Immunizations: A Gateway to Collaborative Practice

Pharmacists are increasingly emphasizing their role as health care providers, not simply packagers of medications. The provision of immunizations falls within the goals of Healthy People 2010, which include objectives designed to decrease or eliminate illness, disability, and premature death among individuals and communities. Immunization is listed among the 27 focus areas of Healthy People 2010.

As an indicator of health, in 1998, for adults 65 years, the influenza and pneumococcal immunization rates were a dismal 64% and 46%, respectively. The goals of Healthy People 2010 include a target rate of 90% for influenza and pneumococcal vaccination rates.1 If the nation is to achieve this lofty goal, then health care providers from all areas need to take action.

Collaboration

Pharmacists are able to administer a variety of immunizations under collaborative practice agreements, but most of the attention seems to focus on influenza and pneumonia vaccine. The topic of these vaccines is timely because influenza season is fast approaching. According to the National Vital Statistics Reports released in 2001, the number of deaths due to influenza rose from 63,730 in 1999 to 67,024 in 2000.2 This rise is unfortunate, considering that effective vaccines are available to prevent some cases of influenza and pneumococcal disease.

Pharmacists have a key advantage in the collaborative practice setting for the provision of immunizations. They have been shown to be the most accessible providers of health care, compared with primary care physicians, physician assistants, nurse practitioners, and nurse midwives.3 Pharmacists and their pharmacies are situated in a variety of locations, including grocery stores, strip malls, medical buildings, and independent locations. Pharmacies tend to be open longer hours and on weekends, when traditional providers? offices often are closed.4 This increased access as health care providers for the community may allow a niche for interested pharmacists to enter into the immunization arena.

The core tenets of pharmacy-based immunization include prevention, partnership, quality, documentation, and empowerment.5 Partnership includes collaboration not only with local physicians, but also with other health agencies in the area. Coordination of care can help to prevent duplication of services, as well as to identify areas where individuals are underserved.

Currently, pharmacists have the authority to provide immunizations in 37 states in the nation (Table). In 30 of the 37 states, pharmacists are known to be actively administering immunizations to patients.6

Pharmacists need to choose to what degree they would like to become involved in immunization efforts. A study done in a rural community found that a collaborative effort between pharmacists and nurses significantly increased the influenza vaccination rate in patients with indications for the vaccine, from 28% in 1998 to 54% in 1999. In this joint effort, the pharmacists were responsible for the design, initiation, implementation, and logistics of the program, and the nurses functioned as administrators of the vaccine.7

In another study, in which a clinical pharmacist administered influenza vaccine in a clinic setting, patients? perceptions of the pharmacist were good. Of the 63 patients surveyed, 97% were comfortable with the immunization provider, 83% agreed that appropriate information was given along with the immunization, and 92% expressed a desire for the same individual to provide the immunization service the next year. It was interesting to note that only 13% of the patients remembered that a pharmacist administered their vaccine. It is possible that, because the immunization was done in a clinical setting, patients did not think of a pharmacist as a health care provider outside of a pharmacy.8

Perceptions by other health care providers surveyed in that same study were positive, with 50% stating that the immunization service allowed them more time to spend in other areas of their practice. Also, 90% were comfortable with clinical pharmacists providing immunizations in their clinic.8 It can be argued that clinicians in other areas may not as readily accept pharmacists providing immunizations. The key may be to already have an established relationship with other clinicians in the area when undertaking the development of a collaborative practice.

Community Pharmacist Involvement

A study by Grabenstein et al looked at the rate of patients immunized by community pharmacists in Washington State, compared with that in a state that did not allow pharmacist immunization (Oregon) at the time of the study in 1998. It was determined that the pharmacists in Washington administered more influenza vaccine to patients than their nursing counterparts in Oregon pharmacies. The overall increase in immunized patients was clinically significant, with 4.7% more patients aged 65 years old and 10.6% more patients <65 years old immunized in Washington, compared with Oregon.9

This study was of great value because it found that more people were immunized in pharmacies where pharmacists administered influenza vaccine, compared with pharmacies where nurses administered the vaccine. This finding could be attributed to the increased access to pharmacists who immunized, compared with the usual 1-day immunization clinics when nurses are invited to a community pharmacy during influenza season.

How Can I Become Involved?

Pharmacists across the nation are addressing the health issue of immunizations by functioning as vaccine advocates, educators, facilitators, or administrators.5,10 A pharmacist serving as an educator functions as a motivator for people to become immunized (providing pamphlets, posters, etc). This role is extremely important because, in a 1999 Centers for Disease Control and Prevention report, the most common reason Medicare beneficiaries gave for not receiving influenza or pneumococcal vaccination was not knowing that the vaccine was needed.11 Also, 40% of the beneficiaries did not receive influenza vaccine because of misconceptions about its mechanism of action, adverse effects, and efficacy.11

Being a facilitator is the common way in which immunizations are provided in community pharmacies, with the pharmacy acting as a host site for other organizations that immunize patients. Finally, the pharmacist as an immunizer provides the complete package, which includes vaccine education as well as administration of vaccine.6 The biggest decision is choosing at which level to become involved. The patient?s best interest should be the focus of any health care professional. By linking with other health care providers in the area, pharmacists can help to make the goals of Healthy People 2010 a reality and not just a dream.

For information on a pharmacist training program for pharmacy-based immunization delivery or for links to useful immunization materials, visit www.aphanet.org.

For a list of references, send a stamped, self-addressed envelope to: References Department, Attn. D. Ryan, Pharmacy Times, 241 Forsgate Drive, Jamesburg, NJ 08831; or send an e-mail request to: dryan@mwc.com