Using the 4 Pillars Practice Transformation Program to Increase Pneumococcal Immunizations for Older Adults: A Cluster‐Randomized Trial

Moehling

Lin

et al. 2017

Vaccine

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Objective Uptake of meningococcal vaccine (MCV) and tetanus, diphtheria and pertussis (Tdap) vaccine among adolescents has approached Healthy People 2020 goals,[1] but human papillomavirus (HPV) vaccination has not. This study evaluated an intervention using the 4 Pillars™ Practice Transformation Program to increase HPV, MCV and Tdap uptake among adolescents in primary care practices. Methods Practices with at least 50 patients 11–17 years old with estimated vaccination rates less than national goals, were assigned to intervention (n=11) and control (n=11) groups in a randomized controlled cluster trial; 9 intervention and 11 control sites completed the study. The baseline and active study periods were 7/1/2013–6/30/2014 and 7/1/2014–3/31/2015, respectively. Vaccination and demographic data for patients who had a visit in both study periods were derived from de-identified EMR extractions. Primary outcomes were vaccination rates and percentage point (PP) changes. Data were analyzed in 2015–16. Results Among the cohort of 10,861 adolescent patients, 38% were 11–13 years old; 50% were female; 18% were non-white; and 64% were commercially insured. Average baseline HPV initiation rates were 52.5% for intervention and 61.8% for control groups. After 9 months, the intervention sites increased HPV initiation 10.2 PP compared with 7.3 PP in control sites (P<0.001); HPV series completion rates did not differ between groups. Implementation of >10 strategies to improve rates significantly increased the likelihood of HPV series initiation (OR=2.06, 95% CI=1.43, 2.96). Conclusions Using >10 strategies from the 4 Pillars™ Practice Transformation Program is effective for increasing HPV series initiation among adolescents.

Section: Discussionmentioning

confidence: 52%

Improving adolescent HPV vaccination in a randomized controlled cluster trial using the 4 Pillars™ practice Transformation Program

Moehling

Lin

et al. 2017

Vaccine

Self Cite

“…The strengths of this study lie in the use of an intervention shown to be effective in adults 22–24 and adapted for use among adolescent patients, the inclusion of five vaccines, lessons learned from the parent RCCT about ways to enhance practice engagement, and the large number of adolescents included. The participating practices were all part of a single health system using a single EMR, enabling consistency in reporting vaccine administration and subsequent vaccination data collection.…”

Section: Discussionmentioning

confidence: 99%

Using the 4 Pillars™ Practice Transformation Program to increase adolescent human papillomavirus, meningococcal, tetanus-diphtheria-pertussis and influenza vaccination

Raviotta

Nowalk

et al. 2017

Vaccine

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Objectives To report the results of an intervention using the 4 Pillars™ Practice Transformation Program (4 Pillars™ Program) to increase adolescent vaccinations including human papillomavirus vaccine (HPV) and influenza vaccines, which remain underutilized in this population. Study Design Eleven pediatric and family medicine practices, previously control sites from a randomized controlled cluster trial, with ≥50 adolescent patients participated. The 4 Pillars™ Program was the foundation of the intervention. De-identified demographic, office visit and vaccination data were derived from electronic medical record extractions for patients whose date of birth was 4/1/1997 to 4/1/2004 (ages 11–17 years at baseline). Vaccination rates for HPV, influenza, tetanus-pertussis-diphtheria (Tdap) and meningococcal (MenACWY) vaccines were determined for all eligible patients pre- and post intervention (i.e., vaccination rates on 4/1/2015 and 4/30/2016). Results Among 9,473 patients ages 11–17 years at baseline (4/1/2015), mean pre-intervention vaccination rates for HPV initiation and completion, meningococcal, Tdap and influenza vaccines were below national levels. Rates increased significantly post intervention (P<0.001) for HPV initiation which increased 17.1 percentage points (PP) from 51.4%; HPV completion increased 14.8 PP from 30.7%, meningococcal vaccine uptake increased 16.6 PP from 79.1%, Tdap vaccine uptake increased 14.6 PP from 76.9%. Influenza vaccine uptake did not increase significantly (2.3 PP from 40.1%). In the regression using generalized estimating equations, odds of vaccination were higher for younger, non-white adolescents for all vaccines; being in a smaller practice decreased the odds of Tdap vaccination but increased the odds of influenza vaccination. Conclusion Clinically and statistically significant improvements in HPV series initiation and completion, and meningococcal and Tdap vaccinations were observed in primary care practices implementing the 4 Pillars™ Practice Transformation Program.

“…The intervention using the Toolkit was designed to assist practices in improving uptake of influenza, pneumococcal, and tetanus‐pertussis‐diphtheria (Tdap) vaccines. Vaccination rates for each vaccine are based on those observed in the trial and improvements in rates after the intervention . To simplify modeling procedures, it was assumed that the probability of receiving each vaccine was not correlated with the probability of receiving other vaccines.…”

Section: Methodsmentioning

confidence: 99%

“…Vaccination rates for each vaccine are based on those observed in the trial and improvements in rates after the intervention. 4 To simplify modeling procedures, it was assumed that the probability of receiving each vaccine was not correlated with the probability of receiving other vaccines. It was also assumed that the probabilities of receiving the two pneumococcal vaccines (23-valent pneumococcal polysaccharide vaccine (PPSV) and 13valent pneumococcal conjugate vaccine (PCV13)) were equal.…”

Section: Methodsmentioning

confidence: 99%

Cost‐Effectiveness of the 4 Pillars Practice Transformation Program to Improve Vaccination of Adults Aged 65 and Older

J American Geriatrics Society

Nowalk

Lin

2016

Self Cite

Objectives Interventions to improve adult vaccination uptake in primary care have met with limited success, raising questions about whether the benefits to patients are worth the time and resources necessary to implement them. Here we examine the cost effectiveness of an intervention to increase pneumococcal, influenza and pertussis-containing vaccine uptake among adults ≥65 years of age in primary care practices. Design Markov decision analysis model, estimating the cost-effectiveness of the 4 Pillars™ Practice Transformation Program compared with no intervention. Setting Diverse primary care practices in 2 US cities Participants Clinical trial patients aged 65 years and older. Vaccination rates and intervention costs were derived from a randomized controlled cluster trial. Other parameters were derived from the medical literature and CDC data. All parameters were individually and simultaneously varied over their distributions. Measurements Quality adjusted life years (QALYs), public health outcomes, and costs Results With the intervention program and extrapolating over 10 years, there would be ~60,920 fewer influenza cases, 2,031 fewer pertussis cases, and 13,842 fewer pneumococcal illnesses among adults ≥65 years. Compared to no intervention, total per-person vaccination and illness costs with the intervention were $1.60 higher with a concurrent increase in effectiveness of 0.0031 QALYs, or $512 per QALY gained. In sensitivity analyses, no individual parameter variation caused the intervention to cost >$20,000 per QALY gained. Conclusions Implementing an intervention based on the 4 Pillars™ Practice Transformation Program is a cost-effective undertaking in primary care practices for patients ≥65 years old with predicted public health benefits.