Success in health care is increasingly being measured by improvements in population
health outcomes in response to interventions rather than by services delivered (1).
In this new landscape, cross-sectoral collaboration is paramount (2), and the profession
of pharmacy is an often-overlooked partner (3). Our vision is that pharmacists and
the profession of pharmacy be included as an integral part of the roundtable of health
care and public health. This special collection of articles in Preventing Chronic
Disease highlights the contributions of pharmacy to the field of public health and
expands the vision of how pharmacy can improve population health.
The collection brings together some of the cutting-edge work at the interface of pharmacy
and public health that was submitted in response to a call for papers in 2019. The
Centers for Disease Control and Prevention (CDC) has long recognized pharmacy’s role
in addressing chronic diseases (4). The 14 articles included in this collection document
a small portion of the innovative work being done by pharmacists to improve population
health. We first review the articles to summarize research approaches and contributions.
We then describe gaps in research that need to be filled to strengthen the evidence
base for the unique role of pharmacy in improving population health. The collection
serves as a call to researchers and professionals in pharmacy and public health to
evaluate and publish their work in hopes of expanding on what is already known and
being done.
Collaboration of Pharmacy With Other Health Care Agencies
Collaboration between pharmacy and other health care professionals and agencies to
implement strategies to improve health outcomes is well represented in this collection
(5–8). Articles by Rodis et al (5) and Ross et al (6) highlight the impact of pharmacists
providing collaborative medication therapy management services to patients in federally
qualified health centers. In another description of a collaborative model for medication
therapy management implemented by the Pharmacy Society of Wisconsin, the Wisconsin
Division of Public Health, and a nonprofit insurer, Thompson et al showed improvements
in self-reported use of self-management tools, reductions in medication adherence
barriers, and high levels of satisfaction with the pharmacist in controlling hypertension
(7). Collaboration between the New Mexico Department of Health and community pharmacies
demonstrated the ability of community pharmacists to safely administer latent tuberculosis
treatment, with a satisfactory completion rate of 75.0% (8). The program was implemented
in collaboration with the local public health department, thus saving time for their
health care providers. Strand et al reported on the many ways in which community pharmacy
has responded to the coronavirus disease 2019 (COVID-19) pandemic, with recommendations
for deepening formal collaboration with local public health agencies (9). Sun et al
reported on pharmacy students training high school students about opioid misuse (10),
showing the opportunity for collaboration with public schools. The integration of
pharmacy with clinical medicine has been recommended by CDC (4) and the American College
of Cardiology (11), and these publications demonstrate that integration with other
health care agencies and the community lead to improved health outcomes.
Many Americans do not receive the services recommended by the US Preventive Services
Task Force (USPSTF) (12). Although community and clinical pharmacists could be key
players in delivering these services (13), barriers to pharmacies receiving reimbursement
for the delivery of some of these services compromises the full incorporation of the
delivery of USPSTF services into many community pharmacy settings (14). Several articles
in this collection speak to this problem. In 2018, only 51.1% of US adolescents aged
13 to 17 were fully covered by the human papillomavirus (HPV) vaccine series (15),
so the need for health care providers other than physicians to administer HPV vaccines
in various settings is great. Yet as Ryan et al found, both pharmacists and community
members identified more barriers than facilitators to providing and receiving the
HPV vaccine in the pharmacy setting (16). Work is needed to determine best practices
for removing barriers that prevent community pharmacists from delivering vaccines,
especially as we anticipate a vaccine against severe acute respiratory coronavirus
2 (SARS-CoV-2). Freeland and Ventricelli made a call to pharmacists to promote the
hepatitis B vaccine more aggressively among at-risk patients in settings heavily affected
by the opioid epidemic (17). Clearly, the need exists to elevate both the self-efficacy
of pharmacists in delivering all vaccines and the awareness among the general public
about the appropriateness of pharmacists administering vaccines, to expand beyond
vaccines that are currently most frequently administered — influenza, pneumococcal,
and herpes zoster (shingles) vaccines.
Diabetes and its determinants are epidemic in the United States, and prevention and
management are of vital importance (18). To that end, Roszak and Ferreri conducted
key informant interviews among pharmacy executives to identify barriers to and opportunities
for implementing the National Diabetes Prevention Program (DPP) in community pharmacies
(19). They concluded that realizing this opportunity will require reimbursement for
pharmacists’ efforts, minimal disruption of routine workflow, and understanding among
patients that pharmacists can provide this program effectively. Demonstrating that
implementation of the DPP in community pharmacies is possible, Ross et al reported
on the ability to nearly triple the number of pharmacies delivering the National Diabetes
Prevention Program by following a systematic process and including stakeholders every
step of the way (20). Pharmacies are present in most communities around the country,
and patients have more interaction with their pharmacist than with any other health
care providers (21–23), so pharmacists are well positioned to deliver preventive services.
Delivery of USPSTF-recommended and other preventive health services should be expanded
in community pharmacies to broaden the base of preventive service delivery across
the population, but barriers remain to scaling up the delivery of these services by
pharmacists. Widespread implementation of such services, with rigorous evaluation,
is needed.
Pharmacy Contributions to Improving Population Health
Since the seminal work of the Asheville Project demonstrated the effect of clinical
pharmacists on improving outcomes in diabetes, hypertension, and hyperlipidemia in
2003 (24,25), pharmacist participation in care coordination to manage chronic conditions
has been consistently demonstrated. Cowart et al described how a physician–pharmacist
team brought a cohort of patients with diabetes to the hemoglobin A1c goal of less
than 7.0% in 99 fewer days than the usual medical care of physician alone (26). Clearly,
a pharmacist brings added value to the care team.
In this era of health care workforce shortages across the country, pharmacists fill
this gap by serving as critical members of team-based care. Two articles in this collection
examined the question What happens when access to pharmacies is limited? Using claims
data, Pathak et al showed that medication adherence among people with diabetes and
hypertension using telepharmacy support was not inferior to medication adherence achieved
in face-to-face support (27). Telepharmacy support creates opportunities to expand
services to remote areas that lack an onsite pharmacist. Working in Washington State,
Graves et al showed that the likelihood of access to a Medicaid-contracted pharmacy
decreased significantly as rurality increased (28). To ensure medication access and
adherence among low-income Americans who live in rural areas, rural pharmacies need
to increase enrollment in Medicaid service provision.
Multisector collaboration is needed to address the epidemic of chronic diseases in
the United States. Most chronic diseases depend on the use of long-term medications
and high levels of adherence for successful management. As medication experts, the
pharmacist is a natural member of the chronic disease management team. Studying US
states and census regions, Yang et al found that prescription- and payment-related
promoters of adherence to blood pressure medication varied by geography and across
the largest patient market segments (medication prescriber, insurance payer type,
and age) (29). Blood pressure control rates nationwide are inadequate and could be
improved by uptake of promoter strategies such as fixed-dose combinations, mail order
refills, being under the management of a designated primary care provider, and having
commercial insurance. Many of these promoter strategies can be manipulated by pharmacists.
More consistent use of these promoter strategies could increase adherence to blood
pressure medication, but more consistent use requires incorporating pharmacists into
collaborations that include prescription benefit manager programs, payers, and health
care providers.
Evidence of pharmacists evolving beyond their traditional roles is apparent throughout
CDC. Through numerous cooperative agreements, CDC’s National Center for Chronic Disease
Prevention and Health Promotion instructs state health department grantees to engage
pharmacists as health care extenders and in team-based care approaches (30). CDC recognizes
pharmacists can help to achieve public health outcomes not only in chronic diseases
but also in HIV testing, antimicrobial stewardship programs, immunizations, and many
others. The role of pharmacists has come a long way, from dispensing, to providing
clinical care, to now administering vaccinations, screening for diseases, and health
coaching. They are, indeed, critical members of the public health roundtable.
More Research Needed
Several important areas of research at the interface of pharmacy and public health
were not covered in this collection. We now turn our attention to research areas that
merit further evaluation and reporting.
Social determinants of health such as poverty, unequal access to health care and education,
and racism are drivers of health inequities and, thus, are central to the public health
mission to achieve health for all. Healthy People 2020 calls for approaches that address
these social factors to help improve health equity for populations who are disproportionately
affected by chronic conditions and other causes of death and disability (31). The
pharmacy profession is sensitive to the social determinants of health: it prioritizes
customizing patient care, a concern for cultural competency (32), and attention to
health literacy (33), and it fosters each of these concepts through curricula and
workforce development. For example, results from the Project IMPACT study show that
pharmacists have improved health outcomes for diverse populations disproportionately
affected by diabetes (34).
However, achieving health equity will require that social determinants of health be
considered not only in how one treats an individual patient but also in the delivery
of pharmacist-provided services more broadly, such as determining who receives care
and how it is received. In a systematic review of 157 studies on public health services
delivered by community pharmacists, none discussed health inequities (13). Qato et
al showed that residents of predominantly low-income racial/ethnic minority communities
on the south side of Chicago could not use their nearest pharmacy because of cost
issues and had to travel further from home to overcome these issues (35); however,
more research is needed on how social determinants can be integrated into delivery
of care and the outcomes associated with their integration.
Another area of future research is training pharmacists to increase their public health
skills to improve population health beyond traditional pharmacy functions. The number
of doctor of pharmacy/master of public health (PharmD/MPH) dual degree programs is
increasing (36), but enrollment in these programs is not high. Although pharmacy education
accreditation standards related to public health competencies exist (37), many schools
of pharmacy do not prioritize public health competencies in their curricula. Postgraduate
training in public health competencies is another way of conceptualizing public health
education for pharmacists. One such example is a 3-hour continuing education training
program for pharmacists to implement screening of opioid misuse in community pharmacies
(38). The researchers showed improvement in the attitudes and perceptions among pharmacists
about opioid-related patient behaviors and the clinical value of screening for opioid
misuse. It would be helpful to know what further public health education pharmacists
need, and which types of training directly lead to improved population health.
Being located in the community and having the most frequent interaction with patients,
compared with all other health professionals (21,22), pharmacists could collaborate
with public health to identify and implement systems for disease surveillance and
monitoring health outcomes (39). Such systems represent another research gap in this
collection, but not entirely. Matus et al used GIS mapping to track opioid use in
wastewater, stating, “These maps can in turn provide an evidentiary basis for deployment
of pharmacy-centered public health responses” (40). A search of the literature provides
further examples. A unique system in Maine used public records from law enforcement
to inform medical providers of potential misuse and diversion of narcotic medication
(41). Another example of surveillance by community pharmacies is Walgreens’ use of
Esri location analytics to track retail prescription data for antiviral medications
used to treat influenza (42). The volume of antiviral medications dispensed serves
as a proxy for the temporal and geographic spread of the influenza season in real
time. Linked to the local epidemiology division of the public health department, the
data generated by sales records of antiviral medication could lead to early mitigation
of influenza outbreaks. However, this linkage would require formal integration of
pharmacy and public health informatics systems, something that still needs to be improved.
In a systematic review of 522 studies on the contributions of pharmacy to the 10 essential
services of public health, the 2 services least represented were community health
needs assessments and diagnosing health problems in the community (43). Community
health needs assessments are a key element of the Affordable Care Act and have increased
engagement of hospitals in the communities they serve. However, little published evidence
exists of pharmacies collaborating with hospitals and public health agencies to conduct
these needs assessments. Although some might argue that such work is outside the areas
of training for pharmacists, the community location of pharmacists and their accessibility
to populations gives pharmacists a unique opportunity to participate in community
health needs assessments. None of the articles in this Preventing Chronic Disease
collection reported on this area of research. Furthermore, a PubMed search identified
26 studies on community health needs assessments, but none of these studies included
pharmacy. We see this gap as an opportunity to expand the viewpoint of community health
needs assessments and increase access to community members to better inform needs
assessments.
We recognize a need for clear criteria by which to evaluate pharmacist contributions
to intervention studies (44). Several aspects of interventions should be evaluated
(45), such as whether the intervention was implemented as intended as well as its
effectiveness and cost-effectiveness. Many studies have shown the effectiveness of
pharmacy services as measured by patient outcomes or cost-effectiveness (46), but
process evaluations are scarce, especially for services that demonstrate collaboration
between public health agencies and pharmacists. Process evaluations involve critical
appraisal of whether the intended activities are taking place, who is performing the
activities, who is affected by the activities, and whether sufficient resources have
been allocated to accomplish the purpose of the intervention (44,45). Evaluations
should be performed in such a way that they determine the unique attributes and distinct
value provided by collaborations that include pharmacy partners as compared with collaborations
that include other disciplines. Additionally, the plan for evaluation should begin
while the program is being designed (45). Many readers of Preventing Chronic Disease
are familiar with such models as RE-AIM (Reach, Effectiveness, Adoption, Implementation,
Maintenance) (47), and this model has been used to evaluate the population impact
of projects implemented in community pharmacies (48). Such evaluation tools, considered
best practices in public health, need to be more frequently implemented in pharmacy
interventions (49).
It is evident from the small sample of studies articulating the contributions of pharmacists
or pharmacies in addressing the health of the population that much work is yet to
be done. The pharmacy profession has made advances and contributions, but gaps in
service exist and the role of pharmacists in public health needs to be broadened.
This recognition leads us to a call to action by both pharmacy and the public health
professions to expand their collaboration to improve population health and mitigate
health inequities.
Call to Action
The health care system, including pharmacy and public health, have opportunities to
improve population health through greater collaboration (13). To realize this opportunity,
partnerships need to be strengthened, current barriers need to be removed, and pharmacists
need to be more fully integrated into community health needs assessments, disease
surveillance, and monitoring of health outcomes. Furthermore, the profession of pharmacy
needs to become more proactive in pursuing opportunities to make these contributions,
evaluate them, and then publicly report on them.
Leaders in public health and pharmacy should develop more partnerships that serve
to mutually benefit each sector’s goals and leverage their strengths. Readers of this
collection will find many examples of public health partnering with pharmacists to
deliver their programs at the federal, state, and local levels. Pharmacists are uniquely
positioned to enhance the quality, reach, and sustainability of preventive services.
As pharmacists are asked to implement more preventive services, public health partners
have opportunities to apply their expertise to support them, thus establishing mutually
beneficial collaborations. For example, public health partners can help pharmacists
evaluate their process and outcomes to strengthen the way they capture and communicate
success stories, especially to nonpharmacist audiences. Public health partners should
be more proactive in ensuring that pharmacy representatives are a part of statewide
health planning efforts. Public health and pharmacy leaders can also advocate for
policies that reduce the current obstacles to pharmacists delivering preventive and
health promotion services.
Barriers need to be considered, with interventions designed to overcome those barriers.
Currently, privileges granted to pharmacists in most states do not ascend to the level
of their training. An article in this collection by Hamilton et al raises awareness
of this issue by describing barriers in Louisiana (50). All states need to grant pharmacists
privileges to practice at a level commensurate with their training and education and
require third-party payers to reimburse pharmacists for their services. These steps
are necessary to fill shortages in the primary care workforce and enable pharmacists
to contribute more substantially to improved population health.
The public health infrastructure needs to use pharmacists better in community health
needs assessments, disease surveillance, and monitoring of health outcomes. This infrastructure
improvement will require transformation in what data pharmacists have access to and
contribute to. Community pharmacies now exist in a patient-information vacuum. We
need to break down the barriers that isolate community pharmacy from the wider public
health and health care systems and to include pharmacy in health information exchanges
and surveillance systems.
In addition, the pharmacy profession must aggressively pursue the opportunities available
to it. Collaborations with local health care entities in community-based health interventions
could be expanded. Pharmacists will need to envision themselves as participants in
the wider community and seek ways to collaborate with other health care professions.
More collaboration could be achieved in part by pharmacists stepping out of their
comfort zone and welcoming people from various disciplines into their professional
organizations and meetings. The pursuit of new opportunities will also require expanded
training in public health. Although the PharmD degree affords a high level of training
in patient care and medication management, it has competency gaps in public health
skills such as informatics, program design and evaluation, and policy development.
Finally, pharmacists needs to advocate more proactively for their role in the public
health arena and to raise awareness of their contributions by publishing more often
in journals read by a wider audience than just pharmacy researchers.
We hope that this collection of articles in Preventing Chronic Disease will spur others
involved in improving population health through pharmacy applications to share their
work and expand their research in this arena. Dissemination of information on the
contribution of the pharmacy profession to public health is essential to creating
awareness among other health professionals and the public about the integral role
of pharmacy in public health. Such awareness is crucial to addressing health disparities,
given that in most underserved communities, pharmacies are the initial point of contact
with the health infrastructure. To this end, we advocate for more integrated involvement
of pharmacists in public health and the dissemination of information on their contributions
to the health of the people.