ArticlePDF Available

Abstract and Figures

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 (
Content may be subject to copyright.
The availability of pharmacies in the United
States: 2007–2015
Dima Mazen Qato
*, Shannon Zenk
, Jocelyn Wilder
, Rachel Harrington
Darrell Gaskin
, G. Caleb Alexander
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
Despite their increasingly important role in health care delivery, little is known about the
availability, and characteristics, of community pharmacies in the United States.
(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.
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.
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 | August 16, 2017 1 / 13
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.
Editor: Jacobus P. van Wouwe, TNO,
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
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.
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.
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 | 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.
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
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”
Availability of pharmacies in the US
PLOS ONE | August 16, 2017 3 / 13
[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
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.
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
PLOS ONE | August 16, 2017 4 / 13
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).
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).
Availability of pharmacies in the US
PLOS ONE | August 16, 2017 5 / 13
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.
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.
Availability of pharmacies in the US
PLOS ONE | August 16, 2017 6 / 13
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.
Availability of pharmacies in the US
PLOS ONE | August 16, 2017 7 / 13
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).
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.
Availability of pharmacies in the US
PLOS ONE | August 16, 2017 8 / 13
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
Availability of pharmacies in the US
PLOS ONE | August 16, 2017 9 / 13
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
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 | 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).
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
Supporting information
S1 Fig. Trends in pharmacy characteristics and accomodation services overall and by phar-
macy type, 2009–2015.
S2 Fig. Number of pharmacies per 10,000 population (per-capita) in the U.S., 2007–2015.
S3 Fig. The availability of pharmacy accomodations by county in the U.S., 2015.
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
1. Kaiser Family Foundation. Retail Prescription Drugs Filled at Pharmacies (Annual per Capita) 2015.
2. Drug Store News. Rx Impact: A Drug Store News Special Report. March 2016. http://www.
Availability of pharmacies in the US
PLOS ONE | August 16, 2017 11 / 13
3. Rudavsky R, Pollack CE, Mehrotra A. The geographic distribution, ownership, prices, and scope of
practice at retail clinics. Annals of internal medicine. Sep 1 2009; 151(5):315–320. PMID: 19721019
4. Brennan TA, Dollear TJ, Hu M, Matlin OS, Shrank WH, Choudhry NK, Grambley W. An integrated phar-
macy-based program improved medication prescription and adherence rates in diabetes patients.
Health Aff (Millwood). 2012 Jan; 31(1):120–9.
5. Ritchey M, Chang A, Powers C, Loustalot F, Schieb L, Ketcham M, Durthaler J, Hong Y. Vital Signs:
Disparities in Antihypertensive Medication Nonadherence Among Medicare Part D Beneficiaries—
United States, 2014. MMWR Morb Mortal Wkly Rep. 2016 Sep 16; 65(36):967–76.
15585/mmwr.mm6536e1 PMID: 27632693
6. Davis AM, Taitel MS, Jiang J, Qato DM, Peek ME, Chou CH, Huang ES. A National Assessment of
Medication Adherence to Statins by the Racial Composition of Neighborhoods. J Racial Ethn Health
Disparities. 2017 Jun; 4(3):462–471. PMID: 27352117
7. Qato DM, Daviglus ML, Wilder J, Lee T, Qato D, Lambert B. ’Pharmacy deserts’ are prevalent in Chica-
go’s predominantly minority communities, raising medication access concerns. Health Aff (Millwood).
Nov 2014; 33(11):1958–1965.
8. Qato DM, Wilder J, Zenk S, Davis A, Makelarski J, Lindau ST. Pharmacy accessibility and cost-related
underuse of prescription medications in low-income Black and Hispanic urban communities. J Am
Pharm Assoc (2003). 2017 Mar—Apr; 57(2):162–169.
9. Iyengar RN, LeFrancois AL, Henderson RR, Rabbitt RM. Medication Nonadherence Among Medicare
Beneficiaries with Comorbid Chronic Conditions: Influence of Pharmacy Dispensing Channel. Journal
of managed care & specialty pharmacy. May 2016; 22(5):550–560.
10. Fischer MA, Stedman MR, Lii J, et al. Primary medication non-adherence: analysis of 195,930 elec-
tronic prescriptions. Journal of general internal medicine. Apr 2010; 25(4):284–290.
1007/s11606-010-1253-9 PMID: 20131023
11. Ferna
´ndez A, Quan J, Moffet H, Parker MM, Schillinger D, Karter AJ. Adherence to Newly Prescribed
Diabetes Medications Among Insured Latino and White Patients With Diabetes. JAMA Intern Med.
2017 Mar 1; 177(3):371–379. PMID: 28114642
12. Westberg SM, Sorensen TD. Pharmacy-related health disparities experienced by non-english-speaking
patients: impact of pharmaceutical care. J Am Pharm Assoc (2003). 2005 Jan-Feb; 45(1):48–54.
13. National Council for Prescription Drug Programs (NCPDP). DATAQ Pharmacy database file (version
14. United States Census Bureau Population Estimates Program.
15. American Community Survey (2010–2014) 5-year estimates. Language Spoken at Home. http://
16. United States 2010 Census. Percent of Total Population 65 years or older.
17. Health Resources and Services Adminisration Data Warehouse.
18. Hoadley JF, Cubanski J, Neuman P. Medicare’s Part D Drug Benefit At 10 Years: Firmly Established
But Still Evolving. Health Aff (Millwood). 2015 Oct; 34(10):1682–7. d
19. Zullig LL, Granger BB, Bosworth HB. A renewed Medication Adherence Alliance call to action: harness-
ing momentum to address medication nonadherence in the United States. Patient preference and
adherence. 2016; 10:1189–1195. PMID: 27462145
20. Zhang Y, Baicker K, Newhouse JP. Geographic variation in the quality of prescribing. The New England
journal of medicine. Nov 18 2010; 363(21):1985–1988. PMID:
21. Newhouse JP, Garber AM. Geographic variation in Medicare services. The New England journal of
medicine. Apr 18 2013; 368(16):1465–1468. PMID: 23520983
22. Radley DC, Schoen C. Geographic variation in access to care—the relationship with quality. The New
England journal of medicine. Jul 5 2012; 367(1):3–6. PMID:
23. IMS Institute for Healthcare Informatics. Medicines Use and Spending in the U.S.: A Review of 2015
and Outlook to 2020.
24. Klepser DG, Xu L, Ullrich F, Mueller KJ. Trends in community pharmacy counts and closures before
and after the implementation of Medicare part D. J Rural Health. 2011 Spring; 27(2):168–75. https://doi.
org/10.1111/j.1748-0361.2010.00342.x PMID: 21457309
Availability of pharmacies in the US
PLOS ONE | August 16, 2017 12 / 13
25. Szanton SL, Leff B, Wolff JL, Roberts L, Gitlin LN. Home-Based Care Program Reduces Disability And
Promotes Aging In Place. Health Aff (Millwood). Sep 1 2016; 35(9):1558–1563.
26. Bissonnette S, Goeres LM, Lee DS. Pharmacy density in rural and urban communities in the state of
Oregon and the association with hospital readmission rates. Journal of the American Pharmacists Asso-
ciation: JAPhA. Sep-Oct 2016; 56(5):533–537. PMID:
27. Elizabeth Cornachione MM, and Samantha Artiga. Summary of HHS’s Final Rule on Nondiscrimination
in Health Programs and Activities Kaiser Family Foundation. 2016.
28. Eric B. Jensen RB, and Melissa Scopilliti. Demographic Analysis 2010: Estimates of Coverage of the
Foreign-Born Population in the American Community Survey.
29. Meghan Hufstader Gabriel MS. E-Prescribing Trends in the United States (2014). http://www.healthit.
30. Joseph SB, Sow MJ, Furukawa MF, Posnack S, Daniel JG. E-prescribing adoption and use increased
substantially following the start of a federal incentive program. Health Aff (Millwood). Jul 2013; 32
31. National Community Pharmacists Association (NCPA). NCPA 2016 Digest: Opportunities for Commu-
nity Pharmacy in a Changing Market.
Availability of pharmacies in the US
PLOS ONE | August 16, 2017 13 / 13
... 28 Pharmacists are some of the most accessible healthcare providers and are underutilized in the HIV and HCV care continuum. 29 Considerable research has shown pharmacist involvement in the care of individuals with HIV and HCV leads to improvement in adherence, reduced pill burden, and higher rates of viral load suppression for HIV, and enhanced cure rates and medication optimization for HCV infection. [30][31][32][33][34] Given the established success of pharmacy involvement in the management of HIV and HCV, there is precedent for community pharmacists to take on a greater role to expand access in the HIV and HCV care continuum by targeting suboptimal linkage and retention in care that is currently impeding the success of UNAIDS initiative and the National Viral Hepatitis Action Plan. ...
... Pharmacists are some of the most accessible healthcare providers and are underutilized in the current healthcare system in the U.S. 29,42,43 For vulnerable populations such as individuals who are experiencing homelessness, pharmacists can play a significant role in the health management of these patients who have built a trusting relationship through coordination of care and referral. 44 Individuals experiencing homelessness tend to overutilize emergency department services as their primary or only source of healthcare resulting from a lack of proactive engagement in care. ...
Full-text available
Introduction In 2019, there were over 1.1 million people living with human immunodeficiency virus (HIV) and 2.4 million people living with hepatitis C virus (HCV) in the United States. One in seven (14%) are unaware of their HIV infection and almost half of all HCV infections are undiagnosed. People with unstable housing are disproportionately affected by HIV and HCV. The present study will evaluate interventions by community pharmacists that may reduce HIV and HCV transmission and promote linkage to care. Methods This study was conducted in an independent community pharmacy in Spokane, Washington. Eligible study participants were walk-in patients of the pharmacy, over the age of 18, and experiencing homelessness. Pharmacy patients were excluded if they had a history of HIV or HCV diagnosis, received a screening for HIV or HCV in the last six months or were unable to give informed consent. The intervention included administration of HIV and HCV point-of-care testing (POCT) using a blood sample, risk determination interview, comprehensive HIV and HCV education, and personalized post-test and risk mitigation counseling followed by referral to partnering health clinics. Results Fifty participants were included in the final data analysis. Twenty-two participants (44%) had a reactive HCV POCT, and one participant had a reactive HIV POCT. Of the 94% of participants who reported illicit drug use, 74% reported injection drug use. Seventy-six percent (n = 38) qualified for PrEP. Pharmacist referrals were made for 28 participants and 71% were confirmed to have established care. Conclusion Individuals experiencing homelessness are at an increased risk for acquiring HIV and HCV due to risky sexual behaviors and substance misuse. PrEP is underutilized in the U.S. and pharmacist involvement in the HIV and HCV care continuum may have a significant impact in improving linkage and retention in care of difficult to treat populations.
... [13][14][15][16][17] The accessibility of vaccination services provided by pharmacies may be especially important for older adults, a population that experiences more physical and psychological barriers to accessing health care due to lack of transportation and concerns about provider availability and responsiveness as compared to younger adults. 18,19 With >90% of the US population living within two miles of a community pharmacy, 20 [21][22][23] Despite the increased trend in the use of retail pharmacies to receive the influenza vaccination, influenza vaccination rates of older adults in the US have remained below the 90% goal set by Healthy People 2020. 24,25 About 1.6 million older adults in the US are homebound and half of them have one or more barriers to accessing vaccination services. ...
Full-text available
Background Pharmacy-provided influenza vaccination services have become more prevalent among the older adult population. However, little is known about the characteristics of older adults associated with receiving the influenza vaccination at retail pharmacies and how these associated characteristics have changed. Objective To examine characteristics of older adults associated with use of retail pharmacy-provided influenza vaccination services and how the characteristics changed between 2009 and 2015. Methods The study used a retrospective, cross-sectional design with data from the 2009 and 2015 Medicare Current Beneficiary Survey. Older adults aged 65 and older who completed a community questionnaire and received the influenza vaccination during the previous winter were identified. Andersen's Behavioral Model of Health Services Use was the conceptual framework for inclusion of the population characteristics. A multivariable log-binomial regression was performed to estimate the association between the population characteristics and use of pharmacy-provided vaccination service, and the relative change in associations between 2009 and 2015. Survey weights were applied in all analyses. Results The results showed older adults who were non-Hispanic black (compared to non-Hispanic white), who did not have secondary private insurance (compared to those who had), who did not have physician office visit (compared to those who had) and who lived in non-metro area (compared to those who lived in metro area) had become more likely to use pharmacy-provided influenza vaccination services in 2015 than in 2009. Conclusions Pharmacy-provided influenza vaccination services appear to reduce access barriers for racially and socioeconomically disadvantaged older adults. Findings could help inform not only the retail pharmacies that provide vaccination services to better outreach to potential target populations but also policy makers about the disadvantaged populations that would benefit from the vaccination services provided by retail pharmacies.
... DHHS aims to accelerate testing and other pandemic-related care for more Americans in communities across the country. [17][18][19] Twenty-eight (80%) participants supported COVID-19 testing from pharmacists, and sixteen (45.7%) were encouraged to receive their COVID vaccination, which could also translate to increased patient access to, and utilization of, other pharmacy point-of-care screening tests such as streptococcus, influenza, or Human Immunodeficiency Virus (HIV) screening services. Patients interact with pharmacists significantly more frequently than their primary care providers. ...
Full-text available
Introduction: Community pharmacies across the country have been adapting the ways their patients receive medications and prescription information during the COVID-19 pandemic. In order to reduce the risk of COVID-19 infection, the CDC encouraged patients to use pharmacy drive-throughs, curbside pickup, or home delivery services to obtain medications. This research study is one of the first studies to analyze how patients utilize and access Medication Management Services (MMS) in the community pharmacy setting during the COVID-19 pandemic. Objective: To evaluate changes to patients’ utilization of Medication Management Services in the community pharmacy setting during the COVID-19 pandemic. Methods: Eligible patients included persons 18 years old and older, and currently taking at least (1) chronic prescription medication in the last three months. Pharmacists were excluded from the study. Telephonic or video interviews were conducted with patients from community pharmacy settings. Descriptive statistics were used to summarize patient characteristics and responses to select interview questions. A qualitative thematic analysis was conducted with data collected from open-ended interview questions. Results: Thirty-five patients participated in interviews. Patients reported increased use of telehealth and technology, increases in quantity or days supply of medications, initiation of mail delivery services, and curbside pick-up. Five (14.3%) patients used telehealth or increased their technology usage due to the pandemic. Seven (20%) patients reported they were more proactive in refilling their medications. Eleven (31.4%) patients indicated they were currently using a prescription delivery service and were likely to continue the service. On the contrary, five (14.3%) patients experienced decreased healthcare professional interactions, while 3 (8.6%) patients encountered slowed pharmacy processing and 2 (5.7%) faced technology barriers. However, 58% of patients reported no changes to the way they utilized MMS during COVID-19. Conclusion: Like many other healthcare providers, the COVID-19 pandemic caused a shift in how community pharmacies care for the patients they serve. This study identified various changes in how the pandemic impacted the way patients accessed and utilized community pharmacy services. These findings can serve to inform community pharmacies on how to best serve their patients during this and future pandemic.
... This directive should encompass all inclusive of income, region, and accessibility to set-up a healthcare system which upholds equity. More pronounced and probable medical issues should be assigned more resources 19 to reduce their impact while a substantial backup strategy and resources are improvised in the case of an emergency. Such a practice is currently underway in Germany whereby the Bismarck system policies are being reverted 20 to more relevant and effectual in terms of quality and cost of healthcare services to people. ...
Retail pharmacies have been declining in regard to physical stores as well as value as perceived by the society. Even in the face of their declination there are little amendments or implementations made to avert this, most have turned out to be ineffectual to the occurrence. Alongside primary healthcare facilities such as hospitals, pharmacies can offer a decentralized healthcare system whereby they can divert some of the healthcare services and assist in the development of an effectual healthcare system. To create an effectual healthcare system former policies have to be altered and new ones which promote quality and affordable healthcare.
... Patient access to pharmacist services has been the focus of a growing literature. These include studies of pharmacy service availability: across urban and rural areas of New Zealand [3] and the United States; [4] in areas populated predominantly by lower income households in England [5] and in various cities in the United States; [5][6][7][8] and among the elderly living in Scotland [9] and Portugal [10]. Waterson developed an economic framework to determine the optimal number of pharmacies and compared the density of pharmacies in Melbourne, Australia to the optimum [11]. ...
Full-text available
Background Pharmacists in Canada are assuming an increasingly important role in the provision of primary care services. This raises questions about access to pharmacy services among those with medical care needs. While there is evidence on proximity of residents of Ontario and Nova Scotia to community pharmacies, there is little evidence for the rest of Canada. I thus measured the availability of pharmacist services, both the number of community pharmacies and their hours of operation, at both the provincial and sub-provincial level in Canada. Next, I measured associations of indicators of medical need and the availability of pharmacist services across sub-provincial units. Methods I collected data, for each Forward Sortation Area (FSA), on medical need, measured using the fraction of residents aged 65 + and median household income, and pharmacist service availability (the number of community pharmacies and their hours of operation, divided by the FSA population). Linear regression methods were used to assess associations of FSA-level service availability and medical need. Results There are between 2.0 and 3.3 community pharmacies per 10,000 population, depending on the province. There are also provincial variations in the number of hours that pharmacies are open. Quebec pharmacies were open a median of 75 h a week. In Manitoba, pharmacies were open a median of 53 h a week. The per capita number of pharmacies and their total hours of operation at the FSA level tend to be higher in less affluent regions and in which the share of residents is aged 65 or older. Provincial differences in pharmacy availability were still evident after controlling for medical need. Conclusion Community pharmacies in Canada tend to locate where indicators of health needs are greatest. The impact on patient health outcomes of these pharmacy locational patterns remains an area for future research.
... Community pharmacies are an integral component of the US healthcare infrastructure and are the most widely dispersed healthcare access point in the US. Nationally, about 89 % of adults live within 5 miles of a pharmacy [1]. Pharmacies provide a wide range of patient care services, such as vaccinations, point-of-care testing, and dispensing of medications, including public health emergency countermeasures. ...
Full-text available
Community pharmacies are a crucial component of healthcare infrastructure, including for COVID-19 pandemic prevention services like testing and vaccination. Communities that are “pharmacy deserts,” experience healthcare inequities. However, little research has characterized where these communities are, making it difficult for local leaders to prioritize resources for them. This study identifies pharmacy deserts at the census tract level in Washington state for the first time and explores their association with COVID-19 risk. Out of 1,441 tracts, 127 were pharmacy deserts, comprising approximately 454,000 adults, or 8% of the state’s adult population. Among those tracts identified as pharmacy deserts, 67% were considered high risk for COVID-19. Solutions are needed to expand equitable access to pharmacy services in these communities. The methods and data presented herein provide healthcare leaders with information to address this pharmacy access gap in Washington and could be similarly applied to other settings. Three categories of policy changes could address health inequities found in our study: 1) improve financial incentives for pharmacists to practice in underserved areas, 2) prevent pharmacy closures, and 3) deploy innovative care delivery methods such as telehealth services.
Background: Community pharmacies in the United States are beginning to serve as patient care service destinations addressing both clinical and health-related social needs (HRSN). Although there is support for integrating social determinant of health (SDoH) activities into community pharmacy practice, the literature remains sparse on optimal pharmacy roles and practice models. Objective: To assess the feasibility of a community pharmacy HRSN screening and referral program adapted from a community health worker (CHW) model and evaluate participant perceptions and attitudes toward the program. Methods: This feasibility study was conducted from January 2022 to April 2022 at an independent pharmacy in Buffalo, NY. Collaborative relationships were developed with three community-based organizations including one experienced in implementing CHW programs. An HRSN screening and referral intervention was developed and implemented applying a CHW practice model. Pharmacy staff screened subjects for social needs and referred to an embedded CHW, who assessed and referred subjects to community resources with as-needed follow-up. Post intervention, subjects completed a survey regarding their program experience. Descriptive statistics were used to report demographics, screening form, and survey responses. Results: Eighty-six subjects completed screening and 21 (24.4%) an intervention and referral. Most participants utilized Medicaid (57%) and lived within a ZIP Code associated with the lowest estimated quartile for median household income (66%). Eighty-seven social needs were identified among the intervention subjects, with neighborhood and built environment (31%) and economic stability challenges (30%) being the most common SDoH domains. The CHW spent an average of 33 minutes per patient from initial case review through follow-up. All respondents had a positive perception of the program, and the majority agreed that community pharmacies should help patients with their social needs (70%). Conclusions: This feasibility study demonstrated that embedding a CHW into a community pharmacy setting can successfully address HRSN and that participants have a positive perception toward these activities.
Background Respond to Prevent (R2P) is a randomized clinical trial which sought to accelerate distribution of naloxone and other harm reduction materials from community pharmacies. R2P combined an online continuing education course with in-store materials, specifically designed for use in community pharmacies, and then supported implementation through the one-on-one educational technique of academic detailing. Objective The objective of this paper is to describe and synthesize our experiences providing academic detailing as part of the R2P randomized trial. Methods Closed-ended items from standardized post-detailing questionnaires were analyzed with descriptive statistics. Open-ended items were content analyzed for key themes using immersion-crystallization qualitative methods. Results A total of 176 pharmacies participated in R2P with 175 receiving their initial academic detailing visit between August 2019 and May 2021. Initial visits were in-person and lasted a median of 35 minutes (interquartile range [IQR], 20- 45 minutes). The R2P naloxone guide was the most common topic covered (n=162, 92.6%). Following a fidelity check to assess adequacy of the R2P program implementation, 80 pharmacies (45.7%) required secondary academic detailing. Secondary detailing was more targeted and most frequently focused on the sale of nonprescription syringes (n=28; 35.2%) or disposal container distribution (n=30; 37.5%). Analysis of the open-ended items identified factors that the detailers perceived to affect the quality of academic detailing sessions, including the pharmacy environment, participant knowledge of and attitudes towards the subject matter, and ability of the detailer to remain flexible yet consistent. Conclusion R2P provided a standardized process to foster naloxone distribution and engagement in harm reduction with demonstrated implementation in 175 community pharmacies across four states. Academic detailing was perceived to be well-received and effective at providing education and promoting distribution of naloxone and nonprescription syringes in community pharmacies. Additional research is needed to confirm these perceptions through evaluation post-intervention behavioral and attitude changes.
To evaluate practice transformation team (PTT) members' perceptions of the Flip the Pharmacy (FtP) initiative as a strategy for implementing and improving community pharmacy‐based patient care. FtP is a national 2‐year practice transformation initiative for implementing enhanced patient care and medication optimization services at community pharmacies, launched in 2019 with 28 PTTs including over 500 pharmacy locations. Key informant interviews were conducted with team leads, coaches, and pharmacy champions from four PTTs that participated in the first FtP cohort. The interviews were conducted using semistructured interview guides based on the RE‐AIM framework and focused on participants' experiences in the first year of FtP. Interviews were audio‐recorded, transcribed, and analyzed using a rapid content analysis approach. Four leads, 8 coaches, and 8 pharmacy champions were interviewed from 4 PTTs from May to October 2021 and resulted in 10 themes: (1) community pharmacy practice experience is important when selecting coaches; (2) team readiness supports successful pharmacy practice transformation; (3) measures of patient care quality are needed; (4) payment and practice transformation opportunities happen in parallel; (5) successful practice transformation requires strategic involvement of the entire pharmacy team; (6) FtP practice transformation domains are synergistic; (7) change packages, coaching, and performance monitoring are core practice transformation supports; (8) pharmacy teams value opportunities to share and learn from each other; (9) sustaining patient care services is continuous; and (10) COVID‐19 accelerated practice transformation while creating new stress points. Participants in this study perceived the FtP initiative as a helpful strategy implementing and improving community pharmacy‐based patient care. Future research should explore the sustainability of the FtP initiative and similar community pharmacy practice transformation efforts.
The rapid spread of the novel coronavirus (SARS-CoV-2) and the COVID-19 infection captured the world unprepared. Struggles with initial containment strategies led to a pandemic designation in March of 2020. As the pandemic progressed, challenges became overwhelming with the paucity, appraisal, and dissemination of data; prevention and treatment strategies; resource management; testing and vaccine development/distribution/administration efforts. Pharmacists, traditionally known for their dispensing roles in the community pharmacy setting, visibly stepped up to meet the fast-changing and dynamic needs of the COVID-19 pandemic. This chapter outlines the contributions of pharmacists during the pandemic with a deeper insight into the spectrum of roles that pharmacists are regularly engaged in within a range of settings. An explanation of the modified and expanded functions that the pandemic necessitated is presented against the background of evolution of the pharmacy profession and pharmacists through the past few decades.
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.
Full-text available
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.
Objectives: Policy efforts to reduce the cost of prescription medications in the US have failed to reduce disparities in cost-related underuse. Little is known about the relationships between pharmacy accessibility, utilization, and cost-related underuse of prescription medications among residents of low-income minority communities. The aim of this work was to examine the association between pharmacy accessibility, utilization, and cost-related underuse of prescription medications among residents of predominantly low-income Black and Hispanic urban communities. Methods: Data from a population-based probability sample of adults 35 years of age and older residing on the South Side of Chicago in 2012-2013 were linked with the use of geocoded information on the type and location of the primary and the nearest pharmacy. Multivariable regression models were used to examine associations between pharmacy accessibility, utilization of and travel distance to the primary pharmacy, and cost-related underuse overall and by pharmacy type. Results: One-third of South Side residents primarily filled their prescriptions at the pharmacy nearest to their home. Among those who did not use mail order, median distance traveled from home to the primary pharmacy was 1.2 miles. Residents whose primary pharmacy was at a community health center or clinic where they usually received care traveled the farthest but were least likely to report cost-related underuse of their prescription medications. Conclusion: Most residents of minority communities on Chicago's South Side were not using the pharmacies closest to their home to obtain their prescription medications. Efforts to improve access to prescription medications in these communities should focus on improving the accessibility of affordable pharmacies at site of care.
Importance: Medication adherence is essential to diabetes care. Patient-physician language barriers may affect medication adherence among Latino individuals. Objective: To determine the association of patient race/ethnicity, preferred language, and physician language concordance with patient adherence to newly prescribed diabetes medications. Design, setting, and participants: This observational study was conducted from January 1, 2006, to December 31, 2012, at a large integrated health care delivery system with professional interpreter services. Insured patients with type 2 diabetes, including English-speaking white, English-speaking Latino, or limited English proficiency (LEP) Latino patients with newly prescribed diabetes medication. Exposures: Patient race/ethnicity, preferred language, and physician self-reported Spanish-language fluency. Main outcomes and measures: Primary nonadherence (never dispensed), early-stage nonpersistence (dispensed only once), late-stage nonpersistence (received ≥2 dispensings, but discontinued within 24 months), and inadequate overall medication adherence (>20% time without sufficient medication supply during 24 months after initial prescription). Results: Participants included 21 878 white patients, 5755 English-speaking Latino patients, and 3205 LEP Latino patients with a total of 46 131 prescriptions for new diabetes medications. Among LEP Latino patients, 50.2% (n = 1610) had a primary care physician reporting high Spanish fluency. For oral medications, early adherence varied substantially: 1032 LEP Latino patients (32.2%), 1565 English-speaking Latino patients (27.2%), and 4004 white patients (18.3%) were either primary nonadherent or early nonpersistent. Inadequate overall adherence was observed in 1929 LEP Latino patients (60.2%), 2975 English-speaking Latino patients (51.7%), and 8204 white patients (37.5%). For insulin, early-stage nonpersistence was 42.8% among LEP Latino patients (n = 1372), 34.4% among English-speaking Latino patients (n = 1980), and 28.5% among white patients (n = 6235). After adjustment for patient and physician characteristics, LEP Latino patients were more likely to be nonadherent to oral medications and insulin than English-speaking Latino patients (relative risks from 1.11 [95% CI, 1.06-1.15] to 1.17 [95% CI, 1.02-1.34]; P < .05) or white patients (relative risks from 1.36 [95% CI, 1.31-1.41] to 1.49 [95% CI, 1.32-1.69]; P < .05). English-speaking Latino patients were more likely to be nonadherent compared with white patients (relative risks from 1.23 [95% CI, 1.19-1.27] to 1.30 [95% CI, 1.23-1.39]; P < .05). Patient-physician language concordance was not associated with rates of nonadherence among LEP Latinos (relative risks from 0.92 [95% CI, 0.71-1.19] to 1.04 [95% CI, 0.97-1.1]; P > .28). Conclusions and relevance: Nonadherence to newly prescribed diabetes medications is substantially greater among Latino than white patients, even among English-speaking Latino patients. Limited English proficiency Latino patients are more likely to be nonadherent than English-speaking Latino patients independent of the Spanish-language fluency of their physicians. Interventions beyond access to interpreters or patient-physician language concordance will be required to improve medication adherence among Latino patients with diabetes.
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.
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.
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.
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.
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.
Retail clinics are clinics physically located within retail stores, such as grocery stores, drugstores, and “big box” stores like Wal-Mart (1–3),that provide walk-in care for a limited number of acute illnesses and preventative care services.(4) Generally staffed by nurse-practitioners, retail clinics focus on patient convenience by requiring no appointment and offering night and weekend hours. The costs of care are fixed, known to the patient before care is received, and reimbursed by most health insurance plans. The number of retail clinics increased more than ten-fold from 2006 to 2008 (5) and an estimated three million patients visited retail clinics by 2008.(3) Some physician societies have expressed concern about the growth in retail clinics (6–8) while many policymakers cite their potential to improve access to care.(2, 7, 9–16) To characterize this new health care delivery system, we describe the geographic distribution of retail clinics; their scope of services, prices, insurance policies, and ownership; and we estimate the proportion of the population that has easy access to a clinic.