David A. Mott

Exploring generic drug use behavior: The role of prescribers and pharmacists in the opportunity for generic drug use and generic substitution

Objectives. The first objective of this study was to examine the prevalence of prescriptions that offer the opportunity for generic drug use (a prescription for a multisource drug product). The second objective was to examine the prevalence of generic drug use by examining the rate of generic drug prescribing for multisource drug products and the rate of generic substitution by pharmacists. The last objective was to examine the association of prescriber, pharmacist, insurance, patient, and drug variables with the prescribing of drugs allowing the opportunity for generic drug use and generic substitution. Research Design. A database containing information for 6380 prescription orders was used for analysis. Measures. Random-effects logistic regression panel data estimation was used to examine the association of independent variables with whether a prescription allowed the opportunity for generic drug use and whether a prescription allowing generic drug use and written using the brand name was generically substituted. Results. The opportunity for generic drug use existed for 63% of prescription orders. Prescriptions covered by private third party and indemnity insurance were 33% (97.5% CI, 0.56–0.80), and 21% (97.5% CI, 0.62–0.98), less likely, respectively, to allow the opportunity for generic drug use relative to uninsured prescriptions. Unobserved prescriber characteristics accounted for 23% (95% CI, 0.14–0.34) of the variance in the opportunity for generic drug use. Pharmacists generically substituted 83.8% of prescriptions that could be generically substituted. Prescriptions covered by Medicaid were 4.57 (97.5% CI, 2.83–7.39), 5.15 (97.5% CI, 3.25–8.13), and 4.85 (97.5% CI, 2.83–8.17) times more likely, respectively, to be generically substituted relative to uninsured, private third party and indemnity prescriptions. Unobserved characteristics of pharmacists accounted for 44% (95% CI, 0.33–0.55) of the variance in the occurrence of generic substitution. Conclusions. Pharmacists play a large and important role in generic drug use and efforts to increase generic drug use directed at pharmacists should be maintained. Additional efforts to increase generic drug use likely should be targeted at prescribers.

Evaluation of Community Pharmacy Service Mix: Evidence from the 2004 National Pharmacist Workforce Study

OBJECTIVES To describe the mix of pharmacy services being offered in different types of community pharmacy practices and to identify factors associated with a community pharmacy offering pharmacy services. DESIGN Cross-sectional study. SETTING Community pharmacies (independent, chain, mass merchandiser, and supermarket pharmacies). PARTICIPANTS Pharmacists practicing full-time or part-time who worked in community pharmacies and responded to the 2004 National Pharmacist Workforce Survey. INTERVENTION Mailed survey from the 2004 National Pharmacist Workforce Survey, which included core content questions for all sampled pharmacists and supplemental surveys that included workplace questions for a selected subsample of pharmacists. MAIN OUTCOME MEASURES Type and frequency of pharmacy services being offered in a community pharmacy, including dispensing and product-related services (e.g., specialty compounding), and pharmacist care services (e.g., immunizations, smoking cessation, health screening, medication therapy management, wellness screening, nutritional support, and disease management services). RESULTS Four pharmacist care services were reported as being offered at more than 10% of community pharmacy practices: immunizations, smoking cessation, health screening, and diabetes management. The number of pharmacist care services offered at a community pharmacy was positively associated with having at least three pharmacists on duty, innovativeness of the pharmacy, status as an independent pharmacy, and status as a supermarket pharmacy. More than one half of the community pharmacy practices did not offer any of the eight pharmacist care services included in a pharmacy service index. CONCLUSION Pharmacy services were reported at relatively few community pharmacies, and were associated with pharmacy innovativeness, pharmacist staffing levels, and pharmacy setting. Some community pharmacies are offering pharmacy services as part of their business strategy, while others are dedicated to dispensing services. Continued study of pharmacy service availability in community pharmacies is needed to improve our understanding of our capacity to deliver such services, including medication therapy management services.

A modified model of pharmacists' job stress: the role of organizational, extra-role, and individual factors on work-related outcomes.

BACKGROUND Understanding the effects of job stress continues to be a concern for health-care providers as workload and personnel needs increase. OBJECTIVE The overall objective of this study was to test a direct effects model of job stress that examines the characteristics of the organizational environment (interpersonal interactions, environmental aspects, the level of compensation and advancement, role stress, and availability of alternative jobs); extra-role factors (work-home conflict); job stress; individual factors (career commitment); and the work-related psychological outcomes of job satisfaction, organizational commitment, and job turnover intention. METHODS A cross-sectional mail survey was sent to a nationwide random sample of 4895 licensed pharmacists in the United States. Previously validated summated Likert-type scales measured each of the study variables. Data analyses included descriptive statistics, and exploratory and confirmatory factor analyses. Structural equation modeling was used to estimate the final model. RESULTS A response rate of 46% was achieved. Psychometric analyses indicated acceptable reliability and validity. The study model fit the data well (CFI[comparative fit index] = 0.90, RMSEA[root mean square error of approximation] = 0.05). Organizational factors in the form of role overload (standardized beta = 0.45) and conflict (0.31) and ease of finding a job with better interpersonal characteristics (0.26) had the largest effects on job stress. Interpersonal characteristics were also one of the strongest predictors of job satisfaction (-0.61) and organizational commitment (-0.70). Work-home conflict directly affected job turnover intention (0.11) and career commitment (-0.16). Other significant, but sometimes, opposite direct effects were found. Job satisfaction and organizational commitment directly affected job turnover intention. CONCLUSIONS Given the increased demand for pharmacy services, health-care organizations will benefit from increasing positive and reducing negative work outcomes. Increased focus on enhancing interpersonal interactions, developing commitment to the profession, and greater consideration of nonwork factors could help pharmacists better manage their work environments. Future research should continue to refine these models to further enhance our understanding of the effects of job stress in the health professional workplace.

A qualitative assessment of a community pharmacy cognitive pharmaceutical services program, using a work system approach

BACKGROUND Although lack of time, trained personnel, and reimbursement have been identified as barriers to pharmacists providing cognitive pharmaceutical services (CPS) in community pharmacies, the underlying contributing factors of these barriers have not been explored. One approach to better understand barriers and facilitators to providing CPS is to use a work system approach to examine different components of a work system and how the components may impact care processes. OBJECTIVES The goals of this study were to identify and describe pharmacy work system characteristics that pharmacists identified and changed to provide CPS in a demonstration program. METHODS A qualitative approach was used for data collection. A purposive sample of 8 pharmacists at 6 community pharmacies participating in a demonstration program was selected to be interviewed. Each semistructured interview was audio recorded and transcribed, and the text was analyzed in a descriptive and interpretive manner by 3 analysts. Themes were identified in the text and aligned with 1 of 5 components of the Systems Engineering Initiative for Patient Safety (SEIPS) work system model (organization, tasks, tools/technology, people, and environment). RESULTS A total of 21 themes were identified from the interviews, and 7 themes were identified across all 6 interviews. The organization component of the SEIPS model contained the most (n=10) themes. Numerous factors within a pharmacy work system appear important to enable pharmacists to provide CPS. Leadership and foresight by the organization to implement processes (communication, coordination, planning, etc.) to facilitate providing CPS was a key finding across the interviews. Expanding technician responsibilities was reported to be essential for successfully implementing CPS. CONCLUSIONS To be successful in providing CPS, pharmacists must be cognizant of the different components of the pharmacy work system and how these components influence providing CPS.

Pharmacist Participation in the Workforce: 1990, 2000, and 2004

OBJECTIVE To examine work variables for licensed pharmacists for 1990, 2000, and 2004. DESIGN Three cross-sectional, descriptive studies. SETTING United States. PARTICIPANTS Licensed pharmacists: 1,623 in 1990; 2,092 in 2000; and 1,564 in 2004. These numbers of usable responses to the three respective surveys represented 54.0%, 42.7%, and 33.8% of those receiving surveys. INTERVENTION Mailed survey from the 2004 National Pharmacist Workforce Survey; data from the national studies of the pharmacist workforce conducted in 1990 and 2000. MAIN OUTCOME MEASURES Characteristics of pharmacists; work setting, work position and age distribution of actively practicing pharmacists. Work status of licensed pharmacists; proportion actively practicing pharmacy. Proportion of pharmacists working part-time overall and by age group, weekly hours worked by actively practicing pharmacists, and full-time equivalents (FTEs) by age group. Proportion of pharmacists with secondary pharmacy employment; work setting, hours worked, and weeks worked in secondary pharmacy employment. RESULTS In each year studied, more than 86% of licensed pharmacists were actively practicing pharmacy. In 2004, the largest proportion of actively practicing women pharmacists was between the ages of 31 and 45, and the largest proportion of actively practicing men pharmacists was between the ages of 46 and 60. Across the survey years, the proportion of all actively practicing pharmacists working part-time increased, and the proportion of women working part-time was at least double that of men except in 2004. In 2004, the FTE contribution for women was 0.81 and 0.91 for men. CONCLUSION The decrease in FTE contributions by all pharmacists and the aging of the male pharmacist population raise concerns about the adequacy of current and future pharmacist supply. As the demand for pharmacists continues to evolve, pharmacy must continue to monitor the pharmacist workforce to show how pharmacists react to changes to better inform projections of the pharmacist workforce.

Organizational factors influencing pharmacy practice change.

BACKGROUND Some pharmacists have changed the focus of their practice from solely dispensing. Emerging services they have added include medication therapy management and other pharmacy services. OBJECTIVE To assess the effect of entrepreneurial orientation, resource adequacy, and pharmacy staffing on pharmacy practice change. METHODS A total of 1847 licensed U.S. pharmacists received 2 mail surveys as part of a larger national pharmacist survey. The core survey collected information about practice setting, prescription volume, and staffing. The supplemental survey assessed how the pharmacy had changed over the past 2 years to enable the delivery of pharmacy services. The amount of change was assessed by 12 items, which were summed to provide an aggregate change index. Five variables from organizational change literature were assessed as influences on practice change: proactiveness, risk taking, autonomy, work ethic, and adequacy of resources. In addition, the associations of pharmacist and technician staffing with practice change were assessed. A multiple linear regression analysis was performed with the aggregate change index as the dependent variable and the 7 potential influences on change as the independent variables. RESULTS Four hundred usable surveys were analyzed. At least some level of practice change was reported in 60% of pharmacies surveyed. The linear regression analysis of the model was significant (P<.001) with an R-square value of 0.276. Significant influences on change were 2 dimensions of entrepreneurial orientation-proactiveness and autonomy-as well as adequacy of resources and pharmacy technician staffing. CONCLUSIONS Many pharmacies reported that some aspects of their practice have changed, such as collecting patient information and documenting care. Few reported changes in asking patients to pay for pharmacy services. These findings support previous results, which show that the capacity for organizational change can be augmented by increasing proactiveness, autonomy among employees, and the availability of adequate and appropriate resources.

collaborations to facilitate success of community pharmacy practice-based research networks

OBJECTIVE To describe the nature of the collaborations between academia and practitioners in two community pharmacy practice-based research networks (PBRNs). SETTING Community pharmacy practice sites owned by two pharmacy chain corporations that have cooperated with two pharmacy schools for up to 10 years in research efforts. PRACTICE DESCRIPTION A PBRN is a group of community pharmacy practice sites that are affiliated with an academic institution(s) that investigate questions related to community practice. PRACTICE INNOVATION A model of collaboration between academia and community pharmacy practice to enhance PBRNs. Collaborators in academia include practice and science faculty. Collaborators in community pharmacy practice include practitioners and practice-site decision makers. MAIN OUTCOME MEASURES The role of each collaborator in the PBRN, suggestions for developing and maintaining collaborations among PBRN members, strategies to identify collaborators and to expand a PBRN, and the value to each collaborator of participating in a PBRN. RESULTS Academically based pharmacy faculty members connect with practice sites and listen to the needs of practitioners in an effort to design research that will solve practice problems. Practitioners and practice-site decision makers need to understand the role of research in solving projects, propose problems to be addressed and methods to address them, and become committed to completing the research. Building partnerships among collaborators is an important step in developing and maintaining the pharmacy-based PBRN. For faculty members, the value is connecting with community practice, helping to solve problems, and sharing results with the pharmacy community. For practitioners, the value of collaboration centers on improving practice and expanding their professional role. CONCLUSION The involvement of community pharmacy sites with PBRNs has the potential to be a driving force in practice innovation, improving patient care and professional satisfaction.

A national survey of U.S. pharmacists in 2000: Assessing nonresponse bias of a survey methodology

The first objective of this study was to assess the existence of nonresponse bias to a national survey of licensed pharmacists conducted in 2000. Three methods were used to assess nonresponse bias. The second objective of the study was to examine reasons why sampled licensed pharmacists did not respond to the national survey of licensed pharmacists. We used data from 2204 respondents to a national survey of pharmacists and from 521 respondents to a survey of nonrespondents to the national survey. We made comparisons between respondents for 5 variables: employment status, gender, age, highest academic degree, and year of initial licensure. Chi-square tests were used to examine differences in the 5 variables between respondents to the first mailing and second mailing of the survey, early and late respondents to the survey, and respondents to the survey and respondents to the nonrespondent survey. There were no significant differences between first mailing and second mailing respondents, but there were differences in each variable except year of licensure between early and late respondents. These differences likely were due to regional bias possibly related to differences in mailing times. There were differences between respondents and nonrespondents in terms of employment status and year of licensure. The main reasons for not responding to the survey were that it was too long or that it was too intrusive. Overall, the survey methodology resulted in a valid sample of licensed pharmacists. Nonresponse bias should be assessed by surveying nonrespondents. Future surveys of pharmacists should consider the length of the survey and the address where it is sent.

Practice Characteristics of Bachelor of Science and Doctor of Pharmacy Degreed Pharmacists Based on the 2009 National Workforce Survey

Objective. To compare practice settings and activities of pharmacists with bachelor of science (BS) in pharmacy and doctor of pharmacy (PharmD) degrees. Methods. Data from the 2009 National Pharmacist Workforce Survey instrument were analyzed. Multivariate regression was used to examine the association of the PharmD degree with time spent in dispensing and patient care. Results. The survey response rate by pharmacists was 52%, and 562 usable responses met our inclusion criteria. Sixty-three percent of BS and 39% of PharmD pharmacists were employed in community pharmacies, compared with 21% of BS and 38% of PharmD pharmacists employed in hospital pharmacy settings. Practicing in a community setting had the strongest influence on time spent in dispensing and time spent in patient care. Among respondents with PharmD degrees, a residency was associated with less time in dispensing and more time in patient care. Conclusion. Time spent in dispensing and patient care were influenced more by practice setting than by educational degree and residency training.

Demand for a Medicare Prescription Drug Benefit: Exploring Consumer Preferences under a Managed Competition Framework

Several proposals for adding a prescription drug benefit to the Medicare program rely on consumer choice and market forces to promote efficiency. However, little information exists regarding: 1) the extent of price sensitivity for such plans among Medicare beneficiaries, or 2) the extent to which drug-only insurance plans using various cost-control mechanisms might experience adverse selection. Using data from a survey of elderly Wisconsin residents regarding their likely choices from a menu of hypothetical drug plans, we show that respondents are likely to be price sensitive with respect to both premiums and out-of-pocket costs but that selection problems may arise in these markets. Outside intervention may be necessary to ensure the feasibility of a market-based approach to a Medicare drug benefit.