By Sarah Rall, PharmD, and Karen Purgett, MBA

In the interest of patient safety, most medical practice areas are discontinuing the use of abbreviations. However, this is not the case for immunizations. The standard nomenclature for ordering, scheduling, and tracking  immunizations comprises numerous similar abbreviations where deviations in the sequence and capitalization of letters can dramatically alter the meaning of an order and its therapeutic intent. For example, DT represents the diphtheria and tetanus immunization for children under the age of seven, whereas Td—also a tetanus and diphtheria immunization—is for adolescents over the age of seven and adults. The quantity of antigen in the two products differs dramatically.

Vaccine Abbreviations and Availability
The first step in managing vaccine purchasing and product selection is to understand the abbreviations (see Table 1 for a list of abbreviations used in this article). As more and more vaccines become available, the number and combination of abbreviations will continue to grow and change to reflect new technology, new strains, and new antigens. In an effort to stay on top of this rapidly evolving practice discipline, the best source of information for standard vaccine abbreviations is the Center for Disease Control and Prevention (CDC); up-to-date abbreviation information can be found at: www.cdc.gov/vaccines/about/terms.htm

Over the past several years, the pharmaceutical industry has focused a great deal of attention on immunizations and vaccine research. As a result, there has been a significant increase in the number of vaccines and vaccine combinations approved by the FDA and made available on the market. Some examples of recently approved vaccines include those for human papillomavirus, rotavirus, and shingles. As these and other vaccines are added to the immunization schedules, we also have seen an increase in the number of combination vaccine products made available in an effort to decrease the number of individual injections needed to provide immunity. For a list of all commercially available vaccines (except influenza vaccines) in the United States, sorted by antigen, please refer to www.pppmag.com/availablevaccines. There also are several vaccines—such as Meningococcal ACY & W-135 combined with Haemophilus influenzae type b (Hib) for infants by GlaxoSmithKline (MenHibrix)—which should be available in the near future. Just recently, the FDA approved several vaccines including Menveo, a meningococcal conjugate vaccine, strains ACY and W-135, for ages 11 to 55 years by Novartis, and Prevnar 13, a pneumococcal 13-valent conjugate vaccine for infants and young children ages six weeks through five years. Prevnar 13 will be the successor to Prevnar, the pneumococcal 7-valent conjugate vaccine licensed by the FDA in 2000 to prevent invasive pneumococcal disease (IPD) and otitis media. The new vaccine extends protection to six additional types of the disease-causing bacteria. Given the present and future availability of products, the considerable overlap of manufacturers opens the door for product standardization and potential cost savings.

Determining Vaccine Schedules
Prior to standardizing and selecting vaccine products, it is important to familiarize yourself with vaccine schedules both for practice use and forecasting. The CDC currently publishes four different immunization schedules: childhood (birth to six years old), adolescent (seven to 18 years old), a catch-up schedule (four months to 18 years), and an adult schedule, which is segregated into two schedules—one by age and one by condition. The CDC immunization schedules, which are usually updated once or twice per year, can be found at: www.cdc.gov/vaccines/recs/schedules/default.htm

Use the CDC immunization schedules to create model schedules for your organization identifying specific products and manufacturers. In considering pediatric schedules, for example, it may be easiest to start with how many doses of each antigen are required and then use that information to build your models (see Table 2). As prices tend to be based on bundles (discounts based on how many products you purchase from a certain manufacturer), model schedules can help in forecasting the cost to your organization for various scenarios. This can be particularly helpful if you provide pediatric immunizations, as these schedules are complex and contain many options. Generally, the most efficient methodology will be to build the individual models in a spreadsheet so that appropriate costs can be added and total cost can be computed and updated automatically in response to any price changes.

Tables 3 and 4 show examples of model schedules with cost information added. Table 3 outlines the pediatric immunization schedule through age 12 using DTaP-IPV-Hib (Pentacel), while Table 4 outlines the pediatric immunization schedule through age 12 using DTaP-IPV-HepB (Pediarix). For the purpose of our example, the wholesale acquisition cost (WAC) was used. When there is more than one manufacturer listed, the WAC price used was based on random selection of a single manufacturer. The WAC is used for demonstration purposes only. A true analysis should include the net contract cost per vaccine. To determine this, take into consideration all applicable purchasing requirements as determined by the manufacturer, and subtract any discounts and/or rebates offered, which in some cases will depend on the number of vaccines used per manufacturer. After you have built the schedule and added your institutional cost per vaccine, the spreadsheet method allows you to create totals for each age group. In this example, a few recommended summaries located at the bottom right of each table include “Total per Child,” which shows the total cost the particular immunization schedule would be for one child. The second summary, “Total # of Children,” is where the total birth cohort seen by your organization is input. The last field, “Overall Totals,” shows the cost to immunize all the children in your organization’s birth cohort through age 12. Comparing the difference in the totals from the two tables can help in selecting the most cost effective vaccines for purchase.

Usage Factors and Contract Pricing
After developing a working understanding of vaccine abbreviations and availabilities, as well as proper immunization schedules, the next step in disciplined vaccine purchasing is to determine which vaccines are currently being administered by your organization and in what quantities. The population you serve and the services you provide will largely determine the variety of vaccines, and their respective volumes, dispensed on an annual basis.
The most direct way of determining which vaccines are provided and the quantity consumed at your organization is to review your purchase history. Also, if you serve an outpatient pediatric population, it is helpful to determine your average birth cohort to assist any analysis and/or projection of vaccine purchases. This determination will allow you to develop a practice model based on the recommended vaccine schedule using different combinations of products. Determining the average price per child can help in estimating the cost for your entire pediatric population.

Next, determine what contracted pricing is available to your organization. While most vaccine manufacturers have contracts through GPOs, some will offer direct agreements to organizations independent of GPO affiliation. In examining the contract pricing available, you will notice that most vaccine contracts are bundled, meaning the greater the number of different vaccine products purchased from an individual manufacturer, the greater the discounts.

After reviewing the availability and terms of contract pricing, take the collective information and use Table 5 to identify how many vaccines from each of the manufacturers you currently use as well as vaccines that could potentially be exchanged for competing products from another manufacturer. Examples of potential vaccines that could be exchanged include, but are not limited to, hepatitis A, hepatitis B, rotavirus, Tdap, HPV, DTaP, and influenza.

Conclusion
Vaccines and immunizations are an often-untapped opportunity for organizations to participate in a highly effective public health measure that can greatly decrease the amount of disease in the populations served. While a complex and seemingly daunting task, the opportunity to standardize and thus maximize the cost effectiveness of immunization offerings can be seized by using a relatively simple and disciplined systematic approach. Effective management of immunizations can result in significant cost savings for your organization and can be a rewarding professional experience as well.

Sarah Rall, PharmD, is the director of pharmacy purchasing and supply at the Marshfield Clinic pharmacy in Marshfield, Wisconsin. She supervises the entire pharmaceutical supply chain, collaborates with providers to develop best practice guidelines, and manages Marshfield’s relationship with GPOs, vendors, and manufacturers. Prior to her current position, Sarah served as manager of the urgent care pharmacy at Marshfield for seven years.

Karen Purgett, MBA, is the pharmacy contracts and analytics manager at the Marshfield Clinic pharmacy. She supervises the analytics and reimbursement areas, negotiates contracts with the pharmaceutical industry and third-party insurance companies, and conducts
proforma analyses for the pharmacy division.

Key Questions for Vaccine Selection and Use

• Are there any specific manufacturer vaccines that we require?
• To what extent do we want to use combination vaccines?
• What role do inactive ingredients play in product selection?
• What level of control do we have over vaccine use (e.g., are we
  allowed to carry only one DTaP combination vaccine, one Tdap,
  or one rotavirus vaccine)?
• Is Hepatitis B given at birth? If so, how does this impact infant
  vaccine selection?

Factors for Determining Variety and Volume of Vaccine Dispensing

• Do you provide outpatient pediatric services?
• Do you provide outpatient adult services?
• Do you provide only inpatient services?
• Do you provide immunizations for your employees?