Patient Portal Flu Vaccine Reminders (5)

Sub-optimal vaccination rates are a significant problem in the U.S., despite their effectiveness in preventing morbidity and mortality from vaccine-preventable illness. For influenza specifically, annual epidemics of influenza cause substantial morbidity in the U.S. with up to 40,00-80,000 deaths/year and many hospitalizations, emergency and outpatient visits, and significant costs.

Reminder/recall (R/R), sent by phone, mail or other modality, can improve child and adult influenza vaccination rates. However, the majority of pediatric or adult primary care practices do not conduct R/R. Barriers are lack of finances, personnel, and algorithms to identify eligible patients.

A technological breakthrough that might overcome these barriers involves patient portals-- secure, web-based communication systems, embedded within electronic health records (EHRs), for patients and providers to communicate with each other via email and the internet. Portals are used by about half of Americans and half of UCLA patients. Another is text messaging at the health system level.

This randomized controlled trial will assess the effectiveness of reminders messages sent to portal users, encouraging influenza vaccination, on increasing influenza vaccination rates within a health system. Patients will be randomized into three groups: 1) one-third of patients will receive reminder messages with direct scheduling and pre-appointment reminders via the portal, 2) one-third will receive reminders via text messages with direct scheduling and pre-appointment reminders sent by the health system and 3) one-third will not receive reminders.

Patients in the portal-based reminder arm will be further randomized (separately) for two additional components: pre-commitment messages with tailored recall messages and pre-appointment reminders. Patients in the text message-based reminder arm will be further randomized for an additional component: pre-appointment reminders.

Direct scheduling: The convenience of scheduling an appointment for influenza vaccination may increase the likelihood that patients receive an influenza vaccination. All patients receiving reminders (intervention groups) will receive flu vaccine reminder letters with a link to the MyChart direct appointment scheduling page.

Pre-appointment flu reminders: Finally, a missed opportunities for vaccination occurs when patients are eligible for vaccination but are not offered a vaccine at their medical appointment. Pre-appointment reminders, sent in advance of an upcoming appointment, encouraging the patient talk to their doctor about influenza vaccination, may increase the likelihood of that patient receiving a vaccine. Patients in both the portal-based and text message-based reminder arms will be randomized to one of two groups: 1) one half will receive modified pre-appointment reminders that mention influenza vaccination and 2) one half will receive the standard pre-appointment reminders for an upcoming appointment (no mention of influenza vaccination).

Pre-commitment prompts with tailored monthly reminders: pre-planning the place and time of the flu vaccination may improve follow-through. A pre-commitment prompt will be sent via the portal in early September asking patients to commit to a time (September, October, November or December) and place (UCLA, pharmacy, workplace or school, or other) for their flu vaccination. Tailored monthly messages will be sent to patients based on their response to the pre-commitment prompt sent in September. Patients in the portal-based reminder arm will be randomized to one of two groups: 1) one half will receive the pre-commitment prompt and tailored monthly reminders, 2) one half will receive standard monthly reminders.

Interventions that apply Behavioral Economics principles in vaccine promotion messaging can increase vaccine receipt. We will include ownership language in the pre-appointment messages. The convenience of reminders sent via text and with a Direct Appointment Schedule link included enables patients to self-schedule a flu vaccine only visit, reducing friction for vaccine receipt. Additionally, the pre-commitment prompt with tailored reminders will test the principle of implementation intention (pre-planning the place and time of the flu vaccination) has been shown in other health behavior studies to improve follow-through.

For the primary analysis, the primary outcome will be the patient's end of flu season vaccination status. Intervention effects will be assessed using mixed effects log-binomial models. Models will contain terms for messaging modality (text v. portal v. none), pre-appointment reminders (sent v. not sent), and pre-commitment prompt (sent v. not sent).

The portal-based pre-commitment prompt will be sent in September of 2022. The R/R text and portal reminder messages and pre-appointment reminders and will begin in October of 2022.