Reminders showed some benefit, but effect was small

General patient portal reminders failed to dramatically increase influenza vaccination rates, although there was some minimal benefit, researchers reported.

In a randomized, four-arm trial at a single health system, flu vaccination rates were 37.5% for those who received no reminders, 38.0% for those who got one reminder (P=0.008 versus no reminder), 38.2% for those who received two reminders (P=0.03 versus no reminder), and 38.2% for those who got three reminders (P=0.02 versus no reminder), according to Peter G. Szilagyi, MD, MPH, of UCLA Mattel Children’s Hospital at the University of California Los Angeles (UCLA), and co-authors.

While the increase in vaccination rates among those who received patient portal alerts was a statistically significant effect, it did not meet the study’s clinically significant effect cutoff of 2%, they reported in JAMA Internal Medicine.

However, some patients — men, non-Hispanics, and those who did not get vaccinated in the prior two years — did show better response to the reminders with higher vaccination rates versus the control group, the authors added.

Still, “Generic patient portal reminders were effective in minimally increasing influenza vaccination rates… more intensive or more targeted patient motivational strategies appear to be needed,” they concluded.

In an invited commentary accompanying the study, Timothy Judson, MD, MPH, and Ralph Gonzales, MD, MSPH, both of the University of California San Francisco, pointed out that “The novel coronavirus disease 2019 pandemic has caused a health and humanitarian crisis unprecedented in the modern era. The scientific and medical communities are racing to develop a vaccine, [but] it is worth noting that access to an efficacious vaccine is only part of the solution.”

Good outcomes with effective vaccines require widespread adoption, and the current study reminds the medical community that patient portals may be attractive – low cost, easy to implement, far reaching – but, “in the case of influenza vaccination, patient portal reminders alone are not sufficient to move substantial numbers of patients to action.”

Judson and Gonzales praised the authors for conducting a “rigorous, pragmatic… high caliber” study and for making sure that “flaws or limitations in the evaluation itself” were not the drivers of the negative finding.

They also highlighted that getting people to change their health-related behavior calls for three elements: “Predisposing factors include perceived susceptibility to and severity of illness… enabling factors [that] make behavior change natural, convenient, and easy… [and] reinforcing factors [with] reminders and positive reinforcement so that people who initiate behavior change find it rewarding and sustainable.”

In terms of behavior change for vaccinations, Judson and Gonzales noted that the medical community is up against many barriers, including the anti-vaxxer movement, lack of convenient access — they cited Project VIVA as a vaccination success story — and, for healthcare administrators, having to determine if “this type of outreach strategy is worth the cost and message clutter.”

They called for “focus groups and interviews with the target patient populations” to redefine and refine such outreach programs and increase their value.

The study was done from Oct.2018-March 2019 across the UCLA healthcare system. A total of 164,205 patients (mean age 46.2 years; 58.3% female) in 52 primary care practices who had used the patient portal within 12 months were included.

Patients due for an influenza vaccine were sent a letter via patient portal reminding them about the importance of flu vaccination, safety of the vaccine, and morbidity associated with influenza, the authors explained.

The reminder process began with “a message from your doctor” via email or text, followed by a portal reminder letter (accessed after log-in) in English, written below a seventh grade reading level, that included the name of the primary care physician. The identical letter was sent to each group at each round, and “patients who had received an influenza vaccination according to the EHR [electronic health record] were removed from the eligible list,” they stated.

Patients were randomized within primary care practices to one of four study groups, ranging from no reminder to three reminders. The primary analysis was done across all ages and did not include patient self-reported vaccinations in reply to portal reminders.

The authors found adjusted risk ratios of 1.02 for three groups (95% CI 1.00 to 1.03 for 1 reminder; 95% CI 1.00 to 1.04 for two reminders; 95% CI 1.00 to 1.04 for three reminders), which showed “a small effect and no dose response by number of reminders sent.”

In the secondary analysis that did not include patient self-reported vaccinations, Szilagyi and co-authors reported the following vaccination rates:

  • Among those ages 18 to 64 years: 32.0% in the control group, 32.8% in the one-reminder group, 32.8% in the two-reminder group, and 32.8% in the three-reminder group (P=0.001).
  • Male patients: 37.3% versus 38.3%, 38.6%, and 38.8% (P=0.001).
  • Non-Hispanic patients: 37.6% versus 38.2%, 38.3%, and 38.2% (P=0.004).
  • Not vaccinated in the prior 2 years: 15.3% versus 15.9%, 16.3%, and 16.1% (P<0.001).

They also found that, when self-reported vaccinations received elsewhere were included, flu vaccination rates were 1.4 to 2.9 percentage points higher in the portal reminder groups, with a dose-response effect, ranging from 37.8% for no reminders to 40.7% for three reminders (P<0.001).

Study limitations included the lack of generalizability to other health systems and the inability to track all vaccinations received outside the healthcare system.

Szilagyi’s group offered some possible reasons for the negative finding, such as the waning effectiveness of patient-targeted health communications, especially if patients do no read the portal letters. Also, portal letter content may influence whether a patient heeds a health reminder. Finally, there is the issue of “vaccine hesitancy,” but “The intervention was not designed to address hesitancy but rather to nudge patients who desired vaccination,” they stated.

  1. One to four influence vaccine reminders sent through a patient portal had a small, statistically significant effect — but not a clinically significant effect — on increasing flu vaccination rates compared with no reminder.

  2. More intensive, or more targeted, patient motivational strategies may be necessary to make reminders sent through a patient portal effective.

Shalmali Pal, Contributing Writer, BreakingMED™

The study was funded by the National Institute of Allergy and Infectious Diseases (NIAID), and the National Center for Advancing Translational Sciences.

Szilagyi and some co-authors reported grants from NIAID, the Centers for Disease Control and Prevention, and the Pfizer Foundation.

Judson reported a relationship with McKinsey Healthcare Systems & Services Practice. Gonzales reported relationships with Phreesia and Healthwise.

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Topic ID: 88,151,730,138,139,44,192,561,653,151,924