Fewer Pharmacies In Black And Hispanic/Latino Neighborhoods Compared With White Or Diverse Neighborhoods, 2007-15

Healthcare Access in the Aftermath: A Longitudinal Analysis of Disaster Impact on US Communities

Research on climate-related disasters and healthcare infrastructure has largely focused on short-term, localized impacts. This study examined the long-term association between climate-related disasters and healthcare facilities across 3108 contiguous United States counties from 2000 to 2014. Utilizing databases like the National Establishment Time Series and the Spatial Hazards and Events Losses Database, we classified county-level infrastructure changes ("never had", "lost", "gained", and "always had") and disaster severity (minor, moderate, severe), respectively. Autoregressive linear models were used to estimate the total number of moderate and severe disasters (2000-2013) associated with the change in the number of healthcare establishments in 2014, after adjusting for healthcare establishments, total population, and poverty in 2000. Results demonstrate that an increase in one moderate disaster was significantly associated with increased hospital infrastructure (Count, 0.14; 95% CI, 0.03-0.25), while severe disasters were significantly associated with a decrease (Count, -0.31; 95% CI, -0.47--0.14). Similar but stronger associations were observed for ambulatory care (Moderate: Count, 2.52; 95% CI 0.91-4.12 and Severe: Count, -5.99; 95% CI, -8.53--3.64, respectively). No significant associations were found among pharmacies. These findings highlight the varying impacts of climate-related disasters on healthcare accessibility. Future initiatives should prioritize strengthening existing infrastructure and enhance disaster recovery strategies.

Medicare Part D Preferred Pharmacy Networks And The Risk For Pharmacy Closure, 2014-23

Medicare Part D plans incentivize the use of specific pharmacies through preferred networks. We found that independent pharmacies and pharmacies in low-income, Black, and Latinx neighborhoods were less likely to be preferred by most Part D plans than chains and pharmacies in other neighborhoods. Pharmacies that were not preferred by most plans were 70-350 percent more likely to close than other pharmacies.

Health and wellness twenty-four seven: Student preferences for and utilization of a university vending machine

Objective: The objective of this study was to evaluate student use, and potential barriers, for product inclusion in a 24/7 vending machine and to examine student opinions on product selection. Participants: Students currently enrolled at the University of Rhode Island (URI) who were 18 years or older. Methods: Survey responses were collected during the fall semester. Demographic data included sex, race, year of study, involvement in clubs or organizations, and living situation. Researchers utilized restocking data on a weekly basis to assess product utilization. Survey findings were compared to dispensing data. Results: Students reported the vending machine would increase their access to pain relievers as well as sexual and reproductive health products. The most frequently dispensed products included emergency contraception, ibuprofen, safe sex kits, tampons, and COVID tests. Conclusions: Restocking data mirrored preactivation survey preferences suggesting outreach may be a dependable method to ensure student preferences.

Calcimimetic Prescriptions in Fee-for-Service Medicare Beneficiaries Undergoing Dialysis

Importance

Calcimimetics are a mainstay of treatment for secondary hyperparathyroidism (sHPT), a ubiquitous condition in end-stage kidney disease (ESKD) associated with fractures, cardiovascular events, and mortality. In 2018, Medicare implemented the Transitional Drug Add-On Payment Adjustment (TDAPA), which shifted calcimimetic coverage from Part D prescription drug plans to Part B. Prior to TDAPA, Medicare beneficiaries with ESKD faced varying out-of-pocket costs for calcimimetics at the point of pharmacy depending on presence and magnitude of low-income subsidies (LISs). TDAPA differentially alleviated barriers to filling these costly medications.

Objective

To assess whether calcimimetic prescriptions increased post-TDAPA among patients subject to high out-of-pocket costs prior to the policy change (patients with Part D coverage without LIS and those lacking Part D coverage).

Design, Setting, and Participants

In this longitudinal cohort study, a difference-in-differences analysis was performed at the patient-quarter level. The sample included adult Medicare fee-for-service beneficiaries undergoing maintenance dialysis between July 1, 2016, and December 31, 2020, at US outpatient dialysis facilities. The US Renal Data System, a national registry of patients with ESKD, was used to collect patient, facility, and claims data. The data analysis occurred between May 2023 and October 2024.

Exposures

LIS extent for patients with Part D coverage (fully subsidized, partially subsidized, not subsidized); presence of Medicare Part D coverage; and whether the patient-quarter was before/after TDAPA implementation.

Main Outcomes and Measures

The main outcome was having 1 or more filled calcimimetic prescriptions per quarter of the study period. A linear regression model was estimated, adjusting for demographics, dialysis modality and access, comorbidities, and facility characteristics, with 2-way fixed effects at the patient and quarter level.

Results

A total of 509 765 adult Medicare fee-for-service beneficiaries were included in the analysis. The cohort had a mean (SD) age of 64 (14) years, was 57% male, 4% Asian, 38% Black, 15% Hispanic, 41% non-Hispanic White, and 3% other race and ethnicity. In adjusted difference-in-differences models, TDAPA's estimated effect was an absolute increase of 9.8 percentage points (pp) (95% CI, 9.3-10.2 pp) in calcimimetic prescriptions for patients with Part D but no subsidy and a 2.2 pp (95% CI, 1.8-2.6 pp) increase for patients with partial LIS compared to patients with full LIS.

Conclusions and Relevance

The results of this longitudinal cohort study showed that after transitioning calcimimetic coverage from Part D to Part B via TDAPA, calcimimetic prescriptions increased in a graded manner, with the largest increases experienced by patients previously subject to the highest out-of-pocket prescription drug costs. Medicare's TDAPA policy has the potential to expand access to medications for patients.

Out-of-Pocket Prescription Drug Savings for Medicare Beneficiaries with Asthma and COPD Under the Inflation Reduction Act

BACKGROUND

High and rising prescription drug costs for asthma and chronic obstructive pulmonary disease (COPD) contribute to medication nonadherence and poor clinical outcomes. The recently enacted Inflation Reduction Act includes provisions that will cap out-of-pocket prescription drug spending at $2,000 per year and expand low-income subsidies. However, little is known about how these provisions will impact out-of-pocket drug spending for Medicare beneficiaries with asthma and COPD.

OBJECTIVE

To estimate the impact of the Inflation Reduction Act's out-of-pocket spending cap and expansion of low-income subsidies on Medicare beneficiaries with obstructive lung disease.

DESIGN

We calculated the number of Medicare beneficiaries ≥ 65 years with asthma and/or COPD and out-of-pocket prescription drug spending > $2,000/year, and then estimated their median annual out-of-pocket savings under the Inflation Reduction Act's spending cap. We then estimated the number of beneficiaries with incomes > 135% and ≤ 150% of the federal poverty level who would become newly eligible for low-income subsidies under this policy.

PARTICIPANTS

Respondents to the 2016-2019 Medical Expenditure Panel Survey (MEPS).

MAIN MEASURES

Annual out-of-pocket prescription drug spending.

KEY RESULTS

An annual estimated 5.2 million Medicare beneficiaries had asthma and/or COPD. Among them, 360,160 (SE ± 38,021) experienced out-of-pocket drug spending > $2,000/year, with median out-of-pocket costs of $3,003/year (IQR $2,360-$3,941). Therefore, median savings under the Inflation Reduction Act's spending cap would be $1,003/year (IQR $360-$1,941), including $738/year and $1,137/year for beneficiaries with asthma and COPD, respectively. Total annual estimated savings would be $504 million (SE ± $42 M). In addition, 232,155 (SE ± 4,624) beneficiaries would newly qualify for low-income subsidies, which will further reduce prescription drug costs.

CONCLUSIONS

The Inflation Reduction Act will have major implications on out-of-pocket prescription drug spending for Medicare beneficiaries with obstructive lung disease resulting in half-a-billion dollars in total out-of-pocket savings per year, which could ultimately have implications on medication adherence and clinical outcomes.

Vulnerability Index Approach to Identify Pharmacy Deserts and Keystone Pharmacies

Importance

Community pharmacies are crucial for public health, providing essential services such as medication dispensing, vaccinations, and point-of-care testing. Addressing disparities in pharmacy access, particularly in underserved rural and low-income areas, is critical for health equity.

Objective

To identify areas in the US at risk of becoming pharmacy deserts through the development of a novel pharmacy vulnerability index.

Design, Setting, and Participants

This population-based cross-sectional study in the contiguous 48 states performed geographic information systems analysis of pharmacy data from the National Council for Prescription Drug Programs (NCPDP) dataQ. Participants included all open-door pharmacies (community or retail pharmacies open to the general public without restrictions on who can access its services) in the US as of February 2024. Statistical analysis was performed from July to August 2024.

Exposure

The primary exposure was travel time to pharmacies across the US.

Main Outcomes and Measures

A pharmacy desert was defined as a census tract where the travel time to the nearest pharmacy exceeds the supermarket access time for that region and urbanicity level. Building on this definition, a pharmacy vulnerability index was developed, which indicates the number of pharmacies that would need to close for a census tract to become a pharmacy desert. Tracts with a pharmacy vulnerability index of 1, depending solely on a single pharmacy for access, were identified as at risk of becoming deserts. Subpopulation totals and percentages living in pharmacy deserts or relying on keystone pharmacies were computed, and then stratified by urbanicity and race.

Results

Among 321.3 million individuals (39.7 million [12.3%] Black, 59.0 million [18.2%] Hispanic, 195.0 million [60.3%] White) in the contiguous US, 57.1 million (17.7%) were identified as living in pharmacy deserts, with 28.9 million (8.9%) additionally relying on a single pharmacy for access. Small rural areas were particularly affected, with a higher dependency on single pharmacies (4.1 million individuals [14.3%]).

Conclusions and Relevance

In this cross-sectional study of pharmacy access in the US, significant disparities in pharmacy access were identified, especially pronounced in small rural areas. Targeted policy interventions, such as incremental reimbursement rates or other monetary incentives, are needed to ensure the financial sustainability of pharmacies that serve as the sole source of pharmacy services in at-risk areas.

Race and ethnicity, not just insurance, is associated with biologics initiation in asthma and related conditions

BACKGROUND

There are pre-existing inequities in asthma care.

OBJECTIVES

We sought to evaluate effect modification by race of the effect of insurance on biologic therapy use in patients with asthma and related diseases.

METHODS

We conducted inverse probability weighted analyses using electronic health records data from 2011 to 2020 from a large health care system in Boston, Mass. We evaluated the odds of not initiating omalizumab or mepolizumab therapy within 1 year of prescription for an approved indication.

RESULTS

We identified 1132 individuals who met study criteria. Twenty-seven percent of these patients had public insurance and 12% belonged to a historically marginalized group (HMG). One-quarter of patients did not initiate the prescribed biologic. Among patients with asthma, individuals belonging to HMG had higher exacerbation rates in the period before initiation compared to non-HMG individuals, regardless of insurance type. Among HMG patients with asthma, those with private insurance were less likely to not initiate therapy compared to those with public insurance (odds ratio [OR]: 0.67, and 95% CI: 0.56-0.79). Among non-HMG with asthma, privately insured and publicly insured individuals had similar rates of not initiating the prescribed biologic (OR: 1.02; 95% CI: 0.95-1.09). Among those publicly insured with asthma, HMGs had higher odds of not initiating therapy compared to non-HMGs (OR: 1.16; 95% CI: 1.03-1.31), but privately insured HMG and non-HMG did not differ significantly (OR: 0.99; 95% CI: 0.91-1.07).

CONCLUSIONS

Publicly insured individuals belonging to HMG are less likely to initiate biologics when prescribed despite having more severe asthma, while there are no inequities by insurance in individuals belonging to other groups.

Characterizing pharmacy deserts and designing a model to minimize inequities in pharmacy distribution in Virginia

BACKGROUND

Pharmacy closures have become increasingly prevalent in the United States in recent years. Previous literature highlights socioeconomic and racial disparities in the distribution of pharmacy deserts.

OBJECTIVES

To identify and characterize pharmacy deserts in Virginia and to simulate potential locations to minimize inequities in pharmacy distribution.

METHODS

This cross-sectional study used active pharmacy permits data from the Virginia Board of Pharmacy to identify census tracts considered pharmacy deserts by simultaneously satisfying 2 criteria: 1) low-income status (>20% residents living below the federal poverty line, or median household income <80% of a local comparator); and 2) low-access to pharmacies (distance >1, 5, or 10 miles for urban, suburban, and rural census tracts, respectively). Demographic and socioeconomic characteristics of desert vs. nondesert tracts were compared using Wilcoxon rank-sum tests. Locations within identified pharmacy deserts were randomly generated in 10,000 independent iterations.

RESULTS

Of 2198 census tracts, 51 were considered pharmacy deserts, and 69 met the low-access criterion only. Pharmacy deserts were significantly more common in urban census tracts (5.5%), followed by rural (2.9%), and suburban (0.1%). Compared to nondesert, pharmacy desert tracts had significantly lower percentage of residents under 18 year-old, greater percentage of Black residents, uninsured, with Medicare or Medicaid coverage only, lower median household income, and greater percentage of residents living in poverty. Through geospatial simulation, 44 locations were identified where adding pharmacy services could significantly improve access, each potentially benefiting over 10,000 individuals.

CONCLUSION

Fifty-one tracts in Virginia, primarily in urban areas, were considered pharmacy deserts. Compared to nondeserts, pharmacy desert status was associated with a lower proportion of residents under 18 year-old, greater proportion of Black and uninsured/publicly insured residents, and high poverty level, highlighting disparities in pharmacy access. Geospatial simulation identified several locations where placement of pharmacy services could benefit the largest number of residents living in desert tracts.

Naming and Framing: Six Principles for Embedding Health Equity Language in Policy Research, Writing, and Practice

Policy Points Science communication and health policy language often fail to adequately define and contextualize systemic barriers-like structural racism and wealth inequity-that contribute to disparities in health outcomes. Health policy practitioners should understand best practices for communicating research and policy findings to various audiences and understand how to disseminate messages that are culturally and linguistically responsive to different community needs. As no perfect term exists, adopting health equity language principles can help health policy practitioners avoid dehumanizing and exclusionary language as well as ill-suited terminology that perpetuates racist systems and leads to inequities in population health.

CONTEXT

Language specificity in research, advocacy, and writing is an important tool to ensure more equitable health policies. All health policy practitioners working at the intersection of health care, health policy, and health equity have a role in upholding ethical standards that promote the use of humanizing, inclusive, and antisupremacist language.

METHODS

We conducted an environmental scan and synthesized themes across commonly used and publicly available health equity language guides to provide specific guidance to health policy practitioners to inform their policy research, analysis, writing, and dissemination.

FINDINGS

We identify and describe six guiding principles to dismantle systems that work against the goals of health equity through policy-focused research, writing, and communications. These principles include avoiding blaming language, contextualizing health inequities, acknowledging that systems are not passive, understanding that one-size-fits-all terminology does not exist, seeking input from community members, and paying attention to omissions.

CONCLUSIONS

Applying these principles will better equip health policy practitioners to develop or inform equitable policies and meaningfully engage in dialogue with community members to advance equitable health policy.

Census Tract Rurality, Predominant Race and Ethnicity, and Distance to Lung Cancer Screening Facilities : An Ecological Study

BACKGROUND

The U.S. Preventive Services Task Force recommends annual lung cancer screening (LCS) for adults who meet specific age and smoking history criteria.

OBJECTIVE

To evaluate race-, ethnicity-, and rurality-based differences in distance to the nearest LCS facility.

DESIGN

Cross-sectional ecological study.

SETTING

U.S. census tracts.

PARTICIPANTS

71 691 census tracts.

MEASUREMENTS

The outcome variable was road network distance in miles between a census tract and the nearest LCS facility. Distance was log-transformed, and geometric means are reported. Census tracts were classified as majority (>50%) American Indian/Alaska Native (AI/AN), Asian, Black, non-Hispanic White (NHW), no single race, or Hispanic. Rurality was defined using the rural-urban commuting area codes. Ordinary least-squares regression examined the associations between distance and census tract race, ethnicity, and rurality.

RESULTS

Geometric mean distance to the nearest LCS facility was 6.5 miles. Compared with NHW-majority census tracts, distance to the nearest LCS facility was 5.26 times (426%) longer in AI/AN-majority census tracts and 7% to 39% shorter in Asian-, Black-, and Hispanic-majority census tracts. Adjustment for rurality reduced the mean distance in AI/AN-majority census tracts, but the mean distance was still 3.16 times the distance in NHW-majority census tracts. Adjustment for rurality reduced the observed advantage in Asian- and Black-majority census tracts and changed the direction of associations in Hispanic-majority census tracts.

LIMITATION

Analyses did not account for travel time or cost.

CONCLUSION

Differences exist in distance to LCS facilities by race and ethnicity that can only be partially explained by rurality.

PRIMARY FUNDING SOURCE

Lung Ambition Alliance and the Center for Lung Research in Honor of Wayne Gittinger.

Pharmacoequity measurement framework: A tool to reduce health disparities

Pharmacoequity is a health system and policy goal of ensuring equitable access to high-quality medications for all individuals, regardless of factors such as race, ethnicity, socioeconomic status, or resource availability to reduce health disparities. Although measurement frameworks have been widely used in health equity contexts, a focused framework for pharmacoequity remains a critical gap. In this article, we introduce a novel pharmacoequity measurement framework anchored in the patient medication-use journey. The framework includes the following domains: (1) access to health care services, (2) prescription generation, (3) primary medication nonadherence, (4) secondary medication nonadherence, and (5) medication monitoring. For each domain, we provide examples of outcome measures and potential data sources that can be used for evaluation. We also outline an implementation workflow of the pharmacoequity measurement framework that population health stakeholders can use across various settings (eg, health systems, health plans). The framework provides a structured approach to identify existing gaps in the path toward achieving pharmacoequity and lay the foundation for targeted interventions. Additionally, it enables ongoing monitoring of progress toward achieving pharmacoequity while identifying interventions that are effective, scalable, and sustainable.

Speaking Out: Factors Influencing Black Americans' Engagement in COVID-19 Testing and Research

Black communities in the United States (U.S.) have faced stark inequalities in COVID-19 outcomes. The underrepresentation of Black participants in COVID-19 testing research is detrimental to the understanding of the burden of the disease as well as the impact of risk factors for disease acquisition among Black Americans. Prior scholarship notes that the reluctance to engage in medical research among Black people is, in part, due to the exploitation and abuse this community has seen from the medical field and other social institutions. To better understand the barriers and motivations for COVID-19 testing among Black Americans, this study utilized intersectionality as methodological and theoretical frameworks to examine and investigate the barriers and motivations influencing participation in COVID-19 serosurveys (blood test and interview) among the metro-Atlanta Black communities. From May to October 2021, we took a community-based participatory research approach and conducted 52 semi-structured interviews to uncover different Black communities' feelings and opinions towards COVID-19 testing. Key reasons participants agreed to the blood test include (1) curiosity; (2) health upkeep; (3) family/community/social responsibility; and (4) importance of research. Participants' reasons for rejecting the blood test were (1) unnecessary/no benefit; (2) fear (of the known and unknown); (3) fear of needles and/or blood; and (4) discomfort with test setting/procedure. Our findings show that perspectives on willingness to engagement in testing or to not participate varied across gender and age for Black individuals.

Applying a diffusion of innovations framework to characterise diffusion groups and more effectively reach late adopters: a cross-sectional study on COVID-19 vaccinations in Canada in late 2021

Background

Rogers' diffusion of innovation theory suggests innovations are adopted in stages by different groups (innovators/early adopters, early majority, late majority and late adopters). In healthcare, this could mean that there is the potential to worsen health disparities as later groups tend to also face more social and structural barriers. Determining the unique sociodemographic characteristics, beliefs and attitudes of those in each diffusion category could be useful for theorising how to reach later groups more effectively.

Methods

Using a cross-sectional survey among Canadian adults in late 2021, we assigned respondents to diffusion groups based on when they received their first dose, relative to others within their age group in accordance with Rogers' model (ie, cut points: 16%, 50%, 84% with 100% being all those vaccinated within the age group). Participants answered questions about their COVID-19 vaccinations and questions related to their motivations, beliefs, values and attitudes towards COVID-19. A multinomial logistic regression model assessed the likelihood of participants being associated with each diffusion category (with the significance level set at p<0.05).

Results

The final sample included 2131 respondents. Late adopters were significantly more likely to identify as non-white, live in rural locations and receive vaccinations at pharmacies. Innovators and early adopters were significantly more likely to get vaccinated in settings other than pharmacies or community centres.

Conclusion

A diffusion group-based analysis brought insight into how vaccination strategies could be tailored to reach each diffusion group sooner, particularly late adopters who encounter more barriers.

Act for the future of community pharmacy

Community pharmacies serve as a vital gateway to primary care and public health, offering face-to-face pharmacist expert care to assure safe and effective medication use. However, they are disappearing at an alarming rate, with 20%-30% of all community pharmacy locations projected to close within the next year. The objective of this commentary is to highlight the critical need for systemic reforms and collective action within our profession to address the unique challenges faced by community pharmacies, ensuring their sustainability and continued role in providing essential health care services for patients. Key issues and evidence are provided to help pharmacy professionals better articulate why pharmacy closures are happening now and how we can work toward a transformed future. Pharmacy closures stem from an unsustainable business model characterized by declining reimbursement for prescription medications, opaque and anticompetitive pricing practices of pharmacy benefit managers, and limited reimbursement for clinical services. Among these challenges, our profession has the opportunity to create a future for community pharmacy where every person has local access to pharmacist expert care and medications through sustainable, integrated community pharmacy practice. Our profession must embrace community pharmacy teams' role in patient care, champion opportunities to integrate community pharmacists and their support staff as members of the health care team, and advocate for payment transparency and transformation. Creating this future will take all pharmacists and all pharmacy professionals.

Pharmacoequity measurement framework: A tool to reduce health disparities

Pharmacoequity is a health system and policy goal of ensuring equitable access to high-quality medications for all individuals, regardless of factors such as race, ethnicity, socioeconomic status, or resource availability to reduce health disparities. Although measurement frameworks have been widely used in health equity contexts, a focused framework for pharmacoequity remains a critical gap. In this article, we introduce a novel pharmacoequity measurement framework anchored in the patient medication-use journey. The framework includes the following domains: (1) access to health care services, (2) prescription generation, (3) primary medication nonadherence, (4) secondary medication nonadherence, and (5) medication monitoring. For each domain, we provide examples of outcome measures and potential data sources that can be used for evaluation. We also outline an implementation workflow of the pharmacoequity measurement framework that population health stakeholders can use across various settings (eg, health systems, health plans). The framework provides a structured approach to identify existing gaps in the path toward achieving pharmacoequity and lay the foundation for targeted interventions. Additionally, it enables ongoing monitoring of progress toward achieving pharmacoequity while identifying interventions that are effective, scalable, and sustainable.

More US Pharmacies Closed Than Opened In 2018-21; Independent Pharmacies, Those In Black, Latinx Communities Most At Risk

In recent years, federal and state policy makers have expressed concern about retail pharmacy closures throughout the US. However, there is a dearth of timely information on the extent of such closures. We linked data from the National Council for Prescription Drug Programs on all US retail pharmacies to county-level data from the National Center for Health Statistics and ZIP Code Tabulation Area data from the American Community Survey to determine the number and percentage of pharmacy closures during the period 2010-21; identify pharmacy, neighborhood, and market characteristics associated with pharmacy closure; and estimate the risk for closure for independent pharmacies relative to chain pharmacies. We found that of the 88,930 retail pharmacies operating during 2010-20, 29.4 percent had closed by 2021. The risk for closure for pharmacies in predominantly Black and Latinx neighborhoods was higher than in White neighborhoods. Independent pharmacies were at greater risk for closure than chain pharmacies across all neighborhood and market characteristics. Policy makers should consider strategies to increase the participation of independent pharmacies in Medicare and Medicaid preferred networks managed by pharmacy benefit managers and to increase public insurance reimbursement rates for pharmacies that are at the highest risk for closure.

Reduced Cost Sharing and Medication Management Services for COPD: A Randomized Clinical Trial

Importance

High out-of-pocket costs and improper use of maintenance inhalers contribute to poor outcomes among patients with chronic obstructive pulmonary disease (COPD). There is limited evidence for how addressing these barriers could improve adherence and affect COPD exacerbations, spending, or racial disparities in these outcomes.

Objective

To examine the effect of a national program to reduce beneficiary cost sharing for COPD maintenance inhalers and provide medication management services that included education on proper technique for inhaler use.

Design, Setting, and Participants

This randomized clinical trial included individuals with COPD. All individuals were enrolled in Medicare Advantage. Data were collected from January 2019 to December 2021, and data were analyzed from January 2023 to May 2024.

Intervention

Invitation to enroll in a program that reduced cost sharing for maintenance inhalers to $0 or $10 and provided medication management services. The random assignment of the invitation was used to estimate the effects of the invitation and program enrollment, overall and by race.

Main Outcomes and Measures

Inhaler adherence measured as proportion of days covered (PDC), moderate-to-severe exacerbations, short-acting inhaler fills, total spending, and as an exploratory outcome, out-of-pocket spending.

Results

Of 19 113 included patients, 55.2% were female; 9.5% were Black, 81.1% were White, and 9.4% were another or unknown race; and the median (IQR) age was 74 (69-80) years. Program enrollment was higher in the invited group (29.4%) than the control group (5.1%). The PDC for maintenance inhalers was higher in the invited group than the control group (32.0% vs 28.4%; adjusted invitation effect, 3.8 percentage points; 95% CI, 3.1-4.5); the adjusted effect of the program (the local average treatment effect) was 15.5 percentage points (95% CI, 12.8-18.1), a 55% relative increase in adherence. Mean (SD) out-of-pocket spending for prescriptions was lower in the invited group ($619.5 [$863.1]) than the control group ($675.0 [$887.3]; adjusted invitation effect, -$49.5; 95% CI, -68.9 to -30.0; adjusted program effect, -$203.0; 95% CI, -282.8 to -123.2), but there was no statistically significant difference in exacerbations, short-acting inhaler fills, or total spending. Among Black individuals, the adjusted invitation effect on maintenance inhaler PDC was 5.5 percentage points (95% CI, 3.3-7.7), and the adjusted program effect was 19.5 percentage points (95% CI, 12.4-26.7). Among White individuals, the adjusted invitation effect was 3.7 percentage points (95% CI, 2.9-4.4), and the adjusted program effect was 15.1 percentage points (95% CI, 12.1-18.1). The difference between the invitation effects by race was not statistically significant (1.8 percentage points; 95% CI, -0.5 to 4.1; P = .13).

Conclusions and Relevance

Individuals in Medicare Advantage who received an invitation to enroll in a program that reduced cost sharing for maintenance inhalers and provided medication management services had higher inhaler adherence compared with the control group. The difference in the program's effect on inhaler adherence between Black and White individuals was substantial but not statistically significant.

Trial Registration

ClinicalTrials.gov Identifier: NCT05497999.

Leveraging Community Pharmacies to Address Social Needs: A Promising Practice to Improve Healthcare Quality

Emerging research suggests that chronic conditions such as cardiovascular disease, diabetes, and asthma are often mediated by adverse social conditions that complicate their management. These conditions include circumstances such as lack of affordable housing, food insecurity, barriers to safe and reliable transportation, structural racism, and unequal access to healthcare or higher education. Although health systems cannot independently solve these problems, their infrastructure, funding resources, and well-trained workforce can be realigned to better address social needs created by them. For example, community pharmacies and the professionals they employ can be utilized and are well-positioned to deliver balanced, individualized clinical services, with a focus on the whole person. Because they have deep roots and presence in the community, especially in under-resourced neighborhoods, community pharmacies (independent and chain) represent local entities that community members recognize and trust. In this article, we provide case examples from California, United States, to illustrate and explore how community pharmacies can be leveraged to address patient social needs as part of their core responsibilities and overall strategy to improve healthcare quality.

Too Many Deaths, Too Many Left Behind: A People's External Review of the U.S. Centers for Disease Control and Prevention's COVID-19 Pandemic Response

The U.S. population has suffered worse health consequences owing to COVID-19 than comparable wealthy nations. COVID-19 had caused more than 1.1 million deaths in the U.S. as of May 2023 and contributed to a 3-year decline in life expectancy. A coalition of public health workers and community activists launched an external review of the Centers for Disease Control and Prevention's pandemic management from January 2021 to May 2023. The authors used a modified Delphi process to identify core pandemic management areas, which formed the basis for a survey and literature review. Their analysis yields 3 overarching shortcomings of the Centers for Disease Control and Prevention's pandemic management: (1) Centers for Disease Control and Prevention leadership downplays the serious impacts and aerosol transmission risks of COVID-19, (2) Centers for Disease Control and Prevention leadership has aligned public guidance with commercial and political interests over scientific evidence, and (3) Centers for Disease Control and Prevention guidance focuses on individual choice rather than emphasizing prevention and equity. Instead, the agency must partner with communities most impacted by the pandemic and encourage people to protect one another using layered protections to decrease COVID-19 transmission. Because emerging variants can already evade existing vaccines and treatments and Long COVID can be disabling and lacks definitive treatment, multifaceted, sustainable approaches to the COVID-19 pandemic are essential to protect people, the economy, and future generations.

Pharmacy Accessibility and Social Vulnerability

This cross-sectional study examines the association of availability of primary care practitioners and level of socioeconomic vulnerability with risk of pharmacy deserts in regions of the US.

Patient experiences of buprenorphine dispensing from a mobile medical unit

BACKGROUND

Overdose deaths continue to rise within the United States, despite effective treatments such as buprenorphine and methadone for opioid use disorder (OUD). Mobile medical units with the ability to dispense buprenorphine have been developed to engage patients and eliminate barriers to accessing OUD treatment. This study reports survey responses of patients of a mobile medical unit dispensing buprenorphine in areas of Chicago, IL with high overdose rates.

METHODS

All patients who were dispensed buprenorphine via the mobile medical unit were invited to participate in a 7-item anonymous survey between May 24, 2023, and August 25, 2023. The survey included 5-point satisfaction scale, multiple-choice, and open-ended questions. Outcomes included satisfaction with buprenorphine dispensing from the mobile medical unit, satisfaction with filling buprenorphine at a pharmacy in the past, barriers experienced at pharmacies when filling buprenorphine, and whether the client would have started treatment that day if the mobile medical unit had not been present. Satisfaction scale and multiple-choice question responses were assessed using descriptive statistics. Wilcoxon signed-rank test was used to compare median satisfaction levels between receiving buprenorphine from the mobile medical unit versus filling a buprenorphine prescription at a community pharmacy. Open-ended questions were analyzed qualitatively using inductive thematic analysis.

RESULTS

106 unique patients were dispensed buprenorphine from the mobile unit during the study period. Of these patients, 54 (51%) completed the survey. Respondents reported high satisfaction with the buprenorphine dispensing process as a part of a mobile medical unit. Of those who had previously filled buprenorphine at a pharmacy, 83% reported at least one barrier, with delays in prescription dispensing from a community pharmacy, lack of transportation to/from the pharmacy, and opioid withdrawal symptoms being the most common barriers. 87% reported they would not have started buprenorphine that same day if the mobile medical unit had not been present. Nearly half of survey participants reported having taken buprenorphine that was not prescribed to them. Qualitative analysis of open-ended survey responses noted the importance of convenient accessibility, comprehensive care, and a non-judgmental environment.

CONCLUSIONS

Mobile medical units that dispense buprenorphine are an innovative model to reach patients with OUD who have significant treatment access barriers. This study found that patients who experienced barriers to accessing buprenorphine from a pharmacy were highly satisfied with the mobile medical unit's buprenorphine dispensing process. Programs seeking to develop mobile buprenorphine dispensing programs should consider patient priorities of accessibility, comprehensive care, and welcoming, non-judgmental environments.

Using the Index of Concentration at the Extremes to Evaluate Associations of Economic and Hispanic/Latino-White Racial Segregation with HIV Outcomes Among Adults Aged ≥ 18 Years with Diagnosed HIV - United States, 2021

OBJECTIVE(S)

To examine associations between Index of Concentration at the Extremes (ICE) measures (proxy for structural racism) for economic and Hispanic/Latino-White racial segregation and HIV outcomes among adults in the U.S.

METHODS

Census tract-level HIV diagnoses, linkage to HIV medical care within 1 month of diagnosis (linkage), and viral suppression within 6 months of diagnosis (viral suppression) data for 2021 from the National HIV Surveillance System were used. Three ICE measures were obtained from the American Community Survey: ICEincome (income segregation), ICErace (Hispanic/Latino-White racial segregation), and ICEincome + race (Hispanic/Latino-White racialized economic segregation). Rate ratios (RRs) for HIV diagnosis and prevalence ratios (PRs) for linkage and viral suppression were used to examine differences in HIV outcomes across ICE quintiles with Quintile5 (Q5: most privileged) as reference group and adjusted by selected characteristics.

RESULTS

Among the 32,529 adults, diagnosis rates were highest in Quintile1 (Q1: most deprived) for ICEincome (28.7) and ICEincome + race (28.4) and Q2 for ICErace (27.0). We also observed higher RRs in HIV diagnosis and lower PRs in linkage and viral suppression (except for ICErace for linkage) in Q1 compared to Q5. Higher RRs and lower PRs in ICE measures were observed among males (diagnosis), adults aged 18‒34 (diagnosis and linkage) and aged ≥ 45 (viral suppression), and among adults in the South (all 3 HIV outcomes).

CONCLUSIONS

Barriers in access to care/treatment in more Hispanic/Latino-White racialized economic segregated communities perpetuate the disproportionate impact of HIV on the population. Removing barriers to HIV care/treatment created by systemic racism/segregation may improve HIV outcomes and reduce disparities.

Where Does the Black-White Life Expectancy Gap Come From? The Deadly Consequences of Residential Segregation

The disparity in life expectancy between white and black Americans exceeds five years for men and three years for women. While prior research has investigated the roles of healthcare, health behaviors, biological risk, socioeconomic status, and life course effects on black mortality, the literature on the geographic origins of the gap is more limited. This study examines how the black-white life expectancy gap varies across counties and how much of the national gap is attributable to within-county racial inequality versus differences between counties. The estimates suggest that over 90% of the national gap can be attributed to within-county factors. Using a quasi-experimental research design, I find that black-white residential segregation increases the gap by approximately 16 years for men and five years for women. The segregation effect loads heavily on causes of death associated with access to and quality of healthcare; safety and violence; and public health measures. Residential segregation does not appear to operate through health behaviors or individual-level factors, but instead acts primarily through institutional mechanisms. Efforts to address racial disparities in mortality should focus on reducing racial residential segregation or reducing inequalities in the mechanisms through which residential segregation acts: public services, employment opportunities, and community resources.

Sociodemographic inequities in COVID-19 vaccination among adults in the United States, 2022

BACKGROUND

Despite the availability of COVID-19 vaccines since December 2020, sociodemographic inequities in vaccination and preventable COVID-related deaths persist. To inform efforts for equitable COVID-19 vaccination campaigns, a comprehensive national evaluation of existing inequities is necessary.

OBJECTIVE

To examine sociodemographic inequities in COVID-19 vaccination receipt using data from the 2022 National Health Interview Survey (NHIS).

METHODS

This secondary data analysis used cross-sectional nationally-representative data from the 2022 NHIS to assess vaccination inequities among 27,126 adults. Separate Poisson regressions adjusted for clinical factors (e.g., age, sex, high-risk health conditions) were used to evaluate vaccination inequities across sociographic factors (e.g., race/ethnicity, poverty, health insurance).

RESULTS

In 2022, 79.6% of adults received at ≥ 1 vaccine dose, 75.0% received ≥ 2 doses ("fully vaccinated"), 45.7% received ≥ 3 doses (≥ 1 booster), and 17.2% received ≥ 4 doses (≥ 2 boosters). Marked inequities were evident in COVID-19 vaccination across primary and booster doses, especially receipt of at least 1 booster dose (≥ 3 doses). Black (35.7%, prevalence ratio [PR] 0.78 [95% CI 0.74-0.83]) and Latinx (35.5%, PR 0.82 [CI 0.78-0.86]) adults were less likely to receive ≥ 3 doses than Asian (66.5%, PR 1.41 [CI 1.35-1.48]) and White (48.8%) adults. Poverty (31.1% [PR 0.65 {CI 0.61-0.69}] vs. 50.7%) and food insecurity (27.1% [PR 0.63 {CI 0.58-0.68}] vs. 47.3%) were negatively associated with receipt of ≥ 3 vaccine doses. Adults without usual source of care (24.9%, PR 0.61 [CI 0.57-0.65]) or health insurance (17.4%, PR 0.40 [CI 0.36-0.45]) had much lower rates of ≥ 3 doses than those with appropriate health care access (48.7% and 51.9%, respectively).

CONCLUSION

As of 2022, 1-in-5 U.S. adults remain unvaccinated, and more than half have not received any recommended booster doses. Economically/socially marginalized populations-including Black and Latinx adults and those with structural barriers such as poverty, food insecurity, and poor health care access-were less likely to receive a booster. Addressing these vaccination inequities is crucial to achieve equitable COVID-19 protection and reduce preventable deaths among economically/socially marginalized populations.

Evaluating the impact of a discharge pharmacy in the emergency department on emergency department revisits and admissions

IMPORTANCE

Medication nonadherence leads to worse health outcomes, increased healthcare service utilization, and increased overall healthcare costs.

OBJECTIVE

To determine whether a discharge pharmacy located in the Emergency Department (ED) reduces ED revisits and hospitalizations.

DESIGN

This is a cohort study where we extracted data from our electronic medical records with adult encounters between 12/2019-10/2021. For the purpose of this study, we defined a revisit to the ED as within 7 days and an admission within 30 days from prior initial ED visit.

SETTING

The University of Chicago Medicine is an academic medical center located in Chicago's South Side.

PARTICIPANTS

Between dates of 12/2019-11/2021, we had 78,660 adult distinct encounters. We created 5 different groups: no medications prescribed, ED discharge pharmacy only, e-prescriptions to outside pharmacies, combination of ED pharmacy and e-prescription sent elsewhere, and printed prescriptions with or without any e-prescriptions.

EXPOSURE

Our ED pharmacy is located within the adult ED, serving only patients seen and discharged from the adult ED.

MAIN OUTCOME(S) AND MEASURE(S)

Our primary endpoint is to evaluate if prescribing and dispensing prescriptions from only our ED pharmacy is associated with decreased ED revisits within 7 days and reduced hospitalizations within 30 days of initial ED visit.

RESULTS

When comparing patients who received prescriptions only from the ED discharge pharmacy, patients who received no prescriptions were 31.6% (P < 0.001) more likely to revisit our ED, and patients who received e-prescriptions sent to other pharmacies were 10.4% (P = 0.017) more likely to revisit. Patients who received e-prescriptions from other pharmacies were 29.2% (P < 0.001) more likely to be hospitalized and mixture of e-prescriptions were 59.5% (P < 0.001) more likely to be hospitalized compared to the ED pharmacy only group.

CONCLUSIONS AND RELEVANCE

We believe having a pharmacy providing medications to patients being discharged from the ED reduces barriers like cost, transportation, and pharmacy access patients face trying to fill prescriptions at their local pharmacy. All of these reductions in barriers provides an easier and more convenient method for patients to obtain their medications at discharge from the ED, reducing the risk of a repeat ED visit and subsequent hospital admission.

Spatial accessibility and travel to pharmacy by type in the Detroit region

BACKGROUND

Community pharmacies are a critical part of the health care provision system. Yet less is understood about the spatial accessibility to pharmacies and how people travel to reach these services.

OBJECTIVES

This study compared spatial accessibility and actual travel to different types of pharmacies among selected neighborhoods in the Detroit region.

METHODS

Three types of neighborhoods were selected and compared, including two lower income Black urban neighborhoods of high-density and four upper income White suburbs (two of low density and two of high density). Spatial accessibility was computed by pharmacy type and compared among neighborhoods using ANOVA. Pharmacy trips reported in a travel survey were geocoded and linked with community pharmacies in a list generated from ReferenceUSA business data. Destination choices were mapped and the relationship between spatial accessibility and actual distance traveled was examined using ordinary least squares regressions.

RESULTS

On average, urban residents in Detroit had higher access to local independent pharmacies (0.74 miles to the nearest one) but relatively lower access to national chains (1.35 miles to the nearest one), which most residents relied on. Urban residents also tended to shop around more for services even among national chains. In fact, they bypassed nearby local independent pharmacies and traveled long distances to use farther pharmacies, primarily national chains. The average trip distance to pharmacy was 2.1 miles for urban residents, but only 1.1 miles and 1.5 miles for residents in high-density suburbs and low-density suburbs, respectively.

CONCLUSION

Supposedly good spatial access considering all pharmacies together may mask excessive burden in reaching the pharmacy services needed in low-income minority urban communities, as shown in the case of Detroit. Thus, when mapping pharmacy deserts, it is important to distinguish spatial accessibility among different pharmacy types.

Disadvantaged groups have greater spatial access to pharmacies in New York state

BACKGROUND

The accessibility of pharmacies has been associated with overall health and wellbeing. Past studies have suggested that low income and racial minority communities are underserved by pharmacies. However, the literature is inconsistent in finding links between area-level income or racial and ethnic composition and access to pharmacies. Here we aim to assess area-level spatial access to pharmacies across New York State (NYS), hypothesizing that Census Tracts with higher poverty rates and higher percentages of Black and Hispanic residents would have lower spatial access.

METHODS

The population weighted mean shortest road network distance (PWMSD) to a pharmacy in 2018 was calculated for each Census Tract in NYS. This statistic was calculated from the shortest road network distance to a pharmacy from the centroid of each Census block within a tract, with the mean across census blocks weighted by the population of the census block. Cross-sectional analyses were conducted to assess links between Tract-level socio demographic characteristics and Tract-level PWMSD to a pharmacy.

RESULTS

Overall the mean PWMSD to a pharmacy across Census tracts in NYS was 2.07 Km (SD = 3.35, median 0.85 Km). Shorter PWMSD to a pharmacy were associated with higher Tract-level % poverty, % Black/African American (AA) residents, and % Hispanic/Latino residents and with lower Tract-level % of residents with a college degree. Compared to tracts in the lowest quartile of % Black/AA residents, tracts in the highest quartile had a 70.7% (95% CI 68.3-72.9%) shorter PWMSD to a pharmacy. Similarly, tracts in the highest quartile of % poverty had a 61.3% (95% CI 58.0-64.4%) shorter PWMSD to a pharmacy than tracts in the lowest quartile.

CONCLUSION

The analyses show that tracts in NYS with higher racial and ethnic minority populations and higher poverty rates have higher spatial access to pharmacies.

Community Socioeconomic Status, Acute Cardiovascular Hospitalizations, and Mortality in Medicare, 2003 to 2019

BACKGROUND

Socioeconomically disadvantaged communities in the United States disproportionately experience poor cardiovascular outcomes. Little is known about how hospitalizations and mortality for acute cardiovascular conditions have changed among Medicare beneficiaries in socioeconomically disadvantaged and nondisadvantaged communities over the past 2 decades.

METHODS

Medicare files were linked with the Centers for Disease Control and Prevention's social vulnerability index to examine age-sex standardized hospitalizations for myocardial infarction, heart failure, ischemic stroke, and pulmonary embolism among Medicare fee-for-service beneficiaries ≥65 years of age residing in socioeconomically disadvantaged communities (highest social vulnerability index quintile nationally) and nondisadvantaged communities (all other quintiles) from 2003 to 2019, as well as risk-adjusted 30-day mortality among hospitalized beneficiaries.

RESULTS

A total of 10 942 483 Medicare beneficiaries ≥65 years of age were hospitalized for myocardial infarction, heart failure, stroke, or pulmonary embolism (mean age, 79.2 [SD, 8.7] years; 53.9% female). Although age-sex standardized myocardial infarction hospitalizations declined in socioeconomically disadvantaged (990-650 per 100 000) and nondisadvantaged communities (950-570 per 100 000) from 2003 to 2019, the gap in hospitalizations between these groups significantly widened (adjusted odds ratio 2003, 1.03 [95% CI, 1.02-1.04]; adjusted odds ratio 2019, 1.14 [95% CI, 1.13-1.16]). There was a similar decline in hospitalizations for heart failure in socioeconomically disadvantaged (2063-1559 per 100 000) and nondisadvantaged communities (1767-1385 per 100 000), as well as for ischemic stroke, but the relative gap did not change for both conditions. In contrast, pulmonary embolism hospitalizations increased in both disadvantaged (146-184 per 100 000) and nondisadvantaged communities (153-184 per 100 000). By 2019, risk-adjusted 30-day mortality was similar between hospitalized beneficiaries from socioeconomically disadvantaged and nondisadvantaged communities for myocardial infarction, heart failure, and ischemic stroke but was higher for pulmonary embolism (odds ratio, 1.10 [95% CI, 1.01-1.20]).

CONCLUSIONS

Over the past 2 decades, hospitalizations for most acute cardiovascular conditions decreased in both socioeconomically disadvantaged and nondisadvantaged communities, although significant disparities remain, while 30-day mortality is now similar across most conditions.

Locations and characteristics of pharmacy deserts in the United States: a geospatial study

Pharmacies are important health care access points, but no national map currently exists of where pharmacy deserts are located. This cross-sectional study used pharmacy address data and Census Bureau surveys to define pharmacy deserts at the census tract level in all 50 US states and the District of Columbia. We also compared sociodemographic characteristics of pharmacy desert vs non-pharmacy desert communities. Nationally, 15.8 million (4.7%) of all people in the United States live in pharmacy deserts, spanning urban and rural settings in all 50 states. On average, communities that are pharmacy deserts have a higher proportion of people who have a high school education or less, have no health insurance, have low self-reported English ability, have an ambulatory disability, and identify as a racial or ethnic minority. While, on average, pharmacies are the most accessible health care setting in the United States, many people still do not have access to them. Further, the people living in pharmacy deserts are often marginalized groups who have historically faced structural barriers to health care. This study demonstrates a need to improve access to pharmacies and pharmacy services to advance health equity.

Association Between Pharmacy Proximity With Cardiovascular Medication Use and Risk Factor Control in the United States

BACKGROUND

Poor neighborhood-level access to health care, including community pharmacies, contributes to cardiovascular disparities in the United States. The authors quantified the association between pharmacy proximity, antihypertensive and statin use, and blood pressure (BP) and low-density lipoprotein cholesterol (LDL-C) among a large, diverse US cohort.

METHODS AND RESULTS

A cross-sectional analysis of Black and White participants in the REGARDS (Reasons for Geographic and Racial Differences in Stroke) study during 2013 to 2016 was conducted. The authors designated pharmacy proximity by census tract using road network analysis with population-weighted centroids within a 10-minute drive time, with 5- and 20-minute sensitivity analyses. Pill bottle review measured medication use, and BP and LDL-C were assessed using standard methods. Poisson regression was used to quantify the association between pharmacy proximity with medication use and BP control, and linear regression for LDL-C. Among 16 150 REGARDS participants between 2013 and 2016, 8319 (51.5%) and 8569 (53.1%) had an indication for antihypertensive and statin medication, respectively, and pharmacy proximity data. The authors did not find a consistent association between living in a census tract with higher pharmacy proximity and antihypertensive medication use, BP control, or statin medication use and LDL-C levels, regardless of whether the area was rural, suburban, or urban. Results were similar among the 5- and 20-minute drive-time analyses.

CONCLUSIONS

Living in a low pharmacy proximity census tract may be associated with antihypertensive and statin medication use, or with BP control and LDL-C levels. Although, in this US cohort, outcomes were similar for adults living in high or low pharmacy proximity census tracts.

Access to community pharmacies based on drive time and by rurality across the contiguous United States

BACKGROUND

Considering that mail-order pharmacy use remains low in the United States, geographic accessibility of community pharmacies (pharmacy access) can have an outsized impact on a community's access to services and care, especially among rural residents. However, previous measurements of pharmacy access rely on methods that do not capture all aspects of geographic access.

OBJECTIVES

This study aimed to measure pharmacy access across the contiguous United States and by rural, suburban, and urban areas using drive-time analysis and an improved methodological approach.

METHODS

The 2-step floating catchment area method was used to measure pharmacy access by considering the supply capacity of pharmacies, population demand for pharmacies, and the interaction between them within a reasonable travel time range. This method is a methodologically improved approach compared with previous methods for measuring geographic access. Network analysis was used to measure drive time from the population-weighted centroids of census tracts to the geocoded location of community pharmacies. Census tract-level pharmacy access was measured using a 10- and 20-minute drive time. Census tracts were also categorized based on population per square mile as rural (< 1000), suburban (1000-3000), and urban (> 3000).

RESULTS

Across the contiguous United States, 79.9% and 91.1% of census tracts had access to at least 1 pharmacy per 10,000 people within a 10- and 20-minute drive time, respectively. Rural census tracts had the lowest share of access to at least 1 pharmacy per 10,000 people compared with suburban and urban tracts and for both drive times.

CONCLUSION

Community pharmacies are highly accessible health care access points, specifically in urban and suburban areas. Pharmacies should be considered to expand access to services with limited geographic accessibility such as treatment programs for opioid use disorders, primary care, and healthy foods.

Polysubstance mortality trends in White and Black Americans during the opioid epidemic, 1999-2018

BACKGROUND

Psychoactive drug combinations are increasingly contributing to overdose deaths among White and Black Americans. To understand the evolving nature of overdose crisis, inform policies, and develop tailored and equitable interventions, this study provides a comprehensive assessment of polysubstance mortality trends by race and sex during the opioid epidemic.

METHODS

We used serial cross-sectional US mortality data for White and Black populations from 1999 through 2018 to calculate annual age-adjusted death rates (AADR) involving any opioid, opioid subtypes, benzodiazepines, cocaine, psychostimulants, or combinations of these drugs, stratified by race and sex. Trend changes in AADR were analyzed using joinpoint regression models and expressed as average annual percent change (AAPC) during each period of the three waves of the opioid epidemic: 1999-2010 (wave 1), 2010-2013 (wave 2), and 2013-2018 (wave 3). Prevalence measures assessed the percent co-involvement of an investigated drug in the overall death from another drug.

RESULTS

Polysubstance mortality has shifted from a modest rise in death rates due to benzodiazepine-opioid overdoses among White persons (wave 1) to a substantial increase in death rates due to illicit drug combinations impacting both White and Black populations (wave 3). Concurrent cocaine-opioid use had the highest polysubstance mortality rates in 2018 among Black (5.28 per 100,000) and White (3.53 per 100,000) persons. The steepest increase in death rates during wave 3 was observed across all psychoactive drugs when combined with synthetic opioids in both racial groups. Since 2013, Black persons have died faster from cocaine-opioid and psychostimulant-opioid overdoses. Between 2013 and 2018, opioids were highly prevalent in cocaine-related deaths, increasing by 33% in White persons compared to 135% in Blacks. By 2018, opioids contributed to approximately half of psychostimulant and 85% of benzodiazepine fatal overdoses in both groups. The magnitude and type of drug combinations with the highest death rates differed by race and sex, with Black men exhibiting the highest overdose burden beginning in 2013.

CONCLUSIONS

The current drug crisis should be considered in the context of polysubstance use. Effective measures and policies are needed to curb synthetic opioid-involved deaths and address disparate mortality rates in Black communities.

Eliminating Health Disparities in Atrial Fibrillation, Heart Failure, and Dyslipidemia: A Path Toward Achieving Pharmacoequity

PURPOSE OF REVIEW

Pharmacoequity refers to the goal of ensuring that all patients have access to high-quality medications, regardless of their race, ethnicity, gender, or other characteristics. The goal of this article is to review current evidence on disparities in access to cardiovascular drug therapies across sociodemographic subgroups, with a focus on heart failure, atrial fibrillation, and dyslipidemia.

RECENT FINDINGS

Considerable and consistent disparities to life-prolonging heart failure, atrial fibrillation, and dyslipidemia medications exist in clinical trial representation, access to specialist care, prescription of guideline-based therapy, drug affordability, and pharmacy accessibility across racial, ethnic, gender, and other sociodemographic subgroups. Researchers, health systems, and policy makers can take steps to improve pharmacoequity by diversifying clinical trial enrollment, increasing access to inpatient and outpatient cardiology care, nudging clinicians to increase prescription of guideline-directed medical therapy, and pursuing system-level reforms to improve drug access and affordability.

Promoting Latinx health equity through community-engaged policy and practice reforms in North Carolina

Introduction

The Latinx Advocacy Team & Interdisciplinary Network for COVID-19 (LATIN-19) is a unique multi-sector coalition formed early in the COVID-19 pandemic to address the multi-level health inequities faced by Latinx communities in North Carolina.

Methods

We utilized the National Institute on Minority Health and Health Disparities (NIMHD) Research Framework to conduct a directed content analysis of 58 LATIN-19 meeting minutes from April 2020 through October 2021. Application of the NIMHD Research Framework facilitated a comprehensive assessment of complex and multidimensional barriers and interventions contributing to Latinx health while centering on community voices and perspectives.

Results

Community interventions focused on reducing language barriers and increasing community-level access to social supports while policy interventions focused on increasing services to slow the spread of COVID-19.

Discussion

Our study adds to the literature by identifying community-based strategies to ensure the power of communities is accounted for in policy reforms that affect Latinx health outcomes across the U.S. Multisector coalitions, such as LATIN-19, can enable the improved understanding of underlying barriers and embed community priorities into policy solutions to address health inequities.

Racial and Ethnic Representation in Preventive Intervention Research: a Methodological Study

Individuals who are Asian or Asian American, Black or African American, Native American or American Indian or Alaska Native, Native Hawaiian or Pacific Islander, and Hispanic or Latino (i.e., presently considered racial ethnic minoritized groups in the USA) lacked equal access to resources for mitigating risk during COVID-19, which highlighted public health disparities and exacerbated inequities rooted in structural racism that have contributed to many injustices, such as failing public school systems and unsafe neighborhoods. Minoritized groups are also vulnerable to climate change wherein the most severe harms disproportionately fall upon underserved communities. While systemic changes are needed to address these pervasive syndemic conditions, immediate efforts involve examining strategies to promote equitable health and well-being-which served as the impetus for this study. We conducted a descriptive analysis on the prevalence of culturally tailored interventions and reporting of sample characteristics among 885 programs with evaluations published from 2010 to 2021 and recorded in the Blueprints for Healthy Youth Development registry. Inferential analyses also examined (1) reporting time trends and (2) the relationship between study quality (i.e., strong methods, beneficial effects) and culturally tailored programs and racial ethnic enrollment. Two percent of programs were developed for Black or African American youth, and 4% targeted Hispanic or Latino populations. For the 77% of studies that reported race, most enrollees were White (35%) followed by Black or African American (28%), and 31% collapsed across race or categorized race with ethnicity. In the 64% of studies that reported ethnicity, 32% of enrollees were Hispanic or Latino. Reporting has not improved, and there was no relationship between high-quality studies and programs developed for racial ethnic youth, or samples with high proportions of racial ethnic enrollees. Research gaps on racial ethnic groups call for clear reporting and better representation to reduce disparities and improve the utility of interventions.

Disparities in Guideline-Recommended Statin Use for Prevention of Atherosclerotic Cardiovascular Disease by Race, Ethnicity, and Gender : A Nationally Representative Cross-Sectional Analysis of Adults in the United States

BACKGROUND

Although statins are a class I recommendation for prevention of atherosclerotic cardiovascular disease and its complications, their use is suboptimal. Differential underuse may mediate disparities in cardiovascular health for systematically marginalized persons.

OBJECTIVE

To estimate disparities in statin use by race-ethnicity-gender and to determine whether these potential disparities are explained by medical appropriateness of therapy and structural factors.

DESIGN

Cross-sectional analysis.

SETTING

National Health and Nutrition Examination Survey from 2015 to 2020.

PARTICIPANTS

Persons eligible for statin therapy based on 2013 and 2018 American College of Cardiology/American Heart Association blood cholesterol guidelines.

MEASUREMENTS

The independent variable was race-ethnicity-gender. The outcome of interest was use of a statin. Using the Institute of Medicine framework for examining unequal treatment, we calculated adjusted prevalence ratios (aPRs) to estimate disparities in statin use adjusted for age, disease severity, access to health care, and socioeconomic status relative to non-Hispanic White men.

RESULTS

For primary prevention, we identified a lower prevalence of statin use that was not explained by measurable differences in disease severity or structural factors among non-Hispanic Black men (aPR, 0.73 [95% CI, 0.59 to 0.88]) and non-Mexican Hispanic women (aPR, 0.74 [CI, 0.53 to 0.95]). For secondary prevention, we identified a lower prevalence of statin use that was not explained by measurable differences in disease severity or structural factors for non-Hispanic Black men (aPR, 0.81 [CI, 0.64 to 0.97]), other/multiracial men (aPR, 0.58 [CI, 0.20 to 0.97]), Mexican American women (aPR, 0.36 [CI, 0.10 to 0.61]), non-Mexican Hispanic women (aPR, 0.57 [CI, 0.33 to 0.82), non-Hispanic White women (aPR, 0.69 [CI, 0.56 to 0.83]), and non-Hispanic Black women (aPR, 0.75 [CI, 0.57 to 0.92]).

LIMITATION

Cross-sectional data; lack of geographic, language, or statin-dose data.

CONCLUSION

Statin use disparities for several race-ethnicity-gender groups are not explained by measurable differences in medical appropriateness of therapy, access to health care, and socioeconomic status. These residual disparities may be partially mediated by unobserved processes that contribute to health inequity, including bias, stereotyping, and mistrust.

PRIMARY FUNDING SOURCE

National Institutes of Health.

Association Between Redlining and Spatial Access to Pharmacies

This cross-sectional study evaluates whether there is an association between historic redlining and living within 1 or 2 miles of a pharmacy.

Role of independent versus chain pharmacies in providing pharmacy access: a nationwide, individual-level geographic information systems analysis

Pharmacy accessibility is critical for equity in medication access and is jeopardized by pharmacy closures, which disproportionately affect independent pharmacies. We conducted a geographic information systems analysis to quantify how many individuals across the US do not have optimal pharmacy access or solely rely on independent pharmacies for access. We generated service areas of pharmacies using OpenStreetMap data. For each individual in a 30% random sample of the 2020 RTI US Household Synthetic Population™ (n=90,778,132), we defined optimal pharmacy access as having a driving distance to the closest pharmacy ≤2 miles in urban counties, ≤5 miles in suburban counties, and ≤10 miles in rural counties. Individuals were then categorized according to their access to chain and independent pharmacies. Five percent of the sample or ~15.1 million individuals nationwide relied on independent pharmacies for optimal access. Individuals relying on independent pharmacies for optimal access were more likely to live in rural areas, be 65 years or older, and belong to low-income households. Another 19.5% of individuals in the sample did not have optimal pharmacy access, which corresponds to 59.0 million individuals nationwide. Our findings demonstrate that independent pharmacies play a critical role in ensuring equity in pharmacy access.

Duration of medication for opioid use disorder during pregnancy and postpartum by race/ethnicity: Results from 6 state Medicaid programs

BACKGROUND

Medication for opioid use disorder (MOUD) is evidence-based treatment during pregnancy and postpartum. Prior studies show racial/ethnic differences in receipt of MOUD during pregnancy. Fewer studies have examined racial/ethnic differences in MOUD receipt and duration during the first year postpartum and in the type of MOUD received during pregnancy and postpartum.

METHODS

We used Medicaid administrative data from 6 states to compare the percentage of women with any MOUD and the average proportion of days covered (PDC) with MOUD, overall and by type of MOUD, during pregnancy and four postpartum periods (1-90 days, 91-180 days, 181-270 days, and 271-360 days postpartum) among White non-Hispanic, Black non-Hispanic, and Hispanic women diagnosed with OUD.

RESULTS

White non-Hispanic women were more likely to receive any MOUD during pregnancy and all postpartum periods compared to Hispanic and Black non-Hispanic women. For all MOUD types combined and for buprenorphine, White non-Hispanic women had the highest average PDC during pregnancy and each postpartum period, followed by Hispanic women and Black non-Hispanic women (e.g., for all MOUD types, 0.49 vs. 0.41 vs. 0.23 PDC, respectively, during days 1-90 postpartum). For methadone, White non-Hispanic and Hispanic women had similar average PDC during pregnancy and postpartum, and Black non-Hispanic women had substantially lower PDC.

CONCLUSIONS

There are stark racial/ethnic differences in MOUD during pregnancy and the first year postpartum. Reducing these inequities is critical to improving health outcomes among pregnant and postpartum women with OUD.

The Costs Of Disparities In Preventable Heart Failure Hospitalizations In The US South, 2015-17

Black Americans in the US South have high rates of preventable heart failure hospitalizations, which reflects systemic inequities that also produce economic costs. We measured the direct medical costs of disparities in preventable heart failure admissions (that is, excess admissions) among Medicare beneficiaries living in six states in the US South (Kentucky, Arkansas, Florida, Georgia, Mississippi, and North Carolina). We used 2015-17 data from the Healthcare Cost and Utilization Project and constructed negative binomial models with state-level fixed effects to calculate adjusted admission rates with heart failure as the principal diagnosis. We calculated the number of these admissions that would have been avoided if Black, Hispanic, Asian/Pacific Islander, and American Indian/Alaska Native Medicare beneficiaries had the same admission rates as White beneficiaries. We found 28,213 excess admissions (48 percent excess) with $60,845,855 annual costs among Black beneficiaries, 3,499 (14 percent excess) with $8,179,381 annual costs among Hispanic beneficiaries, and 550 (51 percent excess) with $1,093,472 in annual costs among American Indian/Alaska Native beneficiaries. Failure to address heart failure treatment inequities in the community has a high opportunity cost.

The journey to overdose: Using spatial social network analysis as a novel framework to study geographic discordance in overdose deaths

INTRODUCTION

Drug overdose deaths are often geographically discordant (the community in which the overdose death occurs is different from the community of residence). Thus, in many cases there is a journey to overdose.

METHODS

We applied geospatial analysis to examine characteristics that define journeys to overdoses using Milwaukee, Wisconsin, a diverse and segregated metropolitan area in which 26.72 % of overdose deaths are geographically discordant, as a case study. First, we deployed spatial social network analysis to identify hubs (census tracts that are focal points of geographically discordant overdoses) and authorities (the communities of residence from which journeys to overdose commonly begin) for overdose deaths and characterized them according to key demographics. Second, we used temporal trend analysis to identify communities that were consistent, sporadic, and emergent hotspots for overdose deaths. Third, we identified characteristics that differentiated discordant versus non-discordant overdose deaths.

RESULTS

Authority communities had lower housing stability and were younger, more impoverished, and less educated relative to hubs and county-wide numbers. White communities were more likely to be hubs, while Hispanic communities were more likely to be authorities. Geographically discordant deaths more commonly involved fentanyl, cocaine, and amphetamines and were more likely to be accidental. Non-discordant deaths more commonly involved opioids other than fentanyl or heroin and were more likely to be the result of suicide.

CONCLUSION

This study is the first to examine the journey to overdose and demonstrates that such analysis can be applied in metropolitan areas to better understand and guide community responses.

Racial and ethnic disparities in Medicare Part D medication therapy management services utilization

Background

The Medicare Part D medication therapy management (MTM) program has positive effects on medication and health service utilization. However, little is known about its utilization, much less so about the use among racial and ethnic minorities.

Objective

To examine MTM service utilization among older Medicare beneficiaries and to identify any racial and ethnic disparity patterns.

Methods

A retrospective cross-sectional analysis of 2017 Medicare administrative data, linked to the Area Health Resources Files. Fourteen outcomes related to MTM service nature, initiation, quantity, and delivery were examined using logistic, negative binomial, and Cox proportional hazards regression models.

Results

Racial and ethnic disparities were found with varying patterns across outcomes. For example, compared with White patients, the odds of opting out of MTM were 8% higher for Black patients (odds ratio [OR] = 1.08, 95% confidence interval [CI] = 1.03-1.14), 57% higher for Hispanic patients (OR = 1.57, 95% CI = 1.42-1.72), and 57% higher for Asian patients (OR = 1.57, 95% CI = 1.33-1.85). The odds of continuing MTM from the previous years were 12% lower for Black patients (OR = 0.88, 95% CI = 0.86-0.90) and 3% lower for other patients (OR = 0.97, 95% CI = 0.95-0.99). In addition, the probability of being offered a comprehensive medication review (CMR) after MTM enrollment was 9% lower for Hispanic patients (hazard ratio [HR] = 0.91, 95% CI = 0.85-0.97), 9% lower for Asian patients (HR = 0.91, 95% CI = 0.87-0.94), and 3% lower for other patients (HR = 0.97, 95% CI = 0.95-0.99). Hispanic and Asian patients were more likely to have someone other than themselves receive a CMR.

Conclusions

Racial and ethnic disparities in MTM service utilization were identified. Although the disparities in specific utilization outcomes vary across racial/ethnic groups, it is evident that these disparities exist and may result in vulnerable communities not fully benefiting from the MTM services. Causes of the disparities should be explored to inform future reform of the Medicare Part D MTM program.

Integrating the Social Determinants of Health Into Prelicensure Nursing Pharmacology

BACKGROUND

Nursing organizations have called for the incorporation of social determinants of health (SDOH) throughout nursing school curricula. Guidance is needed regarding best practices to integrate SDOH into pharmacology courses in prelicensure nursing programs.

METHOD

Using Emory University's School of Nursing SDOH framework to guide curriculum innovation, pharmacology faculty identified three pharmacology-centric SDOH topics: race-based medicine and pharmacogenomics, pharmacy deserts, and lack of diversity in clinical trials. These three SDOH topics were incorporated into preestablished pharmacology content.

RESULTS

Faculty integrated SDOH into pharmacology courses with heavy science content, and students were receptive to open discussion of SDOH topics.

CONCLUSION

The integration of SDOH into a prelicensure nursing pharmacology course across multiple cohorts of students was feasible, and student feedback was positive. Faculty faced several challenges, including time constraints. Additional and ongoing training is needed to support the integration of SDOH into nursing curricula. [J Nurs Educ. 2023;62(3):175-179.].

Medication Regimen Complexity Index Score at Admission as a Predictor of Inpatient Outcomes: A Machine Learning Approach

BACKGROUND

In the intensive care unit, traditional scoring systems use illness severity and/or organ failure to determine prognosis, and this usually rests on the patient's condition at admission. In spite of the importance of medication reconciliation, the usefulness of home medication histories as predictors of clinical outcomes remains unexplored.

METHODS

A retrospective cohort study was conducted using the medical records of 322 intensive care unit (ICU) patients. The predictors of interest included the medication regimen complexity index (MRCI) at admission, the Acute Physiology and Chronic Health Evaluation (APACHE) II, the Sequential Organ Failure Assessment (SOFA) score, or a combination thereof. Outcomes included mortality, length of stay, and the need for mechanical ventilation. Machine learning algorithms were used for outcome classification after correcting for class imbalances in the general population and across the racial continuum.

RESULTS

The home medication model could predict all clinical outcomes accurately 70% of the time. Among Whites, it improved to 80%, whereas among non-Whites it remained at 70%. The addition of SOFA and APACHE II yielded the best models among non-Whites and Whites, respectively. SHapley Additive exPlanations (SHAP) values showed that low MRCI scores were associated with reduced mortality and LOS, yet an increased need for mechanical ventilation.

CONCLUSION

Home medication histories represent a viable addition to traditional predictors of health outcomes.

Pharmacy Deserts and Pharmacies' Roles Post-Extreme Weather and Climate Events in the United States: A Scoping Review

BACKGROUND

The effects of climate change are seen with a rise of extreme weather and climate events (EWCEs) which lead to the closures of many healthcare facilities, such as community pharmacies. Pharmacists in community pharmacies are seen as the most accessible healthcare professional to the public and are responsible for the continued delivery of care to patients. However, amid closures due to EWCEs and the emergence of pharmacy deserts, there is decreased access to pharmacies and a disruption of care.

OBJECTIVE

It is important to address the preparedness and accessibility of pharmacies post-EWCEs to guide future research and policy. Additionally, to tackle health disparities that arise due to pharmacy deserts, the populations most affected by a decreased access to pharmacies should be identified. We conducted a scoping review to assess the preparedness and accessibility of pharmacies post-EWCEs and to identify populations most affected by pharmacy deserts.

METHODS

We searched PubMed, Embase, and Web of Science from January 1, 2012 to September 30, 2022 and included all English-language, peer-reviewed primary literature that examined the preparedness and accessibility of community pharmacies in the United States post-EWCEs and addressed disparities within pharmacy deserts. Studies meeting these criteria were screened of their titles and abstracts by the first author and discrepancies were resolved with co-authors. We used Covidence for data extraction.

RESULTS

A total of 472 studies were identified (196 duplicates removed) and after screening, 53 studies were assessed for eligibility. The results of included publications (N = 26) showed that pharmacists and pharmacies are not equipped with the necessary emergency protocols which could lead to decreased access of pharmacies in the wake of EWCEs. Pharmacy deserts disproportionately affect residents living in rural, lower income, and Black/African American and Hispanic/Latino neighborhoods. The lack of preparedness of pharmacies post-EWCEs could worsen medication access.

CONCLUSION

This scoping review addresses challenges impacting pharmacies and patients post-EWCEs and within pharmacy deserts. In times of increased need, these challenges implicate the well-being of communities affected by EWCEs by breaking the continuum of care and access to medications. Here we offer suggestions for future research and directions for policy change.

Social Determinants of Health in People Living with Psychiatric Disorders: The Role of Pharmacists

Introduction

Social determinants of health (SDOH) affect outcomes of people living with psychiatric disorders, including substance use disorders. As experts in medication optimization, pharmacists play a vital role in identifying and addressing medication-related problems associated with SDOH. However, there is a paucity of literature on how pharmacists can be part of the solution.

Objective

The purpose of this article is to provide a narrative review and commentary on the intersection between SDOH, medication-related outcomes in people living with psychiatric disorders, and the role of pharmacists in addressing them.

Method

The American Association of Psychiatric Pharmacists appointed an expert panel to research the issue, identify barriers, and develop a framework for including pharmacists in addressing medication therapy problems associated with SDOH in people with psychiatric disorders. The panel used Healthy People 2030 as the framework and sought input from public health officials to propose solutions for their commentary.

Results

We identified potential connections between SDOH and their impact on medication use in people with psychiatric disorders. We provide examples of how comprehensive medication management can afford opportunities for pharmacists to mitigate medication-related problems associated with SDOH.

Conclusion

Public health officials should be aware of the vital role that pharmacists play in addressing medication therapy problems associated with SDOH to improve health outcomes and to incorporate them in health promotion programs.

Consumer perceptions of the OTC Coach: A clinical decision support system aimed at improving the safe use of over-the-counter medications

BACKGROUND

There are more than 300,000 over-the-counter (OTC) medications on the market making it challenging for consumers to select safe and effective products to treat their minor ailments.

OBJECTIVE

We sought to identify consumer perceptions about the use of a clinical decision support system, OTC Coach, to help them make informed decisions about OTC medications.

METHODS

We developed a prototype of the OTC Coach that focused on treating fever in adults. We recruited community members who were 18 years and older via our institutional research website. Participants completed a 30- to 45-minute video interview in which they initially discussed their perceptions and experiences of using OTC medications. We subsequently shared the OTC Coach prototype and sought feedback related to the content and format of the tool. We asked participants to rate their likelihood of using the tool to treat a new symptom (10-point Likert scale, 1 = not at all to 10 = extremely likely) and conducted a qualitative and quantitative analysis of these findings.

RESULTS

Among 20 participants, 11 (55%) were female, 10 (50%) were white, and the mean age was 47.9 years (range 18-81 years). Participants reported that the tool was easy to understand. The questions reported as being extremely important by most participants were allergies (n = 17, 85%), increased risk of bleeding (n = 15, 75%), temperature (n = 12, 60%), and duration of symptoms (n = 12, 60%). Three-fourths of participants (n = 15) selected a score of 7 or higher when asked about their likelihood of using this tool for a new symptom. Concerns that were raised included ensuring that the tool accounted for their personal health history, data storage, and accessibility.

CONCLUSION

Consumers were interested in using an electronic tool to determine if their symptoms can be self-treated and, if so, which medications are appropriate.