Jennifer E. Isenor

Is There a Role for Therapeutic Drug Monitoring of Vitamin D Level as a Surrogate Marker for Fracture Risk

Clinical studies have suggested a possible association of low serum vitamin D levels in patients with bone fractures. This, coupled with a high prevalence of fractures and increases in associated disability and mortality, begs the question, is there evidence to support a role for therapeutic drug monitoring of vitamin D levels to prevent bone fractures? We use a previously published nine‐step decision‐making algorithm to answer this question. Optimal dosages of vitamin D have not been determined, although daily intake guidelines are suggested. Current vitamin D assays yield varying results, making it challenging for clinicians to interpret results from clinical trials and apply them directly to patients and their specific serum level data. Fracture risk is not easily assessable clinically, with no clear relationship between vitamin D concentrations and bone mineral density. The existing primary literature shows no clear relationship between vitamin D concentrations and fracture risk; target concentrations are not well established. Although the pharmacokinetic parameters of vitamin D are unpredictable and vitamin D supplementation is frequently lifelong, results of a vitamin D assay are unlikely to make a significant difference in the clinical decision‐making process (i. e., provide more information than clinical judgment alone). Most published studies on vitamin D levels and fracture risk did not control for other potential reasons to monitor levels, multifactorial risks for fractures, and other confounders. Given limited data to support a direct relation between vitamin D levels and clinical outcome of fracture, inconsistent between‐assay results, and no consensus on optimal levels, there is insufficient evidence to recommend routine therapeutic drug monitoring of vitamin D for fracture prevention; however, other reasons for monitoring might exist that are beyond the scope of this review. Recent availability of vitamin D assay standards may lead to future improvements in comparability of research data, establishment of a target range, and interpretability of patient results.

Impact of pharmacists as immunizers on influenza vaccination coverage in Nova Scotia, Canada

ABSTRACT Immunization coverage in Canada has continued to fall below national goals. The addition of pharmacists as immunizers may increase immunization coverage. This study aimed to compare estimated influenza vaccine coverage before and after pharmacists began administering publicly funded influenza immunizations in Nova Scotia, Canada. Vaccination coverage rates and recipient demographics for the influenza vaccination seasons 2010-2011 to 2012-2013 were compared with the 2013-2014 season, the first year pharmacists provided immunizations. In 2013-2014, the vaccination coverage rate for those ≥5 years of age increased 6%, from 36% in 2012-2013 to 42% (p<0.001). Pharmacists administered over 78,000 influenza vaccinations, nearly 9% of the provinces population over the age of five. Influenza vaccine coverage rates for those ≥65 increased by 9.8% (p<0.001) in 2013-2014 compared to 2012-2013. Influenza vaccination coverage in Nova Scotia increased in 2013-2014 compared to previous years with a universal influenza program. Various factors may have contributed to the increased coverage, including the addition of pharmacists as immunizers and media coverage of influenza related fatalities. Future research will be necessary to fully determine the impact of pharmacists as immunizers.

Patient experiences with influenza immunizations administered by pharmacists

ABSTRACT Influenza vaccination is the most effective way to reduce influenza infection and related complications. Unfortunately, vaccination coverage remains suboptimal. The addition of pharmacists as immunizers may assist in improving vaccine coverage. The experiences of patients who have received influenza vaccines from pharmacists is an important consideration for jurisdictions considering the addition of pharmacists as immunizers. We describe the reported experiences of recipients of influenza vaccinations by pharmacists in the community pharmacy setting in Nova Scotia, Canada. During the 2013–2014 influenza season, a paper-based quality assurance questionnaire was provided to interested vaccine recipients to assess their previous vaccination experiences and current experience at the pharmacy. More than 6,500 vaccine recipients completed questionnaires. The majority of respondents cited convenience as a main reason for receiving the vaccine in the pharmacy, with 50% indicating the service was better in the pharmacy and another 40% that the service was as good as elsewhere. Respondents also reported a positive environment in the pharmacy (e.g., less stressful, less exposure to sick people) as well as professionalism and knowledge of the pharmacists. Areas for improvement identified included better communication around the paperwork required (e.g., consent forms) and the wait time post-vaccination. This evaluation demonstrated that people who chose to be vaccinated by community pharmacists reported positive experiences and convenience was the primary factor for selecting a pharmacy as the site for vaccination.

Evidence for pharmacist vaccination

Introduction The development of vaccines and immunization programs has been one of the most important innovations in health care, resulting in control of once common vaccine-preventable diseases associated with significant morbidity and mortality. Despite this, immunization programs remain underused, so that many Canadians continue to experience unnecessary complications associated with diseases such as measles, pertussis, mumps and varicella. Adult immunization programs are a particular challenge. Data from the 2012 adult National Immunization Coverage Survey indicate that only 40% of Canadians between the ages of 18 and 64 years are fully immunized against hepatitis and that only 38% of those at risk have received pneumococcal vaccine. Likewise, only 37% of at-risk adults under 65 years report receiving their annual influenza vaccine. Traditionally, immunization programs have relied on public health or individual physicians to deliver vaccines. While these means have been effective in reaching some groups, such as children, many hard-to-reach populations, such as those in rural areas, healthy working adults and those without primary care providers, have been missed. Historically, pharmacist involvement in immunization programs was related to distribution of vaccines. Although this important role continues, more recently pharmacists have assumed additional responsibilities as educators, facilitators (hosting traditional providers in pharmacybased clinics) and administrators, as legislation permits. Given that pharmacists are trusted and accessible health care providers, they have the potential to improve overall immunization rates, especially among hard-to-reach populations. Many studies have evaluated pharmacists’ involvement in immunization. We completed a systematic review and meta-analysis of the impact of pharmacists in their various immunization roles (see infographic on next page).

Pharmacy-initiated immunizations in the emergency department—HaliVax PIIE

Introduction Influenza is responsible for thousands of hospitalizations and deaths among Canadian adults annually. Estimations are that between 10% and 20% of the population becomes infected with influenza each year. Immunization is the single most important intervention for preventing influenza-associated morbidity and mortality. The National Advisory Committee on Immunization (NACI) recommends influenza vaccination for all individuals aged 6 months and older and has established criteria for patients deemed to be high risk for excess morbidity and mortality, including age over 65 years, presence of chronic diseases, immunosuppression and pregnancy. NACI’s goals include obtaining 80% or higher vaccine coverage rates for those at high risk for influenza, yet seasonal coverage rates repeatedly fail to meet these national targets. Despite the proven efficacy of the influenza vaccination, NACI data estimate that only 37.2% of the general population receives immunization. Studies based in the emergency department (ED) mirror these low coverage rates, demonstrating that less than 50% of eligible ED patients report receiving the influenza vaccine. Targeting the ED patient population is important, as they have been shown to be largely underimmunized against influenza and are less likely to receive regular physician care. Increasingly represented in the ED population are patients who would be considered high risk for influenza-related complications, such as those aged 65 years and older and patients with multiple comorbidities. NACI recommends placing particular focus on enhancing influenza vaccine coverage in these high-risk patients. In the Charles V Keating emergency department in Halifax, Nova Scotia, pharmacy technicians collect medication histories from patients, complete medication reconciliation forms and liaise with the department pharmacist. This contact represents an important opportunity to address patients’ immunization status. From November 2015 to January 2016, a pilot project for influenza immunization screening and vaccine delivery via the ED pharmacy team was implemented. Until the pilot project, influenza vaccines had not been available to ED patients. Our hypothesis was that this method would represent a sustainable, centralized means of capturing high-risk patients and that patients would be amenable to receiving immunization in the ED. The primary objective of the study was to examine the proportion of patients presenting to the ED who had not received the influenza vaccination and assess unimmunized patients’ willingness to receive vaccination in the ED. Secondary objectives included determining the proportion of patients considered high risk for influenza, determining high-risk patients’ awareness of their risk status and examining the reasons unimmunized patients had not received immunization.

The impact of pharmacists as immunizers in Collaborative cOmmunity Offsite Pharmacy Practice (CO-OPP Phase 1)

Introduction Annual influenza immunization remains the most effective way to reduce influenza-related complications, yet low immunization rates remain an international public health concern. Many factors have been identified as contributors to low immunization rates, including concerns around accessibility and convenience, such as distance to clinics and inconvenient hours. Pharmacists are highly accessible and may improve convenience for receipt of vaccinations. As of December 2016, 9 of 10 provinces in Canada have legislation that enables pharmacists with appropriate training to administer vaccines. Most published data have focused on the impact of pharmacists providing immunizations in the pharmacy. The role of the pharmacist providing immunizations in alternative community settings may further improve patient access and immunization uptake. This article aims to summarize the experiences and results, including patient and collaborative partner satisfaction, impact on the number of immunizations and fiscal feasibility, of a pharmacist-led influenza immunization strategy in nonpharmacy community sites in rural Nova Scotia.