Study population

The U.S. population density is estimated at 80 persons/square mile. With a population density of 52.7 people per square mile, Iowa’s population is more urban than rural, with 61% living in urban areas. Iowa has an estimated population of 3,123,899 people (US Census Bureau, 2015), making it the 30^th most populated state in the country.

North Dakota is highly rural, with an estimated population of 756,927 people (US Census Bureau, 2015). North Dakota has only 9 persons/square mile and has more than 50% (27 of 53) of its counties categorized by the US Health Resources and Services Administration (HRSA) as “frontier counties” (6 persons or fewer per square mile).

While Iowa is more populous than North Dakota, the mixture of urban and rural areas is similar to those throughout the United States. The practice of pharmacy in North Dakota has been progressive but is unique in being one of the few states which limit pharmacy ownership to independent pharmacists, thus limiting the impact of chain pharmacies.¹⁶ Some of Iowa’s research programs include the development of innovative practice models founded on evidence-based research and assessment of quality improvements in patient care resulting from medication therapy management services.¹⁷,¹⁸

The sparse population in both states creates significant challenges in access and delivery of health services, including pharmacy services to remote locations. In rural areas, many communities have lost healthcare providers, including physicians, nurses, and pharmacists, because of their small populations. A 2004 Institute of Medicine study reported medical access problems in rural areas due to hospital and pharmacy closures, greater distance to travel for physician services, and limited if any choice of providers.¹⁹ Many rural counties have no primary care providers and typically there are fewer specialist physicians in these areas. Although rural areas offer opportunities for health providers, most physicians, nurse practitioners, and physician assistants generally practice in urban rather than rural areas.¹⁹ Recent reports indicate that a shortage of pharmacists exists in some practice areas, primarily in rural areas throughout the United States, and it is particularly acute in North Dakota.²⁰,²¹,²²,²³ Pharmacy owners in rural areas often cannot find pharmacists to fill available positions because recent graduates either have not been interested or have pursued other opportunities.²³ One of the strategies to resolve the shortage of pharmacy services in rural North Dakota is the Telepharmacy Project, that has increased pharmacy services in limited access communities.²⁴,²⁵,²⁶,²⁷ In an attempt to improve public services, both Iowa and North Dakota have developed relatively new MPH public health training programs.²⁸,²⁹

While the workforce and patient care situation is probably similar to other states, there are factors unique to North Dakota. State law requires each community pharmacy to have a North Dakota-licensed pharmacist owning 51% of the pharmacy, which has restricted the number of chain stores and is an advantage to independent community pharmacy owners.²³,²⁶ Given the unique situation, there is a need to collect pharmacist workforce efforts in public health and patient care information both in Iowa and North Dakota and compare that to regional and national information.

Survey design

This survey collected data from practicing pharmacists in three areas: 1) public health services currently being provided, 2) level of involvement in the 10 essential services of public health, and 3) barriers to delivering public health services.

The first area surveyed was the critical services that pharmacy is providing which contribute to improved population health. In recent decades, pharmacy practice has significantly changed with the implementation of Omnibus Reconciliation Act of 1990 (OBRA ‘90) and Medicare Part D. OBRA ’90 required that pharmacists provide prospective drug reviews, provide an offer to counsel Medicaid patients, and maintain patient records. Medicare Part D required that MTM be conducted by a pharmacist or another healthcare professional for patients taking multiple chronic disease medications. Both programs have opened the door for numerous pharmacist-mediated opportunities. Some are being utilized, many are not. In more recent times, the Patient Protection and Affordable Care Act of 2010 has set up the opportunity for more healthcare professionals to contribute to improved population-based health outcomes. Frequency of delivery of 18 common service areas was surveyed including: immunizations, disease state management, tobacco cessation, medication therapy management, transitions of care, pain management counseling, prescription medication take-back programs, weight control, preventive screenings, chronic care management, and pain management. Respondents were requested to respond to the question, “How many times in the past 30 days have you delivered the following services in your practice setting?” Response options were: 0, 1, 2, 3, 4, and 5 or more days. Therefore the values in this domain represent the mean number of times delivering the stated service in the last 30 days, with five representing everything from 5 to 30 days.

The second area surveyed was the extent to which pharmacists are contributing to the 10 essential services of public health.¹¹ These services are: evaluate effectiveness, accessibility, and quality of personal and population-based health services; link people to needed personal health services and assure the provision of health care when otherwise unavailable; inform, educate, and empower people about health issues; research for new insights and innovative solutions to health problems; diagnose and investigate health problems and health hazards in the community; monitor health status to identify and solve community health problems; develop policies and plans that support individual and community health efforts; mobilize community partnerships and action to identify and solve health problems; enforce laws and regulations that protect health and ensure safety; and assure competent public and personal healthcare workforce. Response options used a Likert scale with 0 to 5, representing “never” to “always”.

The third area addressed the barriers that exist that may keep some pharmacists from delivering public health services. These barriers need to be understood before the services can be expanded. Therefore, this survey also explored perceived barriers pharmacists may have about delivering public health services. A recent publication reported that pharmacists’ confidence in providing public health services was average to low.¹² Ten barriers were listed by the investigators including: lack of an adequate counseling space, lack of demand, lack of time, and others. Response options used a Likert scale from 0 to 5, representing “not at all problematic” to “extremely problematic”.

This survey was adapted from a pharmaceutical care study conducted in North Dakota and was modified to include items regarding respondents’ socio-demographics, public health services, and essential services.¹⁵ A 48-item survey was created for this research project, comprised of 18 public health service areas, 10 essential services, 11 barriers, and 12 demographic items.¹⁵,³⁰ The survey instrument was created by modifying items in two previously used instruments, thus preserving the validity and reliability of the instrument created. The Assessment, Development, Assurance Pharmacist’s Tool (ADAPT) was used as a model for how to operationalize the public health ten essential services within pharmacy terminology.³⁰ The pharmaceutical care survey was used to guide the design of pharmacists’ self-evaluation of the frequency of and perceived barriers to service delivery.¹⁵ Barriers to care and demographic characteristics were adapted from previous surveys that were based on validated measures.¹⁵,³⁰,³¹ The survey instrument was further validated by operationalizing the items precisely by cross-checking the items against other pharmacy surveys and pilot-testing on a small group of pharmacists (n=7). These pharmacists were chosen based on their practice location and willingness to pilot the survey. Five pharmacists from within the survey states and with varying years of experience were chosen to navigate the entire survey. Two pharmacists outside of the survey states/provinces were chosen to ensure disqualification processes were correctly enabled.

Survey administration

The study protocol and procedures were reviewed and approved by the North Dakota State University Institutional Review Board. The respondents were not identified, but respondents wishing to participate in the lottery (incentive to participate was a raffle held for an iPad mini) could opt-in by providing their email address. For data analysis purposes, the respondents were undisclosed by the researchers in the analysis or reports.

This study was performed among pharmacists in District V of NABP/AACP who met eligibility criteria (i.e., registered pharmacist who lived and practiced pharmacy in the state). Our goal was to obtain at least 150 respondents from each state for a total of 450 respondents; this number exceeded the number of 351 which was calculated by power analysis as the number needed to detect significance at the 0.05 level among a population of 4000 eligible respondents. Rural pharmacists (nonmetropolitan) were defined as those working in areas with populations under 49,999. Urban pharmacists (metropolitan) were defined as those working in areas with populations of 50,000 or more, which included North Dakota’s largest metropolitan area of Fargo/West Fargo (population about 120,000), followed by Bismarck, Minot, and Grand Forks. The largest metropolitan area in Iowa is Des Moines (about 210,000), followed by Cedar Rapids, Davenport, Sioux City, Iowa City, Waterloo, Council Bluffs, Ames, West Des Moines, Dubuque, and Ankeny (all over 50,000 in population).

The investigators used a modified Total Design Method that has been used successfully in mail surveys to obtain a sound response rate.³² The Total Design Method is based on sound research principles and confirms that when attention is paid to administrative detail, high response rates can be achieved from non-responsive subjects, and a modification of this approach was used to ensure the best possible response rate.³³ The 2015 mailing list was obtained from the North Dakota Board of Pharmacy. The Iowa Board of Pharmacy agreed to send out the survey themselves and follow the same procedures as that done in North Dakota. In September 2015, the survey was emailed to all pharmacists registered and living in Iowa and North Dakota. The survey was distributed by e-mail invitation two more times at 2 and 4 weeks.

Data analysis

Qualtrics (Qualtrics LLC, Provo, Utah) was used to compile the data collection from the on-line survey. Open-ended questions were tabulated by the common themes. The themes were reviewed and tabulated by the lead investigator (MS) along with the pharmacy students (GA, AC).

Mean values were compared using the chi-square test for the demographic variables and the ANOVA F-test for public health services and essential public health services. Data were sorted by rural versus urban, based on respondents’ self-reported place of employment. The equality of variance test was used for the two factors variance. A p-value of <0.05 means the variances are equal, so the pooled T test p-value and confidence interval values were used. A p-value of >0.05 means the variances are not equal, so the Student t-tests were conducted on rural versus urban areas using the Satterthwaite’s correction.³⁴ An alpha level of 0.05 was used for all tests of significance.

Respondent characteristics

Chain store (28.2%) and independent pharmacists (27.0%) were similar in distribution, and this is unlike the national distribution of 15.1% independent and 41.3% chain stores in 2004.³⁵ A total of 34 chain pharmacies were reported in North Dakota, including six CVS stores and 28 Thrifty White stores (which includes five telepharmacies). Hence, the number of chain pharmacists working in North Dakota is fewer than in the state of Iowa.¹⁵,²³ These findings were expected since the 51% ownership law in North Dakota has restricted the number of chain pharmacies and hospital pharmacies with an outpatient business. North Dakota also has a higher proportion of rural pharmacies than Iowa. Rural pharmacists in this study report lack of access to additional training as a barrier to delivering public health services more frequently than urban pharmacists.

Increased training offered in urban areas, along with greater access to ancillary services, may also explain the higher rate of lab test and diagnostic ordering in urban areas. While the findings show this trend, there are some rural pharmacists who have developed outstanding patient care and public health programs. For instance, the Indian Health Service (IHS) provides innovation in the provision of chronic disease programs.³⁶ While the IHS is a federal agency, it is an exemplar for innovations for pharmacy in community health centers and other ambulatory care settings.³⁷,³⁸ Pharmacies in many settings in both North Dakota and Iowa have benefitted from a significant number of IHS settings in both states. Pharmacy leaders in both states encourage their students to apply IHS innovations in other ambulatory care settings such as community health centers and managed health care settings.

Additionally, pharmacists in rural areas in Iowa and North Dakota have conducted medication therapy management (MTM) and diabetic programs. These findings should be interpreted as primarily due to differences in practice setting. Since rural areas tend to have more independent pharmacists and urban areas more chain pharmacists, this may be due to a lower volume of prescriptions, therefore providing the pharmacist with more time to pursue public health opportunities.

Public health services

In total, the most frequently reported public health service was disease state management followed by MTM, transition of care from inpatient to outpatient, safe medication disposal, pain management counseling, immunizations, and tobacco cessation counseling. In North Dakota, the “About the Patient”, program has expanded pharmacist involvement in chronic disease management in the areas of diabetes and pain management services.³⁹ Some regions in North Dakota contract with workmen’s compensation programs for pharmacists to provide pain management counseling.⁴⁰,⁴¹ Formal public health programs, such as the dual degree PharmD/MPH program at North Dakota State University, create the opportunity for increased training in the delivery of public health services.⁴² Gortney and colleagues reported on the prevalence of PharmD/MPH dual degree programs nationwide, and this report suggested that more pharmacy students are pursuing and have additional exposure to public health than in traditional pharmacy programs.⁴² Public health education has been enhanced in colleges/schools of pharmacy, in accordance with CAPE Outcomes, and should result in greater exposure in both didactic and experiential pharmacy student training.⁴³ However, this training needs to be combined with recognition of provider status for pharmacists and reimbursement models from insurers.

Services reported more frequently in rural areas than urban areas were disease state management, MTM, immunizations, tobacco cessation counseling, and prescription medication take-back programs. Nationwide, pharmacists provide a significant role in providing immunizations. However, our findings suggest that this role is performed by a relatively small proportion of pharmacists. Similarly, while a number of pharmacists are involved in disease state management programs and MTM programs, this is an area that has considerable room for expansion, particularly in rural areas. Pharmacists are well positioned to provide public health services in all pharmacy settings with particular emphasis in ambulatory settings including the community pharmacy settings.⁴⁴ Pharmacists in rural settings, particularly independent community and chain store pharmacists, were more likely to provide these services than did the hospital pharmacists. Rural pharmacists do lab testing and diagnostic ordering less frequently than their urban counterparts, largely due to low volume that does not justify the investment in testing equipment.

The relatively low rate of the pharmacist delivery of diabetes, dyslipidemia, HIV, and hepatitis C screenings may be a function of lack of need in the community, inadequate training, or a lack of significant reimbursement by insurers for these services. There is great need in Iowa and North Dakota for pharmacy programs to provide certification in these specialty areas, such as those being offered by pharmacy organizations, including the APhA training in diabetes disease state management and immunizations.⁴⁵ North Dakota has developed similar training programs for pharmacists, such as the “About the Patient” program for Diabetes Management and for Pain Management.³⁹,⁴⁰ However, the relatively infrequent involvement in counseling for tobacco cessation, mental health, and weight control may be a function of inadequate training, coupled with a reluctance to engage with patients on these sensitive issues unless the patient actively seeks out this type of counseling support. It is also the case that in some independent and chain pharmacies, screenings are “events” to be held occasionally, and therefore are not perceived as a part of daily operations.

This study has also shown that pharmacists are most inclined to contribute to the public’s health in areas focusing on medications. This is the pharmacist’s specialty, so it is reasonable to focus the pharmacist contributions on disease state management, MTM, immunizations, and prescription medication take-back programs, which all focus on medications. Conversely, screening for conditions such as diabetes, hypertension, hyperlipidemia, HIV, and hepatitis C, are still prior to the start of medication use, and thus do not capitalize on the primary expertise of the pharmacist, which is medication use.

Essential public health services

Pharmacists in rural areas of Iowa and North Dakota more frequently reported providing public health essential services, than in urban areas, and these included: refer people to other healthcare professionals, evaluate the services the pharmacy provides, partner with the community to identify and help solve health problems, and conduct needs assessments to identify health risks in my community. For example, a rural pharmacy in North Dakota reported collaborating with the local hospital to create a discharge plan, complete with prescribing privileges, in order to formally transfer medication management for the newly discharged patient over to the community pharmacist. Overall, the most commonly reported service was to comply with pharmacy laws and regulations, followed by educate people about health issues, participate in training programs, refer people to other healthcare professionals, and review the services offered in my practice to improve future initiatives. Pharmacists practicing in independent community pharmacies in this sample were more likely than chain pharmacists to provide these services.

Opportunities for pharmacists to contribute to rural workforce shortages

Rural areas generally have fewer, and often shortages of, healthcare professionals. This can have far-reaching impacts on the health of rural communities.⁴⁶ Iowa currently has a 31.6% unmet need for primary care in Health Professional Shortage Areas (HPSAs), and North Dakota has a 60.8% unmet need.⁴⁷ Due to their accessibility and expanding public health roles, pharmacists could be of great benefit in helping to improve community health outcomes amidst shortages.⁴⁸ It has been identified in the literature and in this study that pharmacists are in need of forming partnerships with communities as well as other healthcare providers and organizations in order to maximize their contributions.⁴⁸,⁴⁹ For example, in this study working with other healthcare providers was ranked as the seventh most frequently delivered essential public health service out of the 10 services, while partnering with the community was ranked last. With the formation of partnerships, pharmacists could broaden the reach of public health and help close the healthcare workforce shortage gaps.⁵⁰

Barriers and recommendations for rural areas

Lack of time and lack of reimbursement were the most commonly reported barriers to implementing public health into pharmacy practice. Five items, lack of time, lack of patient demand for services, lack of personnel, lack of confidence in my ability, and lack of mentors or role models, were more commonly perceived as barriers in rural areas than in urban areas (p<0.05). This is an opportunity for state pharmacy associations and the boards of pharmacy to collaborate with colleges of pharmacy to identify training needs of rural pharmacists and to establish training programs with the goal of increasing their skill and confidence in delivering public health services, and thus improve the health of populations in rural communities. Furthermore, specific training could be developed to showcase the unique opportunities available in the rural setting. Preceptors could then highlight these opportunities with students on rural rotations, with the hope of retaining these students to practice in rural settings. There is also a movement in pharmacy toward conferring provider status on pharmacists beyond what is currently experienced through collaborative practice agreements.⁵¹ This would allow pharmacists to practice at the top of their scope of practice, which can only help to improve population health outcomes.⁴⁹

Future research.

Our data from Iowa and North Dakota suggest that independent pharmacies have higher involvement than chain pharmacies in the areas of disease state management, MTM services, and tobacco cessation counseling. However, these findings raised questions that have not yet been fully addressed in the literature. These public health services are being delivered more often in independent pharmacies than in chain pharmacies, but the reasons for this difference have not been explored. In general, it is well accepted that time restraints influence service delivery.⁵² Other literature has suggested that rural pharmacies, which are often independent, tend to have a lighter work load and therefore more time to provide ongoing patient care, including increased service delivery.⁵³ Further research into the differences between independent and chain pharmacies could be conducted to help outline the areas where pharmacists could best focus their efforts when trying to increase their patient care service delivery. There may be other motivational factors, such as a desire to make a difference, professional aspirations, and other intrinsic motivators influencing pharmacists’ decisions to implement such services into their pharmacies.

Study limitations

The self-reported nature of this study introduces the possibility of respondent or recall bias. Therefore the results of this study serve as a general comparison of frequency of delivery of public health services in different sites and not actual observation and recording of these activities, which was beyond the scope of this study. With an overall response rate of 14.8%, these results may have selection bias, with respondents being overly enthusiastic about the topic, and thus more likely to respond. Another limitation is that the cross-sectional findings of two states have limited generalizability. North Dakota’s 51% ownership law further limits extrapolation to other states.