Katherine K. Knapp

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.

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.

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 models 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.

Visions for Required Postgraduate Year 1 Residency Training by 2020: A Comparison of Actual versus Projected Expansion

Study Objective. To explore the feasibility of expanding postgraduate year (PGY) 1 residency training as proposed by the American College of Clinical Pharmacy and American Society of Health‐System Pharmacists (ASHP).

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.

Pharmacists And Technicians Can Enhance Patient Care Even More Once National Policies, Practices, And Priorities Are Aligned

In the past thirty to forty years, new clinically oriented roles have emerged for pharmacists, commensurate with their training and consistent with national goals to improve the safety of, access to, and cost of health care. Pharmacists in all settings spend an increasing portion of their time filling these roles, as evidenced more recently in the community pharmacy sector by the success of pharmacy-based immunization programs and such new venues as retail pharmacy clinics. Pharmacy technicians are also assuming new roles and responsibilities, providing services previously delivered only by pharmacists. However, both trends are hindered by current policy. Of particular concern are inconsistent state-level scope-of-practice laws, the lack of mechanisms to reimburse pharmacists for services provided, the need to recognize pharmacists as health care providers, and the need to establish national standards for the preparation of pharmacy technicians. The optimal deployment of the pharmacy workforce will require the closer alignment of pharmacy practice and policy with each other and with the nations health care priorities.

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.

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.

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.

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.