Reaching Adults with Asthma and Diabetes: A Pharmacy Immunization Intervention March 2008 Martha Priedeman Skiles, MPH Cessa Karson-Whitethorn, MPH Carrie Washburn Beck, MPH Oregon Public Health Division Shah Malik, Pharm, Safeway Pharmacy Oregon Adult Immunization Coalition (OAIC)

Background: Immunization Rates among 18-64 year olds with Asthma and Diabetes HP 2010 Goal = 60% Reviewing trend data for Oregon demonstrates that our immunization rates for persons with asthma or diabetes falls below the HP 2010 goal. However, evidence suggests that the immunization rates among these two populations are most likely higher than for other high-risk adults. 2005 Measurement – note that this dip likely reflects the flu vaccine shortage of 2004-05. No recommendation for people with asthma to get PPV Source: Behavioral Risk Factor Surveillance System, 2002-2005

Background: Immunizing Pharmacists in Oregon Pharmacists granted statutory authority to immunize adults ≥ 18 yrs, 2001 Age expanded to ≥ 15 yrs for influenza only, 2005 Opportunity embraced by pharmacists 2001: Statutory authority to provide adult immunizations was sought by the Pharmacy Board. The Immunization Program supported the legislation once age limits were specified, reporting to primary care provider and the State was required, and pharmacy protocols were approved by State Imm Program. Pharmacists have been strong coalition members since legislation passed. Helped to create a very collaborative relationship between pharmacists, State, and other private/public sector partners.

Pharmacy Pilot Project Goal: Improve immunization rates for high-risk adults Population: 18-64 year old clients seeking asthma and or diabetes Rx Sites: 4 retail pharmacy stores 2 retail pharmacy store controls Period: October 2006 – February 2007 Decisions informed by literature review, assessment of data and identification of partners Why Target Pop selected? In 2004, Oregon had a higher percentage of adults with asthma (9.6) than in the US (8.2). Both the Asthma and Diabetes Coalitions and pharmacists were interested in partnering Population-based trend data was available for both these populations Why Pharmacies? Assumption that persons with asthma and/or diabetes may have contact with their pharmacist more frequently than with their healthcare provider Pharmacy partners were interested in pilot project

Pharmacy Pilot Project Intervention: 1) client educational flyer Interventions: All pharmacy clients - A general educational flyer promoting influenza and pneumococcal immunizations for all recommended adult populations was provided to the stores for distribution to all clients served.

Pharmacy Pilot Project Intervention: 2) pharmacist prompt and screening Prompt – an automated prompt on the electronic dispensing profile Screening – Pharmacist or Tech would screen client for immunizations Interventions: Target Population - for those clients meeting the target population criteria, the pharmacist would personally review the vaccination recommendation with the client and offer an immunization at that time.   To aid the pharmacist in correct identification of the target clients and prompt him/her to provide the intervention, an automated prompt was added to the electronic dispensing profile for the pharmacists. Pharmacist or Tech would then screen the client using a scripted set of questions about previous vaccination and interest in vaccination at the time.

Pilot Project Evaluation Understand implementation at retail sites In-depth pharmacist interviews post-season Measure client interest in vaccines analysis of client screening tool Quantify clients vaccinated analysis of doses administered data Determine true rates and attitudes Follow-up survey to target population Created a logic model to map out intervention, intended outcomes/impacts, and evaluation plan. Unfortunately we were unable to conduct a follow-up survey with pharmacy clients due to HIPAA concerns from the retail chain.

Site Interviews Interviews completed at each of the 4 intervention sites - 5 pharmacy managers, 4 techs, 10-15 minute interviews Gathered feedback regarding project components, staff and customer reactions, and overall impressions of project – is this a viable model? Pharmacy staff was paid for an hour of time to complete these interviews

Site Interviews: What worked - What did not? Educational Flyer: Store A - bag stuffer and on counter Store B – bag stuffer Oct/Nov, on counter Store C – on counter Oct/Nov Store D – on counter entire season

Site Interviews: What worked - What did not? Pharmacist’s Computer Prompt: Store A – Pharm & Tech disagreed on effectiveness of prompt Store B – did not work, used letter to recruit target population Store C – used sometimes, also used more “intuitive” efforts Store D – used by staff all season

Site Interviews: What worked - What did not? Client Screening Tool: Store A – used as conversation guide, Oct Store B – included with Rx and attached to flu clinic sign-in sheets, Oct Store C – used sometimes, Oct/Nov Store D – used as conversation guide entire season

Site Interviews: Themes Implementation varied between and within sites – “Protocol was easy to follow but on busy days staff had to pay extra attention to the automated prompt which could get past you when you were really busy.” “Maybe more useful in stores that are new to doing flu shots or that don’t have as large and informed senior base as this store.” “Good for stores just starting flu vaccine.”

Site Interviews: Themes Increased need for training and buy-in “Information was quick and not in-depth.” “Difficult to get everyone involved if they don’t see it as a corporate project.” “Definitely an extra burden of work.”

Client interest in vaccines Client screening data from Pharm/Tech Based on responses to the tear-pad client screening: Clients medically indicated for vax and not previously vaccinated, were asked if: They’d like a vax today; They’d like an appt for a vax at the pharmacy later; They’d see their own doctor about vaccination; or They indicated no interest For Flu: 38% of clients reported previous vax Of the 151 eligible respondents, 76% reported some interest in Flu vax, with 32% interested in a vax at the pharmacy For PPV: 26% of clients reported previous vax Of the 103 eligible respondents, 52% reported some interest in PPV vax, yet only 15% were interested in vax at the pharmacy

Pharmacy-administered PPV23: 2005/06 & 2006/07 Pilot Sites: 64 Total Shots reported by 4 stores over 2 seasons Only one shot given to target population Control Sites: 32 Total Shots reported by 2 stores over 2 seasons 0 shots in target population Target population for PPV included: ages 18-64 with Diabetes RX 2005-06 season target pop = 552 Pilot, 203 Control 2006-07 season target pop = 561 Pilot, 226 Control Note: >1000 eligibles seen at pilot sites over 2 year period > 400 eligibles seen at control sites over 2 year period

Pharmacy-administered Influenza Doses, all adults The total number of flu doses administered by pilot sites increased by 29% from 2,168 doses in 05-06 to 2,793 doses in 06-07. Control sites reporting administering one additional dose of flu vaccine in 06-07

Percent of Target Population Vaccinated against Influenza Target population for Flu included: ages 18-64 with Asthma &/or Diabetes RX 2005-06 season target pop = 1648 Pilot, 553 Control 2006-07 season target pop = 1488 Pilot, 571 Control The percent of the Target Population vaccinated in the Pilot sites increased, by approximately 2 percentage points from 7.5% in 2005/06 to 9.7% in 2006/07; a small but statistically measurable increase. The control sites started out with slightly higher immunization rates, 8.1% in 2005/06 and increase slightly to 8.6%. Note: Includes pharmacy-administered doses only. * p<.001

Percent of Target Population Vaccinated against Influenza by Site Target population for Flu included: ages 18-64 with Asthma &/or Diabetes RX 2005-06 season target pop = 1648 Pilot, 553 Control 2006-07 season target pop = 1488 Pilot, 571 Control 3 of the 4 pilot sites showed some increase in influenza immunization rates among the Target Population from 2005/06 to 2006/07, ranging from 1 to 6 percentage point increase. Only Site C showed a statistically measurable increase from 9.7% to 15.8%. Interestingly, the two sites with the largest increases were those sites that reported not using the prompt regularly nor did they use the screening tool throughout the season. The control sites did not have any statistically measurable change. What we cannot measure is the true immunization rate for this population because we do not know how many of these clients went on to get vaccinated in other venues – doctor’s office, other pharmacy, workplace, etc. Note: Includes pharmacy-administered doses only. * p<.05

Project Limitations Unable to observe implementation Reliance on interviewee for feedback Didn’t measure additional vaccine interventions at pilot or control sites Weren’t able to follow up with clients to document receipt of vaccine elsewhere Rotating pharmacy staff made it difficult to implement protocol uniformly

Conclusions Interventions by pharmacists likely have some positive impact on uptake Target population interested in flu vaccine, but only 1/3 expressed interest in pharmacy-administered vaccine; for PPV only 15% interested in pharmacy-administered vaccine. Unique opportunity for partnering 1. Interventions by pharmacists likely have some positive impact on uptake – increase in doses administered from 7.5% to 9.7% for flu. Implementation at pharmacies looks different due to differences in pharmacy operations. Likely that increase came from pilot sites with very motivated staff willing to adopt project protocol and/or other methods to increase rates. More work needs to be done to understand the disinterest in PPV and flu receipt from pharmacists. Ideas include poor PPV23 reimbursement, good medical management in medical home so clients prefer to confer with their provider about PPV23, less known vaccine. Provided a great opportunity to work with our pharmacy partners.

Acknowledgements Safeway OAIC 18-64 Workgroup -DHS -Asthma Coalition -Diabetes Coalition -Pharmacists ▪ For more information contact Martha Skiles: martha.p.skiles@state.or.us

QUESTIONS?