Electronically Delivered Nudges to Increase Influenza Vaccination Uptake in Older Adults With Diabetes
Authors: Lassen Mats C. Højbjerg , Johansen Niklas Dyrby , Vaduganathan Muthiah , Bhatt Ankeet S. , Lee Simin Gharib , Modin Daniel , Claggett Brian L. , Dueger Erica L. , Samson Sandrine I. , Loiacono Matthew M. , Fralick Michael , Køber Lars , Solomon Scott D. , Sivapalan Pradeesh , Jensen Jens Ulrik Stæhr , Martel Cyril Jean-Marie , Krause Tyra Grove , Biering-Sørensen Tor 
Published: December 2023

ImportanceInfluenza vaccination is associated with a reduced risk of mortality in patients with diabetes, but vaccination rates remain suboptimal.ObjectiveTo assess the effect of electronic nudges on influenza vaccination uptake according to diabetes status.Design, Setting, and ParticipantsThe NUDGE-FLU (Nationwide Utilization of Danish Government Electronic Letter System for Increasing Influenza Vaccine Uptake) trial was a nationwide clinical trial of Danish citizens 65 years or older that randomized participants at the household level to usual care or 9 different electronic nudge letters during the 2022 to 2023 influenza season. End of follow-up was January 1, 2023. This secondary analysis of the NUDGE-FLU trial was performed from May to July 2023.InterventionNine different electronic nudge letters designed to boost influenza vaccination were sent in September to October 2022. Effect modification by diabetes status was assessed in a pooled analysis of all intervention arms vs usual care and for individual letters.Main Outcomes and MeasuresThe primary end point was receipt of a seasonal influenza vaccine.ResultsThe trial included 964 870 participants (51.5% female; mean [SD] age, 73.8 [6.3] years); 123 974 had diabetes. During follow-up, 83.5% with diabetes vs 80.2% without diabetes received a vaccine (P &amp;lt; .001). In the pooled analysis, nudges improved vaccination uptake in participants without diabetes (80.4% vs 80.0%; difference, 0.37 percentage points; 99.55% CI, 0.08 to 0.66), whereas there was no evidence of effect in those with diabetes (83.4% vs 83.6%; difference, −0.19 percentage points; 99.55% CI, −0.89 to 0.51) (P = .02 for interaction). In the main results of NUDGE-FLU, 2 of the 9 behaviorally designed letters (cardiovascular benefits letter and a repeated letter) significantly increased uptake of influenza vaccination vs usual care; these benefits similarly appeared attenuated in participants with diabetes (cardiovascular gain letter: 83.7% vs 83.6%; difference, 0.04 percentage points; 99.55% CI, −1.52 to 1.60; repeated letter: 83.5% vs 83.6%; difference, −0.15 percentage points; 99.55% CI, −1.71 to 1.41) vs those without diabetes (cardiovascular gain letter: 81.1% vs 80.0%; difference, 1.06 percentage points; 99.55% CI, 0.42 to 1.70; repeated letter: 80.9% vs 80.0%; difference, 0.87 percentage points; 99.55% CI, 0.22 to 1.52) (P = .07 for interaction).Conclusions and RelevanceIn this exploratory subgroup analysis, electronic nudges improved influenza vaccination uptake in persons without diabetes, whereas there was no evidence of an effect in persons with diabetes. Trials are needed to investigate the effect of digital nudges specifically tailored to individuals with diabetes.Trial RegistrationClinicalTrials.gov Identifier: NCT05542004