Creating an Immunization Niche in the Community Pharmacy Module 1: Overview of the Immunization Niche Jonathan G. Marquess, PharmD, CDE, CDM Learning Objectives At the conclusion of this program the pharmacist will be able to: Discuss various vaccine preventable diseases and their impact on the community List and describe five reasons why the community pharmacist can improve vaccination resources in their community Describe three methods for incorporating immunization outreach in the community pharmacy Discuss how to research vaccine administration requirements in your state List the various vaccination populations and their required vaccines Outline a step-by-step program for becoming involved in improving immunization awareness and advancing the overall immunization rate in their community Discuss business and professional growth opportunities provided by offering an immunization program in their practice setting 1
Pre-Assessment Questions Pre-Assessment Question #1 According to research, what percentage of the population are likely to take action on the basis of the pharmacist s vaccine recommendation? a. 5% b. 10% c. 25-30% d. 50-94% ** 2
Correct Answer According to research, what percentage of the population are likely to take action on the basis of the pharmacist s vaccine recommendation? d. 50-94% ** Pre-Assessment Question #2 Which of the following questions is the most important one to ask a vaccine candidate? a. How old are you? b. Are you allergic to codeine? c. Did you have any adverse reactions to earlier doses of this vaccine? ** d. How will you be paying for your vaccine? e. Which Medicare Part D plan to you have? 3
Correct Answer Which of the following questions is the most important one to ask a vaccine candidate? c. Did you have any adverse reactions to earlier doses of this vaccine? ** Pre-Assessment Question #3 Which of the following governs prescribing authority? a. Federal Law b. County Law c. State Law ** d. State immunization registry e. None of the above 4
Correct Answer Which of the following governs prescribing authority? c. State Law ** Introduction to Immunization 5
Consider These Questions 1. Can the local pharmacist improve health care awareness and improve health care in the community? Consider These Questions 2. Would establishing a patient-centered immunization program in your pharmacy setting serve your community? 6
Consider These Questions 3. Should I consider becoming an immunizing pharmacist and have immunizations as part of my day-to-day practice? Answer YES! YES! YES! 7
Vaccinations are a Critical Need Vaccination coverage remains at less than 50% among Young children Adults with risk factors for influenza complications Health care personnel (HCP) Pregnant women Why Immunize? Influenza Annual prevalence: 5% to 20% 36,000 deaths per year Mortality increased steadily since 1976-1977 season 90% of influenza mortality (~32,000) greater than 65 years of age 152 deaths in children less than 18 years of age 120,000 hospitalizations 1. Fact Sheet. Available at: http://www.cdc.gov/flu/keyfacts.htm. 2. Sokos DR. Am J Health-Syst Pharm. 2005;62:367-377. 8
Why Immunize? Influenza Influenza kills as many or more Americans than breast cancer Influenza kills 2 to 3 times more Americans than HIV/AIDS Annual impact of influenza in the United States (US) Infection 82 million Illness 65 million Medically attended 30 million Influenza Related Deaths Influenza related pulmonary and circulatory deaths 1976-1990 Average 19,000 1990-1999 Average 36,000 Rates of deaths/100,000 0.4-0.6 aged 0-49 7.5 aged 50-64 98.3 aged 65 and older Thompson WW, Shay DK, Weintraub E, et.al.mortality associated with influenza and respiratory syncytial virus in the United States. JAMA 2003; 289:179-86 9
Influenza Vaccination Reduces Hospitalizations Vaccine was associated with 19% reduction in hospitalization 23% reduction of cerebrovascular disease 29% reduction in pneumonia 50% reduction of death from all causes These findings highlight the benefits of vaccination and supports efforts to increase the rates of vaccination among the elderly Nichol KL, et al, Vaccination and Reduction in Hospitalizations for Cardiac Disease and Stroke among the Elderly. NEJM 2003; 384:1322-32 Why Immunize? Pneumonia Every year, nearly 60,000 Americans die of pneumonia Mortality from pneumonia generally decreases with age until late adulthood Elderly individuals are at increased risk for pneumonia and associated mortality 10
Why Immunize? Hepatitis B Estimated 1.25 million chronically infected Americans, of whom 20-30% acquired their infection in childhood Over 6,000 new cases per year About 30% of persons have no signs or symptoms Death from chronic liver disease occurs in 15% 25% of chronically infected persons Why Immunize? Shingles One million cases of shingles each year Lifetime risk of 20 percent in the US Generally associated with aging and reduced immunocompetence (HIV/AIDS, cancer) One in five patients develop postherpetic neuralgia 11
Why Immunize? Tetanus Tetanus infection causes painful tightening of the muscles, usually all over the body It can lead to "locking" of the jaw, which makes it impossible to open your mouth or swallow Death from suffocation is possible The disease is rare in the US, with less than 100 cases of tetanus reported annually Why Immunize? Human Papillomaviruses (HPVs) Approximately 20 million people are currently infected with HPVs 6.2 million new cases per year HPVs are now recognized as the major cause of cervical cancer 19 states, including the District of Columbia, have passed HPV-related laws or resolutions 12
Why Immunize? Meningococcal Disease ~25,000 and 50,000 hospitalizations due to viral meningitis yearly College freshmen living in dormitories are at higher risk Why Immunize? Other Opportunities Travel vaccines Rotavirus Yellow fever Rabies Typhoid Japanese encephalitis Smallpox Measles, mumps, rubella Varicella Diphtheria, pertussis 13
Achievements in Public Health (Death Rate) MMWR 1999;48(29):621-629 Healthy People 2010 Goals and Current Coverage 100% 90% 90% 98% 90% 80% 70% 60% 60% 60% 60% Healthy People 2010 Goal 50% 40% 30% 20% 10% 0% PPV23 65+ PPV23 65+, 56% PPV23 18-49 High Flu 65+ Flu 18-49 High Risk Hep B MSM Hep B HCW PPV23 Risk 18-49 High Risk, 13% Flu 65+, 70% Flu 18-49 High Risk, 24% Hep B MSM, 9% Hep B HCW, 75% www.healthypeople.gov National Health Interview Survey (CDC, NCHS) 14
Interesting Fact Percentage of persons age over 65 who received a annual influenza shot 65.7% nationwide Top ten states: 1. Minnesota 78.1% 2. South Dakota 76.3% 3. Colorado 74.2% 4. Oklahoma 73.2% 5. Wyoming 72.9% 6. Nebraska 72.6% 7. Hawaii 72.1% 8. Wisconsin 71.8% 9. Iowa 71.7% 10. Connecticut 71.1% Why a Pharmacy-based Immunization Niche? 15
2007 ACIP Report Pharmacist Recommendations 1. Schedule flu vaccine clinics throughout the flu season 2. Recommend and administer the proper flu vaccine dosage for children ages 6 months to 8 years old 3. Strongly recommend school age children through senior adults be vaccinated 4. Encourage health care professionals to be vaccinated for flu Total Patient Care Change your practice to one that is concerned about the patient s overall wellness and your service to the community will be even more valuable Educate your patients of the new service you will be offering 16
Why Your Pharmacy as an Immunization Destination? Convenient hours Extended evening and weekend hours Less paperwork No appointment needed Vaccination given by someone who knows their health history Personal attention provided to answer concerns / questions Identification of high risk patients using the pharmacy s database Most accessible health care professional Trust! Medicare Part D Decreasing Third Party Reimbursement Medicaid AMP Pharmacy PBMs Mail Order 17
Current State of Community Pharmacy Net operating income down 30% Gross profit down from 23.6% to 22.8% Overall and prescription sales stagnant Independent Net Margin (Since 1997) 1997 1999 2001 2003 2005 In the middle of difficulty lies opportunity Albert Einstein 18
Compounding Medication Therapy Management Immunizations Pharmacy Screening Programs DME Provider Pharmacies Play a Growing Role in Immunization Efforts Pharmacies Reporting Activity (%) 30 25 20 15 10 5 0 18.9 27.3 Immunization Promotion 11.9 14.7 Counseling About Adult Immunizations 1998 2001 2.2 6.8 Pharmacist-administered Adult Immunizations Influenza vaccination accounted for majority of immunizations administered, which also included hepatitis A and B, Lyme disease, tetanus, and chicken pox. Kamal KM, et al. J Am Pharm Assoc. 2003;43:470-482. 19
Many of Your Colleagues are Already Providing this Service Over 43% of independent pharmacists offer immunizations Value of Vaccination in Working Adults Those who were immunized 43% fewer days of sick leave 44% fewer MD visits for upper respiratory infection (URI) 25% reduction of frequency of URI 20% reduction of the duration of URI Net savings from vaccination was $4,685 per 100 employees or $46.85 per person Nichol KL, et al. The effectiveness of vaccination against influenza in healthy, working adults. NEJM 1995; 333:889-893 20
Bottom Line Vaccinations are needed Vaccination is a business opportunity Benefits of a Immunization Niche 21
Immunization Can Improve Your Pharmacy? Professional satisfaction Improved community outreach Financial opportunity Professional Satisfaction Increased health care awareness Proactive management of health risks 22
Community Outreach Pharmacy as a community health center Provide a needed service - professional and convenient Financial Opportunity Brings in new customers Add-on sales Word-of mouth advertising Creates a new profit center 23
Return on Investment (ROI) Investment is relatively small Staff training Supplies Documentation Advertisement Payoff is proportionally large Drug reimbursement Administration fees OTC companion sales Increased foot traffic and customer base How to Incorporate Immunization Outreach in Your Pharmacy 24
How to Incorporate Immunization Outreach in Your Pharmacy Level 1: Pharmacist as Advocate Level 2: Pharmacist as Facilitator Level 3: Pharmacist as Immunizer Level 1: Pharmacist As Advocate 25
Pharmacist As Advocate The pharmacist immunization advocate: Determines patients immunization status Identifies high-risk patients Protects patients by becoming immunized and having pharmacy staff do the same Level 2: Pharmacist As Facilitator 26
Immunization Partnerships Pharmacy Physician Increase Immunization Rates Health Department Employer Groups Pharmacist As Facilitator The pharmacist facilitator Assists patients in locating vaccine resources Partners with providers (eg, visiting nurses, clinics) to provide vaccinations in the pharmacy Refers to other health care providers 27
Level 3 - Pharmacist As Immunizer Complement the Physician Pharmacy and the physician or clinic need to be in a partnership relationship. Complement not compete Visit the physician or clinic and discuss your ideas/services and let them know of your desire to work with them in improving patient care in the community 28
Considerations of the Pharmacy-Based Immunization Niche States Authorized to Administer Immunizations a 29
Legal and Regulatory After confirming legal eligibility to administer medications, make sure you have an authorization document (or other state requirement) to administer vaccines Legal and Regulatory ex. Georgia 26-4-4. Definition of "practice of pharmacy. The "practice of pharmacy" means the interpretation, evaluation, or dispensing of prescription drug orders in the patient's best interest; participation in drug and device election, drug administration, drug regimen reviews, and drug or drug related research; provision of patient counseling and the provision of those acts or services necessary to provide pharmacy care; performing capillary blood tests and interpreting the results as a means to screen for or monitor disease risk factors and facilitate patient education, and a pharmacist performing such functions shall report the results obtained from such blood tests to the patient's physician of choice; and the responsibility for compounding and labeling of drugs and devices 30
Liability Legal issues vary state by state and are very complex in nature Consult an attorney or insurance specialist Coverage for pharmacy as well as pharmacist to include drug administration The best way to prevention against liability claims is training and protocol Which Vaccines Will You Administer? Start slow and grow your niche! Choose two to four vaccines and become an expert in administering those Take a look at your patient population and community Incorporate vaccinations into your marketing plan 31
Who Should You Recommend for Immunizations? Children? Eg, influenza, MMR, HPV Adults? Eg, influenza, pneumonia, shingles Travel? Eg, yellow fever, rotavirus, typhoid Children Many are not up to date on their immunizations 32
Child Catch-Up Schedule Adults Adults are not getting the flu shot each year Newer vaccines were not available when they were children Immunity can fade over time 33
ACIP Adult Schedule Travel Vaccinated prior to overseas travel is highly recommended Travel season is year round Publicize your service with travel agencies, adoption agencies, travel clubs, etc. 34
Myths/Facts about Immunizations Immunization Myth #1 MYTH " I might catch the flu from the vaccine" 35
Immunization Fact #1 FACT Injectable influenza vaccines can't give you influenza Injectable influenza vaccines are made from influenza viruses that have been killed, and a killed virus cannot give you influenza Immunization Myth #2 MYTH " my friend had the influenza shot, but still got the flu" 36
Immunization Fact #2 FACT There may be other factors involved While it's true that getting an influenza vaccination doesn't guarantee you won't become infected with influenza, the vaccine prevents influenza in about 70% to 90% of healthy people younger than age 65 Immunization Myth #3 MYTH " the flu is not that serious" 37
Immunization Fact #3 FACT Influenza can have serious results Influenza is a contagious disease that can lead to serious complications Each year on average, in the US more than 200,000 people are hospitalized and 36,000 die from influenza and its complications Immunization Myth #4 MYTH " I never get the flu" 38
Immunization Fact #4 FACT Influenza strains change each year The best way to help protect yourself from new influenza strains is to get vaccinated each fall Immunization Myth #5 MYTH " I'm willing to risk it" 39
Immunization Fact #5 FACT It s not about you Vaccination is recommended for people, who want to reduce the likelihood of becoming ill with influenza or transmitting influenza to others, should they become infected Immunization Myth #6 MYTH " it's for old people and young kids" 40
Immunization Fact #6 FACT The elderly and young children are just two of the groups considered to be at increased risk for complications from influenza, but influenza vaccination can benefit anyone over the age of 6 months From 5% to 20% of the U.S. population develops influenza every year Immunization Myth #7 MYTH " I may be allergic to the vaccine" 41
Immunization Fact #7 FACT Influenza vaccines are safe for most people However, the influenza vaccine is not appropriate for those who have had a severe allergic reaction to eggs or to a previous influenza vaccination Vaccination may not be appropriate if you have a history of Guillain-Barré syndrome Immunization Myth #8 MYTH " I've heard the side effects from the shot are worse than the flu itself" 42
Immunization Fact #8 FACT Most people do not have any serious problems from influenza vaccination Most common side effects of the vaccine include minor soreness or redness at the site of the shot and mild general symptoms May cause serious problems, such as severe allergic reactions Immunization Myth #9 MYTH " I missed the vaccination season" 43
Immunization Fact #9 FACT You can still protect yourself after autumn Getting vaccinated later in the season (December through March) can still help protect you and your loved ones from influenza Conclusion Vaccination provides a valuable health resource to the community The community pharmacy is an ideal location for this service There are three levels of pharmacist involvement in vaccination advocate, facilitator, immunizer 44
Please Proceed to the Post- Test 45