The surprising barrier to ensuring patients get their flu shots

A nurse preparing a medical injection
It's a timely finding, as the next flu season looms and health officials have begun urging patients to get their flu vaccinations in the coming days and weeks. (Getty/scyther5)

On the heels of one of the worst flu seasons on record, a new study published in the Journal of the American Medical Association identified one of the biggest barriers preventing patients from receiving their flu shot: the time of day the patient sees their doctor.

Researchers from the University of Pennsylvania observed 11 primary care clinics over a three-year period and found flu vaccination orders dropped throughout the day, from 44% at 8 a.m. to 32% by 4 p.m.

“Primary care physicians often fall behind schedule as the clinic day progresses, and this tendency may lead to rushed visits, decision fatigue and suboptimal care,” the authors of the study wrote.

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It's a timely finding, as the next flu season looms and health officials have begun urging patients to get their flu vaccinations in the coming days and weeks. The Centers for Disease Control estimated the flu was at epidemic levels for 16 consecutive weeks in the 2017-2018 flu season and 700,000 were hospitalized due to symptoms associated with the flu. The agency is already warning about another potentially nasty flu season, CNBC reported.

During the 2016-2017 flu season—the third year of the study—the researchers wrote that three physician practices utilized a “nudge" when it came to vaccines. Medical assistants received a prompt in a patient’s electronic health record to ask patients about a flu shot upon check-in. Prior to the nudge, primary care physicians had to manually check a patient’s EHR to see if they were due for a flu shot.

Those intervention practices saw a nearly 20% increase in flu shots ordered compared with the preintervention period. However, researchers found the vaccination rate still suffered a decline throughout the day, the authors wrote.

The study reported a 9.5-percentage point increase in vaccination rates at clinics using the nudge. The CDC and the Healthy People 2020 initiative set a target flu vaccination rate of at least 70% for all individuals aged 6 months and older. Data from the CDC showed less than half the population received a flu shot during the 2016-2017 season.

CDC's data indicates only 38.6% of the general population was vaccinated by November 2017.

In a commentary piece about the study also appearing in JAMA this month, Suchitra Rao and co-author Ann-Christine Nyquist cautioned against the reliance of nudges in EHRs. The authors wrote that decision fatigue could be replaced with alert fatigue, and cited other studies that have shown clinicians often ignore nudges, especially when the prompts are considered a lower priority.

The University of Pennsylvania team echoed the point within the study and noted that intervention practices set prompts to only appear for medical assistants, which yielded higher vaccination rates over trials that did not distinguish between medical assistants and physicians. 

“This design increased clarity in who was responsible for addressing the alert and reduced the burden on physicians,” the study authors wrote.

And while the authors said more work is needed to address the time-of-day variations for vaccination rates, the study concluded that :well-designed nudges may be a promising approach to improve medical decision-making behaviors."

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