Ankeet S Bhatt, Niklas Dyrby Johansen, Muthiah Vaduganathan, Daniel Modin, Manan Pareek, Safia Chatur, Brian L Claggett, Kira Hyldekær Janstrup, Carsten Schade Larsen, Lykke Larsen, Lothar Wiese, Michael Dalager-Pedersen, Erica L Dueger, Sandrine Samson, Matthew M Loiacono, Rebecca C Harris, Lars Køber, Scott D Solomon, Cyril Jean-Marie Martel, Pradeesh Sivapalan, Jens Ulrik Stæhr Jensen, Tor Biering-Sørensen
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引用次数: 0
摘要
重要性：急性心肌梗死（AMI）患者接种流感疫苗可减少重大心脏不良事件的发生，临床实践指南强烈推荐接种流感疫苗。我们需要有效的策略来提高这些高危患者的疫苗接种率：评估在 3 项全国范围内实施的随机临床试验 (RCT) 中，通过电子方式提供的行为指导是否能提高急性心肌梗死患者的流感疫苗接种率：全国范围内利用丹麦政府电子信件系统提高流感疫苗接种率（NUDGE-FLU）、全国范围内利用丹麦政府电子信件系统确认行为引导对提高老年人流感疫苗接种率的效果（NUDGE-FLU-2）以及全国范围内利用丹麦政府电子信件系统提高流感疫苗接种率（NUDGE-FLU-3）、和 "全国范围内利用丹麦政府电子信件系统提高慢性病成人流感疫苗接种率"（NUDGE-FLU-CHRONIC）是在丹麦2022年至2023年和2023年至2024年流感季节期间进行的研究。参与者被随机分配到常规护理或各种行为知情、电子递送、基于信件的劝导。在一项预设的参与者水平汇总荟萃分析中，考察了AMI状态对基于信件的劝导与常规护理效果的交互作用。采用二项回归模型估算汇总治疗效果，该模型具有身份链接、试验调整以及家庭和参与者层面的双向聚类 SE。使用 NUDGE-FLU-CHRONIC 中的限制性立方样条模型评估了作为连续变量的 AMI 复发率对治疗效果的影响：主要结果和测量指标：主要终点是流感疫苗接种率：在所有 3 项试验的 2 146 124 名随机参与者（平均 [SD] 年龄 71.1 [11.6] 岁；1 114 725 名女性 [51.9%]）中，59 458 人（2.8%）有 AMI 病史。与常规护理相比，接受任何提示函的有 AMI 病史和无 AMI 病史患者的疫苗接种率提高幅度相似（+1.81 vs +1.32 个百分点；与 AMI 状态交互作用的 P = .09）。一封强调疫苗接种对心血管益处的信件（即心血管增益框架）使有（与没有）急性心肌梗塞病史的患者的疫苗接种率有了更大的提高（+3.91 vs +2.03个百分点；与急性心肌梗塞状态的交互作用P = .002）。在急性心肌梗塞患者中，心血管增益框架信对上一季未接种疫苗的患者的益处更为明显（+13.7 vs +1.48个百分点；P为交互作用结论和相关性：在对丹麦公民进行的 3 项全国性 RCT 研究中，强调接种疫苗对心血管有益的信息提高了流感疫苗的接种率，在有急性心肌梗死病史的患者中观察到更大的益处。应考虑采用这种低成本、可扩展的实施策略来鼓励高危患者接种流感疫苗：试验注册：ClinicalTrials.gov Identifiers：NCT05542004、NCT06030726、NCT06030739。
Electronic Nudges and Influenza Vaccination Among Patients With a History of Myocardial Infarction: Insights From 3 Nationwide Randomized Clinical Trials.
Importance: Influenza vaccination in patients with acute myocardial infarction (AMI) reduces major adverse cardiac events and is strongly recommended in clinical practice guidelines. Effective strategies to improve vaccination are needed in these high-risk patients.
Objective: To evaluate whether electronically delivered behavioral nudges improve influenza vaccine uptake in patients with AMI across 3 nationwide implementation randomized clinical trials (RCTs).
Design, setting, and participants: Nationwide Utilization of Danish Government Electronic Letter System for Increasing Influenza Vaccine Uptake (NUDGE-FLU), Nationwide Utilization of Danish Government Electronic Letter System for Confirming the Effectiveness of Behavioral Nudges in Increasing Influenza Vaccine Uptake Among Older Adults (NUDGE-FLU-2), and Nationwide Utilization of Danish Government Electronic Letter System for Increasing Influenza Vaccine Uptake Among Adults With Chronic Disease (NUDGE-FLU-CHRONIC) were RCTs conducted during the 2022 to 2023 and 2023 to 2024 influenza seasons in Denmark. Participants were randomized to either usual care or various behaviorally informed, electronically delivered, letter-based nudges. In a prespecified participant-level pooled meta-analysis, interaction of AMI status on the effects of letter-based nudges vs usual care was examined. Pooled treatment effects were estimated using binomial regression models with identity link, adjustment for trial, and 2-way clustered SEs at the household and participant levels. Effect modification by recency of AMI as a continuous variable was assessed using restricted cubic spline modeling in NUDGE-FLU-CHRONIC.
Interventions: Behaviorally informed, electronically delivered, letter-based nudges or usual care.
Main outcome and measures: The primary end point was influenza vaccination receipt.
Results: Of 2 146 124 individual randomizations (mean [SD] age, 71.1 [11.6] years; 1 114 725 female [51.9%]) across all 3 trials, 59 458 (2.8%) had a history of AMI. Improvement in vaccine uptake was similar in patients with vs without a history of AMI who received any nudge letter compared with usual care (+1.81 vs +1.32 percentage points; P for interaction by AMI status = .09). A letter highlighting the cardiovascular benefits of vaccination (ie, cardiovascular-gain frame) resulted in larger improvements in vaccine uptake among patients with (vs without) a history of AMI (+3.91 vs +2.03 percentage points; P for interaction by AMI status = .002). Among patients with AMI, the benefits of the cardiovascular-gain frame letter were more pronounced in those not vaccinated in the prior season (+13.7 vs +1.48 percentage points; P for interaction <.001). Among younger participants with chronic disease, the cardiovascular-gain frame letter was particularly effective in patients with more recent AMI (P for interaction by continuous recency of AMI <.001).
Conclusions and relevance: Across 3 nationwide RCTs of Danish citizens, messaging emphasizing the cardiovascular benefits of vaccination improved influenza vaccination uptake, with greater benefits observed in patients with a history of AMI. This low-cost, scalable implementation strategy should be considered to encourage influenza vaccination in high-risk patients.
JAMA cardiologyMedicine-Cardiology and Cardiovascular Medicine
CiteScore
45.80
自引率
1.70%
发文量
264
期刊介绍：
JAMA Cardiology, an international peer-reviewed journal, serves as the premier publication for clinical investigators, clinicians, and trainees in cardiovascular medicine worldwide. As a member of the JAMA Network, it aligns with a consortium of peer-reviewed general medical and specialty publications.
Published online weekly, every Wednesday, and in 12 print/online issues annually, JAMA Cardiology attracts over 4.3 million annual article views and downloads. Research articles become freely accessible online 12 months post-publication without any author fees. Moreover, the online version is readily accessible to institutions in developing countries through the World Health Organization's HINARI program.
Positioned at the intersection of clinical investigation, actionable clinical science, and clinical practice, JAMA Cardiology prioritizes traditional and evolving cardiovascular medicine, alongside evidence-based health policy. It places particular emphasis on health equity, especially when grounded in original science, as a top editorial priority.
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