Seasonal influenza vaccination among people with diabetes: influence of patients’ characteristics and healthcare use on behavioral changes

Figures & data

Figure 1. A graphical representation of the two-state Markov model of seasonal influenza vaccination uptake and of the four kind of transitions

Abbreviation: SIV, seasonal influenza vaccination.^a: transition “SIV uptake to SIV uptake” (i.e., remaining vaccinated)^b: transition “no SIV uptake to no SIV uptake” (i.e., remaining unvaccinated)^c: transition “SIV uptake to no SIV uptake” (i.e., stopping vaccination)^d: transition “no SIV uptake to SIV uptake” (i.e., starting vaccination).

Table 1. Study cohort characteristics during the first and last season n/n + 1 of follow-up (EGB, France, 2006/07–2015/16, n = 16,026)

	2006/07 (n = 16,206)	2015/16 (n = 11,277)^a
	%^b	%^b
Average duration of follow-up in years (min = 2; max = 10) – mean (SD)	8.6 (2.4)
Sociodemographic characteristics
Age (years) on December 31 of year n – mean (SD)	64.5 (13.5)	70.3 (12.7)
Women	46.2	47.1
Clinical characteristics
Patients with newly identified diabetes^c	8.9	NA
Type and treatment of diabetes
Type 1 diabetes^d	9.5	9.8
Other type diabetes treated by insulin and/or antidiabetic drugs	76.1	81.8
Other type diabetes without any treatment	14.4	8.5
Weighted individual chronic condition score^e – mean (SD)	0.8 (0.5)	0.9 (0.5)
Hospitalized for diabetes or its complications between September 1 of year n-1 and August 31 of year n	6.2	4.3
Hospitalized for influenza or its complications between September 1 of year n-1 and August 31 of year n	0.6	1.3
Healthcare use
Number of consultations between September 1 of year n-1 and August 31 of year n, with – mean (SD)
General practitioner	8.6 (7.1)	7.8 (6.3)
Pulmonologist	0.0 (0.3)	0.1 (0.6)
Endocrinologist	0.3 (1.2)	0.4 (1.2)
Cardiologist	0.5 (1.4)	0.5 (1.4)
Change of general practitioner between September 1 of year n-1 and August 31 of year n	4.0	10.2
SIV uptake rate	50.8	57.1

Abbreviations: NA, not applicable; SD, standard deviation; SIV, seasonal influenza vaccination.

^aAmong all patients included in the cohort, 4334 (26.7%) died during follow-up and 595 were lost to follow-up (3.7%).

^bOtherwise stated.

^cPatients with newly identified diabetes were those not detected as having had diabetes the year before inclusion.

^dPeople with type 1 diabetes were those with long-term illness status for type 1 diabetes (E10 according to the ICD-10) and treated by insulin at inclusion.

^eThe individual chronic condition score (ICC) was calculated as a weighted sum of 21 chronic conditions. Weights account for the severity of each condition in the score calculation (ICC range in study cohort: min = 0; max = 3.7).

Figure 2. Proportion of the study population according to the number of SIV uptake transitions over the 10-year follow-up period (EGB, France, 2006/07–2015/16, n = 16,026)

Abbreviations: SIV, seasonal influenza vaccination.^a Transition “SIV uptake to no SIV uptake” or transition “no SIV uptake to SIV uptake”.

Table 2. Demographic and clinical characteristics associated with each SIV uptake transition – Hazard ratios and 95% confidence intervals – Two-state Markov model estimates (EGB, France, 2006/07–2015/16, n = 16,026)

	No SIV → SIV (ref. No SIV → No SIV)	SIV → No SIV (ref. SIV → SIV)
	aHR [95% CI]
Sociodemographic characteristics
Men (ref. Women)	1.09 [1.04;1.14]	0.84 [0.80;0.88]
Age at inclusion (ref. ≤ 55 years)
56–64	1.32 [1.24;1.41]	0.67 [0.62;0.72]
65–84	1.39 [1.30;1.48]	0.44 [0.41;0.47]
≥ 85	1.57 [1.40;1.76]	0.47 [0.43;0.53]
Clinical characteristics
Patients with newly identified diabetes in 2006^a (ref. No)	1.28 [1.09;1.50]	0.97 [0.71;1.32]
Type and treatment of diabetes at season n-1/n (ref. Other type diabetes without any treatment)
Other type diabetes treated by insulin and/or antidiabetic drugs	1.08 [1.00;1.17]	0.71 [0.65;0.79]
Type 1 diabetes^b	1.32 [1.19;1.47]	0.73 [0.64;0.83]
Weighted individual chronic condition score^c at season n-1/n (ref. Min-Q1)
Q1-median	1.39 [1.30;1.49]	0.92 [0.85;0.99]
Median-Q3	1.55 [1.45;1.67]	0.94 [0.87;1.01]
Q3-Max	1.87 [1.74;2.02]	0.98 [0.91;1.06]
Hospitalized for diabetes or its complications during year n-1	1.12 [1.02;1.24]	1.04 [0.94;1.16]
Hospitalized for influenza or its complications between during year n-1	1.35 [1.06;1.72]	1.23 [0.96;1.58]
Healthcare use
Number of consultations with general practitioner > median during year n-1 (ref. No)	1.29 [1.23;1.36]	0.99 [0.94;1.05]
Consultation during year n-1 (ref. No) with:
Pulmonologist	1.41 [1.24;1.60]	0.94 [0.81;1.08]
Endocrinologist	1.00 [0.93;1.07]	0.90 [0.84;0.97]
Cardiologist	1.02 [0.96;1.08]	0.80 [0.75;0.85]
Change of general practitioner at season n/n-1 (ref. No)	1.11 [1.02;1.21]	1.14 [1.04;1.25]
A(H1N1) pandemic season (ref. before pandemic)
Year of pandemic (2009/2010)	1.37 [1.28;1.47]	0.84 [0.76;0.93]
Year following pandemic (2010/2011)	0.57 [0.51;0.62]	1.76 [1.64;1.90]
After 2010/2011	0.76 [0.72;0.81]	1.11 [1.04;1.18]

Abbreviations: aHR [95% CI], adjusted hazard ratio [95% confidence interval]; SIV, seasonal influenza vaccination.

^aPatients with newly identified diabetes were those not detected as having diabetes the year before inclusion.

^bPeople with type 1 diabetes were those with long-term illness status for type 1 diabetes (E10 according to the ICD-10) and treated by insulin at inclusion.

^cThe individual chronic condition score (ICC) was calculated as a weighted sum of 21 chronic conditions. Weights account for the severity of each condition in the score calculation (ICC range in study cohort: min = 0; max = 3.7).

Figure 3. Box-plot diagrams¹ for the expected number of seasons with SIV uptake over 10 SIV seasons according to demographic-clinical profiles² among patients with no SIV uptake at the beginning of the period (Figure 3a) and among patients with SIV uptake at the beginning of the period (Figure 3b) – Two-state Markov model estimates³ (EGB, France, 2006/07–2015/16, n = 16,026).

Abbreviations: F, female; Other noT, other types of diabetes without any treatment; Other T, other type of diabetes treated by insulin and/or antidiabetic drugs; M, men; SIV, seasonal influenza vaccination; T1, type 1 diabetes.

¹ The box extends from the 25th percentile to the 75th percentile. The line in the middle is the median (i.e., the 50th percentile). The diamond inside the box is the mean. The whiskers, those two lines at either end, extend from the box as far as the minimum and maximum values, up to 1.5 times the interquartile range (i.e., the distance from the 25th percentile to the 50th).

² Profiles are ranked in ascending order of the expected (i.e., predicted by the MSM model) number of seasons with SIV uptake for patients not vaccinated at the beginning of the period.

³ For each profile, all remaining covariates (individual chronic condition score, hospital stays for diabetes/influenza, healthcare use) are set to their mean values.

Reading Figure 3a: for a woman not vaccinated at the beginning of the period and younger than 65 years with untreated diabetes, the expected number of seasons with SIV uptake over the next 10 SIV seasons was estimated at 2.6.

Reading Figure 3b: for a woman vaccinated at the beginning of the period and younger than 65 years with untreated diabetes, the expected number of seasons with SIV uptake over the next 10 SIV seasons was estimated at 3.6