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Welcome! Thank you for joining the American College of Physicians Quality Connect Adult Immunization Learning Series Webinar! We will start in a few minutes. Todays webinar is focused on vaccine storage and handling and ordering for your practice. Please keep your phone on mute, when not asking questions, we

are recording this webinar. Feel free to ask questions in the chat feature of WebEx. ACP will share the slides and recorded webinar on MedConcert. 1 Todays Speakers John H. ONeill, DO, FACP Chair, Immunization Technical Advisory Committee, ACP

Level One Faculty, Christiana Care Health System, Newark, DE Charles Michael Soppet, MD, FACP Primary Care General Internist ACP Medical Practice and Quality Committee 2 Webinar Overview: Objectives

Learn strategies to improve your vaccine ordering for different practice sizes Learn tips on how to store and handle your vaccine stock How to work with your staff to streamline this process 3 Managing Your Vaccine Stock: Tips to Improve Ordering, Storage and Handling of Vaccines

John H. ONeill, DO, FACP C. Michael Soppet, MD, FACP June 21, 2016 Adult Immunization Learning Series Webinar 4 Disclosure Dr. John ONeill has received a stipend from ACP to assist in the development of educational programs and tools to promote adult immunization, and otherwise has NO financial relationships

with any entity producing, marketing, reselling, or distributing health care goods or services, consumed by, or used on, patients. 5 The Big Five for Adults Influenza

PCV13 (pneumococcal conjugate) PPSV23 (pneumococcal polysaccharide) Tdap/Td Zoster (VZV) 6 The Other Seven for Adults (Depending on Individual Patient Circumstances)

9vHPV/4vHPV/2vHPV Meningococcal (MenACWY, MPSV4, MenB) Hepatitis B Hepatitis A MMR Varicella Hib: Hemophilus Influenza B

7 Immunization and the Small Practice Ordering Vaccine: How much to Order and When? Influenza Vaccine: Indicated for everyone > 6mo National rates: 43% >19 y/o, 68% > 65 y/o Assume, of # of patients that see you each year: 1/3 will not get flu vaccine

1/3 will get it thru your practice 1/3 will get it elsewhere Other vaccines: depends on need of your patients 8 Immunization and the Small Practice PCV13, PPSV23, Tdap (frequent flyers) Keep these in the fridge at all times Start with one box of 10 doses of each and track use, order accordingly MenACWY: One box of 5 doses in June Hep B: Keep 6 doses on hand

Schedule the follow-up doses 9vHPV: Keep 6 doses on hand Schedule follow-up doses 9 Vaccinate or Refer for Vaccination ACP Center for Quality: I Raise the Rates 10 Ordering Vaccines

Most of the vaccine suppliers have incentive programs: e.g.. Sanofi, Merck, Pfizer Vaccine Discount Suppliers: (examples) Atlantic Health Partners Vaxserve National Discount Vaccine Alliance Vaccine purchasing groups: talk to local pediatricians 11 Log the vaccines as they come in

Vaccine Date Recd # of doses Lot # NDC # Exp. date Hi dose Flu

Quadrivalent Flu PCV13 PPSV23 Tdap Hep B MenACWY 9vHPV 12 Storage of Vaccines

CDC: Vaccine Storage and Handling Toolkit Maintain the chain of cold 36 45 degrees F (aim for 40) Zoster, Measles, Varicella: -58 to +5 degrees Store in separate freezer No dorm style refrigerators! Vaccine Fridge Czar 13

Refrigerators for Vaccines No food or drink in the Vaccine Fridge! No vaccine on the top shelf or in the crisper drawer Line the door with water bottles labeled: Do Not Drink Also line the crisper box, and along top shelf Size: At least 4.5 cubic feet under counter fridge Examples: LABRepCo, American Biotech Supply, Aegis Scientific Back-up plan for power failure and temp out-of-range 14

Data-logging Thermometers Record temperature of vaccine fridge every minute Data stored digitally in device, USB port for uploading to computer/spreadsheet Thermometer probe in glycerol for temp stability Out of range alerts: local alarm at fridge, text message, email alerts Examples:, Southern Labware, and LABRepCo 15

Helpful Resources 16 Standing Order Example 17 Vaccine Ordering: How Much Do I Need?

Initial Order Parameters 18 What size is your patient population? If you dont know your vaccination rates for your patient population, use the CDC default estimates: The Big Five and the unvaccinated population

47% of patients remain unvaccinated for flu 80% of eligible remain unvaccinated for pneumococcal vaccine 70% of eligible for Tdap remain unvaccinated 80% of eligible for Zoster remain unvaccinated 19 Did You Know? For each 1000 patients in the average internal medicine practice: 9% are older than 85 years of age

90 Patients out of 1000 64% are older than 65 years of age (640 patients) 75% are older than 60 years of age (750 patients) 88% are older than 50 years of age (880 patients) Only 12% are 49 years of age or younger

20 21 Predictive Analytics for Flu Orders All 1000 need flu vaccine CDC estimates that 47% get vaccinated Lets aim higher! Order based upon last years experience plus 5% Be proactive and aim higher for your practice 494 doses which equals CDC estimates plus 5% increase

22 Prediction Analysis for Pneumococcal At least 640/1000 patients need some form of pneumococcal protection 13 before 23 is the way to go However, give them something if not high risk PPSV23 is cheaper ($60) to buy than PCV13 ($150)

You can immunize lower risk patients with PPSV23 than PCV13 so do it! High risk patients need PCV13 before PPSV23 Ballpark your orders at 75% PCV13 and 25% PPSV23 23 Prediction Analysis for Zoster 750/1000 need Zoster 134 are between 60 65 years old and eligible for commercial coverage

Identify those 60 65 and vaccinate them ASAP before Medicare D coverage starts 616/1000 are older than 65 and are covered under Part D 24 Prediction Analysis for Tdap Can be more difficult to predict Cost about $35 40 a dose Medicare Part D coverage for specific indications Injuries

Order lower numbers due to uncertain need Consider the cocoon strategy for your patients who are parents or grandparents 25 Inventory Management Now I know the number of vaccines I need for my practice When do I order them? How many do I keep on hand?

26 Ordering: Plan One Flu: 500 doses/1000 patients delivered in August for usage in September January Acquisition cost at $9.50 each = $4,750 for an August delivery PCV13: 40 doses per month of at $150 = $6,000 PPSV23: 13 doses per month at $60 = $800 Zoster: Aim for 10 doses per month at $180 = $1,800

Concentrate on the 60 64 commercial insured age group Tdap: Keep 10 doses on hand and try cocooning 27 Plan One: Total Monthly Outlay $8,950 per month from January December Plus an additional $800 monthly for September January

28 Ordering: Plan Two Flu: 500 doses/1000 patients delivered in August for usage in September January Acquisition cost at $9.50 each = $4,750 for August delivery PCV13: 10 doses per month of at $150 = $1,500 PPSV23: 50 doses per month at $60 = $3,000 Zoster: Aim for 10 doses per month at $180 = $1,800

Concentrate on the 60 64 commercial insured age group Tdap: Keep 10 doses on hand and try cocooning 29 Plan Two: Total Monthly Outlay $7,050 per month from January December Plus an additional $800 monthly for September January

30 Too Costly for Cash Flow? If you are worried about the cash flow. Pick one vaccine to concentrate upon each month of the year and stock up for that vaccine September: Flu month January: Pneumonia month February: Zoster (Shingles) month 31 Discussion and Questions

Questions? Contact Information Dr. John ONeill: [email protected] Dr. Mike Soppet: [email protected] 32

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