Community pharmacies as sites of adult vaccination: A systematic review

Figures & data

Figure 1. Flow diagram documenting systematic search conducted to identify studies on community pharmacies as sites for adult vaccination.

Table 1. Summary of characteristics of included studies with results relevant to PBIS, organized in reverse chronological order. Principal category labels: F-Feasibility, A-Acceptability, E-Effectiveness.

Study	Design	Sample	Study Period	Location	Main Outcome	Category	Summary of Main Findings
Westrick et al. (2016)^57	Cluster-randomized experimental design	96 Community pharmacies	2013–2015	US	Number of pneumococcal vaccination administered; program evaluation indicators	F, E	Both self-directed and coaching groups had significant increases in pneumococcal vaccination rates; pharmacies in the coaching group completed a greater number of process indicators.
Brackett et al. (2015)^73	Pilot evaluation	1 Pharmacy; 19 customers received motivational interviewing intervention	September 2013-April 2014	Atlanta, GA	Number of vaccines delivered at pharmacy chain; pharmacists attitudes	E	Due to a limited sample size, the effect of a motivational interviewing (MI) intervention on vaccination rates was inconclusive; pharmacists considered MI to be an effective communication tool.
Singhal and Zhang (2014)^23	Cross-sectional	2 Health insurance databases, representing 48.7 million patients	2010	US	Vaccine administration costs	F	The total direct cost for the influenza, pneumococcal, and zoster vaccinations were cheaper at pharmacies than other sites. Patients paid the least out-of-pocket cost for influenza and pneumococcal at pharmacies.
Teeter et al. (2014)^45	Cross-sectional	688 Pharmacy patients, 65 y or older	Summer 2013	AL & FL	Vaccination rates; patient characteristics and knowledge	F, E	After a herpes zoster educational intervention led by pharmacy students, 72.5% of unvaccinated patients were interested in speaking with a pharmacist/doctor. Patients who had received a healthcare provider's recommendation were more likely to be vaccinated.
Erickson and Workman (2014)^76	Cross-sectional	503 Community pharmacies	February 2011	Wayne County, MI	Pharmacy characteristics and service offerings	E	Pharmacies in ZIP codes with higher annual household income and higher percentage of white residents offered more immunization services.
Hedden et al. (2014)^69	Cost Analysis Model	19 Pharmacies from one chain	September 2011- January 2012	Kansas City, KA	Financial gains and losses for vaccines administered per pharmacy site	E	Two different pharmacoeconomic models both indicated that a herpes zoster vaccine program at a local pharmacy chain yielded a net profit.
Goad et. al (2013)^24	Cross-sectional	National pharmacy chain	August 2012-July 2013	US	Date and time of vaccines administered	E	30.5% of all adult vaccines delivered at a major national pharmacy chain were administered during off-hours (i.e. nights, weekends, and holidays)
Hess (2013)^72	Randomized Control Trial	16 Pharmacies; 9650 prescription holders received phone message	December 2006- May 2007	GA & TN	Number of vaccines administered	E	Automated telephone messaging to at-risk patients significantly increased herpes zoster vaccination rates between the 2 cohorts.
Bryan et al. (2013)^70	Pre/post with comparison group	745 Pharmacy customers received personal selling in experimental group, 614 in control group	November 2010 - February 2011	MO	Patient commitments to vaccinate and attitudes; time spent with pharmacist	E	Personal selling techniques were more effective than passive methods at increasing herpes zoster vaccination commitments and delivered vaccinations.
Wang et al. (2013)^66	Prospective Intervention; Pre/post Design	3 Pharmacy sites; 16,121 during control, 16,062 during intervention	February 2008 - March 2008	TN	Vaccination rates; patient knowledge	A	Pharmacy-based flyers and letter-based interventions increased herpes zoster vaccination rates and increased acts of vaccination.
Wang et al. (2013)^77	Cross-sectional	71,135,249 Survey responders from the Medicare Expenditure Survey	2009	US	Vaccination rates; patient characteristics	E	Significant racial disparities between black and white responders were found for both community pharmacy and non-pharmacy populations. Community pharmacy patients reported higher overall influenza vaccination rates.
Doucette et al. (2012)^75	Case Report	1 Independent community pharmacy	2008–2010	Iowa City, IA	Profitability of pharmacy services	E	Influenza and herpes zoster immunizations yielded a net profit, while pneumococcal vaccines showed a net loss during the study period.
Murphy et al. (2012)^25	Cross-sectional	6936 Walgreens pharmacies, over 18,000 pharmacists	September 2009-February 2010	US	Number of influenza vaccinations provided in medically-underserved areas	A, E	A single national pharmacy chain served 43.2% of medically underserved areas (MUAs), and 37.7% of the chain's total influenza vaccines were delivered in MUAs.
Crawford et al. (2011)^59	Cross-sectional	103 Pharmacy sites, 437 pharmacy staff	January 2008-March 2009	New York, NY	Individual and neighborhood characteristics of staff; staff support for PBIS	F, A, E	Pharmacists working in pharmacies that provided other public-health services were more supportive of PBIS. Pharmacists working in high-minority communities were significantly less supportive.
Taitel et al. (2011)^78	Cross-sectional	1,343,571 At-risk patients	August 2010 - November 2010.	US	State-level vaccination rates	E	Pharmacies were successful at identifying at-risk patients, and providing additional vaccinations. At-risk patients were vaccinated against pneumococcal at significantly higher rates than adults using traditional care (4.88% vs. 2.90%).
Penfold et al. (2011)^42	Qualitative	65 Flu vaccine stakeholders; 7 pharmacy stakeholders	January 2009 - June 2010	US	Stakeholder perceptions of barriers and solution to community delivery of influenza vaccines	F	Pharmacies cited barriers in billing and insurance reimbursement, and legal constraints based on scope-of-practice.
Pace et al. (2010)^40	Cross-sectional	122 Pharmacists or pharmacy managers	February - March 2009	AR	Practice site characteristics and demographics; pharmacist involvement; perceived barriers	F	A majority of pharmacists believed pharmacist-delivered vaccinations advanced the field and increased access to care. Cited barriers varied by pharmacy setting.
Pilisuk et al. (2010)^39	Mixed Methods; Cross-sectional	Representatives from 8 chain pharmacies, 2,500 store locations	2006–2007	CA	Pharmacy policies and protocols; practice site characteristics and demographics	F	Representatives reported that all chains offered adult immunization services. Maintaining records with patients' medical home was cited as one of the biggest challenges.
Westrick (2010)^50	Cohort	155 Pharmacies responded to both survey stages.	2003, 2004, 2006–2007	WA	Pharmacy and immunization service characteristics	F	Type of pharmacy and time since implementation of vaccination programs affected the scale and pharmacist-involvement in PBIS.
Westrick (2010)^55	Cross-sectional	106 Pharmacies included	2003–2004	WA	Pharmacist characteristics and attitudes; pharmacy organizational factors	F	Pharmacy attitudes toward pharmacist-delivered and out-sourced vaccination services were correlated with decisions to adopt or discontinue services.
Westrick et al. (2009)^53	Cross-sectional	1704 Pharmacists or pharmacy managers	July 2005- February 2006	AL, AZ, ID, MD, MS, MT, NM, NY, OK, OR, PA, SD, TN, TX, WA, WI, WV	Pharmacist involvement and characteristics	F	Pharmacies affiliated with pharmacy schools were significantly more likely to participate in public health services. However, affiliation was non-significant when the presence of a certified pharmacist or positive attitudes were considered.
Grabenstein (2009)^17	Retrospective Cohort Study	13 Pharmacies in Oregon and 11 pharmacies in Washington	1997 and 1998	OR & WA	Number of vaccines administered per pharmacy site	F, E	Pharmacists offering daily vaccinations administered more vaccinations over an influenza season than nurses operating single-day clinics.
Westrick and Breland (2009)^56	Cross-sectional	206 Key informants of pharmacies	2006	WA	Practice site characteristics; pharmacy organizational factors	F	Compatibility between the site and immunization services was found to be key to sustainability. Two paths to compatibility are discussed.
Westrick et al. (2009)^54	Cross-sectional	1704 Pharmacists, 301 offered pharmacist-delivered vaccination services	July 2005- February 2006	AL, AZ, ID, MD, MS, MT, NM, NY, OK, OR, PA, SD, TN, TX, WA, WI, WV	Number of vaccines purchased, administered, and distributed to other sites	F	About one third of vaccines purchased by pharmacies are administered in pharmacies, while the remaining two-thirds are distributed to other vaccinators.
Wood et al.(2009)^63	Retrospective Cost Analysis	1 Independent community pharmacy	February 2007- January 2008	Iowa City, IA	Financial gains and losses for PBIS	F	A financial analysis of the first 11 months of a herpes zoster immunization program resulted in a net profit.
Westrick and Mount (2009)^58	Cohort	115 Pharmacies participated in both stages II and III.	2004 and 2006–07	WA	Immunization service characteristics	F	Perceived benefit, perceived compatibility, and perceived complexity of PBIS independently predicted adoption of pharmacist-delivered immunization services; when considered together, perceived benefit was the only significant predictor.
Westrick et al. (2008)^47	Cross-sectional	1707 Community pharmacists	July 2005- February 2006	AL, AZ, ID, MD, MS, MT, NM, NY, OK, OR, PA, SD, TN, TX, WA, WI, WV	Pharmacy and immunization service characteristics	F	There are wide state-level variations in pharmacies' stages of involvement in PBIS
Kummer and Foushee (2008)^38	Cross-sectional	1,274 Active pharmacists	January- February 2007	NC	Characteristics and perceived barriers of PBIS and practice sites	F, E	Only 22% of responding pharmacists were immunization certified, and 52% had immunized in the last year. Barriers were analyzed based on involvement with immunization services.
Prosser et al. (2008)^74	Cost Decision Model; Qualitative	Cost breakdowns by population, health status, and age group	n/a	n/a	Health benefits and financial costs	E	The mean cost of vaccinations and the cost to prevent a case of influenza were both lower in pharmacies than physician's offices and mass vaccination clinics.
Turner et al. (2007)^44	Cohort; Cross-sectional	2nd and 3rd year pharmacy students (n=121–125, and n=123)	2004–2005	Denver, CO	Number of vaccines administered; pharmacy student and mentor attitudes	F	2nd and 3rd year pharmacy students delivered an estimated 5,000 and 15,000 vaccines in community pharmacies. Self-confidence to administer increased and was maintained a year later.
Goode et al. (2007)^49	Case series	29 Grocery stores, 23 with pharmacies	1998–2005	VA	Number of influenza and pneumococcal vaccines delivered at a pharmacy chain	F, A, E	Documents the expansion of immunization services program at a local pharmacy chain, and increases in the number of vaccines delivered.
Doucette et al. (2006)^46	Cross-sectional	611 Pharmacists, of which 290 community pharmacists	2004	US	Type and frequency of pharmacy services	F	Immunization services were the most commonly offered non-dispensary services (15.1% of pharmacies). Three or more pharmacists on duty, and pharmacy innovativeness were positively associated with greater service offerings.
Capurso and Powers (2006)^2	Cross-sectional	43 Pharmacists	February 2005	OH	Pharmacist-perceived barriers to PBIS	F, A	Surveyed pharmacists cited similar barriers to effective immunization services.
Marrero et al. (2006)^71	Controlled Clinical Trial	50 Pharmacy patients in experimental group with educational activity, and 50 in control group	June-July 2000	Puerto Rico	Vaccination rates; patient knowledge	E	Following a pharmacist-led educational intervention, patients demonstrated greater influenza vaccination knowledge and higher rates than the control group.
Bearden and Holt (2005)^37	Cross-sectional	All pharmacies with immunization programs: 56 in 2001, 88 in 2002, 132 in 2003	2001–2003	OR	Pharmacy-based vaccination rates and characteristics	F, E	In the 3 y following regulatory changes that allowed pharmacist vaccination, the number of adult influenza vaccinations delivered and participating pharmacies increased each year. Over one quarter of vaccines were delivered in rural counties.
Steyer et al. (2004)^36	Quasi-experimental Matched Pair	Sixteen states; 8 that passed legislation in 1997 allowing pharmacist-administered vaccination, and 8 that did not pass until after 2000	1995 and 1999	States with legislation (AR, KS, NE, ND, OK, TN, TX, VA) and those without (LA, MO, IA, WY, UT, WV, FL, MD) in 1997	State vaccinations rates	F, E	States that allowed pharmacist-vaccination had significantly higher influenza vaccination rates for adults 65 y and older, after controlling for policy changes.
Neuhauser et al. (2004)^48	Cross-sectional	90 Immunization-certified pharmacists and 169 pharmacists for control	Not Reported	TX	Practice site characteristics and demographics; pharmacist involvement and satisfaction	F, A	Certified pharmacists were more involved in PBIS than non-certified pharmacists in some capacity. Seventy-four percent of certified pharmacists administered vaccines.
Kamal et al. (2003)^1	Cross-sectional	1266 Immunization-certified Pharmacists	Fall 2001	US	Characteristics and perceived barriers of PBIS; pharmacist involvement	F, E	From 1998 to the updated survey in 2001, nurse- and pharmacist-administered adult vaccinations increased (16.2% to 30.2% and 2.2% to 6.8%, respectively).
Kamal et al. (2003)^51	Cross-sectional	194 Immunization-certified pharmacists	Prior to August 2001	US	Pharmacist involvement and satisfaction	F	92.3% of pharmacists would recommend the certification course. Barriers were assessed for both immunizing and non-immunizing pharmacists.
Grabenstein et al. (2002)^35	Retrospective Cohort	80,462 Pharmacy prescription recipients from 24 Fred Meyer chain pharmacies, 11 in WA and 13 in OR, 4403 pharmacy patients.	1999	OR & WA	Customers' vaccination status, choice of immunization provider, and attitudes	F, A	Responders were most likely to return to their previous vaccine provider. Convenience and provider experience were the 2 most influential factors in determining the choice of vaccine provider.
Grabenstein et al. (2001)^34	Cohort	2090 Adult pharmacy patients in either Washington or Oregon, and either age 21–64 with chronic conditions or age ≥65	Spring 1999	OR & WA	Customers' vaccination status and choice of immunization provider	F, E	Of the studied cohorts, adults age 21–64 with chronic conditions, and patients who were unvaccinated the year prior had significantly higher vaccination rates in Washington state, which offers PBIS.
Ernst et al. (2001)^67	Cross-sectional	11 Physician offices and 16 community pharmacies, 25 pharmacy customers per site	January 1999	IA	Patient history and attitudes toward immunizations	A, E	Pharmacists were the second most supported immunizer behind physicians. Patients with prior experience receiving a vaccination at non-traditional sites were more likely to support immunization at pharmacies.
Grabenstein et al. (2001)^65	Cross-sectional	90 Participating pharmacists, 21 pharmacies returned surveys from 17 cities in 10 states.	August 1998-January 1999	AL, AR, IA, ID, MI, NE, TN, TX, VA, WI	Patient characteristics, history and attitudes toward vaccinations	A, E	Vaccine recipients reported they were treated respectfully, and considered pharmacies to be advantageous because of access, proximity, and/or convenience.
Madhavan et al. (2001)^43	Cross-sectional	1348 Pharmacists	Not Reported	US	Characteristics and perceived barriers of PBIS	F, A, E	Pharmacist involvement in vaccination counseling and promotion were high, while delivery was low. Those who attended educational programs were more involved and perceived barriers to be less problematic.
Weitzel and Goode (2000)^41	Cross-sectional	27 Chain pharmacies	September-December 1998	VA	Number of influenza and pneumococcal vaccines delivered by pharmacists	F, E	Documents the implementation of pharmacist- and nurse-operated immunization services. The program increased the number of vaccines administered in the years after implementation.
Ernst et al. (1997)^64	Implementation Study; Cross-sectional	1 Independent community pharmacy	Fall 1996	Rural IA	Accessibility of influenza vaccines	A, E	The steps to establish PBIS at the study pharmacy are reviewed. Almost one third of patients vaccinated at rural PBIS had not been vaccinated the year before, 60% of patients said they would likely not have been vaccinated elsewhere.
Grabenstein et al. (1992)^68	Cost Analysis Model	n/a	n/a	n/a	Financial gains and losses for vaccine-advocacy letters; vaccination rates	E	Model indicates that a pharmacist-written letter campaign advocating influenza vaccination could prevent hospitalizations and deaths, and yield a net savings to Medicare.

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