Using the 4 pillars™ practice transformation program to increase adult influenza vaccination and reduce missed opportunities in a randomized cluster trial

Implementing evidence-based practices in rural settings: a scoping review of theories, models, and frameworks

Background

Rural healthcare has unique characteristics that affect the dissemination and implementation of evidence-based interventions. Numerous theories, models, and frameworks have been developed to guide implementation of healthcare interventions, though not specific to rural healthcare. The present scoping review sought to identify the theories, models, and frameworks most frequently applied to rural health and propose an approach to rural health research that harnesses selected constructs from these theories, models, and frameworks. This resulting synthesis can serve as a guide to researchers, policy makers, and clinicians seeking to employ commonly used theories, models, and frameworks to rural health.

Methods

We used the Scopus abstract indexing service to identify peer-reviewed literature citing one or more of theories, models, or frameworks used in dissemination and implementation research and including the word "rural" in the Title, Abstract, or Keywords. We screened the remaining titles and abstracts to ensure articles met additional inclusion criteria. We conducted a full review of the resulting 172 articles to ensure they identified one or more discrete theory, model, or framework applied to research or quality improvement projects. We extracted the theories, models, and frameworks and categorized these as process models, determinant frameworks, classic theories, or evaluation frameworks.

Results

We retained 61 articles of which 28 used RE-AIM, 11 used Community-Based Participatory Research (CBPR) framework, eight used the Consolidated Framework for Implementation Research (CFIR), and six used the integrated-Promoting Action on Research Implementation in Health Services (iPARIHS). Additional theories, models, and frameworks were cited in three or fewer reports in the literature. The 14 theories, models, and frameworks cited in the literature were categorized as seven process models, four determinant frameworks, one evaluation framework, and one classic theory.

Conclusions

The RE-AIM framework was the most frequently cited framework in the rural health literature, followed by CBPR, CFIR, and iPARIHS. A notable advantage of RE-AIM in rural healthcare settings is the focus on reach as a specified outcome, given the challenges of engaging a geographically diffuse and often isolated population. We present a rationale for combining the strengths of these theories, models, and frameworks to guide a research agenda specific to rural healthcare research.

Systematic Review Registration

https://osf.io/fn2cd/.

The Effect of a Quality Improvement Project on Improving Patients' Willingness to Receive an Influenza Vaccination in the Emergency Department

The aim of this project was to increase willingness to receive the influenza vaccine to the optimal rate of ≥ 70%. Low acuity adult patients who visited an Emergency Department (ED) were assessed regarding their willingness to receive the influenza vaccine before and after an educational intervention that included a provider recommendation and an educational handout. A total of seventy-six patients (n = 76) were assessed. Patients' willingness to receive the influenza vaccine rose from 29% pre-intervention to 72% post-intervention without disrupting the clinical flow in a busy ED. Similar vaccine educational strategies can be applied to influenza and other vaccines in EDs  to increase vaccination willingness in patients, including those who use the ED as a primary point of contact for healthcare, decreasing the burden of influenza illness in the community.

A review of factors influencing vaccination policies and programs for older adults globally

Policies and programs to increase vaccine coverage rates among adults 50 years of age or older are limited and vaccine uptake is often suboptimal. Our review evaluated evidence on the effectiveness and success of adult-targeted vaccination interventions and identified literature gaps. Literature was retrieved (2021) from PubMed, Embase, and Google Scholar databases. Outcomes assessed included data on an intervention's effectiveness and impact on vaccine uptake. Interventions were characterized thematically: affordability (n = 9), awareness (n = 25), and vaccination access (n = 6); and included influenza, pneumococcal, tetanus-containing, and herpes zoster vaccines. Interactive interventions directed toward patients, including provider-led educational initiatives and provider recommendations showed more positive associations than less interactive interventions, such as posters and reminder-recall letters. Provider interventions, including awareness campaigns, incentives, affordability efforts, or vaccination site expansion generally showed positive associations. Combining interventions was found to be successful across several studies. Barriers and interventions varied for population subgroups, therefore, tailoring programs is critical.

Behavioral interventions for vaccination uptake: A systematic review and meta-analysis

BACKGROUND

Human behavior and more specifically behavioral insight-based approaches to vaccine uptake have often been overlooked. While there have been a few narrative reviews indexed in Medline on behavioral interventions to increase vaccine uptake, to our knowledge, none have been systematic reviews and meta-analyses covering not just high but also low-and-middle income countries.

METHODS

We included 613 studies from the Medline database in our systematic review and meta-analysis categorizing different behavioral interventions in 9 domains: education campaigns, on-site vaccination, incentives, free vaccination, institutional recommendation, provider recommendation, reminder and recall, message framing, and vaccine champion. Additionally, considering that there is variability in the acceptance of vaccines among different populations, we assessed studies from both high-income countries (HICs) and low- to middle-income countries (LMICs), separately.

FINDINGS

Our results showed that behavioral interventions can considerably improve vaccine uptake in most settings. All domains that we examined improved vaccine uptake with the highest effect size associated with provider recommendation (OR: 3.4 (95%CI: 2.5-4.6); Domain: motivation) and on-site vaccination (OR: 2.9 (95%CI: 2.3-3.7); Domain: practical issues). While the number of studies conducted in LMICs was smaller, the quality of studies was similar with those conducted in HICs. Nevertheless, there were variations in the observed effect sizes.

INTERPRETATION

Our findings indicate that "provider recommendation" and "on-site vaccination" along with other behavioral interventions can be employed to increase vaccination rates globally.

The need for vaccination in adults with chronic (noncommunicable) diseases in India - lessons from around the world

Worldwide, chronic diseases (noncommunicable diseases [NCDs]) cause 41 million (71%) deaths annually. They are the leading cause of mortality in India, contributing to 60% of total deaths each year. Individuals with these diseases are more susceptible to vaccine-preventable diseases (VPDs) and have an increased risk of associated disease severity and complications. This poses a substantial burden on healthcare systems and economies, exemplified by the COVID-19 pandemic. Vaccines are an effective strategy to combat these challenges; however, utilization rates are inadequate. With India running one of the world’s largest COVID-19 vaccination programs, this presents an opportunity to improve vaccination coverage for all VPDs. Here we discuss the burden of VPDs in those with NCDs, the benefit of vaccinations, current challenges and possible strategies that may facilitate implementation and accessibility of vaccination programs. Effective vaccination will have a significant impact on the disease burden of both VPDs and NCDs and beyond.

What is already known on this topic?

Annually, chronic or noncommunicable diseases (NCDs) cause >40 million deaths worldwide and 60% of all deaths in India

Adults with these diseases are more susceptible to vaccine-preventable diseases (VPDs); however, vaccine utilization is inadequate in this population

What is added by this report?

We highlight the benefits of vaccination in adults with NCDs that extend beyond disease prevention

We discuss key challenges in implementing adult vaccination programs and provide practical solutions

What are the implications for public health practice?

Raising awareness about the benefits of vaccinations, particularly for those with NCDs, and providing national guidelines with recommendations from medical societies, will increase vaccine acceptance

Adequate vaccine acceptance will reduce the VPD burden in this vulnerable population

Systematic review on reducing missed opportunities for vaccinations in Latin America

Objectives

To estimate the prevalence of missed opportunities for vaccination (MOV) in Latin America and the effect of interventions targeting health systems, health workers, patients, and communities on MOV.

Methods

Searches were conducted in MEDLINE, EMBASE, CINAHL, and LILACS electronic databases and relevant organizations were contacted, including the Pan American Health Organization (PAHO), to identify studies meeting eligibility criteria. A pair of reviewers identified 27 randomized and non-randomized studies quantifying the effectiveness of any intervention for reducing MOV and 5 studies assessing the rate of MOV in Latin America. Results are reported narratively when criteria to pool results were not met, and the certainty of this evidence was assessed using the GRADE approach.

Results

Evidence suggests the rate of MOV in Latin America ranged from 5% to 37% with a pooled estimate of 17% (95% CI [9, 32]) (low certainty) and that monetary incentives to healthcare teams, training for healthcare teams on how to communicate with patients, and educational interventions for caregivers probably reduce MOV (moderate to very low certainty).

Conclusions

There is insufficient evidence supporting the implementation of any intervention as policy based only on the potential reduction of MOV without considering several factors, including costs, feasibility, acceptability, and equity.

Digital Health Interventions to Enhance Prevention in Primary Care: Scoping Review

Background

Disease prevention is a central aspect of primary care practice and is comprised of primary (eg, vaccinations), secondary (eg, screenings), tertiary (eg, chronic condition monitoring), and quaternary (eg, prevention of overmedicalization) levels. Despite rapid digital transformation of primary care practices, digital health interventions (DHIs) in preventive care have yet to be systematically evaluated.

Objective

This review aimed to identify and describe the scope and use of current DHIs for preventive care in primary care settings.

Methods

A scoping review to identify literature published from 2014 to 2020 was conducted across multiple databases using keywords and Medical Subject Headings terms covering primary care professionals, prevention and care management, and digital health. A subgroup analysis identified relevant studies conducted in US primary care settings, excluding DHIs that use the electronic health record (EHR) as a retrospective data capture tool. Technology descriptions, outcomes (eg, health care performance and implementation science), and study quality as per Oxford levels of evidence were abstracted.

Results

The search yielded 5274 citations, of which 1060 full-text articles were identified. Following a subgroup analysis, 241 articles met the inclusion criteria. Studies primarily examined DHIs among health information technologies, including EHRs (166/241, 68.9%), clinical decision support (88/241, 36.5%), telehealth (88/241, 36.5%), and multiple technologies (154/241, 63.9%). DHIs were predominantly used for tertiary prevention (131/241, 54.4%). Of the core primary care functions, comprehensiveness was addressed most frequently (213/241, 88.4%). DHI users were providers (205/241, 85.1%), patients (111/241, 46.1%), or multiple types (89/241, 36.9%). Reported outcomes were primarily clinical (179/241, 70.1%), and statistically significant improvements were common (192/241, 79.7%). Results were summarized across the following 5 topics for the most novel/distinct DHIs: population-centered, patient-centered, care access expansion, panel-centered (dashboarding), and application-driven DHIs. The quality of the included studies was moderate to low.

Conclusions

Preventive DHIs in primary care settings demonstrated meaningful improvements in both clinical and nonclinical outcomes, and across user types; however, adoption and implementation in the US were limited primarily to EHR platforms, and users were mainly clinicians receiving alerts regarding care management for their patients. Evaluations of negative results, effects on health disparities, and many other gaps remain to be explored.

Analysis of the Feasibility of a Vaccination Campaign against Influenza Epidemic and COVID-19 Pandemic in French Emergency Departments: A National Survey

Background: Vaccination is one of the most effective ways to fight the influenza epidemic and the coronavirus disease 2019 (COVID-19) pandemic, which represent a major public issue. The objective was to investigate the adherence of heads of French emergency departments (ED) and nursing departments on a potential vaccination campaign of healthcare workers (HCW) and patients in ED. Method: In February 2021, ED and nursing department heads were asked to answer a national survey. It included 24 questions designed to cover some dimensions, including characteristics of the hospital and emergency departments (ED) and questions on vaccination. Results: 414 responses out of 800 questionnaires (51.8%) were collected. Scores out of 10 were, respectively, 7 (6–8) and 8 (6–9) for vaccination against influenza and COVID-19 for HCW and 2 (2–3) and 2 (2–4) for ED patients (H = 989.3; p < 0.0001). Multivariate logistic regression found that the existence of a vaccine program in the hospital and the use of point of care influenza PCR in ED were positively associated with the acceptance of influenza vaccination campaign for HCW (p = 0.003) and patients (p = 0.015). Factors limiting adherence to a vaccination program of HCW and patients were lack of medical staff (p = 0.041 for HCW and p < 0.0001 for patients), overcrowded ED (p < 0.001), and the inability to follow up with patients after the ED visit (p < 0.0001). Conclusions: There have been many missed opportunities for influenza vaccination, and there is pressure to vaccinate against COVID-19 as soon as possible. Vaccination campaigns in ED could help to improve vaccination coverage. ED staff are more likely to vaccinate HCW than patients. There are factors that support the implementation of such programs, which can be grouped into a culture of diagnosis, control, and prevention of viral infectious diseases within the hospital and ED. On the other hand, there are limiting factors, such as overcrowding and lack of personnel.

Measured Performance and Vaccine Administration After Decision Support and Office Workflow Changes for Influenza Vaccination

Influenza vaccination is underused. We examined changes in vaccination following decision support and workflow changes in a cross-sectional analysis of three vaccination seasons among adult primary care patients from 21 practices. Interventions included clinical decision support changes to facilitate documentation; changes to rooming workflow for medical assistants and licensed practical nurses to promote vaccination, prepare orders, document care done elsewhere; and record patient refusals. We measured rates for a national vaccination performance measure and receipt of onsite vaccination. Approximately 120,000 patients were eligible each season. Performance on the quality measure increased each year (40.6% to 62.5% to 76.4%). Corresponding rates of onsite vaccination were 27.7%, 28.8%, and 31.5%. The adjusted odds ratio for onsite vaccination in the second season compared with the first was 0.94 (95% confidence interval [CI] 0.92, 0.96). Onsite vaccination was more likely in the third season compared with either previous season-adjusted odds ratio for third versus second 1.14 (95% CI, 1.12, 1.16) or adjusted odds ratio for third versus first 1.07 (95% CI 1.05-1.09). Sequential changes in decision support and patient rooming process workflows were associated with large improvements in measured performance and with a significant increase in clinic-administered influenza vaccination by the third season.

Improving influenza and pneumococcal vaccination uptake among incident peritoneal dialysis patients: a quality improvement initiative

INTRODUCTION

Influenza and pneumococcal vaccination rates among peritoneal dialysis (PD) patients remain suboptimal, despite availability of vaccinations and health recommendations.

AIM

The primary aim was to improve influenza and pneumococcal vaccination rates among incident PD patients at our center to 80%. A secondary aim was to develop a sustainable workflow for vaccination in PD patients.

DESIGN

A quality improvement (QI) initiative to increase vaccination rate among incident PD patients was conducted in a tertiary care hospital in Singapore from Jul 2017 to Dec 2018. Key drivers and barriers to success were identified through root cause analysis. Change ideas focusing on improving opportunities, access and enhancement of reminder systems were implemented using Plan-Do-Study-Act methodology. Vaccination rates were monitored at 3-month intervals.

RESULTS

Total of 249 patients were eligible for vaccination. The baseline vaccination rate for influenza, pneumococcal conjugate vaccine (PCV13) and pneumococcal polysaccharide vaccine (PPSV23) were 63%, 54% and 14%, respectively. Root-cause analyses revealed several practice-related barriers, including lack of physician recommendation, time constraints and ineffective reminder systems. Multifaceted interventions, such as the provision of vaccination at non-traditional clinical settings, physician audit and feedback, utilisation of reminder tools, successfully increased influenza, PCV13 and PPSV23 vaccination rates to 86%, 85% and 63%, respectively.

CONCLUSION

A robust influenza and pneumococcal vaccination program implemented using a standardized QI methodology and multidisciplinary approach is effective in improving and sustaining influenza and pneumococcal vaccination uptake among PD patients.

Cost-Effectiveness of Pneumococcal Vaccination and Uptake Improvement Programs in Underserved and General Population Adults Aged < 65 Years

In US adults aged < 65 years, pneumococcal vaccination is recommended when high-risk conditions are present, but vaccine uptake is low. Additionally, there are race-based differences in illness risk and vaccination rates. The cost-effectiveness of programs to improve vaccine uptake or of alternative vaccination policies to increase protection is unclear. A decision analysis compared, in US black and general population cohorts aged 50 years, the public health impact and cost-effectiveness of pneumococcal vaccination recommendations, without and with a vaccine uptake improvement program, and alternative population vaccine policies. Program-based uptake improvement (base case: 12.3% absolute increase, costing $1.78/eligible patient) was based on clinical trial data. US data informed population-specific pneumococcal risk. Vaccine effectiveness was estimated using Delphi panel and trial data. In both black and general population cohorts, an uptake improvement program for current vaccination recommendations was favored, costing $48,621 per QALY gained in black populations ($54,929/QALY in the general population) compared to current recommendations without a program. Alternative vaccination policies largely prevented less illness and were economically unfavorable. In sensitivity analyses, uptake programs were favored, at a $100,000/QALY threshold, unless they improved absolute vaccine uptake < 2.1% in blacks or < 2.6% in the general population. Results were robust in sensitivity analyses. Programs to increase adult pneumococcal vaccination uptake are economically reasonable compared to changes in vaccination recommendations, and more favorable in underserved minorities than in the general population. If addressing race-based health disparities is a priority, evidence-based programs to increase vaccination should be considered.

Improving Vaccination Rates in Adults With Type 2 Diabetes in a Family Practice Setting Through the Use of Evidence-Based Interventions

Background: Adults with diabetes are at increased susceptibility to infectious disease because of hyperglycemia, poor glucose control, and decreased immunity. Diabetes is the seventh leading cause of death in Texas and the United States. Objective: The purpose of this evidence-based quality improvement project was to implement processes to facilitate providers’ adherence to immunization guidelines for adults with type 2 diabetes mellitus. Method: A protocol was created for a family practice clinic using the Four Pillars Transformation Program. Interventions included immunization standing orders, vaccine needs screening, patient education, electronic medical record alerts, an appointed immunization champion, and quality improvement meetings. Results: Ten weeks post project implementation, the increased screening and education resulted in 64% of the eligible patients being vaccinated with pneumococcal polysaccharide vaccine 23, 86% pneumococcal conjugate vaccine, 89% tetanus, and 54% herpes zoster. Conclusions: The results indicate that formal printed education on diabetes and vaccines increased vaccine uptake in eligible patients by 76%. Implications for Nursing: The Four Pillars Transformation Program allows each practice the ability to modify and select interventions best suited to the practice needs, making it a feasible tool for any clinic.

Emergency Department influenza vaccination campaign allows increasing influenza vaccination coverage without disrupting time interval quality indicators

To evaluate the impact of an influenza vaccination (IV) coverage (IVC) in a vaccination campaign of an Emergency Department (EDVC) and its impact on ED time interval quality indicators. We conducted a 4 year observational study, with an intervention during the 4th year. IVC was calculated during pre-and early-epidemic periods. During the final period, a 12 weeks EDVC was implemented. Physicians and nurses were trained and sensitized in the importance of vaccination, and their role in the prevention of severe forms of influenza was reinforced. The vaccine was proposed by physicians and nurses, and delivered by them. Repeated measures ANOVA is a validated method for related not independent groups ( https://statistics.laerd.com/statistical-guides/repeated-measures-anova-statistical-guide.php ). Overall, IVC was 987/3191 (30.9%) with an increasing trend from 28.8 to 33.2%. In the fourth period, out of 868 patients identified with IV indication, 288 had already been vaccinated (IVC 33.2%). After excluding patients presenting criteria of exclusion, IV was proposed to 475 patients: 317 (66.7%) accepted. The vaccination rate after patient's acceptance was 89.6% (288/317). At the end of the EDVC, influenza vaccination coverage was 572 (284 + 288)/868 (65.9%). The delay between arrival at the ED and seeing the triage nurse and physician as well as the overall ED length of stay were not modified during the study period and before and during EDVC. EDVC effectively doubled the influenza vaccination coverage, without modifying ED time interval quality indicators.

RCT of Centralized Vaccine Reminder/Recall for Adults

INTRODUCTION

A proven, but underutilized, method to increase current low vaccination rates is reminder/recall. Centralized reminder/recall using an Immunization Information System reduces the burden of an individual practice conducting reminder/recall. The objectives were to assess the effectiveness of centralized vaccine reminder/recall on improving adult vaccination rates using Colorado's Immunization Information System.

STUDY DESIGN

This study is a pragmatic RCT.

SETTING/PARTICIPANTS

Denver Health patients were divided into three strata: 25,039 individuals aged 19-64 years without a high-risk condition for pneumococcal disease, 16,897 individuals aged 19-64 years with a high-risk condition, and 5,332 individuals aged ≥65 years. Data were collected from October 2015 to April 2016 and analyzed between September 2016 and June 2017.

INTERVENTION

Adults aged 19-64 years without a high-risk condition who needed influenza or tetanus, diphtheria, acellular pertussis vaccine or both, and adults with a high-risk condition and adults aged ≥65 years who needed influenza, or tetanus, diphtheria, acellular pertussis, or pneumococcal vaccine, or all three vaccines were randomized to receive up to three reminder/recalls or usual care.

MAIN OUTCOME MEASURES

Documentation of receipt of any needed vaccine in Immunization Information System ≤6 months after the reminder/recall was the primary outcome. A secondary outcome included implementation costs of the reminder/recall effort. A mixed effects model assessed the association between the intervention and receipt of any needed vaccine while controlling for gender, age, race, ethnicity, insurance type, and history of vaccine refusal.

RESULTS

The intervention was associated with receipt of any needed vaccine in the adults aged ≥65 years population (AOR=1.15, 95% CI=1.02, 1.30), but not the other two populations. Influenza vaccine was the source of this difference, with 32.0% receiving a vaccine in intervention versus 28.6% in usual-care groups (p≤0.01). Start-up and implementation costs per person were $0.86. In the population aged ≥65 years, 29.4 patients would need to be contacted to gain one additional vaccination.

CONCLUSIONS

Centralized reminder/recall was effective at increasing influenza vaccination rates in adults aged ≥65 years over a short time period, without burdening the practices, and at a reasonable cost.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT02133391.

Cost effectiveness of a practice-based intervention to improve vaccination rates in adults less than 65-years-old

The cost-effectiveness of the 4 Pillars™ Practice Transformation Program to improve vaccination rates in adults <65-years-old is unknown. Two vaccines, influenza and Tdap (tetanus, diphtheria, acellular pertussis), were targeted for this age group. Cost-effectiveness of the intervention compared with control, with a primary outcome of cost per quality adjusted life year (QALY) gained, was estimated from societal and third party payer perspectives over a 10-year time horizon using a decision analysis model. Vaccination rates and intervention costs were derived from an intervention trial, and vaccine effectiveness, illness rates, and costs with/without vaccination were obtained from US databases and literature data. Future costs and effectiveness were discounted at 3%/year. The intervention cost was $1.78 per eligible patient/year. From the societal perspective, per patient total vaccination and illness costs with the intervention were $27.43 higher than control while gaining 0.00087 QALYs, costing $31,700/QALY gained. The intervention, extrapolated to the US population, could prevent 4.2 million cases, 87,489 hospitalizations, and 5,680 deaths due to influenza over 10 y in adults <65-years-old. In a probabilistic sensitivity analysis, the intervention was favored in 68.2% of model runs at a $50,000/QALY level and in 94.3% at $100,000/QALY. In a separate scenario analysis, the intervention became cost saving if influenza economic burden was >$2,099 per case (societal base case $846). Thus, the 4 Pillars Practice Transformation Program is an economically reasonable intervention to improve vaccination rates in adults <65-years-old, and could have a substantial public health impact.

Challenges in adult vaccination

Life-long primary prevention interventions beginning and continuing throughout an individual's lifetime are increasingly seen as key to meeting the global healthcare challenges that accompany demographic changes - a concept referred to as "Healthy aging". In this perspective, vaccination is seen as part of a triad, together with healthy diet and exercise. Current adult vaccine coverage is lower than target vaccination rates in most developed countries, and so vaccine preventable diseases continue to present a substantial burden on health and healthcare resources, especially in older individuals. In part, this is due to lack of knowledge and understanding of the benefits of vaccination, inconsistent recommendations by providers and uncertainties about cost benefits. However, lower vaccine effectiveness in older adults plays a part, and new vaccines with novel characteristics to improve effectiveness in older adults are required. A life-course immunization approach to ensure optimal vaccine uptake across adults of all ages can be expected to reduce morbidity and mortality in later life. To achieve this, greater emphasis on public and healthcare provider education is necessary, based on appropriate economic analyses that demonstrate the overall value of vaccination. This article introduces the technical, economic, political and demographic issues that make establishing effective adult vaccination programs such a difficult, but pressing issue, and outlines some of the steps that are now being taken to address them. Key messages Life-long preventive activities that start and continue throughout life are essential, especially as the world's population is "getting older". This "Healthy aging" approach includes not only healthy diet and physical exercise; vaccination is critical in reducing some infectious diseases and their complications. Many adults, especially older adults (who have lower immunity than younger people) develop infections such as influenza and shingles that could potentially be prevented through vaccination. This review provides a perspective on the challenges in delivering a life-course immunization program. While some vaccines are less effective in older people, newer vaccines have been developed which provide stronger and longer protection in older patients than standard existing vaccines. However, the benefits of vaccination can only be realized if the vaccines are recommended and used. For that purpose, greater education of patients and their healthcare providers is necessary. Better knowledge of vaccines and making sure that all adults are up to date with all their recommended vaccines is an essential part of "Healthy aging". This should prevent not only vaccine-preventable diseases but also reduce the risk of complications in later life.

A systematic review of strategies for reducing missed opportunities for vaccination

BACKGROUND

Missed opportunities for vaccination (MOVs) occur when persons eligible for vaccination visit a health facility and do not get the vaccines they need. We conducted a systematic review to assess effects of interventions for reducing MOVs.

METHODS

We searched PubMed, Scopus, and the Cochrane Central Register of Controlled Trials in April 2017. Three authors independently screened search outputs, reviewed potentially eligible papers, assessed risk of bias, and extracted data; resolving disagreements by consensus. We expressed study results as risk ratios (RR) with 95% confidence intervals (CI) and assessed the certainty of the evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) tool.

RESULTS

Six studies (five trials and one cohort study) met our inclusion criteria, all conducted in the United States of America. All six studies had various limitations and were classified as having a high risk of bias. We found moderate certainty evidence that the following interventions probably improve vaccination coverage: patient education (RR 1.92, 95% CI 1.38-2.68), patient tracking using community health workers (RR 1.18, 95% CI 1.11-1.25), and patient tracking and provider prompts (RR 1.24, 95% CI 1.18-1.31). In addition, we found low certainty evidence that concurrent interventions targeting health-facility (education, prompts, and audit and feedback) and family settings (phone calls) may increase vaccination coverage (RR 1.25, 95% CI 1.08-1.46).

CONCLUSIONS

The currently available evidence suggests that patient education, patient tracking, outreach sessions, and provider prompts reduce missed opportunities for vaccination and improve vaccination coverage. Rigorous studies are required to confirm these findings and increase the certainty of the current evidence base. WHO is currently coordinating efforts to generate such evidence, especially from low-income and middle-income countries, and it is likely that the data will be available in the next few years.

Cost-effectiveness of increasing vaccination in high-risk adults aged 18-64 Years: a model-based decision analysis

BACKGROUND

Adults aged 18-64 years with comorbid conditions are at high risk for complications of certain vaccine-preventable diseases, including influenza and pneumococcal disease. The 4 Pillars™ Practice Transformation Program (4 Pillars Program) increases uptake of pneumococcal polysaccharide vaccine, influenza vaccine and tetanus-diphtheria-acellular pertussis vaccine by 5-10% among adults with high-risk medical conditions, but its cost-effectiveness is unknown.

METHODS

A decision tree model estimated the cost-effectiveness of implementing the 4 Pillars Program in primary care practices compared to no program for a population of adults 18-64 years of age at high risk of illness complications over a 10 year time horizon. Vaccination rates and intervention costs were derived from a randomized controlled cluster trial in diverse practices in 2 U.S. cities. One-way and probabilistic sensitivity analyses were conducted.

RESULTS

From a third-party payer perspective, which considers direct medical costs, the 4 Pillars Program cost $28,301 per quality-adjusted life year gained; from a societal perspective, which adds direct nonmedical and indirect costs, the program was cost saving and more effective than no intervention. Cost effectiveness results favoring the program were robust in sensitivity analyses. From a public health standpoint, the model predicted that the intervention reduced influenza cases by 1.4%, with smaller decreases in pertussis and pneumococcal disease cases.

CONCLUSION

The 4 Pillars Practice Transformation Program is an economically reasonable, and perhaps cost saving, strategy for protecting the health of adults aged < 65 years with high-risk medical conditions.

Using the 4 Pillars to increase vaccination among high-risk adults: who benefits?

OBJECTIVES

To compare changes in vaccination rates (pneumococcal polysaccharide vaccine [PPSV]; tetanus, diphtheria, and pertussis [Tdap] vaccine; and influenza vaccine) among high-risk adults following an intervention (June 1, 2013, to January 31, 2015) that used the 4 Pillars Practice Transformation Program (4 Pillars Program).

STUDY DESIGN

Post hoc analysis of data from a randomized controlled cluster trial.

METHODS

Eighteen primary care practices received staff education, guidance for using the 4 Pillars Program, and support for a practice immunization champion. Paired t tests were used to compare vaccination rates separately for those with diabetes, chronic lung or chronic heart disease, or other high-risk conditions. Student's t tests were used to compare vaccination rates across high-risk conditions. Generalized estimating equation modeling was used to determine the likelihood of vaccination.

RESULTS

Based on International Classification of Diseases, Ninth Revision, Clinical Modification codes, 4737 patients aged 18 to 64 years were identified as having diabetes (n = 1999), chronic heart disease (n = 658), chronic lung disease (n = 1682), or another high-risk condition (n = 764). PPSV uptake increased by 12.2 percentage points (PP), Tdap vaccination increased by 11.4 PP, and influenza vaccination increased by 4.8 PP. In regression analyses, patients with diabetes (odds ratio [OR], 2.2; 95% CI, 1.80-2.73), chronic lung disease (OR, 1.50; 95% CI, 1.21-1.87), or chronic heart disease (OR, 1.32; 95% CI, 1.02-1.71) were more likely to receive PPSV than those without the respective high-risk condition. Those with diabetes (OR, 1.14; 95% CI, 1.01-1.28) or chronic lung disease (OR, 1.14; 95% CI, 1.01-1.30) were more likely to receive an influenza vaccine than those without the respective condition. The likelihood of Tdap vaccination was not significantly associated with any of the chronic conditions tested.

CONCLUSIONS

An intervention including the 4 Pillars Program was associated with significant increases in vaccination of high-risk adults. However, the overall uptake of recommended vaccines for those with high-risk conditions remained below national goals.

Using the 4 Pillars™ Practice Transformation Program to increase adolescent human papillomavirus, meningococcal, tetanus-diphtheria-pertussis and influenza vaccination

OBJECTIVES

To report the results of an intervention using the 4 Pillars™ Practice Transformation Program (4 Pillars™ Program) to increase adolescent vaccinations including human papillomavirus vaccine (HPV) and influenza vaccines, which remain underutilized in this population.

STUDY DESIGN

Eleven pediatric and family medicine practices, previously control sites from a randomized controlled cluster trial, with ≥50 adolescent patients participated. The 4 Pillars™ Program was the foundation of the intervention. De-identified demographic, office visit and vaccination data were derived from electronic medical record extractions for patients whose date of birth was 4/1/1997 to 4/1/2004 (ages 11-17years at baseline). Vaccination rates for HPV, influenza, tetanus-pertussis-diphtheria (Tdap) and meningococcal (MenACWY) vaccines were determined for all eligible patients pre- and post intervention (i.e., vaccination rates on 4/1/2015 and 4/30/2016).

RESULTS

Among 9473 patients ages 11-17years at baseline (4/1/2015), mean pre-intervention vaccination rates for HPV initiation and completion, meningococcal, Tdap and influenza vaccines were below national levels. Rates increased significantly post intervention (P<0.001) for HPV initiation which increased 17.1 percentage points (PP) from 51.4%; HPV completion increased 14.8PP from 30.7%, meningococcal vaccine uptake increased 16.6PP from 79.1%, Tdap vaccine uptake increased 14.6PP from 76.9%. Influenza vaccine uptake did not increase significantly (2.3PP from 40.1%). In the regression using generalized estimating equations, odds of vaccination were higher for younger, non-white adolescents for all vaccines; being in a smaller practice decreased the odds of Tdap vaccination but increased the odds of influenza vaccination.

CONCLUSION

Clinically and statistically significant improvements in HPV series initiation and completion, and meningococcal and Tdap vaccinations were observed in primary care practices implementing the 4 Pillars™ Practice Transformation Program. Clinical Trial Registry Number: NCT02165722.