title: Using the 4 Pillars™ Practice Transformation Program to increase adult Tdap immunization in a randomized controlled cluster trial.
abstract: National adult Tdap vaccination rates are low, reinforcing the need to increase vaccination efforts in primary care offices. The 4 Pillars™ Practice Transformation Program is an evidence-based, step-by-step guide to improving primary care adult vaccination with an online implementation tracking dashboard. This study tested the effectiveness of an intervention to increase adult Tdap vaccination that included the 4 Pillars™ Program, provider education, and one-on-one coaching of practice-based immunization champions.
  
  
  
  25 primary care practices participated in a randomized controlled cluster trial (RCCT) in Year 1 (6/1/2013-5/31/2014) and a pre-post study in Year 2 (6/1/2014-1/31/2015). Baseline year was 6/1/2012-5/31/2013, with data analyzed in 2016. Demographic and vaccination data were derived from de-identified electronic medical record (EMR) extractions. The primary outcomes were vaccination rates and percentage point (PP) changes/year.
  
  
  
  The cohort consisted of 70,549 patients ⩾18years who were seen in the practices ⩾1 time each year, with a baseline mean age=55years; 35% were men; 56% were non-white; 35% were Hispanic and 20% were on Medicare. Baseline vaccination rate averaged 35%. In the Year 1 RCCT, cumulative Tdap vaccination increased significantly in both intervention and control groups; in both cities, the percentage point increases in the intervention groups (7.7 PP in Pittsburgh and 9.9 PP in Houston) were significantly higher (P<0.001) than in the control groups (6.4 PP in Pittsburgh and 7.6 PP in Houston). In the Year 2 pre-post study, in both cities, active intervention groups increased rates significantly more (6.2 PP for both) than maintenance groups (2.2 PP in Pittsburgh and 4.1 PP in Houston; P<0.001).
  
  
  
  An intervention that includes the 4 Pillars™ Practice Transformation Program, staff education and coaching is effective for increasing adult Tdap immunization rates within primary care practices. Clinical Trial Registry Name/Number: NCT01868334.
authors: Department of Family Medicine (RKZ, MPN, CJL, KKM, SZ, JESP, DBM, JMR), University of Pittsburgh School of Medicine, Pittsburgh, PA, United States. Electronic address: tnowalk@pitt.edu.
authors: Mary Patricia
authors: MP
authors: Nowalk
authors: Department of Family Medicine (RKZ, MPN, CJL, KKM, SZ, JESP, DBM, JMR), University of Pittsburgh School of Medicine, Pittsburgh, PA, United States.
authors: Chyongchiou J
authors: CJ
authors: Lin
authors: Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX (VNP, AEB), United States.
authors: Valory N
authors: VN
authors: Pavlik
authors: Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX (VNP, AEB), United States.
authors: Anthony E
authors: AE
authors: Brown
authors: Department of Family Medicine (RKZ, MPN, CJL, KKM, SZ, JESP, DBM, JMR), University of Pittsburgh School of Medicine, Pittsburgh, PA, United States.
authors: Song
authors: S
authors: Zhang
authors: Department of Family Medicine (RKZ, MPN, CJL, KKM, SZ, JESP, DBM, JMR), University of Pittsburgh School of Medicine, Pittsburgh, PA, United States.
authors: Krissy K
authors: KK
authors: Moehling
authors: Department of Family Medicine (RKZ, MPN, CJL, KKM, SZ, JESP, DBM, JMR), University of Pittsburgh School of Medicine, Pittsburgh, PA, United States.
authors: Jonathan M
authors: JM
authors: Raviotta
authors: Department of Family Medicine (RKZ, MPN, CJL, KKM, SZ, JESP, DBM, JMR), University of Pittsburgh School of Medicine, Pittsburgh, PA, United States.
authors: Jeannette E
authors: JE
authors: South-Paul
authors: Department of Behavioral and Community Health Sciences (MH, EMR), University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, United States.
authors: Mary
authors: M
authors: Hawk
authors: Department of Behavioral and Community Health Sciences (MH, EMR), University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, United States.
authors: Edmund M
authors: EM
authors: Ricci
authors: Department of Family Medicine (RKZ, MPN, CJL, KKM, SZ, JESP, DBM, JMR), University of Pittsburgh School of Medicine, Pittsburgh, PA, United States.
authors: Donald B
authors: DB
authors: Middleton
authors: Centers for Disease Control and Prevention (SAL, FA), Atlanta, GA, United States.
authors: Suchita A
authors: SA
authors: Patel
authors: Centers for Disease Control and Prevention (SAL, FA), Atlanta, GA, United States.
authors: Faruque
authors: F
authors: Ahmed
authors: Department of Family Medicine (RKZ, MPN, CJL, KKM, SZ, JESP, DBM, JMR), University of Pittsburgh School of Medicine, Pittsburgh, PA, United States; Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX (VNP, AEB), United States.
authors: Richard K
authors: RK
authors: Zimmerman
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D022422:Diphtheria-Tetanus Vaccine / Q000008:administration & dosage*; D057286:Electronic Health Records; D005260:Female; D006801:Humans; D017589:Immunization Programs / Q000379:methods*; D008297:Male; D008875:Middle Aged; D010414:Pennsylvania; D011320:Primary Health Care / Q000458:organization & administration*; D015397:Program Evaluation; D013781:Texas; D014611:Vaccination / Q000706:statistics & numerical data*
chemical_list: D022422:Diphtheria-Tetanus Vaccine
keywords: Adults; Immunization; Pertussis; Tdap vaccine; Tetanus