Primary care clinics who implemented an "active choice intervention" into their electronic health record (EHR) systems were associated with a significant increase in influenza vaccination rates, researchers found.
Though vaccination rates declined as the day progressed, adjusted analyses showed that practices that implemented the intervention had a 9.5 percentage point increase in vaccination rates compared with previous practices over time (95% CI 4.1-14.3, P<0.001), reported Mitesh S. Patel, MD, of the University of Pennsylvania in Philadelphia, and colleagues, writing in JAMA Network Open.
They noted that "'nudges' can have outsized effects on medical decision making," but that while a prior study found an order to accept or decline influenza vaccinations in the EHR increased vaccination rates, it "could lead to clinician alert fatigue." Prior to expanding the practice, the authors then redirected the alerts to medical assistants, who could ask patients about influenza vaccination and "template orders in the EHR for clinicians to review."
The researchers examined data from 11 primary care practices in the University of Pennsylvania Health System for the 2014-2015, 2015-2016, and 2016-2017 influenza seasons. Three of these practices were intervention practices, while eight were control practices. The intervention was comprised of medical assistants being prompted to order the influenza vaccine in the EHR, and the clinician could accept or decline the order. The authors noted that "prior to the intervention, [primary care practitioners] had to remember to manually check if a patient was due for an influenza vaccination, discuss it with the patient, and then place an order for it in the EHR."
Overall, the sample included about 96,000 patients, who were a mean age of 56; about 44% were men, and almost two-thirds were white. Unadjusted vaccination rates ranged from 44% with appointments from 8 am to 10 am to 32.0% at 4 pm. The authors found that compared with the 8 am appointment time, adjusted odds ratios of vaccination were "significantly lower for each subsequent hour of the day and for the overall linear trend" (adjusted OR 0.95, 95% CI 0.94-0.96, P<0.001). In addition, "adjusted preintervention trends during the first 2 years did not differ between groups (adjusted OR 1.08, 95% CI 0.92-1.27, P=0.36)."
Suggestion that 'Decision Fatigue' is a Barrier
An accompanying editorial by Suchitra Rao, MBBS, and Ann-Christine Nyquist, MD, both of the University of Colorado in Aurora, argued that these findings "suggest that decision fatigue is an important barrier to influenza vaccination."
"Clinicians, who make numerous decisions each day, are susceptible to decision fatigue, which is described by psychologists as the impaired ability to control behavior and make decisions as a consequence of repeated acts of decision making."
In addition, Rao and Nyquist said, "substantial data" support using clinical decision support through standing orders, and the CDC's Advisory Committee for Immunization Practices even recommends standing orders in both outpatient and hospital settings to increase the rates of immunization.
Patel and colleagues noted that study limitations included that the active choice intervention was evaluated using a "differences-in-differences approach," that the single health system setting may limit the generalizability of the findings, and that the observational design was thus subject to unmeasured confounders.
The team concluded that while further work may be needed to address variations in vaccination rates by time of day, "scalable approaches that leverage the EHR to deploy well-designed nudges may be a promising approach to improve medical decision-making behaviors."
This study was supported by the University of Pennsylvania Health System.
Patel disclosed support from the Department of Veterans Affairs Health Services Research and Development Service and the Doris Duke Charitable Foundation, Catalyst Health, HealthMine Services, Life.io and Holistic Industries, and being the founder of Catalyst Health, a technology and behavior change consulting firm.
Rao disclosed support from GlaxoSmithKline.
Nyquist reported having no conflicts of interest.
JAMA Network Open
Source Reference: Kim RH, et al “Variations in influenza vaccination by clinic appointment time and an active choice intervention in the electronic health record to increase influenza vaccination” JAMA Network Open 2018; DOI: 10.1001/jamanetworkopen.2018.1770.
JAMA Network Open