The Best Flu Prevention Might Be Behavioral Economics

April 20, 2018 Atul Nakhasi

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Alongside popular misconceptions that healthy people do not need the flu shot and myths about the harmful side effects of the vaccine, numerous studies have shown that one of the biggest reasons people don’t get vaccinated is that a physician never recommends it. (Eighty percent of patients say they would be more likely to get a vaccination if a health care provider recommended it.)

How can we get more care providers to recommend vaccinations? Luckily, there’s a cheap, effective way: “nudging” them to do so by making subtle changes to the context in which they make decisions. Flu vaccinations are a case in point.

Ultimately, the flu could end up infecting more than 30 million Americans this season (October 2017 through April 2018), resulting in more than 50,000 deaths across all age groups, $11.6 billion in health care costs, and 111 million lost workdays.

Although the vaccine’s effectiveness appears to have been lower than usual this season, it’s still easily our best bet to save lives. Unfortunately, it doesn’t matter how good of a vaccine we create if most people don’t get vaccinated. Over the last decade, vaccination rates of the U.S. population have consistently fallen below 50%. This season appears to be no different. According to the U.S. Centers for Disease Control and Prevention (CDC), less than 40% of children and adults were vaccinated at the start of this flu season. And tragically, of the more than 150 children who have died, only an estimated 20% were vaccinated.

Nudges could play a major role in addressing this problem. One of the best examples of a successful nudge was reported last year by University of Pennsylvania researchers who, with a simple tweak in the electronic medical record, increased vaccination rates by almost 40% relative to clinics that did not receive the tech change. The intervention was devastatingly simple: When doctors first logged in to a patient chart, they were prompted to either “accept” or “cancel” an order for the flu shot.

A complementary approach for nudging doctors to vaccinate their patients is to engage their competitive instincts. For instance, a recent study coauthored by one of us (Craig) drastically reduced the rate at which doctors unnecessarily prescribed antibiotics by merely sending them a monthly email. These emails told doctors how often they had prescribed antibiotics unnecessarily, compared with “top performers” in their region.

This simple intervention resulted in a stunning 71% decline in inappropriate antibiotic prescriptions — much larger than the decline observed in clinics that did not use this intervention — and this effect persisted even a year after the emails stopped coming. Now, what if we showed doctors how their flu shot rates stack up against those of their colleagues? Perhaps we’d observe a similarly dramatic improvement in vaccination rates.

Of course, getting doctors to recommend the flu shot only works if patients come to the clinic. Fortunately, we have nudges that can help get them to do so. In a recent study, faculty and staff at Rutgers University were sent an email automatically scheduling them for their flu shot on a specific day, time, and location, with the option to opt out. This automatic enrollment procedure increased vaccination rates by 36%, as compared with faculty and staff who were sent an email giving them the opportunity to opt in by scheduling their own appointments online.

Another study took a gentler approach by helping people remember to follow through on their intentions to get a flu shot. Employees at a large utility firm in the Midwestern United States were sent an informational mailer with available dates and times for workplace vaccination clinics. However, one group received a different mailer that prompted them to write down their chosen date and time to get vaccinated. Impressively, this subtle extra step resulted in a 12% relative increase in flu shot vaccinations, compared with the information-only mailer.

Nudges like active choice, peer comparison, planning prompts, and automatic enrollment leverage the behavioral insight that our cognitive resources are constrained. Thus, making flu shots more salient, socially desired, automatic, and concretely planned can substantially increase the number of people who get them. These nudges have already proven effective in clinical trials, so why not test and implement them across a wider range of health care settings in the service of public health?

Indeed, the CDC estimates that if vaccination rates improved by just 5% in the United States, we would avoid 483,000 influenza illnesses, 232,000 medical visits, and 6,950 hospitalizations — a staggering potential return on a set of low-cost investments in nudging.

It’s time we apply nudge therapy more broadly. It may ultimately be one of our best methods for preventing the next flu season from being as deadly as this one.

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