Hormonal contraception prescribing by pharmacists: 2019 update

Implementation of pharmacy access to hormonal contraception

BACKGROUND

States throughout the country are enacting legislation to authorize pharmacist prescribing of hormonal contraception to decrease barriers to access. Little is known about the process of state implementation of pharmacist prescriptive authority for hormonal contraception.

OBJECTIVES

To understand the state-level steps to enable pharmacist prescribing of hormonal contraception, including implementation challenges and facilitators.

METHODS

We conducted a qualitative study of interviews with 18 key individuals, including pharmacists and other stakeholders, from ten states with laws permitting pharmacist-prescribed hormonal contraception from March 2021 to April 2022. We analyzed data using directed qualitative analysis principles and compared experiences across states. We organized the data using the Consolidated Framework for Implementation Research framework and evaluated relevant constructs in states' implementation efforts.

RESULTS

Participants identified four key steps to implement pharmacist prescribing at the state level, including development of state rules and regulations, educational programs, reimbursement mechanisms, and expansion strategies to pharmacists and pharmacies. Participants identified early involvement of key stakeholders and a culture of support for clinical pharmacists as facilitators to implementation. Challenges included complexity and cost of billing mechanisms, lack of funding for implementation efforts, and competing priorities of pharmacies/pharmacists.

CONCLUSION

Participants in states with pharmacist prescriptive authority for hormonal contraception identified development of reimbursement and billing mechanisms as the most critical state-level step in implementation. Focusing on facilitators of key steps can guide states in developing successful implementation strategies to improve contraceptive access.

Pharmacist prescribed hormonal contraceptives in New York State: Is there a need and an interest?

BACKGROUND

Hormonal contraceptives are a popular option for pregnancy prevention and other indications and require a prescription. Since 2013, 24 states have given pharmacists legal authority to initiate self-administered hormonal contraceptives, allowing for direct pharmacy access (DPA). New York State (NYS) did not allow for DPA of any hormonal contraceptives during the survey period, but passed a bill in 2023 allowing pharmacists to dispense hormonal contraceptives in accordance with a nonpatient-specific order.

OBJECTIVES

This study aimed to characterize the experiences, perceptions, and knowledge of access to and DPA to hormonal contraceptives.

METHODS

A survey was developed to gather responses to demographic- and opinion-related questions and administered online using the Pollfish survey platform. Participants were women between the ages of 16 and 44 years who lived in NYS. To ensure geographic representation, at least one response was gathered from each of the 27 NYS congressional districts. Chi-square tests were used to assess differences in hormonal contraceptive use by patient demographics.

RESULTS

Most of the 500 respondents reported past (76.2%) or current/planned (76.8%) use of hormonal contraceptives. Older age (P = 0.033) and higher income (P = 0.0016) were associated with significantly greater rates of use. The most common challenges when visiting a provider for birth control included needing to schedule an appointment and wait times at the provider. Almost three-quarters of respondents (72.6%) were not aware that pharmacists could initiate contraceptives in other states, and 74.2% reported feeling comfortable with a pharmacist prescribing and dispensing hormonal contraceptives.

CONCLUSION

Contraceptive initiation by pharmacists would be acceptable to most respondents, but there is room for increased acceptance based on patient education and experience. DPA to hormonal contraceptives may eliminate some of the barriers identified in this survey.

Global engagement of pharmacists in test and treat initiatives: Bringing care from clinics to communities

The coronavirus disease 2019 pandemic has placed substantial strain on the global health care workforce, disrupting essential and nonessential services. Task sharing of test and treat services to nontraditional prescribers, such as pharmacists, can facilitate more resilient health care systems by expanding access to health services while simultaneously decreasing the pressure on traditional health care providers. Expansion of pharmacists' scope of work has historically been hindered by sociopolitical, resourcing, and competency considerations; addressing these challenges will be key to including pharmacists in testing and treatment of priority diseases. Sociopolitical considerations include migrating to flexible national legislation and scope of practices as well as engagement with other health care providers and the public to increase the acceptance of pharmacists participating in test and treat services. Resourcing issues include health care financing for test and treat services to parallel established systems or use voucher systems and service competition. In addition, pharmacists can use their training in supply chain management to ease and prevent medication stockouts in test to treat initiatives. Investments in technologies that support disease surveillance, basic reporting, and interoperability with health management information systems can integrate these initiatives into health care systems. Competency considerations comprise test and treat specific education for the pharmacy profession to equip them with the knowledge and confidence to execute successfully. Monitoring and evaluating the outcomes of these services can facilitate the scalability of test and treat initiatives. Pharmacists are uniquely positioned to bring testing and treatment from the clinic to the community.

Women's perspectives on receiving and expanding access to essential health services in pharmacies in the United States

BACKGROUND

Expanding reproductive health services in community pharmacies is a promising strategy for reaching underserved communities. Limited information exists on women's attitudes to receive these services and if interest may differ in urban and rural locations.

OBJECTIVE

We sought to determine whether there were differences by rural location in women's perspectives and willingness to receive essential preventative and diagnostic reproductive health services in community pharmacies.

METHODS

We conducted a cross-sectional national survey of women in November 2020. The survey consisted of demographic data, women's experiences receiving essential preventative health services, and questions regarding perspectives on and interest in receiving these services in community pharmacies. Descriptive statistics assessed differences in survey responses between rural and urban communities.

RESULTS

Our sample size consisted of 867 women. We received 544 responses for a response rate of 62.7%. Rural women were as likely as their urban counterparts to delay receiving preventative care owing to concerns about insurance or how they would pay for services (P = 0.45). Rural women were less likely than urban women to have received the human papillomavirus vaccine (P = 0.02) or have had regular cervical cancer screenings (P = 0.04). Overall, both rural and urban women want to receive preventative reproductive health services in community pharmacies.

CONCLUSION

Expanded access to reproductive health services in community pharmacies has the potential to improve access and health screening, particularly in underserved rural areas.

Physicians' Opinion Regarding Extended Access to Hormonal Contraception in Switzerland

(1) Background: Access to hormonal contraceptives (HC) strongly differs between countries and varies from over the counter (OTC) to prescription-only availability. This study aimed to identify opinions among physicians in Switzerland regarding extended access to HC. (2) Methods: Web-based survey among physicians (gynecologists, general practitioners, and pediatricians) in Switzerland. (3) Results: Hundred sixty-three physicians, mainly gynecologists, participated in this survey and 147 (90%) were included for analysis. A total of 68% (n = 100) answered that prescription-only status could be extended under certain conditions but physicians were concerned about patients' safety (97%, n = 142). Moreover, there was concern about insufficient patient education on HC (93%, n = 136) and that women may forego preventive examinations (80%, n = 118). Participants did not support OTC availability (93%, n = 136). Pharmacists prescribing (including initiation of HC) revealed controversial results, but a combined access model (initial prescription from physician and follow-up prescriptions by pharmacists) found acceptance in 70% (n = 103). (4) Conclusions: Participating physicians stated that prescription-only status for HC could be lifted under certain conditions but also some concerns, e.g., patients' safety or neglection of preventive examinations, were raised. Future research should focus on specific conditions in which extended access to HC could be agreed on.

Pharmacists' perspectives and experience prescribing hormonal contraception in rural and urban New Mexico

BACKGROUND

Pharmacist prescription of contraception is becoming increasingly common in the United States (US). Limited information exists on whether this is improving access to contraception in underserved areas, including rural America.

OBJECTIVE

We sought to determine whether there were differences by rural location in pharmacists' willingness to prescribe hormonal contraception and perceived barriers to doing so.

METHODS

We conducted a cross-sectional survey of pharmacists eligible to prescribe hormonal contraception in New Mexico in March and May 2020. The survey consisted of demographic data, pharmacists' experience prescribing hormonal contraception, and questions regarding perceived barriers to pharmacist-prescribed hormonal contraception. Descriptive statistics assessed differences in survey responses between rural and urban pharmacists. We used multivariable logistic regression to estimate the association between rural practice and prescribing hormonal contraception.

RESULTS

Our sampling frame consisted of 822 licensed pharmacists. We received 256 responses, for a response rate of 31.1%. We found that rural pharmacists were as likely as their urban counterparts to prescribe hormonal contraception (adjusted odds ratio 1.22 [95% CI 0.56-2.68], P = 0.50). Five main barriers included a need for additional training, reimbursement for services, liability concerns, corporate policies, and shortage of staff. No difference in barriers were identified by rural location or staff role.

CONCLUSION

Pharmacy access has the potential to improve access to contraception across New Mexico, including underserved rural areas.

Student pharmacists' perceptions regarding pharmacist-prescribed hormonal contraceptives and their professional responsibility

BACKGROUND

Currently, 13 U.S. jurisdictions allow for pharmacist-prescribed contraception; however, pharmacists' intention to use and ultimate uptake of this patient care opportunity have been variable.

OBJECTIVES

The objectives of this study were to (1) identify student pharmacists' attitudes toward pharmacist-prescribed hormonal contraception (HC), (2) identify student pharmacist perceived barriers regarding pharmacist-prescribed HC, and (3) explore what factors affect student pharmacists' viewpoints.

METHODS

An anonymous survey was administered using Qualtrics among third-year student pharmacists in a public health course. The survey was developed using the Theory of Planned Behavior (TPB) and previously published literature. TPB was developed to predict an individuals' intention to engage in a behavior at a specific time and place. All responses were anonymous. Survey responses were summarized using descriptive statistics, and Wilcoxon Mann-Whitney test was used to compare differences based on student pharmacist gender and religion.

RESULTS

A total of 67 student pharmacists participated in the survey (response rate 80.7%). Most agreed-strongly agreed (n = 59, 88.1%) that pharmacists are capable of appropriately assessing and selecting HC therapies and believe it should be within a pharmacist's scope of practice (n = 53, 79.1%). Similarly, most agreed-strongly agreed that it is a professional responsibility for pharmacists to provide this service (n = 56, 83.6%). Potential barriers identified included limited access to patient medical records (n = 55, 82.1%), interruption to workflow (n = 51, 76.1%), and concerns for a decrease in well-women examinations (n = 51, 76.1%). Most identified with the Christian faith (n = 45, 67.2%) but said this did not influence their opinions (n = 40, 59.7%). Gender, age, and religion were not found to be associated with student pharmacists' attitudes. However, an increasing number of barriers were negatively associated with their attitudes.

CONCLUSION

Student pharmacists believe it is within a pharmacist's scope of practice and a professional responsibly to prescribe HC. Student pharmacists were less supportive of pharmacist-prescribed HC if they reported a greater number of barriers.

Opposition to Pharmacist Contraception Services: Evidence for Rebuttal

Pharmacist contraception services are growing across the United States. Several states have authorized pharmacists to prescribe contraception, and the interest in other states continues to grow. Opposition to these practices exists and centers on discussions related to safety, training, cost, and fragmentation of care. We review these arguments and provide evidence refuting these concerns. Pharmacist-prescribed contraception increases access to care, and patients express interest in utilizing this service at the pharmacy. Pharmacists follow evidence-based recommendations. Counseling on preventative services and referral to other providers is part of contraception care by pharmacists. Training programs have been developed to equip both pharmacy students and pharmacists with the knowledge, skills, and tools needed to successfully provide these services. This article can serve as a guide for pharmacists and advocates when discussing pharmacist-prescribed contraception with policymakers, patients, and other healthcare professionals.

Primary healthcare policy and vision for community pharmacy and pharmacists in the United States

The United States (US) has a complex healthcare system with a mix of public, private, nonprofit, and for-profit insurers, healthcare institutions and organizations, and providers. Unlike other developed countries, there is not a single payer healthcare system or a national pharmaceutical benefits scheme/plan. Despite spending over USD 10,000 per capita in healthcare, the US is among the worst performers compared to other developed countries in outcomes including life expectancy at birth, infant mortality, safety during childbirth, and unmanaged chronic conditions (e.g., asthma, diabetes). Primary care is delivered by physicians and advanced practice providers (i.e., nurse practitioners and physician assistants) in a variety of settings including large health systems, federally qualified health centers or free clinics that provide care to the underserved, or specific facilities for veterans or American Indian and Alaska native peoples. Since 2010, primary care delivery has shifted toward providing patient-centered, coordinated, comprehensive care focused on providing proactive, rather than reactive, population health management, and on the quality, versus volume, of care. Community pharmacy comprises a mix of independently owned, chain, supermarket and mass merchant pharmacies. Community pharmacies provide services such as immunizations, medication therapy management, medication packaging, medication synchronization, point-of-care testing and, in specific states where legislation has been passed, hormonal contraception, opioid reversal agents, and smoking cessation services. There has been criticism regarding the lack of standard terminology for services such as medication synchronization and medication therapy management, their components and how they should be provided, which hampers comparability across studies. One of the main challenges for pharmacists in the US is the lack of provider status at the federal level. This means that pharmacists are not allowed to use existing fee-for-service health insurance billing codes to receive reimbursement for non-dispensing services. In addition, despite there being regulatory infrastructure in multiple states, the extent of service implementation is either low or unknown. Research found that pharmacists face numerous barriers when providing some of these services. State fragmentation and the lack of a single pharmacy organization and vision for the profession are additional challenges.

Special ambulatory gynecologic considerations in the era of coronavirus disease 2019 (COVID-19) and implications for future practice

The coronavirus disease 2019 pandemic has altered medical practice in unprecedented ways. Although much of the emphasis in obstetrics and gynecology to date has been on the as yet uncertain effects of coronavirus disease 2019 in pregnancy and on changes to surgical management, the pandemic has broad implications for ambulatory gynecologic care. In this article, we review important ambulatory gynecologic topics such as safety and mental health, reproductive life planning, sexually transmitted infections, and routine screening for breast and cervical cancer. For each topic, we review how care may be modified during the pandemic, provide recommendations when possible on how to ensure continued access to comprehensive healthcare at this time, and discuss ways that future practice may change. Social distancing requirements may place patients at higher risk for intimate partner violence and mental health concerns, threaten continued access to contraception and abortion services, affect prepregnancy planning, interrupt routine screening for breast and cervical cancer, increase risk of sexually transmitted infection acquisition and decrease access to treatment, and exacerbate already underlying racial and minority disparities in care and health outcomes. We advocate for increased use of telemedicine services with increased screening for intimate partner violence and depression using validated questionnaires. Appointments for long-acting contraceptive insertions can be prioritized. Easier access to patient-controlled injectable contraception and pharmacist-provided hormonal contraception can be facilitated. Reproductive healthcare access can be ensured through reducing needs for ultrasonography and laboratory testing for certain eligible patients desiring abortion and conducting phone follow-up for medication abortions. Priority for in-person appointments should be given to patients with sexually transmitted infection symptoms, particularly if at risk for complications, while also offering expedited partner therapy. Although routine mammography screening and cervical cancer screening may be safely delayed, we discuss society guideline recommendations for higher-risk populations. There may be an increasing role for patient-collected human papillomavirus self-samples using new cervical cancer screening guidelines that can be expanded considering the pandemic situation. Although the pandemic has strained our healthcare system, it also affords ambulatory clinicians with opportunities to expand care to vulnerable populations in ways that were previously underutilized to improve health equity.

Effect of a Simulated Activity on Student Ability, Preparedness, and Confidence in Applying the Pharmacists' Patient Care Process to Contraceptive Prescribing

Several states now permit pharmacists to prescribe hormonal contraception. Consequently, some schools of pharmacy now incorporate activities intending to prepare students to offer this service. This study aimed to assess the impact of a simulated activity on student pharmacists’ readiness for, ability to use, and confidence in applying the Pharmacists Patient Care Process along with the United States Medical Eligibility Criteria to a patient seeking contraception. Students completed a contraceptive-prescribing simulation with standardized patients. Scores were analyzed for safe and appropriate prescribing practices. Pre- and post-workshop surveys measured confidence and perceived preparedness. Chi-square and Mann–Whitney U tests were used to analyze categorical variables and Likert-scale data, respectively.The mean activity score was 86% (median 90%), with significant change in student confidence of ability to complete the process (p < 0.0001). The majority of students at baseline (52.2%) and follow up (53.2%) reported needing more practice during advanced pharmacy practice experiences (APPEs) to feel prepared. There was a significant change pre/post in students who agreed that their curriculum prepared them (15% to 28.7%, p = 0.0014). This study suggests that students are able to safely and appropriately prescribe contraception in a simulated activity. The activity increased student reported confidence and moved some students towards readiness for contraceptive prescribing.

Attitudes of Michigan Female College Students About Pharmacists Prescribing Birth Control in a Community Pharmacy

In the United States, the overall unintended pregnancy rate is about 45%. Women between 20–24 years old account for 59% of the unintended pregnancies. Continuous birth control use is related to decreasing unintended pregnancies. Therefore, we assessed female college students’ opinions about pharmacists prescribing birth control in a community pharmacy using an intersectionality framework. A survey with 49 items about provider attributes, pharmacy services use and evaluation, advantages and barriers of pharmacists prescribing birth control, sexual and reproductive history, and demographics was distributed by survey link and QR code. Recruitment was done by investigators and students (snowballing technique) via emails, social media posts, and direct student contact. Respondents (n = 859) were 23.0 ± 4.9 years old, 83% white, 64% healthcare students, 32% student pharmacists, 69% sexually active, 68% with at least one episode of unprotected intercourse within a year, and 29% never using condoms. Forty-six percent of students were extremely likely and 26% moderately likely to get birth control from a pharmacist because it would be easier to adhere to birth control, could prevent unintended pregnancies, would be more convenient, and require less time. Concerns included the lack of Pap screenings and prescriptions written for the wrong birth control. Within most student characteristics or attitudes assessed, at least 70% of the students would use this service. Based on student opinions, female college students would use pharmacists prescribing birth control services.