Taking Healthcare by Storm: Industry Insights with Dr. Donna Lisi

In this captivating episode of Taking Healthcare by Storm, delve into the world of expert insights as Quality Insights Medical Director Dr. Jean Storm engages in a thought-provoking and informative discussion with Donna Lisi, PharmD, BS Pharmacy, BCPS, BCPP, BCACP, BCGP, BCMTMS, FASCP, FAAPP, a board-certified pharmacotherapy specialist and board-certified psychiatric pharmacist.

Dr. Lisi discusses the importance of immunizations for older adults, addressing vaccine hesitancy, immunosenescence, and barriers like healthcare access. She highlights pharmacists' expanding role, community outreach, culturally competent education, and AI in improving vaccine uptake and infectious disease management. 

If you have any topics or guests you'd like to see on future episodes, reach out to us on our website. 

Publication number QI-032125-GK

Transcript

Welcome to "Taking Healthcare by Storm: Industry Insights," the podcast that delves into the captivating intersection of innovation, science, compassion, and care. 

In each episode, Quality Insights’ Medical Director Dr. Jean Storm will have the privilege of engaging with leading experts across diverse fields, including dieticians, pharmacists, and brave patients navigating their own healthcare journeys. 

Our mission is to bring you the best healthcare insights, drawing from the expertise of professionals across West Virginia, Pennsylvania and the nation.

Subscribe now, and together, we can take healthcare by storm.

  Hello everyone, and welcome to another episode of Taking Healthcare by Storm. I am Dr. Jean Storm, the Medical Director of Quality Insights. And today I am very excited to be speaking with Dr. Donna Lisi. She's a highly respected pharmacist with extensive experience in geriatrics, medication management, and infection control.

Dr. Lisi has served in a variety of healthcare settings from academia to long term care. And she holds multiple board certifications in areas such as pharmacotherapy and geriatric pharmacy. She is an active member of several advisory councils and is a valued member of the Infection Advisory Subcommittee at AltMed, which is the post acute and long term care medical society.

And an antimicrobial stewardship in post acute and long term care settings. Today, we'll be discussing the critical importance of immunizations for older adults, the challenge of vaccine hesitancy, and Dr. Lisi's role in advancing infection control practices. Dr. Lisi, Donna, thank you so much for joining us today.

Thank you, Dr. Stone, for that wonderful introduction. I appreciate All your kind comments, and I hope I can live up to them. So for inviting me. Yeah, so call me Jean. We'll be casual in the podcast. So tell us how you came to do what you do. How did you become interested in the geriatric population? Oh my goodness.

That ranges back for almost four decades. I, after completing both my Bachelor's of Pharmacy degree as well as my Doctor of Pharmacy degree, I did a postdoctoral fellowship in geriatric pharmacy at Montefiore Medical Center back in the 80s, and um, it was a time where very few people knew about what geriatric pharmacy was.

There was also the perception that it was something that was boring, it was something that It was not of something that was widely embraced at the time. And I'm so glad to see that's kind of come full circle. So after that, I've held positions in geriatrics. I was, I worked at the VA as clinical pharmacist in geriatrics for seven years.

I taught at several colleges of pharmacy. I worked for a post acute care pharmacy that was servicing nursing homes. So a variety of different ways. And also I also have a background in behavioral health as well. So, and hospice. And so it's a full circle that all the things that I've done, but at the forefront has always been infections because this is something that is, is very timely given that right now we're dealing with influenza and COVID RSV.

Also the avian flu. So it's something that's ever evolving. And my concern too is that both that we don't have the, the armamentarium to meet the future needs as well as what we do have now using vaccinations to prevent the ones that we can control and, and can minimize or eliminate. So those two aspects are very important to me.

Uh, and I would agree, they're huge, they're very important. So, talking about immunization, so you are a pharmacist, you have a wealth of experience in geriatrics. Can you tell us why you feel that immunizations are so critical for older adults? Oh, absolutely, absolutely. This is one of the most important areas in geriatrics.

We know that as people age, their immune system becomes less effective. It's a process called immunosenescence. Among the things that we see is that the immune system becomes less able to distinguish between foreign entities, like an antigen. And so, as a result of that, it's less able to amount to an immune response.

We know that cells called macrophages, which ingest bacteria and other foreign Cells that these also slow down as people age as part of this immunosenescence. T cells, which remember antigens that have previously been encountered, they're less likely to respond quickly. So this whole process is part of a decrease in T cell formation.

Also, too, there's fewer white blood cells that are capable of responding to new antigens. We have smaller amounts of complement proteins, and we don't produce as many of these proteins as younger people do in response to bacterial infections. So all of these make it very important that not only are older adults vaccinated, but they get the necessary booster shots, uh, for certain conditions that we have booster shots available for.

So these are all very important. And we also know that the mortality when it comes to diseases like pneumonia, influenza, are much higher in the older population than they are in the general adult population. And I think those are huge reasons, and I don't think people truly understand why, why, and there is a scientific reason.

So you explain that very succinctly, so thank you. So we often hear about vaccine hesitancy, particularly among older populations. Why do you, what do you think are the main reasons older adults might hesitate to get vaccinated? Yeah, great question. Great question. I just want to start out because I think there's different perceptions of what vaccine hesitancy is, and my concern is that there's a tremendous amount of misinformation about vaccines out there.

So if you look at a definition of vaccine hesitancy, it's considered a delay in the acceptance or refusal of vaccines, despite availability of vaccine services. It's a very complex and context specific issue, and it varies across time, place, and vaccines. We saw, for example, with COVID, there are different responses to it in different parts of the country, also in different populations, whereas some vaccines have been more widely accepted.

So this is something that, as the definition defines, it varies across the vaccines. When we look at older adults, about 25 percent of older adults report needle phobia. So that can be a big issue for vaccines among older adults. Also, too, education is very important. And sometimes when we have patients who have poor health literacy, That could be a major obstacle, as well as those who don't live close enough to be able to get to a provider who can give it who give it give out vaccines.

That's another issue. Cost barriers can be predictive of decrease immunizations, although the Medicare covers a lot of vaccines, and also lacking a doctor's recommendation or a health professionals recommendation. It's been shown that if if a health care provider recommends a vaccine. An older adult is more likely to, to, uh, accept that recommendation.

So I think there are multiple factors and I think there are many things that are amenable to education and public awareness. Uh, yeah, I, I would agree. I think we all play a role. So how do you feel is the best way to address misinformation about vaccines when someone is speaking with older adults or their caregivers?

I'm sure everyone has kind of heard it and I think we try to come head on and come back. misinformation. It's almost like people push back. And are there any common myths you've frequently heard? No, those are great. Those are important questions. And they really drive to the heart of the issue of why there is that concern about being under vaccinated in our population.

I think an important thing is to get the word out. Senior citizen organizations, especially talking to senior clubs and older adult groups. I've done work in my community. I serve on my office in aging. Excuse me, my office on aging on disability advisory council. I was the past vice president of that group.

I've spoken at senior centers on this topic. So it's something that, you know, and it was interesting. Because one of the things that when I spoke at a senior center, even to talking about antibiotics and that they don't have a role in viral infections, that was something that many people were unfamiliar with.

So, educating, that's important. When it comes to myths, Well, I think one of the myths is that vaccines are unsafe for older people due to their age and health conditions, and specifically, these vaccines are tested in older adults, specifically for the reason that they need them the most. I mean, pediatric patients obviously need their whole set of immunizations because they don't have a mature immune system when they first are born and in their first years of life.

But, you know, older adults, as we talk about the immunosenescence, it decreases with age. I think another issue, another myth is that older adults should not receive vaccines if they have multiple health issues. And in fact, as we saw with COVID, it was those who had multiple health issues that were most at risk of dying.

Those who had hypertension, those who had diabetes, they were most at risk of dying. So I think that that is definitely a myth that needs to be dispelled. There's also concern. that the vaccines can cause serious side effects that are worse than the disease they prevent. And for the most part, the side effects are mild to vaccines and they're usually short lived.

Serious side effects are rare and they are noted. So, for example, just this month, the FDA issued a communications about an increased signal that was associated with the RSV vaccine for Guillain Barré syndrome. So this is something, it's not, I don't think it's a game changer. And they saw a slight increase of maybe seven to nine cases per million doses of Guillain Barré among those who received the RSV vaccine within the first 42 days.

So it was early on, and, and this is something, though, when you think about the number of patients who die every year, older adults from RSV, this is something that is not necessarily a reason not to get the vaccine. I think it's something that people should be educated about, something that they can have a discussion with their physician about, and if that's determined that they're eligible for the vaccine, that they should definitely go ahead and get it.

I also think that there's also the idea that, oh, well, vaccines are for children and they're not as we've been discussing. And that, that they got all the vaccines when they were younger. We know that in some cases immunity wanes. A good example is influenza. It doesn't last from season to season if you've got a flu shot.

Immunity that you got from, from one year does not last to another. So we see that's something that we need to do on a regular basis, a yearly basis. Another common myth, I think probably one of the most, the most, um, important ones when it comes especially to the flu vaccine, is that the flu shot gives you the flu.

I've heard that so many times in, in, in my career and that's just not true. Patients might have had, had been exposed before and might have been in the process of developing the flu. It takes two weeks for full immunity for the vaccine. So if someone was exposed several days ago, before the vaccine could take effect and have its full immunity, they could be manifesting signs and symptoms of influenza that they were predisposed to because of their exposure while that two week period.

Was it in place? So I think those are some of the things that we have to counter, uh, and just education on because I think once people are educated and they see, um, they see the facts, um, and understand the risks, I think they are more likely to want to be vaccinated. Yeah, I would agree. We're talking a lot about like COVID vaccine or influenza vaccine.

I wanted to shift a little bit as you're in, from your perspective as both a healthcare provider and a mentor, how can we better educate older adults about the importance of immunizations? Like we're not just talking about like when immunizations for infectious, um, diseases like it. Influenza and COVID, but also maybe like pneumonia, I think we probably, I don't know if we do such a great job of educating around getting their updated pneumonia shots, Pneumovax, all those, or shingles, right?

So how can we do a better job with those maybe vaccines that are aren't really maybe publicized a lot. No, I think that's an excellent point. Pneumonia in the elderly happens fast. And when it happens, the prognosis is often poor. The mortality rate for severe pneumonia in older adults is about 20%. So this is just, this is something that can be prevented.

And we have effective vaccines against it. There are a number of vaccines. I, I think one of the problems with the pneumonia vaccines is The frequent changes to the vaccination schedules that can be complicated even for health professionals. So I highly recommend that people check out the CDC's website and look for the latest guidelines on what is recommended, because those are updated generally on a yearly basis.

We've seen changes to the pneumonia vaccine recommendations. As far as shingles, one in three people will develop shingles in their lifetime. Think of that. One third of the population. And the risk of having shingles increases with age. And this is secondary to all those, you know, senescence situations that we talked about.

When we think about one of the most risky or one of the most complex, most serious complications of shingles. is the severe pain that can result what we call post herpetic neuralgia. This can occur in about 10 to 18 percent of people who've had herpes zoster will get this herpetic neuralgia. So this is serious and this can be debilitating for patients if they develop that.

The risk of having this neuralgia increases with age. So more the more reason to be vaccinated against shingles. And also too about 1 to 4 percent of people with shingles will go to the hospital for complications. So This is not uncommon. I have a, uh, a colleague of mine whose mother actually died of herpes simplex meningitis.

So This is the Zasta vaccine, but even the different versions of the herpes virus can be serious. So, so that's something to take into consideration. Yeah, absolutely. So we talk about healthcare professionals doing a lot of education. So I don't think I've, in the podcast, talked about the role of pharmacists in increasing vaccine uptake among older adults.

So can you talk a little bit about the role of pharmacists? Sure. I think that when we talk about organizations, organizations definitely have a major role too. So one of the organizations, the Alliance for Aging Research, they have their best shot campaign, which great recommendations highlighted in which they aim to increase the understanding and importance of vaccines and to dismiss misinformation and disinformation and to arm older adults with facts.

Pharmacists can take advantage of the information provided by them. The other thing to the American Geriatric Society. has an older adults vaccine initiative, which I have, which I'm a part of. I've also have attended their webinars and have been involved with that as well as PultMed now has, has, well, formerly AMDA, they have strategies to optimize vaccination rates on their website too.

So I do want to give a plug out for those organizations. AGS is actually part of the Council of Medical Specialty Societies that contracted with the AS, with the CDC to increase vaccinations in older adults. As far as the pharmacist role, pharmacists are key. Pharmacists are the most accessible healthcare professional in the community.

And so, at this point now, all the chain stores vaccinate, many independent pharmacies vaccinate as well. So pharmacists play a role by increasing accessibility to vaccines, as well as counseling patients and educating them on the importance. All of these efforts have definitely demonstrated an uptake in vaccine administration.

among segments of the population. So this is important. The increase availability, the number of hours that pharmacies are open are all important factors. Pharmacists are well educated in this area, too. I mean, we have to before we can vaccinate, we have to go through a whole certification process and also be Um, CPR certified.

So in the event that there is any type of anaphylactic reaction to a vaccine, a pharmacist is prepared to administer epinephrine and be able to call emergency services. But so these are areas where pharmacists played great role. They can have community outreach programs. I'm also chair of my Board of Health Advisory Council for my township.

And I work with our County Board of Health to promote and educate about upcoming vaccine clinics. Uh, we do this through our senior centers, we do this through our township website. So those are ways pharmacists can get involved. Uh, pharmacists can also educate about any clinical trials that are available in their area where they're studying new vaccines.

Pharmacists keep records of vaccines, they get entered into a state, um, immunization record program where if someone needs to know if someone got a vaccine, a physician or clinician needs to know that they can see what vaccines a patient has gotten and which ones they still need. These are all important roles and most importantly too, is monitoring for adverse events, especially when there's a new vaccine on the market.

Pharmacists are the eyes and ears of the community, and they can identify when these occur and report them to the CDC through the Vaccine Adverse Events Reporting System program. So these are all important roles that the pharmacist plays. Yeah, that monitoring system is just so crucial for making sure our vaccines are safe.

So, You talked about all these, um, experiences you've had in, in providing vaccine education. Can you discuss any specific strategies or programs or success stories in addressing vaccine hesitancy among older adults, um, in your experience? Well, in infectious disease in general, one of the things that I did is that I mentioned I, I speak at my local senior centers and I had.

This was during Antibiotic Awareness Week, which is also important and ties into this and I, I discussed with them about appropriate use of antibiotics. And I conducted, I performed a Jeopardy game. So I had various questions from information from the CDC website, did a true and false, had from different amounts of 100 down to up to 500.

And we had a friendly competitive game among two different sides of the Senior Center. Uh, and just to educate them about the importance of infections and diseases. and the role that they can play, whether it's, whether it's knowing when an antibiotic is appropriate for antibiotic stewardship or knowing the importance and significance of vaccines.

So these were all different aspects of this Jeopardy! game and it was so well received that I had several other topics besides infectious disease that I wanted to cover. I was doing a national health observances month type of program and we never got to half of them. People were just so, so involved and so engaged in this topic that I spent most of my time on this talking about infectious diseases, antibiotics and vaccines.

So it was great. It was just great to see the interest that they had. And I think people are hungry for that, especially when you make it in an engaging way. You avoid confrontation, what's not going, did you get your vaccine, why didn't you get your vaccine, stop putting blame on them, and just trying to find out what their hesitancy is, what their concerns are, and trying to alleviate those as much as possible, and trying to educate on the statistics of where we are with diseases that can be prevented with these, with these important agents.

Yeah, that sounds like fun. I would love to play. So just before we come in, we're going to close out our, our kind of conversation around immunizations. What are some of the most common barriers to immunization access for older adults? I think some people, we, we often don't think about, um, barriers to access and how can healthcare systems better support vaccination efforts in this population to overcome these barriers?

Yeah, I know. I think that's a great question. And I would have to say that one of the most important barriers to vaccines and to many senior services is transportation. And I think that's critical, especially when we're talking about more rural areas and having access can be limited. I mentioned pharmacies, but there are areas where there are pharmacy deserts.

And so they don't even have that option. I know one of the things that we have in my area is we have, um, the county has a mobile van and so we go around to different communities and vaccinate and bring the vaccine to the people. So I think that's, that's a strategy that others, if they aren't doing that.

Can do too. And that could be through the department of human services and the county board of health. Uh, those are all important ways. I think partnering with aging disability network organizations, houses of worship, food banks, senior centers, all these different things, retirement communities, adult care programs, any places that older adults congregate.

These are all ways that health systems and organizations can partner to get access to older adults, to educate them and to vaccinate them. I think also to providing culturally competent information. And tailoring the information to let people know the why and how the when and and where they can get vaccines.

I think that's important. Also not neglecting our homebound patients and those who are solo aging, those who may not be connected to the internet to be able to go online and look at when their next, when the next township. Clinic is coming around. I struggle with that one. I struggle with and as my role of chair of my township's Board of Health Advisory Council, that is one of the things that I wrestle with is the homebound.

So maybe partnering with things, organizations like the Visiting Nurse Association, Meals on Wheels program, as well as any faith based organizations that make home visits. That can be another way to, to get the word out. And looking at Medicare yearly wellness visits, I think that's a great opportunity to be able to promote vaccines.

I do medication therapy management. One of the things I always ask about is vaccination as part of the interview process for that. And motivational interviewing is so important. Understanding where people are coming from, meeting them where they're at, being empathetic, asking open ended questions. What do you already know about vaccines?

Can I offer you some more information? What are your concerns about vaccines? What matters most to you about getting vaccines? Asking questions like that instead of just yes and no questions. And And not being judgmental if they answer that they haven't gotten a vaccine before, asking them their willingness after you educate them to want to get vaccinated and how you can move that needle further along to the point of vaccination.

And then always, always consider the patient's circumstances, their cultural, their family situation, their financial situation, if it's something that's going to be out of pocket. Those are all important factors. Yeah, I would agree. So it's great tips and I would agree about homebound. I think about those homebound people a lot.

So shifting a little bit, can you tell us about the Infection Advisory Subcommittee at Paltbed, which is Post Acute and Long Term Medical Society. I always have to say it because we've shifted names from AMDA. How does this group support infection control efforts, particularly in the post acute and long term care settings?

Yeah. No, they're a great group. I, I've only recently, I've only been involved with them for about a year, but I have to say they're highly committed, highly skilled professionals and I, it's my pleasure to serve on that committee. They're dedicated to enhancing the quality of life and wellbeing of residents in post acute care and long term care settings.

And so the way that we do this is this, we develop evidence based infection control and prevention guidance and tools and education for, for, for the post acute care setting. We collaborate with other committees and partner organizations to provide infection prevention and control guidance and subject matter expert expertise.

We just are in the process of writing a policy looking at PCR testing for urinary tract infections. So we do a whole host of things that are of relevance and timely to the community that we serve. So it's, and the caliber of the people I work with is second to none. Very dedicated, very knowledgeable, uh, experts on that panel, on that committee.

I bet. Yes. Very good. So, looking ahead. Last question. How do you see the role of pharmacists evolving in the landscape of immunizations and antibiotic stewardship? Yeah. This is a wonderful question, and I think it's something that pharmacists can really spearhead this. When we think about a disease that is totally managed by pharmaceutical agents.

It's infectious diseases. I mean, yes, you have debridement. Yes, you can have surgical removement, but for the most part, managing this, this condition is going to be drug therapy. It's going to be pharmaceuticals. So I think that's the important area about this. I think looking at antibiotic resistance, it's a growing global problem, public health wise, and the misuse and overuse of antimicrobial agents is very important.

Whether it's The child who has ear pain and goes to the doctor and is given an antibiotic, or the older adult who has some snipples and is otherwise healthy and is prescribed Z Pak. I think these are areas where pharmacists can play a major role. I think it's also important that pharmacists When a prescription is written for an antibiotic or an antiviral, any kind of antimicrobial agent, that the diagnosis be included so the pharmacist knows what's being treated to see if the duration of therapy and the dose, without that information, it's kind of, it's kind of flying in the dark because you really don't know if this course of antibiotics to treat a urinary tract infection is too excessive a dose or too long a duration.

Uh, we know now that the duration of therapy for a lot of conditions is a lot shorter than what we thought it was 20 years ago. So, and if you have clinicians that haven't kept up with that, that can be important. I think also too, looking at, as we said, increasing vaccinations, and also too, pharmacists are more involved in test to treat programs.

So, looking at, Prevention of HIV and testing to treating and starting prep is an important role for pharmacists to pharmacists can help with bridging the gap when there is a new drug, a new antibiotic or a new vaccine that's approved. And the guidelines haven't yet been updated so bridging the gap between new drug approvals available guidelines and the stewardship of the treatment at the patient level I think that's an important role.

And most importantly, expanding. antibiotic stewardship to different areas. I just attended a webinar just this past weekend on antibiotic stewardship in the outpatient setting. And so that's very important. When you think about urgent care centers and you think about emergency rooms, older people frequent those areas as well and having something in place as well as doing post marketing surveillance.

That's very important role for pharmacists. to increase the body of evidence that we have showing any particular harm or especially efficacy of vaccines. I think that's an important role that pharmacists play. When we look at trying to meet these needs, it's encouraging to see that the number of postdoctoral programs for pharmacists are increasing.

So as of 2024, there was 139 infectious disease pharmacy residencies and an estimated additional 12 fellowship programs. That was a 250 percent growth in two year postdoctoral residencies since 2010. So just in the last 15 years, this area has really seen a massive growth. And I think that's so important as we meet global challenges that are occurring.

Everything from COVID to what we're dealing with now. And I think just the last point, I think leveraging AI artificial intelligence is also going to be a growing area for pharmacists. I just authored an article on AI and infectious diseases and looking at using that to help diagnose disease to also help looking at biomarkers for sepsis, looking at.

Patients who are at risk. So AI may have the potential in the future to do those things. I don't think we're quite there yet, especially not in the post acute care setting because most of the models like machine learning require large data sets, which we really I don't necessarily have that, that data to be able to analyze, to look through these things and there is some discrepancies between infectious disease expert recommendations and what AI has generated.

But I think the potential is there and I think that's something to kind of keep an eye on in Verizon. That is so very exciting, AI and infectious disease. I had not thought of that. Now, and one last point, too, as we reign in or at least try to do antibiotic stewardship among humans, I think it's also important to look at the role of agriculture and looking at antibiotic use and resistance beyond human consumption of taking prescriptions.

But also, too, these are in animal feed. These are being used. heavily in agriculture as well. And to me, one of the ways to get around that is to encourage a plant based diet. The less antibiotics that we put in the environment in agriculture, the less right, contaminate our drinking water, our streams will be, because all these run off into the streams and into the other areas, bodies of water, rivers, and other things like that.

So I think that's important, and I think we could all play a role in that by encouraging a plant based diet as well. Such exciting stuff, Dr. Donna Lisi, thank you so much for being with us today and I feel like this is just so evolving, maybe we can have you on again for another conversation in the future.

Oh, that would be wonderful. I appreciate that. Thank you. Thank you. All right. Well, thank you so much for being with us today, Dr. Lisi, such valuable information. Thank you. Thank you for having me. It's been my pleasure. Thank you.

Thank you for tuning in to Taking Healthcare by Storm: Industry Insights with Quality Insights Medical Director Dr. Jean Storm. We hope that you enjoyed this episode. If you found value in what you heard, please consider subscribing to our podcast on your favorite platform.

If you have any topics or guests you'd like to see on future episodes, you can reach out to us on our website. We would love to hear from you.

So, until next time, stay curious, stay compassionate, and keep taking healthcare by storm.