Nichol K L
VA Medical Center, and Department of Medicine, University of Minnesota, Minneapolis 55417, USA.
Am J Med. 1998 Nov;105(5):385-92. doi: 10.1016/s0002-9343(98)00293-9.
Influenza and pneumococcal vaccines are underused. Systems approaches that incorporate administrative and organizational strategies are more successful than education of providers for improving vaccination rates. Little has been published on the long-term success and durability of such efforts.
We performed a 10-year time-series study to examine the durability and success of an ongoing, multifaceted, institution-wide influenza and pneumococcal vaccination program. The program was first implemented at the Minneapolis Department of Veterans Affairs (VA) Medical Center in 1987-88 following the demonstration that a clinic-based standing order policy was much more successful than provider education for improving vaccine delivery. The program ensures that vaccine is offered to all high-risk patients followed up at the medical center, promotes convenient access for patients, and facilitates efficient administration of vaccine. Specific elements include an annual mailing to patients, standing orders for nurses, walk-in clinics, and the use of standardized, preprinted documentation forms. Initially the program targeted high-risk outpatients for influenza vaccination. It was extended to include inpatients in 1989-90. Pneumococcal vaccinations were added to the program in 1994-95. Vaccination rates are estimated each year from surveys mailed to randomly selected patients, and vaccine utilization is monitored through pharmacy logs.
The survey response rates have exceeded 75% each year. Influenza vaccination rates for all high-risk patients followed up at the medical center have increased from 58% following the 1987-88 vaccination season to 84% in 1996-97 (P < 0.001). Pneumococcal vaccination rates have also increased from 34% in 1994-95 to 63% in 1996-97 (P < 0.001). Vaccination rates are similar for inpatients and outpatients, but rates for high-risk patients < 65 years of age remain lower than for the elderly: 69% versus 89% for influenza, 1996-97 (P < 0.001); 52% versus 66% for pneumococcal, 1996-97 (P = 0.05). For elderly patients followed up at the medical center, influenza (89% versus 67%, P < 0.0001) and pneumococcal (66% versus 43%, P < 0.0001) vaccination rates significantly exceeded those for the state of Minnesota in 1996-97. The annual number of influenza vaccine doses dispensed has increased from 10,000 in 1987-88 to more than 22,000 in 1996-97; and more than 13,000 doses of pneumococcal vaccine have been administered from 1994-95 through 1996-97.
This simple, multifaceted program that incorporates administrative and organizational strategies to enhance influenza and pneumococcal vaccination rates has been highly durable and successful over a 10-year peroid. Similar strategies if implemented in other settings may enhance vaccination rates for the millions of high-risk patients who have yet to be immunized.
流感疫苗和肺炎球菌疫苗的使用不足。采用行政和组织策略的系统方法在提高疫苗接种率方面比教育医务人员更为成功。关于此类努力的长期成效和持久性，鲜有文献发表。
我们开展了一项为期10年的时间序列研究，以检验一项正在进行的、多方面的、全机构范围的流感和肺炎球菌疫苗接种计划的持久性和成效。该计划于1987 - 1988年在明尼阿波利斯退伍军人事务部（VA）医疗中心首次实施，此前有证据表明，基于诊所的长期医嘱政策在改善疫苗接种方面比教育医务人员更为成功。该计划确保向在医疗中心接受随访的所有高危患者提供疫苗，为患者提供便利的接种途径，并促进疫苗的高效接种。具体内容包括每年向患者邮寄通知、为护士下达长期医嘱、开设无需预约的诊所，以及使用标准化的预印文档表格。最初，该计划针对高危门诊患者进行流感疫苗接种。1989 - 1990年扩展至包括住院患者。1994 - 1995年将肺炎球菌疫苗接种纳入该计划。每年通过向随机选取的患者邮寄调查问卷来估计接种率，并通过药房记录监测疫苗使用情况。
每年的调查回复率均超过75%。在医疗中心接受随访的所有高危患者的流感疫苗接种率从1987 - 1988年接种季节后的58%增至1996 - 1997年的84%（P < 0.001）。肺炎球菌疫苗接种率也从1994 - 1995年的34%增至1996 - 1997年的63%（P < 0.001）。住院患者和门诊患者的接种率相似，但65岁以下高危患者的接种率仍低于老年人：1996 - 1997年流感疫苗接种率分别为69%和89%（P < 0.001）；肺炎球菌疫苗接种率分别为52%和66%（P = 0.05）。1996 - 1997年，在医疗中心接受随访的老年患者的流感疫苗（89%对67%，P < 0.0001）和肺炎球菌疫苗（66%对43%，P < 0.0001）接种率显著高于明尼苏达州。每年分发的流感疫苗剂量从1987 - 1988年的10,000剂增至1996 - 1997年的22,000多剂；1994 - 1995年至1996 - 1997年期间，已接种超过13,000剂肺炎球菌疫苗。
这个简单的、多方面的计划采用行政和组织策略提高流感和肺炎球菌疫苗接种率，在10年期间具有很高的持久性且成效显著。若在其他环境中实施类似策略，可能会提高数百万尚未接种疫苗的高危患者的接种率。
