The achievement of public health services in pharmacy practice: A ...

Research in Social and Administrative Pharmacy 12 (2016) 247–256

Review Article

The achievement of public health services in pharmacy practice: A literature review Mark A. Strand, Ph.D.a,b,*, Jackie Tellers, Pharm.D.(c)a, Alan Patterson, Pharm.D.(c)a, Alex Ross, Pharm.D.(c)a, Laura Palombi, Pharm.D., M.P.H., M.A.T., A.E.-C.c a

Pharmacy Practice Department, College of Health Professions, North Dakota State University, Fargo, ND, USA b School of Pharmacy, College of Health Professions, North Dakota State University, Fargo, ND, USA c University of Minnesota Duluth, Duluth, MN, USA

Abstract Background: It is known that pharmacists are currently contributing to public health; however, the extent of this contribution as reported in the literature has not been examined. Investigating the ways that pharmacists are currently participating in public health is critical for the profession of pharmacy, pharmacy educators, and the public health community. Objectives: The purpose of this study was to determine the reported contributions of pharmacy to each of the ten essential services of public health, and which of the five core competencies of public health were most frequently utilized in those contributions. Methods: A PubMed search was used to extract references that included both the words pharmacy and services in the title or abstract, and the words public health in any part of the document. A total of 247 references were extracted and categorized into the essential services and core competencies. Results: The essential services Inform, Educate, and Empower, and Link to/Provide Care were more frequently represented in the literature, and the core competency of Health Policy and Administration was most frequently utilized. Conclusion: To further contribute to and integrate their contributions within population health, pharmacists must consider ways to strategically contribute to the essential services of public health and seek to increase competency in public health. Ó 2016 Elsevier Inc. All rights reserved. Keywords: Public health; Services; Pharmacy practice; Interprofessional

Disclosure: The authors declare they have no conflicts of interest to disclose. * Corresponding author. Pharmacy Practice Department, College of Health Professions, P.O. Box 6050, North Dakota State University, Fargo, ND 58108-6050, USA. Tel.: þ1 701 231 7497; fax: þ1 701 231 7606. E-mail address: [email protected] (M.A. Strand). 1551-7411/$ - see front matter Ó 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.sapharm.2015.06.004

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Strand et al. / Research in Social and Administrative Pharmacy 12 (2016) 247–256

Introduction The purpose of public health is to improve the health and well-being of a population through disease prevention and health promotion. Attainment of the goal of broader achievement of public health goals depends on a multidisciplinary approach, which includes the profession of pharmacy. Improving population health outcomes in the United States will require reconfiguring how different participants in the health care system contribute to population health.1–3 Public health goals would be more completely and effectively achieved by increased contributions from the discipline of pharmacy, but how to make these contributions and in which areas remains a matter of ongoing discussion.4 Pharmacists are currently contributing to the health of the public through activities that include delivering immunizations, conducting screenings for various acute and chronic disease states and promoting proper drug use; additionally, pharmacists serve as health and prevention educators in a variety of clinical and community settings.5–11 These contributions are, however, made primarily as an extension of pharmacy-based service delivery models and less often in a community-based setting. The extent to which pharmacy and pharmacists deliver public health services as an active participant on an interdisciplinary team dedicated to improved population health outcomes is unclear. However, in the recent decade, the broader health community is drawing pharmacy into public health work to capitalize on the expertise of the profession.10,12 The expansion of pharmacists into public health roles has developed inconsistently, in part because the disciplines of pharmacy and public health are quite distinct, both professionally and historically.13 One way for pharmacy and public health to partner in a way that achieves significantly improved population health outcomes is for the profession of pharmacy to contribute directly to the ten essential services of public health.14–16 Truong and colleagues have previously utilized the ten essential services of public health as a framework with which to evaluate the public health contributions of pharmacy interventions.16 The prospect of a “public health pharmacist” and some of the policy developments needed to realize a specific role called the “public health pharmacist” are currently being promoted.13,17,18 The transition of the profession of pharmacy into the public health realm is evidenced by the increasing

number of special interest groups in the American Association of Colleges of Pharmacy (AACP) that are devoted to public health, as well as the recent inclusion of a pharmacy special interest group in the American Public Health Association (APHA). This research project seeks to build on these developments, by utilizing the ten essential services of public health as a benchmark against which to evaluate the involvement of pharmacists in achieving public health goals.

Materials and methods Search strategy and selection criteria A systematic literature review was conducted using the PubMed search engine and according to the 27 guidelines of the PRISMA statement on methodology for systematic reviews.19 The PubMed database was searched for published references with both the words pharmacy and services in the Title or Abstract, and the words public health in any part of the document. Additional search criteria included USA address (USA[ad]) to ensure that references were relevant to the US population. The search was limited to references published in the English language, and ten years retrospective of Oct 22, 2014. The search yielded 552 results, as shown in Fig. 1. The review protocol is available from the authors upon request. Definitions Public health was defined by the five core competencies of public health as established by the Association of Schools and Programs of Public Health.20 These core competencies are: 1. Epidemiology 2. Biostatistics 3. Social and behavioral science

552 records identified through preliminary PubMed Search

552 records distributed evenly among 4 reviewers

552 records screened for eligibility

305 records excluded for failure to meet inclusion criteria.

247 records included in analyses

Fig. 1. Flow chart for selection of review references.


4. Environmental health science 5. Health policy and administration Public health services were defined by the ten essential public health services (Fig. 2)21: 1. Monitor health status to identify and solve community health problems. 2. Diagnose and investigate health problems and health hazards in the community. 3. Inform, educate, and empower individuals about health concerns. 4. Mobilize community partnerships and action to identify and solve health problems. 5. Develop policies and plans that support individual and community health efforts. 6. Enforce laws and regulations that protect health and ensure safety. 7. Link people to needed personal health services and assure the provision of health care when otherwise unavailable. 8. Assure competent public and personal health care workforce. 9. Evaluate effectiveness, accessibility, and quality of personal and population-based health services. 10. Research for new insights and innovative solutions to health problems. Pharmacy services were defined as clinical and community-based pharmacy practice services that contribute to population health and prevention. This definition of pharmacy services did not exclude hospital-based services. Because pharmacists are the sole practitioners of the practice of pharmacy, there is some overlap in the terms

Fig. 2. The ten essential services of public health.

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“pharmacist” and “pharmacy” in this paper. Individual pharmacists not only contribute to the practice of pharmacy, but also to the public health functions of the profession. Data extraction and exclusion criteria The 552 references initially identified were divided equally into four groups, and randomly assigned to four of the authors to review compared against the inclusion criteria. References were excluded if they were not from journals published in the United States, if they focused on pharmacy education or pharmaceutical science research, and if pharmacy claims data were used to evaluate something other than the research question, such as the effectiveness of a Medicare policy. Other exclusion criteria included Medication Therapy Management (MTM) references which focused on the business side of service delivery, commentaries or proposals regarding the future or current pharmacy practice, and those articles in which the word pharmacy was only listed as one of a number of health care professions. Hospital-based references and references by the same research group addressing the same research project were not excluded from review. References which were found to be difficult to assign were discussed by the four-person review team, and resolved through consensus after joint reassessment. Study quality was not evaluated. Review and analysis The reviewers categorized their assigned references into the ten essential services and the five core competencies. The process included first assigning each reference to the essential service which was being achieved or improved by the work reported in that reference. If a paper was considered to contribute to multiple essential services, portions of one point were assigned to each of the appropriate services, so that each paper was worth a total of one point. The references were then assigned to the core competency of public health which was utilized in the execution of the study or the delivery of the service or intervention reported in the paper. The Statistical Discover Software, JMPÒ, version 11 was used to compare statistical differences in the mean distribution of references between the core competencies and essential services. The mean number of references in each category was compared to the other categories within that group. For instance, the mean number

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Table 1 Distribution of all references within the ten public health essential services and five core competencies. Mean number of references per category is shown in the last column and row. Epidemiology Biostatistics Social and Health Environmental Mean behavioral policy and health services number (n) sciences administration Monitor Diagnose and investigate Inform, educate, and empower people Community partnerships Policies and plans Laws and regulations; safety Link people to needed personal health services Health care workforce Evaluate Research Mean number (n)

5.50 7.00 0.00

6.00 1.00 3.00

0.00 3.00 16.50

4.00 3.00 16.83

1.00 3.00 1.00

3.30 (16.5) 3.40 (17) 7.47 (37.33)

0.50 0.00 0.00 7.00

0.00 0.00 0.00 6.00

1.50 2.00 0.00 6.50

8.33 8.50 9.00 22.33

1.00 2.00 0.00 2.00

2.27 2.50 1.80 8.76

6.00 36.00 10.00 12.40 (124)

0.00 1.00 0.00 1.10 (11)

0.00 8.00 2.00 3.00 (30)

0.00 18.00 3.00 3.70 (37)

of references that were placed in Epidemiology was compared against the mean number of references assigned to Biostatistics, Social and Behavioral Sciences, Health Policy and Administration, and Environmental Health Services for the five core competencies. The same was done for the ten essential public health services. The alpha level for significance was set at 0.10 for all tests.

Results Two public health essential services were more frequently represented in the pharmacy literature than all other eight (Table 1 and Fig. 3). The essential service Evaluate effectiveness, accessibility, and quality of personal and population80 70 60 50 40 30 20 10 0

2.00 10.50 3.00 4.50 (45)

(11.33) (12.5) (9) (43.83)

1.60 (8) 14.70 (73.5) 3.60 (18) (247)

based health services comprised a mean of 14.7 references (P ! 0.001), which represented 29.8% of all the references. The essential service Link people to needed personal health services and assure the provision of health care when otherwise unavailable comprised a mean of 8.76 references (P ! 0.10), which represented 17.7% of all the references. Although not statistically significant, the essential service Inform educate, and empower people about health issues was the third most represented in the literature, with a mean of 7.47 references (P ! 0.198), representing 15.1% of all references. The remaining seven essential services were represented in the literature, but less frequently, and the differences between them were not statistically significant. ***

*

Fig. 3. Frequency of citations within the 10 Essential Public Health Services. ***P ! 0.001, *P ! 0.10.


The public health core competency of Health Policy and Administration was the most frequently represented in the literature with a mean of 12.40 (P ! 0.0001), representing 50.2% of all references (Table 1 and Fig. 4). The other four core competencies were significantly less frequently found in the literature review.

Discussion Pharmacists and pharmacy practice are well positioned to provide and promote public health services. Until now, the extent to which pharmacy fulfills public health services in alignment with the ten essential services of public health, and utilizing the five core competencies of public health, has not been evaluated. This literature review has determined that pharmacy practice, as reported in the primary literature, currently contributes most significantly to achieving two essential public health services and primarily relies on the utilization of one of the five core competencies. These results will be discussed below, with some of the representative references that were reviewed being cited. The public health essential service most represented in the pharmacy literature was evaluate effectiveness, accessibility, and quality of personal and population-based health services. Some of the references included in this essential service included assessment of the appropriateness of lipid management among diabetic patients,22 the ensuring of safe use of medications,23 pharmacy provision as a way to increase access to emergency contraception,24 cost-effectiveness of opioid use for pain management,25 evaluation of the benefit

of pharmacists providing cognitive pharmaceutical services (CPS) in community pharmacies,26 and reports of the effectiveness of weight management services in the community pharmacy.27 The profession of pharmacy is an evidence-based science, so it is expected that significant effort would be spent evaluating the quality of services delivered. For example, the impact of a Medicaid copayment policy to reduce utilization of prescription medications was reported,28 serving as an example of how pharmacists strive to increase access for underserved populations. Quality assurance programs used to track quality related events (QRE) are a standard component of pharmacy practice.29 The profession of pharmacy also faces accreditation requirements, which depend on ratings and rigorous evaluation that may include both reducing medication errors30 and increasing medication adherence.31 One of the methods identified to achieve these quality outcomes is medication reconciliation, a particularly useful practice for geriatric patients.32 The profession of pharmacy is in some cases a business-driven health care discipline, so it is not surprising that evaluating the effectiveness of pharmacy services is highly represented in the literature. Financial analysis of pharmacy services delivered are frequently found in the literature33 and are important in ensuring that services provided are cost-effective. The literature suggests that the essential public health service where pharmacy is most active is to evaluate the effectiveness, accessibility, and quality of the services they provide. The second most frequently delivered public health essential service was link people to needed personal health services and assure the provision

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***

120 100 80 60 40 20 0 Epidemiology

BiostaƟsƟcs

251

Social and behavioral sciences

Health policy and Environmental administraƟon health services

Fig. 4. Frequency of citations within the 5 Core Competencies. ***P ! 0.001.

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of health care when otherwise unavailable. Pharmacists have demonstrated the ability to link patients with needed services in many ways, including but not limited to the use of telepharmacy service provision in remote locations,34 sexually transmitted disease services in poor urban settings,35 and through participation in patient-centered medical homes.36 Pharmacists often have personal interaction with their patients, and are frequently aware of their patients’ financial status. Thus, they are able to utilize this patient access to link people to needed health services in a culturally-sensitive manner. Retail pharmacists are often in a position to identify or utilize programs that provide financial assistance to underserved populations and may also implement innovative programs that bring health care access to people in need.37 Many pharmacists are strategically positioned in a way that allows them to link patients to services external to the pharmacy, such as bringing needed services to a person who injects illicit drugs.38 Pharmacists have also contributed to population health outcomes through pharmacy-based individual patient services such as the Million Hearts campaign.39,40 The profession of pharmacy, and pharmacists specifically, are therefore able to utilize access to the public to connect individuals and populations to the health services they may desperately need, thus making a large contribution to improved population health. The third most frequently delivered public health essential service was inform, educate, and empower people about health issues. Through the Omnibus Budget Reconciliation Act of 1990 (OBRA 0 90), the U.S. Congress charged pharmacists with the responsibility of providing prospective drug use review, patient counseling and the maintenance of proper patient records.41 This deepened the level of pharmacist involvement in patient care. The Medicare prescription drug benefit (Medicare Part D), which began in 2003, put pharmacists in the position of assisting patients as they enrolled in this government program, thus putting increasing responsibility on pharmacists to inform, educate and empower patients about their prescription drug needs.42 More recently, the authorization of vaccination delivery, as well as the preventive medicine requirements of the Affordable Care Act, put pharmacists in the position of directly helping patients to receive the health services they need.43 Pharmacists are quite often available for free medical advice on demand from patients in the community

pharmacy setting, providing their patients with education on chronic disease as well as topics in health promotion that could include vitamin D requirements and bone health, and many other topics.44 Community pharmacists are active in educating patients on behavioral changes, including tobacco cessation, blood pressure control and weight management.45–47 In summary, pharmacists have an active role to play in informing, educating and empowering patients about health issues. While the results above show that pharmacists are very involved in linking patients with needed services, the essential service mobilize community partnerships to identify and solve health problems ranked eighth out of ten. Pharmacists may engage with other health care providers to address individual patient issues, but this may less frequently extend to address population-wide issues. One barrier pharmacists face is lack of access to electronic medical records.48 Increased pharmacist access to electronic medical records would give pharmacists more information about disease groups, and contribute to increased collaboration with other health care providers in the community.49 Consulting pharmacy is another avenue through which pharmacists may become more involved in community partnerships.50 It is likely that some pharmacists and pharmacies are very engaged in community outreach through brown bag seminars or presentations in community organizations. But it appears that the majority have little time to engage in community partnerships or it is not captured in the literature. Pharmacy as a profession may need to consider ways in which they might contribute to population health through mobilizing and participating in community partnerships. An unexpected finding with this study was that the essential service enforce laws and regulations was ranked ninth out of ten. When considering the role of a pharmacist in a community practice, the majority of their day is spent ensuring that prescriptions are written and filled within all parameters of the law. It is possible that this role is so essential to the practice of pharmacy, that it may not be frequently evaluated as a service provided, and thus rarely found in the literature. The role of the pharmacist in patient safety and prevention of prescription drug abuse are other areas where pharmacists participate in enforcing laws and regulations, but may not report it sufficiently to be recognized for their contribution in this critical public health service.


The remaining five essential public health services appeared infrequently in the literature. Monitor health status to identify and solve community health problems is likely difficult to achieve without greater access to electronic medical records and other aggregated health data. Until now, pharmacist privileges have been more focused on treating health problems at the individual level through the recommendation of various over-the-counter medications as well as more advanced clinical pharmacy services; pharmacists have been less focused on roles that include diagnosing and investigating health problems and health hazards in the community. This expanded public health role may be better achieved if pharmacy were more integrated with other health care providers in the community, such as the county health board, or were participating in community health assessments with hospitals and public health officials. Many pharmacists are invested in business bureaus and civic organizations as part of their role in the business community. However, in order to contribute to develop policies and plans that support individual and community health efforts, pharmacists will need to become more engaged inter-professionally and in health associations and organizations beyond those just devoted to pharmacy or the business community. The profession of pharmacy and individual pharmacists could contribute to assuring a competent public and personal health care workforce by providing training for other health professionals in pharmacy-unique areas such as microbial stewardship and drug interaction evaluation, among others. Finally, research for new insights and innovative solutions to health problems is an ongoing challenge and opportunity for pharmacists, with clear benefits to partnering with other health professionals committed to population health improvements. Further involvement in these five essential public health services that are less frequently represented are opportunities for growth and redesign of pharmacy practice. To achieve improved population health outcomes, it is critical that participants in the public health field are competent to deliver the essential services of public health. Public health competence is defined by five core competencies. When considering the distribution of pharmacy practice references in this study, the competency of health policy and administration was the most frequent. This may be a function of the recent implementation of MTM,51 the role of pharmacy in patient safety,23,51 provider status,52 immunizations,53

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avoidance of errors,54 and other policy-related evaluations of services. Furthermore, health policy and administration have been taught in the pharmacy curriculum through courses such as health law and the U.S. health care system for some time, within the framework of social and administrative pharmacy. Therefore it is not surprising that pharmacists bring this expertise to their profession. Social and behavioral sciences was the second most frequently utilized competency in the literature. This competency is required in patient care, through skills such as motivational interviewing and general patient education, so it is something with which practicing pharmacists are comfortable and use daily in their practice. Environmental health science was utilized least frequently. Pharmacy practice highly prioritizes patient care, and environmental health science is quite far removed from patient care. This core competency could see further representation in pharmacy in the future, but currently, the pharmacy literature is poorly represented by environmental health sciences. The core competencies of biostatistics and epidemiology are needed to contribute to several of the essential services, such as monitor health status to identify and solve community health problems; diagnose and investigate health problems and health hazards in the community; evaluate effectiveness, accessibility, and quality of personal and population-based health services; and research for new insights and innovative solutions to health problems. Until now neither biostatistics nor epidemiology have been high priorities in the pharmacy curriculum. Increasingly, health care providers will be evaluated based on aggregate patient outcomes, not on service provision, so the ability to use and interpret aggregated data will be critical. Therefore, the importance of biostatistics and epidemiology will need to be recognized if pharmacy wishes to contribute more significantly to the public health essential services mentioned above and to increase their skill and self-efficacy within the public health team.

Future research That a public health service is not reported in the primary literature to be delivered by pharmacists does not necessarily mean that this service is not being delivered at all. It is possible that it is simply not being documented or reported. A

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review of the non-PubMed literature may capture the broader scope of public health services offered to pharmacists or in which pharmacists are currently engaged. The next phase of this research project will involve surveying practicing pharmacists to determine what public health services they are actually delivering. In future studies, searching for additional terms beyond those used in the current study will allow an even richer view of how the profession of pharmacy fits into the larger realm of public health. This paper serves as a call to action for individuals and institutions engaged in social and administrative pharmacy research, as well as journals and funding agencies, to consider promoting, supporting, publishing and highlighting projects that address gaps reported by this study. Individuals with completed research projects worthy of publication should be encouraged to publish in journals cited in PubMed in an effort to highlight the pharmacy services that protect the public’s health and to broaden the audience for their work. Given the significant changes that have occurred in pharmacy and public health in the decade covered by this study and the known expansion of pharmacists into public health, it is surprising that some of the categories do not have a number of worthy public health projects on which to report. The reason for this lack of reporting may lie in the absence of studies done at the level of peer-review, or a reluctance of journals to accept and publish such work. Barriers to the completion, submission and publication of such studies should be identified and remedied.

Limitations There are several limitations to this study. Only one search engine was used, which may have excluded references that were within the specified search criteria, but were not necessarily present in this data base. However, PubMed is a reasonable search engine as it thoroughly includes the literature in the United States, which was the focus of this literature search. The term “pharmacy” was used in this search is as it is more broad and inclusive. Using the term “pharmacist” instead may have excluded certain articles that were vital to the study findings. Other search criteria were considered, however, the results of these criteria were not in alignment with the research goals or within the scope of study capability. The choice of terms for this search

unfortunately left out other related terms, including “cultural competency” and “disparity,” which excluded some references that would have added to the depth of this search. This limitation serves as an opportunity for others to build off of the current research. All references used in the search are available upon request. Although objective criteria were used, it is not possible to rule out selection bias resulting from the method used to select references. The references were divided among four reviewers, with each reviewer only reviewing their own references. This may have resulted in misclassification bias. The four reviewers discussed their process in order to reconcile each person’s criteria, but some judgment discrepancy may have occurred. This introduced subjectivity into the sorting process. Pharmacy is a diverse discipline. Generalizing all aspects of the profession into one category does not do justice to the multiplicity of ways in which pharmacy operates. For example, pharmacists employed by the Food and Drug Administration, or the Centers for Disease Control and Prevention, or the Indian Health Service, would find themselves matriculating into the core of public health service. Therefore some of what is reported here, or the generalizations made, may not apply to certain sectors of the pharmacy profession. One dimension of this literature review, pharmacy education, was removed from analysis in order to narrow the findings to current pharmacy practice, not pharmacy education. We were interested in understanding the contemporary status of public health with respect to practicing pharmacists, not how pharmacists are being educated. Having said that, if the basic premise of this study holds, it has significant implications for the redesign of pharmacy education.

Conclusion The future of pharmacy lies in expanding the scope of practice for pharmacists and in increasing service opportunities for pharmacists in community health. This includes contributing to the achievement of population health objectives, as described in the ten essential services of public health. Confidence in the ability of pharmacists to deliver public health services needs to be raised among both pharmacists and the public.4 In order for pharmacy practice to develop in this manner in the future, pharmacy practice education needs to empower pharmacy students to


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