According to data published in JAMA Network Open, influenza vaccination rates declined as the clinic day progressed. Primary care practices that implemented active choice interventions in electronic health records to prompt medical assistants to ask patients about vaccinations, along with template vaccination orders for clinicians to review, were associated with increased vaccination rates.

A retrospective quality improvement study of 11 primary care practices at the University of Pennsylvania Health System from 2014 to 2017 was conducted to compare differences in vaccination rates by clinic appointment time. The association of an active choice intervention in the electronic health record with vaccination rates at 3 primary care practices in the same institution during the 2016 to 2017 influenza season was also evaluated.

The study enrolled a sample of 96,291 adult patients eligible for influenza vaccination. Vaccination rates across the 3 years and among all practices were approximately 44% from 8 AM to 10 AM, 41.2% by 11 AM, and 38.3% by noon. There was an increase at 1 PM to 40.2%, followed by a decline to 34.3% by 3 PM and a further decline to 32.0% by 4 PM (P <.001 for adjusted linear trend). The rates of vaccination for 3 years at control practices were 46.9%, 47.2% and 45.6%, whereas rates at the intervention practices were 49.7%, 52.2%, and 59.3%. The active choice intervention was associated with a 9.5% increase in vaccination rates after adjusted analyses (95% CI, 4.1%-14.3%; P <.001).

It is important to note that observational studies carry potential biases definitively, but investigators established measures to mitigate these; namely, by implementing “a difference-in-differences approach, which reduces potential bias from unmeasured cofounders by comparing changes in vaccination levels over time between the intervention and control practices.” Steps were also taken to adjust for available physician, practice, and patient characteristics, and investigators note that the results should be confirmed in other settings outside of the single healthcare system evaluated here.

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The results indicated that vaccination rates declined as clinic day progressed, and that an active choice intervention was associated with an increased vaccination rate that was of similar magnitude throughout the day. Although further investigations in variations of rates throughout the day are needed, investigators believe scalable approaches that leverage electronic health records to encourage “well-designed nudges” are a promising approach to improving medical decision-making behavior.


Kim RH, Day SC, Small, DS, Snider CK, Rareshide, CAL, Patel, MS. Variations in influenza vaccination by clinic appointment time and an active choice intervention in the electronic health record to increase influenza vaccination. JAMA Netw Open. 2018;1:e181770