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Lund BC. Rural Access to Clinical Pharmacy Services. Poster session presented at: AcademyHealth Annual Research Meeting; 2014 Jun 9; San Diego, CA.
Research Objective To examine the impact of rural residence and primary care site on use of clinical pharmacy services (CPS) and to describe utilization of clinical telepharmacy. Study Design Using national Veterans Health Administration (VHA) data from fiscal year 2011, the frequency of patients with CPS encounters was compared across patient residence (urban or rural) and principal site of primary care (medical center, urban clinic, or rural clinic). The likelihood of CPS utilization was estimated with multivariable logistic regression, where VHA facility was included as a random effect to account for patient clustering within facility. Population Studied The target population was regular medication users receiving primary care services in VHA in FY11. 4,837,951 patients had at least one primary care encounter in VHA. Of these, 3,105,925 were regular medications users, defined as at least 240 calendar days of exposure to VHA dispensed medications. Additional exclusions were made for patients receiving care through VHA sites in Puerto Rico and Manila (n = 37,982) and patients whose urban/rural residence status (n = 25,693) or principal site of primary care (n = 1,615) could not be ascertained. Principal Findings Of 3,040,635 patients, 711,348 (23.4%) received CPS. Patients residing in urban areas were more likely to have a CPS encounter than patients in rural areas (24.9% vs. 19.7%; OR = 1.35), and this relationship remained consistent across all four U.S. Census regions. Similarly, CPS use was more common for patients receiving primary care in medical centers (25.9%) compared to urban clinics (22.5%; OR = 0.82) or rural clinics (17.6%; OR = 0.61). In adjusted multivariable analyses, however, the majority of urban-rural differences in CPS utilization were explained by primary care site and minimally by patient residence. Telehealth encounters were common, accounting for nearly half of patients receiving CPS. Video telehealth was infrequent ( < 0.2%), but more common among patients of rural clinics than medical centers (OR = 9.7; 95% C.I.: 9.0-10.5). Conclusions This study supported our hypothesis that rural patients were less likely than urban patients to receive CPS, but that this difference was explained principally by greater reliance on community clinics for primary care, as opposed to medical centers where the majority of clinical pharmacists are located. We also found that CPS delivery by telephone was very common, but use of clinical video telehealth was rare. Implications for Policy or Practice Our findings indicate a potential disparity in healthcare access where rural patients were 35% less likely to receive CPS, but that this difference was explained by greater reliance on community clinics for primary care. The nature of this relationship is important because it suggests actionable remedies; specifically, that organizational changes which increase the presence of clinical pharmacists in community clinics should alleviate the disparity in access to CPS. Two such strategies are currently underway in VHA, including an expansion in capacity for telehealth services and the transition to the PACT model of primary care. Future research is needed to determine whether these organizational changes ultimately impact CPS access for rural veterans. Further research is also warranted to examine access disparities for rural patients in health care systems outside VHA, and whether lessons learned from VHA may translate to these other settings.
