Dutch influenza vaccination rate drops for fifth consecutive year.

AIM: To determine the prevalence and trend of the influenza vaccination-rate of the overall target population in the period 2008-2013, with a specific focus on groups at risk such as patients with cardiovascular diseases, lung diseases, diabetes and aged 60 years and older. METHODS: In an observational longitudinal study electronic medical records data from the Dutch representative network of general practices, LINH, were analyzed. For each influenza vaccination season, 2008-2013, the number of vaccinated and unvaccinated patients at risk are compared by chi-square tests (χ(2)) for linear trends, linear-by-linear association. The level of significance was set at p<0.001 based on the large number of available records. RESULTS: The influenza vaccination rate of the overall at risk group decreased significantly from 71.5% in the 2008 season, to 59.6% in the 2013 vaccination season. The difference of 11.9% was gradual over the years, with a mean decrease of 2.4% per year. The decrease was seen in all specified groups at risk, but was mainly among patients aged 60-65 years (mean yearly decrease of 3.3%). CONCLUSION: For the fifth subsequent year, we notice a lowering trend of the influenza vaccination rate in the population at risk. Reports in the mass media on questioning the effectiveness of the vaccination program may have been an influence; as well as the relatively light outbreaks of influenza in the past years, which may have affected the sense of urgency. The gradual decrease in vaccination rates over recent years requires further research and a public health debate is needed on the usefulness and necessity of the vaccination program.

Prescription of antiviral drugs during the 2009 influenza pandemic: an observational study using electronic medical files of general practitioners in the Netherlands.

BACKGROUND: After the clinical impact of the A(H1N1) pdm09 virus was considered to be mild, treatment with antiviral drugs was recommended only to patients who were at risk for severe disease or who had a complicated course of influenza. We investigated to what extent antiviral prescriptions in primary care practices were in accordance with the recommendations, what proportion of patients diagnosed with influenza had been prescribed antiviral drugs, and to what extent prescriptions related to the stated indications for antiviral treatment. METHODS: We used data from routine electronic medical records of practices participating in the Netherlands Information Network of General Practice LINH in the period August-December 2009. We considered patient and practice characteristics, clinical diagnoses and drug prescriptions of all patients who contacted their general practitioner in the given period and who had been prescribed antiviral medication (n=351) or were diagnosed with influenza (n=3293). RESULTS: Of all antiviral prescriptions, 69% were in accordance with the recommendations. Only 5% of patients diagnosed with influenza were prescribed antiviral drugs. This percentage increased to 12% among influenza patients belonging to the designated high risk groups. On the other hand, 2.5% of influenza patients not at high risk of complications received antiviral treatment. In addition to the established high risk factors, the total number of drug prescriptions for a patient in this year was a determinant of antiviral prescriptions. Information on time since onset of symptoms and the clinical presentation of patients was not available. CONCLUSIONS: General practitioners in the Netherlands have been restrictive in prescribing antiviral drugs during the influenza pandemic, even when patients met the criteria for antiviral treatment.

Effectiveness of A(H1N1)pdm09 influenza vaccine in adults recommended for annual influenza vaccination.

INTRODUCTION: Because of variability in published A(H1N1)pdm09 influenza vaccine effectiveness estimates, we conducted a study in the adults belonging to the risk groups to assess the A(H1N1)pdm09 MF59-adjuvanted influenza vaccine effectiveness. METHODS: VE against influenza and/or pneumonia was assessed in the cohort study (n>25000), and vaccine effectiveness against laboratory-confirmed A(H1N1)pdm09 influenza was assessed in a matched case-control study (16 pairs). Odds ratios (OR) and their 95% confidence intervals (95% CI) were calculated by using multivariate logistic regression; vaccine effectiveness was estimated as (1-odds ratio)*100%. RESULTS: Vaccine effectiveness against laboratory-confirmed A(H1N1)pdm09 influenza and influenza and/or pneumonia was 98% (84-100%) and 33% (2-54%) respectively. The vaccine did not prevent influenza and/or pneumonia in 18-59 years old subjects, and was 49% (16-69%) effective in 60 years and older subjects. CONCLUSIONS: Even though we cannot entirely rule out that selection bias, residual confounding and/or cross-protection has played a role, the present results indicate that the MF59-adjuvanted A(H1N1)pdm09 influenza vaccine has been effective in preventing laboratory-confirmed A(H1N1)pdm09 influenza and influenza and/or pneumonia, the latter notably in 60 years and older subjects.

Pandemic influenza A(H1N1)pdm09 improves vaccination routine in subsequent years: a cohort study from 2009 to 2011.

BACKGROUND: In 2009 the pandemic influenza virus A(H1N1)pdm09 emerged with guidance that people at risk should be vaccinated. It is unclear how this event affected the underlying seasonal vaccination rate in subsequent years. PURPOSE: To investigate the association of pandemic influenza A(H1N1)pdm09 and seasonal flu vaccination status in 2009 with vaccination rates in 2010 and 2011. METHODS: Data were collected in 40 Dutch family practices on patients at risk for influenza during 2009-2011; data analysis was conducted in 2012. RESULTS: A multilevel logistic regression model (n=41,843 patients) adjusted for practice and patient characteristics (age and gender, as well as those patient groups at risk), showed that people who were vaccinated against A(H1N1)pdm09 in 2009 were more likely to have been vaccinated in 2010 (OR 6.02; 95%CI 5.62-6.45, p<.0001). This likelihood was even more for people who were vaccinated against seasonal flu in 2009 (OR 13.83; 95%CI 12.93-14.78, p<.0001). A second analysis on the uptake rate in 2011 (n=39,468 patients) showed that the influence of the vaccination state in 2009 declined after two years, but the diminishing effect was smaller for people vaccinated against A(H1N1)pdm09 than for seasonal flu (OR 5.50; 95%CI 5.13-5.90, p<.0001; OR 10.98; 95%CI 10.26-11.75, p<.0001, respectively). CONCLUSION: Being vaccinated against A(H1N1)pdm09 and seasonal influenza in the pandemic year 2009 enhanced the probability of vaccination in the next year and this was still effective in 2011. This suggests that peoples' vaccination routines were not changed by the rumor around the outbreak of A(H1N1)pdm09, but rather confirmed underlying behavior.

Patient safety in primary allied health care: what can we learn from incidents in a Dutch exploratory cohort study?

BACKGROUND: Research on patient safety in allied healthcare is scarce. Our aim was to document patient safety in primary allied healthcare in the Netherlands and to identify factors associated with incidents. DESIGN AND SUBJECT: A retrospective study of 1000 patient records in a representative sample of 20 allied healthcare practices was combined with a prospective incident-reporting study. MEASURES: All records were reviewed by trained researchers to identify patient safety incidents. The incidents were classified and analyzed, using the Prevention and Recovery Information System for Monitoring and Analysis method. Factors associated with incidents were examined in a logistic regression analysis. RESULTS: In 18 out of 1000 (1.8%; 95% confidence interval: 1.0-2.6) records an incident was detected. The main causes of incidents were related to errors in clinical decisions (89%), communication with other healthcare providers (67%), and monitoring (56%). The probability of incidents was higher if more care providers had been involved and if patient records were incomplete (37% of the records). No incidents were reported in the prospective study. CONCLUSIONS: The absolute number of incidents was low, which could imply a low risk of harm in Dutch primary allied healthcare. Nevertheless, incompleteness of the patient records and the fact that incidents were mainly caused through human actions suggest that a focus on clinical reasoning and record keeping is needed to further enhance patient safety. Improvements in record keeping will be necessary before accurate incident reporting will be feasible and valid.

[Increased multimorbidity in patients in general practice in the period 2003-2009]. / Toename multimorbiditeit bij patiënten in de huisartsenpraktijk in de periode 2003-2009.

OBJECTIVE: To determine the prevalence of chronic multimorbidity and its increase in primary care. DESIGN: Descriptive longitudinal study. METHOD: We selected patients suffering from chronic pulmonary disease, chronic cardiovascular disease, or diabetes from a national representative general practice research database (LINH). For each year in the period 2003-2009, we calculated the prevalence of these separate conditions. We subsequently assessed the prevalence of multimorbidity and its increase for 4 different age groups (0-14, 15-44, 45-64, ≥ 65 years). RESULTS: The percentage of all patients suffering from at least 1 of these chronic conditions increased from 12.6% in 2003 to 15.0% in 2009, an increase of almost 20%. The multimorbidity among these patients rose from 15.9% in 2003 to 18.3% in 2009. This increase in multimorbidity was found in all 3 chronic conditions under study and in all adult age groups. To what extent this increase was caused by improvements in morbidity registration could not be identified. CONCLUSION: There appears to be a considerable increase in recent years in the prevalence of chronic diseases; multimorbidity appears also to have increased. If this trend continues, in 2015 the multimorbidity among patients over 65 years of age with diabetes, chronic pulmonary and/or cardiovascular disease will be more than 30%.

Urban-rural health differences: primary care data and self reported data render different results.

AIM: Assessing the usefulness of GP electronic medical records for assessing the health of rural populations by comparing these data with data from health interview surveys. DATA: Data from electronic medical records routinely recorded in general practices in 2000-2002. Data on self-reported health problems were obtained through questionnaires in a subset of the same patient population. RESULTS: According to GP-records, acute somatic and chronic diseases were more frequently presented in rural areas. At the same time self reported health problems point to a better health in rural areas. CONCLUSION: GP electronic medical records may be used to monitor the health of rural populations. These data can be obtained relatively quickly and easily and against acceptable cost. However, they do not give the same outcomes as health interview surveys. Reasons for this discrepancy may be; differences in the accessibility of specialist services and help seeking behaviour between urban and rural populations.

Uptake of cervical cancer screening in The Netherlands is mainly influenced by women's beliefs about the screening and by the inviting organization.

BACKGROUND: This study aims to examine the impact of women's characteristics (demographics, risk behaviour, and beliefs) on the uptake of cervical cancer screening, taking practice characteristics (demographic and organizational) into account. METHODS: Routinely collected data of screening status were sampled from electronic medical records of 32 Dutch general practices. Additionally, a questionnaire was sent to a sample of 2224 listed women-1204 screened, 1020 unscreened. We used a step-by-step, logistic, multilevel approach to examine determinants of the screening uptake. RESULTS: Analyses of data for 1392 women (968 screened and 424 unscreened) showed that women's beliefs about cervical screening and attendance are the best predictors of screening uptake, even when demographic and organizational aspects are taken into account. Women aged 40-50 years who felt high personal moral obligation, who had only one sexual partner ever, and who were invited and reminded by their own general practice had the greatest likelihood of screening uptake. A non-response study was performed; the non-responders to the questionnaire (mainly unscreened) thought they had less risk of cervical cancer, were less motivated, less often intended to get future screening, and were more convinced that cervical cancer cannot be cured. CONCLUSION: To improve the uptake rate, we should focus on the personal moral obligation of eligible women, beliefs about the risks of cervical cancer, and available cures. Invitations and reminders within general practices enhance the uptake rate.

Clinical effectiveness of influenza vaccination in persons younger than 65 years with high-risk medical conditions: the PRISMA study.

BACKGROUND: Influenza vaccination has consistently been shown to prevent all-cause death and hospitalizations during influenza epidemics among seniors. However, such benefits have not yet been demonstrated among younger individuals with high-risk medical conditions. In the present study, we evaluated the effectiveness of influenza vaccine in persons recommended for vaccination of any age during an epidemic. METHODS: We conducted a case-control study during the 1999-2000 influenza A epidemic nested in a cohort of 75,227 primary care patients. End points were all-cause mortality and episodes of hospitalizations or general practitioner (GP) visits for influenza, pneumonia, other acute respiratory disease, acute otitis media, myocardial infarction, heart failure, and stroke. The effectiveness of vaccination was evaluated by means of logistic regression analysis with adjustments for age, sex, prior health care use, medication use, and comorbid conditions. RESULTS: Among high-risk children and adolescents younger than 18 years (n=5933; 8% of the study population), 1 death, 3 hospitalizations for pneumonia, and 160 GP visits occurred. After adjustments, 43% (95% confidence interval [CI], 10%-64%) of visits were prevented. Among high-risk adults aged between 18 and 64 years (n=24 928; 33% of the study population), 47 deaths, 23 hospitalizations, and 363 GP visits occurred. After adjustments, vaccination prevented 78% of deaths (95% CI, 39%-92%), 87% of hospitalizations (95% CI, 39%-97%), and 26% of GP visits (95% CI, 7%-47%). Among elderly persons (n=44 366; 59% of the study population), 272 deaths and 166 hospitalizations occurred, and after adjustments the vaccine prevented these end points by 50% (95% CI, 23%-68%) and 48% (95% CI, 7%-71%), respectively. CONCLUSION: Persons with high-risk medical conditions of any age can substantially benefit from annual influenza vaccination during an epidemic.

Does a population survey provide reliable influenza vaccine uptake rates among high-risk groups? A case-study of The Netherlands.

All European countries have recommendations for influenza vaccination among the elderly and chronically ill. However, only a few countries are able to provide data on influenza uptake among these groups. The aim of our study is to investigate whether a population survey is an effective method of obtaining vaccination uptake rates in the different risk groups and to find out what reasons people give as to why they have accepted or refused influenza vaccination and whether this varies among the risk groups. A mail questionnaire was sent out to households in The Netherlands, the response rate was 73%. This resulted in data for 4037 individuals on influenza and influenza vaccination during the 2001-2002 influenza season. The uptake rates and size of different risk groups from the panel survey were comparable with other national representative sources (from the National Information Network of GPs (LINH) and Statistics Netherlands (CBS)). The main reason cited for undergoing vaccination was the existence of a chronic condition. The main reasons for refraining from vaccination were having enough resistance to flu and ignorance about the recommendations. In The Netherlands, the GP is the main administrator of influenza vaccines. We believe that population surveys may be useful for revealing influenza vaccination uptake rates for the groups at risk. When combined with questions about reasons for undergoing vaccination, the results may provide useful policy information and can be used to direct vaccination campaigns at under-vaccinated risk groups or to target the information campaign more effectively.

Patient characteristics determine differences in the influenza vaccination rate more so than practice features.

BACKGROUND: World-wide each year 30-55% of the target population is vaccinated against influenza. Determinants of successful vaccination programs are not clear. This study was aimed at identifying practice- and patient-related factors that determine differences in vaccination rates. METHODS: Data on patients of the target population were extracted from the computerized medical record systems of 48 family practices. Information about organizational factors was collected by a questionnaire for GP's. Multilevel logistic regression analyses were used to assess the determinants. RESULTS: Of all patients at risk (42,426), 76% were vaccinated. The vaccination rate for patients above age 65 was 15% higher when a medical indication was present. Patients with cardiac diseases or diabetes mellitus attained a relatively higher vaccination rate than other groups at risk. Special hours for vaccination led to significantly higher vaccination rates for the elderly and cardiac patients. Patients below 65 years of age were particularly influenced by special information pamphlets. CONCLUSION: Explanations of differences in uptake rates were found at the patient level. All practices in this study were well organized; nevertheless, subgroup analyses showed that special vaccination hours for elderly people and information pamphlets for young people could improve results further.