Influenza Immunization Rates Research Articles

Influenza vaccination coverage among medical residents

Although influenza vaccination is recognized to be safe and effective, recent studies have confirmed that immunization coverage among health care workers remain generally low, especially among medical residents (MRs). Aim of the present multicenter study was to investigate attitudes and determinants associated with acceptance of influenza vaccination among Italian MRs. A survey was performed in 2012 on MRs attending post-graduate schools of 18 Italian Universities. Each participant was interviewed via an anonymous, self-administered, web-based questionnaire including questions on attitudes regarding influenza vaccination. A total of 2506 MRs were recruited in the survey and 299 (11.9%) of these stated they had accepted influenza vaccination in 2011–2012 season. Vaccinated MRs were older (P = 0.006), working in clinical settings (P = 0.048), and vaccinated in the 2 previous seasons (P < 0.001 in both seasons). Moreover, MRs who had recommended influenza vaccination to their patients were significantly more compliant with influenza vaccination uptake in 2011–2012 season (P < 0.001). “To avoid spreading influenza among patients” was recognized as the main reason for accepting vaccination by less than 15% of vaccinated MRs.Italian MRs seem to have a very low compliance with influenza vaccination and they seem to accept influenza vaccination as a habit that is unrelated to professional and ethical responsibility. Otherwise, residents who refuse vaccination in the previous seasons usually maintain their behaviors. Promoting correct attitudes and good practice in order to improve the influenza immunization rates of MRs could represent a decisive goal for increasing immunization coverage among health care workers of the future.

Employing a Multifaceted Approach Aimed at Increasing Influenza Vaccination Rates

Improving influenza vaccination rates continues to be a challenge faced by healthcare providers every flu season. A great amount of time and resources are devoted each year towards advertisement and awareness campaigns aimed at improving public participation. However, despite continued efforts by providers to improve influenza immunization rates in their respective communities, it was reported by the CDC that the influenza immunization rate for all people’s ≥6 months of age during the 2013-2014 flu season was 46.2%. The results reported were obtained via an analysis of state and national telephone survey data in the United States that captured an unweighted sample size of 481,432 individuals through the use of the NIS-Flu and BRFSS telephone survey systems [1]. The 2013-2014 influenza immunization rate falls far short of influenza vaccination goals set by Healthy People 2020. This goal aims to achieve an 80% influenza vaccination rate among individuals 6 months to 64 years old including all pregnant women and a 90% rate among all high risk or institutionalized adults, adults >64 years, and healthcare personnel [2]. Pharmacists have the opportunity as one of the most trusted and accessible healthcare professionals to positively impact vaccination rates throughout their community.

Pharmacy-based Immunization in Rural Communities Strategy (PhICS): A community cluster-randomized trial.

Influenza is a major cause of morbidity and mortality in Canada, with up to 7000 influenza-related deaths occurring every year. The elderly and individuals with chronic diseases are at increased risk for influenza-related morbidity and mortality. We conducted a 2-year, community cluster-randomized trial targeting elderly people and at-risk groups to assess the effectiveness of pharmacy-based influenza vaccination clinics on influenza vaccination rates. Small rural communities in interior and northern British Columbia were randomly allocated to the intervention or control. In the intervention communities, pharmacy-based influenza vaccination clinics were held and were promoted to eligible patients using personalized invitations from the pharmacists, invitations distributed opportunistically by a pharmacist to eligible patients presenting to pharmacies during the flu season and community-wide promotion using posters and the local media. The main outcome measure was a difference in the mean influenza vaccination rates. The immunization rates were calculated using the number of immunizations given in each community divided by the population size estimated from the census data. Baseline influenza immunization rates in the population ≥65 years of age were the same in the control (n = 10, mean 85.6% [SD 16.6]) and intervention (n = 14, mean 83.8% [SD 16.3]) communities in 2009 (p = 0.79). In 2010, the mean influenza immunization rate was 56.9% (SD 28.0) in the control communities (n = 15) and 80.1% (SD 18.4) in the intervention communities (n = 14) (p = 0.01) for those ≥65 years of age. However, in 2010, for those 2 to 64 years with chronic medical conditions, the immunization rates were lower in the intervention communities (mean 16.3% [SD 7.1]) compared with the control communities (mean 21.2% [SD 5.8]) (p = 0.04). Clinics were feasible and well attended and they resulted in increased vaccination rates for elderly residents. In contrast, vaccination rates in the younger population with comorbidities remained low and unchanged.

Flu Vaccination Acceptance among Children and Awareness of Mothers in Japan

BackgroundIn Japan, a number of people who die from influenza are still increasing however seasonal influenza immunization rates among children are still low and estimated to be around 30%. Given these circumstance we organized questionnaire surveys from 2009 to 2010 to examine the factors influencing awareness of mothers under frame work of Health Belief Model (HBM) that affect seasonal flu immunization acceptance among children. MethodFrom 2009 to 2010, we sent questionnaires to randomly selected university graduated women. The questionnaire asked their age, seasonal flu immunization status of their children, working status, subjective life standards, regions where they live, perceived severity of flu to their children, perceived susceptibility to flu of their children, perceived efficacy or non-efficacy of flu vaccination on their children, barriers to vaccination such that flu vaccination is non-mandatory, fear for side effect, busy and others, cues to the action such as family doctors recommendations and willing to pay (WTP). After the correlation of each variable was tested by spearman test (SPSS 17.0) adjusted logistic regression analysis predicting routine vaccination was done. Results; we sent 554 questionnaires to women and 226 mothers (Age 44.67±5.09) responded and 220 responses were analyzed. Among children of respondents, 41.2% were routinely flu shot vaccinated. From the multivariate logistic regression model, HBM framework showed that perceived susceptibility to flu of their children's (aOR=1.46, p>0.05), perceived severity of flu (aOR=1.14, p>0.05) to their children, perceived non-efficacy of flu vaccination on their children (aOR=0.12, p<0.01), and cue to the action such as family doctors’ recommendations (aOR=2.47, p<0.01) and knowing of the flu vaccination subsidy (aOR=1.96, p>0.05) were positive factors for flu immunization acceptance. On contrary, barriers such as subjective lower life standard (aOR=0.59, p<0.05), flu-shot was not mandatory (aOR=0.15, p<0.01), fear from side effects (aOR=0.31, p<0.05) and number of children (aOR=0.64, p<0.05) were negative factors. Discussion; Correct education and knowledge dissemination for mothers are necessary to raise the low coverage rate of their children in order to prepare potential future flu pandemic.

Improving the rate of influenza vaccination in pediatric patients with cancer.

49 Background: Pediatric patients with cancer are at increased risk of influenza, with high mortality, morbidity, and delay of cancer therapy. CDC guidelines support yearly vaccination in these patients. In prior years at our center, only 53-56% of pediatric cancer patients received at least one dose of the vaccine. Our objective was to increase the rates of influenza vaccination in pediatric cancer patients through a multi-faceted QI initiative. Methods: Five interventions were instituted concomitantly, in eligible patients (&gt;6 months old, &gt;100 days from BMT if applicable, and within 1 year of chemotherapy) over a 6-month period (9/1/12 to 3/31/13). 1) Family education: provision of influenza/vaccine handouts to families in clinic waiting rooms; 2) Health informatics intervention: via electronic health records, generation of daily lists of patients due for doses with automated email lists to triage and nurses; 3) Clinical process interventions: standardization of triage process to identify patients needing vaccination and provision of colored wristbands to such patients alerting providers to order the vaccine, or document refusals, during the encounter; 4) Inpatient orders: influenza vaccine order built into computerized physician admission order set to trigger vaccination upon discharge; and 5) Provider education: printed materials and tutorials for staff at conferences on proper screening of patients, vaccine ordering/dose, and correct documenting of refusals/contraindications. These processes were iteratively refined over the 6-month timeframe. Results: Influenza immunization rates increased by 20% after the changes were implemented; this was seen across all tumor subgroups. Overall, 74% of patients received at least one dose as compared with 52% in the prior year. 61% of patients were fully immunized (vs. 42% in 2011-12). Immunizations were deferred due to allergy/refusal in 8% of patients (vs. 7% in 2011-12). Consequently, only 18% of eligible patients were unimmunized as compared to 41% in the prior year. Conclusions: Technology, education, and clinical process changes led to a successful increase in influenza vaccination rates. Ongoing efforts will target subgroups with lowest overall rates of immunization.

Rates of immunization against pandemic and seasonal influenza in persons at high risk of severe influenza illness: a cross-sectional study among patients of the French Sentinelles general practitioners

BackgroundThree main categories of persons are targeted by the French influenza vaccination strategy: all persons aged 65 years or over, those aged less than 65 years with certain underlying medical conditions and health care workers. The main objective of this study was to estimate rates of influenza immunization in these target groups attending a medical consultation for two consecutive influenza seasons: 2009–2010 (seasonal and pandemic vaccines) and 2010–2011 (seasonal vaccine).MethodsA standardized questionnaire was mailed to 1323 general practitioners (GPs) of the Sentinelles Network, collecting data on all patients seen on a randomly assigned day. For every patient, following information was collected: age, gender, BMI, presence of any medical condition that increases risk of severe influenza illness, and vaccination status for the three vaccines mentioned.ResultsTwo hundred and three GPs agreed to participate and included 4248 patients. Overall, in persons with high risk of severe influenza, the estimated vaccine coverages (VC) were 60%, (95% CI = 57%; 62%) for the seasonal vaccine in 2010–2011, 61% (59%; 63%) for the seasonal vaccine in 2009–2010 and 23% (21%; 25%), for the pandemic vaccine in 2009–2010. Among people aged 65 years and over (N=1259, 30%) VC was estimated for seasonal vaccines at 72% (70%; 75%) in 2010–2011 and 73% (71%; 76%) in 2009–2010, and 24% (22%; 26%) for the pandemic vaccine. The lowest seasonal VC were observed in younger persons (<65 years) with underlying medical conditions, in particular pregnant women (<10%) and overweight persons (<30%).ConclusionsOur study shows that influenza vaccination coverage among patients of the French Sentinelles general practitioners remains largely below the target of 75% defined by the 2004 French Public Health Law, and underscores the need for the implementation of public health interventions likely to increase vaccination uptake.

Health care worker influenza immunization rates: The missing pieces of the puzzle

Immunization rates are used to assess the level of protection against influenza, but limited data exist on how such rates are measured in health care organizations. We conducted key informant interviews with campaign planners to learn about processes for collecting immunization data, including barriers and facilitating factors for measuring and reporting rates. We conducted telephone interviews with 23 influenza immunization program planners across Canada working in 7 acute care hospitals, 6 continuing care facilities, and 8 public health organizations in 2012. We used content analysis to examine the interview data. The methods used to collect immunization data varied by the size and type of health care organization. Immunization data from different personnel groups were included in immunization rate calculations depending on the local public health reporting requirements and the organization's size. Challenges associated with collecting immunization data and calculating rates included lack of resources for identifying personnel immunized off-site, tracking personnel who declined immunization, identifying non-payroll staff, and interpreting unclear public health reporting requirements. Support from other vaccine providers, public health, employers, and professional and external bodies is needed to provide the necessary information and resources to calculate accurate and complete rates. Further work is needed to refine and standardize the collection of HCW influenza immunization data so that it may be used for surveillance and quality assessment purposes.

Factors associated with influenza vaccination among US children in 2008

Relative to adults, children have a higher risk of influenza-related illnesses, and they play a major role in the spread of infections through a household. Because the primary caregiver is responsible for the overall health of the child, it is important to analyze the relationship between caregiver characteristics and childhood immunizations. This study examined the characteristics of the caregiver, household, and child to identify factors associated with childhood influenza immunizations. Data for children aged 19-35 months (n=25,256) were collected from the 2008 National Immunization Survey (NIS). The studied caregiver characteristics included age, education level, and marital status. Demographic variables included the child's age, sex, race/ethnicity, firstborn status, and insurance status in addition to household size, region, and poverty status. All analyses were weighted to reflect the complex sampling frame of the NIS. Overall, 56.39% of children aged 19-35 months had received a flu vaccination. Factors associated with an increased likelihood of vaccination included the primary caregiver being older, married, and more educated and living in the Northeast. A child with private insurance was more likely to be immunized than a child with any other type of insurance (public: OR 0.6483, 0.5589, 0.7521; no insurance: OR 0.6759, 0.4694, 0.9732). Hispanic children (OR 1.1554, 1.0312, 1.2945) were more likely to be vaccinated than their counterparts. Understanding the characteristics related to the rates of childhood influenza immunization can help policy makers develop and tailor programs to improve immunization education and delivery, especially to the groups that are least likely to participate.

Influenza Immunization in Older Adults with and without Cancer

To compare the likelihood of receiving an influenza immunization in older adults before and immediately after a cancer diagnosis occurring in 2001 and for the same time periods with older adults not diagnosed with cancer. Retrospective analysis comparing influenza immunization rates of Medicare beneficiaries with and without a diagnosis of cancer. Surveillance, Epidemiology, and End Results-Medicare Data. Propensity score matching matched a group of 35,229 persons without cancer with 35,257 individuals diagnosed with cancer in 2001. Receipt of influenza vaccination based upon Medicare Claims Data. A difference-of-difference analysis revealed that influenza immunization rates increased over time for persons diagnosed with cancer (46.8% before to 50.8% after cancer diagnosis), but the increase was greater in beneficiaries without a cancer diagnosis (42.6% to 79.7%) (P < .001; 95% confidence interval = 0.320-0.324). Logistic regression analysis revealed that individuals without a cancer diagnosis were 7.25 times as likely to receive an influenza immunization. Older adults who have been recently diagnosed with cancer receive influenza immunizations at much lower rates than older adults who have not been diagnosed with cancer despite interaction with healthcare providers. Opportunities exist to improve influenza immunization in this population, who are susceptible to influenza because of compromised immune systems.

Evidence-based initiative to improve influenza immunisation participation among undergraduate nursing students

This evidence-based practice study presents the outcome of specific intervention strategies that have been implemented to improve the immunisation status among undergraduate nursing students in a local university. These interventions included education about the importance of the influenza vaccine, email reminders about convenient times and influenza clinic locations, raffles, and an appeal to the moral responsibility that healthcare personnel have to their patients to increase immunisation. Despite these strategies, the overall percentage of nursing students receiving the influenza immunisation only slightly improved: from 43.1% (influenza season 2010–2011) to 46.3% (influenza season 2011–2012). Similar outcomes have been found with employers who have sought to improve employee influenza immunisation rates without mandating immunisation. Given the clinical settings where students are engaged, schools of nursing, regulatory agencies, and clinical sites should not overlook the impact of students on patients regarding influenza. In order to promote patient welfare, while employer-mandated influenza immunisation as a condition for employment becomes more prevalent, perhaps a similar approach may be required to promote influenza immunisation among nursing students.

Impact of the raising immunizations safely and effectively (RISE) program on healthcare worker influenza immunization rates in long term care settings.

National influenza immunization rates for healthcare workers (HCW) in long-term care (LTC) remain unacceptably low. This poses a serious public health threat to residents. Prior work has suggested high staff turnover rates as a contributing factor to low immunization rates. There is a critical need to identify and deploy successful models of HCW influenza immunization programs to LTC facilities. This report describes one potential model that has been successfully initiated in a network of LTC facilities. All facilities served by a single regional LTC pharmacy were invited to participate in a HCW influenza immunization program. This voluntary immunization program began in 2005 and continues to the present. As part of the program, the pharmacy promoted organizational change by assuming oversight and control of HCW immunization policies and processes for all facilities. Primary and secondary outcomes are the number of facilities reaching HCW influenza immunization rates of 60% and 80%. Fourteen of the 16 LTC facilities participated. Facilities were diverse and included both nursing and assisted living facilities; unionized and nonunionized facilities; and urban, suburban, and rural facilities. The pharmacy provided educational and communication materials, centralized data collection using a standardized definition for HCW immunization rates, and facility feedback. All 14 LTC facilities achieved the primary goal of 60% and nearly two thirds reached the secondary goal of 80%. Twenty percent reached the new Healthy People 2020 goal of 90%. It is possible for LTC facilities to improve HCW immunization rates using a pharmacy based, voluntary HCW influenza immunization approach. Such an approach may help attenuate the negative influence of staff turnover on HCW immunizations. Attainment of the new Health People 2020 goals still remains a challenge and may require mandatory programs.

Five years of non-prescription oseltamivir: effects on resistance, immunization and stockpiling

ObjectivesIn 2007 New Zealand (NZ) became the first country to make oseltamivir (Tamiflu®) available off-prescription. This study investigated the extent of pharmacist supply of oseltamivir over 5 years, including during the influenza A(H1N1) pandemic, and the impact of pharmacist supply of oseltamivir on influenza virus oseltamivir susceptibility, personal stockpiling and influenza vaccine uptake.MethodsRandomly selected community pharmacies in NZ reported oseltamivir provision by prescription and through pharmacist supply from 1 January 2007 to 15 September 2011. Oseltamivir resistance data on influenza viruses isolated during influenza surveillance from 2008 to 2011 were obtained, along with influenza vaccine uptake data from 2005 to 2011 and influenza detection data.ResultsSeventy of 85 eligible pharmacies completed the study (82% response rate). Most supplies of oseltamivir throughout the 5 years were dispensed against a prescription rather than pharmacist supplied, with pharmacist supply responsible for 11% of supplies during the pandemic years (2009–10) versus 27% and 31% during 2007 and 2008, respectively. Pharmacist-supplied oseltamivir did not appear to be associated with the development of resistance, with identified likely stockpiling or with a decline in influenza immunization. Pharmacist supplies largely matched the timing of influenza in the community and peaked in June 2009, as did prescription supplies.ConclusionsFive years of non-prescription oseltamivir in NZ has resulted in no significant change in the development of resistance or rates of influenza immunization. Supplies remained modest and significant consumer stockpiling through pharmacist supply has not occurred, even during the influenza A(H1N1)pdm09 pandemic in 2009 and 2010. Pharmacists could be better utilized in ensuring fast distribution of antivirals to influenza sufferers during a pandemic.

Texting Parents to Improve Influenza Immunization Rates

Texting Parents to Improve Influenza Immunization Rates

Improving Influenza Immunization Rates Through a Specialized Clinic Review

Purpose: The purpose of this capstone project was to determine if alternative access by way of a focused immunization clinic rather than a regular physician office visit caused an increase from 2009 to 2010 in the number of people in a rural community who received the influenza vaccine. Reasons why the immunization clinic was chosen by the patient for immunization were identified. Methods: This project was conducted by using a descriptive survey design. A questionnaire was given to individuals who participated in an influenza immunization clinic in a rural community in a southeastern state. Data were collected using a seven-item questionnaire completed by participants. Results: Evaluation of data revealed that 40% of individuals who did not receive their vaccine in 2009 received a flu shot in 2010 through access to the immunization clinic. Conclusion: Evidence suggests that providing alternative access to immunizations in a rural community could potentially improve the rate of participation of individuals.

Resources and Interest Among Faith Based Organizations for Influenza Vaccination Programs

In the United States, annual influenza vaccination rates are suboptimal and are well below the national health objectives. Project VIVA mobilized community members and organizations to implement an influenza vaccination program in Harlem by administering vaccines in "non-traditional" venues, such as community-based organizations, pharmacies, and faith-based organizations (FBOs). FBOs have been recognized as important venues for health promotion initiatives within medically underserved communities. However, data regarding the extent of resources and interest in health promotion programs among FBOs are sparse. We conducted a telephone survey among 115 FBOs in three New York City neighborhoods with histories of low influenza immunization rates to identify the congregation's health concerns, interest in serving as a community-based venue for influenza vaccinations, and existing resources for health programming. Twenty-six percent of the FBOs had an established health ministry, while 45% expressed interest in developing one. Seven percent included nurses among their health activities and 16.5% had contact with the local health department. Most FBOs expressed interest in common health promotions programs; 60% expressed interest in providing on-site influenza vaccination programs within their organization. Health programs within FBOs can be a point of access that may improve the health of their congregants as well as the larger community.

Low Rates of Influenza Immunization in Young Children Under Ontario's Universal Influenza Immunization Program

Low Rates of Influenza Immunization in Young Children Under Ontario's Universal Influenza Immunization Program

Influenza immunisation status among nursing students

This four-phase evidence-based practice initiative was designed to determine preliminary contextual characteristics of collegian nursing students in receiving, or their lack of receiving, the flu vaccine. Subsequently, strategies were developed to improve and maintain the students’ participation in flu vaccines. This study relates to the welfare of student nurses and patients in their care. Students perform patient care in hospitals, clinics, and other settings where patients in compromised health are especially vulnerable to influenza. The Centers for Disease Control and Prevention reported that the 2009 H1N1 pandemic resulted in more than 12,000 influenza-related deaths in the US. The Joint Commission requires hospitals and long-term care facilities to provide on-site access to influenza immunisation to staff and licensed independent practitioners; however, no provisions for student nurses are specified. Employer-mandated influenza immunisation as a term for employment was associated with a significant increase in healthcare employees receiving the flu vaccine, but, in the main, students are currently not mandated to receive the flu vaccine. A one-day reduction of influenza-like illness for every two college and university students vaccinated has been reported. Therefore, improving influenza immunisation rates may have academic and performance benefits for nursing students.

Pediatric influenza immunization in an integrated safety net health care system

ObjectiveIn 2008 the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) recommended that all children aged 6 months to 18 years receive annual influenza vaccine. Full pediatric influenza administration has proven difficult. We compared rates of full influenza immunization between a safety net health care system and CDC sentinel sites and evaluated sociodemographic factors associated with full influenza immunization. Patients and methodsWe matched influenza immunization data for 2008–2009 from a health care system immunization registry with patient demographic/billing data and compared rates to CDC sentinel sites using bivariate analysis. We evaluted immunization rates by patient characteristics using multivariate analysis. ResultsFull influenza immunization was achieved in 32% of Denver Health (DH) children compared to 12% at the CDC sites (p<0.001). The largest differences occurred in children aged 11–12 and 13–18 years, 47% DH vs 12% CDC sites, and 33% DH vs 9% CDC sites respectively, (p<0.001 for both). In multivariate analysis, DH children were more likely to be immunized if they were Asian, Odds Ratio (OR) 1.59 95%CI (CI) 1.32–1.91, or Hispanic OR 1.18 CI 1.07–1.30, compared to white, spoke Spanish OR 1.19 CI 1.13–1.26, or other non-English language OR 2.05 CI 1.80–2.34, and had a greater number of visits for well care OR 2.86 CI 2.74–2.98 and sick/follow-up care OR 1.59 CI 1.56–1.62, during the influenza season. They were less likely to be immunized if they had commercial insurance OR 0.68 CI 0.62–0.75 or were uninsured OR 0.77 CI 0.72–0.80, compared to Medicaid/SCHIP. ConclusionsUsing immunization registry prompts, standing orders, multiple sites and visit types for immunization, an integrated safety net health care system had higher full influenza immunization rates than the CDC sentinel sites singularly or collectively. These procedures can be applied elsewhere to improve influenza immunization rates.

Using Reminder/Recall Systems to Improve Influenza Immunization Rates in Children With Asthma

IntroductionAsthma is a major public health concern in the U.S. pediatric population. Children with asthma tend to fare worse when they acquire respiratory illnesses such as influenza, requiring more episodic office visits and hospitalizations than do healthy children with the same illnesses. Despite the American Academy of Pediatrics recommendation that children with chronic diseases be immunized for seasonal influenza annually, influenza immunization rates in this population peaks at < 30%. The purpose of this literature review was to examine the effectiveness of reminder/recall systems in improving influenza immunization rates among children with asthma. MethodThis literature review was conducted using PubMed, CINAHL, EMBASE, and Cochrane. Of the 178 articles found, 12 met criteria for inclusion. Articles were included if they addressed influenza vaccination in asthmatic children and “high-risk” children and considered asthmatics in the definition of “high risk.” Additionally, inclusion criteria required discussion of at least one mode of reminder method or recall method that was used to influence the rate of influenza vaccination in children with asthma. For the purposes of this review, “reminders” is defined as any action performed by health provider or representative of the health provider that was aimed at informing and/or reiterating to patients the importance of influenza vaccination for asthmatic children and/or the potential for increased morbidity with acquisition of the flu and/or availability of the vaccine. “Recall” methods included all efforts made by the health provider or his/her representative to encourage patients to return to clinics for vaccination during the influenza season. Articles were excluded if they focused on improving influenza vaccination rates in healthy children and if they used reminder/recall systems to influence vaccination against diseases other than influenza. No systematic review was found on this particular topic. ResultsProviders have used reminder and recall systems that alert patients of the need for vaccination and encourage compliance with this recommendation. Implemented techniques included verbal and mailed reminders, electronically generated alerts, and year-round scheduling of flu vaccination appointments. DiscussionImprovements have been seen in influenza immunization rates with the implementation of reminder/recall systems; however, most have been modest. Enhancements in patient education and access to vaccination are other areas of needed improvement.

Family Doctor Responses to Changes in Incentives for Influenza Immunization under the U.K. Quality and Outcomes Framework Pay‐for‐Performance Scheme

To analyze the effect of setting higher targets, in a primary care pay-for-performance scheme, on rates of influenza immunization and exception reporting. The U.K. Quality and Outcomes Framework links financial rewards for family practices to four separate influenza immunization rates for patients with coronary heart disease (CHD), chronic obstructive pulmonary disease, diabetes, and stroke. There is no additional payment for immunization rates above an upper threshold. Patients for whom immunization would be inappropriate can be excepted from the practice for the calculation of the practice immunization rate. Practice-level information on immunizations and exceptions extracted from electronic records of all practices in England 2004/05 to 2009/10 (n=8,212-8,403). Longitudinal random effect multilevel linear regressions comparing changes in practice immunization and exception rates for the four chronic conditions before and after the increase in the upper threshold immunization rate for CHD patients in 2006/07. The 5 percent increase in the upper payment threshold for CHD was associated with increases in the proportion of immunized CHD patients (0.41 percent, CI: 0.25-0.56 percent), and exception was reported (0.26 percent, CI: 0.12-0.40 percent). Making quality targets more demanding can not only lead to improvement in quality of care but can also have other consequences.