Using the 4 pillars™ practice transformation program to increase adult influenza vaccination and reduce missed opportunities in a randomized cluster trial.
BACKGROUND
An evidence-based, step-by-step guide, the 4 Pillars™ Practice Transformation Program, was the foundation of an intervention to increase adult immunizations in primary care and was tested in a randomized controlled cluster trial. The purpose of this study is to report changes in influenza immunization rates and on factors related to receipt of influenza vaccine.


METHODS
Twenty five primary care practices were recruited in 2013, stratified by city (Houston, Pittsburgh), location (rural, urban, suburban) and type (family medicine, internal medicine), and randomized to the intervention (n = 13) or control (n = 12) in Year 1 (2013-14). A follow-up intervention occurred in Year 2 (2014-15). Demographic and vaccination data were derived from de-identified electronic medical record extractions.


RESULTS
A cohort of 70,549 adults seen in their respective practices (n = 24 with 1 drop out) at least once each year was followed. Baseline mean age was 55.1 years, 35 % were men, 21 % were non-white and 35 % were Hispanic. After one year, both intervention and control arms significantly (P < 0.001) increased influenza vaccination, with average increases of 2.7 to 6.5 percentage points. In regression analyses, likelihood of influenza vaccination was significantly higher in sites with lower percentages of patients with missed opportunities (P < 0.001) and, after adjusting for missed opportunities, the intervention further improved vaccination rates in Houston (lower baseline rates) but not Pittsburgh (higher baseline rates). In the follow-up intervention, the likelihood of vaccination increased for both intervention sites and those that reduced missed opportunities (P < 0.005).


CONCLUSIONS
Reducing missed opportunities across the practice increases likelihood of influenza vaccination of adults. The 4 Pillars™ Practice Transformation Program provides strategies for reducing missed opportunities to vaccinate adults.


BACKGROUND
This study was registered as a clinical trial on 03/20/2013 at ClinicalTrials.gov, Clinical Trial Registry Number: NCT01868334 , with a date of enrollment of the first participant to the trial of April 1, 2013.
Department of Family Medicine, University of Pittsburgh School of Medicine, 4420 Bayard Road, Suite 520, Pittsburgh, PA, 15260, USA.
Chyongchiou J
CJ
Lin
Department of Family Medicine, University of Pittsburgh School of Medicine, 4420 Bayard Road, Suite 520, Pittsburgh, PA, 15260, USA. tnowalk@pitt.edu.
Mary Patricia
MP
Nowalk
Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX, USA.
Valory N
VN
Pavlik
Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX, USA.|Current address: Houston Methodist Primary Care Group, Houston, TX, USA.
Anthony E
AE
Brown
Department of Family Medicine, University of Pittsburgh School of Medicine, 4420 Bayard Road, Suite 520, Pittsburgh, PA, 15260, USA.
Song
S
Zhang
Department of Family Medicine, University of Pittsburgh School of Medicine, 4420 Bayard Road, Suite 520, Pittsburgh, PA, 15260, USA.
Jonathan M
JM
Raviotta
Department of Family Medicine, University of Pittsburgh School of Medicine, 4420 Bayard Road, Suite 520, Pittsburgh, PA, 15260, USA.
Krissy K
KK
Moehling
Department of Behavioral and Community Health Sciences (MH, EMR), University of Pittsburgh Graduate School of Public Health, 130 DeSoto Street, Pittsburgh, PA, 15261, USA.
Mary
M
Hawk
Department of Behavioral and Community Health Sciences (MH, EMR), University of Pittsburgh Graduate School of Public Health, 130 DeSoto Street, Pittsburgh, PA, 15261, USA.
Edmund M
EM
Ricci
Department of Family Medicine, University of Pittsburgh School of Medicine, 4420 Bayard Road, Suite 520, Pittsburgh, PA, 15260, USA.
Donald B
DB
Middleton
Centers for Disease Control and Prevention (SP), Atlanta, GA, USA.
Suchita
S
Patel
Department of Family Medicine, University of Pittsburgh School of Medicine, 4420 Bayard Road, Suite 520, Pittsburgh, PA, 15260, USA.
Jeannette E
JE
South-Paul
Department of Family Medicine, University of Pittsburgh School of Medicine, 4420 Bayard Road, Suite 520, Pittsburgh, PA, 15260, USA.|Department of Behavioral and Community Health Sciences (MH, EMR), University of Pittsburgh Graduate School of Public Health, 130 DeSoto Street, Pittsburgh, PA, 15261, USA.
Richard K
RK
Zimmerman
D000328:Adult; D000368:Aged; D003695:Delivery of Health Care; D003710:Demography; D057286:Electronic Health Records; D005194:Family Practice; D005260:Female; D006293:Health Promotion; D006630:Hispanic or Latino; D006801:Humans; D007252:Influenza Vaccines / Q000627:therapeutic use*; D007251:Influenza, Human / Q000517:prevention & control*; D007388:Internal Medicine; D008297:Male; D008875:Middle Aged; D009042:Motivation; D010353:Patient Education as Topic; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011320:Primary Health Care; D012044:Regression Analysis; D014611:Vaccination; D044465:White People
D007252:Influenza Vaccines
Adults; Immunization; Influenza vaccine