Increasing immunisation in general practice against invasive pneumococcal disease and influenza in people under 70 years old whose chronic conditions put them at higher risk of and from these infections.

In intervention practices, when all eligible patients (those aged <70 years with chronic conditions) book an appointment and prior to attendance at an in-person or telehealth consultation at their general practice, they will receive information about their immunisation status and advice that either pneumococcal or influenza immunisations are recommended for them. The advice will encourage them to ask their GP or practice nurse about this in the imminent consultation. The information and advice will be generated automatically by the practice's clinical software Doctors Control Panel (DCP) software (www.doctorscontrolpanel.com.au). As the patient books, and then again when they arrive for a consultation, the software searches the patient’s electronic clinical record seeking history of the target conditions and immunisations against pneumococcal infection or influenza. If the patient has any of the target conditions and is not fully immunised, DCP will automatically send an SMS to the patient with a prompt to discuss immunisations at the impending appointment. On arrival for the appointment, DCP will automatically print a letter with vaccination information and advice for the patient to read while waiting. In both intervention and control practices, during the consultation the GP or practice nurse that the patient is seeing will receive a small reminder prompt on their computer screen that links to more information. Patients, GPs and practice nurses will be free to act on or to ignore the reminders as they see fit. However, reminders for patients will only be generated in the intervention arm and not the control arm. The intervention will run for approximately 18 months from November 2020, incorporating two influenza immunisation seasons. Aggregated, non-identifiable tabular results about pneumococcal and influenza vaccination and characteristics of patients will be received from the practices who will use the DCP software to generate the required tables. No individual data will be collected in any part of the study. We will analyse the proportion of each practice’s eligible patients who had been immunised at baseline and the proportion who have been immunised by the end of the study, after the use of reminders. We will examine aggregated results according to characteristics of patients and practices. Reminder letters (shown below) that will be generated by the DCP have been specifically designed for the study. As the reminder function is automated via the clinical software DCP, researchers will be able to assess or monitor fidelity to the intervention in real time via a DCP dashboard, which will show aggregate, non-identifiable rates of SMS and printed letter generation for intervention practices. A research support officer will also be in contact with participating practices to ensure they are enacting interventions and addressing concerns when they arise. From all GPS that agreed to be part of the study, we will receive information of the number of eligible patients each GP has seen, whether the patients received the reminder and whether they were vaccinated or not, for the whole period of study. If the GP decides to withdraw the from study, his/her patients will not receive the reminders and we will have this information in the aggregated tables. An equal number of intervention and control practices with similar characteristics (location, number of full-time equivalent GPs) will be recruited into the study, and allocated into intervention and control arms. All eligible patients in intervention practices will receive automatically-generated reminders. Patients from control practices will not receive the reminders. All GPs in intervention and control practices will receive on-screen reminders. Aggregated data from control practices will be collected for comparison. Recruitment into intervention and control arms will be pseudorandomised. During the initial recruitment phase, prioritisation will be given to allocation into the intervention arm. However, once at least four urban practices and at least two rural practices have been recruited, researchers will allocate practices into control or intervention arms to ensure that the study ultimately has equal numbers of practices with similar characteristics in each arm. From this point, where possible, practices will be allocated into intervention and control in alternating order. ****Example of automatically-generated reminder letter**** [Practice Name Address Contact Date] Important information about immunisations Dear [Patient First Name] We want to help you to stay well.The advice below is based on the information that we have in your record.If any of it is incorrect, please tell me. Our records indicate that you have been diagnosed with rheumatoid arthritis. Rheumatoid arthritis and some of the medicines that are commonly used to help to treat it increase your risk of becoming seriously unwell from infections. These infections include influenza (the flu), and pneumococcal infection, which can cause pneumonia. Immunisations for these infections help decrease the risk of contracting these infections. Our practice has no record of pneumococcal vaccine or influenza vaccine for you. National guidelines recommend that you receive a single dose of Prevenar pneumococcal vaccine now. National guidelines recommend that you also receive a total of two doses of Pneumovax 23 pneumococcal vaccine. Our records indicate that you have had fewer than two doses of Pneumovax 23. You should receive a dose of Pneumovax 23 vaccine two months after you have received the Prevenar vaccine. You should receive influenza vaccination now. Please ask me about these immunisations when we meet in a few minutes. Dr. [name of GP]