Public health in managed care: a randomized controlled trial of the effectiveness of postcard reminders.

OBJECTIVES: This study evaluated the effectiveness of an annual public health intervention in a managed care setting. METHODS: Managed care organization members 65 years and older who received influenza immunization in 1996 were randomized to an intervention group (mailed a postcard reminder to receive an influenza vaccination in 1997) or a control group (no postcard). Vaccination rates for both groups were assessed monthly. RESULTS: Members receiving the intervention were no more likely to be immunized (78.6%) than members of the control group (77.2%, P = .222). Members were vaccinated at the same pace regardless of vaccination history and postcard intervention status. CONCLUSIONS: Postcard reminders were not an effective intervention among seniors who had been vaccinated the previous year.     

Patient views on reminder letters for influenza vaccinations in an older primary care patient population: a mixed methods study

OBJECTIVES: To explore the perspectives of older adults on the acceptability of reminder letters for influenza vaccinations. METHODS: We randomly selected 23 family physicians from each Family Health and Primary Care network participating in a demonstration project designed to increase the delivery of preventive services in Ontario. From the roster of each physician, we surveyed 35 randomly selected patients over 65 years of age who recently received a reminder letter regarding influenza vaccinations from their physician. The questionnaires sought patient perspectives on the acceptability and usefulness of the letter. We also conducted follow-up telephone interviews with a subgroup of respondents to explore some of the survey findings in greater depth. RESULTS: 85.3% (663/767) of patients completed the questionnaire. Sixty-five percent of respondents recalled receiving the reminder (n=431), and of those, 77.3% found it helpful. Of the respondents who recalled the letter and received a flu shot (n=348), 11.2% indicated they might not have done so without the letter. The majority of respondents reported that they would like to continue receiving reminder letters for influenza vaccinations (63.0%) and other preventive services (77.1%) from their family physician. The interview participants endorsed the use of reminder letters for improving vaccination coverage in older adults, but did not feel that the strategy was required for them personally. CONCLUSIONS: The general attitude of older adults towards reminder letters was favourable, and the reminders appear to have contributed to a modest increase in influenza vaccination rates.     

Influenza immunization: the impact of notifying patients of high-risk status

BACKGROUND. The influenza immunization rate in the high-risk military and retired military population has not been reported. To determine this rate, and to test whether the rate could be improved by notifying patients of their high-risk status, a clinical trial was conducted using a postcard reminder as an intervention. METHODS. All 1068 high-risk patients enrolled in a large, residency-affiliated, military family practice department were identified. Of these, 519 patients were randomly selected to receive a reminder postcard; the remainder (549) were not sent a card. The immunization rates of each group were compared. RESULTS. A significantly higher percentage of those to whom postcards were sent received an influenza immunization (25.2% vs 9.1%, P less than .001). This difference was significant in all demographic groups except in those less than 21 years of age and those 21 to 40 years of age, in which very few patients presented for immunization. In those in the study group aged 65 years and over, 46.7% were immunized vs 20% of controls (P less than .001). Those aged 65 years and older and those in the higher income group had higher immunization rates, while those aged 40 years and under had very low immunization rates. CONCLUSIONS. The influenza immunization rate among military beneficiaries in high-risk groups is low, but can be significantly improved with a reminder postcard. This intervention may be more effective in the older and higher-income segments of the high-risk population. The low immunization rates of the lower-income group and the younger age groups have significant public health implications and should be studied further.     

Enhancing influenza immunization. Postcard and telephone reminders and the challenge of immunization site shift

OBJECTIVE: To determine if postcard and telephone reminders increased the rate of influenza immunization of Medicare beneficiaries. DESIGN: Before and after trial (postcard reminders) with systematically allocated control group (telephone reminder intervention). SETTING: A semirural family practice residency program. PATIENTS AND OTHER PARTICIPANTS: All 475 noninstitutionalized persons older than 65 years who had received at least 1 office service in the previous 2 years. INTERVENTION: In September 1996, each of 475 patients received a postcard urging prompt influenza immunization. Those not responding within 1 month were systematically allocated either to a group receiving further telephone contact or to a control group. At the time of telephone contact, any offered information about influenza immunization received outside the Smoky Hill Family Practice Center, Salina, Kan, was recorded. MAIN OUTCOME MEASURES: We measured the percentage of change in practice-administered influenza immunizations compared with the baseline rate of the preceding 2 years; the difference in immunization rates between the telephone intervention group and controls; and the number of patients contacted by telephone who reported receiving influenza immunization at a site other than the Family Practice Center. RESULTS: Twenty-eight percent of patients who received a postcard obtained office influenza immunizations within 1 month, but no additional immunizations could be attributed to the telephone intervention. Thirty-five percent of patients contacted by telephone reported receiving influenza immunization at a site other than the Family Practice Center. CONCLUSIONS: The postcard intervention was associated with a significant increase in the office immunization rate. This increase may have been confounded by "site shift" in which individuals came to the office for an immunization that they might otherwise have received at other community sites.     

Practice and Physician Characteristics Associated with Influenza Vaccination Delivery Rates Following a Patient Reminder Letter Intervention

As part of the “Provider and Patient Reminders in Ontario: Multi-strategy Prevention Tools” demonstration project, the purpose of this study was to explore the practice and physician characteristics associated with influenza vaccination rates following a reminder letter intervention for patients 65 years of age and older. Using a sample of 179 physicians, we estimated a multiple linear regression model to examine variables predictive of vaccination delivery rates. Several provider characteristics, including certification with the College of Family Physicians of Canada and practicing in an urban area, were predictive of the success of the reminder letter campaign. Examining other physician and practice factors associated with vaccination delivery following a reminder letter campaign may help improve such prevention efforts.     

Randomized Trial of a Program to Increase Staff Influenza Vaccination in Primary Care Clinics

PURPOSE Although vaccination of health care workers against influenza is widely recommended, vaccination uptake is low. Data on interventions to increase staff immunization in primary care are lacking. We examine the effect of a promotional and educational intervention program, not addressing vaccine availability, to raise the influenza vaccination rate among staff in primary care clinics.METHODS The study included all 344 staff members with direct patient contact (physicians, nurses, pharmacists, and administrative and ancillary staff) in 27 primary care community clinics in the Jerusalem area during the 2007–2008 influenza season. Thirteen clinics were randomly selected for an intervention that consisted of a lecture session given by a family physician, e-mail-distributed literature and reminders, and a key figure from the local staff who personally approached each staff member.RESULTS Influenza immunization rate was 52.8% (86 of 163) in the intervention group compared with 26.5% (48 of 181) in the control group (P<.001). When compared with the rate of immunization for the previous season, the absolute increase in immunization rate was 25.8% in the intervention clinics and 6.6% in the control clinics. Multivariate analysis showed a highly significant (P<.001) independent association between intervention and immunization, with an odds ratio of 3.51 (95% confidence interval, 2.03–6.09).CONCLUSION We have developed an effective intervention program to increase previously low vaccination rates among primary health care workers. This simple intervention could be reproduced easily in other clinics and organizations with an expected substantial increase in influenza immunization rates.     

Improving the rates of inpatient pneumococcal vaccination: impact of standing orders versus computerized reminders to physicians.

OBJECTIVE: To determine the impact of interventions using standing orders and computerized reminders to physicians on inpatient pneumococcal vaccination rates relative to a control group. DESIGN: Open trial of the following approaches, each on a different ward: (1) standing orders for vaccination of eligible consenting patients, (2) computerized reminders to physicians, and (3) usual practice. SETTING AND PATIENTS: Four hundred twenty-four patients were admitted to three 30-bed inpatient medical wards during a 4-month period in 1999 at one hospital. Unvaccinated patients 65 years or older and competent to give oral consent were included. INTERVENTION: A pharmacist activated a standing orders protocol for vaccination of all eligible consenting patients on one ward and computerized reminders to physicians on a second ward. A third ward served as a control group. RESULTS: Forty-two patients met inclusion criteria and accepted vaccination in the standing orders arm versus 35 patients in the computerized reminder arm. Vaccination rates on the standing orders ward included 98% of those eligible and accepting vaccination, 73% of eligible patients, and 28% of all patients admitted. Rates on the computerized reminder ward were 23%, 15%, and 7%, respectively. All of the rates from the standing orders ward were significantly greater than those from the computerized reminder ward (P < .0001). Only 0.6% of all patients on the control arm were vaccinated. CONCLUSION: Although both interventions were effective in increasing inpatient pneumococcal vaccination rates relative to baseline practice, physician independent initiation of standing orders was clearly more effective.     

Vaccination of high-risk patients for influenza. A comparison of telephone and mail reminder methods

During the 1984-1985 influenza season two study groups were used to compare telephone and letter reminder methods with a control group that received no reminder to determine which was the most effective strategy to increase influenza vaccination rates among the high-risk patient population of a university-based family practice. Seven hundred eighty-seven high-risk patients were randomly assigned to one of the three study groups: a mailed-reminder group, a telephone-reminder group, and a control group. Vaccination rates for both reminder methods were significantly higher than for the control group (P less than .02), and if successfully contacted, the telephone-reminder group had a significantly better vaccination rate than the mailed-reminder group (P less than .05). If successful telephone contact can be made, this reminder method is more effective than a letter reminder to increase influenza vaccination rates among high-risk patients.     

Effect of mobile phone text messaging for improving the uptake of influenza vaccination in patients with rare diseases

ObjectivesInfluenza vaccine is recommended in some chronic medical conditions, including several rare diseases. The objectives of the study were to assess the effect of text message reminders on influenza vaccination uptake of patients with selected rare diseases and delayed vaccination, and to describe their characteristics.MethodsQuasi-experimental pre-post intervention study performed along the 2016 influenza vaccination campaign in the Autonomous Community of Madrid. Unvaccinated patients diagnosed with a selected rare disease were targeted for intervention. SMS were sent to them at least one month after the beginning of the campaign, in four consecutive weeks. Those with no mobile phones available or no certainty of message reception, were assigned as controls. The association between the reception of the SMS and vaccination uptake was assessed using multiple poisson regression models.ResultsOf 69.040 patients with delayed vaccination, 87.2% received an SMS reminder in the asigned contact mobile telephone. Global influenza vaccine coverage reached 41.3%. The uptake of influenza vaccine was significantly higher among those receiving the reminder (9.3% vs. 7.1% in the control group, p < 0.001). Those who received a SMS reminder were 30% more likely to uptake seasonal influenza vaccine. By sex and age, the reception of the reminder was associated with a significantly higher probability of vaccination in men ≥65 years with at least a concurrent chronic condition (IRR: 1.58, CI95%: 1.25–2.00). Among women, this higher probability was detected in those between 14 and 64 years of age (IRR: 1.41, CI95%: 1.22–1.63), and ≥65 years without concurrent chronic conditions (IRR: 1.40, CI95%: 1.05–1.89).ConclusionAlthough the intervention was modestly effective, it proved beneficial in some cases. It can be an additional strategy to improve vaccine uptake, since it is simple, feasible, affordable and easily scalable, particularly when immunization and target population data are available in population registries.     

Association between patient reminders and influenza vaccination status among children

BackgroundPatient reminders are recommended to increase vaccination rates. The objectives of this study were to estimate the percentage of children 6 months–17 years for whom a patient reminder for influenza vaccination was received by a child’s parent or guardian, estimate influenza vaccination coverage by receipt of a patient reminder, and identify factors associated with receipt of a patient reminder.MethodsNational Immunization Survey-Flu (NIS-Flu) data for the 2013–14 influenza season were analyzed. Tests of association between patient reminders and demographic characteristics were conducted using Wald chi-square tests and pairwise comparison t-tests. Multivariable logistic regression was used to determine variables independently associated with receiving a patient reminder.ResultsApproximately 22% of children had a parent or guardian report receiving a patient reminder for influenza vaccination for their child, ranging from 12.9% in Idaho to 41.2% in Mississippi. Children with a patient reminder were more likely to be vaccinated compared with children without a patient reminder (73.7% versus 55.5%). In the multivariable model, reminder receipt was higher for children 6–23 months compared with children 13–17 years, black children compared with white children, and children whose parent completed the survey in English compared with children whose parent completed the survey in a language other than English or Spanish.ConclusionsAlthough patient reminders are associated with a higher likelihood of influenza vaccination, nationally, less than one-fourth of children had a parent report receiving one. Despite being based on parental report, with its limitations, this study suggests that increasing the number of parents who receive patient reminders for their children may improve vaccination coverage among children.     

The effect of microcomputer-generated reminders on influenza vaccination rates in a university-based family practice center

Less than 20 percent of elderly and other high-risk persons targeted for annual influenza vaccination are immunized each year. In most busy practice settings, it is difficult for primary care physicians to identify every patient in need of preventive health interventions. The purpose of this study was to assess the effect of microcomputer-generated reminders on influenza vaccination rates in a university-based family practice center. The practice uses an interactive encounter form system from which updated clinical information is routinely entered into a cumulative database. During a 2-month period, 686 patients were identified in the database as eligible to receive influenza vaccine according to accepted criteria. Practice physicians (n = 32) were stratified by level of training and randomized to one of three groups, thereby receiving printed reminders on the encounter forms of all, none, or half of their eligible patients. Patients of physicians who always received reminders were more likely to receive influenza vaccine during the study period than patients of the never-reminded physicians (51 percent versus 30 percent, P less than 0.001). Patients whose physicians received reminders for only half their patients had an intermediate likelihood of receiving a vaccination if a reminder was printed (38 percent) but were less likely than the patients of never-reminded physicians to receive the vaccine if no reminder was printed (20 percent, P less than 0.001). This study suggests that physicians learn to depend on reminders for preventive health activities and that reminders are most effective when they are provided at every patient encounter.     

Influenza vaccination among adults living with persons at high-risk for complications from influenza during early 2016–17 influenza season

BackgroundThe Advisory Committee on Immunization Practices (ACIP) recommends all persons aged ≥6 months get vaccinated for influenza annually, placing particular emphasis on persons who are at increased risk for influenza-related complications and persons living with or caring for them.MethodsData from the 2016 National Internet Flu Survey (NIFS), a nationally representative, probability-based Internet panel survey of the noninstitutionalized U.S. civilian population aged ≥18 years, was used to compare influenza vaccination coverage among adults who live with household members at high-risk for complications from influenza with those who do not. Logistic regression was used to evaluate the difference in the adjusted vaccination coverage prevalence between persons living with and without high-risk household members.ResultsFrom the 2016 NIFS (n = 4,113), we estimated that 29.2% of noninstitutionalized U.S. adults had at least one household member at increased risk for influenza-related complications. Unadjusted influenza vaccination coverage was significantly higher for adults with a high-risk household member compared with those without (46.7% vs 38.6%, respectively). After adjustment for demographic and access-to-care factors, adults with high-risk household members were more likely to be vaccinated than those without (adjusted prevalence difference = 5.3 [0.3, 10.3]). Among vaccinated respondents with high-risk household members, 88.7% reported that protection of their family and close contacts was one of the reasons they were vaccinated.ConclusionApproximately half of adults living with someone at increased risk of complications from influenza did not report receiving an influenza vaccination. Vaccination reminder/recall for persons at increased risk should include reminders for their household contacts.     

Impact of public vaccination programs on adult vaccination rates: two examples from Ontario, Canada

This study examined adult vaccination rates in Metropolitan Toronto/Peel Region following the implementation of publicly funded adult pneumococcal and universal influenza vaccination programs in Ontario. Community-living adults eligible for pneumococcal vaccines were surveyed regarding vaccination rates, and factors potentially associated with vaccination. Influenza vaccine rates increased over time, but only respondents 65 years of age and older met Canadian targets. Pneumococcal vaccine rates were below target for all respondents. More than 90% of unvaccinated respondents had seen a physician within the past year, and most vaccinations occurred in a physician's office, suggesting a role for physician advocacy to improve immunization rates. Adult vaccination programs may be less successful than pediatric programs in achieving vaccine uptake, and require on-going assessment and promotion.     

Statewide Pandemic Influenza Vaccination Reminders for Children with Chronic Conditions

Objectives. We evaluated the use of a statewide immunization information system (IIS) to target influenza vaccine reminders to high-risk children during a pandemic.Methods. We used Michigan’s IIS to identify high-risk children (i.e., those with ≥ 1 chronic condition) aged 6 months to 18 years with no record of pH1N1 vaccination among children currently or previously enrolled in Medicaid (n = 202 133). Reminders were mailed on December 7, 2009. We retrospectively assessed children’s eligibility for evaluation and compared influenza vaccination rates across 3 groups on the basis of their high-risk and reminder status.Results. Of the children sent reminders, 53 516 were ineligible. Of the remaining 148 617 children, vaccination rates were higher among the 142 383 high-risk children receiving reminders than among the 6234 high-risk children with undeliverable reminders and the 142 383 control group children without chronic conditions who were not sent reminders.Conclusions. Midseason reminders to parents of unvaccinated high-risk children with current or past Medicaid enrollment were associated with increased pH1N1 and seasonal influenza vaccination rates. Future initiatives should consider strategies to expand targeting of high-risk groups and improve IIS reporting during pandemic events.Shortly after the onset of the 2009 global pandemic of influenza A (H1N1)pdm09 virus (pH1N1),1 the Advisory Committee for Immunization Practices released recommendations for vaccination that specifically identified 5 target groups, including persons at higher risk for infection or for severe influenza-related complications because of chronic medical conditions.2 Although administration of a monovalent pH1N1 vaccine began throughout the United States in October 2009, initial vaccine supplies were very limited in many jurisdictions. As a consequence, numerous state and local health departments requested that providers focus vaccine administration on a smaller subset of the initial target groups,3 based on subgroups designated by the advisory committee as a priority in the event of a vaccine shortage.2Early indications from the Centers for Disease Control and Prevention estimated that more than 1 million cases of pH1N1 influenza had occurred in the United States by August 20094 and that pediatric deaths from pH1N1 influenza were more common among children with 1 or more chronic medical conditions (hereinafter referred to as “high-risk children”).5 Reminder–recall for pH1N1 vaccine represented a potential strategy for reaching parents of high-risk children. It had previously been demonstrated as an effective mechanism for increasing pediatric seasonal influenza vaccination among children with chronic conditions.6–8 In addition, during the 2009–2010 influenza season, a midseason report from the Advisory Committee for Immunization Practices urged health departments to consider implementing practices shown to increase influenza vaccination coverage, including reminder–recall.9The Michigan Department of Community Health (MDCH) used the Michigan Care Improvement Registry (MCIR) to target pH1N1 vaccination reminders to children known to have a high-risk condition. MCIR has a high degree of provider participation with more than 95% of children age 6 years or younger having 2 or more vaccine doses entered.10 At the time of this reminder effort, all immunization providers in Michigan were required by state law to report school-exclusionary vaccinations administered to children to MCIR. In addition, pH1N1 vaccine providers were required to report to MCIR all pH1N1 doses administered during the pandemic.Although using MCIR to target reminders to high-risk children had been demonstrated on a small scale,11 the use of such notifications during an influenza pandemic was untested. With that in mind, our objective was to describe the feasibility and utility of this effort. To our knowledge, this is the first assessment of a statewide reminder–recall during an influenza pandemic.     

Interventions to increase influenza vaccination rates in children with high-risk conditions—A systematic review

BackgroundInfluenza is a common cause of morbidity and mortality, especially among the elderly and those with certain chronic diseases. Annual influenza vaccination is recommended for individuals in at-risk groups, but rates of vaccination are particularly low in children with high-risk conditions (HRCs).ObjectiveTo conduct a systematic review of studies that have examined interventions aimed at improving influenza vaccination in children with HRCs.MethodsTwo databases – PubMed and SCOPUS – were searched (with no time or language restrictions) using a combination of keywords – Influenza AND vaccination OR immunization OR children AND asthma OR malignancy OR high-risk AND reminder. Duplicates were removed, and abstracts of relevant articles were screened using specific inclusion/exclusion criteria. Thirteen articles were selected, and five additional studies were identified following a review of the reference lists of the initial thirteen articles, bringing the total number to eighteen.ResultsMost studies were conducted in the United States. Among the 18 studies, there was one systematic review of a specific intervention in asthmatic children, seven randomized controlled trials (RCTs), six before-and-after studies, one non-randomized controlled trial, one retrospective cohort study, one quasi-experimental post-test study, and one letter to editors. Interventions reported include multi-component strategies, letter reminders, telephone recall, letters plus telephone calls, an asthma education tool and year-round scheduling for influenza vaccination, amongst others.ConclusionThere is good evidence that reminder letters will improve influenza vaccination uptake in children with HRCs, but the evidence that telephone recall or a combination of letter reminder and telephone recall will improve uptake is weak. It is not known if multiple reminder letters are more effective than single letters or if multi-component strategies are more effective than single or dual component strategies. There is a need for further research of these interventions, possibly outside the United States.     

The use of patient and physician reminders for preventive services: results from a National Study of Physician Organizations

BACKGROUND: Clinical preventive services improve patient health, and reminder systems can increase the use of such services. However, physician organizations often underutilize clinical preventive service reminders. Little is known about the incentives, capabilities, and organizational characteristics associated with the use of reminders by physician organizations. METHODS: The predictors of patient and physician reminder system use were examined in a sample of 1,104 US physician organizations. The cross-sectional sample was obtained through a telephone survey with a 70% response rate. RESULTS: Fifty-one percent of physician organizations used mammogram reminders, 41% used influenza immunization reminders, and 26% used eye exam reminders for patients. Eighteen percent of physician organizations used computer-generated reminders to physicians. Required reporting of data (P = 0.0006), public recognition for quality (P = 0.0002), and IT capabilities (P < 0.0001) were strongly associated with patient reminder use. Medical groups were more likely to use patient-level reminders than independent practice associations (IPAs) (P < 0.0001). Physician reminder use was related to required reporting of data (P < 0.0001) and IT capabilities (P < 0.0001). CONCLUSIONS: Physician organizations have relatively low use of preventive service reminders to patients and physicians. Offering quality incentives to physician organizations and improving their IT capabilities may increase the use of preventive service reminders and improve the delivery of preventive care.     

Tailored interventions to increase influenza vaccination in neighborhood health centers serving the disadvantaged

OBJECTIVES: We designed and evaluated interventions to increase adult immunizations within inner-city health centers. METHODS: Interventions included reminders, standing orders, and walk-in "flu shot clinics." Patients were surveyed and records evaluated. RESULTS: Records from 1 center showed that immunization rates increased from 24% to 30% (P <.001) for patients aged 50 to 64 years and from 45% to 53% for patients aged 65 years and older (P <.001). Self-reported vaccination rates did not increase. In logistic regression analyses, the strongest predictor of vaccination among patients aged 50 to 64 years was the belief that unvaccinated persons will contract influenza (odds ratio [OR] = 5.4; 95% confidence interval [CI] = 2.4, 12.0). Among patients aged 65 years and older, the strongest predictor of vaccination was the belief that friends/relatives thought that they should be vaccinated (OR = 9.7; 95% CI = 4.2, 22.3). CONCLUSIONS: Tailored interventions can improve immunization rates at inner-city health centers.     

Why do older people not get immunised against influenza? A community survey

Many older people who would benefit from influenza vaccine do not get immunised. We carried out a postal questionnaire survey of people aged 65 years and over living in the community to explore views about influenza vaccine and identify ways of improving uptake. Completed questionnaires were returned by 1468/2553 (57.5%). Vaccine coverage for 1998-1999 season was 50.5% (95% confidence interval (CI) 47.9-53.1%). Important predictor variables for non-uptake included absence of medical risk factors, perceived good health, lack of advice from a doctor or nurse, and negative views on vaccine efficacy and safety. Most people had to request vaccination, only one in five got a reminder from their general practitioner. There is scope for improving influenza vaccine coverage in older people by placing more emphasis in patient information materials on vaccine efficacy and safety and by greater use of reminders.     

Promoting influenza and pneumococcal immunization in older adults

BACKGROUND: Reducing the risk of influenza and pneumococcal disease in older adults is a long-standing goal of Medicare's Quality Improvement Organization (QIO) program and parallels the Joint Commission's National Patient Safety Goal 10. ADDRESSING THE GOAL: Since 1999 the West Virginia Medical Institute has worked with a statewide partnership of health organizations on a program to improve influenza and pneumonia vaccination rates in hospitalized Medicare beneficiaries. Methods included education, audit and feedback, toolkits, and training meetings. RESULTS: During the first three years (1999-2001) of the effort, the rate of assessment for pneumococcal immunization at discharge increased from < 10% to 74.1% statewide and for influenza immunization from near zero to 63.4% statewide. Since 2002 pneumococcal immunization administration has increased from 16.1% to 41.1%, with similar improvement in influenza measures. LESSONS LEARNED/NEXT STEPS: Hospitals--and, by extension, long term care facilities--can make dramatic improvements in quality performance in a relatively short time when key staff receive feedback about the need to improve and the tools to assist in improving.     

Physician practices and attitudes regarding adult immunizations

OBJECTIVES: To assess immunization practices and attitudes of U.S. primary care physicians regarding adult influenza and pneumococcal immunizations. METHODS: Mailed survey of primary care internists and family physicians across the United States; four follow-up contacts by mail and telephone. Bivariate and multivariate analyses assessed immunization practices and attitudes and differences by physician characteristics. RESULTS: Three hundred and sixteen of 668 eligible physicians responded (50 refused, response rate of 266 = 40%); 220 provided adult vaccinations. More than 64% indicated they routinely vaccinated patients >/=65 years and those <65 years with chronic disease indications with both influenza and pneumococcal vaccine. Reported barriers for influenza vaccination included vaccine safety concerns by patients (58%), urgent concerns dominating visits (43%), and inadequate reimbursement (26%). Reported barriers for pneumococcal vaccination included urgent concerns during office visits (44%), no patient immunization history (36%), patient concerns about vaccine safety (31%), and inadequate reimbursement (25%). Many physicians indicated willingness to try tracking systems (72%), chart reminders (55%), patient reminders (53%), standing orders (36%), external lists of unimmunized patients for pneumococcal vaccination (74%), external patient reminders (70%), and office training of physicians (36%) or staff (46%). CONCLUSIONS: While most physicians favored adult vaccinations, practical barriers to vaccination exist. Most physicians would adopt evidence-based strategies to improve immunization delivery.