human
***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: PURPOSE Influenza and pneumococcal vaccines are underused . Systems approaches that incorporate administrative and organizational strategies are more successful than education of providers for improving vaccination rates . Little has been published on the long-term success and durability of such efforts . METHODS We performed a 10-year time-series study to examine the durability and success of an ongoing , multifaceted , institution-wide influenza and pneumococcal vaccination program . The program was first implemented at the Minneapolis Department of Veterans Affairs ( VA ) Medical Center in 1987 - 88 following the demonstration that a clinic-based st and ing order policy was much more successful than provider education for improving vaccine delivery . The program ensures that vaccine is offered to all high-risk patients followed up at the medical center , promotes convenient access for patients , and facilitates efficient administration of vaccine . Specific elements include an annual mailing to patients , st and ing orders for nurses , walk-in clinics , and the use of st and ardized , preprinted documentation forms . Initially the program targeted high-risk out patients for influenza vaccination .  It was extended to include in patients in 1989 - 90 .  Pneumococcal vaccinations were added to the program in 1994 - 95 . Vaccination rates are estimated each year from surveys mailed to r and omly selected patients , and vaccine utilization is monitored through pharmacy logs . RESULTS The survey response rates have exceeded 75 % each year .  Influenza vaccination rates for all high-risk patients followed up at the medical center have increased from 58 % following the 1987 - 88 vaccination season to 84 % in 1996 - 97 ( P < 0.001 ) . Pneumococcal vaccination rates have also increased from 34 % in 1994 - 95 to 63 % in 1996 - 97 ( P < 0.001 ) . Vaccination rates are similar for in patients and out patients , but rates for high-risk patients < 65 years of age remain lower than for the elderly : 69 % versus 89 % for influenza , 1996 - 97 ( P < 0.001 ) ; 52 % versus 66 % for pneumococcal , 1996 - 97 ( P = 0.05 ) . For elderly patients followed up at the medical center , influenza ( 89 % versus 67 % , P < 0.0001 ) and pneumococcal ( 66 % versus 43 % , P < 0.0001 ) vaccination rates significantly exceeded those for the state of Minnesota in 1996 - 97 . The annual number of influenza vaccine doses dispensed has increased from 10,000 in 1987 - 88 to more than 22,000 in 1996 - 97 ; and more than 13,000 doses of pneumococcal vaccine have been administered from 1994 - 95 through 1996 - 97 . CONCLUSION This simple , multifaceted program that incorporates administrative and organizational strategies to enhance influenza and pneumococcal vaccination rates has been highly durable and successful over a 10-year peroid . Similar strategies if implemented in other setting s may enhance vaccination rates for the millions of high-risk patients who have yet to be immunized Annual influenza vaccination of elderly and chronically ill persons has been a long-st and ing recommendation of the U.S. Public Health Service [ 1 , 2 ] . Recent studies have documented the health benefits of annual influenza vaccination [ 3 - 10 ] , but despite the exhortations of the Surgeon General and the clear evidence of vaccine efficacy , many persons in high-risk groups fail to receive the recommended vaccinations [ 11 , 12 ] . Because of the low level of compliance with the U.S. Public Health Service influenza vaccination guidelines [ 13 ] , the Centers for Disease Control and Prevention ( CDC ) have proposed new strategies to increase the proportion of high-risk persons who are immunized [ 14 ] . One such strategy is to promote assessment s of the net financial costs to health maintenance organizations of operational vaccine delivery programs . Successful demonstrations of net financial benefit should encourage managers of organized medical care programs and health insurance companies to advocate improved vaccine delivery . Methods General Methods Setting The study was done at Kaiser Permanente , Northwest Region , a prepaid group practice health maintenance organization ( HMO ) that includes 20 % of the Portl and , Oregon-Vancouver , Washington , St and ard Metropolitan Statistic Area population . Members receive almost all of their medical care from the health plan , and each contact they make with the HMO is recorded in a single , central ized chart . Epidemic Periods Epidemic periods were defined as periods during which influenza viruses circulated persistently in Oregon according to influenza virus isolation date s reported by the Oregon State Virology Laboratory . The eight epidemic periods defined using this approach are shown in Table 1 . The study period for the nonepidemic 1981 - 1982 reference period was defined by averaging the months and days of the epidemic periods . The number of  specimens tested ranged from 118 in 1981 - 1982 to 652 in 1988 - 1989 . Table 1 . Influenza Epidemic Periods and Study Sample s Influenza viruses were isolated from only 9 of 118 specimens ( 8 % ) tested in the 1981 - 1982 nonepidemic reference period ; B viruses were isolated from two specimens obtained in late April . During the epidemic study periods , influenza viruses were typically isolated from 25 % of specimens , isolations were sustained , and isolation frequency distributions described epidemic curves . Participants Participants included in a study period were Kaiser Permanente members 65 years of age or older , each with at least 1 month of eligibility during that period and during the September-December vaccination period . These members represent almost all elderly persons enrolled in the HMO . High-risk participants were defined as those who had had medical care contacts for chronic pulmonary ( ICDA [ International Classification of Diseases , Adapted ] codes 9:491 - 493.9 , 496 , 500 - 505 , 506.4 , 508.1 , 510 - 516 , 714.8 ) , cardiovascular ( 112.81 , 130.3 , 393 - 398 , 401.0 , 402 - 405 , 410 - 414 , 416 , 420 - 429 , 430 - 438 , 440.1 , 785.2-.3 ) , metabolic ( 250 - 250.9 , 571 - 571.9 ) , renal ( 274.10 , 580 - 583.9 , 585 , 587 - 588.0 ) , or malignant ( 140 - 208.9 ) conditions . These risk factors for influenza-related complications are defined by the CDC 's Advisory Committee for Immunization Practice s. Data Sources An  automated inpatient data base was used to identify all hospitalizations for pneumonia and influenza during the nine study periods . This data base contains discharge diagnoses and records of inpatient procedures and is the source of the discharge summaries . The outpatient data base contains outpatient diagnoses and records of procedures for a continuously up date d research sample composed of 5 % of elderly health plan members . Each month , a r and om 5 % sample of all new elderly Kaiser Permanente subscriber units is added to the cumulative pool of enrollees whose records are abstract ed . Automated outpatient diagnoses were available through 1987 . Medical record abstract ions were the source of outpatient diagnoses for the first quarter of 1988 . Inpatient high-risk discharge diagnoses made during the 3 years before the study period were obtained from the inpatient data base . Outpatient high-risk diagnoses made during the year before the study period were obtained from the outpatient data base and by chart abstract ion . Influenza and pneumococcal vaccination status was abstract ed from the medical records for pneumonia and influenza cases that were not in the 5 % research sample .  Automated vaccination data through 1987 were available for cases and controls in the research sample . Medical record abstract ions were the source of 1988 - 1989 vaccination data for all study participants . Participants receiving influenza vaccine after the start of epidemics were classified as unvaccinated . Case-Control Assessment of Vaccine Effectiveness Population -based , casecontrol design s were used to estimate influenza vaccine effectiveness in preventing medically attended episodes of pneumonia and influenza . To exclude pneumonias that were unlikely to be influenza related , we included only persons with pneumonia and influenza who were admitted to medical services . Because we based participant selection on discharge diagnoses , participants with both hospital- and community-acquired pneumonia and influenza were included . Pneumonia and Influenza Cases and Controls Participants who were hospitalized with pneumonia and influenza during the study period , who were eligible Kaiser Permanente members , and who had a pneumonia and influenza ICDA-9 code ( 480 - 483,485,486,487 ) listed as a discharge diagnosis were included as cases of hospitalized pneumonia and influenza . Controls were members of the 5 % research sample who met the study eligibility criteria and who were not hospitalized with pneumonia or influenza during the given period . Pneumonia and influenza deaths during a study period were defined as hospitalized patients with pneumonia and influenza who died in the hospital . Controls were members of the 5 % research sample who were not pneumonia and influenza hospital deaths during that period . Outpatient pneumonia and influenza cases included members of the 5 % research sample who had an outpatient episode of pneumonia and influenza with no inpatient component during the given study period . Controls were members of the 5 % research sample who did not have an outpatient episode of pneumonia and influenza during the given period . Cases and controls were group matched for high-risk status . Logistic regressions were used to adjust influenza vaccine effects on occurrence of pneumonia and influenza episodes for differences in age , sex , months of HMO eligibility , and pneumococcal vaccine status . Vaccine Effectiveness Relative risks for pneumonia and influenza episodes in unvaccinated and vaccinated population s were estimated by the adjusted exposure ( unvaccinated ) odds ratios . The effectiveness of influenza vaccine  in preventing pneumonia and influenza episodes was computed from the estimated relative risk as effectiveness = 1-(1/relative risk ) . Pneumonia and Influenza Episodes Prevented The population -based , casecontrol design allowed unbiased estimation of the total number of participants vaccinated and of the pneumonia and influenza episode rates among unvaccinated participants . The product of these estimates multiplied by the vaccine effectiveness is the estimated number of pneumonia and influenza episodes prevented by influenza vaccination : pneumonia and influenza episodes prevented = ( number of participants vaccinated)(effectiveness of vaccination)(pneumonia and influenza episode rate among unvaccinated participants ) . Statistical Methods The units of analysis for period-specific vaccine effectiveness analyses were persons . A case for a given period had an episode of pneumonia or influenza during that period . A control for a given period did not have an episode of pneumonia or influenza during that period . The same person could appear as a case in more than one period . Person-periods were the units of analysis for aggregate analyses . A person contributed a person-period of observation to each period when study criteria were met . Some members of the 5 % research sample were controls in some periods and cases in other periods . Study participants not in the 5 % research sample could only contribute person-periods as hospitalized cases . Risks for pneumonia and influenza episodes during high-risk and nonhigh-risk person-periods are separately modeled as logistic functions of influenza vaccine status , pneumococcal vaccine status , age , sex , and length of observation time . The SAS logistic procedure was used to estimate odds ratios and confidence intervals for model variables . The Hosmer-Lemeshow statistic was used to assess the goodness of fit of logistic models . Cost Analysis Methods Medical Care Costs of Pneumonia and Influenza Episodes Costs of providing inpatient care for pneumonia and influenza episodes were obtained from Kaiser Permanente accounting systems for the various patient care cost centers .  Costs of providing outpatient care were estimated from the 5 % research sample , using relative value units included in the outpatient data base and unit costs for accounting cost centers . Cost of Vaccine Delivery Costs of the vaccine delivery program were estimated by a micro-costing approach and included overhead costs . The purchase cost of vaccine was obtained from administrative records and included all vaccines used and wastage . Distribution costs were allocated based on the proportion of direct drug costs represented by influenza vaccine . Two methods of promoting the vaccination program were identified : an article in the member newsletter and referrals by nurses , generally by the telephone advice nurse . Time estimates were obtained from interviews with providers , and labor costs per hour were obtained from Kaiser Permanente administrative records . Cost-Effectiveness Ratios Three cost-effectiveness measures were computed : cost per prevented episode of In early 1983 , all 1,280 faculty and resident physicians at one hospital who were eligible to be vaccinated against hepatitis B  were divided r and omly into three groups : Group 1 physicians received general information about the risks and benefits of alternative vaccine decisions ; Group 2 physicians were 
    Output:
    
agent
***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: PURPOSE Influenza and pneumococcal vaccines are underused . Systems approaches that incorporate administrative and organizational strategies are more successful than education of providers for improving vaccination rates . Little has been published on the long-term success and durability of such efforts . METHODS We performed a 10-year time-series study to examine the durability and success of an ongoing , multifaceted , institution-wide influenza and pneumococcal vaccination program . The program was first implemented at the Minneapolis Department of Veterans Affairs ( VA ) Medical Center in 1987 - 88 following the demonstration that a clinic-based st and ing order policy was much more successful than provider education for improving vaccine delivery . The program ensures that vaccine is offered to all high-risk patients followed up at the medical center , promotes convenient access for patients , and facilitates efficient administration of vaccine . Specific elements include an annual mailing to patients , st and ing orders for nurses , walk-in clinics , and the use of st and ardized , preprinted documentation forms . Initially the program targeted high-risk out patients for influenza vaccination .  It was extended to include in patients in 1989 - 90 .  Pneumococcal vaccinations were added to the program in 1994 - 95 . Vaccination rates are estimated each year from surveys mailed to r and omly selected patients , and vaccine utilization is monitored through pharmacy logs . RESULTS The survey response rates have exceeded 75 % each year .  Influenza vaccination rates for all high-risk patients followed up at the medical center have increased from 58 % following the 1987 - 88 vaccination season to 84 % in 1996 - 97 ( P < 0.001 ) . Pneumococcal vaccination rates have also increased from 34 % in 1994 - 95 to 63 % in 1996 - 97 ( P < 0.001 ) . Vaccination rates are similar for in patients and out patients , but rates for high-risk patients < 65 years of age remain lower than for the elderly : 69 % versus 89 % for influenza , 1996 - 97 ( P < 0.001 ) ; 52 % versus 66 % for pneumococcal , 1996 - 97 ( P = 0.05 ) . For elderly patients followed up at the medical center , influenza ( 89 % versus 67 % , P < 0.0001 ) and pneumococcal ( 66 % versus 43 % , P < 0.0001 ) vaccination rates significantly exceeded those for the state of Minnesota in 1996 - 97 . The annual number of influenza vaccine doses dispensed has increased from 10,000 in 1987 - 88 to more than 22,000 in 1996 - 97 ; and more than 13,000 doses of pneumococcal vaccine have been administered from 1994 - 95 through 1996 - 97 . CONCLUSION This simple , multifaceted program that incorporates administrative and organizational strategies to enhance influenza and pneumococcal vaccination rates has been highly durable and successful over a 10-year peroid . Similar strategies if implemented in other setting s may enhance vaccination rates for the millions of high-risk patients who have yet to be immunized Annual influenza vaccination of elderly and chronically ill persons has been a long-st and ing recommendation of the U.S. Public Health Service [ 1 , 2 ] . Recent studies have documented the health benefits of annual influenza vaccination [ 3 - 10 ] , but despite the exhortations of the Surgeon General and the clear evidence of vaccine efficacy , many persons in high-risk groups fail to receive the recommended vaccinations [ 11 , 12 ] . Because of the low level of compliance with the U.S. Public Health Service influenza vaccination guidelines [ 13 ] , the Centers for Disease Control and Prevention ( CDC ) have proposed new strategies to increase the proportion of high-risk persons who are immunized [ 14 ] . One such strategy is to promote assessment s of the net financial costs to health maintenance organizations of operational vaccine delivery programs . Successful demonstrations of net financial benefit should encourage managers of organized medical care programs and health insurance companies to advocate improved vaccine delivery . Methods General Methods Setting The study was done at Kaiser Permanente , Northwest Region , a prepaid group practice health maintenance organization ( HMO ) that includes 20 % of the Portl and , Oregon-Vancouver , Washington , St and ard Metropolitan Statistic Area population . Members receive almost all of their medical care from the health plan , and each contact they make with the HMO is recorded in a single , central ized chart . Epidemic Periods Epidemic periods were defined as periods during which influenza viruses circulated persistently in Oregon according to influenza virus isolation date s reported by the Oregon State Virology Laboratory . The eight epidemic periods defined using this approach are shown in Table 1 . The study period for the nonepidemic 1981 - 1982 reference period was defined by averaging the months and days of the epidemic periods . The number of  specimens tested ranged from 118 in 1981 - 1982 to 652 in 1988 - 1989 . Table 1 . Influenza Epidemic Periods and Study Sample s Influenza viruses were isolated from only 9 of 118 specimens ( 8 % ) tested in the 1981 - 1982 nonepidemic reference period ; B viruses were isolated from two specimens obtained in late April . During the epidemic study periods , influenza viruses were typically isolated from 25 % of specimens , isolations were sustained , and isolation frequency distributions described epidemic curves . Participants Participants included in a study period were Kaiser Permanente members 65 years of age or older , each with at least 1 month of eligibility during that period and during the September-December vaccination period . These members represent almost all elderly persons enrolled in the HMO . High-risk participants were defined as those who had had medical care contacts for chronic pulmonary ( ICDA [ International Classification of Diseases , Adapted ] codes 9:491 - 493.9 , 496 , 500 - 505 , 506.4 , 508.1 , 510 - 516 , 714.8 ) , cardiovascular ( 112.81 , 130.3 , 393 - 398 , 401.0 , 402 - 405 , 410 - 414 , 416 , 420 - 429 , 430 - 438 , 440.1 , 785.2-.3 ) , metabolic ( 250 - 250.9 , 571 - 571.9 ) , renal ( 274.10 , 580 - 583.9 , 585 , 587 - 588.0 ) , or malignant ( 140 - 208.9 ) conditions . These risk factors for influenza-related complications are defined by the CDC 's Advisory Committee for Immunization Practice s. Data Sources An  automated inpatient data base was used to identify all hospitalizations for pneumonia and influenza during the nine study periods . This data base contains discharge diagnoses and records of inpatient procedures and is the source of the discharge summaries . The outpatient data base contains outpatient diagnoses and records of procedures for a continuously up date d research sample composed of 5 % of elderly health plan members . Each month , a r and om 5 % sample of all new elderly Kaiser Permanente subscriber units is added to the cumulative pool of enrollees whose records are abstract ed . Automated outpatient diagnoses were available through 1987 . Medical record abstract ions were the source of outpatient diagnoses for the first quarter of 1988 . Inpatient high-risk discharge diagnoses made during the 3 years before the study period were obtained from the inpatient data base . Outpatient high-risk diagnoses made during the year before the study period were obtained from the outpatient data base and by chart abstract ion . Influenza and pneumococcal vaccination status was abstract ed from the medical records for pneumonia and influenza cases that were not in the 5 % research sample .  Automated vaccination data through 1987 were available for cases and controls in the research sample . Medical record abstract ions were the source of 1988 - 1989 vaccination data for all study participants . Participants receiving influenza vaccine after the start of epidemics were classified as unvaccinated . Case-Control Assessment of Vaccine Effectiveness Population -based , casecontrol design s were used to estimate influenza vaccine effectiveness in preventing medically attended episodes of pneumonia and influenza . To exclude pneumonias that were unlikely to be influenza related , we included only persons with pneumonia and influenza who were admitted to medical services . Because we based participant selection on discharge diagnoses , participants with both hospital- and community-acquired pneumonia and influenza were included . Pneumonia and Influenza Cases and Controls Participants who were hospitalized with pneumonia and influenza during the study period , who were eligible Kaiser Permanente members , and who had a pneumonia and influenza ICDA-9 code ( 480 - 483,485,486,487 ) listed as a discharge diagnosis were included as cases of hospitalized pneumonia and influenza . Controls were members of the 5 % research sample who met the study eligibility criteria and who were not hospitalized with pneumonia or influenza during the given period . Pneumonia and influenza deaths during a study period were defined as hospitalized patients with pneumonia and influenza who died in the hospital . Controls were members of the 5 % research sample who were not pneumonia and influenza hospital deaths during that period . Outpatient pneumonia and influenza cases included members of the 5 % research sample who had an outpatient episode of pneumonia and influenza with no inpatient component during the given study period . Controls were members of the 5 % research sample who did not have an outpatient episode of pneumonia and influenza during the given period . Cases and controls were group matched for high-risk status . Logistic regressions were used to adjust influenza vaccine effects on occurrence of pneumonia and influenza episodes for differences in age , sex , months of HMO eligibility , and pneumococcal vaccine status . Vaccine Effectiveness Relative risks for pneumonia and influenza episodes in unvaccinated and vaccinated population s were estimated by the adjusted exposure ( unvaccinated ) odds ratios . The effectiveness of influenza vaccine  in preventing pneumonia and influenza episodes was computed from the estimated relative risk as effectiveness = 1-(1/relative risk ) . Pneumonia and Influenza Episodes Prevented The population -based , casecontrol design allowed unbiased estimation of the total number of participants vaccinated and of the pneumonia and influenza episode rates among unvaccinated participants . The product of these estimates multiplied by the vaccine effectiveness is the estimated number of pneumonia and influenza episodes prevented by influenza vaccination : pneumonia and influenza episodes prevented = ( number of participants vaccinated)(effectiveness of vaccination)(pneumonia and influenza episode rate among unvaccinated participants ) . Statistical Methods The units of analysis for period-specific vaccine effectiveness analyses were persons . A case for a given period had an episode of pneumonia or influenza during that period . A control for a given period did not have an episode of pneumonia or influenza during that period . The same person could appear as a case in more than one period . Person-periods were the units of analysis for aggregate analyses . A person contributed a person-period of observation to each period when study criteria were met . Some members of the 5 % research sample were controls in some periods and cases in other periods . Study participants not in the 5 % research sample could only contribute person-periods as hospitalized cases . Risks for pneumonia and influenza episodes during high-risk and nonhigh-risk person-periods are separately modeled as logistic functions of influenza vaccine status , pneumococcal vaccine status , age , sex , and length of observation time . The SAS logistic procedure was used to estimate odds ratios and confidence intervals for model variables . The Hosmer-Lemeshow statistic was used to assess the goodness of fit of logistic models . Cost Analysis Methods Medical Care Costs of Pneumonia and Influenza Episodes Costs of providing inpatient care for pneumonia and influenza episodes were obtained from Kaiser Permanente accounting systems for the various patient care cost centers .  Costs of providing outpatient care were estimated from the 5 % research sample , using relative value units included in the outpatient data base and unit costs for accounting cost centers . Cost of Vaccine Delivery Costs of the vaccine delivery program were estimated by a micro-costing approach and included overhead costs . The purchase cost of vaccine was obtained from administrative records and included all vaccines used and wastage . Distribution costs were allocated based on the proportion of direct drug costs represented by influenza vaccine . Two methods of promoting the vaccination program were identified : an article in the member newsletter and referrals by nurses , generally by the telephone advice nurse . Time estimates were obtained from interviews with providers , and labor costs per hour were obtained from Kaiser Permanente administrative records . Cost-Effectiveness Ratios Three cost-effectiveness measures were computed : cost per prevented episode of In early 1983 , all 1,280 faculty and resident physicians at one hospital who were eligible to be vaccinated against hepatitis B  were divided r and omly into three groups : Group 1 physicians received general information about the risks and benefits of alternative vaccine decisions ; Group 2 physicians were 
    Output:
    