THE PHARMACIST ROLE IN

DISEASE PREVENTION AND

HEALTH PROMOTION

Comprehensive

Final R e p o r t

Covers Period of Performance

During

O c t o b e r , 1981 - D e c e m b e r , 1 9 8 2

Contract No. HRA-232-81-00040

C o n t r a c t o r

Georgetown University School of Medicine

Department of Community and Family Medicine

W a s h I n g t o n , D .C . 20007

C o n t r a c t o r ’ s P r o j e c t D I r e c t o r : P a t r I c I a J . B u s h , P h .D ., M.Sc.

(For other key personnel, see Preface)

Sponsor

DEPARTMENT OF HEALTH AND HUMAN SERVICES

P u b l I c H e a l t h S e r v I c e

H e a l t h R e s o u r c e s a n d S e r v I c e s A d m I n I s t r a t I o n

Bureau of Health Professions

Division of Associated and Dental Health Professions

Parklawn Building

5600 Fishers Lane

Rockville, Maryland 20857

OCTOBER 1983.

TABLE OF CONTENTS

Preface

Project Personnel....................................V

Chapters

1. Introduction to the Pharmacist Role in Disease Prevention and Health Promotion.........l

2 . The Pharmacist Role in Individual Preventive Health Care ...........................................9

3 . The Pharmacist Role in Community Preventive Health Care.........................................33

4 . The Pharmacist Role in Primary Care...........................................................................51

5 . The Pharmacist Role in Referral...................................................................................65

6 . The Pharmacist Role in Health Education.....................................................................77

7 . The Pharmacist Role in Drug Information.....................................................................95

8 . The Pharmacist Role in Toxicology..............................................................................111

9 . The Pharmacist Role in Health Planning and Policy......................................................121

10 . Documentation of Pharmacist Activities in Disease Prevention and Health Promotion...133

11. Competencies for the Pharmacist Role in Disease Prevention and Health Promotion.....157

12. Summary......................................................................................................................165

iii.

INTRODUCTION

Nearly 163,000 persons with degrees in pharmacy are employed in the United States . Most, over 146,000 are pharmacy practitioners of these are employed in community pharmacies, either and most independent or chain, with the remainder of practicing pharmacists employed in clinics, hospitals, nursing homes or as other facilities. Nearly 17,000 pharmacist are employed as non-practitioners. This category includes pharmacists in drug manufacturing, educational institutions, government (Federal, State, local), drug whole selling, chain drug administration, professional associations, and others. About 1,200 non-practitioners, however, deliver health care through an educational institution or they are now in a different health profession.

As the third largest, most accessible, and most trusted by the public health care profession, and considering that most practicing pharmacists have four to five years of professional education, it seems highly improbable that pharmacists would not play a significant role in disease prevention and health promotion. The good news is that, considering their numbers, and the frequency with which pharmacists come into contact with the public, the evidence in this series of papers suggests that pharmacists have a significant impact on the health status of the nation’s population. Also to the good is that pharmacists are beginning to participate in what Jinks , (Chapter 2), called the "second public health revolution."

The bad news is that those disease prevention and health promotion activities which are not directly related to dispensing or selling medication, are not daily, and sometimes not ever,

activities of most community pharmacists. Moreover, the evidence suggests that the average pharmacist does not participate on a regular basis in community health promoting activities.

In general, the authors of the papers point to two areas where change is needed to promote the pharmacist role in disease prevention and health promotion. These are as are education and incentives.

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MACRO LEVEL PHARMACISTS

Many of the authors distinguished between macro and micro level pharmacists, a concept suggested by Bush and Johnson discussing the pharmacist role in public health. At the macro

level, pharmacists are usually salaried, and they work in public and private agencies, institutions, and organizations who focus health care on defined population groups. In certain roles, e.g. toxicology described I n Chapter 8, or drug information described in Chapter 7, the role is clearly defined and clearly related to disease prevention and health promotion. However, these macro level pharmacists are in frequently involved indirect patient care. The majority of pharmacists employed by the public sector are micro level practitioners in the sense of being involved in direct patient care. These pharmacists may spend most of their time in product distribution related activities, and only in frequently be involved in disease prevention or health promotion activities, whether population or individually focused. However, pharmacists employed by the public sector are more likely to report spending time in these activities than counterparts in community pharmacies, as indicated by Beardsley (Chapter 10).

In the case of macro level pharmacists, a wide breadth and depth of knowledge is required, which derives from the highly varied nature of their work, usually requiring considerable administrative and organizational skills and often a further qualification. This poses a problem for pharmacy educator who might wish to expose their students to macro level roles. While the trend in pharmacy education has been away from the drug as a product, it has not been toward administrative and organizational skills, but toward clinical pharmacy practice. Historically,

education in pharmacy administration concentrated on drug store management, marketing, and perhaps accounting. No attention has been given to teaching undergraduates the skills they need to work in health planning agencies, monitor state Medicaid drug programs, provide in service education, develop health promotional materials, plan community health campaigns, or any of the other specialized tasks performed by pharmacists at the macro level. Indeed, Campbell (Chapter 9) argues that despite the scientific background that pharmacists bring to health planning and policy development, their tasks are so varied, and often so far removed from pharmacy, that they might better be thought of as ex-pharmacists. He argues further, that it should not be the business of pharmacy educators to prepare pharmacists for these roles which often require a further qualification, but that pharmacy educators should concentrate on micro level pharmacists,

i.e. practitioners, particularly community practitioners, who will interface between fellow pharmacists and community health planning agencies.

At this time, it is uncertain how much pharmacy education is relevant to the macro level roles performed by pharmacists. Bush and Johnson have suggested that pharmacists in these roles not

only serve as role models, but may open the door to other pharmacists. Outside of health planning and policy, there are,

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as indicated by the chapters on drug information, patient education, and toxicology, macro level roles for which at raining in pharmacy is, if not critical, an asset. Although their numbers maybe small as compared to micro level pharmacists, their impact is greater than could be predicted by numbers alone. The reason is that they affect the activities of many others they control monies and positions, regulate labeling, control the flow of professional and consumer oriented information, plan disease specific public health campaigns, etc. While some of these efforts result in laws, e.g. requirements to counsel patients, keep drug profiles, provide patient package inserts,

other efforts are voluntary, e.g., provide screening for hypertension, diabetes, colon rectal cancer, and the frequency with which they are performed is variable.

MICRO LEVEL PHARMACISTS

The most frequently performed disease preventing and health promoting activities by community pharmacist, as indicated by the papers in this series (See Chapters 2, 3, 6, 10), are hypertension screening and counseling, and counseling about nutrition, weight control, allergies, proper use of prescribed and OTC medications, referring patients to their health care providers, and taking drug and medical problem histories. For example, a survey of West Virginia pharmacists indicated that

17.8% offered hypertension screening.²

Both the West Virginia study and the inquiry by Beardsley (Chapter 10) indicated that the frequency of hypertension screening is related to the organization and site of pharmacy practice. Pharmacists who practice in clinics, who are based in the same place as physicians, who are in independent practice, and who are sited in suburban areas are somewhat more likely to provide screening, and other primary and secondary disease preventing and health promoting services.

The relationship of organization and site to these services suggests that there are opposing forces, one deriving from the fact that an increasing proportion of prescriptions are dispensed from urban chain pharmacies where preventive health activities are least likely to occur, and the other deriving from the growing patient orientation of pharmacists.

Community activities such as speaking to groups on health related matters, referring patients to community agencies, participating in community based programs on sexually transmitted diseases,

mental health, substance abuse, poisoning, and cancer signals, are not regular activities of practicing pharmacists. The most common activities relate to the selection and proper use of drug

products/Nevertheless, because of their number and place in the community, the incidence of individual acts of disease prevention and health promotion by pharmacists is significant. For example, even though only a fifth of pharmacists report providing written information to their patients, if they provide it for only 10 percent of prescriptions, this means that written information is provided over 28 million times in a year to U.S. patients. Thus,

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because of the sheer numbers of prescriptions, the impact is likely to be greater than the percentages of pharmacists who provide written information indicates. An analogous argument can be made for more rare activities such as speaking to community groups. If only one percent of pharmacists do this once-a year, this means that there are more than 1,600 occurrences annually.

However, the number of individuals in the audiences would be much higher than this number, and some individuals in the audiences would surely pass on information they received to others. Thus,

the impact of even a very low percentage of pharmacists each speaking but one time a year, is potentially much greater than the percentage suggests. But perhaps, the argument seems best

suited to highlighting the potential. Almost all of the authors agree that much more can and should be done by pharmacists. Moreover, most are agreed on the problem areas.

DETERRENTS

The conditions mitigating against pharmacists performing more public health activities in the area of disease prevention and health promotion lie primarily in two areas, education and incentives, although others, e.g. regulations, inhibit other roles such as primary care(Chapter 4). Education is faulted for not teaching pharmacists how to perform these activities on the micro level, failing to teach students about community health planning, failing to provide role models, and failing to teach the written and oral communication skills needed for the roles described.

The lack of incentives, whether financial or other, maybe overriding and the most difficult to address, There are few coercive mechanisms to assure that pharmacists perform non-product related health promoting activities. Most pharmacists are not employed in places where either management, their fellow pharmacists, or the public, would fault them for not performing these activities, and there is limited evidence that performing them is financially rewarding unless the services is related to a product such as antihypertensive or diabetic medications. Where they are performed voluntarily, they seem to derive from a sense of civic responsibility and professionalism,

and thus, the rewards are primarily psychological - the self-reward that comes from providing high quality care whether to individuals or communities as a whole.

DIRECTIONS

Although many of the authors suggest actions that could, must, or should be taken such as arranging the physical lay out of the pharmacy to encourage pharmacist -patient interaction, it should be recognized that change is likely to be slow, at the margin, and most especially so when there is a lack of direct financial incentives. Change results from a complex process of shifting

expectations among various groups, not the least of which are consumers, so that eventually activities considered innovative and rare become such an essential and integrated part of a role,

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that others would not recognize the role without the performance of these activities.

At this time, one can be a pharmacist without performing most of the activities referred to in this series. There are a relatively small number of mostly macro level pharmacists who spend all of their time in some of the roles described. At this time, there are few demonstrations of the cost-effectiveness or benefits of pharmacists performing these roles, and some movement toward reimbursement for them. Most reimbursement remains product related, and most of that is based on the cost of the product to the pharmacist. However, there are trends which make it likely that pharmacists will increase their performance of activities described. These vary from innovative practice arrangements, to drug information newsletters published by HMO pharmacists to the more common pharmacist participation in health fairs,. Nearly every chapter describes some activity that might, if extended, improve the nation’s health status.

What’s to be done now? The list of "must" and "should have" competencies in Chapter 11 provides guidance for pharmacy educators. Nearly every author has offered suggestions as well, but perhaps Jinks has offered the one most likely to result in a consideration of the suggestions of other authors. In Chapter 2, Jinks calls for an interdisciplinary, interpersonal group to address the problems of community pharmacists not being as effective as they could be in preventive health care. As Jinks points out, the report of the Secretary of Health and Human Services and the Surgeon General, Healthy People³, provides direction. The paper in this series are but a beginning.