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With national influenza immunization rates still below 50%, the main obstacles to vaccination remain, as evidenced by the exceptional influenza rates reported last season. Psychological, physical and systemic barriers can all play a role, as can physician decision fatigue.
To further explore the barriers to influenza vaccination, researchers at the University of Pennsylvania conducted a study comparing differences in immunization and evaluating the association of a "reminder" (active choice intervention) in the electronic health record with the evolution of vaccination rates.
Among their findings, the team found a significant decrease in influenza vaccination rates as the clinical day progressed, as well as an increase in influenza vaccination rates through a "flu shot". thumb".
By following the Standards for Quality Improvement Reporting Excellence (SQUIRE) reporting guidelines, the team evaluated, between 2014 and 2017, 11 primary care practices in the University of Pennsylvania health system. at least one of the three influenza seasons (September 1 to March 31).
Investigators evaluated 96,291 patients. The average age of the patients was 56.2 years; 41,865 (43.5%) were male, 61,813 (64.2%) were white, and 23,802 (24.7%) were black.
From 8:00 to 10:00 for every 3 years in all practices, vaccination rates were about 44%. At noon, vaccination rates dropped to 41.2%, but by 1 pm, the rates rose to 40.2%. But rates fell further in the late afternoon, from 34.3% to 15 hours and 32% to 16 hours.
In control practices for three years, vaccination rates were 46.9%, 47.2% and 45.6%, while in intervention practices, vaccination rates were 49.7%, 52.2% and 59.3%.
Compared with control practices over time in adjusted analyzes, a significant increase of 9.5% in vaccination rates was correlated with active choice intervention. At 16 hours in the post-intervention period, vaccination rates were 40%, almost the same as the rate of 8 hours before the intervention (41%).
In a dissertation accompanying the study, Suchitra Rao, MBBS, and Ann-Christine Nyquist, MD, MSPH, discussed the impact of decision fatigue in physicians and how it can contribute low vaccination rate.
"These important findings suggest that decision fatigue is a significant impediment to influenza vaccination and that clinical decision support based on electronic medical records and auxiliary medical personnel can help overcome this barrier." wrote the authors.
Rao and Nyquist have pointed out the burden of decision-making among doctors, who have to make many calls every day. Constant and repetitive decision-making can help reduce the ability to control behavior and make decisions, they note, which can lead to clinical practices that are inconsistent with evidence-based recommendations. In the end, decision fatigue can lead to inaction.
As a result, the duo suggested using a clinical decision support tool to allow other auxiliary staff to participate in ordering and distributing flu shots. A multi-faceted approach including electronic reminders was also mentioned as potentially beneficial.
"These strategies, such as those tested in this study, should combat the fatigue of decisions, incorporate shared decision-making among health staff, and improve the automated functions of the electronic health record," Rao and Nyquist concluded. "By using evidence-based approaches to measure and overcome barriers to vaccination, the effectiveness of strategies to increase vaccination rates could be improved and the ultimate burden of influenza reduced."
The study titled "Variations in Influenza Vaccination by Clinic Appointment and Active Intervention in the Electronic Health Record to Increase Influenza Vaccination" was published online in JAMA Open.
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