1. 25/05/2011
Working with general practice to evaluate and increase vaccination uptake
Working with General Practice to evaluate and increase the uptake of seasonal influenza vaccinations
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Dr. Diane kirkland: Senior Public Health Practitioner, Gwent Public Health Team

2. Background
Failure to reach 70% target uptake of seasonal influenza vaccination
Target for uptake increased to 75%
Limited systematic evidence of effective interventions to increase the uptake of flu vaccination in targeted groups
Inter practice variation
The variation in reported uptake across Gwent was wide, ranging from 24 to 85% in those over 65 years and 21 to 83% in clinical ‘at risk’ groups below the age of 65 years of age. Twenty two of 94 practices (23.4%) reached the 70% target uptake rate in those 65 years and over according to Audit + reporting, whilst only 5 practices across Gwent reached the 70% target uptake rate in at risk groups below the age of 65 years.
Dr. Diane Kirkland

3. Source: Uptake of seasonal influenza vaccine LHB Specific Report ABHB 2009/10 Public Health Wales VPDP)
Dr. Diane Kirkland

4. The Aim
To identify and share good practice to increase the uptake rate of seasonal influenza vaccination in targeted groups across ABHB area
The aim of the seasonal influenza immunisation campaign is to minimise flu related morbidity, mortality, and hospital admissions. In Wales in 2009/10, free seasonal influenza immunisation was offered to all people aged 65 years and over, and people aged between 6 months and 65 years in clinical risk groups. For 2009/10 the WAG target immunisation uptake rate was 70% in these selected groups. There is limited systematic evidence for interventions to increase rates of uptake of seasonal flu vaccination. Call-recall systems appear to be the most effective means to increase uptake, but are not used consistently across Gwent.
The variation in reported uptake across Gwent was wide, ranging from 24 to 85% in those over 65 years and 21 to 83% in clinical ‘at risk’ groups below the age of 65 years of age. Twenty two of 94 practices (23.4%) reached the 70% target uptake rate in those 65 years and over according to Audit + reporting, whilst only 5 practices across Gwent reached the 70% target uptake rate in at risk groups below the age of 65 years.
Dr. Diane Kirkland

5. Method
Semi structured telephone interviews with Practice Managers / Practice Nurses
All Practices reportedly achieving 70% uptake in any at risk group in 2009/10
‘Mission shift’ (n=35)
Semi-structured telephone interviews with Practice Mangers and Nurses were conducted to explore how the ‘Flu Campaign’ in each practice with high uptake rates had been conducted in 2009/10, with the intention of sharing effective practice.
Staff from all General Practices across Caerphilly, Monmouthshire and Newport Localities, reaching the 70% target in any recommended group in 2009/10, were invited to participate. All Practices invited to participate did so.
Information from these interviews was themed and commonalities identified.
As a result of requests by ABHB Locality staff, all Practices in Monmouthshire and Newport were approached and participated in interviews regarding their flu vaccination work. Barriers to uptake were identified from practices with poor uptake, but are not reported here.
In total, 35 telephone interviews were conducted.
Dr. D Kirkland

6. Key interventions perceived to increase uptake
Call-recall systems
Personal patient interaction
Good access to clinics
Personal markers/ pop ups on notes
Offering ‘added value’
General reminders/ advertising
· Call-recall systems : either by letter or telephone appear effective in achieving good uptake rates in various groups and this is reflected in the Practices across Gwent. However, not all of the Practices with reported good uptake operated a call-recall system. Several practices with good uptake rates felt it would be a waste of resources to call up people they knew would come in anyway.
It appeared particularly important that once the initial ‘flu jab’ clinics have past, those patients who have not attended are actively called up either by telephone and an appointment made there and then, or by letter, giving an appointment time or asking the person to make an appointment.
· Access to clinics: This included providing some out of hours clinics for people who work during regular practice hours. Whist large ‘one off’ clinics are fine, practices who operate such clinics also need to have ‘mop up’ clinics at alternative times and dates.
· Personal interaction with patients was perceived to be pivotal by several participant to good uptake. E.g. reminding patients well in advance of the importance of the vaccination and to make an appointment to receive it. Also checking during routine appointments whether people have had their flu jab, appears to be effective.
· Individual patient markers e.g. use of a computer ‘reminder’ tags / pop ups on the screen so those who have not yet had their vaccination were identified during routine appointments with the GP or Practice nurse appears an efficient means of identifying those who have not yet been vaccinated and offering an appointment opportunistically.
· Offering ‘added value’
An effective means of increasing uptake appeared to be offering services along side vaccination which patients valued, E.g. checking weight and blood pressure, providing advice regarding safety, benefits or energy saving in the home etc. via partners agencies or combining flu vaccination with routine statutory health reviews of residents in care.
· Advertising/ general reminders
One practice with exceptionally high uptake rates who do not call up individual patients advertise clinics widely in the local area; e.g. in their practice, in local shops, village halls, library etc. calling patients up only after the main clinics have been run.
Other activities Practice Managers felt were effective in facilitating the uptake of flu vaccination were:
· Reminders on Prescriptions
· General reminders on the Surgery answer-phone
· Inserting an information sheet from the drugs company with the invitation
Dr Diane Kirkland

7. Monitoring and reporting
‘Just because they can monitor uptake does not mean they do’
Practice level feedback/ benchmarking
Ambiguity re ‘home grown lists’ and Read codes
Mistrust/apprehension re: Audit+ data quality system
There is evidence that feedback to practices can increase the rate of vaccination uptake. Although Practice Managers can access uptake rates for their practice, most said they did not do so. Several Practice Managers thought their uptake was better than that reported either by Audit + or their Practice system and were surprised, particularly at how low uptake in ‘at risk’ groups was. This may have been because they had scored maximum QOF points for influenza vaccination, in spite of relatively low uptake rates in specific groups.
There appeared to be a genuine interest in discussing uptake rates and where Practice Managers were asked if they could be contacted again in late October to check progress, all accepted.
Some Practice Managers were interested to hear how they performed compared to other local practices, particularly where they felt the practice population was similar to their own. Interest in benchmarking against other practices was dependent on the personalities involved.
· There appeared to be limited appreciating for the need for and use of coverage data to support policy decision making and health protection.
· Audit+ Data Quality System, the computer package that retrieves uptake data from individual practice systems regarding uptake of influenza vaccination remains problematic in some cases.
· Practice Managers commonly reported discrepancies between Audit reports and those from their own Practice systems, which they could not explain. Since participants knew the number of vaccinations they had ordered, used and for which they received payment, the discrepancy between systems led to lack of trust in Audit +. This discrepancy may be due to inclusion/ exclusion of ‘informed descenters’ in the reports.
· There was some ambiguity regarding both read codes and ‘home grown’ lists for targeted groups.
· Where the number of people within a specific clinical ‘at risk’ group is low, e.g. those with Stroke below the age of 65, having just 1 or 2 patients decline vaccination in a practice can reflect badly in the reporting system.
Dr. Diane Kirkland

8. Recommendations for Primary Care
To emphasise to Practices the importance of Audit+ reporting to the informed development of national policy and to health protection
To facilitate training with the Audit+ system and ‘trouble shooting’ to overcome related problems in specific General Practices
Regular practice level feedback to Practice Managers on vaccination uptake
The circulation of good practice guidance regarding means of increasing uptake rates
Promote call-recall, but accept ‘one size does not fit all’
Dr. Diane Kirkland

9. Outcome in those 65 yrs +
Increased reported uptake in ABHB area for those over 65 years (63% in to 66.2% people)
Increased uptake in each LA area within ABHB area for those over 65 years
More complete reporting via Audit+ in Monmouthshire
Reported uptake for Monmouthshire (58.5%-71.6%)
Increased reported uptake via Audit +- all but 4 practices submitted
Increased reported uptake in over 65s of 3.2% 3.2% of eligible 65 yrs and over= increase of people (Although we clearly can’t attribute that increase to this intervention)
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10. Acknowledgments
Many thanks to everybody contributing to this work particularly Practice staff who were interviewed and STRIVE members Lorna Bennett, Jane Francis, Julia Osmond, Anna Morgan and Josef Prygodzicz. I am grateful to Dr. Simon Cottrell (VPDP) -Public Health Wales, for his permission to reproduce his graphics and Dr. Lika Nehaul for his support.
Dr. Diane Kirkland