People with diabetes are at high risk for morbidity and mortality from influenza and pneumonia (1). Both the Centers for Disease Control and Prevention and the American Diabetes Association recommend that individuals with diabetes receive a pneumococcal and an annual influenza immunization regardless of age (2,3). Although the prevalence of pneumococcal immunizations among people with diabetes has increased, the level is still suboptimal, particularly among those aged <65 years (4). Efforts to increase the coverage level of immunizations in adults have largely been directed toward those ≥65 years of age who are Medicare beneficiaries (5,6). Thus clinicians and younger individuals with diabetes may be less likely to consider pneumococcal immunization. Several interventions have been shown to increase adult immunizations, including provider and patient reminder/recall, assessment and feedback to physicians, and standing orders for immunization (7). This report describes a quality improvement effort to increase pneumococcal immunizations in people with diabetes using a simple computerized diabetes monitoring system to facilitate patient reminders.

The Montana Department of Public Health and Human Services began to work in collaboration with three practices in Great Falls, MT, to monitor and improve diabetes care. The settings included a multispecialty practice, a community health center, and an Indian health center. Each of these practices used the Diabetes Care Monitoring System (DCMS), an electronic data system developed for primary care practices to track the delivery of care to patients with diabetes (8). Briefly, patients were identified in the electronic billing system at each practice at baseline. Patients who had one or more diabetes-related (ICD-9-CM 250.x–250.9) office visits in the 12-month period before installing the DCMS were included. Demographic information, the most recent dates and results for selected tests and examinations, and the dates of the last influenza and pneumococcal immunizations were abstracted from each patient’s medical record and entered. After installation, information about newly identified patients with diabetes was added to the system as they presented for care. A one-page patient summary was generated and placed in the medical record to highlight services due at the next office visit. This sheet became a template for updating the computer-based data, thus making current information available for each subsequent visit. The DCMS readily produced lists identifying all patients whose records did not reflect a specific service, such as pneumococcal immunization. As of December 2002, there were 1,857 patients with diabetes being monitored in these clinics, including 1,591 in the multispecialty practice, 186 patients in the community health center, and 80 in the Indian health center. The mean (±SD) age of patients was 60.7 ± 16.3 years, and 53% were women.

In 2001, each of these three primary care practices used DCMS to monitor care, but none conducted any special outreach for immunizations. In fall 2002, each practice generated provider-to-patient letters for patients not known to have received a pneumococcal immunization. Both of the health centers used personalized letters signed by the clinical team. The multispecialty practice sent personalized reminder letters to their patients aged <65 years, and sent a generic reminder letter to all patients (with and without diabetes) aged ≥65 years.

To assess the effectiveness of this intervention, we conducted a time series evaluation over three time periods: September to December 2001, January to August 2002, and the intervention time period, September to December 2002. χ2 tests were used to compare the proportion of patients with a pneumococcal immunization between the three time periods. We also compared the proportion of patients with a pneumococcal immunization by age to assess the effect in both older (aged ≥65 years) and younger patients (aged <65 years). Data analyses were performed using SPSS version 8.0 software (Chicago, IL).

Overall, the proportion of patients with a pneumococcal immunization increased by six percentage points between September and December 2001 (34–40%) and by one percentage point from January to August 2002 (40–41%). However, between September and December 2002, when patient reminders were sent, the overall proportion of patients with a pneumococcal immunization increased by 12 percentage points (41–53%), which was a significantly greater increase compared to the previous time periods (P < 0.001). Between September and December 2001, when no reminder intervention was used, the proportion of pneumococcal immunizations in patients aged ≥65 years increased six percentage points, and in those aged <65 years, the proportion increased five percentage points. In the following months (January to August 2002), there was a three- and less than one-percentage point increase in the proportion of older and younger patients with a pneumococcal immunization, respectively. During the intervention period, there was a 10-percentage point increase for patients aged ≥65 years and a 13-percentage point increase among patients aged <65 years. Both increases were significantly greater than those from the prior time periods (P < 0.001). Between September and December 2002, the percentage point increase in pneumococcal immunization increased in each of these practices (4, 14, and 21 percentage points) and two of the three practices (the largest and smallest) made statistically significant improvement in the overall proportion of patients immunized (P < 0.05).

Of the 1,857 patients with diabetes receiving care in these clinics during the intervention period, 778 had a pneumococcal immunization documented before September 2002. Of the 1,079 remaining patients not known to have a pneumococcal immunization, 525 (49%) had one or more clinic visits from September through December 2002 and 203 (39%) of these patients received a pneumococcal immunization during this period.

The use of a simple office-based electronic monitoring system to produce patient reminders was effective in increasing pneumococcal immunizations among both younger and older patients with diabetes in different practice settings. Patient reminders for immunization clinics generated in managed care settings have also been shown to increase pneumococcal immunization among individuals with diabetes (9). Continued effort will be needed to reach the Year 2010 National Health Objectives of a 90% pneumococcal immunization level among patients with diabetes aged ≥65 years, and 60% among patients with diabetes aged <65 years (10). The objectives are ambitious but attainable through using simple strategies to alert patients with diabetes of the need for immunization and to help practices provide the immunizations in a systematic way.

This project was supported through a cooperative agreement (U32/CCU815663-04) with the Centers for Disease Control and Prevention (CDC), Division of Diabetes Translation. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the CDC.

We recognize the efforts of the clinical and support teams at the Great Falls Clinic, Great Falls Community Health Center, and the Great Falls Indian Health Center. We also thank Susan Day and Rita Banta for their assistance throughout this project.

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Address correspondence to Todd S. Harwell, MPH, Montana Department of Public Health and Human Services, Cogswell Building, C-317, P.O. Box 202951, Helena, Montana 59620-2951. E-mail:

D.G. has received honoraria from Novo Nordisk and Aventis.