J Antimicrob Chemother 2015; 70: 594 – 597 doi:10.1093/jac/dku417 Advance Access publication 19 October 2014

Free antibiotic and vaccination programmes in community pharmacies of Miami-Dade County, FL, USA Timothy P. Gauthier1*, Katie J. Suda2, Sunil Kumar Mathur3, David Harriman4, Jenny Pham4, Laura Aragon5, Lilian M. Abbo6 and Thomas M. Hooton6 Department of Pharmacy Practice, Nova Southeastern University College of Pharmacy, 3200 South University Drive, Fort Lauderdale, FL 33328, USA; 2Center of Innovation for Complex Chronic Healthcare, Department of Veterans Affairs and University of Illinois at Chicago, 5000 S. 5th Avenue, 151H, Chicago, IL, USA; 3Department of Biostatistics and Epidemiology, College of Medicine, Georgia Regents University, 1120 15th Street, Augusta, GA 30912, USA; 4College of Pharmacy, Nova Southeastern University, 3200 South University Drive, Fort Lauderdale, FL 33328, USA; 5Department of Pharmacy, Jackson Memorial Hospital, 1611 N.W. 12th Avenue, Miami, FL 33136, USA; 6 Division of Infectious Diseases, University of Miami Miller School of Medicine, 1120 N.W. 14th Street, Miami, FL 33136, USA *Corresponding author. Tel: +1-954-262-1362; Fax: +1-305-355-1529; E-mail: [email protected] or [email protected]

Received 5 June 2014; returned 5 September 2014; revised 22 September 2014; accepted 25 September 2014 Objectives: Some community pharmacies provide prescribed oral antibiotics for free to incentivize customers. This can influence prescribing practices and may increase inappropriate antibiotic use. Thus, pleas to incorporate education and/or vaccinations into these initiatives have been made by the CDC and IDSA. This study aims to investigate the prevalence and characteristics of free antibiotic programmes (FAPs) and free vaccination programmes (FVPs) offered by community pharmacies within a major US county. Additionally, we evaluated the association between FAP location and proximate socioeconomic status. Methods: A telephone survey was administered to all community pharmacies in operation and located in MiamiDade County, FL, USA (n¼ 668). Population characteristics at the five-digit ZIP code level were acquired from the 2010 US Census and American Communities Survey. An independent t-test, Kruskal– Wallis and logistic regression were used for statistical analysis. Results: A total of 660 community pharmacies agreed to the telephone survey (response rate ¼ 98.8%). FAPs were present in 6.8% of pharmacies (n ¼ 45) and none incorporated an educational component targeted at patients or prescribers. Ciprofloxacin and amoxicillin were offered by all FAPs and 84.4% provided up to a 14 day supply (n¼38). Thirty-four of 72 ZIP codes had an FAP and those with a programme had larger populations and higher incomes (P ≤0.05). Family income ≥$75 000 (P ¼0.0002) was an independent predictor of FAP availability. None of the surveyed pharmacies offered a FVP. Conclusions: Frequently provided by chain pharmacies and located in areas of higher income, FAPs within MiamiDade County offer broad-spectrum antibiotics for long durations without additional education to patients or prescribers. Keywords: socioeconomic, appropriate drug use, pharmacy services

Introduction In 2008, community pharmacies within the USA began offering select oral antibiotics at no cost to patients with a valid prescription.1,2 Although promotions have indicated that these free antibiotic programmes (FAPs) are meant to assist the economically challenged, previous literature identifies them as a promotional tool aimed at enhancing non-pharmacy sales and expansion of the customer base.1 Given that, in the USA, nearly half of antibiotic prescriptions in the ambulatory care setting are inappropriate3

and therefore unnecessarily contribute to the progression of antibiotic resistance, the appropriateness of FAPs has been questioned.4 The CDC and IDSA have both expressed concerns about the potential impact of FAPs on public health, communicating with chain community pharmacies to urge FAP replacement with a free vaccination programme (FVP) and/or the incorporation of an educational component.4 FAPs can impact prescribing by increasing prescription numbers and decreasing prescribing for drugs not included by FAPs.2 Today, FAPs still remain. However, data on their frequency, characteristics and impact remain scarce.

# The Author 2014. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy. All rights reserved. For Permissions, please e-mail: [email protected]

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JAC

Free antibiotic programmes in pharmacies

The purpose of this study was to document the prevalence and characteristics of FAPs and FVPs offered by community pharmacies within one of the most populous US counties.

Methods

Results The survey was administered in July and August 2012 with a 98.8% response rate (n¼ 660 pharmacies). Forty-five community pharmacies (6.8%) offered an FAP. While only 46.9% of pharmacies within the total sample were affiliated to a chain, 88.9% of FAPs were offered by a chain pharmacy (P, 0.0001; Table 1). None of the programmes reported a specific educational component for prescribers or patients beyond standard medication counselling. All FAPs offered amoxicillin and ciprofloxacin. A maximum of a 14 day supply was the most commonly offered duration. No community pharmacies reported providing an FVP. One pharmacy provided free influenza vaccinations for a single 3 h session annually and several pharmacies noted that they provide regular verbal referrals to nearby facilities. Thirty-four of 72 ZIP codes (47.2%) in Miami-Dade County had at least one FAP (Table 2). FAPs were more common in areas with greater numbers of Caucasian (P ¼ 0.0001) and Hispanic individuals (P ¼ 0.0233). They were also more common in more populous areas (P ¼ 0.0423) and in areas with more families (P ¼ 0.0297) and persons ≤14 years of age (P ¼ 0.0191). Additionally, FAPs were significantly more common in ZIP codes with higher incomes and less unemployment. FAPs were not associated with family/household size, the proportion of black persons or Medicare/Medicaid or public benefits (i.e. social security, cash public assistance and food stamps). In the multivariate model, only a household income ≥$75 000 was independently associated with FAPs.

Characteristic

Number (%)

Offered antibiotic penicillin VK amoxicillin ampicillin cefalexin sulfamethoxazole/trimethoprim doxycycline hyclate ciprofloxacin azithromycin

44 (97.8) 45 (100) 44 (97.8) 44 (97.8) 43 (95.5) 39 (86.7) 45 (100) 1 (2.2)

Maximum days of supply provideda 14 days for every drug 30 days for every drug varies per drug

38 (84.4) 2 (4.4) 5 (11.1)

Vaccinations free influenza vaccine free vaccines, other

0 (0) 0 (0)

Educationb educational component

0 (0)

Pharmacy type chain pharmacy

40 (88.9)

a The days of supply provided by the FAP was the maximum amount provided for no charge to the patient. The days of supply provided as indicated in the prescription refers to the maximum drug supply provided, regardless of the maximum drug quantity indicated by the FAP. b Education was defined as any education beyond standard patient counselling.

Discussion We demonstrate that 6.8% of community pharmacies in Miami-Dade County offered an FAP and none offered an FVP. All FAPs lacked an educational component, showing that the concerns voiced by the CDC and IDSA have gone unrecognized. Up to 2 weeks of therapy was the most common duration offered by an FAP, while some offered considerably longer durations. The quantity dispensed by the pharmacy was determined by the prescription; however, 2 weeks or more is much longer than most recommended treatment durations for outpatient infections. Given that Li and Laxminarayan2 found a shift towards more prescriptions for antibiotics covered by FAPs with their initiation, FAPs may facilitate unnecessary quantities of drug becoming available for inappropriate use. We feel this concern is strengthened by the facts that: (i) the offered antibiotics are less expensive than over-the-counter medications used for symptomatic relief of viral infections; (ii) a considerable portion of the public believes that antibiotics can be used for the treatment of viral infections;6 and (iii) patients pressure prescribers to provide antibiotics for viral infections.7 Supplying free medications may increase treatment rates and facilitate an earlier initiation of therapy, which can improve the overall health of the community. FAPs were more likely to be available in areas of higher socioeconomic status, demonstrating that

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A community pharmacy was defined as a pharmacy where pharmacists dispense medications, administer vaccinations and provide other professional services to local patients.5 Community pharmacies include pharmacies located in food stores, retail stores and clinics (outpatient pharmacies), as well as free-standing facilities. Chain pharmacies were defined as four or more locations under common ownership. Mail order, hospital and long-term care pharmacies were excluded. A survey tool was created in English and Spanish for administration via telephone to all community pharmacies in Miami-Dade County, FL, USA. Prior to the study, we tested our tool on pharmacies outside the study area and modified it to validate its structure and content. Contact information for community pharmacies and frequency of Medicaid and Medicare enrollees were acquired from the Florida Department of Health. Race/ethnicity and socioeconomic status were acquired from the 2010 US Census and American Community Survey. All responses were compiled using Microsoftw Excelw (Microsoft, Inc., Redmond, WA, USA). The Nova Southeastern University Institutional Review Board granted exempt approval for this study. SAS version 9.3 (SAS, Inc., Cary, NC, USA) was used for data and statistical analyses. An independent t-test, Kruskal – Wallis and Wilcoxon rank sum test were used as appropriate. Generalized linear modelling was applied with the dependent variable of FAP availability. Variables were included in the models based on a P value ≤0.1 in the univariate analysis and a Pearson correlation coefficient of ≥0.5. A P value of ≤0.05 was considered significant.

Table 1. Characteristics of FAPs (n ¼45)

Gauthier et al.

Table 2. ZIP code characteristics stratified by availability of an FAP All ZIP codes (n¼72)

ZIP code with ≥1 FAP (n¼34)

ZIP code with no FAP (n¼38)

P

Demographics total populationb median populationb population density (population/square mile) familiesb age in years age ≤14 yearsb age ≥65 yearsb white raceb Hispanic race black race

2 458470 34145 6770 7780 38.6 6162 4828 24976 19431 2325

1 288410 37894 6386 8799 38.7 7070 5162 29810 26249 1499

1170060 30791 7539 6871 36.7 5349 4529 20651 14422 2827

0.0423 0.0423 0.0752 0.0297 0.1290 0.0191 0.1254 0.0001 0.0233 0.3003

Incomec household income ($) family income ($) mean family income ($) family income ≥$75000 income per capita ($) percentage of families below the poverty level in the past 12 months percentage of people below the poverty level in the past 12 months percentage of population employed within the civilian labour force over 16 years of age Benefits social security total persons receiving cash public assistance total households receiving food stamps/SNAP benefits total Medicaid beneficiaries total Medicare beneficiaries

44880 50931 66931 2158 20740 13.45

52100 59175 76176 2955 23908 10.45

41746 45506 55162 1710 17239 16.15

0.0063 0.0095 0.0046 0.0002 0.0092 0.1764

16

13.5

19.65

0.3198

57.9

58.3

55.4

0.01

3123 13720 145562 608831 171525

3310 6454 61757 253810 77729

2956 7266 83805 355021 93796

0.4049 0.7659 0.7488 0.5007 0.7659

SNAP, supplemental nutrition assistance programme. Data are represented as medians of median ZIP code values and by number of persons unless otherwise indicated. b Data are normally distributed and are represented by the mean value of the median ZIP code value. c Data are represented in US dollars ($). a

these programmes are not best located to serve those most in need. Lower socioeconomic status has been associated with worse access to healthcare and lower levels of knowledge regarding the potential adverse impact of antibiotics.8 While extending FAPs to reach underserved populations is an option, we believe that, from the public health perspective, offering FVPs instead of FAPs would be more prudent. Vaccination appointments may be scheduled in advance and an FVP is probably more convenient to access than seeking treatment from an FAP during the period of an acute infection. There are several limitations to this study. The study sample represents only one major metropolitan area. Thus, the generalizability of these data to other geographical locations may be limited. In addition, our study does not investigate the influence of FAPs on prescribing practices or antimicrobial resistance. Finally, patients may not receive their prescriptions in the same area as they live. However, US data demonstrate that patients who use

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community pharmacies (versus mail order pharmacies) live in close proximity to their pharmacy provider.9 In conclusion, our data identify an opportunity to enhance current practices related to the use of antimicrobials in the outpatient setting. We believe our study has relevance to public health, policy-makers, healthcare professionals and outpatient antimicrobial stewardship. Future research is warranted to further describe the impact of FAPs on prescribing decisions and public health.

Acknowledgements We wish to acknowledge Stephen G. Grant, PhD, Visiting Associate Professor of Pharmaceutical Sciences at Nova Southeastern University’s College of Pharmacy, for his insight and direction during the manuscript preparation process.

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Characteristica

Free antibiotic programmes in pharmacies

Funding This study was carried out as part of our routine work.

JAC 2 Li S, Laxminarayan R. Are physicians’ prescribing decisions sensitive to drug prices? Evidence from a free-antibiotics program. Health Econ 2013; doi:10.1002/hec.3008. 3 Besser RE. Antimicrobial prescribing in the United States: good news, bad news. Ann Intern Med 2003; 138: 605–6.

Transparency declarations

5 National Council for Prescription Drug Programs. DataQ Pharmacy Database File Standard Implementation Guide: Version 3.0. Scottsdale, Arizona, USA: National Council for Prescription Drug Programs, 2011. 6 Filipetto FA, Modi DS, Beck Weiss L et al. Patient knowledge and perception of upper respiratory infections, antibiotic indications and resistance. Patient Prefer Adherence 2008; 2: 35 –9. 7 Stivers T, Mangione-Smith R, Elliot MN et al. Why do physicians think parents expect antibiotics? What parents report versus what physicians believe. J Fam Pract 2003; 52: 140– 8.

References

8 Eng JV, Marcus R, Hadler JL et al. Consumer attitudes and use of antibiotics. Emerg Infect Dis 2009; 9: 1128 –35.

1 US supermarkets redefine antibiotic misuse. Lancet Infect Dis 2009; 9: 265.

9 Liberman JN, Wang Y, Hutchins DS et al. Revealed preference for community and mail service pharmacy. J Am Pharm Assoc 2011; 51: 50– 7.

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Conflicts of interest: none to declare. At the time of project initiation and data analysis: K. J. S. was faculty at Department of Clinical Pharmacy, University of Tennessee College of Pharmacy, Memphis, TN, USA; S. K. M. was faculty at Department of Epidemiology, Biostatistics, and Environmental Health Science, University of Memphis School of Public Health, Memphis, TN, USA; and L. A. was named L. Smith. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.

4 Hicks LA, Gershon A. Letter to Wegman from the CDC and IDSA. http:// www.idsociety.org/uploadedFiles/IDSA/Policy_and_Advocacy/Current_ Topics_and_Issues/Advancing_Product_Research_and_Development/ Antimicrobials/Letters/FreeAntibiotics%20Letter%20Wegmans%2002 1909.pdf.

Free antibiotic and vaccination programmes in community pharmacies of Miami-Dade County, FL, USA.

Some community pharmacies provide prescribed oral antibiotics for free to incentivize customers. This can influence prescribing practices and may incr...
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