Could “Nudging” PCPs Improve Influenza Vaccine Uptake?—Public Health Watch


Adding reminders to electronic health records shows promise at improving influenza vaccination rates, according to results of JAMA Open Network study.

As influenza season approaches, one single issue takes center-stage: vaccine uptake.

Although multiple studies have concluded that vaccination can reduce the burden of disease—lowering risk for severe infection and, possibly, mortality for at-risk populations—data from the US Centers for Disease Control and Prevention (CDC) suggests that fewer than half of American adults get “flu shot” each year. The exact reasons for this shortfall have been a subject of much debate; however, some believe that rushed primary care physicians too often neglect to remind patients of the availability of the vaccine during routine visits.

If this is indeed the case, a team of investigators from the Perelman School of Medicine at the University of Pennsylvania in Philadelphia may have a solution—and it is the modern-day equivalent, at least in the health care setting, of tying a string around one’s finger.

In a quality-improvement study of 11 primary care practices and 96,291 patients published online on September 14 by JAMA Open Network, the team found that what they describe as “an active-choice intervention” in the electronic health record (EHR) system designed to prompt staff to ask patients about influenza vaccination and template vaccination orders for clinicians to review were “associated with a significant increase in influenza vaccination rates when compared with a control group of primary care practices.” Which is significant, given what they observed about vaccination rates in the practices they assessed.

“Influenza vaccination rates in primary care clinics declined as the day progressed, which indicates there is an opportunity to improve rates by focusing on these gaps in care,” study co-author Mitesh S. Patel, MD, MBA, MS, assistant professor, Perelman, told Contagion®. “A simple nudge in the electronic health record led to a significant increase in vaccination rates.”

To reach this conclusion, Dr. Patel and his colleagues performed a retrospective, quality-improvement study of 11 primary care practices in the University of Pennsylvania Health System over a 3-year period, focusing on adult patients eligible for influenza vaccination. For the purposes of the research, 3 of the primary care practices included in the study implemented an active-choice intervention in their EHR systems that “nudged” staff to ask patients about influenza vaccination during check-in. “Nudge” sounds like a slang term, but it is, in fact, a formal change in the clinical practice architecture “that can have outsized effects on medical decision making,” as noted in earlier papers published by the same research team. A study published by the same group, in the July 2017 issue of the Journal of General Internal Medicine, found that using active choice, which requires clinicians to accept or decline an order in the EHR, significantly increased influenza vaccine uptake at a primary care practice.

Among the 11 practices in the recent study, daily vaccination uptake among eligible adults was approximately 44% from 8 am to 10 am, before it declined to 41.2% by 11 am, and 38.3% at noon. After a slight increase to 40.2% by 1 pm, vaccination uptake then declined again to 34.3% at 3 pm, and 32.0% at 4 pm.

However, the EHR “nudge” had a positive effect on these rates over the study period. Vaccine uptake at the practices in which the intervention was used was 49.7%, 52.2%, and 59.3%, respectively, over each of the 3 years of the study, compared to 46.9%, 47.2%, and 45.6% at the control practices. Given the success with this approach, Dr. Patel and his colleagues are optimistic that such “nudges” offer promise in improving vaccine uptake. They will be testing the protocol in more primary care clinics in the near future, and comparing it to similar “nudge” models aimed at patients.

“More than 90% of clinicians and hospitals use EHRs, and so the intervention in our study could be easily scaled more broadly,” added Dr. Patel.

And anything that mitigates the risk associated with influenza is a good thing.

Brian P. Dunleavy is a medical writer and editor based in New York. His work has appeared in numerous health care-related publications. He is the former editor of Infectious Disease Special Edition.

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