Electronic reminders improve flu vaccination rates among non-diabetics, but diabetic patients remain unresponsive. Tailored approaches, including integration into diabetes care, could offer a more effective solution for this vulnerable group.
Study: ‘Electronic Nudges to Increase Influenza Vaccination in Patients With Chronic Diseases.’ Image Credit: Shutterstock AI / Shutterstock.com
A recent study published in JAMA Network Open explores whether diabetic patients who were reminded through electronic messaging to get vaccinated against the flu had a higher uptake than patients without diabetes.
How does diabetes affect flu severity?
Patients with diabetes who are infected with the flu are at a greater risk of developing severe complications such as pneumonia, bronchitis, sinus infections, and ear infections. Therefore, annual flu vaccines are strongly recommended in this patient population, as vaccination has been shown to reduce the risk of death from all causes, particularly in patients with diabetes.
Despite these benefits, up to 33% of diabetic patients do not receive yearly flu shots. Some of the different reasons for this reduced uptake may include cognitive impairment, decline in functional level, previous bad experiences with the vaccine, accessibility issues, hesitancy linked to their medical condition, or vaccine hesitancy.
About the study
The current study was a secondary analysis of the Danish Nationwide Utilization of the Danish Government Electronic Letter System for Increasing Influenza Vaccine Uptake (NUDGE-FLU) randomized control trial (RCT). A total of 964,870 individuals who were at least 65 years old were included in the study, with a mean age of 73.8 years.
Denmark has among the highest vaccination rates in the world. Nevertheless, flu vaccine uptake is estimated at 62.4% of the 315,928 people with diabetes in Denmark.
Flu vaccine uptake among diabetes patients at least 65 years of age is 82.5%, as compared to only 40.7% of younger patients. Thus, it is crucial to target younger diabetics to increase vaccine uptake.
All study participants were randomly assigned to either usual care or one of nine different electronic letters designed to encourage them to get vaccinated against the flu. Nine controls were assigned every round, compared to one participant in each of the nine intervention groups, each receiving a different version of the electronic letter.
All letters were mailed in September and October 2022, with study participants monitored until January 1, 2023. Notably, none of the study participants were aware that the letters were part of an RCT.
Slight increase in flu vaccination rate
Among the study cohort, 12.8% had diabetes. The mean age was 74.1 years for diabetes patients, who were more likely to be older males and have cardiovascular disease or other chronic diseases affecting the kidneys or lungs or cancer.
About 82% of individuals with diabetes were vaccinated against the flu the previous season, compared to 76.9% of those without diabetes, which may be attributed to the earlier onset of the flu season that year. Among the current study cohort, 83.5% were vaccinated in the diabetes group, compared to 80.2% of those without diabetes, by the end of the follow-up period.
A small increase in flu vaccine uptake was observed among patients without diabetes who received letters as compared to usual care. A difference of 0.37 percentage points was observed between these groups at 80.4% and 80%, respectively.
The cardiovascular benefits letter and repeating the letter after two weeks were associated with an improved effect compared to usual care. The non-diabetes group gained one and 0.87 percentage points, respectively, with cardiovascular gains and repeated letters.
Comparatively, diabetic patients did not change their response to any of the letters. Reactance or fatigue to the letters may explain why diabetes patients resist advice to change their health behaviors. However, these effects were not observed with other health behaviors, including the use of glucagon-like peptide 1RA (GLP-1RA) agents.
Stratification by comorbidity showed that CVD, treatment with a GLP-1RA or sodium-glucose co-transporter 2 inhibitors (SGLT2i), and a longer duration of disease were associated with higher vaccine uptake during the follow-up period among those with diabetes. Thus, these patients may be more mindful of their care or have doctors who include other preventive strategies for cardiometabolic health, including vaccination.
Conclusions
The small increase in vaccination rates among patients without diabetes who received electronically generated letters designed to encourage uptake contrasts with the lack of effect observed among those with diabetes. This may indicate a somewhat higher effectiveness among those without diabetes.
Further studies are needed to understand whether letters specifically adapted for diabetes patients would have the same or a different effect on the diabetes subgroup.
Alternative and more targeted strategies, such as packaging vaccination as part of diabetes care, a multimodel approach with communication tailored specifically for persons with diabetes, or in-home vaccination, may be effective in this group and require further study.”
Journal reference:
- Lassen, M. C. H., Johansen, N. D., Vaduganathan, M., et al. (2024). ‘Electronic Nudges to Increase Influenza Vaccination in Patients With Chronic Diseases’. JAMA Network Open. doi:10.1001/jamanetworkopen.2023.47630.