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NUDGE-FLU: Repeated electronic nudges improve flu vaccination rates in patients with HF

Presented By
Dr Niklas Dyrby Johansen, University of Copenhagen, Denmark
HFA 2023

Repeated electronic nudges and letters focusing on the cardiovascular benefits of flu vaccination are successful tools to motivate patients with heart failure (HF) to get vaccinated. The current pre-specified analysis of the NUDGE-FLU study also revealed alarmingly low vaccination rates in HF patients <65 years.

Influenza vaccination rates remain suboptimal among patients with HF despite known effectiveness and strong guideline recommendations. The recently published results of the Danish NUDGE-FLU (NCT05542004) trial revealed that select electronic letter-based nudges effectively increase influenza vaccination rates among adults ≥65 years of age [1]. In the 2022–2023 influenza season, all eligible Danish citizens ≥65 years (n=964,870) received, through the Danish governmental electronic letter system, either no letter or letter-based nudges based on 9 different behavioural strategies in a 9:1:1:1:1:1:1:1:1:1 randomisation. The primary endpoint of the trial was a receipt of influenza vaccination. The most successful motivators to get vaccinated were repeated electronic letters and letters emphasising the cardiovascular benefits of the vaccination.

Dr Niklas Dyrby Johansen (Herlev and Gentofte Hospital, University of Copenhagen, Denmark) presented the current prespecified analysis of the NUDGE-FLU trial, which explored whether the effectiveness of these electronic nudges also extends to patients with HF and whether they have unintended off-target effects [2]. The prespecified analysis also included patients <65 years (n=65,075).

In total, 33,109 patients with HF were identified. The overall vaccination rate in the HF population was 71.8%, but in HF patients <65 years of age only 44.6%. The likelihood of HF patients getting an influenza vaccination increased significantly with the number of guideline-directed medical therapy (GDMT) classes at baseline, from 75.2% in those with no GDMT medication to 86.5% in those with 4-5 GDMT classes (P<0.001).

As in the main study, repeated electronic letters with a reminder follow-up letter 14 days later and those focusing on the cardiovascular benefits were most successful in the HF subgroup. The effectiveness of both nudging strategies was consistent across all major cardiovascular disease subgroups. Independent of HF status and the number of GDMT classes, patients receiving the nudges were more likely to get a flu vaccination compared with those receiving no letters. Moreover, the nudges did not have a negative influence on the uptake of the total number of GDMT prescriptions filled.

“Our study showed that HF status did not modify the effectiveness of electronic behaviourally designed letters, although we did observe a trend towards attenuated effectiveness of the cardiovascular benefits nudges among those on low levels of GDMT,” Dr Johansen concluded.

    1. Johansen ND, et al. Lancet. 2023;401(10382):1103–1114.
    2. Johansen ND, et al. Electronic nudges to increase influenza vaccination uptake among patients with heart failure. A prespecified analysis of the NUDGE-FLU trial. Session Late breaking clinical trials: drugs and devices, Heart Failure 2023, 20–23 May, Prague, Czechia.


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