Improving influenza vaccination rates in people aged 65 years and over

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Influenza, or “the flu”, is caused by viruses of the orthomyxoviridae family, and is most prevalent in the winter months. Symptoms develop rapidly and can include fever, myalgia, rhinitis, cough and gastrointestinal disturbances. Transmission of influenza occurs quickly, predominantly via respiratory droplets. Influenza can cause serious complications, such as pneumonia, bronchitis, and sinus and ear infections. Older people, particularly those with long-term comorbidities, are at increased risk of developing complications from influenza.

Annual vaccination is the best protection against influenza

The dominant strains of influenza in circulation can change from year to year. The World Health Organisation (WHO) therefore makes annual recommendations on what strains of influenza should be covered by the vaccine based on global surveillance data. Annual vaccination is recommended to ensure individuals have optimal immunity.

Post-vaccination immunity in people aged over 65 years can decline rapidly and in some individuals may not be high enough six months post-vaccination to provide immunity.1 To ensure older people receive the maximum protection against influenza, annual offers of vaccination should be made by your practice to every person aged 65 years and over either during consultations or by recall letters or phone-calls, during each annually funded period. Patients aged 65 years and over who refuse an offer of vaccination during a consultation should be followed-up by letter or phone call.

Further information is available from: (search = influenza)


  1. Song J, Cheong H, Hwang I, et al. Long-term immunogenicity of influenza vaccine among the elderly: Risk factors for poor immune response and persistence. Vaccine. 2010;28:3929–35.


The purpose of this audit is to determine the rate at which patients aged 65 years and over are routinely offered annual influenza vaccinations by your practice. The audit does this by recording both the number of influenza vaccinations received by people aged 65 years and over and the number of people aged 65 years and over who are contacted with offers of vaccination.

The audit assesses this process during the most recently completed influenza season. For the purposes of this audit, this is defined as the most recently completed period when fully-funded influenza vaccinations were offered. In some situations, this will mean the influenza season of the previous calendar year. For example, if the audit is performed in May, the period audited will be the funded period of the previous calendar year.

Audit indications

All patients aged 65 years and over at the beginning of the most recently completed influenza season should have been offered an influenza vaccination during the previous influenza season.

Criteria for a positive outcome

During the most recent influenza season, the patient:

  • Received an influenza vaccination, or
  • Was sent a patient recall letter, or was contacted via phone with an offer of a vaccination

Recommended audit standards

At least 90% of eligible patients should either receive an influenza vaccination, or be contacted with an offer of vaccination.


Eligible people

Any person aged 65 years and over at the beginning of the most recently completed influenza season is eligible for this audit.

Identifying patients

Eligible patients can be identified by running a ‘query’ through the PMS to search for patients aged 65 years and at the start of the funded period.

Sample size

A random sample of 30 patients is sufficient for this audit.

Data analysis

Use the data sheet to record your audit. Calculate the percentage of positive outcomes by adding the total number of people who received an influenza vaccination (column A) to the total number of people who did not receive an influenza vaccination but were made an offer of vaccination (column B), then dividing by the total number of people audited, multiplied by 100.

For example – 25 people were audited, 17 of whom received an influenza vaccination during the influenza season. Of the remaining eight, three were sent a letter with an offer of vaccination. Therefore the percentage of eligible patients who received an influenza vaccination or were followed-up with an offer of vaccination is calculated as: (17+3)/25 x 100 = 80%.

Identifying opportunities for CQI

Taking action

The first step in taking action is to identify the criteria where gaps exist between expected and actual performance and decide on priorities for change.

Once priority areas for change have been decided on, an action plan should be developed to implement any changes.

The plan should assign responsibility for various tasks to specific members of the practice team and should include a timeline.

It is important to include the whole practice team in the decision-making and planning process.

It may be useful to consider the following points when developing a plan for action (RNZCGP 2002).

Problem solving process

  • What is the problem or underlying problem(s).
  • Change it to an aim.
  • What are the solutions or options?
  • What are the barriers?
  • How can you overcome them?

Overcoming barriers

  • Identifying barriers can provide a basis for change.
  • What is achievable – find out what the external pressures on the practice are and discuss ways of dealing with them in the practice setting.
  • Identify the barriers.
  • Develop a priority list.
  • Choose one or two achievable goals.

Effective interventions

  • No single strategy or intervention is more effective than another, and sometimes a variety of methods are needed to bring about lasting change.
  • Interventions should be directed at existing barriers or problems, knowledge, skills and attitudes, as well as performance and behavior.


Monitoring change and progress

It is important to review the action plan against the timeline at regular intervals with the practice team. It may be helpful to discuss the following questions:

  • Is the process working?
  • Are the goals for improvement being achieved?
  • Are the goals still appropriate?
  • Do you need to develop new tools to achieve the goals you have set?

Following the completion of the first cycle, it is recommended that practices complete the first part of the CQI activity summary sheet.

Undertaking a second cycle

In addition to regular reviews of progress with the practice team, a second audit cycle should be completed in order to quantify progress on closing the gaps in performance.

It is recommended that the second cycle be completed within 12 months of completing the first cycle. The second cycle should begin at the data collection stage. Following the completion of the second cycle it is recommended practices complete the remainder of the CQI activity summary sheet.

Claiming MOPS credits

This audit has been endorsed by the RNZCGP as an Audit of Medical Practice activity (previously known as Continuous Quality Improvement - CQI) for allocation of MOPS credits; 10 credits for a first cycle and 10 credits for a second cycle. General practitioners taking part in this audit can claim credits in accordance with the current MOPS programme.

To claim points go to the RNZCGP website:

Record your completion of the audit on the MOPS Online credit summary, under the Audit of Medical Practice section. From the drop down menu, select the audit from the list or select “Approved practice/PHO audit” and record the audit name in “Notes”, the audit date and 10 credits.

General practitioners are encouraged to discuss the outcomes of the audit with their peer group or practice.

As the RNZCGP frequently audit claims you should retain the following documentation, in order to provide adequate evidence of participation in this audit:

  1. A summary of the data collected
  2. An Audit of Medical Practice (CQI) Activity summary sheet (included as Appendix 1).