The Cost of Interventions to Increase Influenza Vaccination: A Systematic Review


      Influenza vaccination rates remain below Healthy People 2020 goals. This project sought to systematically review economic evaluations of healthcare-based quality improvement interventions for improving influenza vaccination uptake among general populations and healthcare workers.

      Evidence acquisition

      The databases MEDLINE, Econlit, Centre for Reviews & Dissemination, Greylit, and Worldcat were searched in July 2016 for papers published from January 2004 to July 2016. Eligible studies evaluated efforts by bodies within the healthcare system to encourage influenza vaccination by means of an organizational or structural change. For each study, program costs per enrollee and per additional enrollee vaccinated were derived (excluding vaccine costs, standardized to 2017 U.S. dollars). Complete economic evaluations were examined when available.

      Evidence synthesis

      Of 2,350 records, 18 articles were eligible and described 29 unique interventions. Most interventions improved vaccine uptake. Among 23 interventions in general populations, the median program cost was $3.27 (interquartile range, $0.82–$11.53) per enrollee and $50.78 (interquartile range, $27.85–$124.84) per additional enrollee vaccinated. Among ten complete economic evaluations in general populations, three studies reported net cost savings, four reported costs <$50,000 per quality-adjusted life year, and three reported costs <$60,000 per life saved. Among six interventions in healthcare workers, the median program cost was $8.09 (interquartile range, $5.03–$10.31) per worker enrolled and $125.24 (interquartile range, $96.06–$171.38) per additional worker vaccinated (there were no complete economic analyses).


      Quality improvement interventions for influenza vaccination involve per-enrollee costs that are similar to the cost of the vaccine itself ($11.78–$36.08/dose). Based on limited available evidence in general populations, quality improvement interventions may be cost saving to cost effective for the health system.
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      1. Rolfes MA, Foppa IM, Garg S, et al. Estimated influenza illnesses, medical visits, hospitalizations, and deaths averted by vaccination in the United States. Published 2016. Accessed January 5, 2016.

        • Molinari N.
        • Ortega-Sanchez I.
        • Messonnier M.
        • et al.
        The annual impact of seasonal influenza in the U.S.: measuring disease burden and costs.
        Vaccine. 2007; 25: 5086-5096
        • Grohskopf L.A.
        • Sokolow L.Z.
        • Broder K.R.
        • et al.
        Prevention and control of seasonal influenza with vaccines.
        MMWR Recomm Rep. 2016; 65: 1-54
      2. National Vaccine Advisory Committee. Recommendations on strategies to achieve the Healthy People 2020 annual influenza vaccine coverage goal for health care personnel. Published 2012.

        • Black C.
        • Yue X.
        • Ball S.
        • et al.
        Influenza vaccination coverage among health care personnel—United States, 2013–14 influenza season.
        MMWR Morb Mortal Wkly Rep. 2014; 63: 805-811
      3. Centers for Disease Control and Prevention (CDC). National early-season flu vaccination coverage, United States, November 2016. Published 2016. Accessed August 16, 2017.

      4. Centers for Medicare and Medicaid Services. Quality measures. Published 2016. Accessed January 3, 2017.

      5. Centers for Medicare and Medicaid Services. Hospital value-based purchasing. Published 2017. Accessed January 3, 2016.

      6. Centers for Medicare and Medicaid Services. Physician quality reporting system. Published 2016. Accessed January 4, 2017.

      7. The National Committee for Quality Assurance. HEIDIS 2017 summary table of measures, product lines and changes. Published 2017. Accessed February 24, 2017.

        • Danz M.S.
        • Rubenstein L.V.
        • Hempel S.
        • et al.
        Identifying quality improvement intervention evaluations: is consensus achievable?.
        Qual Saf Health Care. 2010; 19: 279-283
        • Task Force on Community Preventive Services
        Recommendations to improve targeted vaccination coverage among high-risk adults.
        Am J Prev Med. 2005; 28: 231-237
        • Helms C.
        • Guerra F.
        • Klein J.
        • Schaffner W.
        • Arvin A.
        • Peter G.
        Strengthening the nation’s influenza vaccination system: a National Vaccine Advisory Committee assessment.
        Am J Prev Med. 2005; 29: 221-226
        • The National Vaccine Advisory Committee
        Recommendations on strategies to achieve the Healthy People 2020 annual influenza vaccine coverage goal for health care personnel.
        DHHS, U.S2012 (Published February 8)
      8. Community Preventive Services Task Force. Worksite: seasonal influenza vaccinations using interventions with on-site, free, actively promoted vaccinations—healthcare workers. Published 2008. Accessed February 28, 2017.

        • The Joint Commission
        Providing a safer environment for health care personnel and patients providing a safer environment for health care through influenza vaccination: strategies from research and practice.
        Joint Commission on Accreditation of Healthcare Organizations. 2009; (Published)
        • Thomas R.E.
        • Lorenzetti D.L.
        Interventions to increase influenza vaccination rates of those 60 years and older in the community.
        Cochrane Database Syst Rev. 2014; : CD005188
        • Lau D.
        • Hu J.
        • Majumdar S.R.
        • Storie D.A.
        • Rees S.E.
        • Johnson J.A.
        Interventions to improve influenza and pneumococcal vaccination rates among community-dwelling adults: a systematic review and meta-analysis.
        Ann Fam Med. 2012; 10: 538-546
        • Rashid H.
        • Yin J.K.
        • Ward K.
        • King C.
        • Seale H.
        • Booy R.
        Assessing interventions to improve influenza vaccine uptake among health care workers.
        Health Aff (Millwood). 2016; 35: 284-292
        • Peasah S.K.
        • Azziz-Baumgartner E.
        • Breese J.
        • Meltzer M.I.
        • Widdowson M.A.
        Influenza cost and cost-effectiveness studies globally—a review.
        Vaccine. 2013; 31: 5339-5348
        • Salo H.
        • Kilpi T.
        • Sintonen H.
        • Linna M.
        • Peltola V.
        • Heikkinen T.
        Cost-effectiveness of influenza vaccination of healthy children.
        Vaccine. 2006; 24: 4934-4941
        • Ott J.J.
        • Klein Breteler J.
        • Tam J.S.
        • Hutubessy R.C.
        • Jit M.
        • de Boer M.R.
        Influenza vaccines in low and middle income countries: a systematic review of economic evaluations.
        Hum Vaccin Immunother. 2013; 9: 1500-1511
        • de Waure C.
        • Veneziano M.A.
        • Cadeddu C.
        • et al.
        Economic value of influenza vaccination.
        Hum Vaccin Immunother. 2012; 8: 119-129
        • Ting E.E.
        • Sander B.
        • Ungar W.J.
        Systematic review of the cost-effectiveness of influenza immunization programs.
        Vaccine. 2017; 35: 1828-1843
        • Moher D.
        • Liberati A.
        • Tetzlaff J.
        • Altman D.G.
        Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
        Ann Intern Med. 2009; 151: 264-269
        • Nuckols T.K.
        • Maglione M.
        • Shekelle P.
        • Morton S.
        • Escarce J.
        • Keeler E.
        Systematic review of cost outcomes of quality improvement.
        PROSPERO. 2015; (CRD42015014950. Accessed January 4, 2017)
        • Glanville J.
        • Kaunelis D.
        • Mensinkai S.
        How well do search filters perform in identifying economic evaluations in MEDLINE and EMBASE.
        Int J Technol Assess Health Care. 2009; 25: 522-529
        • Goeree R.
        • He J.
        • O’Reilly D.
        • et al.
        Transferability of health technology assessments and economic evaluations: a systematic review of approaches for assessment and application.
        Clinicoecon Outcomes Res. 2011; 3: 89-104
        • Hempel S.
        • Shekelle P.G.
        • Liu J.L.
        • et al.
        Development of the Quality Improvement Minimum Quality Criteria Set (QI-MQCS): a tool for critical appraisal of quality improvement intervention publications.
        BMJ Qual Saf. 2015; 24: 796-804
      9. Higgins JPT, Altman DG, Sterne JAC, Cochrane Statistical Methods Group, Cochrane Bias Methods Group, eds. Chapter 8: Assessing risk of bias in included studies. In: Cochrane Handbook for Systematic Reviews of Interventions, Version 5.1.0. Published 2011. Accessed January 5, 2017.

      10. Wells GA, Shea B, O’Connell D, et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. Accessed January 5, 2017.

        • Chiou C.F.
        • Hay J.W.
        • Wallace J.F.
        • et al.
        Development and validation of a grading system for the quality of cost-effectiveness studies.
        Med Care. 2003; 41: 32-44
        • Walker D.G.
        • Wilson R.F.
        • Sharma R.
        • et al.
        AHRQ Methods for Effective Health Care.
        Best Practices for Conducting Economic Evaluations in Health Care: A Systematic Review of Quality Assessment Tools. Agency for Healthcare Research and Quality, Rockville, MD2012
        • Nuckols T.K.
        • Keeler E.
        • Morton S.C.
        • et al.
        Economic evaluation of quality improvement interventions for bloodstream infections related to central catheters: a systematic review.
        JAMA Intern Med. 2016; 176: 1843-1854
      11. Centers for Disease Control and Prevention (CDC). VFC CDC vaccine price list archives. Published 2017. Accessed August 31, 2016.

        • Herrett E.
        • Williamson E.
        • van Staa T.
        • et al.
        Text messaging reminders for influenza vaccine in primary care: a cluster randomised controlled trial (TXT4FLUJAB).
        BMJ Open. 2016; 6: e010069
        • Hull S.
        • Hagdrup N.
        • Hart B.
        • Griffiths C.
        • Hennessy E.
        Boosting uptake of influenza immunisation: a randomised controlled trial of telephone appointing in general practice.
        Br J Gen Pract. 2002; 52: 712-716
        • Hoshi S.L.
        • Kondo M.
        • Honda Y.
        • Okubo I.
        Cost-effectiveness analysis of influenza vaccination for people aged 65 and over in Japan.
        Vaccine. 2007; 25: 6511-6521
        • Ohkusa Y.
        Policy evaluation for the subsidy for influenza vaccination in elderly.
        Vaccine. 2005; 23: 2256-2260
        • Prosser L.A.
        • O’Brien M.A.
        • Molinari N.A.
        • et al.
        Non-traditional settings for influenza vaccination of adults: costs and cost effectiveness.
        Pharmacoeconomics. 2008; 26: 163-178
        • Teufel 2nd, R.J.
        • Basco Jr., W.T.
        • Simpson K.N.
        Cost effectiveness of an inpatient influenza immunization assessment and delivery program for children with asthma.
        J Hosp Med. 2008; 3: 134-141
        • Berg G.D.
        • Silverstein S.
        • Thomas E.
        • Korn A.M.
        Cost and utilization avoidance with mail prompts: a randomized controlled trial.
        Am J Manag Care. 2008; 14: 748-754
        • Patterson B.W.
        • Khare R.K.
        • Courtney D.M.
        • Lee T.A.
        • Kyriacou D.N.
        Cost-effectiveness of influenza vaccination of older adults in the ED setting.
        Am J Emerg Med. 2012; 30: 1072-1079
        • Michaelidis C.I.
        • Zimmerman R.K.
        • Nowalk M.P.
        • Smith K.J.
        Cost-effectiveness of programs to eliminate disparities in elderly vaccination rates in the United States.
        BMC Public Health. 2014; 14: 718
        • Lin C.J.
        • Nowalk M.P.
        • Zimmerman R.K.
        Estimated costs associated with improving influenza vaccination for health care personnel in a multihospital health system.
        Joint Comm J Qual Patient Saf. 2012; 38: 67-72
        • Lam A.Y.
        • Chung Y.
        Establishing an on-site influenza vaccination service in an assisted-living facility.
        J Am Pharm Assoc (2003). 2008; 48: 758-763
        • Honeycutt A.A.
        • Coleman M.S.
        • Anderson W.L.
        • Wirth K.E.
        Cost-effectiveness of hospital vaccination programs in North Carolina.
        Vaccine. 2007; 25: 1484-1496
        • Terrell-Perica S.M.
        • Effler P.V.
        • Houck P.M.
        • Lee L.
        • Crosthwaite G.H.
        The effect of a combined influenza/pneumococcal immunization reminder letter.
        Am J Prev Med. 2001; 21: 256-260
        • Leitmeyer K.
        • Buchholz U.
        • Kramer M.
        • et al.
        Influenza vaccination in German health care workers: effects and findings after two rounds of a nationwide awareness campaign.
        Vaccine. 2006; 24: 7003-7008
        • Stuck A.E.
        • Moser A.
        • Morf U.
        • et al.
        Effect of health risk assessment and counselling on health behaviour and survival in older people: a pragmatic randomised trial.
        PLoS Med. 2015; 12: e1001889
        • Atkins K.
        • van Hoek A.J.
        • Watson C.
        • et al.
        Seasonal influenza vaccination delivery through community pharmacists in England: evaluation of the London pilot.
        BMJ Open. 2016; 6: e009739
        • Shoup J.A.
        • Madrid C.
        • Koehler C.
        • et al.
        Effectiveness and cost of influenza vaccine reminders for adults with asthma or chronic obstructive pulmonary disease.
        Am J Manag Care. 2015; 21: e405-e413
        • LaVela S.L.
        • Hill J.N.
        • Smith B.M.
        • Evans C.T.
        • Goldstein B.
        • Martinello R.
        Healthcare worker influenza declination form program.
        Am J Infect Control. 2015; 43: 624-628
        • Neumann P.J.
        • Cohen J.T.
        • Weinstein M.C.
        Updating cost-effectiveness—the curious resilience of the $50,000-per-QALY threshold.
        N Engl J Med. 2014; 371: 796-797
        • Thomas R.E.
        • Russell M.
        • Lorenzetti D.
        Interventions to increase influenza vaccination rates of those 60 years and older in the community.
        Cochrane Database Syst Rev. 2010; (CD005188.
        • Fairbrother G.
        • Cassedy A.
        • Ortega-Sanchez I.R.
        • et al.
        High costs of influenza: direct medical costs of influenza disease in young children.
        Vaccine. 2010; 28: 4913-4919
        • Keren R.
        • Zaoutis T.E.
        • Saddlemire S.
        • Luan X.Q.
        • Coffin S.E.
        Direct medical cost of influenza-related hospitalizations in children.
        Pediatrics. 2006; 118: e1321-e1327
        • Lee B.Y.
        • Tai J.H.
        • Bailey R.R.
        • Smith K.J.
        The timing of influenza vaccination for older adults (65 years and older).
        Vaccine. 2009; 27: 7110-7115
        • Ortega-Sanchez I.R.
        • Molinari N.A.
        • Fairbrother G.
        • et al.
        Indirect, out-of-pocket and medical costs from influenza-related illness in young children.
        Vaccine. 2012; 30: 4175-4181
        • Karanfil L.V.
        • Bahner J.
        • Hovatter J.
        • Thomas W.L.
        Championing patient safety through mandatory influenza vaccination for all healthcare personnel and affiliated physicians.
        Infect Control Hosp Epidemiol. 2011; 32: 375-379
        • Ksienski D.S.
        Mandatory seasonal influenza vaccination or masking of British Columbia health care workers: year 1.
        Can J Public Health. 2014; 105: e312-e316
        • Leibu R.
        • Maslow J.
        Effectiveness and acceptance of a health care-based mandatory vaccination program.
        J Occup Environ Med. 2015; 57: 58-61
        • Miller B.L.
        • Ahmed F.
        • Lindley M.C.
        • Wortley P.M.
        Increases in vaccination coverage of healthcare personnel following institutional requirements for influenza vaccination: a national survey of U.S. hospitals.
        Vaccine. 2011; 29: 9398-9403
        • Pitts S.I.
        • Maruthur N.M.
        • Millar K.R.
        • Perl T.M.
        • Segal J.
        A systematic review of mandatory influenza vaccination in healthcare personnel.
        Am J Prev Med. 2014; 47: 330-340
        • Rakita R.M.
        • Hagar B.A.
        • Crome P.
        • Lammert J.K.
        Mandatory influenza vaccination of healthcare workers: a 5-year study.
        Infect Control Hosp Epidemiol. 2010; 31: 881-888
        • Centers for Disease Control and Prevention (CDC)
        Menu of state hospital influenza vaccination laws.
        Published, 2016
        • Fielding J.E.
        Health officer order for annual influenza vaccination programs for healthcare personnel or masking of health care workers during the influenza season.
        County of Los Angeles Department of Public Health, 2013