Policy reforms and legislation to enhance the authority of pharmacists to administer vaccines may lead to increased immunization rates among individuals in low-income communities, especially older adults. These findings were published in the Journal of the American Pharmacists Association.1

Researchers assessed the accessibility of immunization services among adults living in low-income communities, including those aged 65 years and older. Data were obtained between October 1 and November 30, 2021 to compare the number of primary care offices vs pharmacies within a ZIP code tabulation area (ZCTA), with adjustments made for differences in hours of operation and Medicare Part D billing capabilities. The analysis included only primary care offices which sought Medicare Part D reimbursement. 

Among 32,989 ZCTAs nationwide, 1329 (4.0%) were located in areas in which 30% or more of the residents lived below the federal poverty line. Of these ZCTAs, the number of pharmacy locations was increased compared with primary care offices (1894 vs 1646). Further analysis showed that the difference in hours of operation was more pronounced. There was a 95.7% increase in the total number of operating hours for the 1894 pharmacy locations vs the 1646 primary care offices (128,860 vs 65,840 hours).


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In regard to immunization access among older adults at primary care offices, adjustments made for Medicare Part D capabilities decreased the number of available offices from 1646 to 625. The total number of operating hours at primary care offices also decreased from 65,840 to 25,019, resulting in a 415.0% difference with that of pharmacy locations.

New York and Pennsylvania had the greatest discrepancy in immunization access at pharmacies vs primary care offices for the 10 most populous States.

Limitations included the inability to assess operating hours by specific pharmacy locations as the hours of operation may significantly differ between retail and independent pharmacies.

For additional insight into these findings, we spoke with lead author Robert Popovian, PharmD, MS. Dr Popovian is Chief Science Policy Officer at the Global Healthy Living Foundation; Senior Health Policy Fellow at the Progressive Policy Institute; and Visiting Health Policy Fellow at the Pioneer Institute.

What initially prompted you to conduct this study, and was this discrepancy in vaccination access something that you had noticed prior to the COVID-19 pandemic?

Dr Popovian:  Well, you know, the discrepancy in vaccination wasn’t the motivation.  The motivation was really to look at adult vaccination in the United States, and how we can facilitate better adult vaccination rates. Adult vaccination rates are really lagging in the US, and the motivation was to see the ways that we can increase vaccination rates for this population.

There has been an effort to expand authority of pharmacists to administer all Food and Drug Administration (FDA)-approved and Centers for Disease Control and Prevention (CDC)-recommended vaccinations. Can you comment on legislative efforts on this front?  

Dr Popovian: A small number of states already allow pharmacists to administer all FDA-approved and CDC-recommended vaccines. For the past 2 to 3 legislative sessions, several states have considered expanding this authority. Although not all the states have successfully passed legislation to expand pharmacists’ authority to the ideal level, most, if not all of them, have expanded the authority compared with the level it was at prior when the legislation was introduced.

Results from your study suggest that pharmacies can successfully increase accessibility to vaccination, especially for adults insured by Medicare Part D.  Could you expand more on narrowing gaps in care for this vulnerable population?

Dr Popovian: Repeated studies have demonstrated that pharmacists are the most accessible health care professionals in the US. The same number of studies also have demonstrated that patients would rather go to a pharmacy for their vaccines than to the physician’s office.

In the US, we have an undervaccination conundrum for adult patients. Most CDC data have demonstrated that we are well below ideal vaccination rates in the US for adult patients. As you know, seniors are the most vulnerable patient population who benefit from vaccines, as demonstrated by the COVID-19 pandemic.

Could you speculate as to why the greatest discrepancy in accessible hours for primary care offices vs pharmacies was observed in New York and Pennsylvania?

Dr Popovian: It’s regrettable that these two states have the most significant discrepancy in accessibility and the most restrictive laws limiting pharmacists’ ability to administer vaccines. 

I believe there are parties within those states that are against the expansion that are doing a great disservice to the patients and are undermining equitable access to vaccines in our most vulnerable populations. These states comprise the greatest discrepancy in pharmacies vs primary care offices while also having the most restrictive laws regarding accessibility.

Why did you choose to focus on individuals from low-income communities and older adults, and do you think that these findings would be generalizable to the general population?

Dr Popovian: I don’t think they’re generalizable to the general population, and I’ll tell you why. In essence, most adults in low-income communities have poor access to health care services at baseline, so my interest was to investigate a population that doesn’t have the optimal access to health care services. 

In addition, these patients cannot easily receive vaccines during the typical working hours since they lack flexible schedules and may not be able to take time off work when most physician offices are open. These patients may not only value but prefer access during lunch hours, after work, or on weekends more than they value access during the typical workday and that’s the challenge, with not having pharmacy involved in immunization.  Physician office hours are generally 9:00 to 5:00, and these people who work hourly wage jobs don’t have access during those hours, because they will lose money if they take off during the day.

I think overall, increasing access will benefit everyone, but the more pronounced effect will be for patients in low-income communities. Let me provide you with an example unrelated to immunization. In Oregon, when the Affordable Care Act (ACA) was instituted and the Medicaid program was expanded to increase health coverage for uninsured patients, the assumption was that these patients would not go to the emergency department (ED) for typical primary care services. However, following the ACA and Medicaid expansion, ED visits for these patients actually increased. Although access to insurance had increased there was no increase in access to health care services, so patients continued to visit the ED for primary care-related services. The reality is access to insurance without access to health care doesn’t work — access needs to be increased for both. And for immunization access, this study shows that simply providing more patients with insurance cards does not increase immunization access without having somewhere to go to receive a vaccine.

Findings from a study published in July of 2021 showed that although most pharmacists would receive and recommend a COVID-19 vaccine, a substantial number of pharmacists reported vaccine hesitancy in regard to administering vaccines to children.2 Can you speak to these findings, and particularly how they might affect efforts to expand pharmacists’ authority to give vaccinations?

Dr Popovian: Frankly, I don’t think pharmacists are unique in these concerns, and I think these concerns apply to other health care professionals. I’m not sure any of these matters should undermine the findings that show individuals in low-income communities — especially older adults — have better access to pharmacies than primary care offices for immunization services. We have an adult undervaccination problem in the US. Any way we can remedy that problem benefits patients and society overall.

Disclosures: One author declared affiliations with pharmaceutical, biotech, and/or device companies. Please see the reference for a full list of disclosures.

References

  1. Popovian R, Winegarden W, Rivera E, Gavigan K. Accessibility of adult immunizations in pharmacies compared to physician offices in low-income communities. J Am Pharm Assoc. Published online March 20, 2022. doi.10.1016/j.japh.2022.03.021
  1. Jacob SS, Bridgeman MB, Kim H, et al. Pharmacists’ perceptions and drivers of immunization practices for COVID-19 vaccines: results of a nationwide survey prior to COVID-19 vaccine emergency use authorization. Pharmacy. Published online July 26, 2021. doi.10.3390/pharmacy9030131