Variations in Influenza Vaccination by Clinic Appointment Time and an Active Choice Intervention in the Electronic Health Record to Increase Influenza Vaccination

Abstract

Importance: Influenza vaccination rates in the United States are suboptimal near 40%, but little is known about variations in care based on clinic appointment time.

Objectives: To compare differences in influenza vaccination rates by clinic appointment time and to evaluate the association of an active choice intervention in the electronic health record with changes in vaccination rates.

Design, setting, and participants: Retrospective, quality improvement study of 11 primary care practices at the University of Pennsylvania Health System from September 1, 2014, to March 31, 2017. Participants included adults eligible for influenza vaccination. Data analysis was conducted from October 20, 2017, to March 9, 2018.

Interventions: During the 2016 to 2017 influenza season, 3 primary care practices at the University of Pennsylvania Health System implemented an active choice intervention in the electronic health record that prompted medical assistants to ask patients about influenza vaccination during check-in and template vaccination orders for clinicians to review during the visit.

Main outcomes and measures: Influenza vaccination rates.

Results: The sample comprised 96 291 patients with a mean (SD) age of 56.2 (17.0) years; 41 865 (43.5%) were men, 61 813 (64.2%) were white, and 23 802 (24.7%) were black. Among all practices across all 3 years, vaccination rates were approximately 44% from 8 am to 10 am, declined to 41.2% by 11 am and 38.3% at noon, increased to 40.2% at 1 pm, and then declined to 34.3% at 3 pm and 32.0% at 4 pm (P < .001 for adjusted linear trend). For the 3 years, vaccination rates were 46.9%, 47.2%, and 45.6% at control practices and 49.7%, 52.2%, and 59.3% at intervention practices, respectively. In adjusted analyses, compared with control practices over time, the active choice intervention was associated with a significant 9.5-percentage point increase in vaccination rates (95% CI, 4.1-14.3; P < .001). Vaccination rates increased similarly across times of the day.

Conclusions and relevance: Influenza vaccination rates significantly declined as the clinic day progressed. The active choice intervention was associated with a significant increase in influenza vaccination rates that were similar in magnitude throughout the day.

Figure 1.. Influenza Vaccination Rates by Clinic Appointment Time for All Practices in All 3 Years

Vaccination rates are based on each patient’s first visit with his or her primary care physician. Appointment times are grouped by the start of the hour (eg, 8:15 am and 8:30 am were grouped to 8 am).

Figure 2.. Influenza Vaccination Rates by Practice Group and Year

Vaccination rates include all patient visits at the 3 intervention practices and 8 control practices. The active choice intervention was implemented at the intervention practices during the 2016 to 2017 influenza season.

Figure 3.. Influenza Vaccination Rates by Clinic Appointment Time Before and After an Active Choice Intervention in the Electronic Health Record

Vaccination rates are based on each patient’s first visit with his or her primary care physician. Appointment times are grouped by the start of the hour (eg, 8:15 am and 8:30 am were grouped to 8 am). Preintervention represents the first influenza seasons from 2014 to 2016. Postintervention represents the third influenza season from 2016 to 2017. A, Control practices were not exposed to the intervention in either period. B, Intervention practices were exposed during the postintervention period.