Bernard A. Sorofman

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.

Implementation of a Community Pharmacy-Based Influenza Vaccination Program

OBJECTIVE To increase accessibility of influenza vaccine in a rural community by establishing a community pharmacy-based influenza vaccination program. SETTING An independent pharmacy in a rural eastern Iowa community of 5,000 people. PRACTICE DESCRIPTION Protocols for identification and screening of patients, administration of vaccine, and treatment of emergencies were developed by the pharmacist and approved by the county health department medical director. Administration of vaccine began October 15, 1996, and was completed on December 6, 1996. PRACTICE INNOVATION Patients were prospectively and retrospectively identified to receive the vaccination. Informed consent was obtained. Vaccine was administered by the pharmacist after screening for contraindications and counseling the patient. Weekly vaccination records were forwarded to the collaborating physician to update patient charts. MAIN OUTCOME MEASUREMENTS To determine whether accessibility of influenza vaccine in the community was increased through pharmacist administration, the proportion of patients immunized in the pharmacy who were not vaccinated the previous year was determined. RESULTS The pharmacist administered 343 doses of vaccine. Two-thirds of the immunized patients (67.9%) reported also being immunized the previous year. These patients were generally older (65 years of age +/- 13) than the previously nonimmunized patients (54 years of age +/- 16). However, 60.8% of the patients not immunized the previous year reported either they would not have gone elsewhere for the immunization (45.3%), or were unsure (25.5%). CONCLUSION The data collected suggest that pharmacist administration of influenza vaccination in a rural community pharmacy increases access and, possibly, immunization rates. This may be especially true among high-risk younger adults who are often overlooked and would not normally have received the immunization.

Organizational predictors of adherence to ambulatory care screening guidelines

Objective. The purpose of this study was to identify hospital organizational characteristics consistently associated with adherence to multiple clinical practice guidelines (CPGs). We examined the relationship between organizational and patient population characteristics and adherence to three screening CPGs implemented throughout the Veterans Health Administration (VHA). Materials and methods. The study included 114 acute care facilities. Three sources of data were used: 1998 American Hospital Association data, VHA External Peer Review Program data for 1998 and 1999, and the 1999 Veterans Satisfaction Survey. Organizational characteristics likely to affect adherence with the CPGs were classified into five conceptual domains (clinical emphasis, operational capacity, patient population, professionalism, and urbanicity). Organizational characteristics were ranked, based on their standardized beta coefficients in bivariate logistic regressions predicting the likelihood of adherence. Within-domain multivariable logistic analyses assessed the robustness of individual predictors of CPG adherence, controlling for other organizational factors within the same domain. Results. Overall, 46 of 48 relationships in the bivariate logistic analyses were significant, and 43 of these remained significant in the within-domain multivariate analyses. The relative rankings of the variables as predictors of CPG adherence within conceptual domains were also quite consistent. Conclusions. Strong evidence was found for the importance of specific organizational factors, including mission, capacity, professionalism, and patient population characteristics that influence CPG adherence in a large multiinstitutional sample involving multiple provider practices. Research and programs to improve adherence to CPGs and other quality improvement activities in hospitals should incorporate these organizational factors.

A Model for Understanding Patient Attribution of Adverse Drug Reaction Symptoms

The study addressed issues surrounding the patients recognition of whether a symptom is drug- or disease-related. Studies have demonstrated that the information the lay population has about illness can be organized into five categories: identity (symptoms and label), cause, time course, consequences, and cure. These elements, termed illness representations or prototypes, facilitate patient interpretation and response to symptoms as they occur. Theoretically, patients may have such a framework for interpretation of symptoms that they considered adverse drug reactions. The purpose of this study was to explore whether an adverse drug reaction (ADR) prototype exists. A self-administered questionnaire was used to elicit the subjects perceptions and awareness of adverse drug reactions. Subjects were also asked to make judgments about severity of ADRs and frequency of particular symptoms as drug-related effects. The study population was a sample of 338 adults visiting a family practice clinic over a four-week period. A majority of the respondents reported personal experience of an ADR and described the event with information which was consistent with the five categories. Subjects who reported ADR experience believed drug reactions occur more frequently and are less severe than those without such experience. Results also indicated that people have knowledge about ADR symptoms that is substantially accurate, and may use a prototype to facilitate identification of symptoms as an adverse effect.

Market factors and the availability of community pharmacies

The purpose of this study was to examine the relationships between the availability of community pharmacies and 4 types of market factors. A composite data set was created that linked, at the county level, data on: (1) type and number of pharmacies; (2) population characteristics; (3) payer variables; (4) health care system factors; and (5) competitive factors. In this exploratory study, secondary data were used to assess the association between the availability of community pharmacies and the influence of market factors. To assess the market influences on availability of community pharmacies, 2 regressions were performed. In 1 model, the number of community pharmacies per 10,000 population was the dependent variable, whereas the dependent variable in the other regression was the proportion of independently owned community pharmacies. The independent variables in each regression were the market factors--population characteristics, payer variables, health care system factors, and competitive variables. Squared terms were included for 8 of 15 market factors to account for nonlinearities in the relationships. Multiple market factors were correlated with both the number of community pharmacies and the proportion of independently owned pharmacies in an area. Several of the relationships were not linear and changed direction within the range of data. Counties with either a low or a high percentage of elderly people had fewer pharmacies and a lower proportion of independently owned pharmacies compared with counties with a moderate percentage of elderly people. Counties that were scarcely or highly rural had fewer community pharmacies but a higher proportion of independently owned pharmacies than counties that were moderately rural. Areas with a greater percentage of the population earning less than the poverty level had more pharmacies, especially independently owned ones. Fewer community pharmacies were found in areas with higher health maintenance organization penetration rates. The number of hospital admissions was positively associated with the number of pharmacies but negatively associated with the proportion of independently owned pharmacies. The availability of community pharmacies varies across the country. In light of the trend toward fewer independently owned pharmacies, potential problems in accessing pharmacy services could develop in certain areas, including those that are highly rural and those with a high percentage of people earning less than the poverty level. Future research and policy issues are identified.

Evaluation of instruments to assess health literacy in Arabic language among Iraqis

BACKGROUND Low health literacy is associated with lack of medical information, less use of preventive measures, low medication adherence rates, high health care costs and high risk of hospitalization. OBJECTIVE The aims were to compare the results of the three health literacy tests, to measure for the first time the health literacy level of Iraqis, to describe the use of standardized health literacy tests, to evaluate reliability and validity of the Arabic versions of these tests, and to investigate whether there is relationship between the participant characteristics and the health literacy level. METHODS A convenience sample of 95 subjects was studied in five community pharmacies in Al-Najaf and Babylon governorates, Iraq. Three health literacy tests, the Single Item Literacy Screener (SILS), the New Vital Sign (NVS) and the Short version of the Test of Functional Health Literacy in Adults (S-TOFHLA), were translated in the Arabic language and administered to the pharmacy customers. RESULTS There were no statistically significant associations between age, gender, education and current education status and NVS score, but there were significant positive associations between the level of education and each one of SILS, New SILS, and S-TOFHLA scores. CONCLUSIONS SILS has one subjective, possibly culturally biased question. Since Iraqis are generally not exposed to reading product labels, the NVS test might be not an accurate measure for them. S-TOFHLA was the most comprehensive test and gave equitable results. The Arabic version of S-TOFHLA can be used to measure health literacy in 22 Arabic speaking countries.

Multi-Institutional Study of Women and Underrepresented Minority Faculty Members in Academic Pharmacy

Objectives. To examine trends in the numbers of women and underrepresented minority (URM) pharmacy faculty members over the last 20 years, and determine factors influencing women faculty members’ pursuit and retention of an academic pharmacy career. Methods. Twenty-year trends in women and URM pharmacy faculty representation were examined. Women faculty members from 9 public colleges and schools of pharmacy were surveyed regarding demographics, job satisfaction, and their academic pharmacy career, and relationships between demographics and satisfaction were analyzed. Results. The number of women faculty members more than doubled between 1989 and 2009 (from 20.7% to 45.5%), while the number of URM pharmacy faculty members increased only slightly over the same time period. One hundred fifteen women faculty members completed the survey instrument and indicated they were generally satisfied with their jobs. The academic rank of professor, being a nonpharmacy practice faculty member, being tenured/tenure track, and having children were associated with significantly lower satisfaction with fringe benefits. Women faculty members who were tempted to leave academia for other pharmacy sectors had significantly lower salary satisfaction and overall job satisfaction, and were more likely to indicate their expectations of academia did not match their experiences (p<0.05). Conclusions. The significant increase in the number of women pharmacy faculty members over the last 20 years may be due to the increased number of female pharmacy graduates and to women faculty members’ satisfaction with their careers. Lessons learned through this multi-institutional study and review may be applicable to initiatives to improve recruitment and retention of URM pharmacy faculty members.

Prescription drug advertising trends: A study of oral hypoglycemics

A content analysis of oral hypoglycemic drug advertisements was performed in selected medical journals published in the United States from 1963 to 1986. The 665 advertisements subsequently examined were studied for certain predetermined parameters in order to indicate trends. The trend results may be summarized as follows. As an extension of prescription drug advertising trends in general, oral hypoglycemic drug advertising showed an increasing length along with a subsequent decrease in the amount of space devoted to the copy portion of the advertisement. They also showed a decrease in the use of statistical information and rarely made references to competitors. Nongender specific, colored advertisements with product and use related appeals have become more common with the passage of time. Although the rationale and purpose behind advertising is unchanged, the format has changed considerably. These changes are primarily due to the enhancement of print technology and to some extent, the changing social environment.

System for Exchanging Information Among Pharmacists in Different Practice Environments

OBJECTIVES A system for exchanging patient information among hospital, long-term-care (LTC), and ambulatory care pharmacies is described, and the influence of that system on pharmacist interventions is reported. METHODS Study sites consisted of three ambulatory care pharmacies, one LTC pharmacy, and one hospital in a small Midwestern city. Meetings were held by clinicians, the investigators, and hospital administrators to plan the information-exchange system. From January through June 1996, patients admitted to the hospital were checked to see if they came from a participating (source) pharmacy; if so, they were randomly assigned to experimental and control groups. The hospital requested preadmission information from the source pharmacy for experimental group patients and did not do so for control patients. After the information arrived, the hospital pharmacists could use it to identify and document drug therapy problems. When an experimental group patient was discharged, the hospital sent information to the appropriate source pharmacy. A total of 156 patients were enrolled in the study. RESULTS Complete information transfer occurred for 75% of experimental group patients. Significantly more experimental group patients than control patients had at least one in-hospital pharmacist intervention recorded. Similarly, in the ambulatory care pharmacies (but not the LTC pharmacy) significantly more interventions per patient were documented for the experimental group. CONCLUSION Hospital and ambulatory care pharmacists documented more interventions for patients about whom information had been supplied than for patients for whom that information had not been supplied. No difference in intervention rates was observed for LTC pharmacists, who were already being supplied information by the LTC facilities about patients discharged from the hospital.

The Path Forward: The Future of Graduate Education in the Pharmaceutical Sciences: The Report of the 2010-2011 Research and Graduate Affairs Committee

According to the Bylaws of the American Association of Colleges of Pharmacy (AACP), the Research and Graduate Affairs Committee (RGAC) shall provide assistance to the Association in developing its research, graduate education, and scholarship agenda. This assistance may include facilitating colleges and schools in formulating and advancing legislative and regulatory initiatives, and nurturing collaborative activities with organizations sharing an interest in issues related to the pharmaceutical sciences. President Rod Carter presented the following charge for the 2010-11 RGAC: Utilizing the report titled “The Path Forward: The Future of Graduate Education in the U.S.”1 from the Commission on the Future of Graduate Education, critically examine the current status of graduate programs in colleges and schools of pharmacy across the spectrum of pharmaceutical sciences and recommend actions by AACP and/or its member colleges and schools that would allow pharmacy graduate programs to flourish in this envisioned future. President Carter further recommended that the Committee consider key past reports, including those of former Research and Graduate Affairs Committees, AACP task forces and council reports. The Committee met in person in Crystal City, Virginia, in October 2010 and communicated subsequently by conference calls and other electronic communication. During the October meeting the committee was fortunate to have Patricia McAllister, Vice President of Government Relations and External Affairs from the Council of Graduate Schools (CGS) and staff for the “Path Forward” report, meet with the Committee to summarize the issues and recommendations contained in this April 2010 analysis of graduate education. The Committee also considered the recently released report from the National Research Council which offers a data-based assessment of doctoral programs in 62 fields in the United States.2