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Patients with morning appointments more likely to get flu vaccine

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September 14, 2018

Mitesh S. Patel, MD
Mitesh S. Patel

Patients with primary care appointments early in the day are more likely to receive the influenza vaccine than those with appointments after lunch time, according to study results published today in JAMA Network Open.

Researchers found that implementing a “nudge” intervention in several primary care practices in the University of Pennsylvania Health System increased influenza vaccination rates overall, but that the effect waned as the day progressed.

“Patients who see their doctor later in the day were less likely to get the influenza shot,” Mitesh S. Patel, MD, MBA, director of the Penn Medicine Nudge Unit and assistant professor of medicine and health care management at the Perelman School of Medicine and the Wharton School at the University of Pennsylvania, told Infectious Disease News. “This finding is important to recognize as primary care practices look for ways to improve vaccination rates.”

At around 40%, influenza vaccination rates in the United States are “suboptimal,” Patel and colleagues wrote. For their study, they explored whether vaccination rates could be increased using an active choice intervention — a “nudge” — in the electronic health record directed at medical assistants, and whether vaccination rates varied by appointment time.

They conducted a retrospective, quality improvement study between Sept. 1, 2014, and March 31, 2017, enrolling adults eligible for influenza vaccination from 11 primary care practices in the University of Pennsylvania Health System. The intervention was implemented at three internal medicine clinics during the 2016 to 2017 influenza season.

According to Patel and colleagues, standard practice prior to the intervention required primary care providers to manually check patient influenza vaccination status, discuss it with them and place an order for vaccination in the EHR. During the study period, an active choice intervention in the EHR prompted medical assistants to ask patients at check-in about their influenza vaccination status and template vaccination orders in the EHR for clinicians to review, they explained.

Patel and colleagues reported that there was a 9.5 percentage point increase in vaccination rates overall, but the rates significantly declined as the day progressed. From 8 a.m. to 10 a.m. vaccination rates were approximately 44% across all 3 years and among all practices. They declined to 41.2% by 11 a.m. and 38.3% at noon. At 1 p.m., rates increased to 40.2% but declined to 34.3% at 3 p.m. and 32% at 4 p.m. (P < .001).

At control practices, year 1 vaccination rates were 46.9%; at year 2, they were 47.2%; and at year 3, 45.6%, according to the study. The 3-year vaccination rates for the intervention practices were 49.7%, 52.2% and 59.3%, respectively.

“A nudge in the electronic health record can help boost influenza vaccination rates overall, but more study is needed to change the decline over the course of the day,” Patel said.

He said the decline could be driven by several factors, such as clinicians falling behind schedule and rushing through patient visits, decline in staffing numbers as the day progresses, or patients wanting to get home sooner.

“It could also be due to a phenomenon known as ‘decision fatigue,’ which is the cumulative toll of making repeated decisions that leads to clinicians not asking patients about the vaccine as often later in the day,” he said.

Patel and colleagues said the intervention “may be a promising approach to improve medical decision-making behaviors.” However, they emphasized that further research into the association between time of day and vaccination rates is critical. – by Marley Ghizzone

Disclosures: Patel reports receiving support from the Department of Veterans Affairs Health Services Research and Development Service and the Doris Duke Charitable Foundation; being the founder of Catalyst Health and a technology and behavior change consulting firm; receiving research funding from Deloitte not related to this study; receiving personal fees from Catalyst Health; and serving as an advisory board member for HealthMine Services,, and Holistic Industries. Please see the study for all other authors’ relevant financial disclosures.

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Ernest Baskin, ITJ+

I think the time of day finding is interesting, but it is correlational. In other words, we don't know what causes people later in the day to be less likely to be vaccinated. Is there some sort of third variable that connects folks who schedule appointments later in the day with being less likely to be vaccinated? For instance, are people who schedule in the morning more likely to be “go-getters” who care more about their health. This study doesn't answer that question, but it is interesting and important, nevertheless.

Active choice has been shown to be a successful nudge in the past literature in a variety of settings. Minimally, it prompts people to think about the vaccination process when they may not have given it much thought before, and it forces them to make an active decision to go against a positive medical recommendation.

Ernest Baskin, PhD

Assistant professor of food marketing,
Saint Joseph's University, Philadelphia  

Disclosure: Baskin reports no relevant financial disclosures.