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Invited Commentary
Infectious Diseases
September 14, 2018

The Power of the Nudge to Decrease Decision Fatigue and Increase Influenza Vaccination Rates

Author Affiliations
  • 1Division of Hospital Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora
  • 2Department of Epidemiology, Colorado School of Public Health, University of Colorado, Aurora
  • 3Children’s Hospital Colorado, Aurora
  • 4Section of Infectious Diseases, Department of Pediatrics, University of Colorado School of Medicine, Aurora
JAMA Netw Open. 2018;1(5):e181754. doi:10.1001/jamanetworkopen.2018.1754

The 2017 to 2018 influenza season demonstrated that influenza remains a persistent global health threat. Achieving and maintaining high influenza vaccination rates are an important public health priority. The Centers for Disease Control and Prevention Healthy People 2020 initiative set a target influenza vaccination goal of at least 70% for all individuals aged 6 months and older. However, vaccination rates remain lower than 50% nationally.1 Major obstacles to annual influenza vaccination include psychological barriers that drive vaccine hesitancy, physical barriers such as lack of access or interaction with the health care system, and other system barriers, including clinicians forgetting to order vaccines due to lack of time or not considering it a high priority.2 Many system barriers are surmountable yet require further study to develop evidence-based strategies to promote vaccination and enhance vaccination efforts, in the primary care setting as well as other settings such as pharmacies and hospitals.

Kim and colleagues3 explored factors associated with influenza vaccination ordering. They conducted a retrospective, quality improvement study of 11 primary care and internal medicine practices in a large university health care system. Two significant findings were discovered in their study. First, they found that vaccination rates were highest in the morning at 44%, followed by a decline to 32% by the end of the day. Second, practices that used an active choice intervention, referred to as a nudge (whereby medical assistants were prompted to order the influenza vaccine and clinicians had to either accept or decline the vaccine order) had significantly higher vaccine ordering rates compared with those practices without the active choice intervention. These important findings suggest that decision fatigue is an important barrier to influenza vaccination and that clinical decision support that relies on electronic health records and ancillary medical staff may help overcome this obstacle.

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.3 This decision fatigue may result in clinical practices that do not align with evidence-based recommendations and may be exacerbated over the course of the day. Recent studies that corroborate this phenomenon showed antibiotic prescribing for acute respiratory illnesses increasing over the course of the day in a primary care practice setting, and passive behavior during repeated decision making, with the ultimate decision of inaction.4,5 A growing body of literature describes ways to enhance decision making in health care to optimize outcomes for patients and overcome decision fatigue, such as use of automated reminders using clinical decision support tools and delegating decisions to other staff members.

Clinical decision support tools using automated features in the electronic health record are increasingly used to improve primary preventive care, enhance acute medical care, and improve adherence to guidelines. Clinical decision support tools that are integrated into the clinician’s workflow and provide recommendations at the time of clinician decision making are the most successful. However, studies show that many prompts are ignored by clinicians, especially prompts considered lower priority.6 Among 3 randomized clinical trials that evaluated clinical decision support tools for vaccination, only 1 was associated with increased influenza vaccination rates in elderly patients, when compared with usual care.7 Therefore, there is not sufficient evidence to support their use as the sole method of improving vaccination rates and they may just replace clinicians’ decision fatigue with alert fatigue.

Therefore, an extension of this strategy is to use clinical decision support through standing orders, thus allowing nurses, medical assistants, and other allied health staff to order vaccines and practice at the top of their scope. Substantial data support its superiority over physician reminders and education in the primary care setting, in addition to evidence of cost-effectiveness. The Advisory Committee on Immunization Practices thus recommends standing order use in outpatient and hospital settings to increase immunization rates.8

Several studies have failed to demonstrate an increase in the rates of influenza vaccination through standing orders and alerts in the medical record alone despite multiple trials showing the use of computerized reminders for preventive care measures in the outpatient setting.9 Kim and colleagues3 similarly showed that influenza vaccination rates declined over time in the active choice intervention group as well as the control group. Other studies suggest that a multifaceted approach incorporating computerized reminders may be more beneficial.10

The limitations of the study by Kim and colleagues3 are representative of those that arise from observational studies, and these findings may not be generalizable to other settings. The study was not randomized, and the active choice intervention was conducted in internal medicine clinics, whereas the control group clinics were a mix of primary care and internal medicine. The authors attempted to select control clinics with similar vaccination rates to provide a more balanced comparison, but there is the potential for additional confounders that could skew the study findings. Lastly, the internal validity relies on accurate screening of influenza vaccination status, which was not verified through other means.

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. 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. By using evidence-informed approaches to measure and overcome vaccination barriers, the effectiveness of strategies to increase vaccination rates may be improved, and the ultimate burden of influenza reduced.

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Article Information

Published: September 14, 2018. doi:10.1001/jamanetworkopen.2018.1754

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2018 Rao S et al. JAMA Network Open.

Corresponding Author: Ann-Christine Nyquist, MD, MSPH, Children’s Hospital Colorado, 13123 E 16th Ave, Ste B-276, Aurora, CO 80045 (chris.nyquist@childrenscolorado.org).

Conflict of Interest Disclosures: Dr Rao reported receiving research funding support from GlaxoSmithKline. No other disclosures were reported.

Centers for Disease Control and Prevention.  2016-17 influenza season vaccination coverage report. https://www.cdc.gov/flu/fluvaxview/reportshtml/reporti1617/reporti/index.html. Accessed July 20, 2018.
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