1. Richard Zimmerman, MD, MPH, MS Anthony E. Brown, MD, MPH Valory N. Pavlik, PhD Krissy K. Moehling, MPH Jonathan M. Raviotta, MPH Chyongchiou J. Lin, PhD Song Zhang, MS Mary Hawk, DrPH Shakala Kyle, MA Suchita Patel, DO Faruque Ahmed, PhD Mary Patricia Nowalk, PhD, RD Using the 4 Pillars™ Immunization Toolkit to Increase Pneumococcal Immunizations for Older Adults: A Cluster Randomized Trial

2. Acknowledgements  This investigation was supported by grant (U01 IP000662) from the Centers for Disease Control and Prevention.  Views expressed herein are those of those authors and not those of the CDC.  This project was also supported by the National Institutes of Health through grants UL1RR024153 and UL1TR000005.  Dr. Zimmerman has received research grants from Merck & Co., Sanofi Pasteur, and Pfizer, Inc.

3. Background  Quality improvement in primary care has focused on improving adult immunizations.  Sustainable change requires a coordinated, multipronged, adaptable approach  Need for a practice improvement toolkit that can support change among diverse practice cultures is evident

4. 4 Pillars™ Immunization Toolkit  The Toolkit was the foundation of a 2 year randomized controlled cluster trial of primary care practices in two cities  The intervention includes:  staff education  one on one coaching of office base  immunization champion

5. 4 Pillars™ Immunization Toolkit  4 Pillars™ Immunization Toolkit:  1) Convenience and easy access  2) Patient communication  3) Enhanced vaccination systems  4) Motivation by an immunization champion http://www.4pillarstoolkit.pitt.edu/

6. Methods  25 primary care sites participated with adult patients  All sites used a common electronic medical record (EMR)  Eligibility requirements included:  have at least 100 patients ≥18 years of age  preliminary baseline vaccination rates for at least one adult vaccine (influenza, pneumococcal, Tdap) <50%  willingness to make office changes to increase vaccination rates.

7. Methods (cont’d.)  Practices were stratified by:  city (Pittsburgh or Houston)  location (urban, suburban or rural)  discipline (internal or family medicine)  Practices were randomized into the Year 2 intervention or Year 2 intervention

8. Results  At intervention year end, PPSV rates increased in both intervention and control groups in both cities.  Increases ranged from 6.5 to 8.7 PP (P<0.001 by Chi square test for baseline to Year 1 rates).  Differences in PP changes between intervention and control groups were significant for Houston sites (P<0.001), but not for Pittsburgh sites (P=0.84).

9. Results: PPSV  By the end of Year 2, 79% of practices (19/24) had PPSV rates at or above 70%  58% of practices (14/24) had PPSV rates at or above 80% * *P<0.001 for percentage point difference from Baseline to Year 2 between Active Intervention and Maintenance groups by Chi- square test

10. Results: PCV  The active intervention group was 14.7 times more likely to receive PCV than the maintenance group. *P<0.001 for percentage point difference from Baseline to Year 2 between Active Intervention and Maintenance groups by Chi- square test

11. Discussion  PPSV uptake increased in both intervention and control groups  In Year 2, the active intervention group increased average PPSV rates by 4.6 to 5.2 percentage points while the maintenance groups continued to increase their average PPSV rates (2.4-6.5 percentage points)  This study shows that even practices with higher baseline vaccination rates can increase the proportion of their patients who receive PPSV with a directed approach  National coverage for PPSV among adults ≥65 years of age was 59.7% in 2013. In this study at baseline, many but not all, sites reported rates above that level and still increased vaccination rates

12. Strengths and Limitations  Strengths:  randomized design  large number and diversity of patients  diverse practice settings including safety net clinics  two intervention years of vaccination reporting  Limitations:  in year 1 intervention, delivery of the EMR data was delayed  CDC’s change in recommendations regarding PCV late in Year 2  confusion about Medicare coverage interfered with implementation.