Trends in the delivery of care to oncology patients in the United States: Emphasis on the role pharmacists on the healthcare team

Objective

The purpose of this study was to identify trends in oncology care that allow one to forecast workforce supply and demand, the training and skills needed by the oncology pharmacist for the likely future of oncology care.

Methods

Interviews were conducted with experienced oncology pharmacists in leadership roles at 20 organizations balanced by geographic region and type of practice site (academic or community/ambulatory). Results were analyzed using descriptive statistics and theme identification.

Results

Practice sites differed widely in numbers of patient visits, practitioner/patient ratios, residency program presence, and other structural features. Despite this, the majority reported an expectation of growth in cancer patients, oncology physicians, oncology pharmacists, pharmacy technicians, oncology nurses, and advanced practice practitioners in the next two to five years. Fifty percent of sites currently support Post Graduate Year 2 (PGY2) oncology residencies. At least 50% reported routine pharmacist involvement in 12 clinical functions. More future involvement was predicted for immunotherapy (80%) and oral oncolytic therapy (90%). Interprofessional involvement was reported for a broad variety of practice-related committees and patient education teams. Limited pharmacist involvement in credentialing, quality measurement, and value-based reimbursement systems was found.

Conclusion

Anticipated increases in demand for oncology pharmacists strongly suggest the need for more PGY2 oncology residency programs and on-the-job oncology training programs. Oncology pharmacists are currently involved in many clinical and administrative functions including multidisciplinary management. While a core set of clinical functions has been identified, oncology pharmacists must prepare for the increased use of oral oncology agents and immunotherapy. Pharmacist involvement in value-based reimbursement and other data-based quality outcome measurements should be increased to optimize involvement in team-based patient care.

Retail clinics colocated with pharmacies: A Delphi study of pharmacist impacts and recommendations for optimization

OBJECTIVES

To identify workforce issues likely to affect pharmacists working in retail clinics (RCs) colocated with community pharmacies and to generate recommendations for optimizing health, cost, and operations outcomes.

DESIGN AND PARTICIPANTS

A Delphi expert panel process using researchers with pharmacist workforce research experience was used. Panelists responded to 2 surveys of 3 rounds each. In survey 1, panelists used a 4-point linear numeric scale to rate the importance of 15 impact factors on pharmacists working in the RC/pharmacy setting. In survey 2, panelists used a 3-point linear numeric scale to rate the importance of recommendations for optimal outcomes. Recommendations were structured around elements from collaboration theory, a framework for evaluating critical areas for success in merged operations.

MAIN OUTCOME MEASURES

Consensus was defined as ≥ 80% rating an impact "very" or "moderately" important (survey 1) and "very" important (survey 2). Impact factors were rank-ordered by ratings and numeric scoring. Selected comments about consensus items were reported.

RESULTS

The 8-person panel had 100% response rates for both surveys. 12 of the 15 impact variables achieved consensus (survey 1). The highest ranking impacts were ability to establish collaborative relationships, relationships with coworkers, including nurse practitioners, and location of the RC relative to the pharmacy. Of 15 recommendations (survey 2), 5 achieved consensus and focused heavily on information sharing and early and ongoing collaboration among all stakeholders.

CONCLUSION

Clinical, economic, health care quality, and patient preference data suggest that RCs colocated with pharmacies are likely to play a permanent role in U.S. health care. RCs can affect pharmacists and pharmacies positively or negatively. Positive impacts are most likely where establishing collaborative partnerships with all stakeholders, including patients, throughout planning, implementation, and operation are emphasized. With only about 3% of pharmacy operations colocated with RCs now, attention and resources should be devoted to developing and testing models based on collaboration principles.

Factors impacting self-perceived readiness for residency training: results of a national survey of postgraduate year 1 residents

OBJECTIVE

To examine the factors impacting postgraduate year 1 (PGY1) residents' self-perceived readiness for residency.

METHODS

A total of 1801 residents who matched in American Society of Health-System Pharmacists (ASHP)-accredited PGY1 programs were e-mailed individualized invitations to take an online survey. The survey collected self-ratings of readiness for residency training competencies including time management and organization, foundational knowledge, clinical practice, project management, and communication.

KEY FINDINGS

Data from 556 completed surveys were analyzed. Residents agreed they were ready to perform activities requiring time management and organization (median = 4, mean = 4.08), foundational knowledge (median = 4, mean = 3.83), clinical practice (median = 4, mean = 3.67), and communication (median = 4, mean = 4.05). Residents who completed at least 1 academic advance pharmacy practice experience (APPE), 5 clinical APPEs, or held a bachelors degree felt more confident than their counterparts in regard to project management (P < .001, <.001, and .01, respectively).

CONCLUSION

PGY1 residents generally felt prepared for time management and organization, foundational knowledge, and communication residency training competencies. This was significant for those who completed 1 or more academic APPEs, 5 or more clinical rotations, or a bachelors degree. Study results may assist pharmacy schools in preparing students for residency training, prospective resident applicants in becoming more competitive candidates for residency programs, and residency program directors in resident selection.

Factors affecting the unmet demand for pharmacists: state-level analysis

OBJECTIVE

To describe the relationship between state-level Aggregate Demand Index (ADI) data and market factors reflecting both supply and demand: unemployment rates, pharmacy graduates, community pharmacy prescription growth rates, and Medicare Part D.

DESIGN

Cross-sectional time series analysis using state-level data.

SETTING

U.S. labor market for pharmacists, from 2001 to 2010.

INTERVENTION

Model ADI data for states (dependent variable) against five independent variables: previous year ADI, unemployment rates, pharmacy graduates, prescription growth rates, and Medicare Part D.

MAIN OUTCOME MEASURES

Significance and predictive ability of the model, sign of the variables studied, and R2.

RESULTS

In the two-way (state and time) fixed-effects model, all variables were significant and R2 was 0.79. Contributions to state-level ADIs were, in rank order, previous year ADI, unemployment rates, pharmacy graduates, and prescription growth rates. The model predicted 2010 ADI values for 44 of 51 states within ±10%. The model depicts the independent contributions of each variable for the short (∼1 year) and longer term. Although the nature of ADI data precludes quantitative predictions about the pharmacist job market, the model results show marketplace directions (up or down) and comparative impacts.

CONCLUSION

The model demonstrated that unemployment rates, pharmacy graduates, prescription growth rates, and Medicare Part D contributed significantly to state-level ADIs between 2001 and 2010. The relationships uncovered should be monitored and reexamined as new data emerge in order to anticipate the directions of the pharmacist job market.

Pharmacy school survey standards revisited

In a series of 3 papers on survey practices published from 2008 to 2009, the editors of the American Journal of Pharmaceutical Education presented guidelines for reporting survey research, and these criteria are reflected in the Author Instructions provided on the Journal's Web site. This paper discusses the relevance of these criteria for publication of survey research regarding pharmacy colleges and schools. In addition, observations are offered about surveying of small "universes" like that comprised of US colleges and schools of pharmacy. The reason for revisiting this issue is the authors' concern that, despite the best of intentions, overly constraining publication standards might discourage research on US colleges and schools of pharmacy at a time when the interest in the growth of colleges and schools, curricular content, clinical education, competence at graduation, and other areas is historically high. In the best traditions of academia, the authors share these observations with the community of pharmacy educators in the hope that the publication standards for survey research about US pharmacy schools will encourage investigators to collect and disseminate valuable information.

Depressive symptoms in patients with type 2 diabetes mellitus: do stress and coping matter?

This article examines the relationship among diabetes-related stress, appraisal, coping and depressive symptoms in patients with type 2 diabetes mellitus (T2DM) using the transactional model of stress and coping (TMSC) as the theoretical framework. In this cross-sectional study, a convenience sample of 201 patients with T2DM was recruited from three outpatient clinics. Patients with depressive symptoms reported significantly more diabetes-related stress than patients without depressive symptoms. The results of path analysis suggest that patients who experience greater diabetes-related stress or greater depressive symptoms have a negative appraisal of their diabetes. Negative appraisal is, in turn, associated with greater use of avoidance, passive resignation and diabetes integration coping and lesser use of problem-focused coping. Avoidance, passive resignation and diabetes integration coping are, in turn, related to greater depressive symptoms or greater diabetes-related stress. Overall, the results of this study support the TMSC as a framework to elucidate the relationships among diabetes-related stress, appraisal, coping and depressive symptoms in patients with T2DM. However, given the cross-sectional nature of the study, we are unable to elucidate the directionality of the relationship between stress and depressive symptoms. Implications of the findings and the need for longitudinal studies to evaluate these relationships are discussed.

Projected growth in pharmacy education and research, 2010 to 2015

OBJECTIVES

To determine projected growth in pharmacy education and research from 2010 to 2015 and to relate findings to external and internal factors.

METHODS

An e-mail survey instrument was sent to all US pharmacy deans, and responses were used to estimate growth in the number of first-professional-degree doctor of pharmacy (PharmD) graduates, residents/fellows, graduate students, faculty members, graduate research faculty members, and postdoctoral fellows. Results were related to the national economy, trends in faculty vacancies, growth trends in other health professions, pharmacist roles, and healthcare reform.

RESULTS

Five-year growth projections were: 58% increase in the number of residents/fellows, 23% in postdoctoral fellows, 21% in entry-level PharmD graduates, 19% in graduate/research faculty members, 17% in graduate students, and 13% in total pharmacy faculty members. Residencies/fellowships showed the highest projected growth rates (58%). Graduate education and research data suggest a growing research enterprise. Faculty vacancy trends were downward and this suggests better faculty availability in coming years.

CONCLUSIONS

Substantial growth is expected from 2010 to 2015 in all areas of pharmacy education. External factors and how well the profession is able to demonstrate its contribution to resolving healthcare problems may influence the actual growth rates achieved.

Association between increased number of US pharmacy graduates and pharmacist counts by state from 2000-2009

OBJECTIVE

To determine whether growth in the number of pharmacy graduates and newly accredited schools from 2000 to 2009 were larger in states with fewer pharmacists per population age ≥ 65 years.

METHODS

States were aggregated into quartiles based on rank-ordered ratios of in-state pharmacists per 100,000 population aged ≥ 65 years. Quartiles were then compared with respect to the number of new graduates.

RESULTS

The mean cumulative number of graduates was highest in the first quartile of states (those with the greatest need for pharmacists) and lowest in the fourth quartile of states. States with the greatest need for pharmacists had the lowest positive growth in number of pharmacists per population ≥ 65 years. The majority of new schools in 2009 were located in states with relatively low numbers of pharmacists.

CONCLUSION

The growth in new pharmacy graduates created by expansion in schools as well as in graduates per school helped states meet demand between 2000 and 2009. However, tremendous variation remains in the number of graduates as well as the number of pharmacists across states. The quartile framework is useful for assessing the number of new pharmacy graduates based on pharmacists per population ratios. Based on current dynamics in the supply and demand of pharmacists, frequent monitoring is recommended.

Interprofessional education: cooperation among osteopathic medicine, pharmacy, and physician assistant students to recognize medical errors

Thirty-nine volunteer students from 3 health science colleges at Touro University California participated in an exercise designed to promote interprofessional collaboration. In the event, thirteen 3-person multidisciplinary teams of students identified potential medical errors in a series of case-based scenarios. In an immediate postevent survey, 33 of 39 respondents (85%) indicated that the exercise marked the first time that they had worked on clinical problems with students from other health professions. All respondents agreed that interprofessional education was useful and necessary. A 6-month follow-up survey had 24 respondents, 9 of whom (38%) indicated that the experience helped them in interprofessional communications in their clinical rotations. Twenty-two respondents (92%) recalled that all team members were involved in the selection of answers. Respondents reported that team answer selections were made by consensus (12 [50%]), by accepting the opinion of an "expert" on the team (9 [38%]), or by majority vote (3 [13%]). Since this exercise, there has been a surge of interprofessional activities at Touro University California, including steps toward the implementation of campus-wide interprofessional education.

The pharmacist Aggregate Demand Index to explain changing pharmacist demand over a ten-year period

OBJECTIVES

To describe Aggregate Demand Index (ADI) trends from 1999-2010; to compare ADI time trends to concurrent data for US unemployment levels, US entry-level pharmacy graduates, and US retail prescription growth rate; and to determine which variables were significant predictors of ADI.

METHODS

Annual ADI data (dependent variable) were analyzed against annual unemployment rates, annual number of pharmacy graduates, and annual prescription growth rate (independent variables).

RESULTS

ADI data trended toward lower demand levels for pharmacists since late 2006, paralleling the US economic downturn. National ADI data were most highly correlated with unemployment (p < 0.001), then graduates (p < 0.006), then prescription growth rate (p < 0.093). A hierarchical model with the 3 variables was significant (p = 0.019), but only unemployment was a significant ADI predictor. Unemployment and ADI also were significantly related at the regional, division, and state levels.

CONCLUSIONS

The ADI is strongly linked to US unemployment rates. The relationship suggests that an improving economy might coincide with increased pharmacist demand. Predictable increases in future graduates and other factors support revisiting the modeling process as new data accumulate.

Progress examination for assessing students' readiness for advanced pharmacy practice experiences

OBJECTIVES

To create a valid assessment tool to evaluate the readiness of pharmacy students for advanced pharmacy practice experiences (APPEs).

DESIGN

The Triple Jump Examination (TJE) was tailored to the 4-year, 2-plus-2 curriculum of the College. It consisted of (1) a written, case-based, closed-book examination, (2) a written, case-based open-book examination, and (3) an objective structured clinical examination (OSCE). The TJE was administered at the end of each 4 academic semesters. Progression of students to APPEs was dependent on achieving a preset minimum cumulative (weighted average) score in the 4 consecutive TJE examinations.

ASSESSMENT

The predictive utility of the examination was demonstrated by a strong correlation between the cumulative TJE scores and the preceptor grades in the first year (P3) of APPEs (r = 0.60, p > 0.0001). Reliability of the TJE was shown by strong correlations among the 4 successive TJE examinations. A survey probing the usefulness of TJE indicated acceptance by both students and faculty members.

CONCLUSION

The TJE program is an effective tool for the assessment of pharmacy students' readiness for the experiential years. In addition, the TJE provides guidance for students to achieve preparedness for APPE.

New pharmacist supply projections: Lower separation rates and increased graduates boost supply estimates

OBJECTIVE

To revise the 2000 Bureau of Health Professions Pharmacist Supply Model based on new data.

DESIGN

Stock-flow model.

SETTING

United States.

PARTICIPANTS

A 2004 estimate of active pharmacists reported by the Bureau of Labor Statistics was used to derive the base count for the 2007 supply model.

INTERVENTIONS

Starting with a 2004 base of active pharmacists, new graduates are added to the supply annually and losses resulting from death and retirement are subtracted.

MAIN OUTCOME MEASURES

Age- and gender-based pharmacist supply estimates, 2004-2020.

RESULTS

Increased U.S. pharmacist supply estimates (236,227 in 2007 to 304,986 in 2020) indicate that pharmacists will remain the third largest professional health group behind nurses and physicians. Increases were driven by longer persistence in the workforce (59%), increased numbers of U.S. graduates (35%), and increases from international pharmacy graduates (IPGs) achieving U.S. licensure (6%). Since more pharmacists are expected to be working part time the full-time equivalent (FTE) supply will be reduced by about 15%. The mean age of pharmacists was projected to decline from 47 to 43 by 2020. Because of unequal distribution across age groups, large pharmacist cohorts approaching retirement age will result in fewer pharmacists available to replace them. The ratio of pharmacists to the over-65 population is expected to decrease after 2011 and continue to fall beyond 2020; this is likely a reflection of baby boomers passing through older age cohorts.

CONCLUSION

The revised estimated active U.S. pharmacist head count in 2006 is 232,597, with equivalent FTEs totaling approximately 198,000. The substantial increase over the 2000 pharmacist supply model estimates is primarily attributable to pharmacists remaining in the workforce longer and educational expansion. U.S. licensed IPGs account for less than 6% of overall increases. The pharmacist work-force is projected to become younger on average by about 4 years by 2020. Coincident demands for more physicians and nurses over the same period and shortages in all three professions stipulate that active steps be taken, including continued monitoring of work trends among pharmacists and other health professionals.

Examination of state-level changes in the pharmacist labor market using Census data

OBJECTIVE

To examine long-term changes in the U.S. pharmacist labor market across states.

DESIGN

Retrospective cohort study.

SETTING

The United States as a whole and individual states in 1990 and 2000.

PARTICIPANTS

Pharmacists and pharmacy school graduates from Census data and previous research, respectively.

INTERVENTION

Retrospective analysis of 5% Public Use Microdata Samples data on pharmacists from the 1990 and 2000 U.S. Census surveys, information on migration among states between 1995 and 2000, and previous research on pharmacy school graduates.

MAIN OUTCOME MEASURES

Changes in pharmacist counts and wages, as well as migration of pharmacists across states and pharmacy school graduates by state.

RESULTS

From 1990 to 2000, the ratio of pharmacists to 100,000 population increased from 70 to 76, but 13 states experienced declines in this datum, and overall changes in pharmacist counts varied considerably among states. The average wage, expressed in 2000 U.S. dollars, for pharmacists increased from $26.58 per hour to $33.80 per hour (17%), while the average wages of non-pharmacist college graduates increased from $26.37 to only $28.76 (9%). Wage changes varied across states.

CONCLUSION

According to the Census, the number of pharmacists per 100,000 population varied substantially across states. This variance in supply across states is not converging or easily explained. Overall, the shortage had a clear impact on the pharmacist labor market, yet this effect was not consistent across states.

ASHP survey of ambulatory care pharmacy practice in health systems--2004

PURPOSE

The characteristics of and trends in pharmacy practice in ambulatory care settings across the United States were studied.

METHODS

A 2004 national survey of the ambulatory care responsibilities of pharmacists across a spectrum of organizational types (community hospitals, county facilities, Indian Health Services facilities, Veterans Affairs (VA) facilities, teaching institutions, integrated health networks, military facilities, and health maintenance organizations) was conducted and related to organizational features that could promote pharmacist participation.

RESULTS

From 1672 deliverable Web-based surveys, 233 organizations reported at least some pharmacist involvement in ambulatory activities, while 475 reported none. Over half of the 228 organizations with some pharmacist involvement reported pharmacists tracking adverse drug reactions (67%), providing written (53%) or oral (52%) information with new prescriptions, and conducting medication management programs (51%). Some 85% reported having at least one clinic with pharmacist involvement. Clinics for anticoagulation services (36%) and oncology services (28%) were most prevalent, followed by primary care or family practice clinics (23%) and diabetes clinics (21%). New survey items found a high prevalence of pharmacist involvement in emergency preparedness programs (90%), medication management services in complex medication situations (63%), and using evidence-based practice guidelines (60%). Of nine enabling factors (factors potentially promoting pharmacist involvement) investigated, participation on multidisciplinary teams and having collaborative practice agreements were significantly associated with pharmacist participation in at least one ambulatory care activity. Having at last one ambulatory care staff pharmacist with advanced training, having at least one residency program, and having collaborative practice agreements were significantly associated with pharmacist participation in at least one clinic or program. Pharmacist participation in ambulatory care activities was not equally distributed across different types of organizations, and VA facilities were notable for the amount and extent of participation.

CONCLUSION

Pharmacists' roles and responsibilities in ambulatory care appear to continue to evolve, with VA facilities leading the way.

Update on the pharmacist shortage: National and state data through 2003

PURPOSE

Aggregate Demand Index (ADI) survey results were used to describe the severity of the pharmacist shortage at the national and state levels and by practice site and impact on the U.S. population.

METHODS

Time-series analysis was used to characterize national and state trends in the ADI from September 1999 through September 2003. The time trends for the distribution of ratings and the demand index by practice site were also examined. Historical data about retail prescriptions filled and related growth rates were compiled and compared. ADI survey results were also compared with data from other surveys.

RESULTS

Over time, ADI data demonstrated a continuing national pharmacist shortage, as the ability to fill pharmacist vacancies was rated at least moderately difficult. A very slight downward trend in severity (slope = -0.008) was observed. Other survey series had similar findings. States with the most severe shortage levels tended to have large populations, while those with the lowest levels tended to have smaller populations. More states improved than worsened the severity of their shortage, with 30 states maintaining the same ADI rating. Although there was a high correlation between the retail prescription growth rate and the ADI (r = 0.84), there was a much greater decrease in prescription growth (73%) than ADI levels (6.5%).

CONCLUSION

There was a sustained unmet demand for pharmacists throughout the United States from September 1999 through September 2003. More states moved toward having an adequate supply of pharmacists than toward having a more severe shortage of pharmacists, but the national ADI suggests that the system remains stressed.

Analysis of Pharmacist and Pharmacist-Extender Workforce in 1998–2000: Assessing Predictors and Differences Across States

OBJECTIVE

To examine the impact of supply and demand factors on filled positions for pharmacists and pharmacist extenders (pharmacist technicians and aides) and assess differences across states through analysis of state-level pharmacist labor market data.

DESIGN

Cross-sectional analysis.

SETTING

United States.

PARTICIPANTS

Not applicable.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

State-level counts of filled pharmacist and pharmacist-extender positions, wages, and various available demographic, health, policy, and other factors related to the pharmacist labor market.

RESULTS

Across states, the total population and the number of community pharmacy prescriptions were very accurate predictors (R2 = 0.99) of the number of pharmacist and pharmacist-extender positions, and all other variables were insignificant after these two variables were controlled for. Pharmacists and pharmacist-extenders were positively correlated, and the ratio of the two was not related to observable policy-related variables. Outlying states, in terms of simple pharmacist-to-population ratios, were difficult to categorize.

CONCLUSION

Future changes in prescriptions are likely to affect the pharmacist and pharmacist-extender labor markets. Across states, pharmacists and extenders relate as complements rather than substitutes. The number of pharmacist graduates and state-level regulations regarding technician-to-pharmacist ratios appears to have a small effect on filled positions across states.

Pharmacy school graduates by state and region: 1990-1999

OBJECTIVE

To describe the distribution of pharmacy schools and graduates (first professional degree) at the state, divisional, and regional levels during the 10-year period from 1990 through 1999, as well as enrollment patterns by residential status.

DESIGN

Yearly school-level graduate counts from 1990 through 1999 were obtained from the American Association of Colleges of Pharmacy and analyzed at the state, division, region, and national levels. Comparisons were made before and after adjusting for state population. In-state enrollment patterns for 1998 were examined.

SETTING

United States.

MAIN OUTCOME MEASURES

At various geographic levels, the distribution of schools and new graduates adjusted to population; cumulative production of graduates; percentage of in-state enrollment.

RESULTS

Over the 10-year study period, 73,541 new pharmacists graduated from U.S. pharmacy schools, about 9,500 more than graduated in the 1980s. The number of schools varied across states (range, 0-5), as did cumulative graduate counts (range, 0-7,303), with high-producing states including those with four and five schools. Nationally, 28 new pharmacists graduated per year per 1 million population. Several populous states, including California, Florida, Illinois, and Texas, produced pharmacists at a rate substantially below the national average when computed as graduates per year per million population. The West region had the lowest annual graduate count adjusted for population. In-state enrollment was consistently high, with nearly 80% of individuals graduating from schools in their state of residence.

CONCLUSION

The number of pharmacy schools and graduates increased during the 1990s, a period of substantial educational and workforce change in pharmacy. Numbers of schools and graduates varied significantly across states. The West region and several populous states had graduate counts less than one-half the national average. With the current national pharmacist shortage, greater attention should be directed to the development of strategies to address imbalances between supply and demand within individual states.

Unmet needs in the medication use process: perceptions of physicians, pharmacists, and patients

OBJECTIVES

To explore the perception of unmet needs in the medication use process from the perspectives of three of the principal participants in the process--physicians, pharmacists, and patients--and to identify the individual(s) or strategy(ies) perceived to be the best or most likely candidate(s) to resolve the problems identified.

PARTICIPANTS

Physicians (primary care, cardiology, oncology, and obstetrics/gynecology specialties), pharmacists (community and health-system settings), and patients from four medium-sized U.S. cities. The survey instrument was modified for each group.

MAIN OUTCOME MEASURES

The medication use process was divided into nine steps, based on a previous study. A two-part question was framed for each step. In part A, respondents were asked to indicate their level of agreement (on a 5-point scale) about whether the step was being conducted appropriately. In part B, those who disagreed with a statement in part A were asked their opinions on the best possible candidate or strategy for improving that step.

RESULTS

Both physicians and pharmacists identified four areas of unmet needs: timing of physician visit, patient counseling, patient use of medications, and patient monitoring. Each group held itself primarily responsible for the resolution of most of these problems. Patients did not identify any unmet needs from the survey. In responses to open-ended questions, however, they cited medication cost, appropriateness, access, and convenience as problems.

CONCLUSION

Providers and patients reported substantially different perspectives on medication use problems and on improving the process. Addressing the unmet needs identified in this study will require better understanding, communication, and collaboration among physicians, pharmacists, and patients.

Clinical and economic outcomes of pharmacist recommendations in a Veterans Affairs medical center

Pharmacist recommendations and their clinical and economic outcomes in a Veterans Affairs (VA) medical center were studied. The first 600 pharmacist recommendations that met study criteria were evaluated for type and frequency, rate of acceptance by physicians, potential benefit or harm, and economic consequences. The study site included inpatient and outpatient settings and a skilled-nursing facility. The most frequent types of pharmacist recommendations involved adjusting the dosage or frequency of administration and discontinuing a drug that was not indicated for the patient's medical problem. The rate of acceptance of the recommendations was 92%. The recommendations led to improved clinical outcomes in over 30% of cases in each setting and no change in over 40% of cases in each setting. Evaluators determined that patient harm was avoided by the recommendations in 90% of cases; patient harm was caused in less than 1% of cases. The overall mean cost avoidance per recommendation was $700, and the mean total cost avoidance for all 600 recommendations was $420,155. Pharmacist recommendations improved clinical outcomes and saved money at a VA medical center.

Challenges to the pharmacist profession from escalating pharmaceutical demand

Unexpected growth in medication use has escalated demand for pharmacists that has outpaced supply. Responses to the pharmacist shortage include larger workloads and greater use of pharmacist extenders and technology. As the profession has moved from a product orientation (dispensing medications) to a patient focus, clinical training requirements have expanded. However, structural and process barriers, particularly in community and retail pharmacies, must be addressed to improve the medication-use process. These issues merit greater attention from health care leaders and policymakers.

The Aggregate Demand Index: measuring the balance between pharmacist supply and demand, 1999-2001

OBJECTIVE

To describe the development and 2-year performance of the Aggregate Demand Index (ADI) survey, a tool for longitudinally tracking the difficulty of filling open pharmacist positions throughout the United States.

DESIGN

From August 1999 through July 2001, panelists completed a monthly survey on the difficulty of filling open pharmacist positions by state. Results are reported on the Web (www.pharmacymanpower.com).

SETTING

Panelists estimated difficulty filling pharmacist vacancies in the community, institutional, both community and institutional, and nonpatient care pharmacy settings.

PARTICIPANTS

A panel of individuals involved in the direct hiring of pharmacists.

INTERVENTION

A monthly survey.

MAIN OUTCOME MEASURES

Monthly indices reflecting the level of difficulty filling open pharmacy positions at the state, regional, and national levels and by pharmacy position type. Over time, these data formed a longitudinal record of the balance between the supply of and demand for pharmacists.

RESULTS

Cumulative data from 50 states and the District of Columbia showed, on average, excess demand over available supply. The five states with the highest unmet demand level (i.e., where it was most difficult to fill open positions) were Minnesota, California, Wisconsin, Iowa, and Kentucky. The only states in which demand was in balance with supply were Hawaii and Rhode Island. Over 2 years, at least 92% of the U.S. population each month resided in areas where demand for pharmacists exceeded supply. The demand level in the Northeast was significantly lower than in other regions. Unmet demand was greatest for organizations with both community and institutional positions and least for organizations with primarily community positions.

CONCLUSION

For the study period, the demand for pharmacists exceeded the available supply in the United States; ADI survey data indicated than open pharmacist positions were "somewhat difficult" to "difficult" to fill. Substantial but unexplained differences were noted by state, by region, and by type of pharmacy position. Other health care professions could use the ADI survey methodology to study workforce issues.

ASHP survey of ambulatory care responsibilities of pharmacists in managed care and integrated health systems--2001

The results of a 2001 national survey of the ambulatory care responsibilities of pharmacists in managed care organizations (MCOs) and integrated health systems are reported and compared with the results of similar surveys conducted in 1997 and 1999. Three hundred and seventy-six MCOs and integrated health systems participated in the telephone survey. The surveyelicited data about organizational structure and pharmacist functions in the ambulatory care environment. Survey respondents were asked about 24 specific ambulatory care pharmacist functions. The performance of functions was related to five "enabling" factors: pharmacists on interdisciplinary care teams, automated dispensing systems, integrated electronic medical records, very supportive medical staff, and very supportive senior management. Twenty previously measured functions decreased since 1999. Decreases were greatest in negotiating pharmaceutical contracts (-28%), administering immunizations (-27%), and immunization screening (-24%). Enabling factors supported continued expansion. Two clusters of functions, patient-related and population-related activities, were identified and supported differentially by enabling factors. Group-model and staff-model HMOs had the most enabling factors and the broadest scope of pharmacist functions. Independent practice associations had fewer enabling factors and a different mix of functions, with an emphasis on population-focused functions. Ambulatory care functions of pharmacists have expanded to new areas and have decreased in more traditional areas, perhaps because of the current pharmacist shortage and the increase in the number of prescriptions and patients.

How many pharmacists are in our future? The Bureau of Health Professions Projects Supply to 2020

OBJECTIVE

To describe a Bureau of Health Professions model for estimating the numbers and selected demographic characteristics of active pharmacists in the United States and to relate the model's findings.

DESIGN

We constructed a model using as base counts data from the Pharmacy Manpower Project census of 1989 to 1991 and advancing the counts annually based on estimates of pharmacists entering and leaving the workforce. The total number of active pharmacists in any year was the sum of the male and female cohorts from age 24 through age 75. The model and its underlying assumptions included consideration of U.S. graduates through 1998, international pharmacy graduates who become licensed in the United States, new schools, type of entry-level degrees, and separation rates. A basic series and high and low alternative series were constructed based on different assumptions.

RESULTS

The basic series projected 196,011 active pharmacists in 2000, 224,524 by 2010, and 249,086 by 2020. Estimated pharmacists per-100,000 population were 71.2 in 2000, 74.9 in 2010, and 76.7 in 2020. The workforce was projected to consist increasingly of women: 32% in 1991, 46% in 2000, 50% in 2003, and 64% in 2020. Percentages of graduates receiving the BS degree fell from 94% (1980) to 64.4% (1998) and were projected to decrease to 0% by 2005. Estimated U.S. graduates were 7,945 in 2000, 8,133 in 2010, and 8,452 in 2020. The mean age in 2000 was 38 years for women pharmacists, 46 for men, and 42 overall. Estimates of total pharmacists in 1998 were similar to those from other sources, increasing confidence in the model.

CONCLUSION

The Bureau of Health Professions model, which can be readily revised as more and better data become available, provided estimates of active pharmacists by age and sex from 1991 to 2020. The model portrayed an increasingly female pharmacy workforce, with more pharmacists holding the PharmD degree. The model and data are useful for research, analysis, and health care planning.

The availability and distribution of dentists in rural ZIP codes and primary care health professional shortage areas (PC-HPSA) ZIP codes: comparison with primary care providers

OBJECTIVE

This paper maps dentists, primary care physicians, physician assistants, nurse practitioners, and nurse midwives in rural areas and rural areas meeting criteria as underserved for primary health care.

METHODS

Computer-based mapping was used to localize health care provider groups by five-digit ZIP code. For each rural and each rural primary care health professional shortage area (PC-HPSA) ZIP code, the number of providers in each group was determined. The different combinations of providers were determined.

RESULTS

All providers in rural areas were present at levels substantially lower than national averages, particularly in PC-HPSA areas. Dentists were approximately equal in number to primary care physicians in rural areas and the largest group in PC-HPSAs. Approximately 75 percent of rural residents lived in ZIP code areas with dentists available. Over 5.8 million rural residents and over 50 percent of rural PC-HPSA residents had no providers available in their ZIP code areas.

CONCLUSIONS

Rural areas continue to have a short supply of primary care providers and dentists. Dentists were present in many areas where primary care provider presence was absent or very low. These data, including those relating to provider co-presence, can be used to develop strategies to overcome health care access problems due to provider shortages.

ASHP survey of ambulatory care responsibilities of pharmacists in managed care and integrated health systems--1999

The results of a 1999 national survey of the ambulatory care responsibilities of pharmacists in managed care organizations (MCOs) and integrated health systems are reported and compared with the results of a similar survey conducted in 1997. Four hundred MCOs and integrated health systems participated in the telephone survey. The survey elicited data about organizational structure and pharmacist functions in the ambulatory care environment. Survey recipients were asked about 24 specific ambulatory pharmacist functions. The performance of functions was related to five "enabling" factors: pharmacists on interdisciplinary teams, automated dispensing systems, integrated electronic medical records, and "very supportive" medical staff and senior management. Thirteen functions were reported to be routine activities for more than 50% of the respondents, compared with nine functions in 1997. The top four functions-using pharmacoeconomic data to make formulary decisions, conducting medication management programs, tracking adverse drug reactions, and providing written information with each new prescription-were performed in 75% or more of organizations. Some 15-18% of respondents indicated they would add specialized pharmacy-managed clinics, services to determine patient use of herbal products and dietary supplements, and Internet prescription services within 12 months, suggesting this expansion is likely to continue. Enabling factors supported expansion. Two clusters of functions were identified that related to either population-focused or patient-focused activities, and these were supported differentially by enabling factors. Group-model and staff-model HMOs had the most enabling factors and the greatest scope of pharmacist functions. Independent practice associations had fewer enabling factors and a different mix of pharmacist functions, with an emphasis on population-focused functions, suggesting that a second model of ambulatory care pharmacist activity may be emerging. Ambulatory care functions of pharmacists in integrated health-system settings have expanded broadly since 1997.

Charting the demand for pharmacists in the managed care era

The demand for pharmacists in the changing health care market is discussed. The Pharmacy Manpower Project (PMP) evolved out of concerns raised in the late 1980s, when the demand for pharmacists exceeded the supply. PMP collects, analyzes, and disseminates data on pharmacy work force variables. PMP's Subcommittee to Study Demand Issues was formed after the publication in 1995 of the Pew Health Professions Commission report projecting dramatic surpluses of pharmacists. In 1996-97, the PMP subcommittee held a series of sessions to discuss the future demand for pharmacists and their services. The panel identified a wide range of work force projections, but it concluded that medication management problems in the context of increasing prescription numbers and the emergence of data-driven health care support a scenario of a steadily increasing demand for pharmacists and pharmaceutical services. The data did not show that higher penetration by managed care is associated with smaller pharmacy staffs or job loss in institutions. There is little reason to expect the dramatic downsizing of the pharmacy work force predicted by the third report of the Pew Commission. However, retaining pharmacy roles that are useful to the system and satisfying to pharmacists will require a continuation of current proactive measures by the profession.

Charting the demand for pharmacists in the managed care era

OBJECTIVE

To discuss the future demand for pharmacists and pharmaceutical services in the managed care area.

DATA SOURCES

Published reports about the future demand for health professionals and data relating to managed care and the institutional pharmacy work force.

DATA SYNTHESIS

A panel from the Pharmacy Manpower Project's Subcommittee to Study Demand Issues examined a broad range of pharmacy-related work-force projections and found widely differing predictions. The panel reviewed recent health care trends related to managed care and data about staff size and changing job numbers in institutional pharmacies to determine which of the predictions were most likely. Medication management problems in the context of increasing prescription numbers and the emergence of data-driven health care support a scenario of a steadily increasing demand for pharmacists and pharmaceutical services. Higher penetration by managed care was not associated with job loss or reduced pharmacy staff size in institutions.

CONCLUSION

There is little reason to expect the dramatic downsizing of the pharmacy work force predicted by the third report of the Pew Commission. However, retaining pharmacy roles that are useful to the system and satisfying to pharmacists will require a continuation of current proactive measures by the profession.

Availability of primary care providers and pharmacists in the United States

OBJECTIVE

To determine the rural distribution of primary care providers (primary care physicians, physician assistants, nurse practitioners, and nurse midwives) and pharmacists.

DESIGN

Five-digit ZIP code mapping to study the availability of primary care providers and pharmacists, alone and in combinations, in rural areas and ZIP code-based health professional shortage areas (HPSAs). National averages for annual physician visits for hypertension, asthma, and diabetes were used to estimate the sufficiency of the rural physician supply.

SETTING

Rural areas of the United States.

RESULTS

In rural areas, all providers were present in lower densities than national averages, particularly in HPSAs. The primary care physician supply was insufficient to meet national averages for office visits for hypertension, asthma, and diabetes. Among available providers, the most prevalent co-presence was primary care physician with pharmacist. HPSAs showed very low physician density (1 per 22,122), and the most prevalent providers were pharmacists. States varied widely in provider density.

CONCLUSION

Despite longstanding efforts and the expansion of managed care, primary care providers remain in short supply in rural areas, especially ZIP code-based HPSAs. Making the best use of available providers should be encouraged. The continued shortfall of primary care providers in rural areas, particularly HPSAs, makes it logical to use other available providers and combinations to increase health care access. Pharmacists could increase care for patients with conditions treated with medications. Other available providers, based on skills and work site, could also offset shortages.

Community pharmacist interventions in a capitated pharmacy benefit contract

Documented interventions associated with processing prescriptions in a managed care environment were analyzed, and a bench-mark for interventions was proposed. A retrospective analysis of documented interventions by 31 pharmacies contracted by a managed care organization to serve 22,000 Medi-Cal patients was undertaken. An intervention consisted of identifying any problem related to a prescription, taking action, and recording the problem, action, and outcome on a form. Problems were categorized as drug selection issues, clinical issues, errors in prescription writing, and patient education issues. A similar process was followed for describing actions and outcomes. The data were used as an indicator of prescription-related problems in contemporary pharmacies in a managed care environment; data from another study were used as an indicator of "ideal" pharmacist performance in detecting and resolving problems. The estimated intervention rate when pharmacists meeting ideal performance expectations worked in a managed care environment was set as a benchmark. The economic impact of drug selection interventions was determined as well. Data were retrieved and compiled from 595 (93.4%) of 637 interventions performed in 1995, when 93,483 contract-related prescriptions were processed by the 31 pharmacies. Fifty percent of problems related to drug selection issues. The most frequent action was contacting the presciber (56.1%). The overall intervention rate was 0.7% (range, 0-4.1%). It was estimated that 4% of prescriptions would require an intervention; two pharmacies met this level. Interventions resulting in prescription change realized an average decrease in cost of 65.8%. Community pharmacies under contract with a managed care organization intervened on 0.7% of prescriptions, but the rate of intervention across pharmacies was inconsistent, ranging from 0% to 4.1%; a benchmark of 4% would be reasonable.

Pharmacy manpower: implications for pharmaceutical care and health care reform

Our understanding of the pharmacy work force has improved substantially over the past five years. Research efforts have described the existing work force and projected for the next decade the effect that changes in educational programs, increasing numbers of female pharmacists, and increasing numbers of employee pharmacists will have on the effective work force size. Projections about the effect of pharmacy technicians and automation are less certain. Continued research is needed to document the changing nature of the pharmacy work force, to provide work force data that are essential to representing pharmacy in health care policy decisions, and to help confirm the value of pharmacy services.

Pharmacist-managed medication review in a managed care system

A medication-review service at a managed care facility was studied. The service, developed in 1991, provides in-depth analysis of medication use and patient consultation by a pharmacist. Patients are seen by referral. During a visit, the pharmacist reviews each medication for patterns of use, clinical response, and adverse effects and if necessary teaches the patient how to use the drugs more appropriately. The pharmacist may change some aspect of the prescription and may schedule follow-up visits. The investigators reviewed data on (1) medication-related problems for all new patients seen by the pharmacist during the first 12 months of the service, (2) patient demographics for the first 23 months, (3) utilization of the service and pharmacist productivity for the first 23 months, (4) utilization of medications and health care services in a representative subset of patients 12 months before and after they used the service, and (5) costs. A total of 2720 medications were reviewed during months 1-12. On average, 64.9% of the drugs reviewed each month were problematic. A total of 836 patients were seen during the first 23 months; most of the referrals were from physicians. The patients averaged 2.6 diagnoses and 4.7 drugs each and were not dominated by any one age group, gender, diagnosis, or drug therapy. A representative subgroup showed reductions in the number of unscheduled physician visits, urgent care visits, emergency room visits, and hospital days; a savings of $644 per patient per year was calculated. Patients used fewer health services during the year after they began participating in a pharmacist-managed medication-review program.