TOPLINE:

Implementing a multicomponent nudge program for patients and clinicians was associated with increased rates of influenza vaccination during primary care visits — translating to more than 2600 additional vaccinations. Interactive text messages, through which high-risk patients could ask questions, did not improve vaccine uptake further.

METHODOLOGY:

• This pragmatic cluster-randomized trial assessed whether an intervention using a multicomponent nudge program for patients and clinicians increased the rate of influenza vaccination during primary care visits.
• The intervention included text reminders sent 3 and 1 days before the visit, a default flu shot order in the electronic health record for clinicians to sign, and monthly emails to clinicians regarding peer comparison. Interactive text messages were sent to a subset of high‑risk patients to which they could reply and get quick automated answers.
• Researchers enrolled 80,039 adults aged 50 years or older (mean age, 65.8 years; 56.0% women) across 47 clinics in Philadelphia and Seattle between 2023 and 2024.
• In a randomized manner, 31 clinics were assigned to the intervention and 16 to usual care. Usual care consisted of sending early‑season reminders on the patient portal about vaccinations and standard documentation in the electronic health record.
• The primary outcome was influenza vaccination during the visit. The secondary outcome was vaccination within 3 months of the visit; whether a vaccine was ordered at the visit was also determined.

TAKEAWAY:

• Patients at intervention clinics were more likely to receive influenza vaccines during the visit than those at usual care clinics (31.4% vs 26.4%; adjusted odds ratio [aOR], 1.28; adjusted P < .001).
• Within 3 months of the visit, 37.5% of patients who visited intervention clinics were likely to receive the influenza vaccine compared with 33.8% of those who visited usual care clinics (aOR, 1.18; P = .003).
• Clinicians at intervention clinics were more likely to sign influenza vaccine orders than those at usual care clinics (34.7% vs 27.6%; aOR, 1.40; P < .001).
• Among high-risk patients, the use of interactive two-way texts vs standard texts was not associated with higher vaccination rates.

IN PRACTICE:

“We showed that multilevel behavioral interventions can be scalable with available technologies and effective at improving preventive health with minimal additional resources,” the researchers wrote.

SOURCE:

This study was led by Shivan J. Mehta, MD, MBA, MSHP, of the University of Pennsylvania in Philadelphia. It was published online on January 5, 2026, in JAMA Internal Medicine.

LIMITATIONS:

The researchers could not determine which component of the nudge program worked best. Records for shots given outside the systems were incomplete; about 24% had already been vaccinated elsewhere but were still included. 

DISCLOSURES:

The study received funding from the National Institutes of Health’s National Institute on Aging. One author reported receiving personal fees from Guardant Health. Another reported receiving personal fees, payments, support to attend meetings from, and having other financial and nonfinancial ties with multiple organizations including Analysis Group, Catholic Health Services, and Navvis Healthcare.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.