Trends in community pharmacy counts and closures before and after the implementation of Medicare part D

Buprenorphine dispensing in an epicenter of the U.S. opioid epidemic: A case study of the rural risk environment in Appalachian Kentucky

BACKGROUND

Buprenorphine is a cornerstone to curbing opioid epidemics, but emerging data suggest that rural pharmacists in the US sometimes refuse to dispense this medication. We conducted a case study to explore buprenorphine dispensing practices in 12 rural Appalachian Kentucky counties, and analyze whether and how they were shaped by features of the rural risk environment.

METHODS

In this case study, we conducted one-on-one semi-structured interviews with 14 pharmacists operating 15 pharmacies in these counties to explore buprenorphine dispensing practices and perceived influences on these practices. Thematic analyses of the resulting transcripts revealed three features of the rural risk environment that shaped dispensing. To explore these three risk environment features, we analyzed policy documents (e.g., Attorney General lawsuits) and administrative databases (e.g., incarceration data). Textual documents were analyzed using thematic analyses and administrative data were analyzed using descriptive statistics; memoes explored relationships among risk environment features and dispensing practices.

RESULTS

Twelve of the 15 pharmacies limited dispensing, by refusing to serve new patients; limiting dispensing to known patients or prescribers; or refusing to dispense buprenorphine altogether. Concerns about exceeding a "Drug Enforcement Administration (DEA) cap" on opioid dispensing stifled dispensing. A legacy of aggressive and fraudulent marketing of opioid analgesics (OAs) by pharmaceutical companies and physician OA overprescribing undermined pharmacist trust in buprenorphine and in its prescribers. The escalating local war on drugs may have undermined dispensing by reinforcing stigma against people who use drugs.

CONCLUSIONS

Initiatives to increase buprenorphine prescribing must be accompanied by policy changes to increase dispensing. Specifically, buprenorphine should be removed from opioid monitoring systems; efforts to de-escalate the war on drugs should be extended to encompass rural areas; initiatives to dismantle aggressive OA marketing should be strengthened; and efforts to re-build pharmacist trust in physicians are needed.

Rural-Urban Disparities in Access to Medicaid-Contracted Pharmacies in Washington State, 2017

INTRODUCTION

Community retail pharmacies offer multiple public health services to meet the health care needs of medically underserved rural communities. Many rural residents are enrolled in Medicaid insurance, and it is important that pharmacies contract with Medicaid to meet the health care needs of these people. The objective of this study was to evaluate disparities in access to Medicaid-contracted pharmacies across the rural-urban continuum in Washington State.

METHODS

We linked data on licensed community retail pharmacies in Washington State in 2017 to lists of state Medicaid-contracted pharmacies. We classified pharmacies as being located in small rural, large rural, suburban, and urban areas by using rural-urban commuting area (RUCA) codes. We evaluated the likelihood of zip code-level access to at least 1 pharmacy that was contracted with a Medicaid insurance plan across the rural-urban continuum by using descriptive statistics and modified Poisson regression models, adjusted for zip code-level community characteristics.

RESULTS

Of 1,145 pharmacies in our study sample, 8.4% (n = 96) were not contracted with a Medicaid plan. Compared with urban core zip codes, small rural zip codes (adjusted relative risk [ARR] = 0.64; 95% CI, 0.46-0.91) and large rural zip codes (ARR = 0.68; 95% CI, 0.49-0.95) were significantly less likely to have access to a Medicaid-contracted pharmacy. Suburban zip codes did not differ significantly from urban core areas in their access to Medicaid-contracted pharmacies.

CONCLUSION

In Washington State, the likelihood of access to a Medicaid-contracted pharmacy decreased significantly as rurality increased. Policy efforts should aim to improve access for Medicaid enrollees, especially those outside urban centers.

Association Between Pharmacy Closures and Adherence to Cardiovascular Medications Among Older US Adults

IMPORTANCE

It is unknown whether and how pharmacy closures alter medication adherence.

OBJECTIVE

To examine the association between pharmacy closures and adherence to statins, β-blockers, and oral anticoagulants among adults 50 years or older in the United States.

DESIGN, SETTING, AND PARTICIPANTS

In this retrospective cohort study, comparative interrupted time series analyses were performed using a nationally representative 5% random sample of anonymized, longitudinal, individual-level pharmacy claims from IQVIA LRx LifeLink. Analyses included all prescription claims for individuals followed up between January 1, 2011, and December 31, 2016. Separate cohorts were derived for users of statins, β-blockers, and oral anticoagulants. The differential association of pharmacy closure was examined as a function of baseline adherence, pharmacy, and individual characteristics.

MAIN OUTCOMES AND MEASURES

Difference in monthly adherence, measured as proportion of days covered, during 12-month baseline and follow-up periods among patients using a pharmacy that subsequently closed (closure cohort) compared with their counterparts (control cohort).

RESULTS

Among 3 089 803 individuals filling at least 1 statin prescription between January 1, 2011, and December 31, 2016 (mean [SD] age, 66.3 [9.3] years; 52.0% female), 3.0% (n = 92 287) filled at a pharmacy that subsequently closed. Before closure, monthly adherence was similar in the closure and control cohorts (mean [SD], 70.5% [26.7%] vs 70.7% [26.5%]). In multivariable models, individuals filling at pharmacies that closed experienced an immediate and significant decline (on average, an absolute change of -5.90%; 95% CI, -6.12% to -5.69%) in statin adherence during the first 3 months after closure compared with their counterparts. This difference persisted over 12 months of follow-up. A similar decline in adherence was observed when examining cohorts using β-blockers (-5.71%; 95% CI, -5.96% to -5.46%) or oral anticoagulants (-5.63%; 95% CI, -6.24% to -5.01%). The mean association of pharmacy closure with adherence was greater among individuals using independent pharmacies (-7.89%; 95% CI, -8.32% to -7.47%) or living in neighborhoods with fewer pharmacies (-7.98%; 95% CI, -8.50% to -7.47%) compared with their counterparts.

CONCLUSIONS AND RELEVANCE

Pharmacy closures are associated with persistent, clinically significant declines in adherence to cardiovascular medications among older adults in the United States. Efforts to reduce nonadherence to prescription medications should consider the role of pharmacy closures, especially among patients at highest risk.

Regional Variation in Pharmacist Perception of the Financial Impact of Medicare Part D

The objective of this study was to perform a nationwide investigation of the financial performance of community pharmacies in the United States since the inception of Medicare Part D. A nationwide, cross-sectional survey of pharmacists was conducted in 2013. The 43-item online survey collected information about demographics, financial implications of Part D on community pharmacy and patients, provision of Medication Therapy Management (MTM) services and opinions about Medicare Part D 2010 updates. The adjusted response rate was 22.3% (419/1885). A majority of respondents (75.6%) reported a stable or increased prescription volume since 2006 but only 40.4% indicated that the financial performance of their pharmacy as either excellent or good during the same period. Owners and part-owners of rural independent pharmacies were more likely to report a below average or poor financial performance (75.0%). The provision of MTM services was not related to the financial performance of the pharmacy. Nearly half (44.7%) of pharmacy owners or part-owners indicated that they were considering selling their pharmacy, with most (94.1%) reporting that their decision to sell was due to the Part D financial pressures. However, the decision to sell was not related to the change in financial performance since 2006 or the volume of prescriptions dispensed.

Identifying Barriers and Facilitators at Affect Community Pharmacists' Ability to Engage Children in Medication Counseling: A Pilot Study

OBJECTIVES

This study aimed to describe the barriers and facilitators that influence community pharmacists' ability to provide medication counseling to pediatric patients.

METHODS

Semistructured interviews (n = 16) were conducted with pharmacy staff at 3 community pharmacies in 2 Eastern states. The interview guide elicited pharmacy staff experiences interacting with children and their perceived barriers and facilitators to providing medication counseling. Transcripts were reviewed for accuracy and a codebook was developed for data analysis. NVivo 10 was used for content analysis and identifying relevant themes.

RESULTS

Ten pharmacists and 6 pharmacy technicians were interviewed. Most participants were female (69%), aged 30 to 49 years (56%), with ≥5 years of pharmacy practice experience. Eight themes emerged as barriers to pharmacists' engaging children in medication counseling, the most prevalent being the child's absence during medication pickup, the child appearing to be distracted or uninterested, and having an unconducive pharmacy environment. Pharmacy staff noted 7 common facilitators to engaging children, most importantly, availability of demonstrative and interactive devices/technology, pharmacist demeanor and communication approach, and having child-friendly educational materials.

CONCLUSIONS

Findings suggest that pharmacy personnel are rarely able to engage children in medication counseling because of the patient's absence during medication pickup; however, having child-friendly materials could facilitate interactions when the child is present. These findings can inform programs and interventions aimed at addressing the barriers pharmacists encounter while educating children about safe and appropriate use of medicines.

The availability of pharmacies in the United States: 2007-2015

Importance

Despite their increasingly important role in health care delivery, little is known about the availability, and characteristics, of community pharmacies in the United States.

Objectives

(1) To examine trends in the availability of community pharmacies and pharmacy characteristics (24-hour, drive-up, home delivery, e-prescribing, and multilingual staffing) associated with access to prescription medications in the U.S. between 2007 and 2015; and (2) to determine whether and how these patterns varied by pharmacy type (retail chains, independents, mass retailers, food stores, government and clinic-based) and across counties.

Methods

Retrospective analysis using annual data from the National Council for Prescription Drug Programs. Pharmacy locations were mapped and linked to the several publically-available data to derive information on county-level population demographics, including annual estimates of total population, percent of population that is non-English speaking, percent with an ambulatory disability and percent aged ≥65 years. The key outcomes were availability of pharmacies (total number and per-capita) and pharmacy characteristics overall, by pharmacy type, and across counties.

Results

The number of community pharmacies increased by 6.3% from 63,752 (2007) to 67,753 (2015). Retail chain and independent pharmacies persistently accounted for 40% and 35% of all pharmacies, respectively, while the remainder were comprised of mass retailer (12%), food store, (10%), clinic-based (3%) or government (<1%) pharmacies. With the exception of e-prescribing, there was no substantial change in pharmacy characteristics over time. While the number of pharmacies per 10,000 people (2.11) did not change between 2007 and 2015 at the national-level, it varied substantially across counties ranging from 0 to 13.6 per-capita in 2015. We also found that the majority of pharmacies do not offer accommodations that facilitate access to prescription medications, including home-delivery, with considerable variation by pharmacy type and across counties. For example, the provision of home-delivery services ranged from less than <1% of mass retailers to 67% of independent stores and was not associated with county demographics, including ambulatory disability population and percent of the population aged ≥65 years.

Conclusions

Despite modest growth of pharmacies in the U.S., the availability of pharmacies, and pharmacy characteristics associated with access to prescription medications, vary substantially across local areas. Policy efforts aimed at improving access to prescription medications should ensure the availability of pharmacies and their accommodations align with local population needs.

What can pharmacists' do about the Medicare Part D Donut hole and reimbursement? A six-state survey

BACKGROUND

While Medicare Part D was signed into law in 2003 and initiated in 2006, there is a scarcity of information related to the implications of Part D on community pharmacies and subsequent effects.

OBJECTIVE

To determine the financial implications of Part D on community pharmacy, to identify pharmacists' and beneficiaries concerns from the pharmacists' perspective and to determine the pharmacists' responses to these impactions and concerns.

METHODS

A cross-sectional survey of pharmacists practicing in six states (Maine, New Jersey, New York, Maryland, Massachusetts and Pennsylvania) was conducted online between June and December 2011. The 37-question online survey collected demographic data, data about implications of Part D on community pharmacy and patients, and pharmacists' beliefs about ideal pharmacy practice and Part D plans.

RESULTS

Of the 4,888 online surveys, only 1,108 were assumed to have reached the intended recipients (response rate 25 %). Fifty-six percent reported that reimbursement was the most significant concern, and 34.5 % of the owners or part-owners were planning to close their pharmacy due to financial pressures exerted by Part D. A significant relationship was observed between dispensing of 90 days' supply of medications and better financial performance (χ (2) = 6.95, p = 0.0084). The most significant patient concerns were formulary and copayment (52.8 %) and Donut hole (52.4 %). Fifty-four percent respondents stated that his/her pharmacy helped patients obtain financial assistance while patients were in the Donut hole.

CONCLUSION

Respondents were most concerned about the poor reimbursement rates, but pharmacists who dispensed 90 day supply of medications reported acceptable financial performance. Pharmacists also reported helping patients obtain financial assistance while in the Donut hole.

Cardiovascular medication utilization and adherence among adults living in rural and urban areas: a systematic review and meta-analysis

BACKGROUND

Rural residents face numerous barriers to healthcare access and studies suggest poorer health outcomes for rural patients. Therefore we undertook a systematic review to determine if cardiovascular medication utilization and adherence patterns differ for rural versus urban patients.

METHODS

A comprehensive search of major electronic datasets was undertaken for controlled clinical trials and observational studies comparing utilization or adherence to cardiovascular medications in rural versus urban adults with cardiovascular disease or diabetes. Two reviewers independently identified citations, extracted data, and evaluated quality using the STROBE checklist. Risk estimates were abstracted and pooled where appropriate using random effects models. Methods and reporting were in accordance with MOOSE guidelines.

RESULTS

Fifty-one studies were included of fair to good quality (median STROBE score 17.5). Although pooled unadjusted analyses suggested that patients in rural areas were less likely to receive evidence-based cardiovascular medications (23 studies, OR 0.88, 95% CI 0.79, 0.98), pooled data from 21 studies adjusted for potential confounders indicated no rural-urban differences (adjusted OR 1.02, 95% CI 0.91, 1.13). The high heterogeneity observed (I(2) = 97%) was partially explained by treatment setting (hospital, ambulatory care, or community-based sample), age, and disease. Adherence did not differ between urban versus rural patients (3 studies, OR 0.94, 95% CI 0.39, 2.27, I(2) = 91%).

CONCLUSIONS

We found no consistent differences in rates of cardiovascular medication utilization or adherence among adults with cardiovascular disease or diabetes living in rural versus urban settings. Higher quality evidence is needed to determine if differences truly exist between urban and rural patients in the use of, and adherence to, evidence-based medications.