Prompts improve flu jab uptake

1 November 2012

Can use of reminder prompts to both the patient and the provider increase influenza vaccination rates amongst the elderly?


Mailout, telephone outreach, and a simple reminder prompt can increase the uptake of influenza vaccination among an elderly primary care population by about 40 per cent over no organised strategy.


You are a practice nurse working in a primary healthcare centre. Influenza vaccination rates among the elderly were low last year. You are considering whether sending patient reminders and putting reminder prompts on patient records would increase immunisation rates.


Do patient and provider reminders increase the uptake of the influenza vaccination among the elderly population when compared to standard care?


Pubmed clinical queries – (therapy, narrow): Increasing AND influenza vaccination AND adult.


Humiston SG, Bennett N, Long L, Eberly S, Arvelo L, Stankaitis J, Szilagyi PG. Increasing inner-city adult influenza vaccination rates: a randomized controlled trial. Public Health Reports 2011;126(Suppl 2):39-47.


Two-arm, parallel group, randomised controlled trial conducted in six urban primary care centres (PCCs) in the United States between 2002 and 2004. All ‘active’ patients were eligible if aged 65 years or older and residents in New York state. An ‘active’ patient was considered a patient with at least one visit to the clinic in the previous two to five years. Patients who had received the influenza immunisation earlier within the influenza vaccination season were not eligible. It is not known how many patients were assessed for eligibility, but

3752 were randomised. Participants were more commonly female (62 per cent), aged 70 or older (66 per cent), and a mix of ethnicities (African American 33 per cent, White 50 per cent, Hispanic 10 per cent and Other 7 per cent). At the study’s end, all participants were assessed for vaccination status based on their medical record.

Intervention: (n=1748) Participants received influenza immunisation reminders in the mail. Those participants who had no routine appointment scheduled during the three-month’ flu-vaccine period were telephoned and asked to make an appointment. Brightly coloured reminders were placed on the medical charts of all patients.

Control: (n=2004) Participants received the normal standard of care as provided by their primary care centre. Only one centre reported sending patient reminders regarding influenza vaccination. Most providers indicated that they did not have systems in place to remind themselves to evaluate immunisation records during patient visits.

Outcomes: The primary outcome measure was documented vaccination against influenza within the study period of 12 months. No secondary outcomes were identified.


Individual participants were randomly assigned to groups on the basis of the last digit of their social security number being odd or even but it is not described whether the randomisation was concealed. There was was 100 per cent follow-up and analysis was on an intention-to-treat basis, with all participants included. Use of patient reminders prevented blinding of participants and outcome assessors. Healthcare providers tended to be unaware of individuals’ group assignment except during healthcare visits. Groups did not differ significantly at baseline, except more participants in the intervention group were covered by Medicare health insurance than those in the control group (66 per cent vs 62 per cent) and more participants had no Medicare in the control (which may mean they had no insurance or commercial insurance only, but no federal assistance). No differences in treatments were likely apart from the intervention. Overall, the study quality was reasonable, but it cannot be determined if the allocation strategy was truly random.


There was a significantly higher rate of vaccination in the intervention group when compared with the control group (see table). Adjusted results to control for minor between-group differences at baseline in age, sex, ethnicity, and healthcare insurance were similar to unadjusted results (OR 6.27, 95 per cent CI 5.42 to 7.26). Intervention said to have similar effect across different subgroups, but results not reported. Effect at different study sites ranged from 9 per cent to 70 per cent in terms of absolute difference.



Ethnically diverse population suggests that this intervention could be applied to the New Zealand population, especially as both mailout and telephone contact reminders are used.

Participants recruited from inner-city healthcare settings, but there is no reason to expect that the intervention would not be effective for the suburban population.

Influenza immunisation is free for New Zealanders at high risk of complications: people aged 65 years and over, anyone under 65 years of age with long-term health conditions, and pregnant women, so it is not clear whether uptake effect would be as large in New Zealand environment.

Reviewers: Gemma Veale, 3rd year nursing student, and Dr Andrew Jull, Associate Professor, University of Auckland and Nurse Advisor, Quality, Auckland District Health Board.