Improving Pneumococcal and Herpes Zoster Vaccination Uptake: Expanding Pharmacist Privileges
Published Online: September 11, 2013
Michael S. Taitel, PhD; Leonard E. Fensterheim, MPH; Adam E. Cannon, MPH; and Edward S. Cohen, PharmD
Community pharmacies are uniquely positioned to increase immunization rates in the United States for vaccine-preventable diseases. A recent survey of public health leaders identified pharmacists as playing a pivotal role in vaccine administration and pandemic planning.1 Evidence in published medical literature suggests that pharmacies have the capacity to influence previously difficult-to-reach populations.2-5 Pharmacists may be especially effective in immunizing high-risk, older adults who are more likely to utilize pharmacy services for prescription medication than the general population.6 Pharmacists are also able to leverage their ability to identify people with key risk factors (eg, diabetes, heart disease), encourage them to receive their Centers for Disease Control and Prevention (CDC)-recommended vaccinations, and administer the required vaccine.7
A major challenge to pharmacist-provided immunizations is variability in state legislation on the practice. Authority for pharmacists to administer vaccinations and the scope of that practice is defined by the Board of Pharmacy in each state, including the process by which pharmacists administer vaccines, the type of vaccines permitted, and legal patient age for vaccination. Although the scope of practice is defined by the board of pharmacy, the actions of each board are subject to legislative regulatory oversight. Consequently, the legislative process produces variability in state statutes governing pharmacy privileges, which has resulted in “considerable differences in how pharmacist-provided immunizations are delivered at the state level.”7
The objectives of this study are to (1) investigate how state-authorized pharmacist immunization privileges influence pharmacist intervention effectiveness in delivering pneumococcal and herpes zoster vaccinations and (2) assess the implications these state-authorized pharmacist immunization privileges have on vaccination rates.
This cross-sectional study analyzed vaccination records from the Walgreens pharmacy chain between August 1, 2011, and March 1, 2012. Vaccination records for influenza, pneumococcal disease, and herpes zoster offered by Walgreens during the study period were identified from pharmacy claims and information extracted from the pharmacy computer system for the purposes of the study. Type of vaccination was determined from the US Food and Drug Administration National Drug Code (NDC11).
Risk factors for pneumococcal infection were determined from the Advisory Committee on Immunization Practices (ACIP) of the CDC (Table 1).8 Risk factors for herpes zoster infection were defined as patients aged 60 years or greater, as identified by the ACIP.9
A random sample of 53,000 patients was selected from all patients having a pharmacy claim for influenza vaccination during the study period. For these patients, their Vaccination Administration Record (VAR), a mandatory form which is completed by the patient and the pharmacist upon administration of all vaccinations, was analyzed. The Walgreens VAR form serves as a screening tool to identify relevant high-risk factors for vaccine-preventable diseases, which the pharmacist can then recommend to the patient; it also serves as a patient consent form and administrative record for vaccination. In this study, the VAR was utilized to gather a more complete vaccination history of the patient and to identify relevant high-risk factors. High-risk status for pneumococcal disease, as outlined by the previously mentioned ACIP recommendations, was determined from completed VAR forms. High-risk status for herpes zoster was determined from patient’s age from pharmacy claims. Patients who indicated they previously received a vaccination for pneumococcal disease or herpes zoster were excluded from the analysis. State-level pharmacist privileges for the administration of pneumococcal and herpes zoster vaccinations were identified from American Pharmacists Association (APhA)7 and internal Walgreens data.
State privileges were classified into 3 levels for pneumococcal and herpes zoster vaccinations: (1) pharmacist authorized to administer vaccinations under a protocol or prescriptive authority; (2) pharmacist authorized to administer vaccinations only with a patient-specific prescription; and (3) pharmacist not authorized to administer vaccinations; however, within this classification, vaccine may be dispensed by pharmacists and administered by onsite nurses. Pharmacy claims for the state of North Dakota, which does not have a Walgreens pharmacy, were excluded from the analysis. We defined vaccination uptake rate as the proportion of previously unvaccinated, high-risk patients who subsequently received vaccination after pharmacist intervention. Rates were determined for pneumococcal disease and herpes zoster, stratified by each of the 3 state privilege categories. There were no known changes in state privileges during the study period. Patients who received a pneumococcal or herpes zoster vaccination in a state with a different pharmacist privilege level than their influenza vaccination were excluded from the analysis. The percentage of patients excluded was 0.02%. All data analysis was performed with SAS 9.2 software (SAS Institute Inc, Cary, North Carolina). Statistical significance was assessed at the α = 0.05 level. This study was approved by Quorum IRB #26510.
Of the 53,000 randomly selected patients who had claims for an influenza vaccination, 46,257 (87.3%) had a complete and legible VAR form and pharmacy records (Table 2). The average age of the sample was 58.5 years and the sample was 42.8% male. Of the total patient population, 30.3% had 1 or more chronic conditions as indicated by their VAR form; these chronic conditions included anemia, asthma, diabetes, heart disease, kidney disease, liver disease, and lung disease. For pneumococcal disease, 30,966 (66.9%) of the patients were found to be at high risk: 22,631 (73.1%) were 65 years or older and 8335 (26.9%) were younger than 65 years and had a high-risk condition for pneumococcal disease. For herpes zoster, 27,190 (58.8%) were high-risk patients.
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