Nudges to Clinicians and Patients for Influenza Vaccines During Visits: The BE IMMUNE Randomized Clinical Trial.

Importance: Annual influenza vaccination reduces burden of disease for older adults, but rates remain suboptimal. Objective: To evaluate if a multicomponent nudge intervention to clinicians and patients increases vaccine completion during primary care visits. Design, Setting, and Participants: The pragmatic BE IMMUNE (Behavioral Economics to Improve and Motivate Vaccination in Primary Care Using Nudges Through the Electronic Health Record) randomized clinical trial took place across 48 primary care clinics through Penn Medicine (Philadelphia, Pennsylvania) and UW Medicine (Seattle, Washington). Patients 50 years and older who were scheduled for a primary care visit and were due for an influenza vaccine within the active intervention period (September 25, 2023, to February 20, 2024) were included. Interventions: Clinics were randomized in a 2:1 ratio to receive (1) previsit text message reminders to patients, (2) an automatic pended order, and (3) monthly comparisons of panel vaccination rates to peer clinicians, or usual care. Additionally, patients in the intervention arm who were identified as high risk for noncompletion were individually randomized 1:1 to receive previsit bidirectional text messaging or a standard text reminder. Main Outcomes and Measures: The primary outcome was influenza vaccination during the visit. Results: Among 80 039 patients across 47 clinics, the mean (SD) age was 65.8 (10.2) years, and 56.0% were female while 43.6% were male. The adjusted odds ratio (AOR) for vaccine completion comparing intervention to usual care was 1.28 (97.5% CI, 1.13-1.45; adjusted P < .001). The probability of completion in the intervention was 31.4% compared to 26.4% under usual care, with a risk difference of 5.1 percentage points (97.5% CI, 2.6-7.5 percentage points; adjusted P < .001). The adjusted odds ratio comparing bidirectional vs standard text messaging among high-risk patients was not statistically significant (1.00; 97.5% CI, 0.98-1.02; adjusted P = .92). Conclusions and Relevance: In this randomized clinical trial, the multicomponent nudge resulted in a statistically significant higher rate of influenza vaccination during the primary care visit, but the bidirectional text messaging did not further increase vaccination in the high-risk group. Trial Registration: ClinicalTrials.gov Identifier: NCT06057727.