Systematic reviews including this primary study

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Systematic review

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Authors Thomas RE , Lorenzetti DL
Journal The Cochrane database of systematic reviews
Year 2018
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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 the reference lists of included studies. SELECTION CRITERIA: Randomised controlled trials (RCTs) and cluster-randomised trials 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 three 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)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 (11 with 95% CI entirely above unity); 16 tested personalised reminders (12 with 95% CI entirely above unity); two investigated customised compared to form letters (both 95% CI above unity); and four studies examined the impact of health risk appraisals (all had 95% CI above unity). 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 two studies of home visits (OR 1.30, 95% CI 1.05 to 1.61) and two 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 two studies of home visits by nurses plus a physician care plan (both with 95% CI above unity) and two studies of free vaccine compared to no intervention (both with 95% CI above unity). One study of group visits (OR 27.2, 95% CI 1.60 to 463.3) was effective, and one 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 four studies that looked at physician reminders (three studies with 95% CI above unity) and three studies of facilitator encouragement of vaccination (two studies with 95% CI above unity). 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 levelNo studies reported on societal-level interventions.Study funding sourcesStudies 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.

Systematic review

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Journal Annals of family medicine
Year 2012
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PURPOSE: Influenza and pneumococcal vaccination rates remain below national targets. We systematically reviewed the effectiveness of quality improvement interventions for increasing the rates of influenza and pneumococcal vaccinations among community-dwelling adults. METHODS: We included randomized and nonrandomized studies with a concurrent control group. We estimated pooled odds ratios using random effects models, and used the Downs and Black tool to assess the quality of included studies. RESULTS: Most studies involved elderly primary care patients. Interventions were associated with improvements in the rates of any vaccination (111 comparisons in 77 studies, pooled odds ratio [OR] = 1.61, 95% CI, 1.49-1.75), and influenza (93 comparisons, 65 studies, OR = 1.46, 95% CI, 1.35-1.57) and pneumococcal (58 comparisons, 35 studies, OR = 2.01, 95% CI, 1.72-2.3) vaccinations. Interventions that appeared effective were patient financial incentives (influenza only), audit and feedback (influenza only), clinician reminders, clinician financial incentives (influenza only), team change, patient outreach, delivery site changes (influenza only), clinician education (pneumococcus only), and case management (pneumococcus only). Patient outreach was more effective if personal contact was involved. Team changes were more effective where nurses administered influenza vaccinations independently. Heterogeneity in some pooled odds ratios was high, however, and funnel plots showed signs of potential publication bias. Study quality varied but was not associated with outcomes. CONCLUSIONS: Quality improvement interventions, especially those that assign vaccination responsibilities to nonphysician personnel or that activate patients through personal contact, can modestly improve vaccination rates in community-dwelling adults. To meet national policy targets, more-potent interventions should be developed and evaluated.

Systematic review

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Journal Journal of Population Therapeutics and Clinical Pharmacology
Year 2011
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PURPOSE: Influenza and pneumococcal vaccination rates remain below national targets. We systematically reviewed the effectiveness of quality improvement interventions for increasing the rates of influenza and pneumococcal vaccinations among community-dwelling adults. METHODS: We included randomized and nonrandomized studies with a concurrent control group. We estimated pooled odds ratios using random effects models, and used the Downs and Black tool to assess the quality of included studies. RESULTS: Most studies involved elderly primary care patients. Interventions were associated with improvements in the rates of any vaccination (111 comparisons in 77 studies, pooled odds ratio [OR] = 1.61, 95% CI, 1.49-1.75), and influenza (93 comparisons, 65 studies, OR = 1.46, 95% CI, 1.35-1.57) and pneumococcal (58 comparisons, 35 studies, OR = 2.01, 95% CI, 1.72-2.3) vaccinations. Interventions that appeared effective were patient financial incentives (influenza only), audit and feedback (influenza only), clinician reminders, clinician financial incentives (influenza only), team change, patient outreach, delivery site changes (influenza only), clinician education (pneumococcus only), and case management (pneumococcus only). Patient outreach was more effective if personal contact was involved. Team changes were more effective where nurses administered influenza vaccinations independently. Heterogeneity in some pooled odds ratios was high, however, and funnel plots showed signs of potential publication bias. Study quality varied but was not associated with outcomes. CONCLUSIONS: Quality improvement interventions, especially those that assign vaccination responsibilities to nonphysician personnel or that activate patients through personal contact, can modestly improve vaccination rates in community-dwelling adults. To meet national policy targets, more-potent interventions should be developed and evaluated.

Systematic review

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Journal BMC health services research
Year 2010
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BACKGROUND: Pay-for-performance (P4P) is one of the primary tools used to support healthcare delivery reform. Substantial heterogeneity exists in the development and implementation of P4P in health care and its effects. This paper summarizes evidence, obtained from studies published between January 1990 and July 2009, concerning P4P effects, as well as evidence on the impact of design choices and contextual mediators on these effects. Effect domains include clinical effectiveness, access and equity, coordination and continuity, patient-centeredness, and cost-effectiveness. METHODS: The systematic review made use of electronic database searching, reference screening, forward citation tracking and expert consultation. The following databases were searched: Cochrane Library, EconLit, Embase, Medline, PsychINFO, and Web of Science. Studies that evaluate P4P effects in primary care or acute hospital care medicine were included. Papers concerning other target groups or settings, having no empirical evaluation design or not complying with the P4P definition were excluded. According to study design nine validated quality appraisal tools and reporting statements were applied. Data were extracted and summarized into evidence tables independently by two reviewers. RESULTS: One hundred twenty-eight evaluation studies provide a large body of evidence -to be interpreted with caution- concerning the effects of P4P on clinical effectiveness and equity of care. However, less evidence on the impact on coordination, continuity, patient-centeredness and cost-effectiveness was found. P4P effects can be judged to be encouraging or disappointing, depending on the primary mission of the P4P program: supporting minimal quality standards and/or boosting quality improvement. Moreover, the effects of P4P interventions varied according to design choices and characteristics of the context in which it was introduced.Future P4P programs should (1) select and define P4P targets on the basis of baseline room for improvement, (2) make use of process and (intermediary) outcome indicators as target measures, (3) involve stakeholders and communicate information about the programs thoroughly and directly, (4) implement a uniform P4P design across payers, (5) focus on both quality improvement and achievement, and (6) distribute incentives to the individual and/or team level. CONCLUSIONS: P4P programs result in the full spectrum of possible effects for specific targets, from absent or negligible to strongly beneficial. Based on the evidence the review has provided further indications on how effect findings are likely to relate to P4P design choices and context. The provided best practice hypotheses should be tested in future research.

Systematic review

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Journal American journal of preventive medicine
Year 2000
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This paper presents the results of systematic reviews of the effectiveness, applicability, other effects, economic impact, and barriers to use of selected population-based interventions intended to improve vaccination coverage. The related systematic reviews are linked by a common conceptual approach. These reviews form the basis for recommendations by the Task Force on Community Preventive Services (the Task Force) regarding the use of these selected interventions. The Task Force recommendations are presented on pp. 92-96 of this issue.

Systematic review

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Journal American journal of public health
Year 1999
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OBJECTIVES: This review was conducted to determine the effectiveness of different interventions to improve the delivery of preventive services in primary care. METHODS: MEDLINE searches and manual searches of 21 scientific journals and the Cochrane Effective Professional and Organization of Care of trials were used to identify relevant studies. Randomized controlled trials and controlled before-and-after studies were included if they focused on interventions designed to improve preventive activities by primary care clinicians. Two researchers independently assessed the quality of the studies and extracted data for use in constructing descriptive overviews. RESULTS: The 58 studies included comprised 86 comparisons between intervention and control groups. Postintervention differences between intervention and control groups varied widely within and across categories of interventions. Most interventions were found to be effective in some studies, but not effective in other studies. CONCLUSIONS: Effective interventions to increase preventive activities in primary care are available. Detailed studies are needed to identify factors that influence the effectiveness of different interventions.

Systematic review

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Authors Sarnoff R , Rundall T
Journal Medical care research and review : MCRR
Year 1998
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Public health interventions have been developed to increase influenza immunization rates among the high-risk elders and patients suffering from cardiopulmonary, metabolic, and other chronic conditions. The relative effectiveness of alternative intervention strategies is not yet well understood. Determination of the most effective strategy should consider characteristics of the target population and the health care delivery system. This meta-analysis of intervention evaluation -studies highlights the importance of considering the baseline immunization rate of the target population in selecting the most effective strategy. While the analysis confirms the feasibility of achieving the 60 percent target coverage established in Healthy People 2000, the results also suggest that as coverage levels increase, single-faceted patient-focused interventions may need to be strengthened by the addition of complementary changes in provider behaviors and/or the delivery system. Further research is needed to identify the most cost-effective combination of intervention strategies, particularly in populations with higher immunization coverage.

Systematic review

Unclassified

Authors Anderson LA , Janes GR , Jenkins C
Journal Annals of behavioral medicine : a publication of the Society of Behavioral Medicine
Year 1998
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Strategies to improve the delivery of preventive care often consist of office-based interventions, which are designed to modify provider behaviors or practice patterns. We report on a meta-analysis of 117 behavioral outcomes extracted from 43 studies. Meta-analytic techniques were used to express the results in a common metric, which allowed quantitative comparisons across outcomes. Studies were examined by domains of preventive care (screening, immunization, and counseling) and divided into two groups based on unit of analysis (provider or patient categories). The mean effect size reflects the difference in proportion of physicians providing the targeted behavior between the experimental and comparison groups. In the provider category, the weighted mean effect size for screening was .14, for immunization was .18, and for counseling was .28. In the patient category, the weighted means for screening and immunization were .12 and .15, respectively, but were smaller for the counseling (.08). Because tests for homogeneity of effect sizes were rejected in the patient category, caution in interpreting mean effect sizes is warranted because of variability across individual values. In summary, office-based interventions were found to have positive effects on providers' adherence to preventive recommendations. We discuss the methodological issues and needs for future work to enhance the delivery of preventive services.