relation: http://d-scholarship-dev.library.pitt.edu/37432/
title: The development testing and implementation of the 4 Pillars™ practice transformation program for immunization: achieving public health outcomes through primary care quality improvement
creator: Raviotta, Jonathan
description: The 4 Pillars™ Practice Transformation Program for Immunization is an evidence-based quality improvement program to improve immunization outcomes in primary care. The intervention strategies, implementation methods and the 4 Pillars™ of Convenience and Access, Patient Communication, Enhanced Vaccination Systems, and Motivation were informed by theoretical frameworks from the sciences of medicine, public health, systems and implementation and the social ecological model. The program was most-recently deployed in three different settings; a multi-center cluster-randomized clinical trial, a continuing medical education performance-in-practice module, and a quality improvement initiative in a regional community medicine health care organization.  In clinical trials, the program demonstrated efficacy to improve increased uptake of seasonal influenza vaccine in children; meningococcal and Tdap vaccines and HPV initiation and completion in adolescents; seasonal influenza, pneumococcal, and pertussis vaccines in adults; and pneumococcal vaccines in older adults. Population-level cost-effectiveness models of the data report that the program was a good value with incremental cost-effectiveness ratios of $4937 within American Board of Family Medicine physicians seeking continuing education credit and $31,700 as a clinical trial per quality adjusted life year gained. An analysis of the efficacy of the program as conducted in 63 practices of a primary care division of a large regional health organization was inconclusive failing to replicate the results observed in clinical trials. Secular trends, data availability, and methodological limitations interfered with the fidelity of the intervention which led to sub-optimal results.   Public Health Significance - System limitations in practice of health care were observed. Nearly all domains of medical quality improvement would benefit from substantial changes to the user experience at the point of care, health data systems interoperability, and the availability of consistent patient-level data for epidemiologic research and the development of simulation models of health systems and health behavior dynamics. Translating a complex intervention from a laboratory controlled clinical trial to an organization-directed quality improvement program is a significant challenge in public health. This process of scaling mirrors the barriers of influencing behavior in nested social ecological levels. Consequently, the 4 Pillars™ can provide guidance to improve efficacy of future public health programs.
date: 2019-09-26
type: University of Pittsburgh ETD
type: PeerReviewed
format: application/pdf
language: en
identifier: http://d-scholarship-dev.library.pitt.edu/37432/1/Raviotta_J_dissertation_Aug_2019.pdf
identifier:   Raviotta, Jonathan  (2019) The development testing and implementation of the 4 Pillars™ practice transformation program for immunization: achieving public health outcomes through primary care quality improvement.  Doctoral Dissertation, University of Pittsburgh.    (Unpublished)