Higher Flu-Vaccination Rates Seen After EHR Nudge

By Will Boggs MD

NEW YORK (Reuters Health) - An electronic health record (EHR)-based intervention that prompts medical assistants to ask patients about influenza vaccination is associated with higher adult vaccination rates, researchers report.

"Nudges in the electronic health record were found to significantly increase flu vaccination rates, and this approach is low-cost and could be scaled more broadly by leveraging the technology in the right way," Dr. Mitesh S. Patel from the University of Pennsylvania, in Philadelphia, told Reuters Health by email.

The U.S. Centers for Disease Control and Prevention recommends that clinicians offer patients the influenza vaccine during routine clinic visits, but several factors keep this from happening, especially as the clinic day progresses and physicians fall behind schedule.

In an early preliminary study, Dr. Patel's team found that an EHR nudge requiring clinicians to accept or decline an influenza-vaccination order significantly increased vaccination rates. Since this type of approach can lead to clinician alert fatigue, however, they redirected the active-choice intervention to medical assistants.

The current study evaluated differences in influenza-vaccination rates by clinic appointment time and compared changes in vaccination rates among three practices receiving the medical-assistant nudge versus eight control practices.

At the intervention practices, the EHR checked for patient eligibility for the influenza vaccine and prompted medical assistants to accept or cancel an order for the vaccine. If accepted, the order would be templated for the clinician to review and sign during the patient visit.

As anticipated, vaccination rates decreased with later appointment times for all practices, with the adjusted odds of vaccination being significantly lower for each subsequent hour of the day relative to the 8 AM appointment time, the team reports in JAMA Network Open, online September 14.

During the two years before the intervention, vaccination rates were not significantly different at control and intervention practices (46.9% versus 49.7%, respectively, for the first year and 47.2% versus 52.2%, respectively, for the second year).

After implementation of the intervention, however, vaccination rates were significantly higher at intervention practices (59.3%) than at control practices (45.6%). In adjusted analyses, influenza vaccination rates were 9.5 percentage points higher at intervention practices than at control practices.

Among intervention practices, vaccination rates at the end of the day (4 PM) were 33% in the preintervention period and 40% in the postintervention period, which was nearly the same as at 8 AM in the preintervention period (41%).

"Flu-vaccination rates were found to decline over the course of the day, and being aware of this presents an opportunity to improve vaccination rates," Dr. Patel said. "Simple nudges in the EHR can be effective and could be better utilized to improve vaccination rates."

"Evidence-based strategies and system changes to enhance seasonal influenza vaccination rates should incorporate collaborative and multifaceted approaches including standing order use, vaccination-only clinics, strong recommendations from health care professionals, reminder and recall efforts, vaccinating at every opportunity rather than just during primary care well visits, and vaccinating in nontraditional settings such as emergency departments, hospitals, schools, and the workplace," write Dr. Suchitra Rao and Dr. Ann-Christine Nyquist from Children's Hospital Colorado and the University of Colorado School of Medicine, in Aurora, in a linked editorial.

"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," they add.

Dr. Roger E. Thomas from the University of Calgary, Canada, who recently reviewed interventions to increase influenza-vaccination rates in older people, told Reuters Health by email that the authors "showed vaccination acceptances decrease during the day, and hypothesized physicians got behind and were stressed/fatigued, but did not gather data to test this key hypothesis. How about office staff getting fatigued glued to the phone all day? Nor did they entertain the hypothesis that those who show up at 8 bright and early are systematically different."

"It is not an (randomized controlled trial), and the control groups include internal-medicine clinics where the decision makers were not interested," he said. "Thus, the results probably overstate the effects compared to the comparison group."

Dr. Susan H. Wootton from McGovern Medical School at The University of Texas Health Science Center at Houston recently found that opting out was no better than opting in for improving influenza-vaccination rates during pregnancy. She told Reuters Health by email that she was "surprised the intervention didn't have more of an impact. This was an observational study, so results may be impacted by biases or confounders."

"Creative new strategies are needed to increase influenza vaccination rates among adults," said Dr. Wootton, who was not involved in the research. "Even with this intervention, 40% of adults remained unvaccinated."

"There are many evidence-based strategies for improving immunization rates (e.g., enhancing access to services, increasing community demand, using provider- or system-based interventions, or combining interventions at a community level)," Dr. Wootton said. "Practices should focus on interventions proven to work."

SOURCE: https://bit.ly/2POygMZ and https://bit.ly/2ODG4RA

JAMA Network Open 2018.

(c) Copyright Thomson Reuters 2018. Click For Restrictions - https://agency.reuters.com/en/copyright.html

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