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Flu shot rates in clinics drop as day progresses, but nudges help give them a boost

September 14, 2018

PHILADELPHIA - Primary care clinics experienced a significant decline in influenza vaccinations as the day progressed, researchers from Penn Medicine report in a new study published in JAMA Open Network. However, "nudging" clinical staff to order vaccines using a behavioral economics technique known as "active choice" may help curb some of that drop off, the study suggests. The study is the first to show how clinic appointment times can influence influenza vaccination rates.

"As the day progresses, clinicians may have less time to spend on discussing the vaccine with patients," said lead author Rebecca Kim, MD, MPH, a resident physician in the primary care track at Penn Medicine. "Our findings show that time of day is an important factor in vaccination rates and could help to inform the design of future interventions to improve vaccination rates."

Researchers found that vaccination rates dropped significantly throughout the day across 11 primary care clinics part of the University of Pennsylvania Health System over a three-year period (2014 - 2017) - from 44 percent at 8 a.m. to 32 percent at 4 p.m.

In the third year, the team implemented a nudge in the electronic health record (EHR) at three of the clinics, which prompted medical assistants to "accept" or "decline" an influenza vaccination order for eligible patients for the clinicians to review. They found the intervention was associated with a 9.5 percent increase in vaccinations, which is nearly a 20 percent relative increase compared to practices with no intervention.

"In the United States, influenza vaccination rates have been suboptimal at about 40 percent for nearly a decade," said study senior author Mitesh S. Patel, MD, MBA, an assistant professor of Medicine and director of the Penn Medicine Nudge Unit. "Our study indicates that nudges in the EHR could be an effective and scalable approach to increase vaccination in the primary care setting."

While rates did improve with the nudge in place, they still declined as the day progressed, suggesting further strategies may be needed to address the variations in care by time of day, the authors said. The research builds off a 2017 study from the same team that found implementing a "nudge" in the EHR was associated with a six percent increase in flu vaccinations for one practice compared to practices with no intervention. The researchers not only included more practices in the latest study, but also directed the nudge alert to only medical assistants, rather than to physicians, to eliminate any redundancy - which may have helped improve the vaccination rates, the authors said.

"Importantly, this intervention was directed to staff, not clinicians," Patel said. "At a time when physicians are often overburdened with alerts and facing burn out, these types of well-designed nudges can address these issues while improving patient care," Patel said.

Next, the researchers aim to expand the "nudge" intervention across more primary care practices within the health system to further study and improve upon the approach. If these types of interventions were implemented in all 36 primary care practices, for example, in Philadelphia and the suburbs, the researchers estimate that 5,000 more patients would be vaccinated in a year.

The concept of "nudging" comes from the field of behavioral economics and is about intervening--often in small, subtle ways--to improve decision-making and ultimately patient care. Patel and colleagues from the Penn Medicine Nudge Unit in prior research have shown the value of nudge strategies in a wide range of areas, including opioid prescribing behavior, cancer screening, and more recently with cholesterol-lowering statins.
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On September 17 and 18, the Penn Medicine Nudge Unit, which is a collaboration between the Penn Medicine Center for Health Care Innovation and the Center for Health Incentives and Behavioral Economics, will host a "Nudge Units in Health Care" Symposium on the Penn Medicine campus. Executive leaders and representatives from 20+ health systems across the United States and Canada will convene to share insights and engage in designs sessions for those looking to launch their own nudge units.

Co-authors on the study include Susan C. Day, MD, MPH, Dylan S. Small, PhD, Christopher K. Snider, MPH, and Charles A. L. Rareshide, MS.

Support for the study was provided by UPHS via the Nudge Unit.

Penn Medicine is one of the world's leading academic medical centers, dedicated to the related missions of medical education, biomedical research, and excellence in patient care. Penn Medicine consists of the Raymond and Ruth Perelman School of Medicine at the University of Pennsylvania (founded in 1765 as the nation's first medical school) and the University of Pennsylvania Health System, which together form a $7.8 billion enterprise.

The Perelman School of Medicine has been ranked among the top medical schools in the United States for more than 20 years, according to U.S. News & World Report's survey of research-oriented medical schools. The School is consistently among the nation's top recipients of funding from the National Institutes of Health, with $405 million awarded in the 2017 fiscal year.

The University of Pennsylvania Health System's patient care facilities include: The Hospital of the University of Pennsylvania and Penn Presbyterian Medical Center -- which are recognized as one of the nation's top "Honor Roll" hospitals by U.S. News & World Report -- Chester County Hospital; Lancaster General Health; Penn Medicine Princeton Health; Penn Wissahickon Hospice; and Pennsylvania Hospital -- the nation's first hospital, founded in 1751. Additional affiliated inpatient care facilities and services throughout the Philadelphia region include Good Shepherd Penn Partners, a partnership between Good Shepherd Rehabilitation Network and Penn Medicine, and Princeton House Behavioral Health, a leading provider of highly skilled and compassionate behavioral healthcare.

Penn Medicine is committed to improving lives and health through a variety of community-based programs and activities. In fiscal year 2017, Penn Medicine provided more than $500 million to benefit our community.

University of Pennsylvania School of Medicine

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