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The development testing and implementation of the 4 Pillars™ practice transformation program for immunization: achieving public health outcomes through primary care quality improvement

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 (Unpublished)

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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.


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Item Type: University of Pittsburgh ETD
Status: Unpublished
CreatorsEmailPitt UsernameORCID
Raviotta, Jonathanjmr154@pitt.eduJMR1540000-0001-7551-0628
ETD Committee:
TitleMemberEmail AddressPitt UsernameORCID
Committee ChairAlbert, Steven M.smalbert@pitt.eduSMALBERT0000-0001-6786-9956
Committee MemberLin, Chyongchiou J.CJLIN@pitt.eduCJLIN
Committee MemberMair, Christina F.cmair@pitt.educmair
Committee MemberSmith, Kenneth J.kjs8@pitt.edukjs8
Committee MemberZimmerman, Richard K.zimmer@pitt.eduZIMMER
Date: 26 September 2019
Date Type: Publication
Defense Date: 14 August 2019
Approval Date: 26 September 2019
Submission Date: 23 July 2019
Access Restriction: No restriction; Release the ETD for access worldwide immediately.
Number of Pages: 148
Institution: University of Pittsburgh
Schools and Programs: School of Public Health > Behavioral and Community Health Sciences
Degree: PhD - Doctor of Philosophy
Thesis Type: Doctoral Dissertation
Refereed: Yes
Uncontrolled Keywords: quality improvement, vaccine, immunization, decision analysis, healthcare intervention, primary care
Related URLs:
Date Deposited: 26 Sep 2019 16:43
Last Modified: 26 Sep 2019 21:00


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