Clinical Decision Support Tool Raises Flu Vaccination Rates in Hospitalized Children

Hospitalized children whose doctors used a default-focused clinical decision support (CDS) tool had higher rates of influenza vaccination, according to a recent study.

The flu vaccine is considered highly effective and is strongly endorsed by the CDC. Yet, only about 63% of children in the United States received a flu vaccine in the 2018-2019 school year. Children who are from low-income families and who do not have “medical homes” where they receive regular care are less likely to receive flu vaccines.

However, even among children with high rates of interaction with the health care system—those with high-risk conditions that can make them especially vulnerable to influenza—vaccination rates are low. Existing literature suggests 33%-59% of hospitalized children have the flu vaccine, despite the CDC’s recommendation that such children receive the vaccine while in hospital.

Corresponding author Evan W. Orenstein, MD, of the Emory University School of Medicine, and colleagues, wanted to find out whether implementing a CDS strategy might help providers achieve higher rates of vaccination among hospitalized children. Writing in JAMA Network Open, they explained that existing studies evaluating using CDS to boost compliance with health care maintenance objectives are inconsistent, and other studies have shown that health-record-embedded CDS tools only work if they deliver the right messages to the right providers at the right time.

Orenstein and colleagues devised a study which took place at a tertiary pediatric health system comprising 3 hospitals. A CDS tool was developed that included 3 main components, a default vaccine order for eligible patients, a script to offer the vaccine, and just-in-time education for clinicians with links to reference material.

The intervention was rolled out in the health system for the 2019-2020 flu season. Eligible children who were hospitalized during that time span were split into 2 groups, an intervention group and a control group. A second control group, based on patients who sought care in the 2018-2019 influenza season, was also evaluated.

The study population was mostly boys (52%) with a median age of 8; 50% were Black and 43% were White. Nearly two-thirds (64%) were on a public insurance plan.

The hospitals in the study reported 10,997 eligible hospitalizations during the 2019-2020 flu season. Those patients were divided on a 1:1 basis, with half receiving the CDS intervention. Among those in the intervention group, 31% received the vaccine. Among the concurrent control group, the vaccination rate was 19%. Of the 6743 patients in the 2018-2019 control group, the vaccination rate was 14%.

Orenstein and colleagues said the CDS is built around making the vaccine the default action, rather than framing it as an “addition” to routine care.

“These interventions stress the use of defaults as a behavioral economic strategy to influence behavior, including targeted defaults for clinicians to order the influenza vaccine as well as a nursing staff script emphasizing a default option for families of patients receiving the influenza vaccine during the hospitalization,” they wrote.

However, the study also showed that while both vaccine orders and administration increased, the former increased more than the latter, suggesting vaccine refusal or other barriers remain an issue.

“Additional work to understand persistent reasons for low uptake and the potential effect of combining CDS with other behavioral economic and implementation science interventions would likely reduce the burden of influenza in a vulnerable population and provide lessons to improve vaccine coverage for other diseases, such as COVID-19,” the authors concluded.

Reference

Orenstein EW, ElSayed-Ali O, Kandaswamy S, et al. Evaluation of a clinical decision support strategy to increase seasonal influenza vaccination among hospitalized children before inpatient discharge. JAMA Netw Open. Published online July 1, 2021. doi:10.1001/jamanetworkopen.2021.17809