RESEARCH

Charitable pharmacy services: Impact on patient-reported hospital use, medication access, and health status Holly P. Fahey Babeaux, Laura E. Hall, and Jennifer L. Seifert

Abstract Objective: To evaluate the impact that Charitable Pharmacy of Central Ohio (CPCO), a pharmacy providing free pharmacy services and medications, had on an indigent patient population by determining the change in patientreported hospital use, ability to access medications, and perception of health status after receiving CPCO services. Design: Cross-sectional study with face-to-face interviews using a convenience sample. Setting: Columbus, OH, in January to March 2013. Patients: 206 English-speaking patients 18 years or older at CPCO. Intervention: Free pharmacy services and medications provided by CPCO.

Holly P. Fahey Babeaux, PharmD, Manager of Clinical Operations and Experiential Education, Charitable Pharmacy of Central Ohio; at time of study, PGY-1 Community Pharmacy Resident, College of Pharmacy, Ohio State University, Columbus, OH Laura E. Hall, PharmD, BCPS, Clinical Assistant Professor, College of Pharmacy, Ohio State University, Columbus, OH Jennifer L. Seifert, BSPharm, MS, Director of Clinical Services, Charitable Pharmacy of Central Ohio, Columbus, OH Correspondence: Holly P. Fahey Babeaux, PharmD, Charitable Pharmacy of Central Ohio, 200 E. Livingston Ave., Columbus, OH 43215; [email protected]

Main Outcomes Measures: Number of patient-reported hospital visits before and after CPCO use.

Disclosure: The authors declare no relevant conflicts of interest or financial relationships.

Results: In the year before using CPCO, patients reported using the hospital a mean of 2.36 (median, 2.00) times per year versus 1.33 (median, 0.67) times per year after, a decrease of 1.03 hospital visits per year per patient. Before coming to CPCO, 41% of patients were able to have all of their prescribed medications filled; this rose to 85% after using CPCO. A total of 89% of patients reported that not only was their overall health better, but they also had a better understanding of their medications and believed they were in more control of their own health since receiving CPCO services.

Acknowledgments:  2013 Dan Herbert Incentive Grant Recipient from the American Pharmacists Association Foundation; Charitable Pharmacy of Central Ohio Executive Director, Allan Zaenger, BSPharm; student pharmacist interviewers: Amanda Singrey, Rachel Hipp, Abi Corrigan, Ee Jye Poi, and Leah Bierley

Conclusion: A charitable pharmacy model has the potential to decrease health care costs and empower patients to be more in control of their health.

Received January 16, 2014. Accepted for publication May 21, 2014.

J Am Pharm Assoc. 2015;55:59–66. doi: 10.1331/JAPhA.2015.14010

Journal of the American Pharmacists Association

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T

he 2008 Ohio Family Health survey showed that 35% of uninsured patients aged 18–64 years could not afford needed medications, substantially more than the 13% of insured patients.1 In Ohio in 2012, more than 28% of uninsured patients had used emergency department (ED) services at least once in the previous 12 months, compared with 20% of insured patients aged 18–65 years. Almost 7% of this uninsured population used the ED more than 3 times in the previous 12 months compared with 3.5% for insured patients.2 Uninsured patients are likely aware that EDs usually cannot decline care because of inability to pay, as urgent and primary care offices may do. This increased use of emergency services by uninsured Ohioans indicates that uninsured patients may have chronic conditions that are more uncontrolled or that uninsured patients simply lack a primary care provider. On average, one ED visit costs $922, compared with $199 for a physician office visit.3 Patients who frequently visit hospitals when primary care would be more appropriate can unnecessarily increase costs to the health care system. With health care costs on the rise, efficient and effective methods to decrease or avoid expenses should be explored. Medication adherence is associated with better health outcomes and reduced hospital use.4 Fewer than one-half of patients with chronic diseases take their essential medications as directed.5 Nonadherence to medications can result from cost-related and noncost barriers. For such patients, understanding and addressing noncost barriers may decrease the likelihood of patients foregoing treatment.

Key Points Background: ❚❚ ❚❚

Access to health care and essential medications is a challenge for patients in poverty. By increasing access to medications, providing pharmacist counseling, and ensuring a consistent support system, community-based charitable pharmacies strive for positive effects on underserved communities.

Findings: ❚❚

❚❚

By providing pharmacy services and medications at no cost, the Charitable of Pharmacy of Central Ohio demonstrated a reduction of approximately 1 patient-reported hospital visit per year per patient. These pharmacy services also lead to increased prescription access and improved patient perception of overall health status.

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A noncost barrier is lack of education and disease knowledge. A meta-analysis showed that 44% of programs with patient education and disease control evaluation as interventions for patients with chronic illnesses significantly improved disease control. The programs with the highest percentages of substantial improvements were those for depression, asthma, and hypertension. Among all diseases, patient education produced a small-yet-substantial improvement in disease control.6 Evidence shows that cost-related adherence barriers also put patients’ health at risk.7–9 One study showed that increased cost of medications among older and indigent patients led to significant increases in acute care use, long-term care admissions, and deaths.10 This increases expenses for the health care system. Though improving medication access does not ensure adherence, adequate access to medication is necessary for adherence to a pharmacotherapeutic plan. In Ohio, 25% of uninsured patients aged 18–64 years reported poor or fair health status compared with 15% of insured patients.1 Additionally, patients who underused their prescription medications because of costs were more likely to experience a significant decline in their health status compared with those who did not underuse medications (32% vs. 21%).11 When the health status of individuals who underuse their medication does not improve, an unaware prescriber may increase medication doses or add further therapy. This may make the patient more prone to adverse drug effects and further increase medication cost. By increasing access to medications, providing pharmacist counseling, and ensuring a consistent support system, community-based charitable pharmacies strive for positive effects on underserved communities. Community-based charitable pharmacies’ long-term goals include improving patients’ access to pharmacist services, and having a positive impact on their overall health.

Objectives The purpose of this study was to evaluate the impact of medication services on an indigent patient population served by the Charitable Pharmacy of Central Ohio (CPCO). The primary objective was to determine the change in patient-reported hospital use before and after provision of CPCO services. The hypothesis was that patients would report fewer hospital visits after CPCO use. Secondary objectives included assessment of ability to access medications before and after CPCO services and patient perceptions of health status after CPCO services.

Methods

Practice setting CPCO opened in February 2010 to address the needs of the growing number of adults in Franklin County withJournal of the American Pharmacists Association

CHARITABLE PHARMACY SERVICES RESEARCH

out access to prescription medications. CPCO serves Franklin County residents at or below 200% of the Federal Poverty Level who are either uninsured or underinsured and cannot afford medications. From opening through November 2014, CPCO has qualified more than 3,900 patients and dispensed more than 202,000 prescriptions with a value of almost $16 million. At the time of this study, CPCO staff included two pharmacists, one pharmacy practice resident, two technicians, one intern, and one patient service coordinator. Fourth-year student pharmacists on advanced practice pharmacy experience (APPE) rotations and a variety of pharmacy and hospitality volunteers also contributed greatly to managing the workflow of the pharmacy. The ongoing goals set forth by CPCO include increasing access to medications, providing health and wellness education, and improving access to health care professionals by providing information about affordable health care options and networking with existing clinics. Patients are referred to CPCO from entities such as free clinics, hospitals, and outpatient clinics. CPCO goes beyond simply providing medications at no cost. The pharmacy provides blood glucose education and testing supplies, blood pressure monitoring, health education, vaccinations, smoking cessation, and other similar clinical services. In a private consultation room, patients receive extensive medication counseling from a pharmacist or APPE student pharmacist at each visit. At the time of the study, CPCO was open 6 hours a day, 3 days a week, serving 40 to 90 patients per day with patients routinely waiting 1 to 3 hours for prescriptions to be filled. In 2012, CPCO dispensed a mean of 320 prescriptions per day. CPCO has several funding and medication sources. Funding comes from private individuals and businesses, public entities (including annual awards from the city of Columbus and Franklin County), and the four major health systems of Central Ohio. These funds support pharmacy operations and the purchase of medications (primarily generics). CPCO also obtains medications from pharmaceutical manufacturers through bulkreplenishment programs and by assisting patients in applying for manufacturer assistance programs. As a drug repository program, CPCO also receives dispensed, unused medications from long-term care facility pharmacies at no cost. As of 2009, 35 states in the United States have laws permitting drug repository programs.12 The pharmacy is constantly pursuing additional support for continued growth. Methodology This cross-sectional study was accomplished using face-to-face interviews administered by trained student pharmacists to individual CPCO patients. Interviews were conducted from January to March 2013. Journal of the American Pharmacists Association

CPCO serves more than 600 patients per month. A convenience sample was used so that as many patients as possible were offered the opportunity to participate. While waiting for their prescriptions to be dispensed, patients were called to a private room at random and asked to participate in the interview. Interviewers were trained by the lead researcher and met the requirements set by Ohio State University’s Office of Responsible Research Practices. Patients were eligible to be enrolled in the study if they were English-speaking, 18 years of age or older, and had used CPCO services for 3 or more months. Patients were excluded if they were unable to answer questions on their own, comprehend interview questions, or communicate due to cognitive impairments. A standard informed consent and Health Insurance Portability and Accountability Act of 1996 (HIPAA) waiver audio recording was played for patients before each interview explaining the purpose of the study along with risks, benefits, and ability to drop out of the study at any time. If the patient agreed to participate, this was considered his or her informed consent and HIPAA authorization. Using funds from an American Pharmacist Association (APhA) Foundation grant and the CPCO budget, a $5 gift card to a local chain grocery store was provided as an incentive for participation. If the patient decided to opt out of answering further questions after the interview began, he or she still received the incentive. Interview questions were asked and answers entered in a password-protected Qualtrics software database. The full interview procedure, including questions, is provided as an online appendix to this article (see Supplemental Content on JAPhA.org). CPCO maintains paper charts of medical records, including progress notes at each visit as well as basic demographic and health information. Survey data entered into Qualtrics were collected from both the patient chart and verbal patient answers to the survey. A laminated visual guide was shown to participants to assist in their understanding of the questions about hospital-use and ability to have prescriptions filled. To avoid duplicate surveys of a patient, a red sticker was placed on the face of the chart of interviewed patients. A blue sticker placed on the patient chart denoted that patients either did not meet inclusion criteria or had declined participation. Charts were refiled; the number of patients who declined participation was not recorded. Patient name or identifying information was not recorded or linked to answers. Patients returned to the lobby after being interviewed to await dispensing of their medications. Data analysis For the primary objective, hospital use was defined as visiting a hospital for any reason for any duration. An j apha.org

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ED visit alone would count as one visit, and an ED visit that lead directly to an admission would count as one visit. Being admitted to the hospital, discharged, and readmitted constituted two visits. Mean visits per year variables were calculated for before and after CPCO usage. Patients self-reported how many hospital visits they recalled having in the year before becoming a patient at CPCO, and this was used as the before-CPCO metric. The after-CPCO metric was the number of times that the patient used the hospital after becoming a patient at CPCO divided by the number of months CPCO was used. This number was multiplied by 12 months to produce an annualized number of hospital visits per year after beginning use of CPCO. While the patient responses to number of hospital visits were integers, calculations could result in a fraction or decimal number for the post-CPCO visit value. To calculate the change in number of hospital visits between the after and before periods, the reported number of visits per year before CPCO use was subtracted from the calculated average per year after CPCO use. Because of the transformation of partial-year data to annualized estimates of after-CPCO hospital visits, outliers were possible. For example, a patient who used CPCO for only 3 months but had several hospital visits within that short time frame had an exaggerated calculated number of hospital visits per year. To address this potential design flaw, a subgroup analysis was conducted using patients who had used CPCO for at least 12 months. Patients were asked to estimate how many of their prescribed medications they had filled before and after they began using CPCO. Categories were all, more than one-half, one-half, less than one-half, and none. For ease of reporting and also because of small cell sizes within the middle categories, these were collapsed into all, some, and none categories. Patients were asked a series of four close-ended (yes or no) questions regarding their perceived change in health status since using CPCO. This research was approved by the Ohio State University (OSU) Institutional Review Board. Data analysis was supported by the OSU Center for Biostatistics. Descriptive and inferential statistics were used to report results for patient-reported hospital use and ability to have prescriptions filled before and after CPCO services use. Wilcoxon-signed, rank-sum tests were used to assess statistical significance for frequency of patient-reported hospital visits per year and ability to have prescriptions filled. Continuous responses were expressed using mean, standard deviation, and median. Categorical responses were expressed using frequencies and percentages.

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Results Demographic and baseline information is presented in Table 1. Patients were, on average, middle-aged but ranged from young to old. Slightly more women than men participated; patients were generally either white or black; and the typical patient was using multiple medications (mean, 8 medications/patient). The results of the primary outcome show patientreported hospital use decreased by 1 hospital visit per year when median change was evaluated. The change in frequency of patient-reported hospital visits between the before- and after-CPCO periods (Figure 1) was statistically significant (P 4 visits

1 visit

2-4 visits

>4 visits

6%

15%

32%

46%

62%

39%

Figure 1. Comparison of annualized number of hospital visits before and after use of CPCO services (n = 200)* Abbreviation used: CPCO, Charitable Pharmacy of Central Ohio P < 0.0001 for all three before and after comparisons. a Before CPCO, 6 participants declined to answer, giving a sample size of 200 for this item. After CPCO, 1 participant declined to answer, giving a sample size of 205 for this item.

In the year before beginning use of CPCO, patients visited hospitals a mean of 2.36 (median, 2.00) times per year; this figure was 1.33 (median, 0.67) times per year after CPCO, yielding a mean decrease of 1.03 (median, 1.00) hospital visits per year per patient. Of the 206 patients interviewed, 152 patients had been using CPCO services for at least 12 months. On subgroup analysis, these patients had mean and median changes in hospital use of –1.13 and –1.00, respectively, consistent with the full cohort of patients. Figure 2 represents the percentage of patients able to have their prescriptions filled. Patients able to have filled all of the prescriptions prescribed to them more than doubled (40.9% to 85.3%) during the after-CPCO use period (P

Charitable pharmacy services: Impact on patient-reported hospital use, medication access, and health status.

To evaluate the impact that Charitable Pharmacy of Central Ohio (CPCO), a pharmacy providing free pharmacy services and medications, had on an indigen...
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