Evaluation of behavioral economic strategies to raise influenza vaccination rates across a health system: Results from a randomized clinical trial.

Influenza vaccination rates are low. Working with a large US health system, we evaluated three health system-wide interventions using the electronic health record's patient portal to improve influenza vaccination rates. We performed a two-arm RCT with a nested factorial design within the treatment arm, randomizing patients to usual-care control (no portal interventions) or to one or more portal interventions. We included all patients within this health system during the 2020-2021 influenza vaccination season, which overlapped with the COVID-19 pandemic. Through the patient portal, we simultaneously tested: pre-commitment messages (sent September 2020, asking patients to commit to a vaccination); monthly portal reminders (October - December 2020), direct appointment scheduling (patients could self-schedule influenza vaccination at multiple sites); and pre-appointment reminder messages (sent before scheduled primary care appointments, reminding patients about influenza vaccination). The main outcome measure was receipt of influenza vaccine (10/01/2020-03/31/2021). We randomized 213,773 patients (196,070 adults ≥18 years, 17,703 children). Influenza vaccination rates overall were low (39.0%). Vaccination rates for study arms did not differ: Control (38.9%), pre-commitment vs no pre-commitment (39.2%/38.9%), direct appointment scheduling yes/no (39.1%/39.1%), pre-appointment reminders yes/no (39.1%/39.1%); p > 0.017 for all comparisons (p value cut-off adjusted for multiple comparisons). After adjusting for age, gender, insurance, race, ethnicity, and prior influenza vaccination, none of the interventions increased vaccination rates. We conclude that patient portal interventions to remind patients to receive influenza vaccine during the COVID-19 pandemic did not raise influenza immunization rates. More intensive or tailored interventions are needed beyond portal innovations to increase influenza vaccination.

Behavioral and Social Drivers of COVID-19 Vaccination in the United States, August-November 2021.

INTRODUCTION: COVID-19 vaccines are safe, effective, and widely available, but many adults in the U.S. have not been vaccinated for COVID-19. This study examined the associations between behavioral and social drivers of vaccination with COVID-19 vaccine uptake in the U.S. adults and their prevalence by region. METHODS: A nationally representative sample of U.S. adults participated in a cross-sectional telephone survey in August-November 2021; the analysis was conducted in January 2022. Survey questions assessed self-reported COVID-19 vaccine initiation, demographics, and behavioral and social drivers of vaccination. RESULTS: Among the 255,763 respondents, 76% received their first dose of COVID-19 vaccine. Vaccine uptake was higher among respondents aged ≥75 years (94%), females (78%), and Asian non-Hispanic people (94%). The drivers of vaccination most strongly associated with uptake included higher anticipated regret from nonvaccination, risk perception, and confidence in vaccine safety and importance, followed by work- or school-related vaccination requirements, social norms, and provider recommendation (all p<0.05). The direction of association with uptake varied by reported level of difficulty in accessing vaccines. The prevalence of all of these behavioral and social drivers of vaccination was highest in the Northeast region and lowest in the Midwest and South. CONCLUSIONS: This nationally representative survey found that COVID-19 vaccine uptake was most strongly associated with greater anticipated regret, risk perception, and confidence in vaccine safety and importance, followed by vaccination requirements and social norms. Interventions that leverage these social and behavioral drivers of vaccination have the potential to increase COVID-19 vaccine uptake and could be considered for other vaccine introductions.

The Association of Broadband Internet Access and Telemedicine Utilization in rural Western Tennessee: an observational study.

BACKGROUND: Broadband access has been highlighted as a national policy priority to improve access to care in rural communities. OBJECTIVE: To determine whether broadband internet availability was associated with telemedicine adoption among a rural patient population in western Tennessee. METHODS: Observational study using electronic medical record data from March 13th, 2019 to March 13th, 2021. Multivariable logistic regression incorporating individual-level characteristics with broadband availability, income, educational attainment, and primary care physician supply at the zip code level, and rural status as determined at the county level. SETTING: Single health system in western Tennessee. PARTICIPANTS: Adult patients with one or more in-person or remote encounter in a health system in western Tennessee and residing in western Tennessee between March 13th, 2019 and March 13th, 2021 (N = 54,688). OUTCOME MEASURES: Completion of one or more video encounters in the year following March 13th, 2020 (N = 3199; 7%). Our primary characteristic of interest was the proportion of residents in each zip code with access to the internet meeting the Federal Communications Commission definition of broadband access, adjusting for age, gender, race, income, educational attainment, insurance type, rural status, and primary care provider supply. RESULTS: Patients in a rural western Tennessee health system were predominantly white (79%), residing in rural zip codes (73%) with median household incomes ($52,085) less than state and national averages. Patients residing in a zip code where there is 80 to 100% broadband access compared to 0 to 20% were more likely in the year following March 13th, 2020 to have completed both telemedicine and in-person visits ([OR; 95% CI] 1.57; 1.29, 1.94), completed only telemedicine visits (2.26; 1.71, 2.97), less likely to have only completed in-person visits (0.81; 0.74, 0.89), but no more or less likely to have accessed no care (1.07; 0.97, 1.18). DISCUSSION: The availability of broadband internet was shown to be one of many factors associated with the utilization of telemedicine for a rural, working-class community after March 13th, 2020. CONCLUSIONS: Access to broadband internet is a determinant of access to telemedicine for patients in rural communities and should be a priority for policymakers interested in improving health and access to care for rural patients.

Examining the role of COVID-19 testing availability on intention to isolate: A Randomized hypothetical scenario.

BACKGROUND: Little information exists on how COVID-19 testing influences intentions to engage in risky behavior. Understanding the behavioral effects of diagnostic testing may highlight the role of adequate testing on controlling viral transmission. In order to evaluate these effects, simulated scenarios were conducted evaluating participant intentions to self-isolate based on COVID-19 diagnostic testing availability and results. METHODS: Participants from the United States were recruited through an online survey platform (Amazon Mechanical Turk) and randomized to one of three hypothetical scenarios. Each scenario asked participants to imagine having symptoms consistent with COVID-19 along with a clinical diagnosis from their physician. However, scenarios differed in either testing availability (testing available v. unavailable) or testing result (positive v. negative test). The primary outcome was intention to engage in high-risk COVID-19 behaviors, measured using an 11-item mean score (range 1-7) that was pre-registered prior to data collection. Multi-variable linear regression was used to compare the mean composite scores between conditions. The randomized survey was conducted between July 23rd to July 29th, 2020. RESULTS: A total of 1400 participants were recruited through a national, online, opt-in survey. Out of 1194 respondents (41.6% male, 58.4% female) with a median age of 38.5 years, participants who had no testing available in their clinical scenario showed significantly greater intentions to engage in behavior facilitating COVID-19 transmission compared to those who received a positive confirmatory test result scenario (mean absolute difference (SE): 0.14 (0.06), P = 0.016), equating to an 11.1% increase in mean score risky behavior intentions. Intention to engage in behaviors that can spread COVID-19 were also positively associated with male gender, poor health status, and Republican party affiliation. CONCLUSION: Testing availability appears to play an independent role in influencing behaviors facilitating COVID-19 transmission. Such findings shed light on the possible negative externalities of testing unavailability. TRIAL REGISTRATION: Effect of Availability of COVID-19 Testing on Choice to Isolate and Socially Distance, NCT04459520, https://clinicaltrials.gov/ct2/show/NCT04459520.

Racial Disparities in Potentially Avoidable Hospitalizations During the COVID-19 Pandemic

IMPACT: These findings identify a new way in which the COVID-19 pandemic exacerbates racial/ethnic health disparities, and will thus direct future research to explore potentially avoidable hospitalizations, as well as direct health policy to improve the value of this specific aspect of care without further widening the disparity. OBJECTIVES/GOALS: Racial and ethnic disparities in potentially avoidable hospitalizations predate COVID-19. In order to identify and address healthcare disparities exacerbated by the pandemic, we examined whether and to what extent the pandemic affected numbers of potentially avoidable hospitalizations by race and ethnicity. METHODS/STUDY POPULATION: This single-center pre-post study of 904 patients at UCLA included all patients admitted to an internal medicine service for an ambulatory care sensitive condition (ACSC) between March-August of 2020 (post) and March-August of 2019 (pre). We measured the change in number of potentially avoidable hospitalizations (defined per the Agency for Healthcare Research and Quality guidelines) stratified by race and ethnicity. We calculated 95% CIs for the number of potentially avoidable hospitalizations using a cluster bootstrap procedure, clustering at the level of patients. We inverted the bootstrap CIs to calculate p-values for overall changes within racial/ethnic groups as well as differential changes between groups. Patients with missing or unspecified racial/ethnic data were excluded (n=1,003;7.8%). RESULTS/ANTICIPATED RESULTS: Between March 1 and August 31, 2020, 347 out of 4,838 hospitalizations (7.2%) were potentially avoidable, compared to 557 out of 6,248 (8.9%) during the same 6-months of 2019. Reductions in potentially avoidable hospitalizations among Non-Hispanic White (-50.3%;95% CI, -60.9 - -41.2;p<0.001) and Latinx (-32.3%;95% CI, -59.8 - -12.2%, p<0.001) patients were statistically significant, whereas reductions among African American (-8.0%;95% CI, -39.9 - +16.2) and Asian (-16.1%;95% CI, -75.7 - +20.4) patients were not statistically different from 0%. The relative differences in magnitudes of reduction were only statistically significant between African American and non-Hispanic White patients (-50.3% v. -8.0%;95% CI as above;p=0.015). DISCUSSION/SIGNIFICANCE OF FINDINGS: Racial disparities in potentially avoidable hospitalizations increased during the COVID-19 pandemic at this large urban health system. Healthcare leaders, researchers, and policy makers should focus on efforts to prevent a post-pandemic resurgence of low-value hospitalizations in ways that do not further widen disparities.

School-Age Children's Wellbeing and School-Related Needs During the COVID-19 Pandemic.

BACKGROUND AND OBJECTIVES: The COVID-19 pandemic and related school closures may have disrupted school-related supports and services important to children's wellbeing. However, we lack national data about US children's wellbeing and family priorities for school-related services. We sought to determine 1) children's social-emotional wellbeing and 2) needs and priorities for school-based services in the 2021-2022 school year among a US sample of parents of school-aged children. METHODS: In June 2021, we surveyed 1504 parents of children enrolling in grades K-12 in the 2021-2022 school year participating in the Understanding America Study, a nationally representative probability-based Internet panel of families completing regular internet-based surveys (Response rate to this survey was 79.2%). Parents completed the Strengths and Difficulties Questionnaire and reported their needs for school-related services regarding "support getting healthcare", "mental wellness support", "food, housing, legal or transportation support", and "learning supports and enrichment." Weighted regressions examined associations among wellbeing, needs, and sociodemographic characteristics. RESULTS: Approximately one-quarter of children had deficits in hyperactivity (26.1%), one-third in peer problems (32.6%), and 40% in prosocial areas. Most parents (83.5%) reported a school-related need, with 77% reporting learning supports and enrichment needs and 57% reporting mental wellness needs. The highest priority needs were for tutoring, socialization, increased instructional time, coping with stress, and physical activity. CONCLUSIONS: US school children have high social-emotional and school-related needs. Investments in schools are urgently needed, particularly for learning supports and mental wellness, to meet the high demand for services and parents' priorities to support child health and wellbeing.

The Impact of Telemedicine on Quality of Care for Patients with Diabetes After March 2020.

BACKGROUND: The impact of telemedicine on ambulatory care quality is a key question for policymakers as they navigate payment reform for remote care. OBJECTIVE: To evaluate whether utilizing telemedicine in the first 9 months of the COVID-19 pandemic impacted performance on a diabetes quality of care measure for patients at a large academic medical center. We hypothesized care quality would reduce less among telemedicine users. DESIGN: Quasi-experimental design using binomial logistic regression. Covariates included age, gender, race, ethnicity, type of insurance, hierarchical condition category score, primary language at the individual level, and zip code-level income. PARTICIPANTS: All adult patients younger than 75 years of age diagnosed with type 2 diabetes mellitus (N = 16,588) as of 3/19/2020 at a single academic health center. INTERVENTIONS: Completion of one or more telemedicine encounters with an institutional primary care physician or endocrinologist between 3/19/2020 and 12/19/2020. MAIN MEASURES: The components met in a five-item composite measure of diabetes quality of care, as of patients' last clinical encounter. Items were (1) systolic blood pressure less than 140 mmHg, (2) hemoglobin A1c less than 8.0%, (3) using a statin and (4) aspirin, and (5) tobacco non-use. KEY RESULTS: From the pre- to post-period, the probability of meeting any given component of the composite measure for patients only utilizing in-person care was 21% lower (OR, 95% CI 0.79; 0.76, 0.81) and for the telemedicine users 2% lower (OR 0.98; 0.85, 1.13). There was an increased likelihood of meeting any given component among telemedicine users compared to in-person care alone (OR 1.25; 1.08, 1.44). CONCLUSIONS: Patients with diabetes utilizing telemedicine performed similarly on a composite measure of diabetes care quality compared to before the pandemic. Those not utilizing telemedicine had reductions. Telemedicine use maintained quality of care for patients with diabetes during the first 9 months of the COVID-19 pandemic.

Impact of COVID-19 on Primary Care Quality Measures in an Academic Integrated Health System.

BACKGROUND: Access to primary care was hindered by the coronavirus disease 2019 (COVID-19) pandemic. OBJECTIVE: Evaluate changes in health screening rates before and during the pandemic. DESIGN: Retrospective analysis of health maintenance and disease management screening rates among primary care patients before and during the pandemic. PARTICIPANTS: Over 150,000 patients of a large, academic health system. MAIN MEASURES: Six quality measures were analyzed: colon cancer, breast cancer, cervical cancer, diabetes Hgb A1C, diabetes eye, and diabetes nephropathy monitoring. Based on US Preventative Services Task Force screening guidelines, we determined which patients were due for at least one of the quality measures. We tracked completion rates during three time periods: pre-pandemic (January 1-March 3, 2020), stay-at-home (March 4-May 8, 2020), and phased reopening (May 9-July 8, 2020). Differences in quality measure completion rates were evaluated using mixed-effects logistic regression models. KEY RESULTS: Compared to pre-pandemic rates, completion of all health screenings declined during the stay-at-home period: mammograms (OR: 0.34; 95% CI: 0.31-0.37), cervical cancer (OR: 0.83; 95% CI: 0.76-0.91), colorectal cancer (OR: 0.25; 95% CI: 0.23-0.28), diabetes eye (OR: 0.34; 95% CI: 0.29-0.41), diabetes Hgb A1c (OR: 0.41; 95% CI: 0.37-0.46), and diabetes nephropathy (OR: 0.46, 95% CI: 0.41-0.53). During phased reopening, completion of all quality measures increased compared to the stay-at-home period, except for cervical cancer screening (OR: 0.83; 95% CI: 0.76-0.92). There was a persistent reduction in completion of all quality measures, except for diabetic nephropathy monitoring (OR: 0.99; 95% CI: 0.89-1.09), during phased reopening compared to pre-pandemic. CONCLUSIONS: Healthcare screening rates were reduced during the early part of the COVID-19 pandemic and did not fully recover to pre-pandemic rates by July 2020. Future research should aim to clarify the long-term impacts of delayed health screenings. New interventions should be considered for expanding remote preventative health services.

Influence of Perceived Adolescent Vaccination Desire on Parent Decision for Adolescent COVID-19 Vaccination.

PURPOSE: The purpose of this study was to assess the influence of adolescents' desire for COVID-19 vaccination on their parents' vaccination decision for their adolescent. METHODS: We surveyed an internet-based panel of 1,051 parents of 1,519 adolescents aged 11-18 years from February to March 2021 about their adolescent's desire for COVID-19 vaccination and whether they consider this desire in their vaccination decision for the adolescent. We used multivariable Poisson regression to assess associations with parent-stated likelihood of adolescent vaccination. RESULTS: A total of 58.3% of parents reported that they and their adolescents had the same vaccination desire; similarly, 58.3% considered their adolescent's desire in their vaccination decision. These latter parents were more likely to vaccinate their adolescent than parents who did not consider their adolescent's desire (adjusted risk ratio = 1.25 [95% confidence interval = 1.05-1.50]). DISCUSSION: Most parents considered their adolescent's desire for COVID-19 vaccination. These parents were more likely to state that they will have their adolescent receive a COVID-19 vaccine.

Behavioural nudges increase COVID-19 vaccinations.

Enhancing vaccine uptake is a critical public health challenge1. Overcoming vaccine hesitancy2,3 and failure to follow through on vaccination intentions3 requires effective communication strategies3,4. Here we present two sequential randomized controlled trials to test the effect of behavioural interventions on the uptake of COVID-19 vaccines. We designed text-based reminders that make vaccination salient and easy, and delivered them to participants drawn from a healthcare system one day (first randomized controlled trial) (n = 93,354 participants; clinicaltrials number NCT04800965) and eight days (second randomized controlled trial) (n = 67,092 individuals; clinicaltrials number NCT04801524) after they received a notification of vaccine eligibility. The first reminder boosted appointment and vaccination rates within the healthcare system by 6.07 (84%) and 3.57 (26%) percentage points, respectively; the second reminder increased those outcomes by 1.65 and 1.06 percentage points, respectively. The first reminder had a greater effect when it was designed to make participants feel ownership of the vaccine dose. However, we found no evidence that combining the first reminder with a video-based information intervention designed to address vaccine hesitancy heightened its effect. We performed online studies (n = 3,181 participants) to examine vaccination intentions, which revealed patterns that diverged from those of the first randomized controlled trial; this underscores the importance of pilot-testing interventions in the field. Our findings inform the design of behavioural nudges for promoting health decisions5, and highlight the value of making vaccination easy and inducing feelings of ownership over vaccines.

Parents' Intentions and Perceptions About COVID-19 Vaccination for Their Children: Results From a National Survey.

OBJECTIVES: Assess the degree to which US parents are likely to have their children get coronavirus disease 2019 (COVID-19) vaccines and identify parental concerns about the vaccines. METHODS: In February 2021 to March 2021, we surveyed parent members of a nationally representative probability-based Internet panel of ∼9000 adults regarding their intent to have their children receive a COVID-19 vaccination, perceptions of COVID-19 vaccines for children, and trust in sources of information about COVID-19 vaccines for children. We used descriptive and multivariate analyses to evaluate parent-stated likelihood of having their children get a COVID-19 vaccine and to assess the association between likelihood of child COVID-19 vaccination and child age, parent demographics, and parental perceptions about COVID-19 vaccines. RESULTS: Altogether, 1745 parents responded (87% of eligible parents, 3759 children). Likelihood of child COVID-19 vaccination was as follows: very likely (28%), somewhat likely (18%), somewhat unlikely (9%), very unlikely (33%), and unsure (12%). The stated likelihood of child vaccination was greater among parents of older children (P < .001) as well as among parents who had a bachelor's degree or higher education (P < .001), had already received or were likely to receive a COVID-19 vaccine (P < .001), or had Democratic affiliation (P < .001); variations existed by race and ethnicity (P = .04). Parental concerns centered around vaccine safety and side effects. A key trusted source of information about COVID-19 vaccines for children was the child's doctor. CONCLUSIONS: Less than one-half of US participants report that they are likely to have their child receive a COVID-19 vaccine. Pediatric health care providers have a major role in promoting and giving COVID-19 vaccination for children.

The role of trust in the likelihood of receiving a COVID-19 vaccine: Results from a national survey.

High acceptance of coronavirus disease 2019 (COVID-19) vaccines is instrumental to ending the pandemic. Vaccine acceptance by subgroups of the population depends on their trust in COVID-19 vaccines. We surveyed a probability-based internet panel of 7832 adults from December 23, 2020-January 19, 2021 about their likelihood of getting a COVID-19 vaccine and the following domains of trust: an individual's generalized trust, trust in COVID-19 vaccine's efficacy and safety, trust in the governmental approval process and general vaccine development process for COVID-19 vaccines, trust in their physician about COVID-19, and trust in other sources about COVID-19. We included identified at-risk subgroups: healthcare workers, older adults (65-74-year-olds and ≥ 75-year-olds), frontline essential workers, other essential workers, and individuals with high-risk chronic conditions. Of 5979 respondents, only 57.4% said they were very likely or somewhat likely to get a COVID-19 vaccine. More hesitant respondents (p < 0.05) included: women, young adults (18-49 years), Blacks, individuals with lower education, those with lower income, and individuals without high-risk chronic conditions. Lack of trust in the vaccine approval and development processes explained most of the demographic variation in stated vaccination likelihood, while other domains of trust explained less variation. We conclude that hesitancy for COVID-19 vaccines is high overall and among at-risk subgroups, and hesitancy is strongly tied to trust in the vaccine approval and development processes. Building trust is critical to ending the pandemic.

Likelihood of COVID-19 vaccination by subgroups across the US: post-election trends and disparities.

The coronavirus disease 2019 (COVID-19) pandemic has disproportionately impacted older individuals, those with lower educational attainment, and Black and Hispanic populations, yet vaccine hesitancy remains prevalent. Because widespread uptake of COVID-19 vaccines is critical to end the pandemic, addressing vaccine hesitancy is an important public health priority. Between April 1, 2020 and March 16, 2021, we have repeatedly surveyed a nationally representative online panel of adults and have tracked their stated likelihood of getting COVID-19 vaccinations. We present new evidence that in recent months disparities in self-reported likelihood of COVID-19 vaccination have narrowed by race/ethnicity, with an increasing proportion of Black individuals and Hispanic individuals indicating that they are likely to get a vaccine. At the same time, younger adults have progressively become less likely than older adults to state they will get a COVID-19 vaccine. Most vaccine-hesitant individuals are concerned about both vaccine efficacy and safety and do not trust the vaccine development or vaccine approval process. We conclude that outreach efforts to minority populations may be achieving their objectives in raising confidence in COVID-19 vaccines, but special outreach efforts are needed to address both vaccine hesitancy among younger adults and mistrust in the vaccine development and approval process.

Racial Disparities in Potentially Avoidable Hospitalizations During the COVID-19 Pandemic.

INTRODUCTION: Potentially avoidable hospitalizations are disproportionately experienced by racial and ethnic minorities and expose these groups to unnecessary iatrogenic harm (including the risk of nosocomial COVID-19) and undue financial burden. In working toward an overarching goal of eliminating racial and ethnic health disparities, it is important to understand whether and to what extent potentially avoidable hospitalizations have changed by race and ethnicity during the COVID-19 pandemic. METHODS: This single-center pre-post study included patients admitted to any UCLA Health hospital for an ambulatory care-sensitive condition between March-August 2019 (prepandemic period) and March-August 2020 (postpandemic period). Investigators measured the change in the number of potentially avoidable hospitalizations (defined per the Agency for Healthcare Research and Quality guidelines) stratified by race and ethnicity and calculated the 95% CIs for these hospitalizations using a cluster bootstrap procedure. RESULTS: Between March 1, 2020 and August 31, 2020, 347 of 4,838 hospitalizations (7.2%) were potentially avoidable, compared with 557 of 6,248 (8.9%) during the same 6-month period in 2019. Potentially avoidable hospitalizations decreased by 50.3% (95% CI=41.2, 60.9) among non-Hispanic Whites but only by 8.0% (95% CI= -16.2, 39.9) among African Americans (50.3% vs 8.0%, p=0.015). CONCLUSIONS: Racial disparities in potentially avoidable hospitalizations increased during the COVID-19 pandemic at a large urban health system. Given that the prepandemic rates of potentially avoidable hospitalizations were already higher among racial and ethnic minorities, especially among African Americans, this finding should cause alarm and lead to further exploration of the complex factors contributing to these disparities.