151. Listen Up: Prioritizing RSV Vaccination for Adults (CE)

Join expert nurse practitioners Drs. Ruth Carrico and Audrey Stevenson on this engaging podcast episode as they illuminate the critical importance of respiratory syncytial virus (RSV) vaccination for adults. Learn actionable strategies to boost RSV vaccine uptake, address health disparities and protect your most vulnerable patients from this serious respiratory illness.

A participation code will be provided at the end of the podcast — make sure to write this code down. Once you have listened to the podcast and have the participation code, return to this activity in the AANP CE Center (aanp.org/cecenter). Click on the "Next Steps" button of the activity and:

• Enter the participation code that was provided.
• Complete the post test.
• Complete the activity evaluation.

This will award your continuing education (CE) credit and certificate of completion.

1.25 CE will be available through June 30, 2026.

This podcast was supported by an independent medical education grant from GSK.

Download the clinical resource handout here: 101199-PCE-AANP-RSV-Vaccine-infographic

Episode Transcript

(00:13):
From the American Associationof Nurse Practitioners,
I'm the host of today'sspecial edition episode,
Nurse Practitioner and Directorof Education, Eve Roberts,
and this is NP Pulse, the Voiceof the Nurse Practitioner.
Welcome to NP Pulse,

(00:34):
AANP's podcast bringing you unique nursepractitioner voices and expertise on
issues that matter to NPsand our patients. As always,
be sure to subscribe to this podcast,
share with your colleagues and check backoften for new conversations with nurse
practitioners and healthcareleaders from across the nation.
Today's episode is in partnershipwith Practicing Clinicians Exchange,

(00:57):
and is supported by an independenteducational grant from GSK.
NP Pulse podcast listeners may claimCE credit for this program through
June, 2026. After youlisten to the podcast,
visit aanp.org/cecenter.
Register for this activity.
Enter the participation code providedat the end of this podcast and then

(01:17):
complete the evaluation. Our objectivesfor today's CE podcast,

Listen Up (01:22):
Time to Prioritize RSV Vaccination for Adults,
are as follows.Number one,
counsel vaccine candidates on riskfactors for severe RSV disease.
Number two,
incorporate the latest RSV vaccinerecommendations into clinical practice.
Number three,
identify and implementstrategies to improve RSV vaccine uptake across diverse

(01:44):
populations.
Respiratory Syncytial Virus (RSV)
significantly impacts adults,
especially those over the age of 60and those with chronic conditions.
In this podcast, Drs.
Carrico and Stevenson discuss theunderestimated burden of RSV and explore
practical strategies forincreasing vaccine uptake that you can apply to your
practice starting today to protectyour patients against RSV. Dr. Ruth

(02:08):
Carrico is a family nurse practitionerand senior consultant with Carrico &
Ramirez, focused on infectious diseases,infection prevention and control,
and vaccinology. She's basedin Louisville, Kentucky,
and is a Professor adjunct faculty withthe University of Louisville School of
Medicine, Division of Infectious Diseases.
Dr. Carrico has received training specificfor healthcare epidemiology at the

(02:31):
Centers for Disease Control andPrevention in conjunction with the Rollins
School of Public Health at EmoryUniversity in Atlanta and the Society for
Healthcare Epidemiology of America.Dr. Carrico has worked in the field of
infectious diseases and infectioncontrol for more than 30 years.
Dr. Carrico also maintains a clinicalpractice focused on vaccines,
vaccination and immunization processes.

(02:53):
Dr. Audrey M. Stevenson is a family nurse practitionerwith over 40 years of clinical public
health and leadershipexperience. Dr. Stevenson,
who holds a master of public healthand master of nursing degrees,
received her doctorate in publichealth from the University of Utah.
She formerly worked in public healthfor over 34 years and was the former
division director of Family Health andClinical Services of the Salt Lake County

(03:16):
Health Department in Salt Lake City, Utah.
She currently works as a consultant andteaches graduate FNP and MPH students at
two universities. Dr. Stevenson isalso a member of the statewide Vaccine
Advisory Board where she collaborateson vaccine policies and recommendations
for the state. Previously,
Dr. Stevenson served as vaccine branchdirector for the COVID-19 Incident

(03:38):
Command for Salt Lake County,
where she directed the vaccine strategiesfor 1.2 million residents of Salt Lake
County. She's been a vaccinechampion for over 30 years.
It is my pleasure to welcome our nursepractitioner experts, Audrey and Ruth!
Thank you for that kind introduction Eve,
and thank you to everyone for joiningRuth and I today to discuss this important

(04:00):
topic. I want to start by talkingabout the burden of adult RSV.
How do we explain the risk of RSVand severe outcomes to our patients?
Well,
the burden of RSV in adults is substantialand likely underestimated due to the
lack of testing.
It's really difficult to differentiateRSV from many of the other

(04:22):
respiratory viruses withoutdiagnostic testing. However,
it's estimated that each year in theUnited States among adults age 65 years of
age and older RSV leadsto 60,000 to 160,000
hospitalizations, 6,000 to 10,000 deaths.
And when compared toinfluenza and COVID-19,

(04:43):
the number of hospitalizations and deathsare lower for RSV compared to COVID-19
and influenza. But the severityof RSV is similar or worse.
In a recently publishedmulticenter cohort study,
the odds of invasive mechanicalventilation or in-hospital death was similar for
RSV influenza and COVID-19among unvaccinated adults.

(05:07):
The odds of invasive mechanicalventilation or in-hospital death was
significantly higher for unvaccinatedpatients with RSV compared to vaccinated
patients with COVID-19 or influenza.
Some studies have shown that RSV inassociation with more severe disease and
poorer outcomes, things such aslonger hospital length of stay,

(05:29):
greater ICU admissions and highermortality at one year compared to
influenza.
The presentation of RSV variessignificantly among our patients.
Severe disease can lead torespiratory failure and even death.
Severe disease is morecommon in older adults,
particularly our patients75 years of age and older,

(05:51):
and those with chronic conditions suchas heart and lung disease and immune
compromise. Ruth,
talk to us about the disparities inRSV disease incidents and outcomes.
Audrey, thanks. That was a great overview.
That really helps us recognizethe severity of disease and how much we need to
respect this respiratory viral illness.

(06:13):
And I think as nurse practitionersare present and leading
healthcare and care decisions alongwith our patients in virtually
every setting,
it's important that we recognizethe impact on the entire population.
And as you mentioned,
this involves then recognizingthat RSV does not impact all of our

(06:33):
patients the same.
So we know that we will oftentimes havepatients from minoritized groups such
as racial and ethnic minorities,
as well as those that are inlower socioeconomic groups,
and it is these individualsthat are likely to also have
chronic medical conditions. Also,

(06:54):
these may occur at youngerages or many times even be
undiagnosed.
We know that individuals with chronichealth conditions may also have no health
insurance coverage or havedifficulty accessing healthcare at
all. Those individuals mayalso be more likely to be
hospitalized.

(07:14):
They visit emergency departmentsmore frequently and unfortunately
experience those catastrophichealth conditions relating to RSV
up and including death.
These groups are also morelikely to be diagnosed with RSV
just due to those factors suchas living conditions or social

(07:35):
environments. And when RSVoccurs in these individuals,
it is more likely to be severe.
So this serves as a reminder thatRSV is an equal opportunity type
of illness,
but we need to make sure that we ashealthcare providers recognize that not
all individuals are goingto be impacted the same.

(07:56):
So being on the lookout for thisamong our patient population.
Now I also want to bring upthe importance of testing. Now,
in the past we know thatreally prior to 2014,
before we had a reliable RSV test,
many times we ended uplumping this into those,

(08:18):
I don't know what youhave, I can't identify it,
but it is a problematic respiratoryillness. Well, now that has changed.
And so RSV as a disease may be on the
radar for our clinicians. And thisis unfortunately, as I mentioned,
different from what may have occurredprior to 2014 when we had a reliable

(08:41):
test.
But we need to make sure that we realizethat a test now is available and we
need to make sure that itis no longer underused.
We now have commercially availablecombination tests and even CLIA waved over
the counter tests.
So this is important for us torecognize then the opportunities
to diagnose. Unfortunately, however,

(09:03):
we still have no treatment for RSV.
So sometimes we fall intothat habit of saying, well,
without an intervention, Idon't really need to test.
But I think all of us are increasinglyrealizing that it's important that when
we can understand the etiology of arespiratory pathogen and therefore that
lets us know what is present, what isnot present, what is worth treating,

(09:26):
what is not worth treating,
and helps us do what the InfectiousDiseases Society of America or
IDSA has really helped us recognizethat we need to use our treatments
appropriately. That means not only treatappropriately, but withhold treatment,
particularly antibiotics which weknow are not useful for a viral
infection, withhold those appropriately.

(09:48):
So this makes testing asan important consideration.
So just some basic guidance thatwe have from the IDSA is that
when you are looking at adisease during its season,
test in high risk patients whenthey are symptomatic, again,
when we are in season forthat respiratory illness test,

(10:09):
patients with acute respiratory symptomsand either those that are experiencing
exacerbation of chronicmedical conditions or if it is
unknown. So for example, whenwe're looking at influenza,
we're looking at understanding thepresence of that infection and looking
perhaps for the development ofconsequences such as pneumonia.

(10:31):
Same thing for RSV. When we'reoutside of the RSV season,
we want to consider testing in patientsthat have acute respiratory symptoms.
Again primarily so we know whatthis may be and then rule out then
what it may not be. So some takehome points is I think looking
both at the informationthat you provided, Audrey,

(10:52):
as well as our questionsabout health disparities,
presence of disease and testing.
Make sure that we have in ourtoolkit an awareness of RSV
as a potential etiology ofinfection as our patient is
presenting to us, use testing aspart of diagnostic stewardship,
when to test, when not to test, and thenhow that drives our decision making.

(11:16):
And then use positivetest results in practice.
And it really serves as areminder about the utility of an
upstream approach,
and that is looking at how do we preventthese viral illnesses and we do that
through use of vaccination.
So let me add after we have talkeda little bit about this, Audrey,
how do you think many of your olderadult patients are perceiving RSV?

(11:40):
Do they have an awareness?
I believe that many of our patientsthink about RSV as a childhood disease.
They've heard about it in grandchildrenor in their children or the
hospitalization numbers thatwe hear in the media. However,
many of the adults that we care forin our practices aren't aware that
RSV is a risk for them as well.

(12:03):
So we're fortunate in that wehave RSV vaccines that have been
developed for adults that arethree vaccines that are currently
available for older adults.
Two of these are proteinsubunit vaccines which use the
RSVPreF.
And if you recall back whenwe had the COVID-19 vaccine,

(12:25):
it was the spike protein that wasthe target for those vaccines.
Well, in the RSV vaccines,
the PreF is a form of the F proteinthat's present on the viral surface
before it interacts with thehost cells to cause infection.
And this is the primary target for theneutralizing antibodies in those RSV
vaccines. So the two protein subunitvaccines that we have available,

(12:49):
there's RSVPreF,
which is a non adjuvantedRSV vaccine made by Pfizer,
and this vaccine is also approved forthe use in pregnant women for infant
protection. The second is RSVPreF3,
which is an adjuvantedRSV vaccine made by GSK.
And as you'll recall,
adjuvanted vaccines include a substancethat enhances our immune system's

(13:13):
response of the vaccine.
These adjuvants help our bodies torecognize the vaccine's antigen and to
stimulate a stronger, moreeffective immune reaction.
And the third is amessenger RNA based vaccine,
which is mRNA-1345 made by Moderna.
Our patients are concerned aboutvaccine efficacy as we are as clinicians

(13:38):
in clinical trials.
All three vaccines were proven effectivein preventing lower respiratory tract
infections when compared to placebo.
In emerging real world data in thefirst season after vaccination,
the protein subunitvaccines were 75 to 82%
effective in preventing RSVassociated hospitalization. We don't

(14:00):
currently have data onthe messenger RNA vaccines
in talking about vaccine safety.
RSV vaccines are safe and welltolerated and serious adverse
events have been similarto those of placebo.
But there's two topics thatmay come up with our patients.

(14:21):
The first is atrial fibrillation.
There was a numerical difference in theincidence of atrial fibrillation with
vaccine versus placebo in phase threetrials for the protein subunit vaccines.
However, in a population-basedpropensity matched study,
there was no difference between RSVvaccination and influenza or Tdap

(14:43):
vaccination.
The other topic has beenGuillain-Barre syndrome or GBS.
In clinical trials there were twocases of GBS that occurred following
vaccination with the non adjuvantedvaccine and one case following
vaccination with the adjuvanted vaccine.
So in January of this year,

(15:04):
the FDA added a warning thatpost-marketing observational studies suggest an
increased risk of GBSfollowing vaccination. However,
post-marketing evidencesuggests increased risk,
but currently not enough evidenceto establish a causal relationship.
We need to keep in mind that the riskof GBS is rare and it's much lower than

(15:26):
the risk of severe RSV disease,
and we do see cases of GBSthat occur naturally as a
complication associatedwith viral illnesses.
Ruth, I know that ACIPrecently was able to meet,
talk to us about the advisorycommittee on immunization practices

(15:46):
recommendations.
Thanks. I think the ACIPrecommendations become such an important
factor for us in looking at howwe are determining when and which
patients meet clinicalindication for vaccination.
So we know that previously RSVvaccination was recommended for adults

(16:07):
60 years of age and olderusing shared clinical
decision-making,
and all of us who have followed andcontinue to use those outlines and
those tenets for shared clinicaldecision-making sometimes found it to be
overly cumbersome. And sometimes it waseven confusing for clinicians to say,
well, what is the difference betweenshared clinical decision-making and the

(16:30):
conversations that I alwayshave with my patients?
So the ACIP has recognized thatthis may have actually produced a
barrier for the ability of theclinician to have the discussion.
They viewed that as this is a requiredelement. I'm not sure that I can do this,
therefore I'm going to defer discussionor I'm going to refer a patient

(16:52):
somewhere else for vaccination.So I think ACIP was very wise in saying,
wait a minute,
let's do what we need to do to havethese appropriate conversations with our
patients that enable themthen to ask the questions,
have clinicians thenapproach conversations in a way that is relevant and
conversational for them duringtheir patient encounters.

(17:12):
So I was really happy to hear that.
So our current ACIP recommendationsare we have an age-based
recommendation for all adultsthat are aged 75 years and older,
and that we do not then havea focus or a requirement for
shared decision-making. We talkwith our patients like we always do.
So 75 years of age and older,

(17:35):
then that vaccination is appropriateunder the age-based recommendation.
Well, what about individualsthat are younger than 75? Well,
we have risk-based recommendationfor those patients 50 to
74. So that age was lowered by the ACIP.Some of you may remember,
well wait, wasn't it 60? Yes, it was.

(17:57):
But the ACIP recognizedthat as I mentioned earlier,
we have some of these health disparityissues that we will see disease in some
individuals within our communitybased on not only race and ethnicity,
but also it is based on poverty.
So we're looking more closely at whatare the medical conditions of our

(18:18):
patients? How able arethey to access healthcare?
How do some of these barriersthen represent and present then a
risk factor for RSV and thosenegative health outcomes that
occur? So the ACIP said,all right, recognizing that,
let's look at then a risk-basedrecommendation for individuals 50 up

(18:39):
through 74.
So we then use our knowledge about thepatient and their underlying medical
conditions and then have that conversationwith them about appropriate use
of vaccination and patientacceptance. So again,
we are not tied to shared decision-making.Instead we're looking at what is the
risk and benefit with our patient.

(19:00):
We are of course having anongoing conversation with them,
but we're looking at what risksare present in our population.
So as I mentioned, that's a risk-basedrecommendation for 50 to 74.
And these risk factors includeconditions such as chronic cardiovascular
disease. So for example, heart failure,
but specific or isolatedhypertension is not included,

(19:24):
but those that have chroniccardiovascular disease,
chronic lung or respiratorydisease, end-stage renal disease,
diabetes mellitus,
patients that have neurologicor neuromuscular conditions that cause impaired
airway clearance orrespiratory muscle weakness,
that is a recognized riskfactor. Chronic liver disease,

(19:45):
chronic hematologic conditionssuch as sickle cell.
Also a risk factor are patientswho experience severe obesity,
that means a BMI 40 or greater,
those who are moderately orseverely immunocompromised.
Also risk factors.
Here's another one that I think isreally important for our NP audience,

(20:06):
and these include individualswho are living in a nursing home,
and I know many of ourNPs are leading care in
long-term care facilities. So this isan opportunity for NPs who are seeing
and are either providingprimary or specialty care.
For those that areresidents in a nursing home,

(20:27):
remember they are inthis risk factor list,
age 50 to 74,
other chronic medical conditionsshould also be included.
You may have patients who are frail,
but they do not have some of therecognized health conditions.
Frailty itself then isrecognized as a risk factor.
So that means we needto know our patients.

(20:47):
We need to be thinkingabout where do they live.
Maybe our NPs are providingcare in rural communities where
escalation of care would bedifficult. Then remember,
we have an eye toward prevention.
So provision of this vaccine if wehave a concern about an undiagnosed
medical condition, again,

(21:08):
think about preventionof RSV as important.
So kind of summarizing this,
it's I think important for us to remember.It is recommended in our
individuals aged 50 to74 who have any of that
relatively long list of riskfactors that I went through.
So it is a risk recommendedrisk-based recommendation for that

(21:32):
group. Once you reach age 75,
we consider that you in all likelihoodhave that we know age is the strongest
risk factor for developing thesecomplications from respiratory illnesses.
So once you reach age 75,
you automatically win the prize forthat discussion about vaccination.
So we know that we have FDAapproval for the vaccine,

(21:55):
but we also may not have ACIPrecommendations for some age
groups that fall below that aged 50.
So we will follow then whathappens with ACIP for other
discussions.
But let's talk about individuals whomay have risk factors for severe disease
and are in that age bracket below age 60.

(22:19):
So we know that we have the non adjuvantedvaccine that is approved by the FDA,
but again without the ACIPrecommendation for those aged 18 to
59 who are at increasedrisk for severe RSV disease,
then we have the adjuvanted vaccine thatis approved for individuals 50 to 59
at increased risk of severe RSV disease.So I think kind of a take home

(22:42):
message here is it's important forus to always be aware of what we have
in our recommendations from the ACIP.
That is where we have the most firmguidance that is readily available to us,
but as we continue tolook at our population,
we may have approval by theFDA for use of that vaccine
in lower age groups, and wemay keep our eye on that,

(23:05):
but I think for many of us,
we go to what we are seeing in ourACIP recommendations and then wait for
firm guidance to help us be ableto provide vaccine and vaccine
recommendations specifically. But keepin mind those younger populations,
certainly more is to come. So Audrey,
what about some timing ofthe use of these vaccines?

(23:26):
When should we provideit then for our patients?
Well, obviously we want to ensure thatpatients are receiving this vaccine
prior to the onset of diseasewithin their communities
just as we do for influenza and COVID-19,
the ACIP has recommended that RSVvaccination can be offered year round.

(23:48):
We want to make sure that individualsare being vaccinated before we start to
see disease within those communities.
So vaccination is most beneficial ifadministered in late summer or early fall,
maybe between August and Octoberor just before the RSV season.
And we're going to have to be a littlebit cognizant of that because our
patients may not always come in duringthose fall months when it would be best

(24:11):
to provide this vaccine.
There is seasonality of RSV withsome variability that's based upon
the region that our patients live in,
generally in thecontinental United States.
The RSV season starts in thefall and it peaks in the winter.
We think about the RSV season basicallybetween October and April each

(24:31):
year.
Now I'm already starting to have patientsasking about whether or not they're
going to need a booster of this vaccine.
Likely there will be aneed for revaccination,
but the interval has not yetbeen determined and we found
in the information that protectionpersists for at least two

(24:53):
years with this particular vaccine. Ruth,
tell us a little bit about how wellwe're doing with regard to RSV vaccine
uptake in the US.
Thanks, Audrey. Well,
I think all of us would love to be ableto say that we're going great guns with
vaccination and acceptance,
but we know that still this isa relatively new vaccine in its

(25:15):
availability.
So it's going to take our healthcareproviders time to be able to reach the
entire population who iseligible, meets indication,
but also to be able to addressconversations that our patients are having
and their questions that they arehaving regarding the vaccine and the
appropriateness for them.

(25:35):
So the CDC provides us with somegreat information through the National
Immunization Survey, and this isspecific outreach to individuals,
a verbal telephone survey thatgets feedback directly from
our US population, asampling of our population.
So some of the results I thinkare very interesting for this

(25:57):
particular vaccine.
So information that wasavailable as of March 8th, 2025,
showed that only about 47.4%of adults aged 75 years and
older had reported ever havingreceived an RSV vaccine. Now,
it's important to remember that thissurvey asks for the patient to provide the
information, so certainly there'sgoing to be some recall bias,

(26:19):
but it lets us know that interms of providing the vaccine,
our glass is not yet evenhalf full. Interestingly,
only 35.8% of adults aged 60 to
74 with one of those high riskconditions that we have previously
mentioned reporting havingreceived an RSV vaccine.
This tells me a coupleof things. Number one,

(26:40):
that are we as clinicians identifyingthose patients with risk factors and are
we letting them know about theavailability of that vaccine?
And on the other side of the coin,
are our patients who areexperiencing those risk factors?
Are we conveying information in away that they can understand and
accept and internalize and then realizethat it may be important for them

(27:04):
so that they go on then to receivethe vaccine? And then of course,
the third part of that is,
is the vaccine available and accessibleto individuals in the event that they
are ready to be vaccinated? Also,we know, as I've mentioned earlier,
we have disparities amongindividuals who are eligible for

(27:24):
vaccine and appropriate interms of preventing disease.
And we know that vaccineuptake unfortunately,
is lower among patients who are in someof these lower socioeconomic groups
as well as those who may lack healthinsurance or healthcare access
for a variety of reasons. Now,
we know that there are differences inRSV vaccine uptake based upon race and

(27:47):
ethnicity,
and let me give you a little bit ofinformation about that in those groups.
Among individuals that are75 years of age and older,
vaccine uptake is lowest amongour Hispanic and black patients.
Under the age of 74,
vaccine uptake is lowest inHispanic patients, and until recently,
it was also lower in black patientscompared to Asian and white.

(28:12):
So this is a reminder that as NPs areseeing patients not only across the
lifespan but across all ofthe race and ethnicities,
it's important for us to be thinkingabout that in our vaccination discussion.
So there's still a lot of work to doto ensure that all of our patients have
equal opportunity for protectionthat can be provided by this vaccine.

(28:35):
And then we need to make surethat all NPs in all settings,
both primary care and specialties,
are discussing with ourpatients this vaccine,
the importance of this vaccine and whatit can do for them in order to optimize
the uptake. So now that weknow we have great vaccines,
we have a lot of utility of that vaccine,

(28:57):
we have challenges in addressingpatients for whom the vaccine is
appropriate.
We have a lot to do in some ofthese practical strategies to help
increase the RSV vaccine uptake.So we know that when
we implement risk-based vaccinerecommendations into clinical practice,
that can be quite challengingbecause we have so much on our plate.

(29:21):
But we know that prioritizingvaccination access to vaccination and the
discussions regarding vaccines,
both in terms of our patientinteractions in primary and specialty
settings, this takes verymuch a targeted approach.
And we've got to rememberto bring this up,
maybe we have decisionsupport opportunities or maybe we have standing orders,

(29:42):
so we have otherapproaches in our setting.
But we know that all healthcareproviders should access the
immunization status at every opportunity.
And this means that everyclinical encounter, acute care,
preventive healthcare visits everywherewhere we are seeing patients.
So how we do this I think is important.

(30:04):
How do we identify our high risk patients?
How do we begin to havethese conversations?
How do we develop someof these individualized vaccination plans? So Audrey,
with your experiences both inpublic health and research settings,
in practice settings,
I'm interested to hear whatyou are doing to help identify

(30:25):
our high risk patientsand enable them to receive
vaccination. Well, whatcan we learn from you?
One of the important strategies is goingto be having everyone on board within
the entire practice so that we knowthat when the patient is coming in
that have certain conditionsor fall within one of those

(30:47):
age-based risk groups,
we're going to flag those recordswithin our electronic medical records
system.
We're going to use promptslooking at the chart so that
everyone from the front deskthat is checking the patient in,
to the MA or the nursethat is working with the
patient, to the clinician,

(31:08):
that all of us are lookingfor those opportunities to identify those individuals
that would benefit fromthis particular vaccine.
I think that it's also very importantto make sure that we're providing
education to patientsas they're coming in.
Because we may be unawareof a certain condition
that if we're not seeing thepatient on a routine basis,

(31:30):
and so making sure that we're lookingat all of those opportunities to
provide this preventive medicineand to provide this protection.
In terms of this andother eligible vaccines,
what have you been doing in your practice?
Yeah, I think that yourcomments are spot on in that

(31:51):
RSV is a disease of breathing,just like influenza,
just like COVID, justlike bacterial pneumonia.
So when we think about the importanceof this in conjunction with other
respiratory illnesses, thatdoes need to be top of our mind.
And so whatever ourapproach is, whether again,
we are using decision support throughour electronic medical record system,

(32:15):
I think all of us realize that if we canhave a prompt that is much better than
trying to rely on our memory.
But you also mentioned I thinksomething really important,
and that is we need to make sure thatour entire office is working with us
for the good of the patient.
So that means no matter what preventiveapproach we're talking about,

(32:35):
the patient recognizes that we, like they,
want to prevent disease at the earliestopportunity. And so every person in our
office has an opportunityto make that difference.
And there are so many resourcesthat we have available in
helping to implement an individualizedvaccination plan. I know,

(32:57):
I like you, love immunized.org.
That is a great website to go fortools such as helping us look at
standardized orders,
helping us with education amongthose within our practice setting.
But we realize that our plateas a provider is very full.
And so how do we make sure then thatour office speaks for us and that we're

(33:20):
using every opportunity forindividuals to have those conversations
with patients about how to makethe discussion personal for
them.
So as we look at making effectivevaccine recommendations,
we know that a provider recommendation,
a strong provider recommendation,

(33:42):
is a main reason thatpatients receive vaccination.
And I will tell then many of mycolleagues and others that please
remember our patients hear our words,
but they hear our silence just as loudly.So if we don't bring it up,
if we don't have the conversation,
then our patients may incorrectlyassume that vaccination is not

(34:03):
important for them.
So we have to be very consciousabout how we are messaging,
and I think all of us realize that maybesome of the words that we used before
our COVID pandemic, that those nolonger resonate with our patients.
That we are having very differentconversations with our patients now

(34:23):
and our patients want toknow how I understand that
yes, we have population-basedrecommendations,
but what about me asyour individual patient?
How does this impact how Iapproach the conversation?
So we're using very different words.
We're framing ourmessaging very differently.

(34:45):
We're looking at our potentialgains rather than risks,
and we're using then biasesrecognizing that we may have a bias
for or against a particularvaccine or approach,
but that may not be relevant for ourpatients. So we're having to really
recognize how we are approachingthis as well as what is happening

(35:06):
on the part of our patients andmaybe what they have encountered
on TikTok or other socialmedia channels and how that is
influencing their approaches.
So I like some of these frameworksthat have become increasingly
popular,
and I want to use the five A'sas one that really helps me to

(35:29):
ask my patient,
ask 'em where they are with respectto their approaches for vaccination.
That helps me begin aconversation where the patient is.
So instead of maybe launchinginto a discussion and thinking about where I would
start, I'm trying to elicit from thepatient where is their starting point.
So I'm asking them morequestions. I'm advising them.

(35:52):
I'm helping to make sure that theyunderstand the importance of risk benefit,
what are their risk factors and how thevaccine may benefit them. I'm really
assessing where they are comingfrom, what their concerns are,
what their approachesare, what their fears are,
and I'm using that then to assistthem to meet the goals of a

(36:13):
plan that we develop together. Soit's not all about what I recommend,
what I think.
I'm trying to take what I think andhelp them blend it into what the patient
thinks and what they feel. And afterwe know what they are thinking,
then I'm trying to assist them withgetting across the finish line for
vaccination. Now, I maybe a vaccinating office,

(36:35):
maybe I have vaccine readilyavailable right there,
and then I can assist them and arrangefor vaccination. If I don't have vaccine
in the office, then I'm lookingat who are my community partners?
Am I referring them to one of mypharmacy partners to receive vaccine?
So I'm trying to again,
determine where is the patient in thisdiscussion. That's my starting point.

(36:58):
And then I'm reaching then acrossthe aisle to my patients so
they understand risk and benefit.
And then I'm trying to figure out thenhow do we develop a personalized plan for
them that includesaccessing the vaccination.
So with that in mind,
when I'm thinking about it's notan easy discussion anymore, is it?

(37:21):
And I'm having to use different words,maybe my body language is different.
Audrey, how do you normallyrecommend vaccination?
And I want to look not only at howdo you make sure that vaccine is
available, but when we think aboutthis as a respiratory illness,
we know that we may be alsorecommending co-administered vaccine.

(37:41):
I've got RSV, flu, COVID, maybethat pneumococcal vaccine,
that may be all relevant.And then other vaccines,
maybe shingles vaccine is alsorelevant for that patient.
How am I kind of balancing thecounseling and the co-administration and
how am I bringing in all of thatto the patient so we can recognize

(38:02):
their hesitance, maybe theirvaccine fatigue? Audrey,
how are you addressingthis in your practice?
Well,
you've asked a variety of questionsthere that I think are really important,
and I think that every visitthat we have with a patient is
an opportunity to be looking at thosevaccines that that patient may be

(38:24):
needing.
As you mentioned at the time thatwe're wanting to administer the RSV
vaccine,
there's a number of other vaccinesthat we might consider co-administer.
You mentioned the shinglesvaccine. There's also pneumococcal,
there's the COVID, the influenza vaccine,and talking to the patient

(38:44):
about which vaccines are mostimportant to receive at that
visit.
And in some cases it's safe toprovide numerous vaccines at the same
visit, but to be able to warnthe patient about any potential
reactogenicity symptomsthat they may have,
especially if they're gettingan adjuvanted vaccine.

(39:05):
So I think that it's importantfor us to provide those options to
patients and see what works best forthem, meeting them where they are,
trying to find out what aretheir goals in terms of their
preventive health,
how can we best help them to meet thoseparticular goals? I think that it's

(39:25):
important for us to always be lookingat any missing vaccines. Ruth,
you and I have talked before aboutasking patients if they're up to date on
their vaccines, and the answerthat they always give us is, yes,
I've received all of my vaccines.
But when we start to drill downto the specific vaccine, okay,
what date did you receive your influenzavaccine or when did you receive your

(39:45):
pneumococcal, and going throughthe specific vaccine. Well,
I haven't received that one orI didn't know about that one.
So we can't rely on thepatient's memory on that.
And unless the vaccine goesinto the vaccine registry
system,
not all pharmacies and not all providersenter that information into the

(40:06):
registry.
And so the patient may not know thatthey have received a particular vaccine.
So I think that we need to take thetime to update the vaccine record,
find out what vaccinesthe patient is needing,
and with respect to RSV vaccine,
patients may not be aware thatthere is a vaccine available to
help to prevent this disease or thecomplications from this disease.

(40:30):
And so having that discussionwithin the context of all of
the preventive medicine that we'reproviding to that patient or that
anticipatory guidance that we'reproviding is really going to be very,
very important. What are your thoughts?
Yeah, I think absolutely.
I think earlier I mentioned that lessthan half of the patients 75 and older

(40:50):
who should be considering thisvaccine, 75 years and older,
you are, age is the strongest risk factor,
yet we've only been able to reachhalf less than half of that group.
So I agree completely that we willhave many of our patients that are not
vaccinated simply becausethey're not aware,
we haven't had the discussion with them.

(41:12):
Others may be concerned about the vaccine,
is this something I need? Is it goingto help me? Do I meet indications?
So it goes back to the strongrecommendation from the healthcare
provider and then makingit real to that individual,
having those timely discussions, havingthose open discussions with them,

(41:33):
and as you mentioned, knowingwhat they have and have not had.
And I think this can really circleback to the importance of having our
office working alongside us.We are all in this together.
And so I may need then to make sure thatwithin my practice there is someone who
is updating vaccine informationand may be as simple

(41:56):
as in your EMR,
maybe you're just simply able to hit thereconcile button and pull information
from your existing state immunizationinformation system. For others,
it may be a little bit moredifficult. I'm in Louisville,
Kentucky and we are righton the border with Indiana,
so I may have patients that receive somevaccines in Kentucky and some vaccines

(42:17):
in Indiana. Well,
I need to maybe go through some additionalhoops to make sure that I can not
only access the information onthose two different state systems,
but also then including the patient inthe conversation. But as you mentioned,
my patients don't always remember whatvaccines they've had or they get confused
about what vaccines they have.So I can't always rely on what the

(42:41):
patient tells me verbally because if I do,
if I go by what the patient tells meverbally and I enter that information
as historic data into thatimmunization information system,
if it's wrong, it's in thereand it's viewed as the gospel.
So I have to realize thelimitations that exist in our

(43:04):
information systems and howinformation a patient may be
absolutely certain about what they have.
I have one patient that loves to cometo see me every year that will say, oh,
Dr. Carrico, you're goingto be so proud of me.
I had my pneumococcal vaccine again,
and I have to remind them that it isthe flu vaccine that is every year.

(43:24):
It is now our COVID vaccine that forthis individual is going to be more than
once a year.
Their pneumococcal vaccine is dependingupon the type of vaccine they've had,
their different seriesor schedules for that,
but it's not something that they haveevery year. So I take that opportunity to
educate them,
but how much time do I want to spendbringing a patient down who is already

(43:47):
excited that he's rememberingto go and get his vaccines?
I want to celebrate that success,
but it's just a reminder that I can'talways rely on the patient's memory.
So we know that this is a challenge andthat we know we have multiple vaccines
that we are going to be recommending.Many of them, as you mentioned,
co-administration, I've gotthe patient in the office.

(44:07):
I don't want to be hesitantmyself about recommending multiple
vaccines to be given at the same timebecause these are diseases of breathing.
I can't tell what my patient isgoing to be around when or whom.
So making sure that they have opportunityto receive vaccines that may be
clinically important for them.

(44:28):
But I know that we havepatients that are hesitant.
We also know that we've got patientsthat are tired of the conversation
about vaccines. I know some of usat clinicians, we are tired too,
but we're trying to figure out how wecontinue to have these discussions about
hesitance and fatigue.
What are some of the approaches that youhave in dealing with vaccine hesitancy

(44:52):
and fatigue in your patients?
Well, and I think that thevaccine hesitancy and fatigue,
especially the fatigue portioncan be clinicians as well.
And so I think we need to recognize withinourselves that when we have a patient
who is hesitant about vaccine,it's not the same as refusal,
they may be hesitant about a particularvaccine and maybe not all vaccines,

(45:14):
but what we need to consider is whatis the foundation of their hesitancy?
One of the models that we can usein understanding vaccine hesitancy
is called the three C'sof vaccine hesitancy.
And this stands for complacency,confidence and convenience.
The complacency portion ofthis is the referral to a

(45:37):
low perception of risk regardingvaccine preventable diseases. So,
many people believe that thesediseases are rare or been eradicated,
which makes them less concerned aboutvaccination. I know in my own practice,
especially with pediatric vaccines, thata lot of times the families would say,
well,
I don't want the child to get all ofthese vaccines at the same time. So which

(45:59):
ones are the mostimportant vaccines? Well,
all of our vaccines are important aswe're seeing with the current measles
outbreak.
It's important that we not becomplacent and that we remind
patients that we are seeing outbreaksof many of these vaccine preventable
diseases. Everything frompolio to pertussis to measles,

(46:19):
complacency can happen becauseof that low perception of risk.
So talking about the risks and talkingabout the outbreaks that are happening
within the country is reallygoing to be an important factor.
And RSV is definitely one of thosediseases that we're seeing an increase in
on an annual basis. Confidence.
This involves the trust and the safetyand the effectiveness of the vaccines as

(46:42):
well as trust in theinstitutions that recommend them.
So we found during thepandemic of COVID-19 that there
was a lot of loss ofconfidence in government,
CDC and other groups,
and we may have even seen someperipheral loss of confidence in
healthcare providers. So this lack ofconfidence can stem from misinformation,

(47:06):
fear of side effects or doubtsabout the scientific evidence,
and we know that there's so muchmisinformation that's out there.
So as clinicians,
we can provide a real service to ourpatients by talking to them about
what it is that they're hearing andproviding clarification about the
information and the level of risk.
And the final thing is convenience.

(47:27):
And this is how easy is it going to befor that individual to be able to access
the vaccines. So where arethe location of the vaccines?
What are our hours of operation?
Are they conducive to the individualsthat are working or that they have shift
work or that they are unableto take time off of work?
And the cost is always afactor for many patients,

(47:50):
especially if they'reuninsured or underinsured.
There's also the vaccine hesitancycontinuum. So continuing to
recommend vaccination, evenif it's initially declined.
I think of that as planting the seed.
So I will tell my patients thateven if they're hesitant or they're
reluctant to get the vaccine today,

(48:10):
I will tell them why I think it'simportant for them to receive that vaccine
because of their condition, their age,
or why it's important forthem as an individual.
And then I'll tell them we're going tobe revisiting this at a future time.
So I just want to tell you upfront thatI think this is important enough that I
would like to revisit this. Then Ruth,

(48:31):
I'd like to know,
do you face vaccine hesitancy whenyou're recommending the RSV vaccination
specifically?
I haven't had individuals thatwill point out the RSV vaccine
specifically,
but I have had patients that willask me basically the questions about
will whatever vaccineyou're recommending for me,

(48:54):
will it help me? Also, will it hurt me?
So patients are interested ineverything as it relates to them as a
unique individual.
And I think there are a couple of takehome messages that I have had from
listening to these patient conversations.
And number one is I need todo a better job about risk and

(49:15):
talking with them about risk factors.
And I know it's interesting becausewhen I go to the provider and I'm doing
my electronic check-in,
many of us will fill out paperwork oranswer questions before we actually have
our visit. And it's interesting thatone of the questions I'm often asked is,
how do I rate my health?And it'll say, poor, good,

(49:36):
excellent. And it's interesting becauseI think, gosh, how do I rate my health?
I get up every day, I go towork, I feel pretty good.
So that must mean thatI'm in excellent health.
But then I look and I thinkwell shoot, I'm in that older,
getting closer to thatolder adult age. Yeah,
I take medication for hypertension.

(49:56):
I also deal with struggle alittle bit with my lipid profile.
I got a few extra pounds on me.So I do have those risk factors,
but if I don't recognize risk in myself,
it makes it then very hard for me tohave a risk-based conversation with my
patient, and I may beless likely to do that.
So I have to really remember thatI need to be always having that

(50:20):
conversation with the patient.
So I'm able to convey why is itthat this is important? And I
typically start a conversation withmy patient. I'm so glad to see 'em,
and you're the most importantperson in my whole world right now.
Our time together is uninterrupted.
I'm going to turn my backon the computer screen,
I'm going to turn my phone over, and Iwant to make this visit all about you.

(50:42):
And we have to address avariety of issues during what
is sometimes a very limited time.So I have to be very organized.
And so how I have these conversationsis really going to be led by what the
patient is asking andwhat they're telling me,
and I have to be able to make sure thatI'm addressing any of their points.

(51:03):
So your question was dopatients have a particular
question about RSV vaccine?I have not experienced that,
but it gives me the opportunityto talk about RSV as a disease of
breathing and talk about what thenare my patient's individual risk
factors,
and then I can address then themisinformation that you have mentioned.

(51:27):
And I have the opportunity to usesome of the new terms or new words
that I have with patients. So for example,
previously I may havediscounted their concerns,
but when they bring anytype of question to me,
no matter how, maybe off the wall,
I think it is the fact that theyare bringing that concern to me,

(51:52):
I want to legitimize notnecessarily the actual issue.
So if my patient is saying, well, Idon't want to be injected with a chip,
or I don't want any vaccine toimpact my DNA, I'm not going to say,
yeah, that happens. No, absolutely.
I know that we don't have thescientific evidence behind that.
But what we do and what Ido is I say, yeah, well,

(52:15):
I understand fears orconcerns about vaccines.
Let me share information that I know.
Can I tell you more information?Or many times my patients will say,
they'll ask me that.Well, what would you do?
Or they will ask me a very pinpointquestion, have you received that vaccine?
So this really brings up a lot ofimportant points about how we as

(52:39):
providers view vaccines andare we equipped then to answer
those very pointedquestions from our patients?
So that helps us then frame,
maybe think about individually howwe view vaccines or vaccination.
Because remember,
hesitance is not only in onepart of our patient population,

(53:01):
that all of us have questionsor concerns. And Audrey,
you mentioned that vaccinehesitance is not a consistent issue,
and it may vary and it mayvary both in its intensity and
how it impacts a full spectrumof vaccinations and vaccines.
And so we need to be prepared to havethese questions and then bring them up in

(53:23):
an ongoing manner. So just likeif I have a patient that smokes,
I'm not going to addresssmoking cessation just one time.
I may bring that up repeatedly.
Same thing for vaccines and vaccinationthat I realize that if I have a
vaccine but I don't get itinto the arm of a patient,
I've not provided full benefitand full use of that vaccine.

(53:45):
So I've got a lot of work to dowith my patients in answering their
questions about will a vaccinehelp me? Will a vaccine hurt me?
And I've got to be able totalk about those things.
Just like you had mentioned someof the side effects of vaccines,
I've got to be able to saysome of these side effects.
I would recognize that asconsistent. So for example,

(54:08):
if I stick you with the needle,I know you may have a sore arm.
If I'm administering a vaccine that Iexpect to elicit an immune response,
I need to tell you that it's not goingto surprise me if you have body aches or
fever,
that is part of that antigen antibodyresponse. But I want to make sure that
patients are equipped and able toreach out to me if they experience

(54:29):
something beyond that, that they knowthat not only I want to hear from them,
I'm enabling them to get back in touchwith me and I want to answer some of
their questions.
So one of the most common questionsnow that I get from patients are,
what about my insurance coverage?Is this going to help me?
What are some of thoselogistical considerations?

(54:50):
So I need to have informationreadily available to patients,
and maybe I'll know it.
Maybe I will have some basicknowledge about insurance coverage and
how that impacts the not onlyability of a patient to identify a
vaccine. But what about theability to accept a vaccine?
So I know that many ofour private insurances,

(55:11):
particularly those when I'm talkingabout those patients that are covered by
Medicare,
Medicare and private insurance shouldcover then vaccines without a copayment.
Sometimes our challenge is where canthey get it and where will that coverage
then be in effect?
So this is when I need to make surethat I'm reaching out to my pharmacy
partners that I know then thatif I have a vaccine, for example,

(55:35):
that is covered as partof Medicare Part D,
that vaccine may need to be giveneither in a pharmacy or I need
to make sure that it is given in apractice setting that has access to that
particular type of insurancecoverage. So for example,
does your office useTransactRX or VaxCare,

(55:57):
that may help them then providevaccines that are covered under Part
D. But in your actual practice setting,
I also need to make sure that if I am a
non-vaccinating office, maybeI don't carry vaccines on site.
Where do I refer patients?
Our federally qualified familyhealth centers, health departments,

(56:20):
pharmacies and others may bethose places where my patient can
access a vaccine. But just like Ineed to help my patients develop a
vaccination plan,
I as the provider need toalso have a plan in place,
where can I refer individuals? Icertainly don't want to tell them, well,
just go out and see where you can findit. No, that's not a good answer, is it?

(56:42):
And that's not respectful.
I think for our patients who are goingto have these challenges instead,
I need to say,
here are some places where you may beable to access vaccine on the local
level. Maybe I'm going to include lists.
Maybe I've got phone numbersor websites for them,
but I need to be able to helpthem. If I'm helping them,
I want a patient to getacross the finish line,

(57:04):
then I've got to givethem information. Now,
I know in the US most of our RSV vaccineshave been provided in pharmacies.
So what is my approach? Do Isend an electronic prescription?
Do I realize that, well if I do that,
maybe I'm going to send theprescription to Walgreens or CVS,
but my patient may remember that theyneed a vaccine when they're waiting in

(57:26):
line at Costco. That we havemany of these opportunities.
So I've got to enablemy patient to access.
So I know that when Isee 'em in a practice,
they may leave with a printoutof that after visit summary.
This is when I may say, all right,I'm going to take this highlighter.
I'm going to circle thisis what vaccine you need.

(57:46):
But I'm also going to remember that thatpaper may end up at the bottom of their
purse or on the floor of their car.
So many times now I'm sayingget out your cell phone.
I want you to take a picture of thisbecause you may be in line at Costco or
Walgreens or CVS, and Iwant you to say, oh my gosh,
I remember my provider talked with me.
Let me pull up my photos in my cell phone.

(58:07):
And that may be that additionalreminder. So as a provider,
we're having to really think aboutmany ways that we can enable our
patients to receive vaccine. So Audrey,
I want to ask your feedback.
Do you have vaccine onsite ordo you refer your patients?

(58:27):
And how do you approach this?
I think as you mentioned before,
that in most of the continental UnitedStates that this is Medicare part D,
and so we are having to referindividuals to pharmacies. However,
we do try to check inwith other practices,
including our local health departmentto see if they have vaccine that's

(58:47):
available. And then as you mentioned,we provide those resources.
I think one of the points that you madeis it's really important that we make it
as easy as possible for patientsto be able to access those vaccines
because otherwise we're going to have amissed opportunity if we create barriers
for them in terms oftransportation or coverage,

(59:08):
they may be less likely toget this important vaccine.
We mentioned also someimpacts about disparities in
vaccine coverage and abit about how do we make
sure that we are appropriatelyconveying risk to our patients,
so they realize that the vaccineis even important to them?
But we may also have areas,

(59:30):
particularly areas in our communitiesthat are experiencing high poverty.
For example, they may not have a pharmacy.
There may be very limitedhealthcare providers that are there.
So actually their abilityto access health services as
well as access vaccine maybe severely compromised.
So we have spoken, you and I,

(59:53):
about community outreachcampaigns and the importance of
realizing that many of thesegrassroot efforts can be
critical for us in terms ofreaching our populations,
both identifying groupsthat our individuals trust.
You had mentioned previously that we'reall challenged with a loss of trust

(01:00:16):
across every aspect of healthcare.
But if we are trying then to make vaccineavailable in a community where they
may have a lot of barriers,a lot of challenges,
it is important for us as providersand really use the power of nurses.
Remember, it's a good time,
I think to remember that mostevery year the general public will

(01:00:37):
recognize nursing as themost trusted profession.
So they're going to listen to us andthey also are going to recognize that
nurses are out there in a variety ofhealthcare settings and that we may be
having over the fence conversations,maybe conversations at church.
We may be talking in our localcommunities about vaccination.

(01:01:00):
Let's really think about how tomake sure that our approaches
are using those elementsof cultural competence.
We're talking with ourpatients using verbiage,
using language that they recognize.
We're talking about accessingvaccine in places where they feel
comfortable and confident that weare doing this all within a very

(01:01:24):
individualized approach to healthcare.That at the end of the day,
our patients want to berecognized as an individual.
And so it is up to us to use then thestrengths and the skills that we have
as nurse practitioners,
as nurses to have these conversations.So we are able then to drive home
this point.

(01:01:44):
So I want to use this opportunity tokind of bring some take home messages
that I hope people willuse in our time together.
And as they are trying to examinehow they view and how they
make vaccine available in their settings,
how do they establish theseconversations with our patients?

(01:02:04):
What are some of these,
maybe just a short list of takehome messages for this very
important and impactfulvaccine. The RSV vaccine,
first of all,
the RSV vaccine is for everyone75 years of age and older.
For those individuals who are 50 to 74,

(01:02:25):
if they have a risk factor, and rememberthat was a long set of risk factors,
and I'm just going to pull outheart failure as an example.
Risk factors that are presentto both impact how they
may struggle with RSV if they become ill.
Then we need to be having thoseconversations with them and make
sure that there is RSVvaccine available to them.

(01:02:49):
We know that the ACIP drove down the age
range for RSV vaccine. In thepast it was age 60 and older.
Now it's down to age 50.
So that 50 to 74 individualswho have one of those risk
factors, and 75 and older,

(01:03:09):
those individuals shouldreceive that vaccine.
But having a discussion about whythey are at risk and why the ACIP is
recommending that we don't haveto rely on shared decision-making.
We explain,
and we have this discussion as partof our routine conversation with our
patient about disease preventionand why they may be at

(01:03:33):
risk as an individual,
also making sure that we areusing every opportunity as a
vaccinating opportunity,
and that may be co-administration ofa vaccine. So don't think that we have
to just do one vaccine at a time,
but we may have patientsthat are eligible for RSV,
COVID, flu, shingles vaccine.All those can be given.

(01:03:58):
At the same time,
making sure that our staff areappropriately trained so they know how to
administer multiple vaccinesto a single patient.
So clearly our discussion today, Audrey,
has brought that we have maybea lot to learn with RSV and the
vaccine.
Hopefully our listeners willview this as a good start for

(01:04:21):
them.
I hope that we have raised somequestions that some of our NP
providers then are going to say,I want to think more about this.
I want to think about howthis will impact my patient.
I want to look at my patient populationspecifically and think about how we
can bring then the vaccineto them, the information,

(01:04:41):
as well as perhaps the vaccine itself.
Maybe I want to make changesin my practice so I'm able to provide this vaccine
in my practice, in my medical home,
so that I can then get my patient moreeasily across the finish line. Audrey,
you may have some pointsthat you want to raise.
Anything that you want to add inour short list of take home points?

(01:05:03):
I think you've coveredthem really well, Ruth.
I just want to thank everyone for theirparticipation today and thank each of
our participants for everythingthat they do for their patients,
for improving the health and thewellbeing of their patients and their
communities. So it's been apleasure being here with you, Ruth,
and thank you everyonefor your attendance today.

(01:05:26):
I couldn't agree more.Thank you so much, Audrey.
It's always a delight to work with you.
Well, thank you so much, Ruth and Audrey.
It's been an absolute pleasure listeningto you and gaining your perspective and
insights on this extremelyimportant topic. To our listeners,
I hope you found this episode educationaland can apply some of what was
discussed to your practice.

(01:05:46):
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(01:06:07):
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(01:06:28):
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