Active Reminders Increase Flu Vaccine Rates

With national influenza vaccination rates remaining below 50%, major obstacles to vaccination stand firm, as demonstrated by the standout influenza rates reported last season. Psychological, physical, and system barriers can all play a role, as well as decision fatigue in physicians.

To delve deeper into the obstacles surrounding influenza vaccinations, investigators from the University of Pennsylvania conducted a study that compared differences in vaccinations and evaluated the association of a reminding “nudge” (active choice intervention) in the electronic health record with changes in vaccination rates.

Among their results, the team found significant declines in influenza vaccination rates as the clinic day progressed, as well as an increase in influenza vaccination rates spurred with a “nudge.”

By following the Standards for Quality Improvement Reporting Excellence (SQUIRE) reporting guideline, the team assessed 11 primary care practices (PCP) at the University of Pennsylvania Health System between 2014 and 2017 that had a new or return patient clinic visit with their PCP during at least 1 of 3 influenza seasons (September 1 to March 31).

Investigators evaluated 96,291 patients. Mean patient age was 56.2 years; 41,865 (43.5%) were men, 61,813 (64.2%) were white, and 23,802 (24.7%) were black.

From 8 AM to 10 AM during all 3 years across all practices, vaccination rates were approximately 44%. By noon, vaccination rates declined to 41.2%, but by 1 PM., rates increased to 40.2%. But rates declined again by the late afternoon—by 34.3% at 3 PM and 32% at 4 PM.

At control practices for 3 years, vaccination rates were 46.9%, 47.2%, and 45.6%, while at intervention practices, vaccination rates were 49.7%, 52.2%, and 59.3%.

Compared with control practices over time in adjusted analyses, a significant 9.5% increase in vaccination rates was correlative with the active choice intervention. By 4 PM in the postintervention period, vaccination rates were 40%, which were almost the same as the 8 AM rate in the preintervention period (41%).

In an essay accompanying the study, Suchitra Rao, MBBS, and Ann-Christine Nyquist, MD, MSPH, discussed the impact of decision fatigue in physicians and how it can contribute to low influenza vaccination rates.

“These important findings suggest that decision fatigue is an important barrier to influenza vaccination and that clinical decision support that relies on electronic health records and ancillary medical staff may help overcome this obstacle,” the authors wrote.

Rao and Nyquist emphasized the burden of decision-making in physicians, who are faced with making numerous calls every day. The constant and repetitious acts of decision-making can contribute to an impaired ability to control behavior and make decisions, they note, which may result in clinical practices unaligned with evidence-based recommendations. Ultimately, decision fatigue can lead to inaction.

Consequently, the duo suggested the use of clinical decision support to allow other allied staff members to assist in the task of ordering and distributing influenza vaccinations. A multifaceted approach including electronic reminders were also mentioned as being potentially beneficial.

“These strategies, such as those tested in this study, should combat decision fatigue, incorporate shared decision making among health care staff, and enhance automated features in the electronic health record,” Rao and Nyquist closed. “By using evidence-informed approaches to measure and overcome vaccination barriers, the effectiveness of strategies to increase vaccination rates may be improved, and the ultimate burden of influenza reduced.”

The study, "Variations in Influenza Vaccination by Clinic Appointment Time and an Active Choice Intervention in the Electronic Health Record to Increase Influenza Vaccination," was published online in JAMA Open.