The availability of pharmacies in the United States: 2007–2015

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Abstract
Importance: Despite their increasingly important role in health care delivery, little is known about the availability, and characteristics, of community pharmacies in the United States. Objectives: (1) To examine trends in the availability of community pharmacies and pharmacy characteristics (24-hour, drive-up, home delivery, e-prescribing, and multilingual staffing) associated with access to prescription medications in the U.S. between 2007 and 2015; and (2) to determine whether and how these patterns varied by pharmacy type (retail chains, independents, mass retailers, food stores, government and clinic-based) and across counties. Methods: Retrospective analysis using annual data from the National Council for Prescription Drug Programs. Pharmacy locations were mapped and linked to the several publically-available data to derive information on county-level population demographics, including annual estimates of total population, percent of population that is non-English speaking, percent with an ambulatory disability and percent aged ≥65 years. The key outcomes were availability of pharmacies (total number and per-capita) and pharmacy characteristics overall, by pharmacy type, and across counties. Results: The number of community pharmacies increased by 6.3% from 63,752 (2007) to 67,753 (2015). Retail chain and independent pharmacies persistently accounted for 40% and 35% of all pharmacies, respectively, while the remainder were comprised of mass retailer (12%), food store, (10%), clinic-based (3%) or government (<1%) pharmacies. With the exception of e-prescribing, there was no substantial change in pharmacy characteristics over time. While the number of pharmacies per 10,000 people (2.11) did not change between 2007 and 2015 at the national-level, it varied substantially across counties ranging from 0 to 13.6 per-capita in 2015. We also found that the majority of pharmacies do not offer accommodations that facilitate access to prescription medications, including home-delivery, with considerable variation by pharmacy type and across counties. For example, the provision of home-delivery services ranged from less than <1% of mass retailers to 67% of independent stores and was not associated with county demographics, including ambulatory disability population and percent of the population aged ≥65 years. Conclusions: Despite modest growth of pharmacies in the U.S., the availability of pharmacies, and pharmacy characteristics associated with access to prescription medications, vary substantially across local areas. Policy efforts aimed at improving access to prescription medications should ensure the availability of pharmacies and their accommodations align with local population needs.
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RESEARCH ARTICLE
The availability of pharmacies in the United
States: 2007–2015
Dima Mazen Qato
1,2
*, Shannon Zenk
3
, Jocelyn Wilder
1,2
, Rachel Harrington
1
,
Darrell Gaskin
4
, G. Caleb Alexander
5,6
1Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago, College of
Pharmacy, Chicago, Illinois, 2Division of Epidemiology and Biostatistics, University of Illinois at Chicago
School of Public Health, Chicago, Illinois, 3Department of Health System Sciences, University of Illinois at
Chicago, Chicago, Illinois, 4Department of Health Policy and Management, Johns Hopkins School of Public
Health, Baltimore, Maryland, 5Department of Epidemiology, Johns Hopkins School of Public Health,
Baltimore, Maryland, 6Center for Drug Safety and Effectiveness, Johns Hopkins School of Public Health,
Baltimore, Maryland
*dimaqato@uic.edu
Abstract
Importance
Despite their increasingly important role in health care delivery, little is known about the
availability, and characteristics, of community pharmacies in the United States.
Objectives
(1) To examine trends in the availability of community pharmacies and pharmacy character-
istics (24-hour, drive-up, home delivery, e-prescribing, and multilingual staffing) associated
with access to prescription medications in the U.S. between 2007 and 2015; and (2) to
determine whether and how these patterns varied by pharmacy type (retail chains, indepen-
dents, mass retailers, food stores, government and clinic-based) and across counties.
Methods
Retrospective analysis using annual data from the National Council for Prescription Drug
Programs. Pharmacy locations were mapped and linked to the several publically-available
data to derive information on county-level population demographics, including annual esti-
mates of total population, percent of population that is non-English speaking, percent with
an ambulatory disability and percent aged 65 years. The key outcomes were availability of
pharmacies (total number and per-capita) and pharmacy characteristics overall, by phar-
macy type, and across counties.
Results
The number of community pharmacies increased by 6.3% from 63,752 (2007) to 67,753
(2015). Retail chain and independent pharmacies persistently accounted for 40% and 35%
of all pharmacies, respectively, while the remainder were comprised of mass retailer (12%),
food store, (10%), clinic-based (3%) or government (<1%) pharmacies. With the exception
PLOS ONE | https://doi.org/10.1371/journal.pone.0183172 August 16, 2017 1 / 13
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OPEN ACCESS
Citation: Qato DM, Zenk S, Wilder J, Harrington R,
Gaskin D, Alexander GC (2017) The availability of
pharmacies in the United States: 2007–2015. PLoS
ONE 12(8): e0183172. https://doi.org/10.1371/
journal.pone.0183172
Editor: Jacobus P. van Wouwe, TNO,
NETHERLANDS
Received: January 28, 2017
Accepted: July 31, 2017
Published: August 16, 2017
Copyright: ©2017 Qato et al. This is an open
access article distributed under the terms of the
Creative Commons Attribution License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
Data Availability Statement: All relevant data are
within the paper and its Supporting Information
files.
Funding: This work was funded by the National
Institutes of Health, National Institute on Aging
grant number R21AG04923. The funding source
had no role in the design and conduct of the study,
analysis, or interpretation of the data; and
preparation or final approval of the manuscript
prior to publication.
Competing interests: Dr. Alexander is Chair of the
FDA’s Peripheral and Central Nervous System
of e-prescribing, there was no substantial change in pharmacy characteristics over time.
While the number of pharmacies per 10,000 people (2.11) did not change between 2007
and 2015 at the national-level, it varied substantially across counties ranging from 0 to 13.6
per-capita in 2015. We also found that the majority of pharmacies do not offer accommoda-
tions that facilitate access to prescription medications, including home-delivery, with consid-
erable variation by pharmacy type and across counties. For example, the provision of home-
delivery services ranged from less than <1% of mass retailers to 67% of independent stores
and was not associated with county demographics, including ambulatory disability popula-
tion and percent of the population aged 65 years.
Conclusions
Despite modest growth of pharmacies in the U.S., the availability of pharmacies, and phar-
macy characteristics associated with access to prescription medications, vary substantially
across local areas. Policy efforts aimed at improving access to prescription medications
should ensure the availability of pharmacies and their accommodations align with local pop-
ulation needs.
Introduction
In 2015, 4 billion prescriptions or 12.7 prescriptions per-capita, were filled at community phar-
macies in the United States [1], and more than 90% of Americans live within 2-miles to one of
these pharmacies[2]. Pharmacies are also expanding their operations beyond dispensing to
include preventative care, such as health screenings and medication therapy management[3,
4], especially at retail chains. Thus, pharmacies supply and facilitate access to prescription
medications and are a vital, and increasingly important, component of healthcare delivery in
the United States.
Despite the growing role of pharmacies in healthcare delivery, there is limited information
on their prevalence, distribution and characteristics. For example, it is unclear whether there
are large differences in the availability of pharmacies across local areas in the U.S., as well as
how characteristics of pharmacy operations or accommodations that improve access to pre-
scription medications, such e-prescribing, home delivery, multilingual staffing, and hours-of-
operation, vary between different types of pharmacies and local areas. This information is
important because accessing and obtaining a prescription medication at a pharmacy is a neces-
sary precondition to adherence, which is known to vary across localities in the U.S. [5,6].
Several studies suggest that many patients encounter barriers in accessing prescription medi-
cations associated with the availability, and characteristics of, their local pharmacies. For example,
inadequate pharmacy accessibility[7,8] or the lack of accommodations, such as home delivery
[9] and e-prescribing [10], are associated with higher rates of non-adherence to prescription
medications in some communities. There is also some evidence that language concordance
between patients and providers, and the provision of multilingual staff or interpreter services at
local pharmacies, reduce non-adherence, including primary non-adherence, in non-English
speaking patients [11,12]. Finally, patients filling their prescription medications at independent
pharmacies, which are most prevalent in medically underserved areas [7], are less adherent than
those using retail chains[8].
Availability of pharmacies in the US
PLOS ONE | https://doi.org/10.1371/journal.pone.0183172 August 16, 2017 2 / 13
Advisory Committee; serves as a paid consultant to
PainNavigator, a mobile startup to improve
patients’ pain management; serves as a paid
consultant to IMS Health; and serves on an IMS
Health scientific advisory board. This arrangement
has been reviewed and approved by Johns
Hopkins University in accordance with its conflict
of interest policies. This does not alter our
adherence to PLOS ONE policies on sharing data
and materials.
We examined trends in the availability of pharmacies and their characteristics in the United
States between 2007 and 2015. In addition, we quantified the per-capita availability of pharma-
cies across counties over time. We were particularly interested in the growth of pharmacies
and the provision of accommodations that may promote access to prescription medications,
such as multilingual staffing and home delivery. We hypothesized that pharmacies are increas-
ingly available, but that their availability varies substantially across local areas and their charac-
teristics may not always align with the needs of the served population.
Methods
Data sources
We used several data sources for this study. First, we derived annual data on community phar-
macies in the U.S. from master files provided by the National Council for Prescription Drug
Programs (NCPDP) for February 2007 through February 2015 [13]. An NCPDP number is a
unique identifier assigned to every licensed pharmacy for processing prescription claims.
These data provide detailed information on an annual basis regarding each active community
pharmacy in the United States, including location and pharmacy type, which was internally
validated by NCPDP. Information on pharmacy characteristics such as home-delivery, is self-
reported online by the pharmacy. We geocoded pharmacy addresses using ArcGIS version
10.0.
Second, we used annual estimates from the US Census Bureau’s Population Estimates Pro-
gram to derive information on total population for all counties for each year [14]. Third, we
used estimates from the 5-year (2010–2014) American Community Survey (ACS), the largest
national household survey in the United States, to derive information—also at the county level
—on the percent of the total adult population 18 years and older) with an ambulatory disability
and percent that is non-English speaking defined as those who “speak a language other than
English” [15]. We used the 2010 U.S. decennial Census to derive variables on percent of total
population 65 and older at the county level [16] Finally, we used data from the Health
Resources and Service Administration (HRSA) to identify counties that are designated by the
federal government as completely or partially Medically Underserved Areas/Populations
(MUA/Ps) or primary health care Health Professional Shortage Areas (HPSA) [17].
We linked annual geocoded information on community pharmacies to county-level data
from the American Community Survey, 2010 Census, and HRSA. We included 3,141 counties
that comprise the continental U.S. in our analyses.
Outcome variables
We examined two primary outcomes on an annual basis. First, we quantified pharmacy avail-
ability, which we defined as the number of pharmacies overall. We also derived a variable on
the number of pharmacies per 10,000 population, or per-capita, using annual county-level esti-
mates on the total population from the Census. To account for changes in the population at
the national and county-level over time, we divided the number of pharmacies by the total
population for each county each year.
Second, we examined a series of five binary variables for pharmacy characteristics. Phar-
macy characteristics were defined as characteristics of pharmacy operations that can improve
access to prescription medications. Data for these variables were not available for 2007 and
2008, thus we derived this outcome annually for each pharmacy between 2009 and 2015. In the
NCPDP Pharmacy Services Files, pharmacies self-reported whether they “accept electronic
prescriptions”, “offer a home delivery service”, “have one or more drive-up windows for pre-
scriptions”, and “offer 24-hour emergency access to a pharmacist with access to the location”
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[referred to as “24-hour emergency access”]. Pharmacies also reported all the languages spoken
by pharmacy staff. Pharmacies reporting a language other than English were coded as offering
multilingual pharmacy staff.
Other variables
We used NCPDP dispenser class codes, such as whether the store was an independent phar-
macy or not, and information on any parent organization, such as CVS Health, to classify
pharmacies into six mutually exclusive categories: 1) chains, including large retail pharmacies
such as Walgreens or Rite Aid; 2) independent (up to three stores under the same parent orga-
nization), including franchised pharmacies such as Medicine Shoppe; 3) mass retailers, such as
Costco or Target; 4) food stores, such as Giant or Jewel; 5) government, defined as a pharmacy
under the jurisdiction of federal, state, county or city government including the Indian Health
Service and the Veterans Administration; and 6) clinic-based (retail or government pharmacy
located on-site at a clinic, emergency room or outpatient medical center) such as Kaiser
Permanente.
Analysis
First, we used descriptive statistics to examine the distribution of our primary outcomes over-
all and by pharmacy type aggregated at the national and at county-level. Second, we used time-
series ordinary least squares (OLS) linear regression to determine the statistical significance of
differences over time in the number of pharmacies per-capita. Third, we used time-series logis-
tic regression to determine the statistical significance in differences in the distribution of phar-
macy type and pharmacy characteristics. Fourth, logistic regression was used to compare the
prevalence of pharmacy characteristics by pharmacy type for 2015. Fifth, in our county-level
analyses, we created categories of quintiles for each primary outcome. To account for differ-
ences in the sizes of the total population in different counties, we applied population-weights
when deriving national estimates (e.g. mean per-capita, mean % chain, mean % home deliv-
ery). We used OLS linear regression to test the statistical significance of the differences in these
primary outcomes by quintile category. Sixth, we examined the distribution of select pharmacy
characteristics by quintiles of county-level population demographics (i.e. % of total adult popu-
lation 65 years or older) for 2015. We used OLS linear regression to test the statistical signifi-
cance of the differences in the mean number of pharmacies per-capita and prevalence of
pharmacy characteristics (mean % multilingual staff) by quintile category. Finally, we used the
coefficient of variation (COV), calculated as the population-weighted standard deviation
divided by population-weighted mean, as a summary measure of the amount of variation in
the availability of pharmacies (i.e. mean per-capita), prevalence of pharmacy type (i.e. mean %
chain) and pharmacy characteristics (e.g. mean % multilingual) across counties. All analyses
were performed using STATA version 14 [College Station, Texas, USA]. The study was consid-
ered exempt by the University of Illinois at Chicago Institutional Review Board.
Results
The number of community pharmacies increased by 6.3%, from 63,752 pharmacies in 2007 to
67,753 pharmacies in 2015 (Table 1). This trend, however, varied across pharmacy type. For
example, there was an 18% increase in mass retailer pharmacies, compared to an 8.3% and 3.8%
increase, in chain and independent pharmacies, respectively. The distribution of pharmacy
types did not change considerably over this period, with chain and independent pharmacies
consistently more prevalent than their counterparts (Fig 1). For example, chain pharmacies
accounted for 38.8–39.0% of all pharmacies during this period, with fewer accounted for by
Availability of pharmacies in the US
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government-affiliated (~1%), clinic-based (~3%), mass retailer (~11%), food store (~10%) and
independent (~35%) pharmacies.
Overall, pharmacy characteristics did not change substantially between 2009 and 2015 (S1
Fig). In 2015, 27% of pharmacies reported offering home-delivery of prescription medications,
18% reported having a drive-up, 12% reported having multilingual staff, and 5% reported hav-
ing 24-hour emergency access (Table 2). By contrast, the share of pharmacies that reported
they accept e-prescriptions increased by 40% from 35.8% of all community pharmacies in
2009 to 50.1% in 2015 (p<0.001).
There were large differences in pharmacy characteristics by pharmacy type (Table 2). Of
the 26,789 chain pharmacies in 2015, 10.7% were opened for 24 hours and 23.9% reported
offering a drive-up window, which is a significantly higher proportion than all other pharmacy
types. Chain pharmacies, however, were significantly less likely than independent pharmacies
to report offering home-delivery (6.2% vs. 64.2%) or multilingual staff (1.8% vs. 30.6%). All of
these differences were statistically significant (p<0.001). This distribution of these characteris-
tics by pharmacy type was similar in 2009.
Although the number of pharmacies per-capita remained at 2.11 per 10,000 individuals
between 2007 and 2015 (S2 Fig), we found substantial variation across counties (Fig 2). In
2015 counties in the highest quintile had nearly three-fold more pharmacies than those in the
lowest quintile (mean 3.6 vs. 1.3 per-capita, respectively; p<0.001 from regression). Counties
in the lowest quintile appear to cluster in the Pacific West, Southwest and Great Lakes regions,
Table 1. Total number of pharmacies overall and by pharmacy type, 2007 to 2015.
2007 2008 2009 2010 2011 2012 2013 2014 2015 % Change
(2015 vs. 2007)
Chain 24,837 25,424 25,772 26,165 26,429 26,467 26,571 26,632 26,906 8.3%
Independent 22,737 20,844 20,389 20,792 21,165 22,124 22,438 22,900 23,596 3.8%
Mass 6,901 7,180 7,380 7,429 7,483 7,538 7,717 7,902 8,142 18.0%
Food 6,898 6,744 6,710 6,701 6,735 6,838 6,837 6,857 6,636 -3.8%
Clinic 1,924 2,078 2,075 2,067 2,003 1,984 1,915 1,957 1,897 -1.4%
Government 455 476 493 519 541 562 555 559 576 26.6%
Overall 63,752 62,746 62,819 63,673 64,356 65,558 66,033 66,807 67,753 6.3%
Source: Authors analysis of data from the National Council for Prescription Drug Programs (February 2007 to February 2015).
https://doi.org/10.1371/journal.pone.0183172.t001
Fig 1. Trends in the availability of community pharmacies by pharmacy type in the US, 2007–2015.
Data source: Authors’ analyses of data from the National Council for Prescription Drug Programs on licensed
community pharmacies in the U.S. (February 2007-February 2015).
https://doi.org/10.1371/journal.pone.0183172.g001
Availability of pharmacies in the US
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Table 2. Pharmacy characteristics overall and by pharmacy type, 2015.
Chain Independent Mass Food Clinic Government Overall
24 hour emergency access, % 10.7 1.2*0.85*0.73*2.24*7.5*4.9
Drive-up, % 23.9 15.5*2.64*21.0 2.2*4.9*17.5
Home Delivery, % 6.24 66.6*0.02 9.25*24.9*7.8 27.1
Multilingual Staff, % 1.8 30.6*0.2 1.54 28.7*6.9*12.4
Accept e-prescriptions, % 49.2 56.7*28.4*61.2*43.1*13.6*50.1
Source: Authors analysis of data from the National Council for Prescription Drug Programs (February 2015). Notes: Logistic regression was used to
compare the prevalence pharmacy accommodations across pharmacy types. Significance refers to differences in prevalence between chain and all other
pharmacy types.
*p-<0.001
https://doi.org/10.1371/journal.pone.0183172.t002
Fig 2. Pharmacies per 10,000 People by County in the U.S., 2015. Data source: Authors’ analyses of data from the National Council for
Prescription Drug Programs on licensed community pharmacies in the U.S. for February 2015, and the US Census Bureau’s Population
Estimates Program to derive information on annual total population for all counties (N = 3,141) for each year between 2007 and 2015.
https://doi.org/10.1371/journal.pone.0183172.g002
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while counties with the highest tend to be located in the Northeast, Southeast, Northern Appa-
lachia, and Plain states.
Fig 3 depicts the distribution of chain and independent pharmacies across counties in 2015.
Chain pharmacies predominate in the Northeast and Western regions, while independent
pharmacies account for the majority of pharmacies in the Southeast, Southwest and Plain
states. Independent pharmacies accounted for the total pharmacy market in 446 counties (14%
of counties); more than half (52.3%) of these counties, however, had only one independent
pharmacy. In contrast, less than 2% (66 counties) were exclusively comprised of retail chains.
In addition, there are disproportionately more independent pharmacies in counties designated
as MUAs (35.6%) when compared to non-MUAs (30.6%) (p<0.001).
Fig 4 depicts the association between the per-capita availability of pharmacies, select phar-
macy characteristics and population demographics at the county level. Although there was no
substantial difference in the availability (or accessibility) of pharmacies by MUA status, phar-
macies offering 24-hour emergency access were least prevalent in MUAs. There were also
notable differences across population demographics. For example, counties in the highest
Fig 3. Retail Chain and Independent Pharmacies by County in the U.S., 2015.
https://doi.org/10.1371/journal.pone.0183172.g003
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non-English speaking population quintile had significantly fewer pharmacies than those in the
lowest quintile (1.97 vs. 2.57 per-capita, respectively; p<0.001). Although multilingual phar-
macies were most prevalent in these counties, more than 80% of pharmacies in these areas did
not have multilingual staff in 2015. The share of pharmacies offering home-delivery of pre-
scription medications was less in counties with the highest population of adults with an ambu-
latory disability compared to those counties with the least (25.5% vs. 34.7%, respectively;
p<0.001). In addition, there was no strong association between the proportion of pharmacies
offering home delivery and quintiles for percent of the population 65 years or older.
Pharmacy characteristics also varied substantially across counties. This variation was partic-
ularly pronounced for multilingual staffing and least pronounced for e-prescribing (coefficient
of variation 1.02 vs. 0.26, respectively). (S3 Fig).
Discussion
We linked detailed information from the National Council for Prescription Drug Programs
with publically available demographic data to examine the availability and characteristics of
pharmacies in the United States. The total number of pharmacies increased by 6.3% over a
nine-year period, reaching more than sixty-seven thousand pharmacies in 2015. The availabil-
ity of pharmacies per-capita, however, did not change during this period, but varied substan-
tially across local areas. While retail chains persistently account for the largest share of the
Fig 4. The availability of pharmacies and accommodations by quintiles of county population demographics,
2015. Data sources: Authors’ analyses of data from the National Council for Prescription Drug Programs on licensed
community pharmacies in the U.S. for February 2015; the US Census Bureau’s Population Estimates Program to derive
information on annual total population at the county-level for 2015; 2010 US decennial Census to derive information in
the % of the population aged 65 years or older; 5-year estimates (2010–2014) from the American Community Survey to
derive information on the percent of the population that is non-English speaking defined as those who “speak a language
other than English” and percent of the adult population that has an ambulatory disability; and the Health Resources and
Services Administration to identify counties that are designated as completely or partially Medically Underserved Areas/
Populations (MUA/P) or primary care Health Professional Shortage Areas (HPSA). Quintiles (range) are reported from
lowest to highest percent (Quintiles 1 to 5) of county population demographics. For example, 0 to 2.5% of the total
population is non-English speaking for counties in Quintile 1. Reported means are population-weighted to account for
differences in the size of county total populations; Error-Bars are 95% Confidence Intervals.
https://doi.org/10.1371/journal.pone.0183172.g004
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pharmacy market, independent pharmacies continued to constitute approximately a third of
all stores in the U.S. With the exception of e-prescribing, there was no marked change in phar-
macy characteristics, including accommodations that may promote access to prescription
medications for vulnerable Americans, such as home delivery and multilingual staffing.
To our knowledge, this is the first study to characterize the availability of pharmacies at the
national and local level. This information is important to a variety of stakeholders in both the
public and private sector, including local, state and federal public health and policy officials
and pharmacy retailers, interested in better understanding the role of pharmacies in improving
access and adherence to prescription medications. Although policy efforts—such as Medicare
Part D—have focused on ensuring the affordability of prescription medications [18], non-
adherence, which varies across localities [5,6], persists as important public health problem in
the U.S. [19], suggesting access barriers, including pharmacy accessibility and the provision of
pharmacy accommodations associated with access to prescription medications, are also impor-
tant to consider.
Despite the growing number of pharmacies in the U.S., we identified nearly a three-fold dif-
ference in their availability across local areas. This extends findings on geographic variation in
access to care [2022], to pharmacies. In 2015, there was more than a 3-fold difference in the
number of pharmacies per-capita between counties in the highest and those in the lowest quin-
tile, with no clear difference by MUA status. Specifically, there were fewer pharmacies located
in the Southwest and Pacific West regions of the country, including counties in Texas, Califor-
nia, New Mexico and Arizona; many of these areas also have a disproportionately higher rate
of medication non-adherence among Medicare-Part D beneficiaries[5]. These findings suggest
some localities are disproportionately more likely to encounter barriers in the availability of
pharmacies when attempting to fill and adhere to their prescription medications.
Although the distribution of pharmacies by type has not changed over time, it varies across
local areas. While retail chains dominate the pharmacy market, and fewer than one-fifth of
prescriptions are dispensed at independent pharmacies [23], independent pharmacies persis-
tently accounted for more than one-third of all community pharmacies in the U.S. In fact, in
numerous areas in the country, particularly in the Southwest and Plain states, independents
dominate market share and are frequently the only pharmacy serving the local population.
Ensuring pharmacies are available and accessible in these populations should be a public
health priority considering independents are the most at-risk for pharmacy closures [24].
According to our analyses of pharmacy characteristics, the provision of accommodations
that may improve access to prescription medications has not changed and the vast majority of
pharmacies do not offer them. For example, only one-fourth of pharmacies offered home
delivery, despite a growing population of homebound elderly [25], as well as some evidence
that home delivery improves medication adherence [9]. The availability of 24-hour pharmacies
is also of interest; since only one in twenty pharmacies we examined are opened for 24-hours,
yet longer hours of operation may be associated with lower hospital re-admissions [26].
Despite federal legislation that mandates non-discriminatory access to accommodations and
language services [27], our findings also suggest that many pharmacies lack multilingual staff-
ing which may impede access and adherence to prescription medications for a growing popu-
lation of immigrant Americans who may not be proficient in English [28].
While we found a large increase in the share of pharmacies that reported accepting e-pre-
scriptions, nearly half of pharmacies still didn’t accept them in 2015. This is surprising consid-
ering most pharmacies are enabled for, and seventy percent of clinics have adopted, e-
prescribing [29]. The underuse of e-prescribing by pharmacies may be due to the exclusion of
pharmacies as eligible providers under the Centers for Medicare and Medicaid Services elec-
tronic health record incentive programs, for which e-prescribing is part of the “meaningful
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use” requirement [30]. Including pharmacies as eligible providers may encourage pharmacy
participation and promote the “meaningful use” of e-prescribing and, most importantly,
reduce medication non-adherence [9].
We also found that pharmacy characteristics, specifically the provision of accommodations
associated with access to prescription medications, varied across counties and may not align
with the needs of the local population. For example, multilingual pharmacies were only slightly
more prevalent in predominately non-English speaking counties. For example, more than 90%
of the population in Starr County, Texas speaks a language other than English, but only six of
the twelve pharmacies have multilingual staff. In addition, less than one-third of pharmacies
located in counties with a disproportionately higher older adult or ambulatory disability popu-
lation offered home-delivery services. These findings suggest Americans that do not speak
English and the homebound elderly may encounter accommodation, including language, bar-
riers as they attempt to fill their prescription medications or engage with community
pharmacies.
Efforts to improve access to pharmacies, and, in turn, prescription medications, should
consider policies and programs that support the measuring and monitoring of pharmacy
accessibility. For example, the Health Resources and Services Administration (HRSA), the fed-
eral agency responsible for designated MUA/Ps and health professional shortage areas, should
consider including a designation to identify pharmacy shortage areas. In partnership with
pharmacy retailers, federal and state policy officials and local health departments can then pri-
oritize resources and funding decisions to target the development of pharmacies in these phar-
macy shortage areas.
Pharmacy retailers, including chains and independents, may also consider monitoring pop-
ulation demographics to inform decisions on pharmacy operations to better ensure pharma-
cies offer accommodations that specifically target the needs of the local population. For
example, the provision of home-delivery services would be a priority for pharmacies located in
areas that have a disproportionately higher homebound elderly population. Such efforts can
strengthen the capacity of pharmacies to promote access to prescription medications locally,
particularly in vulnerable populations, and also support a more efficient and equitable distri-
bution of pharmacy accommodations.
Our analyses have several limitations. First, our information regarding the characteristics of
pharmacies is based on self-report. However, we randomly selected a subset of 100 pharmacies
and were able to independently validate that 98 were operational. Of these 100 cases, the data
we obtained regarding 24-hour emergency access and drive-up service were correct in 95 and
98% of cases, respectively. Our national findings on the prevalence of home-delivery services
among independent pharmacies and the percent of pharmacies that accept e-prescriptions
were similar to prior reports [29,31]. In addition, our information is comparable to our prior
analyses of pharmacy licensure in one large Midwestern city [7]. Second, while we were able to
assess important pharmacy characteristics that may impact access to prescription medications,
these characteristics nevertheless provide an incomplete picture of how easily consumers can
use these pharmacies. For example, we do not incorporate the hours of operation of these
stores, walkability, vehicle ownership, public transportation characteristics of counties, and
geographic accessibility based on travel distance/time to nearest pharmacy. We also do not
capture information on interpreter services, which may be offered at pharmacies that lack mul-
tilingual staff. Third, there may be considerable variation in the availability of pharmacies
within counties [7]. Fourth, the target population served by pharmacies we have defined as
government or clinic-based, in contrast to retail pharmacies, may not include the entire local
population. Finally, while we characterized how pharmacy characteristics varied based on sev-
eral county characteristics, we did not incorporate information that directly measures the need
Availability of pharmacies in the US
PLOS ONE | https://doi.org/10.1371/journal.pone.0183172 August 16, 2017 10 / 13
for pharmacies to be located in a specific geography (e.g. demand for prescription medications
based on underlying disease burden).
Conclusion
Although the number of pharmacies has slightly increased over the last nine years in the
United States, with both retail chains and independent pharmacies consistently leading the
pharmacy market, availability of pharmacies varies substantially across local areas. Many phar-
macies do no offer accommodations that facilitate access to prescription medications, and
pharmacists, and, in turn, promote medication adherence. Future programs and policies
should address the availability of pharmacies and ensure pharmacy characteristics, including
accommodations such as multilingual staffing and home delivery, align with local population
needs.
Supporting information
S1 Fig. Trends in pharmacy characteristics and accomodation services overall and by phar-
macy type, 2009–2015.
(PDF)
S2 Fig. Number of pharmacies per 10,000 population (per-capita) in the U.S., 2007–2015.
(PDF)
S3 Fig. The availability of pharmacy accomodations by county in the U.S., 2015.
(PDF)
Author Contributions
Conceptualization: Dima Mazen Qato, Shannon Zenk, Darrell Gaskin, G. Caleb Alexander.
Data curation: Dima Mazen Qato, Jocelyn Wilder, Rachel Harrington.
Formal analysis: Jocelyn Wilder.
Funding acquisition: Dima Mazen Qato, G. Caleb Alexander.
Methodology: Dima Mazen Qato, Shannon Zenk, Darrell Gaskin, G. Caleb Alexander.
Project administration: Dima Mazen Qato.
Resources: Dima Mazen Qato.
Software: Dima Mazen Qato.
Supervision: Dima Mazen Qato, Shannon Zenk, G. Caleb Alexander.
Validation: Dima Mazen Qato.
Writing – original draft: Dima Mazen Qato, G. Caleb Alexander.
Writing – review & editing: Dima Mazen Qato, Shannon Zenk, Darrell Gaskin, G. Caleb
Alexander.
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Supplementary resources

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    Full-text available
    Introduction: Nonadherence to taking prescribed antihypertensive medication (antihypertensive) regimens has been identified as a leading cause of poor blood pressure control among persons with hypertension and an important risk factor for adverse cardiovascular disease outcomes. CDC and the Centers for Medicare and Medicaid Services analyzed geographic, racial-ethnic, and other disparities in nonadherence to antihypertensives among Medicare Part D beneficiaries in 2014. Methods: Antihypertensive nonadherence, defined as a proportion of days a beneficiary was covered with antihypertensives of <80%, was assessed using prescription drug claims data among Medicare Advantage or Medicare fee-for-service beneficiaries aged ≥65 years with Medicare Part D coverage during 2014 (N = 18.5 million). Analyses were stratified by antihypertensive class, beneficiaries' state and county of residence, type of prescription drug plan, and treatment and demographic characteristics. Results: Overall, 26.3% (4.9 million) of Medicare Part D beneficiaries using antihypertensives were nonadherent to their regimen. Nonadherence differed by multiple factors, including medication class (range: 16.9% for angiotensin II receptor blockers to 28.9% for diuretics); race-ethnicity (24.3% for non-Hispanic whites, 26.3% for Asian/Pacific Islanders, 33.8% for Hispanics, 35.7% for blacks, and 38.8% for American Indians/Alaska Natives); and state of residence (range 18.7% for North Dakota to 33.7% for the District of Columbia). Considerable county-level variation in nonadherence was found; the highest nonadherence tended to occur in the southern United States (U.S. Census region nonadherence = 28.9% [South], 26.7% [West], 24.1% [Northeast], and 22.8% [Midwest]) CONCLUSIONS AND IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: More than one in four Medicare Part D beneficiaries using antihypertensives were nonadherent to their regimen, and certain racial/ethnic groups, states, and geographic areas were at increased risk for nonadherence. These findings can help inform focused interventions among these groups, which might improve blood pressure control and cardiovascular disease outcomes.
  • Article
    The Community Aging in Place, Advancing Better Living for Elders (CAPABLE) program, funded by the Center for Medicare and Medicaid Innovation, aims to reduce the impact of disability among lowincome older adults by addressing individual capacities and the home environment. The program, described in this innovation profile, uses an interprofessional team (an occupational therapist, a registered nurse, and a handyman) to help participants achieve goals they set. For example, it provides assistive devices and makes home repairs and modifications that enable participants to navigate their homes more easily and safely. In the period 2012-15, a demonstration project enrolled 281 adults ages sixtyfive and older who were dually eligible for Medicare and Medicaid and who had difficulty performing activities of daily living (ADLs). After completing the five-month program, 75 percent of participants had improved their performance of ADLs. Participants had difficulty with an average of 3.9 out of 8.0 ADLs at baseline, compared to 2.0 after five months. Symptoms of depression and the ability to perform instrumental ADLs such as shopping and managing medications also improved. Health systems are testing CAPABLE on a larger scale. The program has the potential to improve older adults' ability to age in place. © 2016 Project HOPE-The People-to-People Health Foundation, Inc.
  • Article
    Objectives: To characterize the pharmacy density in rural and urban communities with hospitals and to examine its association with readmission rates. Design: Ecologic study. Setting: Forty-eight rural and urban primary care service areas (PCSAs) in the state of Oregon. Participants: All hospitals in the state of Oregon. Intervention: Pharmacy data were obtained from the Oregon Board of Pharmacy based on active licensure. Pharmacy density was calculated by determining the cumulative number of outpatient pharmacy hours in a PCSA. Main outcome measures: Oregon hospital 30-day all-cause readmission rates were obtained from the Centers for Medicare and Medicaid Services and were determined with the use of claims data of patients 65 years of age or older who were readmitted to the hospital within 30 days from July 2012 to June 2013. Results: Readmission rates for Oregon hospitals ranged from 13.5% to 16.5%. The cumulative number of pharmacy hours in PCSAs containing a hospital ranged from 54 to 3821 hours. As pharmacy density increased, the readmission rates decreased, asymptotically approaching a predicted 14.7% readmission rate for areas with high pharmacy density. Conclusion: Urban hospitals were in communities likely to have more pharmacy access compared with rural hospitals. Future research should determine if increasing pharmacy access affects readmission rates, especially in rural communities.
  • Article
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    The problem: Nonadherence to prescription medications is a common and costly problem with multiple contributing factors, spanning the dimensions of individual behavior change, psychology, medicine, and health policy, among others. Addressing the problem of medication nonadherence requires strategic input from key experts in a number of fields. Meeting of experts: The Medication Adherence Alliance is a group of key experts, predominately from the US, in the field of medication nonadherence. Members include representatives from consumer advocacy groups, community health providers, nonprofit groups, the academic community, decision-making government officials, and industry. In 2015, the Medication Adherence Alliance convened to review the current landscape of medication adherence. The group then established three working groups that will develop recommendations for shifting toward solutions-oriented science. Commentary of expert opinion: From the perspective of the Medication Adherence Alliance, the objective of this commentary is to describe changes in the US landscape of medication adherence, framing the evolving field in the context of a recent think tank meeting of experts in the field of medication adherence.
  • Article
    Adherence to statins is lower in black and Hispanic patients and is linked to racial/ethnic disparities in cardiovascular mortality. Poverty, education, and prescription coverage differentials are typically invoked to explain adherence disparities, but analyses at the level of neighborhoods and their pharmacies may provide additional insights. Among individuals filling new statin prescriptions in a national pharmacy chain (N = 326,171), we compared adherence for patients residing in mostly minority neighborhoods to those living in mainly white areas. In analyses adjusting for patient-level factors associated with poor adherence, including age, insurance, payer, prescription cost, and convenience, patients residing in black and Hispanic neighborhoods had 2-3 weeks less statin therapy over 1 year, a pattern not seen in Asian areas. In black and Hispanic neighborhoods, good adherence was associated with co-pays under $10, the use of 90-day refills, and payers other than Medicaid. Efforts to improve medication adherence for vulnerable populations may benefit from interventions at the level of local pharmacies, as well as medication benefit redesign.
  • Article
    Background: Taking medications as prescribed is imperative for their effectiveness. In populations such as Medicare, where two thirds of Medicare beneficiaries have at least 2 or more chronic conditions requiring treatment with medications and account for more than 90% of Medicare health care spend, examining ways to improve medication adherence in patients with comorbidities is warranted. Objective: To examine the association of pharmacy dispensing channel (home delivery or retail pharmacy) with medication adherence for Medicare patients taking medications with comorbid conditions of diabetes, hypertension, and high blood cholesterol (3 of the top 5 most prevalent conditions), while controlling for various confounders. Methods: A retrospective analysis was conducted using de-identified pharmacy claims data from a large national pharmacy benefits manager between October 2010 and December 2012. Continuously eligible Medicare Part D patients (Medicare Advantage Prescription Drug plan and Prescription Drug Plan only) aged 65 years or older who had an antidiabetic, antihypertensive, and antihyperlipidemic prescription claim between October and December 2010 were identified and analyzed over a 2-year period. Multivariate logistic regression was used to evaluate the association between dispensing channel (DC) and medication adherence in calendar year (CY) 2012 controlling for prior adherence behavior (adherence in CY2011), differences in demographics, low-income subsidy status, days supply, disease burden, and drug-use pattern. Patients with a proportion of days covered (PDC) of at least 80% for each of the 3 conditions were considered to be adherent, and patients with PDC less than 80% for each of the 3 conditions were considered to be nonadherent. Patients were assigned to a DC depending on where they filled at least 66.7% of their prescriptions for each of the 3 conditions, and the rest were assigned to a mixed channel group. Results: The final analytical sample consisted of 40,632 patients. The adjusted odds of adherence for patients using home delivery were 1.59 (95% CI = 1.40-1.80) higher compared with patients using retail channels to obtain their prescriptions. Conclusions: Medicare Part D patients taking medications for comorbid conditions who used home delivery had a greater likelihood (adjusted) of adherence than patients who filled their antidiabetic, antihypertensive, and antihyperlipidemic prescriptions using retail channels. Managed care stakeholders looking to make informed decisions in a cost-constrained environment to assess, implement, and promote solutions that improve health outcomes should consider the use of home delivery of prescriptions to improve adherence for Medicare Part D patients with comorbid conditions. Disclosures: Funding for this study was provided internally by Express Scripts Holding Company. Iyengar, LeFrancois, Henderson, and Rabbitt are employees of Express Scripts. Study concept and design were created by Iyengar and LeFrancois. Iyengar was responsible for acquisition of data, statistical analysis, and interpretation of data. The manuscript was written by Iyengar and LeFrancois and revised by all the authors.
  • Article
    Despite initial controversy and uncertainties, Medicare Part D now provides drug coverage to thirty-nine million beneficiaries through dozens of private plans in each region. Although firmly established, the program faces challenges, including projected spending growth. Enrollees also face challenges as plans adopt new strategies to control costs. © 2015 Project HOPE-The People-to-People Health Foundation, Inc.