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The association between physicians’ and patients’ preventive health practices

Although much has been written about the potential power of the association between physicians' personal health practices and those of their patients, objective studies of this relationship are lacking. We investigated this association using objectively measured health care indicators. We assessed 8 indicators of quality of health care (screening and vaccination practices) for primary care physicians (n = 1488) and their adult patients (n = 1,886,791) in Israel's largest health maintenance organization; the physicians were also patients in this health care system. For all 8 indicators, patients whose physicians were compliant with the preventive practices were more likely (p < 0.05) to also have undergone these preventive measures than patients with noncompliant physicians. We also found that more similar preventive practices showed somewhat stronger relations. For example, among patients whose physician had received the influenza vaccine, 49.1% of eligible patients received flu vaccines compared with 43.2% of patients whose physicians did not receive the vaccine (5.9% absolute difference, 13.7% relative difference). This is twice the relative difference (7.2%) shown for pneumococcal vaccine-eligible patients of influenza-vaccinated versus nonvaccinated physicians (60.9% v. 56.8%). When we examined the rates of unrelated practices, we found that, for example, mammography rates were identical for patients whose physicians did and did not receive the influenza vaccine. We found a consistent, positive relation between physicians' and patients' preventive health practices. Objectively establishing this healthy doctor-healthy patient relation should encourage prevention-oriented health care systems to better support and evaluate the effects on patients of improving the physical health of medical students and physicians.

Erythropoietin treatment is associated with an augmented immune response to the influenza vaccine in hematologic patients

The objective of this study was to examine whether treatment with recombinant human erythropoietin (rHuEPO), previously found to be associated with a positive effect on cell-mediated immunity and humoral immunity (hepatitis B vaccine), is associated with an improved response to the seasonal influenza (flu) vaccine. Three groups received flu vaccine: healthy controls, hematologic patients not treated with rHuEPO ("No EPO" group), and hematologic patients receiving rHuEPO for their anemia ("EPO" group). Anti-flu Ab titer was measured (complement fixation test) from blood samples drawn before and approximately 3-4 weeks, 7-8 weeks and 4 months after vaccination. Nineteen healthy subjects were compared with 17 No EPO and 17 EPO patients. Mean ages were 59.5, 61.3, and 73.1 years, respectively (EPO patients were older; p = 0.005). In the healthy group, the percentage of those sustaining only a partial (twofold) response, a strong (fourfold or greater) response, and an overall response (combined partial and strong responses) were 31.6%, 57.9%, and 89.5%, respectively. In the No EPO group, values were 35.3%, 17.6%, and 52.9%, respectively. EPO group results were similar to those of the healthy controls: 23.5%, 58.8%, and 82.4% (p = 0.016, EPO vs. No EPO). In conclusion, hematologic patients (NoEPO group) respond poorly to the flu vaccine, compared with healthy subjects, and rHuEPO treatment is associated with an improved immune response to the flu vaccine in hematologic patients, with titers similar to those of healthy subjects.

Identifying Children With Chronic Conditions for Influenza Vaccination Using a Statewide Immunization Registry

Children with chronic medical conditions are at increased risk of complications from influenza, yet their vaccination rates are low. The Michigan Care Improvement Registry (MCIR), a statewide immunization registry, was expanded in 2006 to include an indicator, based on Medicaid administrative claims, that prompts providers to offer influenza vaccine to high-risk children (ie, those with chronic conditions). To assess primary care providers' experiences with the MCIR high-risk indicator. A cross-sectional, self-administered survey mailed in July 2009. State of Michigan. A total of 300 family physicians and 300 pediatricians who served as primary care providers for children in Michigan's Medicaid program. Provider experiences with the high-risk indicator; suggestions for improvement. Response rate was 79%. Only 32% of pediatricians and 17% of family physicians recalled seeing the high-risk indicator during the 2008-2009 influenza season. Of those who saw the indicator, 48% rated it as "helpful" or "very helpful" in identifying which children should receive flu vaccine. To improve its usefulness, 77% of respondents wanted the indicator to reflect all children, rather than only those enrolled in Medicaid, and 71% wanted MCIR to generate a list of high-risk children in their practice. Three years after implementation, the registry-based high-risk indicator is not viewed by most providers. Half of those who saw the indicator found it helpful, and most respondents endorsed enhancements to broaden its scope. Future work should explore whether enhanced capabilities help to facilitate identification of priority cases by providers.

Despite small improvement, black nursing home residents remain less likely than whites to receive flu vaccine.

Vaccination is a key deterrent to influenza and its related complications and outcomes, including hospitalization and death. Using 2006-09 data, we found a small improvement in vaccination rates among nursing home residents, particularly for blacks. Nonetheless, overall vaccination rates remained well below the 90 percent target for high-quality care, and black nursing home residents remained less likely to be vaccinated than whites. Blacks were less likely to be vaccinated than were whites in the same facility and were more likely to live in facilities with lower vaccination rates. Blacks were also more likely to be noted as refusing vaccination. Strategies are needed to ensure that facilities offer vaccination to all residents and to make vaccination more acceptable to black residents and their families.

Hepatitis B vaccination among a national sample of gay and bisexual men.

Less than half of gay and bisexual men indicated they had received some doses of hepatitis B virus vaccine. Hepatitis B virus vaccination was higher among men who were 18 to 29 years old (compared to those 50-59 years old), gay, or had received flu vaccine within the last year.

Is unhealthy substance use associated with failure to receive cancer screening and flu vaccination? A retrospective cross-sectional study

ObjectiveTo compare cancer screening and flu vaccination among persons with and without unhealthy substance use.DesignThe authors analysed data from 4804 women eligible for mammograms, 4414 eligible for Papanicolou (Pap) smears,...

Influenza vaccination among high-risk subgroups in eleven European countries: findings from the Survey of Health, Ageing and Retirement in Europe (SHARE)

Background: The risk of influenza-related complications is elevated in older adults and in persons with one or more chronic diseases. Vaccination of such individuals is therefore recommended in Europe as a preventive measure. We aimed to compare between European countries 1) to what extent high-risk subgroups receive influenza vaccination and 2) how likely they are to receive vaccination compared to the non-risk group. Methods: We used data from the Survey of Health, Ageing and Retirement in Europe collected in 2004/05. Adults aged 50+ years from eleven countries (Austria, Belgium, Denmark, France, Germany, Greece, Italy, the Netherlands, Spain, Sweden, Switzerland) were asked whether they had received flu vaccination in the previous year. Using self-reported data from 16,182 individuals, we defined several high-risk subgroups (age 65+, presence of chronic lung disease [CLD], cardiovascular disease [CVD], diabetes/high glucose level). We calculated weighted and design-adjusted estimates of vaccination prevalence with 95% confidence intervals (CI) for each country. Country-specific multivariable logistic regression was used to explore associations between membership in a high-risk subgroup and vaccination uptake. Results: The prevalence of influenza vaccination in high-risk subgroups was generally highest in the Netherlands (e.g., 76.7% [95% CI: 73.6%, 79.8%] for those aged 65+ years and 74.6% [95% CI: 68.3%, 80.9%] for CLD) and was consistently lowest in Greece (26.3% [95% CI: 23.2%, 29.3%] and 18.5% [95% CI: 11.3%, 25.6%], respectively). Comparison of multivariable models suggested substantial cross-national variation in targeted influenza prevention. The adjusted odds of self-reported vaccination in those aged 65+ (versus &lt;65), for example, ranged from 2 (Austria and Germany) to more than 10 (Denmark and the Netherlands). Conclusions: Influenza vaccination coverage among high-risk subgroups varies considerably between European countries. Most countries did not achieve recommended coverage rates; some fell well below recommendations, raising questions about the effectiveness of national efforts in reaching high-risk individuals.

Flu Vaccine May Not Be Effective in the Elderly

CHICAGO — Trivalent inactivated influenza vaccine may not elicit a clinically adequate antibody response in elderly adults, pilot data suggest. Based on blood assays taken before and 4 weeks after administration of the Fluarix 2007/2008 formula, 88% of 71 community-dwelling older adults, mean age 85 years, failed to mount a fourfold antibody response to any of the three virus strains present in the trivalent influenza vaccine (TIV). Only two patients had a fourfold antibody response to both influenza A types, H1N1 and H3N2, and none had such a response to all three strains—H1NI, H3N2, and influenza B—Sean X. Leng, MD, PhD, said at the annual meeting of the American Geriatrics Society. A fourfold or higher vaccine antibody titer increase, also called positive seroconversion, is the criterion for a clinically adequate antibody response. In contrast, he noted that the vaccine insert reports that 444 (60%) of 745 persons, aged 18-64 years, had a fourfold antibody response to the H1N1 strain, 461 (62%) had such a response to H3N2, and 575 (77%) did so to the influenza B strain. “Obviously this is pilot data, but [it does] point out the importance of the need for comprehensive evaluation of this vaccine in older and frail populations,” said Dr. Leng of the division of geriatric medicine and gerontology at Johns Hopkins University in Baltimore. Patients had received flu vaccine for an average of 7 years prior to study entry, although this was based on self-report and subject to memory bias. Still, 25 (3.4%) participants reported signs and symptoms of flulike illness during the 2007-2008 flu season, although a laboratory diagnosis of influenza was not confirmed. No influenza-related death was reported. Dr. Leng noted that those aged 75 years and older make up a small percentage of vaccine trial cohorts, despite being the fastest growing segment of the population. In one vaccine trial, only 11% of patients were at least 75 years old (JAMA 1994;272:1661-5). The one-size-fits-all approach to influenza vaccine needs to be re-examined, as is being done with cancer screening in elderly and other high-risk groups, he suggested. Patients in the study ranged in age from 72 to 95 years, 79% were women, and 93% were white. Comorbidities included hypertension (67%), osteoarthritis (45%), and dyslipidemia (38%). Dr. Leng and associates reported no conflicts of interest. The study was sponsored by the National Institute on Aging and the American Federation for Aging Research. “While this study is interesting, it doesn't call for any action on the part of long-term care practitioners,” said David Nace, MD, MPH, director of the long-term care and flu programs at the University of Pittsburgh Institute on Aging. “It is worth noting that only 3.4% of participants reported signs or symptoms of flulike illness, and this is lower than what we would anticipate from the literature—typically one out of five older individuals per season. “This low rate of influenza illness is especially interesting given the fact that during the 2007-2008 season, strains covered by the flu vaccine didn't match the influenza that circulated through the U.S.”

Development and testing of the Asthma Self-Management Questionnaire

Assessing self-management knowledge can guide physicians in teaching patients necessary skills. To develop and test the Asthma Self-Management Questionnaire (ASMQ). The ASMQ was developed from patient interviews. Validity was evaluated by comparison with the established Knowledge, Attitude, and Self-Efficacy Asthma Questionnaire, and test-retest reliability was evaluated with repeated administration (mean, 5 days apart) in 25 patients (mean age, 41 years; 96% women). The ASMQ was further described in additional patients by comparison with cross-sectional self-management practices and longitudinal change in Asthma Quality of Life Questionnaire scores. The 16-item, multiple-choice ASMQ measures knowledge of preventive strategies, inhaler use, and medications and generates a score of 0 to 100, with higher scores indicating more correct responses. The ASMQ was correlated with the Knowledge, Attitude, and Self-Efficacy Questionnaire (r = 0.58) and had a Cronbach alpha of 0.71. The correlation between administrations was 0.78, and the intraclass correlation coefficient was 0.58. When given to another 231 patients (mean age, 41 years; 74% women), the mean (SD) ASMQ score was 60 (20). Patients with better ASMQ scores were more likely to own peak flow meters (P = .04) and to have received flu vaccines (P = .03). For 12 months, these patients received self-management information through workbooks and telephone reinforcement. Patients with higher ASMQ scores after 12 months were more likely to have clinically important improvements in quality of life compared with patients with lower ASMQ scores (65% vs 46%; P = .01). The ASMQ is valid and reliable and is associated with clinical markers of effective self-management and better asthma outcomes.

Factors influencing influenza-vaccination in adults under immunosuppressive therapy for a systemic inflammatory disease

Objective The aim of this study was to evaluate flu vaccination rates and influencing factors in patients with systemic inflammatory diseases. Methods All patients presenting with a systemic inflammatory disease and taking immunosuppressants, who were hospitalized or had consulted in our internal medicine department between January 2 and 31, 2006, were included in the study. The information concerning flu vaccination was collected with a standardized form. Results One hundred and thirty-seven patients (mean age 53.1 ± 17.6 years; 40 [29%] male patients) were included: 39 (28%) had received flu vaccination in 2005 including 14 (16.7%) of the 84 patients with no other indication for flu vaccination than IS-induced immunodepression and 25 (47.2%) of the 53 patients with other flu vaccination indication(s) ( p < 0.001). The most frequent reasons for non-vaccination were: absence of physician recommendation (58%), fear of adverse effects (35%) and concern on vaccine clinical effectiveness (5%). The vaccination rate was significantly higher (49%) among patients who remembered having received a voucher from the French National Health Insurance Agency versus 18% among those who did not (OR = 4.2 [95%CI, 1.92–9.19] p < 0.05). This correlation remained significant after adjustment for confounding factors in a logistic regression model. Conclusion Influenza-vaccination coverage is low in patients receiving immunosuppressive therapy for systemic inflammatory diseases. We have to increase the influenza-vaccination coverage in this population.

Unhealthy Drinking Patterns and Receipt of Preventive Medical Services by Older Adults

Preventive service use among older adults is suboptimal. Unhealthy drinking may constitute a risk factor for failure to receive these services. To determine the relationship between unhealthy drinking and receipt of recommended preventive services among elderly Medicare beneficiaries, applying the framework of current alcohol consumption guidelines. The data source is the nationally representative 2003 Medicare Current Beneficiary Survey. The sample included community-dwelling, fee-for-service Medicare beneficiaries 65 years and older (N = 10,523). Based on self-reported drinking, respondents were categorized as nondrinkers, within-guidelines drinkers, exceeding monthly but not daily limits, or heavy episodic drinkers. Using survey and claims data, influenza vaccination, pneumonia vaccination, glaucoma screening, and mammogram receipt were determined. Bivariate and logistic regression analyses were conducted. Overall, 70.3% received flu vaccination and 49% received glaucoma screening during the year, 66.8% received pneumonia vaccination, and 56.2% of women received a mammogram over 2 years. In logistic regression, heavy episodic drinking was associated with lower likelihood of service receipt compared to drinking within guidelines: flu vaccination (OR 0.75, CI 0.59-0.96), glaucoma screening (OR 0.74, CI 0.58-0.95), and pneumonia vaccination (OR 0.75, CI 0.59-0.96). Nondrinkers when compared with those reporting drinking within guidelines were less likely to receive a mammogram (OR 0.83, CI 0.69-1.00). Heavy episodic drinking is associated with lower likelihood of receiving several preventive services. Practitioners should be encouraged to screen all elders regarding alcohol intake and in addition to appropriate intervention, consider elders reporting heavy episodic drinking at higher risk for non-receipt of preventive services.

Beliefs, knowledge and attitudes of community-dwelling Greek elders towards influenza and pneumococcal vaccination

Background: Influenza is a major cause of mortality and morbidity in the elderly. Objective: To explore the knowledge, attitudes, and beliefs of community-dwelling Greek elders towards influenza and pneumococcal vaccination. Method: Content analysis methodology was used to analyse three focus group interviews (n=22). The theoretical framework of the Health Belief Model was used. Results: Two-thirds of the elderly participants have received flu vaccine last year. The main motives and barriers that explain elders' behaviour were: having routine access to medical care; the recommendation of health care professionals; beliefs about the benefits of influenza vaccination; having a relative who delivered the vaccine; being less than 75 years old; having unpleasant reactions in the past; lack of adequate information about the side effects of influenza vaccine; and vaccine shortages. Conclusions: Availability of sufficient vaccines and health education programs are needed to increase the uptake of influenza and pneumococcal vaccination.

Premature infants should receive flu vaccine at 6 months

Editor’s Note: As AAP News went to press, a shortage of influenza vaccine had been identified, and the Academy had prepared suggestions for prioritizing the immunization of children with the remaining vaccine ([www.aap.org/new/vaccineshortage.htm][1]). This article addresses the importance of

2493 Flu vaccination in acute coronary syndromes and planned percutaneous coronary interventions (FLUVACS) study: 1-year follow-up

Aims We have previously reported a significant benefit of vaccination against flu on the incidence of a single and composite end-point of death, myocardial infarction or recurrent ischaemia in patients with myocardial necrosis and planned percutaneous coronary interventions. To determine whether the observed benefits of vaccination against flu were maintained beyond the winter season a 1-year follow-up was conducted. Methods and results During the winter season, we enrolled prospectively 200 myocardial infarction patients admitted in the first 72 h, and 101 planned angioplasty/ stent patients (PCI) without unstable coronary artery disease, prior by-pass surgery, angioplasty or tissue necrosis. Only four patients failed to meet the inclusion criteria. Participants were randomly allocated to receive flu vaccination or remain unvaccinated on top of standard medication (control group). The study was conducted in hospitalized patients with the aim to test the potential beneficial effect of flu vaccination in a secondary prevention scenario. Under intention to treat analysis the incidence of the primary end-point cardiovascular death at 1 year was significantly lower among patients receiving vaccination, 6% as compared with controls, 17% (relative risk with vaccine as compared with controls, 0.34; 95% confidence interval (Cl), 0.17 to 0.71; P=0.002). The triple composite end-point occurred in 22% of the patients in the vaccine group vs 37% in controls, hazard ratio 0.59, 95% Cl 0.4 to 0.86) P=0.004. The beneficial effect was mainly detected in acute myocardial infarction patients (four events in the active arm vs 21 in the control group, P=0.0002 [95% Cl 0.19, 0.07-0.53]), and Cox regression analyses revealed that there was a greater benefit with flu vaccination in patients at high risk according with the TIMI score, and those with non-ST-segment deviation myocardial infarction (95% CI: 0.13 [0.030.52]) Conclusions Influenza vaccination may reduce the risk of death and ischaemic events in patients suffering from infarction and post-angioplasty during flu season. This effect was significantly evident at 1-year follow-up. Larger confirmatory studies are needed to evaluate the real impact on flu vaccination on outcome after acute coronary syndromes.

Should patients with HIV infection receive flu vaccine?

Should patients with HIV infection receive flu vaccine?