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Using the 4 Pillars to Increase Vaccination Among High-Risk Adults: Who Benefits?
Mary Patricia Nowalk, PhD, RD; Krissy K. Moehling, MPH; Song Zhang, MS; Jonathan M. Raviotta, MPH; Richard K. Zimmerman, MD, MPH; and Chyongchiou J. Lin, PhD
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Using the 4 Pillars to Increase Vaccination Among High-Risk Adults: Who Benefits?

Mary Patricia Nowalk, PhD, RD; Krissy K. Moehling, MPH; Song Zhang, MS; Jonathan M. Raviotta, MPH; Richard K. Zimmerman, MD, MPH; and Chyongchiou J. Lin, PhD
Pneumococcal; tetanus, diphtheria, and pertussis; and influenza vaccination increased among high-risk adults in a 2-year study.
In regression analyses (Table 2), 2060 patients who had received PPSV before the study began (June 1, 2012) were excluded from the PPSV regression model; similarly, 1796 patients who had received the Tdap vaccine before the study began were excluded from the Tdap vaccine regression model. The odds of pneumococcal vaccination were significantly associated with older age (odds ratio [OR], 1.02; 95% CI, 1.01-1.02), white race (OR, 1.45; 95% CI, 1.02-2.06), and having diabetes (OR, 2.22; 95% CI, 1.80-2.73), chronic lung disease (OR, 1.50; 95% CI, 1.21-1.87), and chronic heart disease (OR, 1.32; 95% CI, 1.02-1.71). The odds of Tdap vaccination were significantly inversely associated with being female (OR, 0.83, 95% CI, 0.70-0.99; reference = males). The odds of influenza vaccination were associated with being female (OR, 1.24; 95% CI, 1.12-1.37), with being older (OR, 1.03; 95% CI, 1.03-1.04), with having diabetes (OR, 1.14; 95% CI, 1.01-1.28), and with having chronic lung disease (OR, 1.14; 95% CI, 1.01-1.30). 


With a concerted effort, primary care practices were capable of modifying their offices’ systems to significantly improve vaccination rates from baseline levels among high-risk adults younger than 65 years. For pneumococcal vaccine, these results (56%) are in stark contrast to the 2014 national rate of 20%,4 and among those with diabetes (66%), the rate surpasses the national goal of 60%.5 Moreover, the improvement of 12.2 PP is notably higher than secular trends of less than 2 PP per year recently observed among adults aged 19 to 64 years with high-risk conditions.4,19,20 Female sex, older age, and white race were related to higher likelihood of receipt of PPSV, similar to recent national data that indicate significantly lower rates among nonwhites compared with whites6 and higher rates among older than younger individuals.4 In this study, those with diabetes, chronic lung disease, or chronic heart disease were more likely to receive PPSV than patients without each respective high-risk condition. The risk of pneumococcal disease is increased for all 3 of these comorbidities21; thus, it is important to know if an intervention shown to be effective among all adults is similarly effective among high-risk adults or if a special intervention is necessary. These data indicate that high-risk adults do not require a separate intervention, as their increases in PPSV uptake approached increases reported in a study of all adults.14 

Tdap vaccine uptake also increased significantly from baseline (by 11.4 PP to 49.4%). These values exceeded the 2015 national rate (20.1%), recent secular trends of 3 PP per year increased uptake for all adults older than 19 years,4,19,20 and the increases among all adults (6.2 PP) shown in a previous study.13 Interestingly, in this study, men with high-risk conditions were more likely to receive the Tdap vaccine, whereas increased rates among women might be expected given the recommendation for pregnant women22 and others who care for infants to receive the Tdap vaccine. Influenza vaccination increased significantly from baseline (3.1-5.9 PP) for those with any high-risk condition. Those with diabetes and those with chronic lung disease were more likely to have received the influenza vaccine compared with those without these conditions, whereas those with chronic heart disease were not more likely to be vaccinated against influenza than those without. Influenza vaccination rates for all groups were still considerably below Healthy People 2020 goals of 70%,5 a troubling finding given their high risk of influenza complications. 

Barriers to adult vaccination include patient, provider, and health system issues, such as lack of awareness of the need for vaccination, competing priorities for the physician, and incomplete documentation of vaccination history.23 The Task Force on Community Preventive Services recommends provider reminders and a combination of interventions to increase vaccination coverage among high-risk adults.24 The 4 Pillars Program offers strategies to address each of these types of barriers, including assessing and communicating the need for vaccination by all members of the clinical staff, implementing best practice alerts in the EHR or other reminders to providers, offering simultaneous vaccination with other indicated vaccines, and using standing order protocols. In an RCCT, the 4 Pillars Program demonstrated modest improvements in vaccination rates for all 3 vaccines among all adults.13-15 Other studies have used similar multifaceted approaches to increasing pneumococcal and influenza vaccination25,26 with moderate success. 


The pneumococcal vaccine is recommended for cigarette smokers.21 We did not specifically include smokers without high-risk medical conditions and therefore do not know how their inclusion would have changed the vaccination estimates. The completeness and accuracy of ICD-9-CM coding was not verified, although EHRs were used. Other records (eg, pharmaceuticals as a proxy for diagnoses) were not evaluated to confirm or augment ICD-9-CM codes. Separate analyses of uncommon ICD-9-CM codes were not done due to funding and time limitations. The population is limited to the greater Pittsburgh region and may not be generalizable to other populations. This is a post hoc analysis derived from an RCCT. The primary purpose of the analysis was to compare the effect of the intervention on groups of adults with common high-risk conditions rather than demonstrate its effectiveness against no program; hence, before-and-after analyses were conducted. 


An intervention including the 4 Pillars Program, staff education, and support for a practice-based IC was associated with significant increases in PPSV, Tdap, and influenza vaccination among high-risk adults aged 18 to 64 years over a 2-year study. These findings further support the use of evidence-based strategies as part of a comprehensive, practice-based effort to address low vaccination rates among adults with high-risk medical conditions. Providers should be aware that the systems that are being successfully used to improve vaccination of non–high-risk patients may be equally effective for vaccinating patients with high-risk conditions.

Author Affiliations: Department of Family Medicine, University of Pittsburgh School of Medicine (MPN, KKM, SZ, JMR, RKZ, CJL), Pittsburgh, PA.

Source of Funding: This investigation was supported by a grant (U01 IP000662) from the CDC. The views expressed herein are those of those authors and not those of the CDC. The project described was also supported by the National Institutes of Health through Grant Numbers UL1 RR024153 and UL1TR000005.

Author Disclosures: Dr Nowalk, Ms Zhang, and Mr Raviotta have received grants from Pfizer Inc and Merck & Co. Drs Zimmerman and Lin and Ms Moehling have received grants from Pfizer, Merck, and Sanofi. 

Authorship Information: Concept and design (MPN, JMR, RKZ); acquisition of data (MPN, KKM, SZ, JMR, RKZ); analysis and interpretation of data (MPN, SZ, RKZ, CJL); drafting of the manuscript (MPN, CJL); critical revision of the manuscript for important intellectual content (MPN, KKM, JMR, RKZ, CJL); statistical analysis (SZ, CJL); provision of patients or study materials (JMR); obtaining funding (RKZ); administrative, technical, or logistic support (KKM, JMR, RKZ); and supervision (MPN, RKZ). 

Address Correspondence to: Mary Patricia Nowalk, PhD, RD, University of Pittsburgh School of Medicine, 4420 Bayard St, Ste 520, Pittsburgh, PA 15260. E-mail:

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