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Original Investigation |

Failure to Vaccinate Medicare Inpatients:  A Missed Opportunity FREE

Dale W. Bratzler, DO, MPH; Peter M. Houck, MD; Hui Jiang, MS; Wato Nsa, MD, PhD; Claudette Shook, RN; Lori Moore, RN; Lisa Red, MSHA
[+] Author Affiliations

From the Oklahoma Foundation for Medical Quality, Inc, Oklahoma City (Drs Bratzler and Nsa and Mss Jiang, Shook, Moore, and Red), and Centers for Medicare & Medicaid Services, Seattle, Wash (Dr Houck).


Arch Intern Med. 2002;162(20):2349-2356. doi:10.1001/archinte.162.20.2349.
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Background  Hospitalized elderly patients are at risk for subsequent influenza and pneumococcal disease. Despite this risk, they are often not vaccinated in this setting.

Methods  We reviewed the medical records of a national sample of 107 311 fee-for-service Medicare patients, 65 years or older, discharged from April 1, 1998, through March 31, 1999, with a principal diagnosis of acute myocardial infarction, heart failure, pneumonia, or stroke. We linked patient identifiers to Medicare Part B claims to identify influenza and pneumococcal vaccines paid for before, during, or after hospitalization. The main outcome measures were documentation by chart review or paid claim of influenza or pneumococcal vaccination.

Results  Of the 104 976 patients with a single hospitalization, 35 169 (33.5%; 95% confidence interval [CI], 33.2%-33.8%) received pneumococcal vaccination prior to admission, 444 (0.4%; 95% CI, 0.4%-0.5%) were vaccinated in the hospital, and 1076 (1.0%; 95% CI, 1.0%-1.1%) were vaccinated within 30 days of discharge. In the subgroup of 40 488 patients discharged from October through December, 12 782 (31.6%; 95% CI, 31.1%-32.0%) received influenza vaccination prior to admission, 755 (1.9%; 95% CI, 1.7%-2.0%) were vaccinated in the hospital, and 4302 (10.6%; 95% CI, 10.3%-10.9%) were vaccinated after discharge. Of patients who were unvaccinated prior to admission, 97.3% (95% CI, 97.1%-97.5%) did not receive influenza vaccine and 99.4% (95% CI, 99.3%-99.4%) did not receive pneumococcal vaccine before hospital discharge.

Conclusion  National recommendations for inpatient vaccination against influenza and pneumococcal disease are not being followed for the vast majority of eligible Medicare patients admitted to the hospital.

INFLUENZA AND PNEUMOCOCCAL vaccines are underutilized for Americans 65 years and older. Based on the 1999 Behavioral Risk Factor Surveillance System (BRFSS) survey, 66.9% received the influenza vaccine during the previous 12 months and 54.1% had ever received the pneumococcal vaccine.1 This underutilization is not without consequences. Influenza causes more than 100 000 excess hospitalizations and 20 000 deaths each year.2 Infection due to Streptococcus pneumoniae accounts for at least 500 000 cases of pneumonia and 50 000 cases of bacteremia in the United States each year.36 The combined reporting category of influenza and pneumonia represents the fifth leading cause of death for this age group.7

Hospitalized patients are at particular risk for subsequent influenza and pneumococcal disease.8 Up to 46% of subsequent influenza-related hospitalizations and approximately two thirds of influenza-related deaths occur in elderly persons who have been previously discharged during that flu season.9 Similarly, up to two thirds of patients hospitalized with serious pneumococcal infections have been hospitalized at least once during the previous 3 to 5 years.1014 Despite the risk of subsequent disease, immunization status is often not documented and vaccination is rarely offered to hospitalized patients.8,1518

The Advisory Committee on Immunization Practices (ACIP) recommends administration of influenza and pneumococcal vaccines to inpatients as a strategy for increasing vaccination coverage among adults.2,3 As a part of the Centers for Medicare & Medicaid Service (CMS) national efforts to improve the quality of care given to Medicare beneficiaries, we evaluated the utilization of influenza and pneumococcal vaccines in a large cohort of patients admitted to the hospital during 1998 and 1999.

SUBJECTS

Details of implementation of the CMS national quality improvement projects have been previously published.19 Medicare fee-for-service hospital claims data were used to identify discharges with a principal diagnosis of acute myocardial infarction, heart failure, pneumonia, or stroke. These 4 clinical topics have been selected as national quality improvement priorities for the Medicare Program.20 Managed care hospitalizations were not included because claims were not consistently submitted for them. Up to 850 discharges (900 for heart failure) were randomly selected for each of the 4 clinical conditions from each state and the District of Columbia.19 We selected all eligible cases if there were fewer than the targeted number of discharges available. Based on Medicare quality improvement organization contract cycles, the sample period varied by state and clinical topic. Discharges for a 6-month period within each state were sampled. For a third of the states, this period was from April to September 1998; for another third of the states, July to December 1998; and for the remaining states, October 1998 to March 1999. All states had pneumonia cases sampled from October to December 1998 to assess inpatient influenza vaccine screening and administration. Informed consent and institutional review board approval were not required because the data were collected for administration of the Medicare program, not for research, and access to these data is given to the Program by law.

DATA COLLECTION

Hospitals sent photocopies of the selected medical records to 1 of 2 CMS-contracted clinical data abstraction centers that used topic-specific computerized data collection tools with explicit predefined criteria for manual chart review and data entry. Continuous monitoring of the quality of data collection through interrater reliability testing occurred throughout the process for each clinical topic. Questions related to influenza vaccine were limited to the charts of patients admitted during October 1998 through December 1998. There was no date restriction on questions related to pneumococcal immunization. Each chart was reviewed to determine if the patient's influenza and pneumococcal vaccination status was documented in the medical record and if indicated vaccines were administered prior to discharge.

Subsequent to medical record review, we linked the unique patient identifiers for all selected cases to Medicare Part B claims for influenza vaccination provided between July 1, 1998, and January 31, 1999, and for pneumococcal vaccination provided during 1991 through 1999.

DATA ANALYSIS

Patients were included in the analysis if they were 65 years or older, were discharged alive, were not transferred to another acute care facility, and did not leave the hospital against medical advice. Diagnosis-specific exclusion criteria included acute myocardial infarction–admission for observation only or ongoing treatment of a recent myocardial infarction (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] code 410.x2); heart failure–procedure code that indicated dialysis (ICD-9-CM codes 39.95 or 54.98); and pneumonia–transfer from another acute care hospital, absence of a working diagnosis of pneumonia, or patient receiving comfort measures only. For this analysis, patients who had only 1 hospitalization during the study period were analyzed separately from those who had multiple hospitalizations for the same or different clinical reasons.

Influenza vaccination was examined for patients with a single hospitalization who were discharged from October 1, 1998, through December 31, 1998. Vaccination prior to admission was based on finding a paid claim from July 1, 1998, to the date of admission, or medical record documentation of patient self-reported vaccination. Inpatient vaccination was determined by documentation in the medical record or by a paid claim during the dates of the hospital stay. Vaccination after discharge was determined by finding a claim for the influenza vaccine from the date of hospital discharge to January 31, 1999.

Pneumococcal vaccination was examined for all patients with a single hospitalization at any point during the year of study. Vaccination prior to admission was based on finding a claim for the pneumococcal vaccine before the date of hospitalization (Medicare Part B claims are available for pneumococcal vaccines paid for since 1991) or by medical record documentation of patient self-reported vaccination. Inpatient vaccination was determined by documentation in the medical record or by a paid claim during the hospital stay. Vaccination after discharge was determined by examining claims during the 30 days after discharge.

Inpatient vaccination of patients with multiple hospitalizations was determined by medical record documentation during any of their hospital stays or by finding a claim during any of the patient's admissions. Analysis of influenza vaccination was limited to those with discharges between October 1, 1998, and December 31, 1998. Outpatient vaccination was determined by identification of a claim for the influenza vaccine (July 1, 1998, through January 31, 1999) or for the pneumococcal vaccine (1991 through 30 days after last discharge) during any of the dates the patient was not hospitalized, or by medical record documentation of patient self-reported vaccination.

For all analyses, where there was conflicting evidence with only 1 source demonstrating vaccination (eg, a paid Part B claim was found but the patient stated that he or she had not been immunized), we assumed that the patients were immunized. This circumstance was rare, occurring in only 0.6% of the cases for influenza vaccine and 0.8% of the cases for pneumococcal vaccine.

STATISTICAL ANALYSES

Descriptive statistics were calculated for the limited demographics available in this data set and all analyses were summarized across clinical topics and patient variables including age, race, and sex. Differences in immunization rates across various population subgroups were compared using χ2 tests. Exact binomial 95% confidence intervals (CIs) were calculated for all results. All reported P values are 2-sided.

Because the sample of cases represented a fixed maximum number of patients per diagnosis per state, we applied normalized weights to adjust all reported vaccination rates. Two factors composed a normalized weight: crude weight and probability of sampling. Crude weight was calculated for each state by dividing the number of sampled cases by the state universe (the total number of records in a state for a given topic). The probability of sampling was calculated using the total number of eligible cases in the samples for the study divided by the corresponding portion of the universe of cases in the Medicare population. Similar procedures were applied when stratifying vaccination rates by age, race, and sex.

All analyses were completed using SAS statistical software (SAS version 8.1, SAS Institute Inc, Cary, NC).

Of the 144 482 total hospitalizations, we excluded 8508 because of diagnosis-specific exclusions, 10 756 because of patient age younger than 65 years, and 15 451 because of patient death during the hospital stay or because the patient left the hospital against medical advice. This resulted in 109 767 hospital discharges in the final data set. Of these, 41 426 occurred from October 1, 1998, to December 31, 1998.

We identified 107 311 unique patients cared for during these hospitalizations. Of these patients, 104 976 (97.8%) had a single hospitalization and 2335 (2.2%) had more than 1 admission. Demographic characteristics of the patients are summarized in Table 1. The mean age of the patients was 78.6 years (median, 78 years), with pneumonia patients being slightly older than those with other conditions (mean, 79.4 years; median, 79 years). The mean age of the patients with more than 1 hospitalization was 78.8 years (median, 79 years). Patients 85 years or older made up almost a quarter of the study population. The majority of patients were white (88%), and females predominated in the sample (55.2%).

Table Graphic Jump LocationTable 1. Demographic Characteristics of 107 311 Medicare Patients Admitted to US Hospitals Between April 1, 1998, and March 31, 1999, With Acute Myocardial Infarction, Heart Failure, Pneumonia, or Stroke*

Influenza vaccination of patients with a single hospitalization is summarized in Table 2. Of the 40 488 unique patients discharged from October through December 1998, 12 782 (31.6%; 95% CI, 31.1%-32.0%) had evidence of vaccination prior to admission, 755 (1.9%; 95% CI, 1.7%-2.0%) were vaccinated in the hospital, and 4302 (10.6%; 95% CI, 10.3%-10.9%) had a claim for vaccination after discharge through January 31, 1999. Expressed in another way, 26 951 (97.3%; 95% CI, 97.1%-97.5%) of the 27 706 patients who were unvaccinated prior to admission did not receive the influenza vaccine before hospital discharge, representing a missed opportunity. There were no significant differences in the utilization of influenza vaccine across clinical topics (P = .12). When the results were adjusted for the sampling strategy, 31.1% (95% CI, 30.7%-31.6%) had evidence of vaccination prior to admission, 1.5% (95% CI, 1.4%-1.7%) were vaccinated in the hospital, and 10.1% (95% CI, 9.8%-10.4%) had a claim for vaccination after discharge.

Table Graphic Jump LocationTable 2. Proportion of Medicare Inpatients Who Received Influenza Vaccination Before, During, or After Hospitalization*

Pneumococcal vaccination of patients with a single hospitalization is summarized in Table 3. Of the 104 976 total patients, 35 169 (33.5%; 95% CI, 33.2%-33.8%) had evidence of vaccination prior to admission, 444 (0.4%; 95% CI, 0.4%-0.5%) were vaccinated in the hospital, and 1076 (1.0%; 95% CI, 1.0%-1.1%) had a claim for vaccination within 30 days of discharge. Expressed in another way, 69 363 (99.4%; 95% CI, 99.3%-99.4%) of the 69 807 patients who were unvaccinated prior to admission did not receive the pneumococcal vaccine before hospital discharge, representing a missed opportunity. There were statistically significant differences across clinical topics in the proportion of patients vaccinated with the pneumococcal vaccine (P<.001), with pneumonia patients being more likely to have received it before, during, or after hospitalization. When the results were adjusted for the sampling strategy, 32.9% (95% CI, 32.6%-33.2%) had evidence of vaccination prior to admission, 0.3% (95% CI, 0.3%-0.4%) were vaccinated in the hospital, and 0.9% (95% CI, 0.9%-1.0%) had a claim for vaccination after discharge.

Table Graphic Jump LocationTable 3. Proportion of Medicare Inpatients Who Received Pneumococcal Vaccination Before, During, or After Hospitalization*

Utilization of influenza vaccine stratified by demographic group is summarized in Table 4. There were significant differences in rates across age groups (P<.001), racial/ethnic categories (P<.001), and between men and women (P<.001). Vaccination rates adjusted for sampling strategy ranged from 23.4% (95% CI, 13.2%-36.5%) for Hawaiian natives to 45.2% (95% CI, 44.7%-45.7%) for white patients. The age group of 65 to 69 years (38.9%; 95% CI, 37.6%-40.2%) and the group 85 years and older (39.6%; 95% CI, 38.6%-40.5%) were least likely to be immunized.

Table Graphic Jump LocationTable 4. Proportion of Medicare Inpatients Who Received Influenza Vaccination Before, During, or After Hospitalization by Age, Race, and Sex*

Similarly, there were significant differences across age groups (P<.001) and racial groups (P<.001) in the proportions of patients who received the pneumococcal vaccine (Table 5). There was no significant difference in pneumococcal vaccination rates based on sex (P = .10). Vaccination rates adjusted for sampling strategy ranged from 19.9% (95% CI, 19.0%-20.8%) for African Americans to 36.2% (95% CI, 35.9%-36.6%) for white patients. As expected, the proportion of patients who had received pneumococcal vaccine at least once increased with age up to 85 years. Patients who were 85 years or older had lower rates of vaccination but this may reflect the lack of Part B claims data for pneumococcal vaccine given prior to 1991.

Table Graphic Jump LocationTable 5. Proportion of Medicare Inpatients Who Received Pneumococcal Vaccination Before, During, or After Hospitalization by Age, Race, and Sex*

Influenza and pneumococcal vaccination rates among patients who had more than 1 hospital admission are summarized in Table 6. Although vaccination in the hospital with the influenza vaccine was more common in patients with more than 1 hospitalization than in patients with a single admission (5.9% vs 1.9%, P<.001), the total vaccination rate for this population was not significantly different (46.9% vs 44.1%, P = .25). Patients with more than 1 hospitalization were 3 times more likely (P<.001) to receive pneumococcal vaccine as an inpatient (1.3%; 95% CI, 0.9%-1.8%) than those with a single hospitalization (0.4%; 95% CI, 0.4%-0.5%). Overall pneumococcal vaccination rates were higher in patients with more than 1 admission (40.3%; 95% CI, 38.3%-42.3%) than among those with a single admission (34.9%; 95% CI, 34.7%-35.2%) (P<.001).

Table Graphic Jump LocationTable 6. Proportion of Medicare Inpatients With More Than 1 Admission Who Received Influenza or Pneumococcal Vaccination in the Hospital or in the Ambulatory Setting

Hospital-based vaccination of adults against influenza and pneumococcal disease has been recommended since the 1980s.15,2131 The ACIP continues to promote hospital-based vaccination of adults in its most recent recommendations for the prevention of influenza and pneumococcal disease.2,3 The Infectious Diseases Society of America4 and the American Thoracic Society32 have endorsed this practice in recently published guidelines for the management of patients admitted with community-acquired pneumonia.

We demonstrated that a large proportion of Medicare inpatients admitted with common clinical conditions had not received influenza and pneumococcal vaccines prior to their stay and rarely received them in the hospital. Our linkage with Medicare claims data also suggests that patients not vaccinated prior to or during hospitalization are often not immunized in the short-term after discharge. Only 10.6% of the patients received influenza vaccine after discharge and 1.0% received pneumococcal vaccine in the month after discharge. A previous report indicated that screening of vaccination status was documented for only 13.3% of inpatients for influenza and only 8.5% of inpatients for pneumococcal vaccine.8 This suggests that hospitalizations represent a missed opportunity for vaccination. Rates of hospital-based influenza and pneumococcal vaccination have changed very little since 1995.16

Consistent with the findings of other investigators,1,2,6,16,3335 we found substantial racial disparities in vaccination rates. African American, Native American, and Hawaiian native patients had the lowest rates of influenza vaccination in our study population and African American patients had the lowest rates of pneumococcal vaccination. These disparities largely reflect differences in ambulatory vaccination rates. Lack of access to primary care, limited awareness of need for vaccination, and misconceptions about vaccination have been implicated as possible reasons for racial disparity in immunization rates.3540 This suggests that hospitalization may be a particularly opportune time to vaccinate minority patients.

Several factors might explain the lack of effective hospital-based vaccination programs.8,16 Skepticism about vaccine effectiveness may impact programs in any patient care setting. However, the effectiveness of the influenza vaccine is now largely unquestioned as having been shown to reduce hospitalizations for pneumonia and influenza, other respiratory conditions, and congestive heart failure, and to reduce mortality from all causes.2,4149 Influenza vaccine is immunogenic when administered to hospitalized patients and those with chronic renal disease.50,51

The efficacy of the pneumococcal vaccine in the elderly has been more controversial.52 Numerous epidemiologic studies have demonstrated that pneumococcal vaccine is approximately 60% effective in preventing invasive disease (bacteremia and meningitis) due to S pneumoniae.48,5358 The effectiveness of vaccination in elderly patients or those who are chronically ill has been more difficult to demonstrate.52,5961 However, a recent retrospective cohort study of elderly patients with chronic lung disease showed pneumococcal vaccine to be associated with a 43% reduction in the number of hospitalizations for pneumonia and a 29% reduction in the risk of death from all causes.62 Preliminary data from a large, prospective, population-based study of influenza and pneumococcal vaccines (the majority received both) in patients 65 years and older suggests marked reductions in the incidence of hospitalization for influenza, pneumonia, pneumococcal pneumonia, and death.63 This is consistent with the findings of a managed care cohort study in the United States that demonstrated the additive benefit of receiving both vaccines.64 Reports from multiple outbreak investigations,6567 and the emergence of antibiotic-resistant strains of S pneumoniae continue to support the need for pneumococcal vaccination in the elderly population.68

Both influenza and pneumococcal vaccinations have been shown to be cost-effective.41,43,46,47,62,69 Medicare Part B pays for influenza and pneumococcal vaccines over and above the basic diagnosis related group payment for inpatient care.58 A hospital can submit a roster bill to reduce the administrative burden of submitting individual claims for administered vaccinations.70

Although concern about adverse reactions is another reason cited for not vaccinating inpatients, serious adverse events are exceedingly rare.2,3 The administration of the influenza vaccine is not associated with higher rates of systemic symptoms compared with placebo injections.71,72 Redness and tenderness at the injection site may occur in 10% to 15% of patients being reimmunized with the pneumococcal vaccine.73 These reactions are almost always mild and self-limited. Among large populations of Medicare patients, rates of hospitalization within 30 days of revaccination with pneumococcal vaccine are no higher than rates of admission for patients being vaccinated the first time.74 In a meta-analysis of 9 randomized controlled trials of pneumococcal vaccine efficacy (including more than 7500 patients), there were no reports of severe febrile, anaphylactic, or neurologic complications.60 Many hospital- and emergency department–based vaccination programs have been safely and effectively implemented with no evidence of significant risk demonstrated in any of these studies.7585

The lack of a systems-based approach might be the most important barrier to inpatient vaccination. A variety of approaches including systems based on nurse-, pharmacist-, or computer-driven reminders have shown varying success.18,7583 However, standing orders programs that authorize nurses or pharmacists to administer vaccinations according to an institution- or physician-approved protocol have achieved higher rates of immunization,15 approaching 90% for influenza and 70% for pneumococcal vaccines.82 The ACIP has recommended the use of standing orders programs to increase immunization rates in outpatient and inpatient settings.2,3,15

Our study has several limitations. Most important is that Medicare claims underestimate vaccination rates. In 1998, the estimated coverage of Medicare beneficiaries that was estimated from claims differed from that estimated by the BRFSS telephone survey by about 23% for both influenza and pneumococcal vaccines (CMS, unpublished data, February 2002). This underestimation may occur because of underascertainment of vaccination through paid Medicare claims (eg, mass vaccination clinics that do not submit Medicare claims) or due to overreporting of vaccination in the BRFSS telephone survey. In addition, data for pneumococcal vaccine claims are not available prior to 1991. This would affect our total pneumococcal vaccine coverage estimates for the oldest age group. Patients who may have received the influenza or pneumococcal vaccines prior to their Medicare eligibility would not have been captured through analysis of paid claims. However, these limitations do not affect our evaluation of inpatient vaccination rates that were based predominantly on chart review. If we assume that our study population had rates of immunization equal to those reported by BRFSS,1 then 13 402 patients discharged from the hospital from October 1, 1998, to December 31, 1998, never received the influenza vaccine during that flu season. Similarly, 48 184 patients were discharged from the hospital during the time frame studied and had never received the pneumococcal vaccine. These results, if extrapolated to the 12 683 000 discharges of patients 65 years and older from nonfederal acute care hospitals during 1999,86 would suggest that millions of patients who have not received the influenza or pneumococcal vaccines are discharged from the hospital each year.

We were not able to account for contraindications to the administration of these vaccines or for patient refusal to be vaccinated. However, specific contraindications to these vaccines are uncommon,2,3 and motivated providers can influence patients' attitudes about influenza and pneumococcal vaccination.37,87 Our study did not include patients younger than 65 years. However, results of the 1997 National Health Interview Survey demonstrated that rates of vaccination for high-risk patients in this age group were lower than rates for patients 65 years and older.15

In summary, published recommendations for inpatient vaccination of adults against influenza and pneumococcal disease are not being followed for the majority of eligible patients admitted to hospitals. Failure to vaccinate these inpatients is a missed opportunity that places them at risk for preventable adverse events including morbidity, hospital readmission, and death associated with influenza and pneumococcal disease. Ensuring that hospital inpatients are screened for immunization status and vaccinated when appropriate will require the implementation of strategies such as those being used to prevent other forms of medical errors—systems-based approaches that provide for the routine delivery of these vaccines to patients at high risk for subsequent disease.

Accepted for publication May 2, 2002.

We thank Raymond A. Strikas, MD, for his thoughtful comments on the analysis and review of an earlier version of the manuscript, and Larry LaVoie, PhD, who was instrumental in obtaining Medicare Part B claims data for this study.

The analyses upon which this publication is based were performed under contract 500-99-P619, entitled "Utilization and Quality Control Peer Review Organization for the State of Oklahoma," sponsored by the CMS, Department of Health and Human Services. The content of this publication does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the US Government. The authors assume full responsibility for the accuracy and completeness of the ideas presented. This article is a direct result of the Health Care Quality Improvement Program initiated by CMS, which has encouraged identification of quality improvement projects derived from analyses of patterns of care, and therefore required no special funding on the part of this contractor. Ideas and contributions to the authors concerning experience in engaging with issues presented are welcomed.

Corresponding author and reprints: Dale W. Bratzler, DO, MPH, Health Care Quality Improvement Program, Oklahoma Foundation for Medical Quality, Inc, 14000 Quail Springs Pkwy, Suite 400, Oklahoma City, OK 73134 (e-mail: okpro.dbratzler@sdps.org).

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Nichol  KLMargolis  KLWuorenma  Jvon Sternberg  T The efficacy and cost effectiveness of vaccination against influenza among elderly persons living in the community. N Engl J Med. 1994;2778- 784
Gross  PAHermogenes  AWSacks  HSLau  JLevandowski  RA Efficacy of influenza vaccine in elderly persons: a meta-analysis and review of the literature. Ann Intern Med. 1995;2518- 527
Nichol  KLMargolis  KLWouremna  Jvon Sternberg  T Effectiveness of influenza vaccine in the elderly. Gerontology. 1996;2274- 279
Nichol  KLGoodman  M The health and economic benefits of influenza vaccination for health and at-risk persons aged 65 to 74 years. Pharmacoeconomics. 1999;16Suppl 163- 71
Nichol  KLWuorenma  Jvon Sternberg  T Benefits of influenza vaccination for low-, intermediate-, and high-risk senior citizens. Arch Intern Med. 1998;21769- 1776
Nguyen-Van-Tam  JSNeal  KR Clinical effectiveness, policies, and practices for influenza and pneumococcal vaccines. Semin Respir Infect. 1999;2184- 195
Nichol  KLBaken  LNelson  A Relation between influenza vaccination and outpatient visits, hospitalization, and mortality in elderly persons with chronic lung disease. Ann Intern Med. 1999;2397- 403
Berry  BBEhlert  DABattiola  RJSedmak  G Influenza vaccination is safe and immunogenic when administered to hospitalized patients. Vaccine. 2001;23493- 3498
Brydak  LBRoszkowska-Blaim  MMachala  MLeszczynska  BSieniawska  M Antibody response to influenza immunization in two consecutive epidemic seasons in patients with renal diseases. Vaccine. 2000;23280- 3286
Flanders  S Pneumococcal vaccination prior to hospital discharge. Shojania  KGDuncan  BWMcDonald  KMMaking Health Care Safer: A Critical Analysis of Patient Safety Practices. Evidence Report/Technology Assessment No. 43 (chap 36), AHRQ Publication 01-E058. Rockville, Md Agency for Healthcare Research and Quality July2001;Available at: http://www.ahrq.gov/clinic/ptsafety/chap36.htm. Accessed April 8, 2002.
Shapiro  EDClemens  JD A controlled evaluation of the protective efficacy of pneumococcal vaccine for patients at high risk of serious pneumococcal infections. Ann Intern Med. 1984;2325- 330
Sims  RVSteinmann  WCMcConville  JH  et al.  The clinical effectiveness of pneumococcal vaccine in the elderly. Ann Intern Med. 1988;2653- 657
Shapiro  EDBerg  ATAustrian  R  et al.  The protective efficacy of polyvalent pneumococcal polysaccharide vaccine. N Engl J Med. 1991;21453- 1460
Butler  JCBreiman  RFCampbell  JF  et al.  Polysaccharide pneumococcal vaccine efficacy: an evaluation of current recommendations. JAMA. 1993;21826- 1831
Farr  BMJohnston  BLCobb  DK  et al.  Preventing pneumococcal bacteremia in patients at risk: results of a matched case-control study. Arch Intern Med. 1995;22336- 2340
Butler  JCShapiro  EDCarlone  GM Pneumococcal vaccines: history, current status, and future directions. Am J Med. 1999;107(suppl 1A)69S- 76S
Ortqvist  AHedlund  JBurman  L  et al.  Randomised trial of 23-valent pneumococcal capsular polysaccharide vaccine in prevention of pneumonia in middle-aged and elderly people. Lancet. 1998;2399- 403
Fine  MJSmith  MACarson  CA  et al.  Efficacy of pneumococcal vaccination in adults: a meta-analysis of randomized controlled trials. Arch Intern Med. 1994;22666- 2677
Hutchison  BGOxman  ADShannon  HS  et al.  Clinical effectiveness of pneumococcal vaccine: meta-analysis. Can Fam Physician. 1999;22381- 2393
Nichol  KLBaken  LWuorenma  JNelson  A The health and economic benefits associated with pneumococcal vaccination of elderly persons with chronic lung disease. Arch Intern Med. 1999;22437- 2442
Christenson  BLundbergh  PHedlund  JOrtqvist  A Effects of a large-scale intervention with influenza and 23-valent pneumococcal vaccines in adults aged 65 years and older: a prospective study. Lancet. 2001;21008- 1011
Nichol  KL The additive benefits of influenza and pneumococcal vaccinations during influenza seasons among elderly persons with chronic lung disease. Vaccine. 1991;17(suppl 1)S91- S93
Nuorti  JPButler  JCCrutcher  JM  et al.  An outbreak of multidrug-resistant pneumococcal pneumonia and bacteremias among unvaccinated nursing home residents. N Engl J Med. 1998;21861- 1868
Bleich  SMorad  YEchague  R  et al.  Streptococcus pneumoniae serotype 4 outbreak in a home for the aged: report and review of recent outbreaks. Infect Control Hosp Epidemiol. 2000;2711- 717
Centers for Disease Control and Prevention, Outbreak of pneumococcal pneumonia among unvaccinated residents of a nursing home—New Jersey, April 2001. MMWR Morb Mortal Wkly Rep. 2001;2707- 710
Whitney  CGFarley  MMHadler  J  et al.  Increasing prevalence of multidrug-resistant Streptococcus pneumoniae in the United States. N Engl J Med. 2000;21961- 1963
Sisk  JEMoskowitz  AJWhang  W  et al.  Cost-effectiveness of vaccination against pneumococcal bacteremia among elderly people. JAMA. 1997;21333- 1339
Centers for Medicare and Medicaid Services, 2001 Fact Sheet for Medicare Influenza/Pneumococcal Vaccination Benefits. Available at: http://cms.hhs.gov/preventiveservices/2.asp#1. Accessed April 8, 2002.
Margolis  KLNichol  KLPoland  GAPluhar  RE Frequency of adverse reactions to influenza vaccine in the elderly. JAMA. 1990;21139- 1141
Govaert  MEDinant  GJAretz  K  et al.  Adverse reactions to influenza vaccine in elderly people: randomised double blind placebo trial. BMJ. 1993;2988- 990
Jackson  LABenson  PSneller  VP  et al.  Safety of revaccination with pneumococcal polysaccharide vaccine. JAMA. 1999;2243- 248
Snow  RBabish  JDMcBean  AM Is there any connection between a second pneumonia shot and hospitalization among Medicare beneficiaries? Public Health Rep. 1995;2720- 725
Klein  RSAdachi  N Pneumococcal vaccine in the hospital: improved use and implications for high-risk patients. Arch Intern Med. 1983;21878- 1881
Magnussen  CRValenti  WMMushlin  AI Pneumococcal vaccine strategy: feasibility of a vaccination program directed at hospitalized and ambulatory patients. Arch Intern Med. 1984;21755- 1757
Klein  RSAdachi  N An effective hospital-based pneumococcal immunization program. Arch Intern Med. 1986;2327- 329
Bloom  HGBloom  JSKrasnoff  LFrank  AD Increased utilization of influenza and pneumococcal vaccines in an elderly hospitalized population. J Am Geriatr Soc. 1988;2897- 901
Clancy  CMGelfman  DPoses  RM A strategy to improve the utilization of pneumococcal vaccine. J Gen Intern Med. 1992;214- 18
Crouse  BJNichol  KPeterson  DCGrimm  MB Hospital-based strategies for improving influenza vaccination rates. J Fam Pract. 1994;2258- 261
Landis  SScarbrough  ML Using a vaccine manager to enhance in-hospital vaccine administration. J Fam Pract. 1995;2364- 369
Nichol  KL Ten-year durability and success of an organized program to increase influenza and pneumococcal vaccination rates among high-risk adults. Am J Med. 1998;2385- 392
Vondracek  TGPham  TPHuycke  MM A hospital-based pharmacy intervention program for pneumococcal vaccination. Arch Intern Med. 1998;21543- 1547
Rodriquez  RMBaraff  LJ Emergency department immunization of the elderly with pneumococcal and influenza vaccines. Ann Emerg Med. 1993;21729- 1732
Slobodkin  DKitlas  JZielske  P Opportunities not missed: systematic influenza and pneumococcal immunization in a public inner-city emergency department. Vaccine. 1998;21795- 1802
Popovic  JR 1999 National Hospital Discharge Survey: Annual Summary with detailed diagnosis and procedure data: National Center for Health Statistics. Vital Health Stat. 2001;(151)i- v1- 206
Fiebach  NHViscoli  CM Patient acceptance of influenza vaccination. Am J Med. 1991;2393- 400

Figures

Tables

Table Graphic Jump LocationTable 1. Demographic Characteristics of 107 311 Medicare Patients Admitted to US Hospitals Between April 1, 1998, and March 31, 1999, With Acute Myocardial Infarction, Heart Failure, Pneumonia, or Stroke*
Table Graphic Jump LocationTable 2. Proportion of Medicare Inpatients Who Received Influenza Vaccination Before, During, or After Hospitalization*
Table Graphic Jump LocationTable 3. Proportion of Medicare Inpatients Who Received Pneumococcal Vaccination Before, During, or After Hospitalization*
Table Graphic Jump LocationTable 4. Proportion of Medicare Inpatients Who Received Influenza Vaccination Before, During, or After Hospitalization by Age, Race, and Sex*
Table Graphic Jump LocationTable 5. Proportion of Medicare Inpatients Who Received Pneumococcal Vaccination Before, During, or After Hospitalization by Age, Race, and Sex*
Table Graphic Jump LocationTable 6. Proportion of Medicare Inpatients With More Than 1 Admission Who Received Influenza or Pneumococcal Vaccination in the Hospital or in the Ambulatory Setting

References

Centers for Disease Control and Prevention, Influenza and pneumococcal vaccination levels among persons aged ≥65 years—United States, 1999. MMWR Morb Mortal Wkly Rep. 2001;2532- 537
Centers for Disease Control and Prevention, Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 2001;50 ((No. RR-4)) 1- 46
Centers for Disease Control and Prevention, Prevention of pneumococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 1997;46 ((No. RR-8)) 1- 24
Bartlett  JGDowell  SFMandell  LA  et al.  Practice guidelines for the management of community-acquired pneumonia in adults: Infectious Diseases Society of America. Clin Infect Dis. 2000;2347- 382
Robinson  KABaughman  WRothrock  G  et al.  Epidemiology of invasive Streptococcus pneumoniae infections in the United States, 1995-1998: opportunities for prevention in the conjugate vaccine era. JAMA. 2001;21729- 1735
Centers for Disease Control and Prevention, Adult immunization programs in nontraditional settings: quality standards and guidance for program evaluation—a report of the National Vaccine Advisory Committee. MMWR Morb Mortal Wkly Rep. 2000;49 ((No. RR-1)) 1- 14
Minino  AMSmith  BL Preliminary data for 2000. National Vital Statistics Reports. Vol 49. Hyattsville, Md National Center for Health Statistics2001; (No. 12)
Fedson  DSHouck  PBratzler  D Hospital-based influenza and pneumococcal vaccination: Sutton's law applied to prevention. Infect Control Hosp Epidemiol. 2000;2692- 699
Fedson  DSWajda  ANicol  JPRoos  LL Disparity between influenza vaccination rates and risks for influenza-associated hospital discharge and death in Manitoba in 1982-1983. Ann Intern Med. 1992;2550- 555
Fedson  DSBaldwin  JA Previous hospital care as a risk factor for pneumonia: implications for immunization with pneumococcal vaccine. JAMA. 1982;21989- 1995
Fedson  DSChiarello  LA Previous hospital care and pneumococcal bacteremia: importance for pneumococcal immunization. Arch Intern Med. 1983;2885- 889
Fedson  DS Improving the use of pneumococcal vaccine through a strategy of hospital-based immunization: a review of its rationale and implications. J Am Geriatr Soc. 1985;2142- 150
Lipsky  BABoyko  EJInui  TSKoepsell  TD Risk factors for acquiring pneumococcal infections. Arch Intern Med. 1986;22179- 2185
Fedson  DSHarward  MPReid  RAKaiser  DL Hospital-based pneumococcal immunization: epidemiologic rationale from the Shenandoah study. JAMA. 1990;21117- 1122
Centers for Disease Control and Prevention, Use of standing orders programs to increase adult vaccination rates: recommendations of the Advisory Committee on Immunization Practices. MMWR Morb Mort Wkly Rep. 2000;49 ((No. RR-1)) 15- 26
Centers for Disease Control and Prevention, Missed opportunities for pneumococcal and influenza vaccination of Medicare pneumonia inpatients—12 Western States, 1995. MMWR Morb Mortal Wkly Rep. 1997;2919- 923
Metersky  MLFine  JMTu  GS  et al.  Lack of effect of a pneumonia clinical pathway on hospital-based pneumococcal vaccination rates. Am J Med. 2001;2141- 143
Dexter  PRPerkins  SOverhage  JM  et al.  A computerized reminder system to increase the use of preventive care for hospitalized patients. N Engl J Med. 2001;2965- 970
Jencks  SFCuerdon  TBurwen  DR  et al.  Quality of medical care delivered to Medicare beneficiaries: a profile at state and national levels. JAMA. 2000;21670- 1676
Centers for Medicare & Medicaid Services, Quality Improvement Organizations (QIOs). National Improvement Priorities. Hospital-Based Projects. Available at: http://www.cms.hhs.gov/qio/1a1.asp. Accessed August 14, 2002.
Centers for Disease Control, Prevention and control of influenza: recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR Morb Mortal Wkly Rep. 1986;2317- 326
Centers for Disease Control, Pneumococcal polysaccharide vaccine: recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR Morb Mortal Wkly Rep. 1989;238- 46
Centers for Disease Control, Public health burden of vaccine-preventable disease among adults: standards of adult immunization practice. MMWR Morb Mortal Wkly Rep. 1990;2725- 729
American College of Physicians Task Force on Adult Immunization, Guide for Adult Immunization. 2nd ed. Philadelphia, Pa American College of Physicians1990;
Association for Practitioners of Infection Control, Position paper: immunizations. Am J Infect Control. 1992;2131- 132
Fedson  DS Adult immunization: a summary report for the National Vaccine Advisory Committee. JAMA. 1994;21133- 1137
Hospital Infection Control Practices Advisory Committee, Centers for Disease Control and Prevention, Guideline for prevention of nosocomial pneumonia. Infect Control Hosp Epidemiol. 1994;2587- 627
American Hospital Association Technical Panel on Infections Within Hospitals, Management advisory—health care delivery: immunization. Am J Infect Control. 1994;242- 46
Health Care Financing Administration, Evidence Report and Evidence-Based Recommendations: Interventions That Increase the Utilization of Medicare-Funded Preventive Services for Persons Age 65 and Older.  Baltimore, Md US Dept of Health and Human Services, Health Care Financing Administration1999;Publication HCFA-02151.
Association for Professionals in Infection Control and Epidemiology, Position paper: immunizations. Am J Infect Control. 1999;252- 53
Task Force on Community Preventive Services, Recommendations regarding interventions to improve vaccination coverage in children, adolescents, and adults. Am J Prev Med. 2000;18(suppl)92- 140
Niederman  MSMandell  LAAnzueto  A  et al.  Guidelines for the management of adults with community-acquired pneumonia: diagnosis, assessment of severity, antimicrobial therapy, and prevention. Am J Respir Crit Care Med. 2001;21730- 1754
Centers for Disease Control and Prevention, Race-specific differences in influenza vaccination levels among Medicare beneficiaries—United States, 1993. MMWR Morb Mortal Wkly Rep. 1995;224- 27
Centers for Disease Control and Prevention, Influenza and pneumococcal vaccination levels among adults aged >65 years—United States, 1997. MMWR Morb Mortal Wkly Rep. 1998;2797- 802
Schneider  ECCleary  PDZaslavsky  AMEpstein  AM Racial disparity in influenza vaccination: does managed care narrow the gap between African Americans and whites? JAMA. 2001;21455- 1460
Centers for Disease Control and Prevention, Reasons reported by Medicare beneficiaries for not receiving influenza and pneumococcal vaccinations—United States, 1996. MMWR Morb Mortal Wkly Rep. 1999;2886- 890
Nichol  KLMacDonald  RHauge  M Factors associated with influenza and pneumococcal vaccination behavior among high-risk adults. J Gen Intern Med. 1996;2673- 677
Gene  JEspinola  ACabezas  C  et al.  Do knowledge and attitudes about influenza and its immunization affect the likelihood of obtaining immunization? Fam Pract Res J. 1992;261- 73
Oehlert  WHNatt  SNguyen  L  et al.  Improving influenza and pneumococcal immunizations in Oklahoma: preliminary results of a survey of Medicare beneficiaries. J Okla State Med Assoc. 2001;2461- 468
Armstrong  KBerlin  MSchwartz  SPropert  KUbel  PA Barriers to influenza immunization in a low-income urban population. Am J Prev Med. 2001;221- 25
Foster  DATalsma  ANFurumoto-Dawson  A  et al.  Influenza vaccine effectiveness in preventing hospitalization for pneumonia in the elderly. Am J Epidemiol. 1992;2296- 307
Mullooly  JPBennett  MDHornbrook  MC  et al.  Influenza vaccination programs for elderly persons: cost-effectiveness in a health maintenance organization. Ann Intern Med. 1994;2947- 952
Nichol  KLMargolis  KLWuorenma  Jvon Sternberg  T The efficacy and cost effectiveness of vaccination against influenza among elderly persons living in the community. N Engl J Med. 1994;2778- 784
Gross  PAHermogenes  AWSacks  HSLau  JLevandowski  RA Efficacy of influenza vaccine in elderly persons: a meta-analysis and review of the literature. Ann Intern Med. 1995;2518- 527
Nichol  KLMargolis  KLWouremna  Jvon Sternberg  T Effectiveness of influenza vaccine in the elderly. Gerontology. 1996;2274- 279
Nichol  KLGoodman  M The health and economic benefits of influenza vaccination for health and at-risk persons aged 65 to 74 years. Pharmacoeconomics. 1999;16Suppl 163- 71
Nichol  KLWuorenma  Jvon Sternberg  T Benefits of influenza vaccination for low-, intermediate-, and high-risk senior citizens. Arch Intern Med. 1998;21769- 1776
Nguyen-Van-Tam  JSNeal  KR Clinical effectiveness, policies, and practices for influenza and pneumococcal vaccines. Semin Respir Infect. 1999;2184- 195
Nichol  KLBaken  LNelson  A Relation between influenza vaccination and outpatient visits, hospitalization, and mortality in elderly persons with chronic lung disease. Ann Intern Med. 1999;2397- 403
Berry  BBEhlert  DABattiola  RJSedmak  G Influenza vaccination is safe and immunogenic when administered to hospitalized patients. Vaccine. 2001;23493- 3498
Brydak  LBRoszkowska-Blaim  MMachala  MLeszczynska  BSieniawska  M Antibody response to influenza immunization in two consecutive epidemic seasons in patients with renal diseases. Vaccine. 2000;23280- 3286
Flanders  S Pneumococcal vaccination prior to hospital discharge. Shojania  KGDuncan  BWMcDonald  KMMaking Health Care Safer: A Critical Analysis of Patient Safety Practices. Evidence Report/Technology Assessment No. 43 (chap 36), AHRQ Publication 01-E058. Rockville, Md Agency for Healthcare Research and Quality July2001;Available at: http://www.ahrq.gov/clinic/ptsafety/chap36.htm. Accessed April 8, 2002.
Shapiro  EDClemens  JD A controlled evaluation of the protective efficacy of pneumococcal vaccine for patients at high risk of serious pneumococcal infections. Ann Intern Med. 1984;2325- 330
Sims  RVSteinmann  WCMcConville  JH  et al.  The clinical effectiveness of pneumococcal vaccine in the elderly. Ann Intern Med. 1988;2653- 657
Shapiro  EDBerg  ATAustrian  R  et al.  The protective efficacy of polyvalent pneumococcal polysaccharide vaccine. N Engl J Med. 1991;21453- 1460
Butler  JCBreiman  RFCampbell  JF  et al.  Polysaccharide pneumococcal vaccine efficacy: an evaluation of current recommendations. JAMA. 1993;21826- 1831
Farr  BMJohnston  BLCobb  DK  et al.  Preventing pneumococcal bacteremia in patients at risk: results of a matched case-control study. Arch Intern Med. 1995;22336- 2340
Butler  JCShapiro  EDCarlone  GM Pneumococcal vaccines: history, current status, and future directions. Am J Med. 1999;107(suppl 1A)69S- 76S
Ortqvist  AHedlund  JBurman  L  et al.  Randomised trial of 23-valent pneumococcal capsular polysaccharide vaccine in prevention of pneumonia in middle-aged and elderly people. Lancet. 1998;2399- 403
Fine  MJSmith  MACarson  CA  et al.  Efficacy of pneumococcal vaccination in adults: a meta-analysis of randomized controlled trials. Arch Intern Med. 1994;22666- 2677
Hutchison  BGOxman  ADShannon  HS  et al.  Clinical effectiveness of pneumococcal vaccine: meta-analysis. Can Fam Physician. 1999;22381- 2393
Nichol  KLBaken  LWuorenma  JNelson  A The health and economic benefits associated with pneumococcal vaccination of elderly persons with chronic lung disease. Arch Intern Med. 1999;22437- 2442
Christenson  BLundbergh  PHedlund  JOrtqvist  A Effects of a large-scale intervention with influenza and 23-valent pneumococcal vaccines in adults aged 65 years and older: a prospective study. Lancet. 2001;21008- 1011
Nichol  KL The additive benefits of influenza and pneumococcal vaccinations during influenza seasons among elderly persons with chronic lung disease. Vaccine. 1991;17(suppl 1)S91- S93
Nuorti  JPButler  JCCrutcher  JM  et al.  An outbreak of multidrug-resistant pneumococcal pneumonia and bacteremias among unvaccinated nursing home residents. N Engl J Med. 1998;21861- 1868
Bleich  SMorad  YEchague  R  et al.  Streptococcus pneumoniae serotype 4 outbreak in a home for the aged: report and review of recent outbreaks. Infect Control Hosp Epidemiol. 2000;2711- 717
Centers for Disease Control and Prevention, Outbreak of pneumococcal pneumonia among unvaccinated residents of a nursing home—New Jersey, April 2001. MMWR Morb Mortal Wkly Rep. 2001;2707- 710
Whitney  CGFarley  MMHadler  J  et al.  Increasing prevalence of multidrug-resistant Streptococcus pneumoniae in the United States. N Engl J Med. 2000;21961- 1963
Sisk  JEMoskowitz  AJWhang  W  et al.  Cost-effectiveness of vaccination against pneumococcal bacteremia among elderly people. JAMA. 1997;21333- 1339
Centers for Medicare and Medicaid Services, 2001 Fact Sheet for Medicare Influenza/Pneumococcal Vaccination Benefits. Available at: http://cms.hhs.gov/preventiveservices/2.asp#1. Accessed April 8, 2002.
Margolis  KLNichol  KLPoland  GAPluhar  RE Frequency of adverse reactions to influenza vaccine in the elderly. JAMA. 1990;21139- 1141
Govaert  MEDinant  GJAretz  K  et al.  Adverse reactions to influenza vaccine in elderly people: randomised double blind placebo trial. BMJ. 1993;2988- 990
Jackson  LABenson  PSneller  VP  et al.  Safety of revaccination with pneumococcal polysaccharide vaccine. JAMA. 1999;2243- 248
Snow  RBabish  JDMcBean  AM Is there any connection between a second pneumonia shot and hospitalization among Medicare beneficiaries? Public Health Rep. 1995;2720- 725
Klein  RSAdachi  N Pneumococcal vaccine in the hospital: improved use and implications for high-risk patients. Arch Intern Med. 1983;21878- 1881
Magnussen  CRValenti  WMMushlin  AI Pneumococcal vaccine strategy: feasibility of a vaccination program directed at hospitalized and ambulatory patients. Arch Intern Med. 1984;21755- 1757
Klein  RSAdachi  N An effective hospital-based pneumococcal immunization program. Arch Intern Med. 1986;2327- 329
Bloom  HGBloom  JSKrasnoff  LFrank  AD Increased utilization of influenza and pneumococcal vaccines in an elderly hospitalized population. J Am Geriatr Soc. 1988;2897- 901
Clancy  CMGelfman  DPoses  RM A strategy to improve the utilization of pneumococcal vaccine. J Gen Intern Med. 1992;214- 18
Crouse  BJNichol  KPeterson  DCGrimm  MB Hospital-based strategies for improving influenza vaccination rates. J Fam Pract. 1994;2258- 261
Landis  SScarbrough  ML Using a vaccine manager to enhance in-hospital vaccine administration. J Fam Pract. 1995;2364- 369
Nichol  KL Ten-year durability and success of an organized program to increase influenza and pneumococcal vaccination rates among high-risk adults. Am J Med. 1998;2385- 392
Vondracek  TGPham  TPHuycke  MM A hospital-based pharmacy intervention program for pneumococcal vaccination. Arch Intern Med. 1998;21543- 1547
Rodriquez  RMBaraff  LJ Emergency department immunization of the elderly with pneumococcal and influenza vaccines. Ann Emerg Med. 1993;21729- 1732
Slobodkin  DKitlas  JZielske  P Opportunities not missed: systematic influenza and pneumococcal immunization in a public inner-city emergency department. Vaccine. 1998;21795- 1802
Popovic  JR 1999 National Hospital Discharge Survey: Annual Summary with detailed diagnosis and procedure data: National Center for Health Statistics. Vital Health Stat. 2001;(151)i- v1- 206
Fiebach  NHViscoli  CM Patient acceptance of influenza vaccination. Am J Med. 1991;2393- 400

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