Trends in the delivery of care to oncology patients in the United States: Emphasis on the role pharmacists on the healthcare team.

OBJECTIVE: The purpose of this study was to identify trends in oncology care that allow one to forecast workforce supply and demand, the training and skills needed by the oncology pharmacist for the likely future of oncology care. METHODS: Interviews were conducted with experienced oncology pharmacists in leadership roles at 20 organizations balanced by geographic region and type of practice site (academic or community/ambulatory). Results were analyzed using descriptive statistics and theme identification. RESULTS: Practice sites differed widely in numbers of patient visits, practitioner/patient ratios, residency program presence, and other structural features. Despite this, the majority reported an expectation of growth in cancer patients, oncology physicians, oncology pharmacists, pharmacy technicians, oncology nurses, and advanced practice practitioners in the next two to five years. Fifty percent of sites currently support Post Graduate Year 2 (PGY2) oncology residencies. At least 50% reported routine pharmacist involvement in 12 clinical functions. More future involvement was predicted for immunotherapy (80%) and oral oncolytic therapy (90%). Interprofessional involvement was reported for a broad variety of practice-related committees and patient education teams. Limited pharmacist involvement in credentialing, quality measurement, and value-based reimbursement systems was found. CONCLUSION: Anticipated increases in demand for oncology pharmacists strongly suggest the need for more PGY2 oncology residency programs and on-the-job oncology training programs. Oncology pharmacists are currently involved in many clinical and administrative functions including multidisciplinary management. While a core set of clinical functions has been identified, oncology pharmacists must prepare for the increased use of oral oncology agents and immunotherapy. Pharmacist involvement in value-based reimbursement and other data-based quality outcome measurements should be increased to optimize involvement in team-based patient care.

Retail clinics colocated with pharmacies: A Delphi study of pharmacist impacts and recommendations for optimization.

OBJECTIVES: To identify workforce issues likely to affect pharmacists working in retail clinics (RCs) colocated with community pharmacies and to generate recommendations for optimizing health, cost, and operations outcomes. DESIGN AND PARTICIPANTS: A Delphi expert panel process using researchers with pharmacist workforce research experience was used. Panelists responded to 2 surveys of 3 rounds each. In survey 1, panelists used a 4-point linear numeric scale to rate the importance of 15 impact factors on pharmacists working in the RC/pharmacy setting. In survey 2, panelists used a 3-point linear numeric scale to rate the importance of recommendations for optimal outcomes. Recommendations were structured around elements from collaboration theory, a framework for evaluating critical areas for success in merged operations. MAIN OUTCOME MEASURES: Consensus was defined as ≥ 80% rating an impact "very" or "moderately" important (survey 1) and "very" important (survey 2). Impact factors were rank-ordered by ratings and numeric scoring. Selected comments about consensus items were reported. RESULTS: The 8-person panel had 100% response rates for both surveys. 12 of the 15 impact variables achieved consensus (survey 1). The highest ranking impacts were ability to establish collaborative relationships, relationships with coworkers, including nurse practitioners, and location of the RC relative to the pharmacy. Of 15 recommendations (survey 2), 5 achieved consensus and focused heavily on information sharing and early and ongoing collaboration among all stakeholders. CONCLUSION: Clinical, economic, health care quality, and patient preference data suggest that RCs colocated with pharmacies are likely to play a permanent role in U.S. health care. RCs can affect pharmacists and pharmacies positively or negatively. Positive impacts are most likely where establishing collaborative partnerships with all stakeholders, including patients, throughout planning, implementation, and operation are emphasized. With only about 3% of pharmacy operations colocated with RCs now, attention and resources should be devoted to developing and testing models based on collaboration principles.

Factors affecting the unmet demand for pharmacists: state-level analysis.

OBJECTIVE: To describe the relationship between state-level Aggregate Demand Index (ADI) data and market factors reflecting both supply and demand: unemployment rates, pharmacy graduates, community pharmacy prescription growth rates, and Medicare Part D. DESIGN: Cross-sectional time series analysis using state-level data. SETTING: U.S. labor market for pharmacists, from 2001 to 2010. INTERVENTION: Model ADI data for states (dependent variable) against five independent variables: previous year ADI, unemployment rates, pharmacy graduates, prescription growth rates, and Medicare Part D. MAIN OUTCOME MEASURES: Significance and predictive ability of the model, sign of the variables studied, and R2. RESULTS: In the two-way (state and time) fixed-effects model, all variables were significant and R2 was 0.79. Contributions to state-level ADIs were, in rank order, previous year ADI, unemployment rates, pharmacy graduates, and prescription growth rates. The model predicted 2010 ADI values for 44 of 51 states within ±10%. The model depicts the independent contributions of each variable for the short (∼1 year) and longer term. Although the nature of ADI data precludes quantitative predictions about the pharmacist job market, the model results show marketplace directions (up or down) and comparative impacts. CONCLUSION: The model demonstrated that unemployment rates, pharmacy graduates, prescription growth rates, and Medicare Part D contributed significantly to state-level ADIs between 2001 and 2010. The relationships uncovered should be monitored and reexamined as new data emerge in order to anticipate the directions of the pharmacist job market.

Education and training of pharmacists: comments on sustaining continuous improvement.

OBJECTIVE: To examine three approaches to improving the education and training of pharmacists and their interrelationships. DATA SOURCES: American Association of Colleges of Pharmacy, American Society of Health-System Pharmacists, National Center for Education Statistics, and peer-reviewed pharmacy literature. SUMMARY: The education of pharmacists continues to change based on a paradigm of continuous quality improvement and broad agreement that many newly graduated pharmacists are not ready to practice in all practice settings. This commentary looks at three avenues for change: increased prepharmacy coursework up to a baccalaureate degree, more clinical experience during the professional Doctor of Pharmacy program, and postgraduate professional residencies. The three avenues are examined in terms of feasibility, unanswered questions, and interrelationships among the variables. CONCLUSION: The interrelationships among the three approaches for change suggest a coordinated approach in which progress in each area informs the others. Requiring additional prepharmacy coursework up to a baccalaureate degree is feasible and likely sustainable relative to total number of awarded and projected baccalaureate degrees. Higher undergraduate academic expectations can provide "space" in the pharmacy curriculum for more clinical education. The space makes more clinical education possible, with the caveat that more clinical education will require many more residency-trained pharmacists to serve in faculty positions. Residency growth could generate needed additional qualified faculty members and preceptors. Further evolution in pharmacist education and training should be driven by the goal of advancing the profession's leadership in improving the safety and quality of the medication-use process.

Depressive symptoms in patients with type 2 diabetes in the ambulatory care setting: opportunities to improve outcomes in the course of routine care.

OBJECTIVES: To assess the frequency of untreated, self-reported depressive symptoms in a cross section of adult ambulatory patients with type 2 diabetes and to identify demographic and/or clinical characteristics associated with depressive symptoms in study patients. DESIGN: Cross-sectional study. SETTING: Three ambulatory care clinics in the southwestern United States in fall 2005. PATIENTS: 217 primary care patients aged 18 years or older with a diagnosis of type 2 diabetes. INTERVENTION: Administration of the Zung Self-rating Depression Scale (Zung SDS). MAIN OUTCOMES MEASURES: Self-reported data on demographic characteristics and depressive symptoms. Data for insurance, comorbid conditions, and glycosylated hemoglobin (A1C) values were abstracted from patient charts. RESULTS: Depressive symptoms (Zung SDS score > or =50) were identified in 72.1% of patients. Overall, 13% of the patients with a diagnosis of depression (based on patient charts) were not receiving treatment. Factors significantly associated with depressive symptoms were past history of depression (beta= 0.53, P < 0.01), Medicaid insurance (beta= 0.15, P < 0.02), and insulin use (beta= 0.12, P < 0.05). CONCLUSION: The results suggest that possible undetected or untreated depression can be assessed in patients with type 2 diabetes through use of a self-rating scale in the course of routine ambulatory care. Adding the Zung SDS screen to routine care protocols could facilitate improved detection and treatment of comorbid depression in ambulatory patients with type 2 diabetes.

New pharmacist supply projections: lower separation rates and increased graduates boost supply estimates.

OBJECTIVE: To revise the 2000 Bureau of Health Professions Pharmacist Supply Model based on new data. DESIGN: Stock-flow model. SETTING: United States. PARTICIPANTS: A 2004 estimate of active pharmacists reported by the Bureau of Labor Statistics was used to derive the base count for the 2007 supply model. INTERVENTIONS: Starting with a 2004 base of active pharmacists, new graduates are added to the supply annually and losses resulting from death and retirement are subtracted. MAIN OUTCOME MEASURES: Age- and gender-based pharmacist supply estimates, 2004-2020. RESULTS: Increased U.S. pharmacist supply estimates (236,227 in 2007 to 304,986 in 2020) indicate that pharmacists will remain the third largest professional health group behind nurses and physicians. Increases were driven by longer persistence in the workforce (59%), increased numbers of U.S. graduates (35%), and increases from international pharmacy graduates (IPGs) achieving U.S. licensure (6%). Since more pharmacists are expected to be working part time the full-time equivalent (FTE) supply will be reduced by about 15%. The mean age of pharmacists was projected to decline from 47 to 43 by 2020. Because of unequal distribution across age groups, large pharmacist cohorts approaching retirement age will result in fewer pharmacists available to replace them. The ratio of pharmacists to the over-65 population is expected to decrease after 2011 and continue to fall beyond 2020; this is likely a reflection of baby boomers passing through older age cohorts. CONCLUSION: The revised estimated active U.S. pharmacist head count in 2006 is 232,597, with equivalent FTEs totaling approximately 198,000. The substantial increase over the 2000 pharmacist supply model estimates is primarily attributable to pharmacists remaining in the workforce longer and educational expansion. U.S. licensed IPGs account for less than 6% of overall increases. The pharmacist work-force is projected to become younger on average by about 4 years by 2020. Coincident demands for more physicians and nurses over the same period and shortages in all three professions stipulate that active steps be taken, including continued monitoring of work trends among pharmacists and other health professionals.

Examination of state-level changes in the pharmacist labor market using Census data.

OBJECTIVE: To examine long-term changes in the U.S. pharmacist labor market across states. DESIGN: Retrospective cohort study. SETTING: The United States as a whole and individual states in 1990 and 2000. PARTICIPANTS: Pharmacists and pharmacy school graduates from Census data and previous research, respectively. INTERVENTION: Retrospective analysis of 5% Public Use Microdata Samples data on pharmacists from the 1990 and 2000 U.S. Census surveys, information on migration among states between 1995 and 2000, and previous research on pharmacy school graduates. MAIN OUTCOME MEASURES: Changes in pharmacist counts and wages, as well as migration of pharmacists across states and pharmacy school graduates by state. RESULTS: From 1990 to 2000, the ratio of pharmacists to 100,000 population increased from 70 to 76, but 13 states experienced declines in this datum, and overall changes in pharmacist counts varied considerably among states. The average wage, expressed in 2000 U.S. dollars, for pharmacists increased from $26.58 per hour to $33.80 per hour (17%), while the average wages of non-pharmacist college graduates increased from $26.37 to only $28.76 (9%). Wage changes varied across states. CONCLUSION: According to the Census, the number of pharmacists per 100,000 population varied substantially across states. This variance in supply across states is not converging or easily explained. Overall, the shortage had a clear impact on the pharmacist labor market, yet this effect was not consistent across states.

ASHP survey of ambulatory care pharmacy practice in health systems--2004.

PURPOSE: The characteristics of and trends in pharmacy practice in ambulatory care settings across the United States were studied. METHODS: A 2004 national survey of the ambulatory care responsibilities of pharmacists across a spectrum of organizational types (community hospitals, county facilities, Indian Health Services facilities, Veterans Affairs (VA) facilities, teaching institutions, integrated health networks, military facilities, and health maintenance organizations) was conducted and related to organizational features that could promote pharmacist participation. RESULTS: From 1672 deliverable Web-based surveys, 233 organizations reported at least some pharmacist involvement in ambulatory activities, while 475 reported none. Over half of the 228 organizations with some pharmacist involvement reported pharmacists tracking adverse drug reactions (67%), providing written (53%) or oral (52%) information with new prescriptions, and conducting medication management programs (51%). Some 85% reported having at least one clinic with pharmacist involvement. Clinics for anticoagulation services (36%) and oncology services (28%) were most prevalent, followed by primary care or family practice clinics (23%) and diabetes clinics (21%). New survey items found a high prevalence of pharmacist involvement in emergency preparedness programs (90%), medication management services in complex medication situations (63%), and using evidence-based practice guidelines (60%). Of nine enabling factors (factors potentially promoting pharmacist involvement) investigated, participation on multidisciplinary teams and having collaborative practice agreements were significantly associated with pharmacist participation in at least one ambulatory care activity. Having at last one ambulatory care staff pharmacist with advanced training, having at least one residency program, and having collaborative practice agreements were significantly associated with pharmacist participation in at least one clinic or program. Pharmacist participation in ambulatory care activities was not equally distributed across different types of organizations, and VA facilities were notable for the amount and extent of participation. CONCLUSION: Pharmacists' roles and responsibilities in ambulatory care appear to continue to evolve, with VA facilities leading the way.

Update on the pharmacist shortage: national and state data through 2003.

PURPOSE: Aggregate Demand Index (ADI) survey results were used to describe the severity of the pharmacist shortage at the national and state levels and by practice site and impact on the U.S. population. METHODS: Time-series analysis was used to characterize national and state trends in the ADI from September 1999 through September 2003. The time trends for the distribution of ratings and the demand index by practice site were also examined. Historical data about retail prescriptions filled and related growth rates were compiled and compared. ADI survey results were also compared with data from other surveys. RESULTS: Over time, ADI data demonstrated a continuing national pharmacist shortage, as the ability to fill pharmacist vacancies was rated at least moderately difficult. A very slight downward trend in severity (slope = -0.008) was observed. Other survey series had similar findings. States with the most severe shortage levels tended to have large populations, while those with the lowest levels tended to have smaller populations. More states improved than worsened the severity of their shortage, with 30 states maintaining the same ADI rating. Although there was a high correlation between the retail prescription growth rate and the ADI (r = 0.84), there was a much greater decrease in prescription growth (73%) than ADI levels (6.5%). CONCLUSION: There was a sustained unmet demand for pharmacists throughout the United States from September 1999 through September 2003. More states moved toward having an adequate supply of pharmacists than toward having a more severe shortage of pharmacists, but the national ADI suggests that the system remains stressed.

Factors impacting self-perceived readiness for residency training: results of a national survey of postgraduate year 1 residents.

OBJECTIVE: To examine the factors impacting postgraduate year 1 (PGY1) residents' self-perceived readiness for residency. METHODS: A total of 1801 residents who matched in American Society of Health-System Pharmacists (ASHP)-accredited PGY1 programs were e-mailed individualized invitations to take an online survey. The survey collected self-ratings of readiness for residency training competencies including time management and organization, foundational knowledge, clinical practice, project management, and communication. KEY FINDINGS: Data from 556 completed surveys were analyzed. Residents agreed they were ready to perform activities requiring time management and organization (median = 4, mean = 4.08), foundational knowledge (median = 4, mean = 3.83), clinical practice (median = 4, mean = 3.67), and communication (median = 4, mean = 4.05). Residents who completed at least 1 academic advance pharmacy practice experience (APPE), 5 clinical APPEs, or held a bachelors degree felt more confident than their counterparts in regard to project management (P < .001, <.001, and .01, respectively). CONCLUSION: PGY1 residents generally felt prepared for time management and organization, foundational knowledge, and communication residency training competencies. This was significant for those who completed 1 or more academic APPEs, 5 or more clinical rotations, or a bachelors degree. Study results may assist pharmacy schools in preparing students for residency training, prospective resident applicants in becoming more competitive candidates for residency programs, and residency program directors in resident selection.

Challenges to the pharmacist profession from escalating pharmaceutical demand.

Unexpected growth in medication use has escalated demand for pharmacists that has outpaced supply. Responses to the pharmacist shortage include larger workloads and greater use of pharmacist extenders and technology. As the profession has moved from a product orientation (dispensing medications) to a patient focus, clinical training requirements have expanded. However, structural and process barriers, particularly in community and retail pharmacies, must be addressed to improve the medication-use process. These issues merit greater attention from health care leaders and policymakers.

Clinical and economic outcomes of pharmacist recommendations in a Veterans Affairs medical center.

Pharmacist recommendations and their clinical and economic outcomes in a Veterans Affairs (VA) medical center were studied. The first 600 pharmacist recommendations that met study criteria were evaluated for type and frequency, rate of acceptance by physicians, potential benefit or harm, and economic consequences. The study site included inpatient and outpatient settings and a skilled-nursing facility. The most frequent types of pharmacist recommendations involved adjusting the dosage or frequency of administration and discontinuing a drug that was not indicated for the patient's medical problem. The rate of acceptance of the recommendations was 92%. The recommendations led to improved clinical outcomes in over 30% of cases in each setting and no change in over 40% of cases in each setting. Evaluators determined that patient harm was avoided by the recommendations in 90% of cases; patient harm was caused in less than 1% of cases. The overall mean cost avoidance per recommendation was $700, and the mean total cost avoidance for all 600 recommendations was $420,155. Pharmacist recommendations improved clinical outcomes and saved money at a VA medical center.

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 nation's health care priorities.

Pharmacy school survey standards revisited.

In a series of 3 papers on survey practices published from 2008 to 2009, the editors of the American Journal of Pharmaceutical Education presented guidelines for reporting survey research, and these criteria are reflected in the Author Instructions provided on the Journal's Web site. This paper discusses the relevance of these criteria for publication of survey research regarding pharmacy colleges and schools. In addition, observations are offered about surveying of small "universes" like that comprised of US colleges and schools of pharmacy. The reason for revisiting this issue is the authors' concern that, despite the best of intentions, overly constraining publication standards might discourage research on US colleges and schools of pharmacy at a time when the interest in the growth of colleges and schools, curricular content, clinical education, competence at graduation, and other areas is historically high. In the best traditions of academia, the authors share these observations with the community of pharmacy educators in the hope that the publication standards for survey research about US pharmacy schools will encourage investigators to collect and disseminate valuable information.

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.

Interprofessional education: cooperation among osteopathic medicine, pharmacy, and physician assistant students to recognize medical errors.

Thirty-nine volunteer students from 3 health science colleges at Touro University California participated in an exercise designed to promote interprofessional collaboration. In the event, thirteen 3-person multidisciplinary teams of students identified potential medical errors in a series of case-based scenarios. In an immediate postevent survey, 33 of 39 respondents (85%) indicated that the exercise marked the first time that they had worked on clinical problems with students from other health professions. All respondents agreed that interprofessional education was useful and necessary. A 6-month follow-up survey had 24 respondents, 9 of whom (38%) indicated that the experience helped them in interprofessional communications in their clinical rotations. Twenty-two respondents (92%) recalled that all team members were involved in the selection of answers. Respondents reported that team answer selections were made by consensus (12 [50%]), by accepting the opinion of an "expert" on the team (9 [38%]), or by majority vote (3 [13%]). Since this exercise, there has been a surge of interprofessional activities at Touro University California, including steps toward the implementation of campus-wide interprofessional education.

Association between increased number of US pharmacy graduates and pharmacist counts by state from 2000-2009.

OBJECTIVE: To determine whether growth in the number of pharmacy graduates and newly accredited schools from 2000 to 2009 were larger in states with fewer pharmacists per population age ≥ 65 years. METHODS: States were aggregated into quartiles based on rank-ordered ratios of in-state pharmacists per 100,000 population aged ≥ 65 years. Quartiles were then compared with respect to the number of new graduates. RESULTS: The mean cumulative number of graduates was highest in the first quartile of states (those with the greatest need for pharmacists) and lowest in the fourth quartile of states. States with the greatest need for pharmacists had the lowest positive growth in number of pharmacists per population ≥ 65 years. The majority of new schools in 2009 were located in states with relatively low numbers of pharmacists. CONCLUSION: The growth in new pharmacy graduates created by expansion in schools as well as in graduates per school helped states meet demand between 2000 and 2009. However, tremendous variation remains in the number of graduates as well as the number of pharmacists across states. The quartile framework is useful for assessing the number of new pharmacy graduates based on pharmacists per population ratios. Based on current dynamics in the supply and demand of pharmacists, frequent monitoring is recommended.