title: Success of the 4 pillars toolkit for influenza and pneumococcal vaccination in adults.
abstract: BACKGROUND
  Standing order programs (SOPs) allowing nonphysician personnel to assess patients' immunization status and administer vaccines without an individual physician order are a proven method of increasing adult vaccinations, yet they are underutilized by primary care physicians.
  
  
  METHODS
  In a before-and-after trial, a pilot-tested and revised SOP toolkit (4 Pillars Toolkit) was implemented in four diverse primary care practices. Changes in influenza and pneumococcal polysaccharide vaccine (PPSV) vaccination rates were measured. The toolkit was evaluated using direct observation, group interviews, and surveys of each practice's staff.
  
  
  RESULTS
  Use of the 4 Pillars Toolkit varied across sites. PPSV rates increased significantly overall for high-risk adults (18-64 years; 25% in 2010-2011 vs. 40% in 2011-2012, p = .02) but not for older adults (≥65 years; 44% vs. 52%, p = .26) and in two of four practices among both high-risk and older adults (p < .05). Influenza vaccination rates increased significantly in three of four sites and overall (22% in 2010-2011 vs. 33% in 2011-2012, overall; p < .001). Practices more fully implementing the toolkit demonstrated larger increases in vaccination rates.
  
  
  CONCLUSIONS
  The 4 Pillars Toolkit is a promising means of improving primary care practice across diverse settings, with better results observed when strategies were maximally utilized.
authors.forename: Mary Patricia
authors.initials: MP
authors.lastname: Nowalk
authors.forename: Beth A D
authors.initials: BA
authors.lastname: Nolan
authors.forename: Jean
authors.initials: J
authors.lastname: Nutini
authors.forename: Faruque
authors.initials: F
authors.lastname: Ahmed
authors.forename: Steven M
authors.initials: SM
authors.lastname: Albert
authors.forename: Michael
authors.initials: M
authors.lastname: Susick
authors.forename: Richard K
authors.initials: RK
authors.lastname: Zimmerman
mesh_terms: D000328:Adult; D000368:Aged; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data; D019538:Health Care Surveys; D006801:Humans; D017589:Immunization Programs / Q000458:organization & administration* / Q000706:statistics & numerical data; D007252:Influenza Vaccines / Q000008:administration & dosage; D008297:Male; D008503:Medical Staff; D008875:Middle Aged; D022242:Pneumococcal Vaccines / Q000008:administration & dosage; D011320:Primary Health Care / Q000458:organization & administration*; D014611:Vaccination / Q000379:methods
chemical_list: D007252:Influenza Vaccines; D022242:Pneumococcal Vaccines
keywords: adult immunizations; influenza vaccine; pneumococcal polysaccharide vaccine; standing order programs