1997 to 2000

Merkel 1994 Not RCT; cohort; reminder data sheet; influenza vaccination baseline data available for only 75% of

cohort; no control

Milman 2005 Not RCT, no control group; effect of patient care team on influenza decisions

Mody 2005 Not RCT; survey of infection control practices in nursing homes in southeast Michigan

Morrow 1995 Not RCT; audit of 3 preventive items; no influenza data

Mosesso 2003 Not RCT; prospective observational cohort study of influenza vaccination by emergency services in

Pittsburgh

Mukamel 2001 Not RCT, no control group, no influenza outcome data

Mulet Pons 1995 Not RCT, telephone survey of influenza vaccination status of those aged ≥ 65 years in a health centre

in Alicante, Spain, and reasons for refusing vaccination

Murphy 1996 Not RCT; intervention to increase childhood 0 to 5 vaccination rates in an inner-city Dublin family

practice using postcard reminders and an improved vaccination record system

Métrailler 2003 Not RCT; no intervention to increase vaccination rates

Müller 2005 Not RCT, no intervention to increase vaccination rates

Nakatani 2002 Not RCT; no intervention to increase vaccination rates. Inappropriate study design

Ndiaye 2005 Not RCT. No intervention to increase vaccination rates. In this review, none of the results are presented

for people aged 60 years or older - summary just shows “high risk” and occasionally results for those

younger than 65 years

Nichol 1990 Not RCT. Self reported vaccination status without validation

154Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

(Continued)

Nichol 1992 No intervention to increase vaccination rates

Nichol 1998 Not RCT

Nichol 2006 No intervention to increase vaccination rates

Nicoleau 2001 Not RCT

Nowalk 2004a No intervention to increase vaccination rates

Nowalk 2004b No intervention to increase vaccination rates

Nowalk 2004c Not RCT; outcomes are office and patient factors associated with vaccination

Nowalk 2008 Not RCT; data for those aged ≥ 60 years not separately identifiable

Nowalk 2012 Not RCT; no data for those aged ≥ 60 years

Nowalk 2014 Not RCT

O’Connor 1996 RCT. No data for those ≥ 60 years

O’Connor 1998 Not RCT; unable to extract vaccination data for target age group

O’Malley 2006 No intervention to increase vaccination rates

O’Reilly 2002 No intervention to increase vaccination rates

Ohmit 1995 Not RCT

Ompad 2006 Not RCT

Ornstein 1991 Not influenza vaccination

Overhage 1996 Not influenza vaccination

Padiyara 2011 Not RCT

Parchman 2004 No intervention to increase vaccination rates

Parry 2004 Not RCT

Pasquarella 2003 Not RCT

Patel 2004 Not RCT; no data for those aged ≥ 60 years

Patel 2006 No intervention to increase vaccination rates

155Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

(Continued)

Patriarca 1985 Not RCT; no intervention to increase vaccination rates

Payaprom 2011 Not RCT; cannot identify outcomes for those aged ≥ 60 years

Pearson 2005 Not RCT

Piedra 1995 Not RCT; no intervention to increase vaccination rates

Pleis 2002 Not RCT

Ploeg 1994 No intervention to increase influenza vaccination rates

Postma 2005 Not RCT; no intervention to increase influenza vaccination rates

Prati 2012 No influenza vaccination outcomes (only risk perception, efficacy, and self efficacy)

Puig-Barberà 1999 Not RCT

Quinley 2004 No influenza vaccination outcomes

Rantz 2001 No intervention to increase influenza vaccination rates

Reichert 2001 No intervention to increase influenza vaccination rates

Resnick 2001 Not RCT; no intervention to increase influenza vaccination rates

Ressel 2003 Not RCT; no intervention to increase influenza vaccination rates

Retchin 1991 Not RCT; no intervention to increase influenza vaccination rates

Rimple 2006 Not RCT

Robare 2011 Unable to extract vaccination data for target age group

Rodewald 1999 Not target age group

Rodriguez 1993 Not RCT

Rodriguez-Rodriguez 2006 No intervention to increase vaccination rates

Roffey 1998 No intervention to increase vaccination rates

Russell 2000 No intervention to increase vaccination rates

Rust 1999 No intervention to increase vaccination rates

Ryan 1984 No intervention to increase vaccination rates

156Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

(Continued)

Sambamoorthi 2005 No intervention to increase vaccination rates

Sansom 2003 No intervention to increase vaccination rates

Sarnoff 1998 Not RCT

Schectman 1995 No intervention to increase vaccination rates

Schensul 2009 Unable to extract vaccination data for target age group

Schluter 1999 Not RCT

Schmitz 1993a Not RCT

Schmitz 1993b Not RCT

Schneider 2001 Not RCT

Schreiner 1988 Not RCT

Schwartz 2006 Not RCT

Schwarz 2005 Not RCT

Scott 1996 No intervention to increase vaccination rates

Setia 1985 Not RCT

Shah 2006 Not RCT

Shahrabani 2006 No intervention to increase vaccination rates

Shank 1989 Not RCT

Shenson 2005 Not RCT. No intervention to increase vaccination rates

Shenson 2007 No intervention to increase vaccination rates

Shenson 2011 Not RCT

Shugarman 2006 Not RCT

Siebers 1985 Not influenza vaccination

Simor 2002 No intervention to increase vaccination rates

Siriwardena 2003a Not RCT

Slobodkin 1998 Not RCT

157Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

(Continued)

Soljak 1987 Not target age group

Song 2000 Participants reported influenza vaccination by telephone and this was not independently validated

[personal communication from author 2009]. We requested needed additional computations from

author in November 2017 but have received no reply

Stancliff 2000 Not RCT; inappropriate age group

Stehr-Green 1993 Not target age group

Stenqvist 2006 Not RCT

Steyer 2004 Not RCT; no intervention to increase vaccination rates

Stott 1998 No intervention to increase vaccination rates

Straits-Troster 2006 No intervention to increase vaccination rates

Stuart 1969 No intervention to increase vaccination rates

Sylvan 2003 Not RCT

Szilagyi 1992 Not target age group

Szilagyi 2005 No intervention to increase vaccination rates

Szilagyi 2006 Not target age group

Szucs 2006 No intervention to increase vaccination rates

Tabbarah 2005 Not RCT. No intervention to increase vaccination rates

Tacken 2002 Not RCT

Tape 1993 Not RCT

Terrell-Perica 2001 Not possible to extract results for those aged ≥ 60 years

Tierney 2005 Not possible to extract results for those aged ≥ 60 years

Tollestrup 1991 Not target age group, not influenza vaccination

Toscani 2003 No intervention to increase vaccination rates

Traeger 2006 Not RCT

Trick 2009 Not RCT

158Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

(Continued)

Tucker 1987 Not RCT

Turner 1989 Not RCT; not influenza vaccination

Turner 1990 Not possible to extract outcomes by age group

Turner 2003 Not RCT. No intervention to increase vaccination rates

Tymchuk 1991 No intervention to increase vaccination rates

Usami 2009 Influenza vaccination data collected through self report.

Van Amburgh 2001 Not RCT

Van den Hooven 2006 No intervention to increase vaccination rates

Van Essen 1997 Not target age group

Van Hoof 2001 Not RCT

Van Lieshout 2012 Not RCT

Wadhwa 1997 RCT; participants ≥ aged 65 years, but 57% of those in the phone arm were not contacted either by

voice or machine, so excluded as unknown large risk of bias

Walker 1992 Not RCT

Walsh 2012 RCT; cannot separate outcome data for those aged ≥ 60 years

Wang 2005 Not RCT. No intervention to increase vaccination rates

Warren 1995 Not RCT. No intervention to increase vaccination rates

Watkinson 2004 Not RCT

Weatherill 2004 Not RCT

Weaver 2001 Not RCT. The data for this study derive from an RCT; however, the focus of this article is a cost-

effectiveness analysis of a community-based outreach initiative to promote pneumococcal and influenza

vaccines for people aged 65 years or older. The full report of the RCT is presented in Krieger 2000.

Weaver 2003 Not RCT. Cannot separate outcome data for those aged ≥ 60 years

Wee 2001 Not RCT

Wei 2007 No intervention to increase vaccination rates

Whelan 2013 No influenza vaccination outcome data

159Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

(Continued)

While 2005 Not RCT. No intervention to increase vaccination rates

Wiese-Posselt 2006 No intervention to increase vaccination rates

Wilkinson 2002 Not target age group. This was a pilot study, and participants were randomly allocated to intervention;

however, it was not possible to extract outcomes by age group

Williams 1987 Not RCT

Wilson 1989 Not RCT

Winston 2006a Not RCT

Winston 2006b Not RCT

Wood 1998 Not target age group

Worasathit 2015 Not RCT

Wortley 2005 Not RCT. No intervention to increase vaccination rates

Wray 2009 RCT; intervention to increase influenza vaccination rates (vaccine safety message versus vaccine infor-

mation statement); no influenza vaccination outcomes; cannot separate results for those aged ≥ 60

years

Wright 2011 RCT; outcome data for those aged ≥ 60 years cannot be identified; we received no reply from e-mail

to author

Wuorenma 1994 Not RCT. Not target age group

Yoo 2006 Not RCT. No intervention to increase vaccination rates

Young 1980 Not target age group

Zimmerman 2003a No intervention to increase vaccination rates

Zimmerman 2003b No intervention to increase vaccination rates

Zimmerman 2003c Not RCT

Zimmerman 2004 Not RCT. No intervention to increase vaccination rates

Zwar 2016 RCT; aged 40 to 85 and cannot separate vaccination outcomes for those aged ≥ 60 years

COPD: chronic obstructive pulmonary disease

CDC: Centers for Disease Control and Prevention

C-RCT: cluster-randomised controlled trial

GP: general practitioner

160Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

HMO: health maintenance organisation

ILI: influenza-like illness

RCT: randomised controlled trial

SD: standard deviation

Characteristics of studies awaiting assessment [ordered by study ID]

Hurley 2017

Methods Randomised controlled trial

Participants 5332 adults ≥ 65 years in Denver, Colorado

Interventions An invitation for influenza, pneumococcal, or Tdap vaccination as indicated either from a centralised reminder and

recall system (Colorado Immunization Information System) or by usual care

Outcomes 32% of seniors in the centralised recall and 28.6% in the usual care group received influenza vaccine (P = 0.007)

Notes We contacted authors to request additional data and information about study methods and risk of bias, but received

no reply before publication of this update

161Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

D A T A A N D A N A L Y S E S

Comparison 1. Increasing community demand

Outcome or subgroup title No. of

studies

No. of

participants Statistical method Effect size

1 Client reminder and recall

(postcard) compared to no

intervention

17 Odds Ratio (M-H, Random, 95% CI) Totals not selected

2 Client reminder and recall

(tailored letter or postcard or

phone call) compared to no

intervention

16 Odds Ratio (M-H, Random, 95% CI) Totals not selected

3 Client reminder and recall (letter

+ leaflet or postcard) compared

to letter

3 64200 Odds Ratio (M-H, Random, 95% CI) 1.11 [1.07, 1.15]

4 Client reminder and recall

(customised letter or phone

call) compared to form letter

4 Odds Ratio (M-H, Random, 95% CI) Totals not selected

5 Client reminder and recall

(telephone call from retired

teacher plus educational

brochure) compared to usual

publicity

1 193 Odds Ratio (M-H, Random, 95% CI) 3.33 [1.79, 6.22]

6 Client reminder and recall

(telephone invitation)

compared to invitation to

patient when ”dropped in” to

clinic

1 243 Odds Ratio (M-H, Fixed, 95% CI) 2.72 [1.55, 4.76]

7 Brochure + lottery for free

groceries compared to no

intervention

1 291 Odds Ratio (M-H, Fixed, 95% CI) 1.04 [0.62, 1.76]

8 Questionnaires to clients about

attitudes

1 13809 Odds Ratio (M-H, Fixed, 95% CI) 1.13 [1.03, 1.24]

9 Client-based education (health

risk appraisal) compared to no

intervention

4 Odds Ratio (M-H, Random, 95% CI) Totals not selected

10 Client-based education (nurses

or pharmacists educated and

nurses vaccinated patients)

compared to no intervention

2 614 Odds Ratio (M-H, Random, 95% CI) 3.29 [1.91, 5.66]

11 Client-based education (nurses

educated and vaccinated

patients) compared to nurses

educated patients

1 485 Odds Ratio (M-H, Fixed, 95% CI) 152.95 [9.39, 2490.

67]

12 Face-to-face 3-minute

conversation compared to no

intervention

1 529 Odds Ratio (M-H, Fixed, 95% CI) 1.62 [1.11, 2.35]

162Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Comparison 2. Enhancing vaccination access

Outcome or subgroup title No. of

studies

No. of

participants Statistical method Effect size

1 Group visits of patients to

physician and nurse compared

to usual care

1 321 Odds Ratio (M-H, Fixed, 95% CI) 27.19 [1.60, 463.25]

2 Home visit compared to

invitation to attend influenza

vaccination clinic

2 2112 Odds Ratio (M-H, Random, 95% CI) 1.30 [1.05, 1.61]

3 Home visit with encouragement

to receive influenza vaccination,

compared to home visit with

safety intervention

1 350 Odds Ratio (M-H, Random, 95% CI) 0.98 [0.64, 1.50]

4 Home visit by nurse or group

sessions with encouragement to

receive influenza vaccination,

plus care plan developed with

physician, compared to no

intervention

2 Odds Ratio (M-H, Fixed, 95% CI) Totals not selected

5 Free influenza vaccine compared

to invitation to be vaccinated

but patient pays

2 2251 Odds Ratio (M-H, Random, 95% CI) 2.36 [1.98, 2.82]

6 Free influenza vaccine compared

to no intervention

2 Odds Ratio (M-H, Random, 95% CI) Totals not selected

Comparison 3. Provider- or system-based intervention

Outcome or subgroup title No. of

studies

No. of

participants Statistical method Effect size

1 Reminder (to physician)

compared to no reminder

4 Odds Ratio (M-H, Random, 95% CI) Totals not selected

2 Reminder to physician about all

patients compared to reminder

about half patients

1 316 Odds Ratio (M-H, Fixed, 95% CI) 2.47 [1.53, 3.99]

3 Reminder (to hospital staff to

vaccinate patient) compared to

letter to GP on day of discharge

1 45 Odds Ratio (M-H, Fixed, 95% CI) 1.7 [0.51, 5.70]

4 Posters in clinic displaying

influenza vaccination rates to

encourage doctors to compete,

plus postcards to patients,

compared to no intervention

1 8376 Odds Ratio (M-H, Fixed, 95% CI) 2.03 [1.86, 2.22]

163Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

5 Posters in clinic displaying

influenza vaccination rates to

encourage doctors to compete,

plus postcards to patients,

compared to posters displaying

vaccination rates

1 5753 Odds Ratio (M-H, Fixed, 95% CI) 1.06 [0.95, 1.19]

6 Facilitator encouragement

of prevention manoeuvres

including influenza vaccination

compared to no intervention

3 Odds Ratio (M-H, Random, 95% CI) Totals not selected

7 Educational reminders, academic

detailing, and peer comparisons

to physicians compared to

mailed educational materials

1 1400 Odds Ratio (M-H, Fixed, 95% CI) 1.13 [0.80, 1.58]

8 Chart review and feedback to

physician plus benchmarking

to vaccination rates achieved

by top 10% of physicians,

compared to chart review and

feedback

1 1360 Odds Ratio (M-H, Fixed, 95% CI) 3.43 [2.37, 4.97]

9 Educational outreach + feedback

to practice teams versus written

feedback to practice teams

1 27580 Odds Ratio (M-H, Fixed, 95% CI) 0.77 [0.72, 0.81]

10 Payment to physicians versus

no payment

2 2815 Odds Ratio (M-H, Fixed, 95% CI) 2.22 [1.77, 2.77]

11 Intervention to increase staff

influenza vaccination rate

versus no intervention

1 26432 Odds Ratio (M-H, Fixed, 95% CI) 1.04 [0.97, 1.12]

164Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Analysis 1.1. Comparison 1 Increasing community demand, Outcome 1 Client reminder and recall

(postcard) compared to no intervention.

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

Comparison: 1 Increasing community demand

Outcome: 1 Client reminder and recall (postcard) compared to no intervention

Study or subgroup

Letter postcard pamphlet No intervention Odds Ratio Odds Ratio

n/N n/N

M- H,Random,95%

Barnas 1989 93/406 137/434 0.64 [ 0.47, 0.88 ]

Hogg 1998 8/48 9/47 0.84 [ 0.30, 2.42 ]

Moran 1992 57/134 31/68 0.88 [ 0.49, 1.59 ]

Berg 2008 5491/26474 16912/81453 1.00 [ 0.97, 1.03 ]

Moran 1995 143/450 142/450 1.01 [ 0.76, 1.34 ]

Maglione 2002c 4725/25000 9230/50437 1.04 [ 1.00, 1.08 ]

Maglione 2002b 3648/16000 3504/16001 1.05 [ 1.00, 1.11 ]

Clayton 1999 2068/2631 2043/2647 1.09 [ 0.95, 1.24 ]

Baker 1998 2154/4388 1997/4389 1.15 [ 1.06, 1.26 ]

Boca 2012 501/1201 449/1201 1.20 [ 1.02, 1.41 ]

McCaul 2002 798/3258 1548/7896 1.33 [ 1.21, 1.47 ]

Maglione 2002a 164/2924 134/3343 1.42 [ 1.13, 1.80 ]

CDC 1995b (Montana) 1381/21250 3912/88900 1.51 [ 1.42, 1.61 ]

Minor 2010 63/94 48/91 1.82 [ 1.00, 3.30 ]

CDC 1995a (Wyoming) 4229/21250 2174/18900 1.91 [ 1.81, 2.02 ]

Moran 1996 57/139 35/138 2.05 [ 1.23, 3.41 ]

Puech 1998 34/154 12/171 3.75 [ 1.87, 7.56 ]

0.02 0.1 1 10 50

Favours no intervention Favours letter postcard

165Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Analysis 1.2. Comparison 1 Increasing community demand, Outcome 2 Client reminder and recall (tailored

letter or postcard or phone call) compared to no intervention.

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

Comparison: 1 Increasing community demand

Outcome: 2 Client reminder and recall (tailored letter or postcard or phone call) compared to no intervention

Study or subgroup

Tailored letter

postcard No intervention Odds Ratio Odds Ratio

n/N n/N

M- H,Random,95%

Baker 1998 4446/8822 1997/4389 1.22 [ 1.13, 1.31 ]

CDC 1995a (Wyoming) 3752/19850 2174/18900 1.79 [ 1.69, 1.90 ]

CDC 1995b (Montana) 1727/19850 3912/88900 2.07 [ 1.95, 2.20 ]

Dietrich 1989 5/59 3/55 1.60 [ 0.36, 7.06 ]

D az Gr valos 1999 19/162 9/478 6.92 [ 3.07, 15.64 ]

Hogg 1998 6/30 9/47 1.06 [ 0.33, 3.34 ]

Hull 2002 328/660 288/658 1.27 [ 1.02, 1.58 ]

Humiston 2011 1112/1748 438/2004 6.25 [ 5.41, 7.22 ]

Kellerman 2000 11/154 4/53 0.94 [ 0.29, 3.10 ]

McCaul 2002 1708/6057 1548/7896 1.61 [ 1.49, 1.74 ]

McDowell 1986 116/611 100/564 1.09 [ 0.81, 1.46 ]

Minor 2010 51/72 48/91 2.18 [ 1.13, 4.18 ]

Mullooly 1987 430/1105 335/1112 1.48 [ 1.24, 1.76 ]

Roca 2012 43/1201 7/1201 6.33 [ 2.84, 14.14 ]

Smith 1999 3110/4508 2891/4503 1.24 [ 1.14, 1.35 ]

Spaulding 1991 53/116 22/108 3.29 [ 1.82, 5.96 ]

0.01 0.1 1 10 100

Favours no intervention Favours tailored letter

166Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Analysis 1.3. Comparison 1 Increasing community demand, Outcome 3 Client reminder and recall (letter +

leaflet or postcard) compared to letter.

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

Comparison: 1 Increasing community demand

Outcome: 3 Client reminder and recall (letter + leaflet or postcard) compared to letter

Study or subgroup Letter + leaflet Letter Odds Ratio Weight Odds Ratio

n/N n/N

M- H,Random,95%

Maglione 2002b 3776/16000 3504/16001 51.7 % 1.10 [ 1.05, 1.16 ]

Maglione 2002d 3442/16082 3147/16057 48.2 % 1.12 [ 1.06, 1.18 ]

Nuttall 2003 7/30 8/30 0.1 % 0.84 [ 0.26, 2.70 ]

Total (95% CI) 32112 32088 100.0 % 1.11 [ 1.07, 1.15 ]

Total events: 7225 (Letter + leaflet), 6659 (Letter)

Heterogeneity: Tau2 = 0.0; Chi2 = 0.35, df = 2 (P = 0.84); I2 =0.0%

Test for overall effect: Z = 5.38 (P < 0.00001)

Test for subgroup differences: Not applicable

0.2 0.5 1 2 5

Favours letter Favours letter + leaflet

167Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Analysis 1.4. Comparison 1 Increasing community demand, Outcome 4 Client reminder and recall

(customised letter or phone call) compared to form letter.

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

Comparison: 1 Increasing community demand

Outcome: 4 Client reminder and recall (customised letter or phone call) compared to form letter

Study or subgroup Customised letter Form letter Odds Ratio Odds Ratio

n/N n/N

M- H,Random,95%

CDC 1995a (Wyoming) 3752/19850 4229/21250 0.94 [ 0.89, 0.99 ]

Hogg 1998 6/30 8/48 1.25 [ 0.39, 4.04 ]

CDC 1995b (Montana) 1727/19850 1381/21250 1.37 [ 1.27, 1.48 ]

Minor 2010 48/68 66/119 1.93 [ 1.02, 3.64 ]

0.001 0.01 0.1 1 10 100 1000

Favours form letter Favours customised letter

Analysis 1.5. Comparison 1 Increasing community demand, Outcome 5 Client reminder and recall

(telephone call from retired teacher plus educational brochure) compared to usual publicity.

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

Comparison: 1 Increasing community demand

Outcome: 5 Client reminder and recall (telephone call from retired teacher plus educational brochure) compared to usual publicity

Study or subgroup

Phione call from

senior Usual publicity Odds Ratio Weight Odds Ratio

n/N n/N

M- H,Random,95%

Krieger 2000 51/102 21/91 100.0 % 3.33 [ 1.79, 6.22 ]

Total (95% CI) 102 91 100.0 % 3.33 [ 1.79, 6.22 ]

Total events: 51 (Phione call from senior), 21 (Usual publicity)

Heterogeneity: not applicable

Test for overall effect: Z = 3.79 (P = 0.00015)

Test for subgroup differences: Not applicable

0.005 0.1 1 10 200

Favours usual publicity Favours senior phone call

168Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Analysis 1.6. Comparison 1 Increasing community demand, Outcome 6 Client reminder and recall

(telephone invitation) compared to invitation to patient when “dropped in” to clinic.

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

Comparison: 1 Increasing community demand

Outcome: 6 Client reminder and recall (telephone invitation) compared to invitation to patient when ”dropped in” to clinic

Study or subgroup Telephone invitation Drop in to clinic Odds Ratio Weight Odds Ratio

n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI

Lukasik 1987 52/120 27/123 100.0 % 2.72 [ 1.55, 4.76 ]

Total (95% CI) 120 123 100.0 % 2.72 [ 1.55, 4.76 ]

Total events: 52 (Telephone invitation), 27 (Drop in to clinic)

Heterogeneity: not applicable

Test for overall effect: Z = 3.51 (P = 0.00045)

Test for subgroup differences: Not applicable

0.01 0.1 1 10 100

Favours drop in to clinic Favours phone invitation

169Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Analysis 1.7. Comparison 1 Increasing community demand, Outcome 7 Brochure + lottery for free

groceries compared to no intervention.

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

Comparison: 1 Increasing community demand

Outcome: 7 Brochure + lottery for free groceries compared to no intervention

Study or subgroup

Brochure + grocery lottery No intervention Odds Ratio Weight Odds Ratio

n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI

Moran 1996 40/153 35/138 100.0 % 1.04 [ 0.62, 1.76 ]

Total (95% CI) 153 138 100.0 % 1.04 [ 0.62, 1.76 ]

Total events: 40 (Brochure + grocery lottery), 35 (No intervention)

Heterogeneity: not applicable

Test for overall effect: Z = 0.15 (P = 0.88)

Test for subgroup differences: Not applicable

0.05 0.2 1 5 20

Favours no invitation Favours brochure + lottery

Analysis 1.8. Comparison 1 Increasing community demand, Outcome 8 Questionnaires to clients about

attitudes.

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

Comparison: 1 Increasing community demand

Outcome: 8 Questionnaires to clients about attitudes

Study or subgroup Control Experimental Odds Ratio Weight Odds Ratio

n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI

Conner 2017 8022/10384 2570/3425 100.0 % 1.13 [ 1.03, 1.24 ]

Total (95% CI) 10384 3425 100.0 % 1.13 [ 1.03, 1.24 ]

Total events: 8022 (Control), 2570 (Experimental)

Heterogeneity: not applicable

Test for overall effect: Z = 2.66 (P = 0.0078)

Test for subgroup differences: Not applicable

0.01 0.1 1 10 100

Favours control Favours experimental

170Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Analysis 1.9. Comparison 1 Increasing community demand, Outcome 9 Client-based education (health risk

appraisal) compared to no intervention.

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

Comparison: 1 Increasing community demand

Outcome: 9 Client-based education (health risk appraisal) compared to no intervention

Study or subgroup Health risk appraisal No intervention Odds Ratio Odds Ratio

n/N n/N

M- H,Random,95%

Garcia-Aymerich 2007 32/44 19/69 7.02 [ 3.01, 16.39 ]

Ives 1994 311/1228 103/761 2.17 [ 1.70, 2.77 ]

Morrissey 1995 192/954 29/960 8.09 [ 5.41, 12.09 ]

Stuck 2015 544/874 781/1410 1.33 [ 1.12, 1.58 ]

0.01 0.1 1 10 100

Favours no intervention Favours health appraisal

171Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Analysis 1.10. Comparison 1 Increasing community demand, Outcome 10 Client-based education (nurses

or pharmacists educated and nurses vaccinated patients) compared to no intervention.

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

Comparison: 1 Increasing community demand

Outcome: 10 Client-based education (nurses or pharmacists educated and nurses vaccinated patients) compared to no intervention

Study or subgroup

Nurses educate+ vaccinate No intervention Odds Ratio Weight Odds Ratio

n/N n/N

M- H,Random,95%

Herman 1994 58/243 20/271 70.4 % 3.93 [ 2.29, 6.77 ]

Marrero 2006 16/50 9/50 29.6 % 2.14 [ 0.84, 5.46 ]

Total (95% CI) 293 321 100.0 % 3.29 [ 1.91, 5.66 ]

Total events: 74 (Nurses educate+ vaccinate), 29 (No intervention)

Heterogeneity: Tau2 = 0.03; Chi2 = 1.21, df = 1 (P = 0.27); I2 =18%

Test for overall effect: Z = 4.29 (P = 0.000018)

Test for subgroup differences: Not applicable

0.005 0.1 1 10 200

Favours no intervention Favours nurse educ+vacc

Analysis 1.11. Comparison 1 Increasing community demand, Outcome 11 Client-based education (nurses

educated and vaccinated patients) compared to nurses educated patients.

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

Comparison: 1 Increasing community demand

Outcome: 11 Client-based education (nurses educated and vaccinated patients) compared to nurses educated patients

Study or subgroup Nurses edu-

cate+vaccinate Nurses educate Odds Ratio Weight Odds Ratio

n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI

Herman 1994 58/243 0/242 100.0 % 152.95 [ 9.39, 2490.67 ]

Total (95% CI) 243 242 100.0 % 152.95 [ 9.39, 2490.67 ]

Total events: 58 (Nurses educate+vaccinate), 0 (Nurses educate)

Heterogeneity: not applicable

Test for overall effect: Z = 3.53 (P = 0.00041)

Test for subgroup differences: Not applicable

0.001 0.01 0.1 1 10 100 1000

Favours nurses educate Favours nurses educ+vacc

172Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Analysis 1.12. Comparison 1 Increasing community demand, Outcome 12 Face-to-face 3-minute

conversation compared to no intervention.

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

Comparison: 1 Increasing community demand

Outcome: 12 Face-to-face 3-minute conversation compared to no intervention

Study or subgroup Experimental Control Odds Ratio Weight Odds Ratio

n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI

Leung 2017 94/265 67/264 100.0 % 1.62 [ 1.11, 2.35 ]

Total (95% CI) 265 264 100.0 % 1.62 [ 1.11, 2.35 ]

Total events: 94 (Experimental), 67 (Control)

Heterogeneity: not applicable

Test for overall effect: Z = 2.51 (P = 0.012)

Test for subgroup differences: Not applicable

0.01 0.1 1 10 100

Favours no intervention Favours education

173Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Analysis 2.1. Comparison 2 Enhancing vaccination access, Outcome 1 Group visits of patients to physician

and nurse compared to usual care.

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

Comparison: 2 Enhancing vaccination access

Outcome: 1 Group visits of patients to physician and nurse compared to usual care

Study or subgroup Group visits Usual care Odds Ratio Weight Odds Ratio

n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI

Beck 1997 12/160 0/161 100.0 % 27.19 [ 1.60, 463.25 ]

Total (95% CI) 160 161 100.0 % 27.19 [ 1.60, 463.25 ]

Total events: 12 (Group visits), 0 (Usual care)

Heterogeneity: not applicable

Test for overall effect: Z = 2.28 (P = 0.022)

Test for subgroup differences: Not applicable

0.002 0.1 1 10 500

Favours usual care Favours group visits

Analysis 2.2. Comparison 2 Enhancing vaccination access, Outcome 2 Home visit compared to invitation to

attend influenza vaccination clinic.

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

Comparison: 2 Enhancing vaccination access

Outcome: 2 Home visit compared to invitation to attend influenza vaccination clinic

Study or subgroup Home visit

Invite vaccination

clinic Odds Ratio Weight Odds Ratio

n/N n/N

M- H,Random,95%

Arthur 2002 174/680 291/1372 96.4 % 1.28 [ 1.03, 1.58 ]

Nuttall 2003 12/30 7/30 3.6 % 2.19 [ 0.72, 6.70 ]

Total (95% CI) 710 1402 100.0 % 1.30 [ 1.05, 1.61 ]

Total events: 186 (Home visit), 298 (Invite vaccination clinic)

Heterogeneity: Tau2 = 0.0; Chi2 = 0.86, df = 1 (P = 0.35); I2 =0.0%

Test for overall effect: Z = 2.45 (P = 0.014)

Test for subgroup differences: Not applicable

0.01 0.1 1 10 100

Favours home visit Favours vaccine clinic

174Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Analysis 2.3. Comparison 2 Enhancing vaccination access, Outcome 3 Home visit with encouragement to

receive influenza vaccination, compared to home visit with safety intervention.

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

Comparison: 2 Enhancing vaccination access

Outcome: 3 Home visit with encouragement to receive influenza vaccination, compared to home visit with safety intervention

Study or subgroup Home visit vaccination Home visit safety Odds Ratio Weight Odds Ratio

n/N n/N

M- H,Random,95%

Black 1993 111/198 86/152 100.0 % 0.98 [ 0.64, 1.50 ]

Total (95% CI) 198 152 100.0 % 0.98 [ 0.64, 1.50 ]

Total events: 111 (Home visit vaccination), 86 (Home visit safety)

Heterogeneity: not applicable

Test for overall effect: Z = 0.10 (P = 0.92)

Test for subgroup differences: Not applicable

0.01 0.1 1 10 100

Favours home visit safety Favours home visit vacc

175Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Analysis 2.4. Comparison 2 Enhancing vaccination access, Outcome 4 Home visit by nurse or group

sessions with encouragement to receive influenza vaccination, plus care plan developed with physician,

compared to no intervention.

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

Comparison: 2 Enhancing vaccination access

Outcome: 4 Home visit by nurse or group sessions with encouragement to receive influenza vaccination, plus care plan developed with physician, compared to no

intervention

Study or subgroup Home visit care plan No intervention Odds Ratio Odds Ratio

n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI

Dalby 2000 66/73 37/69 8.15 [ 3.28, 20.29 ]

Dapp 2011 395/574 768/1353 1.68 [ 1.37, 2.07 ]

0.01 0.1 1 10 100

Favours no intervention Favours home visit + care plan

Analysis 2.5. Comparison 2 Enhancing vaccination access, Outcome 5 Free influenza vaccine compared to

invitation to be vaccinated but patient pays.

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

Comparison: 2 Enhancing vaccination access

Outcome: 5 Free influenza vaccine compared to invitation to be vaccinated but patient pays

Study or subgroup Free vaccination Patient pays Odds Ratio Weight Odds Ratio

n/N n/N

M- H,Random,95%

Nex e 1997 140/195 95/195 17.7 % 2.68 [ 1.76, 4.08 ]

Satterthwaite 1997 422/930 247/931 82.3 % 2.30 [ 1.89, 2.79 ]

Total (95% CI) 1125 1126 100.0 % 2.36 [ 1.98, 2.82 ]

Total events: 562 (Free vaccination), 342 (Patient pays)

Heterogeneity: Tau2 = 0.0; Chi2 = 0.42, df = 1 (P = 0.52); I2 =0.0%

Test for overall effect: Z = 9.55 (P < 0.00001)

Test for subgroup differences: Not applicable

0.01 0.1 1 10 100

Favours patient pays Favours free vaccination

176Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Analysis 2.6. Comparison 2 Enhancing vaccination access, Outcome 6 Free influenza vaccine compared to

no intervention.

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

Comparison: 2 Enhancing vaccination access

Outcome: 6 Free influenza vaccine compared to no intervention

Study or subgroup Free vaccination No intervention Odds Ratio Odds Ratio

n/N n/N

M- H,Random,95%

Nex e 1997 140/195 48/195 7.80 [ 4.97, 12.24 ]

Satterthwaite 1997 422/930 159/930 4.03 [ 3.25, 4.99 ]

0.01 0.1 1 10 100

Favours no intervention Favours free vaccination

177Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Analysis 3.1. Comparison 3 Provider- or system-based intervention, Outcome 1 Reminder (to physician)

compared to no reminder.

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

Comparison: 3 Provider- or system-based intervention

Outcome: 1 Reminder (to physician) compared to no reminder

Study or subgroup

Reminder to

physician No reminder Odds Ratio Odds Ratio

n/N n/N

M- H,Random,95%

Chambers 1991 105/198 53/161 2.30 [ 1.49, 3.54 ]

Chan 2002 1580/4256 1450/4069 1.07 [ 0.98, 1.17 ]

Frank 2004 245/331 248/354 1.22 [ 0.87, 1.70 ]

Kumar 1999 3334/69469 5266/128431 1.18 [ 1.13, 1.23 ]

0.01 0.1 1 10 100

Favours no reminder Favours physician remind

Analysis 3.2. Comparison 3 Provider- or system-based intervention, Outcome 2 Reminder to physician

about all patients compared to reminder about half patients.

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

Comparison: 3 Provider- or system-based intervention

Outcome: 2 Reminder to physician about all patients compared to reminder about half patients

Study or subgroup Remind Dr all patients

Remind Dr half patients Odds Ratio Weight Odds Ratio

n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI

Chambers 1991 105/198 37/118 100.0 % 2.47 [ 1.53, 3.99 ]

Total (95% CI) 198 118 100.0 % 2.47 [ 1.53, 3.99 ]

Total events: 105 (Remind Dr all patients), 37 (Remind Dr half patients)

Heterogeneity: not applicable

Test for overall effect: Z = 3.71 (P = 0.00021)

Test for subgroup differences: Not applicable

0.01 0.1 1 10 100

Favours remind Dr half patients Favours remind Dr all patients

178Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Analysis 3.3. Comparison 3 Provider- or system-based intervention, Outcome 3 Reminder (to hospital staff

to vaccinate patient) compared to letter to GP on day of discharge.

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

Comparison: 3 Provider- or system-based intervention

Outcome: 3 Reminder (to hospital staff to vaccinate patient) compared to letter to GP on day of discharge

Study or subgroup Remind hospital staff

Discharge letter to

GP Odds Ratio Weight Odds Ratio

n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI

MacIntyre 2003 17/27 9/18 100.0 % 1.70 [ 0.51, 5.70 ]

Total (95% CI) 27 18 100.0 % 1.70 [ 0.51, 5.70 ]

Total events: 17 (Remind hospital staff), 9 (Discharge letter to GP)

Heterogeneity: not applicable

Test for overall effect: Z = 0.86 (P = 0.39)

Test for subgroup differences: Not applicable

0.002 0.1 1 10 500

Favours letter to GP Favours remind hospital staff

179Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Analysis 3.4. Comparison 3 Provider- or system-based intervention, Outcome 4 Posters in clinic displaying

influenza vaccination rates to encourage doctors to compete, plus postcards to patients, compared to no

intervention.

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

Comparison: 3 Provider- or system-based intervention

Outcome: 4 Posters in clinic displaying influenza vaccination rates to encourage doctors to compete, plus postcards to patients, compared to no intervention

Study or subgroup Posters remind Drs No intervention Odds Ratio Weight Odds Ratio

n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI

Buffington 1991 2427/3604 2405/4772 100.0 % 2.03 [ 1.86, 2.22 ]

Total (95% CI) 3604 4772 100.0 % 2.03 [ 1.86, 2.22 ]

Total events: 2427 (Posters remind Drs), 2405 (No intervention)

Heterogeneity: not applicable

Test for overall effect: Z = 15.44 (P < 0.00001)

Test for subgroup differences: Not applicable

0.01 0.1 1 10 100

Favours no intervention Favours posters remind Dr

Analysis 3.5. Comparison 3 Provider- or system-based intervention, Outcome 5 Posters in clinic displaying

influenza vaccination rates to encourage doctors to compete, plus postcards to patients, compared to posters

displaying vaccination rates.

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

Comparison: 3 Provider- or system-based intervention

Outcome: 5 Posters in clinic displaying influenza vaccination rates to encourage doctors to compete, plus postcards to patients, compared to posters displaying vaccination

rates

Study or subgroup Posters + pt postcard Posters Odds Ratio Weight Odds Ratio

n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI

Buffington 1991 2427/3604 1420/2149 100.0 % 1.06 [ 0.95, 1.19 ]

Total (95% CI) 3604 2149 100.0 % 1.06 [ 0.95, 1.19 ]

Total events: 2427 (Posters + pt postcard), 1420 (Posters)

Heterogeneity: not applicable

Test for overall effect: Z = 0.99 (P = 0.32)

Test for subgroup differences: Not applicable

0.01 0.1 1 10 100

Favours posters Favours posters + postcard

180Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Analysis 3.6. Comparison 3 Provider- or system-based intervention, Outcome 6 Facilitator encouragement

of prevention manoeuvres including influenza vaccination compared to no intervention.

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

Comparison: 3 Provider- or system-based intervention

Outcome: 6 Facilitator encouragement of prevention manoeuvres including influenza vaccination compared to no intervention

Study or subgroup Facilitators in practices No intervention Odds Ratio Odds Ratio

n/N n/N

M- H,Random,95%

Hogg 2008 161/188 167/226 2.11 [ 1.27, 3.49 ]

Karuza 1995 105/690 0/812 292.81 [ 18.16, 4721.62 ]

Kerse 1999 14/135 13/132 1.06 [ 0.48, 2.35 ]

0.001 0.01 0.1 1 10 100 1000

Favours no intervention Favours facilitators

181Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Analysis 3.7. Comparison 3 Provider- or system-based intervention, Outcome 7 Educational reminders,

academic detailing, and peer comparisons to physicians compared to mailed educational materials.

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

Comparison: 3 Provider- or system-based intervention

Outcome: 7 Educational reminders, academic detailing, and peer comparisons to physicians compared to mailed educational materials

Study or subgroup

Remind + academic detailing Mailed education Odds Ratio Weight Odds Ratio

n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI

Kim 1999 78/706 69/694 100.0 % 1.13 [ 0.80, 1.58 ]

Total (95% CI) 706 694 100.0 % 1.13 [ 0.80, 1.58 ]

Total events: 78 (Remind + academic detailing), 69 (Mailed education)

Heterogeneity: not applicable

Test for overall effect: Z = 0.67 (P = 0.50)

Test for subgroup differences: Not applicable

0.002 0.1 1 10 500

Favours mailed education Favours academic detailing

Analysis 3.8. Comparison 3 Provider- or system-based intervention, Outcome 8 Chart review and feedback

to physician plus benchmarking to vaccination rates achieved by top 10% of physicians, compared to chart

review and feedback.

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

Comparison: 3 Provider- or system-based intervention

Outcome: 8 Chart review and feedback to physician plus benchmarking to vaccination rates achieved by top 10% of physicians, compared to chart review and feedback

Study or subgroup Chart review + benchmark

Chart review

feedback Odds Ratio Weight Odds Ratio

n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI

Kiefe 2001 122/678 41/682 100.0 % 3.43 [ 2.37, 4.97 ]

Total (95% CI) 678 682 100.0 % 3.43 [ 2.37, 4.97 ]

Total events: 122 (Chart review + benchmark), 41 (Chart review feedback)

Heterogeneity: not applicable

Test for overall effect: Z = 6.50 (P < 0.00001)

Test for subgroup differences: Not applicable

0.01 0.1 1 10 100

Favours review + feedback Favours review + benchmark

182Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Analysis 3.9. Comparison 3 Provider- or system-based intervention, Outcome 9 Educational outreach +

feedback to practice teams versus written feedback to practice teams.

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

Comparison: 3 Provider- or system-based intervention

Outcome: 9 Educational outreach + feedback to practice teams versus written feedback to practice teams

Study or subgroup Outreach + feedback Written feedback Odds Ratio Weight Odds Ratio

n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI

Siriwardena 2002 2822/13633 3543/13947 100.0 % 0.77 [ 0.72, 0.81 ]

Total (95% CI) 13633 13947 100.0 % 0.77 [ 0.72, 0.81 ]

Total events: 2822 (Outreach + feedback), 3543 (Written feedback)

Heterogeneity: not applicable

Test for overall effect: Z = 9.26 (P < 0.00001)

Test for subgroup differences: Not applicable

0.5 0.7 1 1.5 2

Favours written feedback Favours outreach + feedback

183Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Analysis 3.10. Comparison 3 Provider- or system-based intervention, Outcome 10 Payment to physicians

versus no payment.

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

Comparison: 3 Provider- or system-based intervention

Outcome: 10 Payment to physicians versus no payment

Study or subgroup

Payment to

physicians No payment Odds Ratio Weight Odds Ratio

n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI

Ives 1994 311/1228 103/761 85.3 % 2.17 [ 1.70, 2.77 ]

Kouides 1998 36/331 23/495 14.7 % 2.50 [ 1.45, 4.31 ]

Total (95% CI) 1559 1256 100.0 % 2.22 [ 1.77, 2.77 ]

Total events: 347 (Payment to physicians), 126 (No payment)

Heterogeneity: Chi2 = 0.23, df = 1 (P = 0.63); I2 =0.0%

Test for overall effect: Z = 6.99 (P < 0.00001)

Test for subgroup differences: Not applicable

0.1 0.2 0.5 1 2 5 10

Favours no payment Favours physician payment

Analysis 3.11. Comparison 3 Provider- or system-based intervention, Outcome 11 Intervention to increase

staff influenza vaccination rate versus no intervention.

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

Comparison: 3 Provider- or system-based intervention

Outcome: 11 Intervention to increase staff influenza vaccination rate versus no intervention

Study or subgroup

Increase staff vacc

rate No intervention Odds Ratio Weight Odds Ratio

n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI

Abramson 2011 1610/11335 2068/15097 100.0 % 1.04 [ 0.97, 1.12 ]

Total (95% CI) 11335 15097 100.0 % 1.04 [ 0.97, 1.12 ]

Total events: 1610 (Increase staff vacc rate), 2068 (No intervention)

Heterogeneity: not applicable

Test for overall effect: Z = 1.18 (P = 0.24)

Test for subgroup differences: Not applicable

0.5 0.7 1 1.5 2

Favours staff vaccination Favours no intervention

184Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

A D D I T I O N A L T A B L E S

Table 1. Cohort, case-control, and time series studies and reasons for exclusion

Author and date Ref ID Description of groups Reason for exclusion

Historically controlled studies

Barton 1990 1647 1983-84 baseline rates

1984 postcard reminders

1985 postcard reminders +

feedback to service chiefs

1986 postcard reminders +

feedback to service chiefs +

feedback to physicians

Excluded. Could not assess sec-

ular trends for increase in rest of

population

Chodroff 1990 Unknown 1986 historical baseline

1986-90 residents given pre-

ventive checklists

Excluded. Could not assess sec-

ular trends for increase in rest of

population

Davidson 1984 1772 Intervention for nurse

reminder: 50% of eligibles in 2

consecutive years

Control: rest of eligible partici-

pants (called historical controls

but are same years)

Excluded. Could not assess sec-

ular trends for increase in rest of

population

De Wals 1989 1677 1984 baseline

1985 information campaign by

family physicians

1986 same + collective info

campaign

Excluded. Could not assess sec-

ular trends for increase in rest of

population

Donato 2007 2016 2002 nurses screened partici-

pants’ reminders

2003 standing orders

2004 education campaign

Excluded. Could not assess sec-

ular trends for increase in rest of

population

Gill 2000 1114, 1251,

1311

1997 baseline rates

1998 reminder to nurse and

physician during visit

Excluded. Could not assess sec-

ular trends for increase in rest of

population

Harris 1990 1633 Retrospective analysis

1979-80 baseline

1981 nurse prompt

1984 computer prompt

Excluded. Could not assess sec-

ular trends for increase in rest of

population

185Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Table 1. Cohort, case-control, and time series studies and reasons for exclusion (Continued)

Humair 2002 2607 1995 baseline

1996 intervention

Excluded. Could not assess sec-

ular trends for increase in rest of

population

Hutchison 1991 Unknown 1982-83 historical baseline

1987-88 reminder placed on all

charts

Excluded. Could not assess sec-

ular trends for increase in rest of

population

Knoell 1991 1619 1987-88 baseline

1989 intervention

Excluded. Could not assess sec-

ular trends for increase in rest of

population

Malmvall 2007 293 1999-2001 baseline (rates were

increasing)

2002-2005 same intervention

in each of 4 years

(Appears initially to be a time

series but is a series of same re-

peated interventions.)

Excluded. Could not assess sec-

ular trends for increase in rest of

population

2 geographical areas (non-randomised controlled trials)

Etkind 1996 1405 2 Massachusetts counties

1 reimbursement for vaccina-

tion + education campaigns

1 usual care

Excluded. Non-comparable

control

Harris 2006 34 S Adelaide; intervention

N and W Adelaide; control

Excluded. Non-comparable

control

Honkanen 1997 (same

databases as Honkanen 2006)

Unknown Admin Area A: risk of dis-

ease-based influenza vaccina-

tion programme

Admin Area B: age-based vacci-

nation programme offered au-

tumn 1993 and 1994

Admin Area C: age-based vac-

cination programme offered

1992-94

Not randomised. Control areas

may not be comparable.

Honkanen 2006 404 14 municipalities: risk of dis-

ease-based intervention x 2

years

29 municipalities: age-based in-

tervention x 2 years

12 municipalities: cross-over

from disease-based intervention

in 1992 to age-based interven-

tion in 1993

Excluded. Control areas may

not be comparable.

186Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Table 1. Cohort, case-control, and time series studies and reasons for exclusion (Continued)

Retrospective chart reviews

Goebel 2005 564 Retrospective chart review of

physicians who used standing

orders and those who did not

Excluded. Non-comparable

control

Jacobs 2001 1045 Retrospective chart review of

use of interpreters and non-use

Excluded. Non-comparable

control

Cohorts, not historical

Bou-Mias 2006 450 1 group assigned voice mail re-

minders

1 group no voice mail reminders

Excluded. Non-comparable

control

Charles 1994 120 Allocated by physician team:

Control

Intervention

Excluded. Non-comparable

control

Crawford 2005 507 1 group assigned voice mail re-

minders

1 group no voice mail reminders

Excluded. Non-comparable

control

Leirer 1989 1661 2 groups assigned voice mail re-

minders

2 groups no voice mail re-

minders

Excluded. Non-comparable

control

Margolis 1992 No ref ID: found by searching

reference lists

2 clinics assigned as interven-

tion and 2 as control clinics

Excluded. Non-comparable

control

Case-control

Earle 2003 846 Comparison of influenza vac-

cination rates of participants

in SEER (Survival, Epidemiol-

ogy, and End Results) tumour

registry area with case-matched

controls

Participants in the SEER reg-

istry were matched with a 5%

random sample of participants

with no history of cancer. Par-

ticipants were excluded if they

were enrolled in a health main-

tenance organisation or if they

were not eligible for both parts

of Medicare “as they would not

have complete treatment infor-

mation.” The 2 cohorts were

thus not comparable

187Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Table 2. Differences in influenza vaccination percentages in the year before intervention for those randomised controlled trials

providing this information

Author and date Allocation concealment Baseline influenza vaccination

rate treatment group (%)

Baseline influenza vaccination

rate control group (%)

Difference 2% Or less

Abramson 2011 Unclear 43.4 44.4

Arthur 2002 Unclear 48.7 46.7

Barnas 1989 Unclear 5 5

Beck 1997 No 74 72

Clayton 1999 Unclear 0% for not vaccinated

100% for vaccinated

0% for not vaccinated

100% for vaccinated

Frank 2004 Yes 65 66

Ives 1994 Unclear 41.3 40.6

Karuza 1995 Unclear 47.5 46.5

Kiefe 2001 Unclear 40 40

Kim 1999 Unclear 79 80

Kouides 1998 Unclear 57.6 58

Krieger 2000 Yes 0% for not vaccinated

100% for vaccinated

0% for not vaccinated

100% for vaccinated

McCaul 2002 Unclear 0 0

McDowell 1986 Unclear 0 0

CDC 1995b (Montana)

(McMahon Wyoming)

Unclear Participants who received a per-

sonal letter: 23.8

Participants who received a form

letter: 20.5

Participants who received no let-

ter: 21.6

Moran 1995 Unclear 16.7 16.6

Nuttall 2003 Unclear 0 0

Roca 2012 Unclear 50.9 49.1

Difference 3% to 4%

Dietrich 1989 Unclear 36 39

188Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Table 2. Differences in influenza vaccination percentages in the year before intervention for those randomised controlled trials

providing this information (Continued)

Herman 1994 Unclear 31.3 34.3

Lemelin 2001 Unclear 46.1 49.4

Lukasik 1987 No 7.3 4.5

MacIntyre 2003 Yes 61 64

CDC 1995b (Montana)

(McMahon Montana 1994)

Unclear Participants who received a per-

sonal letter: 41.2

Participants who received a form

letter: 46

Participants who received no let-

ter: 42.3

Siriwardena 2002 Unclear 48.6 44.7

Difference 5% or more

Chan 2002 Unclear 31.8 solo

42.5 group practice

37.8 solo

30.1 group practice

Puech 1998 Yes 32 38

Marrero 2006 Unclear 36 14

A P P E N D I C E S

Appendix 1. MEDLINE (Ovid) search strategy

1 Influenza, Human/

2 exp Influenza A virus/

3 exp Influenzavirus B/

4 Influenzavirus C/

5 (influenza or flu or h1n1).tw.

6 or/1-5

7 exp Immunization/

8 exp Vaccines/

9 (immuni* or vaccin*).tw.

10 or/7-9

11 6 and 10

12 Influenza Vaccines/

13 11 or 12

14 exp aged/ or middle aged/

15 ((old* or age*) adj3 (people* or person* or adult* or women* or men* or citizen* or residen*)).tw.

16 (pension* or retire* or elderly or senior* or geriatric*).tw.

17 long-term care/ or nursing care/ or palliative care/

189Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

18 homes for the aged/ or nursing homes/

19 nursing home*.tw.

20 Hospitals/

21 residential facilities/ or assisted living facilities/

22 Health Services for the Aged/

23 (institution* adj3 elderly*).tw.

24 (aged care or hospice* or old people* home*).tw.

25 (“50 years or older” or “55 years or older” or “60 years or older” or “65 years or older” or “70 years or older” or “75 years or older”

or “80 years or older”).tw.

26 (“older than 50” or “older than 55” or “older than 60” or “older than 65” or “older than 70” or “older than 75” or “older than

80”).tw.

27 or/14-26

28 13 and 27

Appendix 2. Embase (Elsevier) search strategy

#37 #35 AND #36

#36 #14 AND #29

#35 #33 NOT #34

#34 ’animal’/exp NOT (’animal’/exp AND ’human’/exp)

#33 #30 OR #31 OR #32

#32 allocat*:ti,ab OR assign*:ti,ab OR crossover*:ti,ab OR ’cross over*’:ti,ab OR factorial:ti,ab OR placebo*:ti,ab OR random*:ti,ab

OR trial*:ti,ab OR volunteer*:ti,ab

#31 ((single OR double OR triple OR treble) NEAR/3 (blind* OR mask*)):ti,ab

#30 ’crossover procedure’/de OR ’double blind procedure’/de OR ’randomized controlled trial’/de OR ’single blind procedure’/de

#29 #15 OR #16 OR #17 OR #18 OR #19 OR #20 OR #21 OR #22 OR #23 OR #24 OR #25 OR #26 OR #27 OR #28

#28 ’older than 50’:ti,ab OR ’older than 55’:ti,ab OR ’older than 60’:ti,ab OR ’older than 65’:ti,ab OR ’older than 70’:ti,ab OR ’older

than 75’:ti,ab OR ’older than 80’:ti,ab

#27 ’50 years or older’:ti,ab OR ’55 years or older’:ti,ab OR ’60 years or older’:ti,ab OR ’65 years or older’:ti,ab OR ’70 years or older’:

ti,ab OR ’75 years or older’:ti,ab OR ’80 years or older’:ti,ab

#26 ’aged care’:ti,ab OR hospice*:ti,ab OR ’old people* home*’:ti,ab

#25 (institution* NEAR/3 elderly*):ti,ab

#24 ’elderly care’/de

#23 ’residential home’/de OR ’assisted living facility’/de

#22 ’hospital’/de OR ’geriatric hospital’/de

#21 ’nursing home*’:ti,ab

#20 ’home for the aged’/de OR ’nursing home’/de

#19 ’long term care’/de OR ’nursing care’/de OR ’palliative therapy’/de OR ’palliative nursing’/de

#18 pension*:ti,ab OR retire*:ti,ab OR elderly:ti,ab OR senior*:ti,ab OR geriatric*:ti,ab

#17 ((old* OR age*) NEAR/3 (people* OR person* OR adult* OR women* OR men* OR citizen* OR residen*)):ti,ab

#16 ’middle aged’/de

#15 ’aged’/exp

#14 #12 OR #13

#13 ’influenza vaccine’/de

#12 #7 AND #11

#11 #8 OR #9 OR #10

#10 immuni*:ti,ab OR vaccin*:ti,ab

#9 ’vaccine’/exp

#8 ’immunization’/exp

#7 #1 OR #2 OR #3 OR #4 OR #5 OR #6

#6 influenza:ti,ab OR flu:ti,ab OR h1n1:ti,ab

#5 ’seasonal influenza’/de

190Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

#4 ’influenza c virus’/de

#3 ’influenza b virus’/exp

#2 ’influenza a virus’/exp

#1 ’influenza’/de

Appendix 3. CINAHL (EBSCO) search strategy

1. (MH “influenza vaccine”)

2. AB (influenza or flu) or TI (influenza or flu)

3. AB (vaccin* or immuni*) or TI (vaccin* or immuni*)

4. 2 and 3

5. 1 or 4

6. (MH “aged”) or (MH “aged, 80 and over”)

7. AB (aged or elderly or senior*) or TI (aged or elderly or senior*)

8. 6 or 7

9. 5 and 8

10. Limit 9 to Publication Type: Clinical Trial, Systematic Review

11. ((MH “Clinical Trials”) or (MH “Meta Analysis”) or (MH “Systematic Review”) or (MH “Concurrent Prospective Studies”) or

(MH “Prospective Studies”) or (MH “Placebos”) or (MH “Evaluation Research”)

12. TI ((single or double or triple or treble) and (blind* or mask*))

13. AB ((single or double or triple or treble) and (blind* or mask*))

14. TI ((systematic or synthesis) and (review* or overview*))

15. AB ((systematic or synthesis) and (review* or overview*))

16. TI (allocat* or assign* or control* or crossover* or cross over* or factorial or groups or metaanalys* or meta analys* or metanalys*

or placebo* or rct* or random* or trial* or volunteer*)

17. AB (allocat* or assign* or control* or crossover* or cross over* or factorial or groups or metaanalys* or meta analys* or

metanalys* or placebo* or rct* or random* or trial* or volunteer*)

18. 11 or 12 or 13 or 14 or 15 or 16 or 17

19. 9 and 18

20. 10 or 19

Appendix 4. ERIC (ProQuest) search strategy

ALL(((influenza* OR flu OR h1n1) AND (immuni* OR vaccin*)) AND ((elderly OR senior* OR retire* OR pension* OR geriatric*)

OR (old* NEAR/3 people* OR old* NEAR/3 person* OR old* NEAR/3 adult* OR old* NEAR/3 women* OR old* NEAR/3 men*

OR old* NEAR/3 citizen* OR old* NEAR/3 residen*) OR (aged NEAR/3 people* OR aged NEAR/3 person* OR aged NEAR/3

adult* OR aged NEAR/3 women* OR aged NEAR/3 men* OR aged NEAR/3 citizen* OR aged NEAR/3 residen*) OR (nursing

NEAR/2 home* OR home* NEAR/3 aged OR “aged care” OR retire* NEAR/2 home*) OR (“50 years or older” OR “55 years or

older” OR “60 years or older” OR “65 years or older” OR “70 years or older” OR “75 years or older” OR “80 years or older”) OR

(“older than 50” OR “older than 55” OR “older than 60” OR “older than 65” OR “older than 70” OR “older than 75” OR “older

than 80”)))

191Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Appendix 5. Previous search details

For the 2014 update we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2014, Issue 5), which contains

the Cochrane Acute Respiratory Infections Group’s Specialized Register, to 4 June 2014, MEDLINE (January 2010 to 4 June 2014),

PubMed (January 2010 to 4 June 2014), Embase (Ovid) (January 2010 to 4 June 2014), CINAHL (January 2010 to 4 June 2014)

and ERIC (Proquest) (January 2010 to 4 June 2014). We searched MEDLINE and CENTRAL using the search strategy described

in Appendix 1. We combined the MEDLINE search with the Cochrane Highly Sensitive Search Strategy for identifying randomised

trials in MEDLINE: sensitivity-maximising version (2008 revision); Ovid format (Lefebvre 2011). We adapted the MEDLINE search

strategy to search PubMed (search listed in this Appendix), Embase (Ovid) (search listed in this Appendix), CINAHL (Appendix 3)

and ERIC (Proquest) (Appendix 4). We applied no language or publication restrictions.

For the 2010 search we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2010, issue 3), containing the Cochrane Acute Respiratory Infections Group’s Specialized Register, MEDLINE (January 1950 to July 2010), PubMed

(January 1950 to July 2010), EMBASE (1980 to 2010 Week 28), AgeLine (1978 to July 2010), ERIC (1965 to July 2010) and

CINAHL (1982 to July 2010). PubMed was searched using the PubMed strategy listed in (Appendix 5). Embase (Ovid) was searched

using the Embase strategy listed in this Appendix. CINAHL was searched using the strategy in Appendix 3. Search strategies for the

other databases are presented below in this Appendix. No language or publication restrictions were applied.

MEDLINE (OVID 1950 to 1 July 2010)

1. influenza, human or exp influenzavirus a/ or exp influenzavirus b/ or influenzavirus c/

2. (influenza* or flu).tw.

3. 1 or 2

4. vaccines/ or exp immunization/

5. (immuni* or vaccin*).tw.

6. 4 or 5

7. 3 and 6

8. influenza vaccines/

9. 7 or 8

10. limit 9 to (“middle aged (45 plus years” or “all aged (65 and over)” or “aged (80 and over)”

11. exp middle aged/ or exp aged/ or homes for the aged/ or health services for the aged/

12. (elderly or senior*).tw.

13. 11 or 12

14. 9 and 13

15. 10 or 14

16. (controlled clinical trial or meta analysis or randomized controlled trial).pt.

17. drug therapy.fs.

18. (groups or placebo* or random* or trial*).tw.

19. 16 or 17 or 18

20. 15 and 19

21. limit 20 to animals

22. limit 20 to (humans and animals)

23. 21 not 22

24. 20 not 23

PubMed

1. influenza, human[MeSH] or influenzavirus a[MeSH] or influenzavirus b[MeSH] or influenzavirus c[MeSH]

2. influenza[tiab] or flu[tiab]

3. 1 or 2

4. Vaccines[MeSH:noexp] or immunization[MeSH]

5. (immuni*[tiab] or vaccin*[tiab]

6. 4 or 5

7. 3 and 6

8. influenza vaccines[MeSH]

9. 7 or 8

10. limit 9 to (“middle aged (45 plus years” or “all aged (65 and over)” or “aged (80 and over)”

11. middle aged[MeSH] or aged[MeSH] or homes for the aged[MeSH] or health services for the aged[MeSH]

192Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

12. elderly[tiab] or senior*[tiab]

13. 11 or 12

14. 9 and 13

15. 10 or 14

16. controlled clinical trial[pt] or randomized controlled trial[pt]

17. drug therapy[sh]

18. (groups[tiab] or placebo[tiab] or randomized[tiab] or randomly[tiab] or trial[tiab]

19. 16 or 17 or 18

20. 15 and 19

21. animals [mh] NOT humans [mh]

22. 20 not 21

Embase (Ovid)

1. influenza/ or influenza A/ or exp influenza virus/

2. (influenza or flu).tw.

3. 1 or 2

4. exp immunization/ or exp vaccine/

5. (immun* or vaccin*).tw.

6. 4 or 5

7. 3 and 6

8. influenza vaccine/ or influenza vaccination/

9. 7 or 8

10. limit 9 to (adult <18 to 64 years> or aged (<65+ years>)

11. aged/ or exp elderly care/

12. (elderly or senior*).tw.

13. 11 or 12

14. 9 and 13

15. 10 or 14

16. crossover procedure/ or double blind procedure/ o randomized controlled trial/ or single blind procedure/

17. ((single or double or triple or treble) adj3 (blind* or mask*)).tw.

18. (allocat* or assign* or crossover* or cross over* or factorial or placebo* or random* or trial* or volunteer*).tw.

19. 16 or 17 or 18

20. 15 and 19

21. limit 20 to human

22. limit 20 to animal studies

23. 22 not 21

24. 20 not 23

Cochrane CENTRAL Register of Controlled Trials (CENTRAL) (Issue 3 2010)

1. influenza, human or exp influenzavirus a/ or exp influenzavirus b/ or influenzavirus c/

2. (influenza* or flu).tw.

3. 1 or 2

4. vaccines/ or exp immunization/

5. (immuni* or vaccin*).tw.

6. 4 or 5

7. 3 and 6

8. influenza vaccines/

9. 7 or 8

10. limit 9 to (“middle aged (45 plus years” or “all aged (65 and over)” or “aged (80 and over)”

11. exp middle aged/ or exp aged/ or homes for the aged/ or health services for the aged/

12. (elderly or senior*).tw.

13. 11 or 12

14. 9 and 13

15. 10 or 14

16. (controlled clinical trial or meta analysis or randomized controlled trial).pt.

193Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

17. drug therapy.fs.

18. (groups or placebo* or random* or trial*).tw.

19. 16 or 17 or 18

20. 15 and 19

21. limit 20 to animals

22. limit 20 to (humans and animals)

23. 21 not 22

24. 20 not 23

AgeLine (OVID 1978 to 1 July 2010)

1. (influenza or flu).tw.

2. (immun* or vaccin*).tw.

3. 1 and 2

4. ((single or double or triple or treble) adj3 (blind* or mask*)).tw.

5. (control* or crossover* or cross over* or factorial or groups or placebo* or rct* or random* or trial* or volunteer*).tw.

6. 4 or 5

7. 3 and 6

ERIC (OVID 1965 to July 2010)

1. (influenza or flu).kw,tw.

2. (immun* or vaccin*).kw,tw.

3. 1 and 2

4. (aged or elderly or senior*).kw,tw.

5. 3 and 4

6. ((single or double or triple or treble) adj3 (blind* or mask*)).kw,tw.

7. (control* or cross over* or crossover* or factorial or groups or placebo* or rct* or random* or trial* or volunteer*).kw,tw.

8. 6 or 7

9. 5 and 8

Appendix 6. WHO ICTRP search strategy

influenza* AND immuni* AND elderly OR flu AND immuni* AND elderly OR h1n1 AND immuni* AND elderly OR influenza*

AND vaccin* AND elderly OR flu AND vaccin* AND elderly OR h1n1 AND vaccin* AND elderly OR influenza* AND immuni*

AND senior* OR flu AND immuni* AND senior* OR h1n1 AND immuni* AND senior* OR influenza* AND vaccin* AND senior*

OR flu AND vaccin* AND senior* OR h1n1 AND vaccin* AND senior* OR influenza* AND immuni* AND retire* OR flu AND

immuni* AND retire* OR h1n1 AND immuni* AND retire* OR influenza* AND vaccin* AND retire* OR flu AND vaccin* AND

retire* OR h1n1 AND vaccin* AND retire* OR influenza* AND immuni* AND pension* OR flu AND immuni* AND pension*

OR h1n1 AND immuni* AND pension* OR influenza* AND vaccin* AND pension* OR flu AND vaccin* AND pension* OR h1n1

AND vaccin* AND pension* OR influenza* AND immuni* AND geriatric* OR flu AND immuni* AND geriatric* OR h1n1 AND

immuni* AND geriatric* OR influenza* AND vaccin* AND geriatric* OR flu AND vaccin* AND geriatric* OR h1n1 AND vaccin*

AND geriatric* OR influenza* AND immuni* AND old OR flu AND immuni* AND old OR h1n1 AND immuni* AND old OR

influenza* AND vaccin* AND old OR flu AND vaccin* AND old OR h1n1 AND vaccin* AND old OR influenza* AND immuni*

AND “older people” OR flu AND immuni* AND “older people” OR h1n1 AND immuni* AND “older people” OR influenza* AND

vaccin* AND “older people” OR flu AND vaccin* AND “older people” OR h1n1 AND vaccin* AND “older people” OR influenza*

AND immuni*

194Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Appendix 7. ClinicalTrials.gov search strategy

(influenza OR flu OR h1n1)

AND

(immunization OR immunizing OR immunized OR immunizations OR immunisation OR immunising OR immunised OR immu-

nisations OR vaccination OR vaccinating OR vaccinated OR vaccine OR vaccines)

AND

(elderly OR senior OR seniors OR retired OR retirees OR pensioner OR pensioners OR geriatric OR aged OR nursing OR old OR

older)

Appendix 8. Randomised controlled trials without baseline influenza vaccination rates for the year before the intervention

Baker 1998; Berg 2004; Black 1993; Buffington 1991; Chambers 1991; Dalby 2000; Dapp 2011; Díaz Grávalos 1999; Garcia-Aymerich

2007; Hogg 1998; Hogg 2008; Hull 2002; Humiston 2011; Kellerman 2000; Kerse 1999; Maglione 2002a; Maglione 2002b; Maglione

2002c; Maglione 2002d; Minor 2010; Moran 1992; Moran 1996; Morrissey 1995; Mullooly 1987; Nexøe 1997; Satterthwaite 1997;

Smith 1999; Spaulding 1991. Incomplete prior year vaccination rates for Moran 1996.

F E E D B A C K

Interventions to increase influenza vaccination rates of those 60 years and older in the community, 27 October 2010

Summary

In the systematic review by Thomas et al. (Thomas 2010) titled Interventions to increase influenza vaccination rates of those 60 years

and older in the community, the authors, in our opinion, fail to emphasize 2 key issues. While we do not dispute the findings that the

methods proposed may increase compliance in influenza vaccine use, we question the relevance of reporting these results.

(1) The authors acknowledge the findings of a recently published systematic review Vaccines for preventing influenza in the elderly

(Jefferson 2010), which concludes that ?available evidence is of poor quality and provides no guidance regarding the safety, efficacy or

effectiveness of influenza vaccines for people aged 65 years or older.? Despite the recognition that current evidence is limited and is of

poor quality, the authors proceed to defer to clinical practice guidelines in place since 1964 rather than stressing the importance that

a large-scale, publicly-funded placebo-controlled RCT is required to assess the value of vaccinating the community-dwelling elderly

population.

(2) In their review, Jefferson et al. found no difference in rates of adverse events between people who received vaccination and those

who did not. However, adverse events occurring within one week of vaccine administration were assessed. Jefferson et al. also mention

rare adverse events from vaccination but do not provide any detail, presumably because this data is from observational studies, as

opposed to an RCT. Although the current literature on risk of serious adverse events is conflicting, this should not preclude patients

and clinicians from being made aware of potential adverse effects of influenza vaccination. In addition, the prevalence of adverse events

may substantially increase when a larger population is exposed to the vaccine.

(3) In our opinion, the conclusion of the review by Thomas et al. should include a definitive statement regarding the need for more

robust evidence from properly designed studies on influenza vaccination, as well as an appeal to readers to consider the major gaps

in the evidence. We think the conclusion should say that there is insufficient evidence that the vaccine improves clinical outcomes

in the elderly. In addition, one cannot rule out the possibility that the vaccine increases the risk of serious harm. That being said,

there is evidence that certain methods increase vaccination rates (e.g. postcards to patients) however this finding is of limited clinical

importance based on the aforementioned concerns.

We look forward to hearing your comments.

Reference: Jefferson T, Di Pietrantonj C, Al-Ansary LA, Ferroni E, Thorning S, Thomas RE. Vaccines for preventing influenza in the

elderly. Cochrane Database of Systematic Reviews 2010, Issue 2. Art. No.: CD004876. DOI: 10.1002/14651858.CD004876.pub3.

Submitter agrees with default conflict of interest statement: I certify that I have no affiliations with or involvement in any organization

or entity with a financial interest in the subject matter of my feedback.

195Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

Updated reply (24 April 2018). The Background and the Author’s conclusions sections now quote in detail the conclusions of the

Cochrane Reviews on influenza vaccine for people aged 60 years and older (Demicheli 2018) and influenza vaccine for health care

workers who look after people aged 60 years and older in institutions (Thomas 2016), and the authors’ conclusions now also state the

need for a publicly funded RCT as advocated in the Cochrane Review of which I am also an author (Demicheli 2018). Thanks, Roger

Thomas.

The reply is keyed to the numbers in the feedback above.

(1) The opening sentence of the present review is: “A review (Demicheli 2018) of the effectiveness of influenza vaccine in seniors

includes 75 studies and 100 data sets. One RCT showed benefits against influenza symptoms but was underpowered to detect effects

on complications (1348 participants). Other data sets were not randomised and were which were likely to contain biases. The review

was unable to reach conclusions about the effects of the vaccines in persons 65 or older.”

The ACIP statement for 2010 ( www.cdc.gov downloaded on 27 May 2011) may not have been formulated when the results of the

Jefferson (2010) Cochrane review were available and stated that the recommendations for influenza vaccination for 2010 are:

• All persons aged 6 months and older should be vaccinated annually.

• Protection of persons at higher risk for influenza-related complications should continue to be a focus of vaccination efforts as

providers and programs transition to routine vaccination of all persons aged 6 months and older.

• When vaccine supply is limited, vaccination efforts should focus on delivering vaccination to persons who:

◦ are aged 6 months--4 years (59 months);

◦ are aged 50 years and older;

◦ have chronic pulmonary (including asthma), cardiovascular (except hypertension), renal, hepatic, neurologic, hematologic,

or metabolic disorders (including diabetes mellitus);

◦ are immunosuppressed (including immunosuppression caused by medications or by human immunodeficiency virus);

◦ are or will be pregnant during the influenza season;

◦ are aged 6 months--18 years and receiving long-term aspirin therapy and who therefore might be at risk for experiencing

Reye syndrome after influenza virus infection;

◦ are residents of nursing homes and other chronic-care facilities;

◦ are American Indians/Alaska Natives;

◦ are morbidly obese (body-mass index is 40 or greater);

◦ are health-care personnel;

◦ are household contacts and caregivers of children aged younger than 5 years and adults aged 50 years and older, with

particular emphasis on vaccinating contacts of children aged younger than 6 months; and

◦ are household contacts and caregivers of persons with medical conditions that put them at higher risk for severe

complications from influenza.

The present review and the Jefferson (2010) review were conducted in the same time frame and their conclusions became available at

about the same time and neither group of reviewers could have anticipated the utility or conclusions of their review compared to the

other review or the ACIP recommendations (which their systematic reviews were planned to test).

(2) The commentators are correct that minimal data about potential harms is available. The Jefferson (2010) review concluded:

“Seven studies included in our safety assessment are described below: Four RCTs (Govaert 1993; Keitel 1996; Margolis 1990a; Treanor

1994).

Three surveillance studies with a non-comparative design assessing rare events (Guillan Barré Syndrome (GBS)) (Kaplan 1982; Lasky

1998; Schonberger 1979) were commented on in the text but were not included in our meta-analysis. One RCT assessed a vaccine

which has not been in production for decades (Stuart 1969). Its harms data were not extracted.”

One of the purposes of the larger publicly funded RCT advocated in the conclusions of both reviews would be to assess potential harms.

(3) The conclusions of the present review made precisely the recommendation that the commentators make above and recommended

using the findings of the present study (how to increase uptake of vaccine) to improve execution of the larger publicly funded study of

vaccine effectiveness both reviews recommend:

“The review by Demicheli 2018, which was updated at the same time as this review was being completed, found evidence only from

one RCT to support influenza vaccination in persons 65 and over and the remainder of the 100 data sets were non-RCTs subject to

unknown biases. In the present review, out of 44 RCTs only five RCTs were found to be at low risk and six at moderate risk of bias.

They included three of 13 personalized postcard interventions (all three with the 95% CI above unity), two of the four home visit

interventions (both with 95% CI above unity but one a small study), three of the four reminder to physicians interventions (none

with 95% CI above unity) and three of the four facilitator interventions (one with 95% CI above unity and one P < 0.01). The

196Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

http://www.cdc.gov

other 33 RCTs were at high risk of bias and no recommendations for practice can be drawn. Demicheli 2018 recommends that an

adequately powered publicly-funded (to avoid influences from drug companies) placebo-controlled RCT needs to be conducted over

several influenza seasons. Evidence from such an RCT is thus required to prove that the interventions which we identified as effective

should be implemented. These two reviews have identified that we have not yet established the secure evidence base required to prove

that vaccination of those 65 and over is effective. The RCT recommended by Demicheli 2018 to measure the effectiveness of influenza

vaccine in older persons should maximize uptake of vaccine by implementing the strategies we found effective in increasing influenza

vaccination rates.“

Contributors

Michelle Co, BScPharm

Hayley Coe, BScPharm

Sarah West, BSc, BScPharm

Aaron Tejani, BScPharm, PharmD

W H A T ’ S N E W

Last assessed as up-to-date: 7 December 2017.

Date Event Description

19 July 2018 Amended Text in the Abstract and Effects of interventions sections has been edited to improve clarity

H I S T O R Y

Protocol first published: Issue 2, 2005

Review first published: Issue 9, 2010

Date Event Description

7 December 2017 New search has been performed In this update we included three new studies (Conner

2017; Leung 2017; Stuck 2015). We excluded two ran-

domised controlled trials published in Korean that we

identified in the previous update; we sought, but did

not receive, additional information from the authors

(Lee 2003; Song 2000). We have requested additional

data for Hurley 2017 (Studies awaiting classification).

7 December 2017 New citation required but conclusions have not

changed

The addition of the three new studies did not change

our conclusions

4 June 2014 New search has been performed Searches updated. We included 13 new trials (

Abramson 2011; Dapp 2011; Garcia-Aymerich 2007;

Humiston 2011; Kumar 1999; Maglione 2002a;

Maglione 2002b; Maglione 2002c; Maglione 2002d;

197Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

(Continued)

Minor 2010; Moran 1996; Morrissey 1995; Roca

2012), and identified two potentially relevant trials

that are awaiting translation (Lee 2003a; Song 2000a)

4 June 2014 New citation required and conclusions have changed In this update we concluded that letters and postcards,

tailored letters/postcards or phone calls, educating pa-

tients, home visits, offering free vaccination, some re-

minders to physicians, paying physicians for improved

vaccination rates, and using facilitators in clinics were

all effective in increasing influenza vaccination rates.

However, using educational reminders and feedback

to physicians were not effective

3 May 2011 Feedback has been incorporated Feedback comment added to review.

30 January 2008 Amended Converted to new review format

23 November 2007 New citation required and major changes Substantive amendment

C O N T R I B U T I O N S O F A U T H O R S

Roger E Thomas designed the review, assessed articles for inclusion, performed the analyses, and wrote the text.

Diane L Lorenzetti assessed articles for inclusion and edited and approved the text.

D E C L A R A T I O N S O F I N T E R E S T

Roger E Thomas: none known.

Diane L Lorenzetti: none known.

S O U R C E S O F S U P P O R T

Internal sources

• None, Other.

198Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)

External sources

• No sources of support, Other.

D I F F E R E N C E S B E T W E E N P R O T O C O L A N D R E V I E W

None.

I N D E X T E R M S

Medical Subject Headings (MeSH)

∗Reminder Systems; Attitude of Health Personnel; Community Participation; Health Services Needs and Demand; Immunization

Programs [∗methods]; Influenza Vaccines [∗administration & dosage]; Influenza, Human [∗prevention & control]; Randomized Con-

trolled Trials as Topic; Vaccination [∗utilization]

MeSH check words

Aged; Humans; Middle Aged

199Interventions to increase influenza vaccination rates of those 60 years and older in the community (Review)