Ankeet Bhatt, MD, is a research scientist at Kaiser Permanente Northern California and an associate physician at Kaiser San Francisco Medical Center.

Ankeet Bhatt, MD, MBA

HCPLive interview with Ankeet Bhatt, MD, MBA, ScM, on NUDGE-FLU data from AHA 2024

Ankeet Bhatt, MD, MBA, ScM, on NUDGE-FLU data from AHA 2024

Use of emails highlighting the cardiovascular benefits of influenza vaccination could significantly increase the rate of vaccine uptake among adults with a history of 

, according to a new analysis from the NUDGE-FLU program.

American Heart Association (AHA) Annual Scientific Sessions 2024

, results of the analysis demonstrate messaging highlighting the potential cardiovascular benefits of flu shots led to a 3.9% increase in vaccination among people with a history of heart attack compared to a 2% increase for those with no heart attack history, with results also providing insights into individual-level patient factors influencing rate of vaccine uptake.

“The data suggest that cardiovascular-focused messaging was effective across a broad population; this strategy should be considered as part of a suite of strategies to improve cardiovascular prevention and encourage flu vaccination among high-risk patients, including those with a history of heart attack,” said principal investigator Ankeet Bhatt, MD, MBA, SCM, a cardiologist at Kaiser Permanente San Francisco Medical Center, a research scientist at the Kaiser Permanente Northern California Division of Research, and an adjunct professor at the Stanford University School of Medicine. “Notably, this strategy alone did not close all implementation gaps for flu vaccination. Other strategies in addition to messaging-based intervention need to be tested to fully close this important prevention gap in at-risk patients.”

The NUDGE-FLU program, a groundbreaking initiative launched in Denmark evaluating the effectiveness of behavioral science-informed nudges delivered through government electronic communication systems for improving vaccination rates among high-risk populations. At the time of the AHA 2024 presentation, the program included 3 trials—NUDGE-FLU, NUDGE-FLU-2, and NUDGE-FLU-CHRONIC, which were conducted during the 2022-2023 and 2023-2024 influenza seasons and included a total of 2,146,124 participants.

The original NUDGE-FLU trial randomized 964,870 adults aged 65 and older to receive one of nine behavioral science-informed letters or usual care. NUDGE-FLU-2 involved 881,373 adults in the same age group, randomized to receive one of six behavioral science-informed letters or usual care. NUDGE-FLU-CHRONIC focused on 299,881 adults aged 18 to 64 with chronic conditions, using a similar design. Across all trials, 2.8% (n=59,458) of participants had a history of acute myocardial infarction.

Analysis indicated vaccine uptake improved for both those with and without this history who received any nudge letter compared to usual care (+1.81 vs. +1.32 percentage points, P = .09). Notably, the letter emphasizing the cardiovascular benefits of vaccination yielded greater increases in uptake among those with a history of acute myocardial infarction (+3.91 vs. +2.03 percentage points, 

Additionally, patients who had not been vaccinated in the prior season saw the most significant improvements in vaccine uptake, with a +13.7 percentage point increase for those receiving cardiovascular benefit communications (

 <.001). Investigators also noted this effect was most pronounced in patients with more recent myocardial infarctions (

Relevant disclosures for Bhatt include Sanofi and Novo Nordisk.

Bhatt AS. Electronic Nudges to Increase Influenza Vaccination among Patients with History of Myocardial Infarction: Insights from 3 Randomized Clinical Trials Enrolling >2 Million Patients. Paper presented at: American Heart Association Scientific Sessions 2024; November 15 - 18; Chicago, Il. Accessed November 16, 2024.

American Heart Association. Email reminders improved flu shot rates in Denmark, notably among heart attack survivors. American Heart Association Newsroom. November 11, 2024. Accessed November 17, 2024. https://newsroom.heart.org/news/email-reminders-improved-flu-shot-rates-in-denmark-notably-among-heart-attack-survivors.

Articles

Emails emphasizing the cardiovascular benefits of influenza vaccination significantly increased vaccine uptake among adults with a history of myocardial infarction, as shown by the NUDGE-FLU program. The analysis, presented at the AHA Annual Scientific Sessions 2024, revealed a 3.9% increase in vaccination for those with a heart attack history, compared to 2% for those without. The NUDGE-FLU trials, conducted in Denmark, involved over two million participants and demonstrated that cardiovascular-focused messaging was effective, though additional strategies are needed to fully address vaccination gaps in high-risk patients.

Ankeet Bhatt, MD, MBA, ScM, provides additional insight into NUDGE-FLU data he presented at AHA 2024. 

Understanding NUDGLE-FLU Data from AHA 2024, with Ankeet Bhatt, MD, MBA, ScM

 is underlining the importance of early, rapid uptitration of guideline-directed medical therapy and avoiding unnecessary expenses in patients with 

An analysis of the cost-effectiveness of dapagliflozin (Farxiga) among patients with heart failure with mildly reduced or preserved ejection fraction (HFmrEF/HFpEF) based on the time since HFmrEF/HFpEF diagnosis or the last hospitalization for heart failure, results of the suggest earlier initiation and optimization of dapagliflozin was associated with greater benefits on quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratios (ICERs).

“SGLT2 inhibitors, are now a cornerstone in heart failure management, really across the spectrum of ejection fraction, explained lead investigator Ankeet Bhatt, MD, a research scientist at Kaiser Permanente Northern California and associate physician at Kaiser San Francisco Medical Center. “The challenge now is to ensure rapid, equitable implementation of this therapy, particularly in patients who've had in who have mildly reduced or preserved ejection fraction, in which there are more limited therapeutic options. The question becomes, when is the right time to initiate?”

To further explore the impact of prescription timing on outcomes and cost-effectiveness, Bhatt and investigators used a Markov cohort transition model for the UK setting and leveraged patient-level data from the pivotal DELIVER trial. A multicenter, parallel-group, event-driven, double-blind, randomized, controlled trial conducted at 353 centers in 20 countries, results of DELIVER indicated use of dapagliflozin was associated with an 18% relative risk reduction for the composite endpoint (HR, 0.82; 95% CI, 0.73 to 0.92]; 

 <.001). Further analysis demonstrated use of dapagliflozin was associated with a 21% reduction in risk of worsening heart failure (HR, 0.79; 95% CI, 0.69 to 0.91) and a 12% reduction in risk for cardiovascular mortality (HR, 0.88; 95% CI, 0.74 to 1.05).

In the AHA 2024 analysis, patients were categorized by time since heart failure diagnosis and last hospitalization for heart failure event, including those with no prior hospitalizations for heart failure. The primary outcomes of interest for the analysis were incremental costs, QALYs, and ICERs. For the purpose of analysis, health state transitions were based on quartiles of the Kansas City Cardiomyopathy Questionnaire Total Symptom Scale, with adjustments for baseline characteristics and evolving health states.

Results indicated the lowest ICERs occurred in patients with the shortest time since heart failure diagnosis or last hospitalization for heart failure event. Across all subgroups, ICERs remained below the UK willingness-to-pay threshold of £20,000 per QALY gained, supporting dapagliflozin's cost-effectiveness.

For more on this study and the topic of early, rapid uptitration of GDMT in heart failure, check out our interview with Bhatt from the floor of AHA 2024.

Ankeet Bhatt, MD, MBA: Cost-Effectiveness of Early GDMT Initiation in HFpEF

Bhatt AS, De Boer RA, Booth D, Davis J, Chen J. 

Effect of Time Since Heart Failure Diagnosis or Hospitalization on the Cost-effectiveness of Dapagliflozin in Patients with Heart Failure with Mildly Reduced or Preserved Ejection Fraction

. Paper presented at: American Heart Association Scientific Sessions 2024; November 15 - 18; Chicago, Il. Accessed November 16, 2024.

Campbell P. Dapagliflozin proves HFPEF benefit in deliver trial. HCP Live. August 27, 2022. Accessed April 7, 2024. https://www.hcplive.com/view/dapagliflozin-proves-hfpef-benefit-in-deliver-trial.

Videos

New research emphasizes the importance of early and rapid uptitration of guideline-directed medical therapy in heart failure patients, focusing on the cost-effectiveness of dapagliflozin for those with mildly reduced or preserved ejection fraction. The study, using data from the DELIVER trial, highlights dapagliflozin's significant benefits in reducing risks of worsening heart failure and cardiovascular mortality. The analysis shows that earlier initiation of dapagliflozin is associated with better quality-adjusted life-years and cost-effectiveness, with incremental cost-effectiveness ratios remaining below the UK willingness-to-pay threshold.

Ankeet Bhatt, MD, MBA, discusses a study he led from AHA 2024 examining the cost-effectiveness of dapagliflozin based on how soon therapy was initiated following diagnosis or hospitalization.