eprintid: 37432 rev_number: 21 userid: 702 dir: disk0/00/03/74/32 datestamp: 2019-09-26 16:43:29 lastmod: 2019-09-26 21:00:13 status_changed: 2019-09-26 16:43:29 type: thesis_degree metadata_visibility: show contact_email: jraviotta@gmail.com item_issues_id: thesis_degree_versioning item_issues_id: duplicate_title_37176 item_issues_type: thesis_degree_versioning item_issues_type: duplicate_title item_issues_description: ETD 37432 is using versioning. item_issues_description: Duplicate title to Raviotta, Jonathan 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 (Unpublished) item_issues_timestamp: 2019-08-31 06:02:15 item_issues_timestamp: 2019-08-31 06:02:15 item_issues_status: autoresolved item_issues_status: autoresolved item_issues_count: 0 eprint_status: archive creators_name: Raviotta, Jonathan creators_email: jmr154@pitt.edu creators_id: JMR154 creators_orcid: 0000-0001-7551-0628 title: The development testing and implementation of the 4 Pillars™ practice transformation program for immunization: achieving public health outcomes through primary care quality improvement ispublished: unpub divisions: sch_gsph_behavioralcommhealthsci full_text_status: public keywords: quality improvement, vaccine, immunization, decision analysis, healthcare intervention, primary care abstract: 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 date_type: published pages: 148 institution: University of Pittsburgh refereed: TRUE related_url_url: https://github.com/PittVax/4Pillars_Outcomes related_url_desc: code repository etdcommittee_type: committee_chair etdcommittee_type: committee_member etdcommittee_type: committee_member etdcommittee_type: committee_member etdcommittee_type: committee_member etdcommittee_name: Albert, Steven M. etdcommittee_name: Lin, Chyongchiou J. etdcommittee_name: Mair, Christina F. etdcommittee_name: Smith, Kenneth J. etdcommittee_name: Zimmerman, Richard K. etdcommittee_email: smalbert@pitt.edu etdcommittee_email: CJLIN@pitt.edu etdcommittee_email: cmair@pitt.edu etdcommittee_email: kjs8@pitt.edu etdcommittee_email: zimmer@pitt.edu etdcommittee_id: SMALBERT etdcommittee_id: CJLIN etdcommittee_id: cmair etdcommittee_id: kjs8 etdcommittee_id: ZIMMER etdcommittee_orcid: 0000-0001-6786-9956 etd_defense_date: 2019-08-14 etd_approval_date: 2019-09-26 etd_submission_date: 2019-07-23 etd_release_date: 2019-09-26 etd_access_restriction: immediate etd_patent_pending: FALSE thesis_type: dissertation degree: PhD citation: 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) document_url: http://d-scholarship-dev.library.pitt.edu/37432/1/Raviotta_J_dissertation_Aug_2019.pdf