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Commentary

Community Pharmacies May Be Essential to Rural Health


December 17, 2019

mungerCommunity pharmacies often are a central component of health care in rural counties.  The US health care system realizes the importance of pharmacists to patient welfare.1 Recent studies have shown the benefit of community pharmacist involvement in patient care.  Primary care providers believe that comprehensive medication management improves their work-life, reduces burnout and fosters greater achievement in the quadruple aim (quality, access, cost, and work-life of health care providers).2 Greater usage of community pharmacy services assists persons to manage minor ailments. There are approximately 75,000 U.S. community pharmacies closely located to most persons.  When pharmacies close, access to pharmacists is lost. Thereby, part of the community patient safety net is negatively affected.

Research shows that between 2009 and 2015 one in eight (12.5%) US pharmacies have closed,2 and pharmacies in urban areas have closed more frequently than in rural areas of the US. Further, independent pharmacies serving more low-income persons and persons with public insurance were also more likely to close. 

The point of a community safety net being lost is demonstrated by the results in a study from the US Centers for Disease Control (CDC).3 Mortality data from US residents from the National Vital Statistics System were used to calculate potentially excess deaths from five leading causes of death among persons aged < 80 years old.  The CDCs 2013 National Center for Health Statistics (NCHS) for counties was used to categorize deaths according to urban-rural county classification.  The following categories were used:

  1. Large central metropolitan [most urban];
  2. large fringe metropolitan;
  3. medium metropolitan;
  4. small metropolitan;
  5. metropolitan; and
  6. noncore [most rural]. 

Potentially excess deaths were defined as deaths among persons aged <80 years that exceeded the number expected if the death rates for each cause in all states were equivalent to those in the benchmark states (i.e., the three states with the lowest rates). 

The number of potentially excess deaths during 2010-2017 for unintentional injuries (annual percent change: APC 11.2%) decreased for cancer (-9.1%), remained stable for heart disease, chronic lower respiratory disease, and stroke.  When the data were assessed between urban versus rural, the number of potentially excess deaths in the most rural counties were consistently higher versus those in the urban counties.  Potentially excess deaths from heart disease increased the most in micropolitan counties (APC +2.5%). 

What meaning could this have?  Community pharmacies provide a safety net for health care in rural counties.  These communities often experience substantial health disparities when compared to more urban population.3 The CDC study results might be manifesting in poor medication adherence.  A retrospective cohort study showed pharmacy closures are associated with clinically significant declines in cardiovascular medication adherence in older adults.4 Do these results further confirm that it is far past time for community pharmacy to be recognized for health care and not just for dispensing medications?

Mark A. Munger, PharmD, FCCP, FACC, is a professor of pharmacotherapy and adjunct professor of internal medicine, at the University of Utah, where he also serves as the associate dean of Academic Affairs for the College of Pharmacy.  

References:

  1. “To Err is Human” A Report from the Institute of Medicine. https://www.jpedhc.org/article/S0891-5245(00)70009-5/abstract   Accessed 11/2019
  2. Guadamuz JS, Alexander GC, Zenk SHm, Qato DM. Assessment of pharmacy closures in the United States from 2009 through 2015 JAMA Internal Medicine 2019;published online 10/21/2019.
  3. Funk KA, Pestka DL, Roth MT, Carroll JK, Sorenson TD. Primary care providers believe that comprehensive medication management improves their work-life. JABFM2019;32(4):462-73.
  4. Garcia MC, Rossen LM, Bastian B, et al. Potentially excess deaths from the five leading causes of death in Metropolitan and Nonmetropolitan Counties—United States, 2010-2017. MMWR 2019;68(10)1-11.
  5. Qato DM, Alexander GC, Chakraborty A, Guadamuz, Jackson JW. Association between pharmacy closures and adherence to cardiovascular medications among older U.S. adults. JAMA Network Open 2019;2(4):e192606.
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