Rural Pharmacies Research Articles

Pharmacist-Provided Quantitative Heel Ultrasound Screening for Rural Women at Risk of Osteoporosis

Osteoporosis is underdiagnosed, and rural communities often have limited technical resources for the assessment of osteoporosis. To evaluate the impact of a pharmacist, trained in the use of a portable heel ultrasound device, in screening elderly rural women for risk of osteoporosis and determine whether those found to be at risk seek further help and treatment from their general practitioner (GP) following screening. Following promotion of the service, 345 women were recruited from 6 rural community pharmacies in Tasmania, Australia, and underwent quantitative heel ultrasound screening. Women were comprehensively educated on risk factors for osteoporosis and completed a calcium intake questionnaire. Results were forwarded to each woman's GP, and the participants were followed up 3 months later to assess outcomes from the screening procedure. Approximately 20% of women were shown to be at high risk for osteoporosis; 201 (58%) of these were referred to their GP for further assessment. Sixty-eight percent of women who were screened discussed their results with their GP, and 11% underwent further investigation. Over one-third of women screened began medication (30% calcium, 6% bisphosphonate, 6% vitamin D) for osteoporosis. Pharmacist-provided screening for osteoporosis in rural areas is a potentially useful method to identify women at risk for fracture and a convenient time point for discussion of preventive therapy.

Assessing Risk for Loss of Rural Pharmacy Services in Minnesota

To quantify rural communities' risks for losing access to local pharmacy services using a newly developed risk-assessment tool. Cross-sectional study. Minnesota in June through August 2003. Pharmacy owners and managers in rural communities with populations less than 5,000 residents and only one community pharmacy. Self-administered questionnaire completed by study participants. Each answer was given a score based on the related factor's ability to affect risk of pharmacy closure. Scores were summed to give a comparative risk score with a positive score indicating higher risk; these scores could range from -13.5 to +30.75, depending on responses. From 126 communities outside of the Minneapolis-St. Paul metropolitan area with populations of fewer than 5,000 residents and only one community pharmacy, 81 (64.3%) usable responses were received. The calculated risk scores ranged from -7 to +12.3, with mean (+/- SD) scores of 1.55 +/- 4.17. Factors that contributed most to rural pharmacies' risk index were dramatic decreases in community populations within 5 years, poor community support for the pharmacy, owner's intent to sell pharmacy within 2 years, less than dollar 750,000 in annual prescription revenue, perceived erosion of total market share of prescriptions, difficulties in recruiting full-time pharmacist-employees, lack of access to local primary care, and perceived likelihood that local primary care clinics would not be active in 5 years. Approximately 26% of pharmacy owners responding expressed interest in selling their pharmacy within 3 years, and 62% were interested in selling within 10 years. The tool developed for this study allows prospective assessment of risk, which can facilitate a greater awareness by local and regional officials and consumers of the possibility of loss of rural pharmacies, assist in targeting resources to areas most in need, and serve as a bridge to collaborative relationships aimed at ensuring local access to both pharmacy services and the knowledge of a pharmacist.

Student Pharmacist Perspectives of Rural Pharmacy Practice

To evaluate the level of interest of upper-level doctor of pharmacy students in rural pharmacy practice, rural pharmacy ownership, and a proposed rural pharmacy practice model. Cross-sectional study. Minnesota, North Dakota, and South Dakota in October through December 2003. Third- and fourth-year professional student pharmacists at the University of Minnesota, North Dakota State University, and South Dakota State University. Self-administered questionnaire completed by study participants. Student interest in rural pharmacy practice and potential future directions for maintaining access to medications and the knowledge of pharmacists in rural communities. Of 177 respondents, 62.7% has given serious consideration to practice in rural communities with populations of 5,000 or fewer residents. Of these 111 students, 81% would be interested in the proposed practice model explained in the survey. Of the 108 total students expressing interest in the proposed rural pharmacy practice model, 63% had not previously given serious consideration to pursuing ownership (full or partnership) of a community pharmacy. Students from the schools that have traditionally supplied the majority of Minnesota rural pharmacists indicated an interest in practicing in rural areas as long as opportunities align with their personal and professional interests.

Improving the outcomes of anticoagulation in rural Australia: an evaluation of pharmacist-assisted monitoring of warfarin therapy

The aim of this project was to assess whether rural pharmacist involvement in the management of patients receiving warfarin has the potential to lead to safer and more effective anticoagulation, and is valued and welcomed by patients and their general practitioners (GPs). A convenience sample of rural pharmacists was trained in the use of the CoaguChek S International Normalized Ratio (INR) monitor and then conducted pharmacy-based testing for approximately 3 months. Two types of testing were performed in the pharmacy: (i) comparison testing was defined as pharmacy-based tests taken within 4 h of conventional laboratory testing or (ii) additional testing, which was a pharmacy-based test with no direct comparison laboratory test taken. Pharmacists, GPs and patients completed anonymous satisfaction surveys after the completion of the pharmacy-based testing. Pharmacists from 16 rural pharmacies were trained to use the CoaguChek S monitor. During the trial period, 518 INR tests were performed in the pharmacies on 137 different patients. A total of 120 tests were evaluated against results from laboratory testing. The pharmacy-based INR values were significantly correlated with the laboratory INR values (mean of 2.32+/-0.77 and 2.32+/-0.59 respectively; r=0.88, P<0.0001). A total of 398 additional pharmacy-based tests were conducted in the pharmacy and 8.5% of the additional tests resulted in a subsequent dosage change. The monitoring was well received by pharmacists, GPs and patients. The results of the trial were very positive. The CoaguChek S monitor in pharmacy-based testing performed accurately compared with conventional laboratory testing. Further research needs to be conducted on the impact of community pharmacy-conducted INR monitoring on patient care and outcomes.

Australian national strategy for pharmacy preceptor education and support

(i) To develop a national strategy for pharmacy preceptor education and support, with special consideration for rural and remote practitioners. (ii) To deliver an innovative national core pharmacist preceptor education and support model that could be customised for specific undergraduate programs. A steering committee, with representatives from four Pharmacy Schools in three Australian states, was established to develop an educational curriculum and implementation strategy. The project was designed to provide an online educational program for preceptors of Australian pharmacy students, particularly those in rural areas. The recipients of this program will primarily be rural pharmacy preceptors but could also be urban practitioners. After consultation with an advisory group, the steering committee considered the educational content, delivery strategy and adaptability of the package to maintain its currency and links to universities, pharmacy boards and professional organisations: an extensive literature search was conducted; writers and an educational designer were employed. The steering committee reviewed and modified the content before transfer of the program to the worldwide web. The development of a Pharmacy Preceptor Education Program suitable for national application and able to fulfil the needs of rural preceptors. A Preceptor Education Program has been developed suitable for use in all Australian states and capable of meeting the needs of rural pharmacy preceptors. Collaboration between four schools of pharmacy and pharmacy professional bodies has resulted in development of a flexible program for preceptors of undergraduate pharmacy students. This program can be developed for use by preceptors of pharmacy graduates, and in other disciplines.

How Might the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 Affect the Financial Viability of Rural Pharmacies? An Analysis of Preimplementation Prescription Volume and Payment Sources in Rural and Urban Areas

Passage of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) has created interest in how the legislation will affect access to prescription drugs among rural beneficiaries. Policy attention has focused to a much lesser degree on the implications of the MMA for the financial viability of rural pharmacies. This article presents descriptive information on mail-order prescriptions, volume, and payer type of retail prescriptions in rural vs urban areas. Together, these data provide a baseline for evaluating how implementation of the MMA may affect the financial viability of rural independent pharmacies. Projections of prescriptions dispensed from retail and mail-order pharmacies in 2002 for the total US and a sample of 17 states were obtained from IMS Health. The volume of mail-order prescriptions is small. Rural providers prescribed fewer retail and mail-order prescriptions per person, but more units per person. Rural areas have a higher percentage of prescriptions paid for by cash (18% vs 13%) and Medicaid (16% vs 10%) and a lower percentage of third-party payers than urban areas. Significant variation in volume and payer type exists between states. Rural, independent pharmacies may be negatively affected by MMA implementation as business shifts from cash to third-party reimbursement. The high degree of variation between states also has potentially important implications for the implementation of Prescription Drug Plan regions under MMA.

Community Pharmacists and Men's Health in Rural Victoria

Background: Men are notorious for not attending to their health and seeking health advice, especially in rural areas.Aim: To ascertain the role community pharmacists can play in men's health in rural Victoria.Method: Self‐administered, closed‐response written questionnaires were sent to community pharmacists and men in the Loddon‐Mallee region of Victoria.Results: The men and pharmacists agreed that community pharmacies could be a useful men's health resource. Half the men thought that the only advice pharmacists gave concerned prescription medications. Men said that the gender of a pharmacist would not affect them seeking advice, yet among their criteria for making pharmacies more ‘men friendly’ was the provision of more male pharmacists and pharmacy assistants. Both men and pharmacists saw information leaflets as a valuable resource. The men and pharmacists agreed that the service to men could be improved with provision of more information, counselling, education sessions, referral and collaboration with other health professionals, men's health events and some risk factor screening. Pharmacists were confident and reported success in counselling men in some areas (e.g. smoking cessation) but not others (e.g. alcohol use). Some constraints to improving pharmacy services to men were identified including time constraints, lack of remuneration and training.Conclusion: Rural pharmacies could become a useful men's health resource. Time, lack of remuneration and training may be the main constraints.J Pharm Pract Res 2004; 34: 285–7.

Can telepharmacy provide pharmacy services in the bush?

Rural and remote community pharmacies service large areas of rural Queensland, and because of the distances involved often do not meet the patients for whom they provide medication. Telepharmacy would improve the quality of pharmaceutical services provided in rural and remote areas, by allowing community pharmacists to have realtime contact with dispensing doctors, aboriginal health workers and patients via a video-phone. We used commercial (analogue) videophones to connect community pharmacists to dispensing doctors, patients in depot pharmacies (i.e. those with no pharmacist) and aboriginal health workers. However, various problems occurred and only 10 video-phone interactions were recorded during the six-month project. In all of the recorded interactions, the video-phone was actually used as a conventional telephone because a video-connection could not be established at the time of the call. (This may have been due to telephone network problems in the rural areas.) Despite these problems, all project participants showed great enthusiasm for the potential benefits of such a service.

Across the Dividing Range—Bridging the Divides Pharmacy opportunities across the hospital/ community and inter‐professional divides in rural and remote Australia

Rural and remote areas of Australia offer many opportunities for innovation in healthcare services. Some true healthcare 'network' models based around rural pharmacy can be established and evaluated. The lines between community and hospital pharmacy are often blurred and communication between health professionals enhanced. The blurring divide between hospital and community pharmacy in rural and remote areas has provided significant advances in practice. Projects have been set up to investigate the feasibility of community pharmacists integrating care for patients. These projects take advantage of the dual roles and the enhanced interaction between pharmacists and other health professionals in the bush. Opportunities for provision of clinical services beyond the traditional supply role have been taken in a number of remote communities

Acceptability of pharmacy-based bone density measurement by women and primary healthcare providers.

To assess women's information sources regarding, and monetary value placed on, pharmacy-based bone density screening. In addition, we evaluated clinicians' response to peripheral bone mass measurements. We recruited 197 women 50 years of age or older in four rural Midwestern community pharmacies. Each woman completed a questionnaire and underwent calcaneal bone density testing. Results were sent to participants' primary care providers. These providers, and others practicing within a 50-mile radius, were surveyed anonymously to evaluate usefulness of bone density data provided by this program or pharmacy-based osteoporosis screening in general. In addition, clinicians were asked how they would manage a woman with a calcaneal T-score of -1.3. Fifty-six percent of participants [95% CI, 49%-63%] became interested in screening through the media, and only 6% (CI, 3%-9%) became interested through contact with their primary care provider. Women were willing to pay a median of $25 for screening. Of 18 responding clinicians with patients in this study, 72% (CI, 47%-90%) found the results useful. Of the 67 responding clinicians, 51% (CI, 39%-63%) supported pharmacy-based bone mass measurement. For a case scenario of a woman with a calcaneal T-score of -1.3, 57% (CI, 46%-68%) of clinicians indicated that they would have ordered central dual-energy x-ray absorptiometry, and 20% (CI, 11%-29%) would have prescribed antiresorptive therapy. This study suggests that (1) women are an important force in obtaining bone density testing outside the clinic setting, both by self-education and willingness to pay, and (2) primary care clinicians receiving such results find them useful and indicate willingness to use them in decision-making.

Pharmacy services in rural areas: is the problem geographic access or financial access?

Access to pharmacy services is an important rural health policy issue but limited research has been conducted on it. This article describes rural retail pharmacies in Minnesota, North Dakota, and South Dakota, including their organizational characteristics, staffing, services provided, and planned future changes; examines the availability of pharmacy services and pharmacy closures in rural areas of these three states; and briefly discusses policy issues that affect the delivery of pharmacy services in rural areas. Study data came from a phone survey of 537 rural pharmacies, an analysis of pharmacy licensure data, and phone interviews with clinic, public health, and social services staff in rural communities with potential pharmacy access problems. Using a standard of 20 miles to the nearest pharmacy, most rural residents of these three states currently have adequate geographic access to pharmacy services. However, rural pharmacists and clinic, public health, and social services staff rate financial access to pharmacy services for the elderly and the uninsured as a major problem. Key policy issues that will affect future access to pharmacy services in rural areas include pharmacy staffing and relief coverage; alternative methods of providing pharmacy services; thefinancial viability of rural pharmacies; and the potential impact of a Medicare prescription benefit on rural consumers and rural pharmacies.

Osteoporosis screening by community pharmacists: use of National Osteoporosis Foundation resources.

To assess the feasibility of establishing an osteoporosis screening program in rural community pharmacies based on information and resources provided by the National Osteoporosis Foundation (NOF), to survey primary care providers regarding the usefulness of this screening program, and to recommend strategies for pharmacists interested in working with patients at risk for osteoporosis. Pharmacists and/or nurses enrolled women 65 years of age and older into the study, measured calcaneal bone density, administered a questionnaire to ascertain subjects' osteoporosis risk factors, and provided NOF literature to subjects. With their agreement, women's bone mass data and risk factor assessments were provided to primary care providers along with NOF's Physician's Guide to Prevention and Treatment of Osteoporosis. These providers were surveyed as to whether they found this information useful. Five independent community pharmacies in rural Wisconsin. We enrolled and tested 133 women. Of these, 122 (92%) agreed to have information mailed to their primary health care providers. These 57 providers were surveyed and 24 (42%) responded; of these 24, 20 (83%) found the information they received useful. A community pharmacy-based osteoporosis screening program using NOF materials was well accepted by physicians. NOF resources and recommendations can provide a strong foundation for such programs.

Clinical Pharmacy in 2020: an Alternative Future for Clinical Pharmacy in a Rural Setting

This paper paints one of many possible futures for clinical pharmacy in the year 2020, the role of the pharmacist in that scenario, and the steps required to achieve that reality. In particular, the future of clinical pharmacy in the rural setting will be offered.An emerging issues analysis of global and national trends that are driving change will be used to critique the present. This is complemented by a causal layered analysis (CLA) of problems and issues that arise in rural pharmacy practice. CLA is a tool developed by futurists to explore current issues and paradigms at several different levels of knowing. A vision of rural clinical pharmacy will be offered, using the CLA as a template. Broad strategies to guide the move from current reality to the preferred future are briefly outlined.

Pharmacists' knowledge of and attitudes toward opioid pain medications in relation to federal and state policies.

To assess Wisconsin pharmacists' knowledge of and attitudes toward the use of opioid analgesics in the management of chronic cancer and noncancer pain, and to explore the potential for these beliefs to interfere with pharmacist dispensing, the last link of the distribution chain of controlled substances to patients. Mail survey. Urban and rural pharmacies, long-term care facilities, hospitals, and outpatient clinics in Wisconsin in 1998. Representative sample of Wisconsin pharmacists. None. Responses to self-administered questionnaires. Although most respondents were knowledgeable about the issues addressed in this study, there were important exceptions. Not all pharmacists knew what constitutes legitimate dispensing practices for controlled substances under federal or state policy in emergencies or for patients with terminal illnesses, and many were unaware of the important distinctions among addiction, physical dependence, and tolerance. Many respondents did not view the chronic prescribing/dispensing of opioids for more than several months to patients with chronic pain of malignant or nonmalignant origin as a lawful and acceptable medical practice; this was especially true when the patient had a history of opioid abuse. Pharmacists play a pivotal role in ensuring patient access to medications. Viewed in the context of federal and state controlled substances policies, our findings suggest that the incorrect knowledge and inappropriate attitudes of some pharmacists could contribute to a failure to dispense valid prescriptions for opioid analgesics to patients in pain.

The economic realities of rural pharmacy practice.

Rural pharmacy practice is characterized by difficulties in recruiting and retaining pharmacists, demanding workloads and financial pressures that exceed those felt by pharmacies in urban areas. There is little optimism that these harsh realities will soon ease, given the shortage of pharmacists, high drug costs, and leverage by third-party payers. These realities should create concern among policy-makers for the economic viability of rural pharmacies and for the continued ability of pharmacists to provide health care services to residents of rural and frontier communities.

Search for Drug Information

As they age, baby boomers represent a larger proportion of the population experiencing health-related problems. As such, they are growing users of prescription medications. With pharmaceutical companies increasing their use of the Internet for direct-to-consumer advertising, and boomers leading in the routine use of technology, a shift in the sources used to obtain drug information may occur. Analyzing data from a panel of rural Illinois residents, this paper examines some aspects of the current dynamics of prescription drug information sources and their consequences for rural consumers and pharmacies.

A question of emphasis: efficiency or equality in the provision of pharmaceuticals.

The reported results are part of the overall evaluation of the new drug distribution legislation that went into effect in March 1996, liberalising ownership of community pharmacies in Iceland. We addressed the following question: What impact did the legislation have on users' access to and costs of pharmaceuticals? Seven focus group discussions were conducted with pharmacy customers in different locations in May, August and October 1997. Widespread ignorance about the legislation was observed. Pharmacy customers preferred to discuss the role of physicians in 'irrational drug use' to discussing community pharmacies. A definite split was observed between urban and rural pharmacy customers; whereas definite changes were reported in the urban setting (lower prices and increased access), the rural population's perception is that it is being left out. Although the study design is not generalisable, it is clear that the equilibrium between equality and efficiency in pharmaceutical distribution in Iceland has shifted. The introduction of the free market system has increased inequality between rural and urban residents in exchange for increased efficiency.

Patients' Access to Care — At the Center of Pharmacy's Rebirth

To evaluate the impact of a postgraduate year 1 (PGY1) community pharmacy residency program on clinical pharmacy service implementation and enhancement in a rural Mississippi community.An independent rural community pharmacy in Canton, MS.Delivery of clinical pharmacy services provided by PGY1 community residents 1 day a week to an underserved population during an 18-month period.Economic impact of a community pharmacy residency on the pharmacy's revenue stream determined by calculating an estimated dollar amount generated by clinical pharmacy services.By providing services 1 day a week, the residents were able to directly contribute an estimated $8000 of revenue from vaccinations and medication therapy management services. In addition, residents provided point-of-care testing, facilitated group education, developed a medication synchronization program, and assisted with physician outreach.Overall, community pharmacy residencies can contribute to the generation of revenue in rural independent settings and may also offer an opportunity to generate revenue in different areas that were not present before residency implementation, thereby improving access to care for patients.

Implementation of a community pharmacy-based influenza vaccination program.

To increase accessibility of influenza vaccine in a rural community by establishing a community pharmacy-based influenza vaccination program. An independent pharmacy in a rural eastern Iowa community of 5,000 people. Protocols for identification and screening of patients, administration of vaccine, and treatment of emergencies were developed by the pharmacist and approved by the county health department medical director. Administration of vaccine began October 15, 1996, and was completed on December 6, 1996. Patients were prospectively and retrospectively identified to receive the vaccination. Informed consent was obtained. Vaccine was administered by the pharmacist after screening for contraindications and counseling the patient. Weekly vaccination records were forwarded to the collaborating physician to update patient charts. To determine whether accessibility of influenza vaccine in the community was increased through pharmacist administration, the proportion of patients immunized in the pharmacy who were not vaccinated the previous year was determined. The pharmacist administered 343 doses of vaccine. Two-thirds of the immunized patients (67.9%) reported also being immunized the previous year. These patients were generally older (65 years of age +/- 13) than the previously nonimmunized patients (54 years of age +/- 16). However, 60.8% of the patients not immunized the previous year reported either they would not have gone elsewhere for the immunization (45.3%), or were unsure (25.5%). The data collected suggest that pharmacist administration of influenza vaccination in a rural community pharmacy increases access and, possibly, immunization rates. This may be especially true among high-risk younger adults who are often overlooked and would not normally have received the immunization.

The status of ORT (oral rehydration therapy) in Bangladesh: how widely is it used?

During 1980-1990 BRAC, a Bangladeshi non-governmental organization, taught over 12 million mothers how to prepare oral rehydration therapy (ORT) at home with lobon (common salt) and gur (unrefined brown sugar). This was followed by a strong promotion and distribution of prepackaged ORS by various agencies including the government. In 1993 we assessed knowledge of ORT preparation, its local availability and its use for the management of diarrhoea. Over 9000 households in 90 villages were revisited; 306 government outreach health workers, 296 drug sellers, and 237 village doctors were interviewed; 152 government facilities and 495 pharmacies/shops were visited. ORT prepared by mothers in a sub-sample of the households was analyzed for chloride content and interviewers collected information on use of ORT for diarrhoeal episodes occurring in the preceding two weeks. The data quality was assessed through a resurvey of sample respondents within two weeks of the first interview. Over 70% of the mothers could prepare a chemically 'safe and effective' ORS. A significant proportion of these mothers were very young at the time of the mass campaigns using house to house teaching, implying an intergenerational transfer of the knowledge on ORT. ORT was found to be used in 60% of all diarrhoeal episodes, but the rate varied with the type of diarrhoea, being highest for daeria (severe watery diarrhoea) and lowest for amasha (dysentery). Drug sellers and village doctors now recommend ORT much more frequently than before. Members of the medical profession (qualified and unqualified) still lag behind in prescribing the use of ORT. The availability of pre-packaged ORS in rural pharmacies has improved enormously. There is convincing evidence that the widescale promotion in the past of ORS for dehydration in diarrhoea has led to this marked improvement today. Nevertheless the use of rice-based ORS, culturally appropriate messages and the promotion of ORS with food offer opportunities to further improve the utilization of ORT.