Articles Assessment of Desirable Pharmaceutical Care Practice Skills by Urban and Rural Nebraska Pharmacists

David M. Scott, Lucinda G. Miller and Lori A. Letcher College of Pharmacy, University of Nebraska Medical Center, 600 S. 42nd Street, Omaha NE 68198-6045

Four pharmaceutical care (PC) training issues were presented to 636 randomly selected pharmacists. Information was gathered on: (i) desired PC skills for future pharmacists; (ii) the practitioner’s current PC skills through self-assessment; (iii) a pharmacist desired PC training needs; and (4) pharmacists’ need for a nontraditional PharmD degree. Overall, 431 (67.8 percent) surveys were returned and 373 pharmacists were usable. Respondents (47.2 percent) were from rural areas while 52.8 percent were from urban areas (MSA designation). PC skills were rated as very important in the training of pharmacy students that included counseling the patient, communicating information to providers, and monitoring drug therapy. Overall, 42.6 percent of pharmacists (n=159) perceived a PC certificate program and 16.6 percent (n=43) perceived a nontraditional PharmD degree as a need. If extrapolated to the pharmacist population in Nebraska, approximately 101 would seek the nontraditional PharmD degree and 375 pharmacists would seek the PC certificate program. The training mode needed most by Nebraska pharmacists is through the PC certificate program and is notably requested by rural practitioners.

INTRODUCTION Pharmacy’s future lies with successful application of phar-maceutical care (PC) by all pharmacists regardless of prac-tice setting (e.g., clinic versus institutional, rural versus urban). Specifically, PC addresses the application of drug knowledge and patient counseling to promote proper drug usage(1). The essence of PC is embodied in pharmacists’ abilities to work with patients and health care providers to assure appropriate drug use, safety and compliance. Screen-ing for drug interactions, advising patients regarding proper use, counseling regarding potential adverse interactions, and therapeutic monitoring are some practices associated with this commitment.

Successful pharmacists of the future will be distinguished by their ability to deliver effective PC(2). Effectively imple-mented PC requires competence and confidence by the pharmacist. To be accepted and completed, PC must first overcome pharmacy’s product-focus, opposition from other health care professions and drug manufacturers, financial and logistical problems, and ignorance and inertia among pharmacists themselves(3). The Pew Health Professions Commission Report has been a wake-up call to all members of the health professions including pharmacy. Health care is changing at a faster rate than expected and this report predicts that professions that do not adjust accordingly may find no function in the future health care schema(4). Three major stages of development in pharmacy’s recent past have been identified: (i) the traditional, or drug-distribution stage; (ii) the transitional, or clinical pharmacy stage; and (iii) the patient-focus or pharmaceutical care stage(1).

Pharmacy Education. From the 1960s through the 1980s, most colleges of

pharmacy offered the five-year bachelor of science degree. California was the first state to start a PharmD program in the 1950. University of Nebraska Medical Center (UNMC) in 1976 became the third college of pharmacy to establish an

entry-level Doctor of Pharmacy (PharmD) program. PharmD programs have increasingly replaced the five-year degree. The American Association of Colleges of Pharmacy (AACP) in 1992 recommended adoption of the six-year degree as the entry-level degree to practice. Most colleges of pharmacy have adopted or are undergoing curriculum revi-sion to offer the PharmD degree. Sixty-four of the 79 schools and colleges are offering PharmD programs(5). Fourteen colleges offer a bachelor of science program, 48 colleges are entry-level PharmD programs and 55 colleges offer post-baccalaureate PharmD programs. In 1996, 20,562 students were enrolled in a bachelor of science programs, 12,497 students enrolled in entry-level PharmD programs and 3,008 students were enrolled in postbaccalaureate PharmD pro-grams1.

Currently, the U.S. health care system is fragmented, yet striving to provide “seamless,” more continuous care. Seamless care assumes that treatment begun in hospital settings (secondary and tertiary care) is continued in pri-mary care settings (6). Health reform movements such as managed care have forced rethinking of health care priori-ties and the value of each health professional in providing continuous care. Pharmacy education has responded to this challenge by sponsoring “Pharmacy in the 21st Century” conferences. The thrust of these strategic planning meetings was the realization that pharmacists need to move toward providing pharmaceutical care. Whether the aforementioned degree programs are meeting practitioner needs have not been adequately assessed, especially when considering ur-ban versus rural practitioner needs.

Assessment of Pharmacists’ Training Needs As pharmacy educators are revising curriculums, many

pharmacists are “retooling” to remain competitive in the marketplace. Colleges of pharmacy have responded to this 1AACP, personal communication, 1997 data.

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demand by offering nontraditional pathways leading to the doctor of pharmacy degree, and many schools have also developed PC training programs(6). In the 1995-96 UNMC College of Pharmacy’s (COP) Strategic Plan, one goal was to determine the need for a nontraditional PharmD pro-gram. A second goal of this plan was to determine the need for the development of a PC certificate training program. By differentiating pharmacist “need” from “want” for each program, the College could focus resources on identified need.

Only a few reports have been presented or published that have conducted a needs assessment of pharmacy prac-titioners before their college has embarked on designing and implementing PC training programs. Francisco and Perri at University of Georgia developed a PC curriculum based on focus group assessment of community chain phar-macists’ and patients’ perceptions of PC in the community pharmacy setting2. Bennett and Cable at Ohio State Univer-sity developed a PC training program based on a needs assessment of participating practitioners using a Pharma-ceutical Care Inventory3. While such assessments fulfill a need for the individual institution, they also speak broadly to practitioner needs regardless of institutional affiliation.

Rural Training Infrastructure The Rural Health Education Network (RHEN) was

developed to help address the needs of Nebraska citizens for rural health care. As an RHEN participant, the COP has developed programs to attract rural students and a curricu-lum track focusing on delivery of pharmaceutical care in rural settings(7). Hopefully, many of these students will return to practice in rural areas. Scott et al., found that pharmacists locate in communities similar in size to where they grew up and received clerkship/internship training(8). The COP has rural education programs in hospital, commu-nity, geriatric, and psychiatric pharmacy practice in more than 35 communities and approximately 60 volunteer phar-macy preceptors provide clinical instruction in these prac-tice settings. Two full-time pharmacy faculty at a Regional Medical Center in the western area of the State supervise clerkships designed to prepare students for rural practice. UNMC COP developed a clerkship training program in 1991-1993 where seven rural preceptors were brought to the Medical Center for one to two weeks to upgrade their clinical skills. Another nine preceptors were trained in 1996 as the clinical skill’s focus added a home-based approach to learn the therapeutic modules prior to their accelerated clerkship experience with a greater emphasis on the phar-maceutical care in the rural community setting.

To further rural health and rural training, the Nebraska Drug Information Network (Network) developed comput-erized health and drug information centers in thirty-five rural community pharmacies. Each site is provided with a multimedia computer linked to the Medical Center through telecommunications programs allowing access to various databases including Medline™, International Pharmaceu-

2Francisco, G.E. and Perri, M., “Developing a curriculum to train pharma-cists to provide pharmaceutical care in the community chain pharmacy setting,”. American Association of Colleges of Pharmacy Annual Meet-ing Abstracts, (1995) 95, p. 8.

3Bennett, M.S. and Cable, G.L., “Development and implementation of a pharmaceutical care training program based on needs assessment of participating community pharmacists,” ASHP Midyear Clinical Meeting Abstracts, (1994) 29, p. 183D.

tical Abstracts (IPA) and Micromedex™ (7,9). Many Net-work pharmacists expressed a desire for more education to augment their community-based clinical practices. Given UNMC’s commitment to rural pharmacy education, the investigators designed an assessment of Nebraska pharma-cists educational needs. We compared (both Network and nonNetwork) rural and urban pharmacists in their interest in a PC certificate training program and a non-traditional PharmD Program.

Study’s Purpose and Training Issues. Pharmacists practicing in rural areas are often ignored

when planning and delivering pharmaceutical care(10). Yet, rural pharmacy practice constitutes an area rich in opportu-nities for pharmaceutical care activities. Many of these rural pharmacies however, are struggling for survival. Study data were sorted by urban versus rural pharmacists since the UNMC College of Pharmacy has recognized the critical nature of rural practice and has established rural training as a priority area. The study’s purpose was to ascertain the level of PC conducted in Nebraska, primarily a rural state and the need for PC training to promote its accomplishment. This survey also addressed four important PC training is-sues. First, information was gathered from practicing phar-macists as potential employers and colleagues of our gradu-ates, on desired PC skills they have identified are needed by pharmacists. Second, information was collected on practi-tioners’ current PC skills and competencies through self-assessment. Third, information was gathered on pharma-cists’ desired continuing education and training needs in PC skills, and the best modality to meet them. Fourth, the want and/or need by pharmacists for a nontraditional program leading to the PharmD degree also was assessed. With a distillation of rural versus urban pharmacists needs, it is anticipated that these data will prove useful to schools of pharmacy considering nontraditional PharmD and certifi-cate programs depending on the rural and/or urban nature of their clientele.

METHODS Survey Design

This survey was adapted from a pharmacy work force study, modified to include items regarding demographics and practice characteristics (practice setting, years of prac-tice, population size, and prescriptions dispensed in an average day)(8). To address the first training issue, pharma-cists were asked to rate the importance of 15 PC skills they felt should be included in the training of pharmacy students on a three-point Likert scale (1= not important, to 3= very important). The second training issue requested that each pharmacist rate themselves on how well they perform each of the 15 PC skills using a four-point Likert scale (1=poor, to 4= outstanding). This PC skills list was developed based on a review of curriculum outcomes and was reviewed by the UNMC Pharmacy Practice faculty(11). The compiled PC skills list was combined with other survey items and was sent to 10 practicing pharmacists in rural and urban areas. Based on pharmacist pilot testing, this list was reduced by the investigators to the top 15 PC skills.

Four items addressed the third training issue to deter-mine if there is a need to develop a certificate program to enhance the PC skills of practicing pharmacists. How the program should be constructed to adequately serve their

244 American Journal of Pharmaceutical Education Vol. 62, Fall 1998

Table I. Sample characteristics No. pharmacists (n=373) Rural (n=176) Urban (n=197) Variable n Percent n Percent n Percent Gender

Female 133 35.7 52a 29.6 8a 36.0 Male 234 62.7 121a 68.8 113a 57.4 Missing 6 1.6 3 2.6 3 6.1

Education and trainingb BS/BPharm 263 70.5 129 73.3 134 68.0 PharmD 114 30.6 42 23.8 72 36.5 Residency/fellowship 20 5.4 2 1.1 18 9.1 Masters 11 3.0 3 1.7 8 4.1 PhD 2 0.5 — — 2 1.0

University site of first pharmacy degree Creighton University 104 27.9 32c 18.2 72C 36.6 University of Nebraska 206 55.2 110c 62.5 96C 48.7 Other 63 16.9 34 19.3 29 14.7

Years practicing pharmacy 10 or less years 115 30.8 50 28.4 65 33.0 More than 10 years 257 68.9 126 71.6 131 66.5 Missing 1 0.2 — — 1 0.5

Years at present practice 10 or less years 236 63.3 93d 52.8 143d 72.6 More than 10 years 137 36.7 83d 47.2 54d 27.4

aComparison of rural and urban pharmacists (chi-square = 7.35, d.f. = 1, P = 0.007). bRespondents may have answered more than once. cComparison of rural and urban pharmacists (chi-square = 13.36, d.f. =1, P = 0.0003). dComparison of rural and urban pharmacists (chi-square = 14.76, d.f. =1, P = 0.0001).

needs was addressed as an open-ended response item. The fourth training issue asked whether a nontraditional PharmD program is needed and was addressed by five items similar to those asked in the continuing education component. We pilot-tested the questionnaire by sending it to 15 pharma-cists in urban and rural areas of Nebraska, and refined it based on their comments.

Subject Selection The 1995 mailing list of Nebraska pharmacists was

obtained from the Nebraska Pharmacists Association (NPA), which is compiled annually by the Nebraska State Depart-ment of Health and is updated quarterly by the NPA. In June 1995, the NPC survey was mailed to 636 pharmacists selected randomly from this NPA listing. The random sample of 636 represents 40 percent of the Nebraska pharmacists. Each questionnaire was coded with an identification num-ber permitting name and address location to avoid sending duplicate mailings to those who have responded. A postcard reminder was mailed four weeks later and a repeat survey mailing was sent at eight weeks to nonrespondents.

Urban and Rural Categorization Respondents were categorized into urban and rural

area pharmacists. The Office of Management and Budget (OMB) metropolitan statistical areas (MSAs) designation was used to distinguish between urban and rural areas. An MSA is “a county or group of counties that make up an integrated area with a central city of 50,000 residents or more that is in an urbanized area with a population of 100,000 or more”(12). Pharmacists living in the MSA county areas (zip codes) were categorized as urban. Only five counties in Nebraska, surrounding and including Lincoln and Omaha, qualify as MSAs. The remainder of the respon-

dents was classified as rural area pharmacists. The urban/ rural designation was selected rather than practice setting (e.g., hospital, retail) as many rural pharmacists practice in multiple settings (e.g., the retail pharmacist also provides pharmacy services for community’s hospital and nursing home). Hence, a practice setting designation would be muddled in the rural environment where one individual crosses setting boundaries.

Data Entry and Analysis Open-ended questions were tabulated by the most com-

mon themes. All data were entered into a SAS database(13) using the IBM mainframe at UNMC. Comparison of urban and rural pharmacists by chi-square analysis was done for categorical measurements and Student’s /-test for interval-level measurements. An alpha level of 0.05 was used for all tests of significance.

RESULTS Of the 636 surveys mailed, 431 (67.8 percent) surveys were returned. Of the 431 pharmacists, 28 were retired, and 30 reported being outside the profession were removed from the final sample of 373 pharmacists. The distribution of respondents was 47.2 percent from rural areas (176 of 373) and 52.8 percent (197 of 373) from urban areas. This distri-bution correlates roughly with the population demograph-ics of Nebraska where 49 percent of the 1.6 million people reside in rural areas versus 51 percent living in urban areas.

Sample Characteristics Of 367 pharmacists who reported their gender, 234 (62.7

percent) were male and 133 (35.7 percent) female. A statis-tically significant higher percentage of female pharmacists practiced in urban areas than rural areas (P < 0.05). Ap-

American Journal of Pharmaceutical Education Vol. 62, Fall 1998 245

Table III. Respondents’ rating of pharmaceutical care skills importance needed by graduates

Pharmaceutical care skills

Total meana (n=373)

Rural mean (n=176)

Urban mean (n=197)

Counseling patient or care-giver 2.75 2.74 2.75 Communicating information to

health care provider 2.69 2.65 2.72 Monitoring drug therapy 2.68 2.64 2.71 Using problem-solving skills 2.67 2.57b 2.76b Using ethical decision-making skills 2.65 2.66 2.64 Using drug therapydecision-

making skills 2.61 2.55 2.65 Assessing patient’s medication

compliance 2.47 2.40b 2.53b Conducting drug utilization review 2.42 2.36 2.47 Eliciting medication history

information 2.40 2.3b 2.47b Therapeutic substitution 2.29 2.25 2.32 Referring to another health

provider 2.25 2.25 2.25 Writing skills 2.16 2.0 9b 2.22b Pharmacokinetics skills 2.12 2.03b 2.19b Interpreting physical assessment

data, including signs and symptoms 2.06 2.05 2.08

Performing physical assessments (e.g., pulse, blood pressure) 1.58 1.54 1.61

Other, specify: Communication skills (8) Compounding (5) Computer skills (4) Third Party (2)

aPharmaceutical care skills arranged by total means in ascending order each skill rated on a scale from 1= not important, to 3 = very important.

bSignificant difference between rural and urban groups (P < 0.05). party reimbursement, documentation, and patient assess-ment skills. “Patient assessment skills” was a write-in re-sponse by two respondents and suggest that some pharma-cists feel apprehensive about calling them physical assess-ment skills. Pharmaceutical Care Skills’ Certificate Program Need

The third training issue addressed Nebraska pharma-cists’ continuing education and training needs in PC skills and the best modality to provide them (Table V). Pharma-cists were asked four questions about the need to develop a certificate program to enhance the skills of practicing phar-macists. Overall, 66.8 percent of pharmacists expressed interest in the UNMC College of Pharmacy offering this type of program, with 72.7 percent of rural pharmacists (n=128) and 61.4 percent of urban pharmacists (n=121) (P< 0.05). While many pharmacists may be interested in such a program, some may perceive this program as a “want” instead of a need. A want was defined as “I want these PC skills, but I choose not to pursue them.” A need was defined as “I want these skills, and I am willing to sacrifice the time and cost to obtain them.” Overall, 42.6 percent (159 of 373) of pharmacists perceived this certificate program as a need. Pharmacists agreed that the certificate program is needed [rural group (42.0 percent or 74 of 176) and urban group (43.2 percent or 85 of 197).

Of the pharmacists surveyed, 32.4 percent of pharma-cists (121 of 373) reported they would be willing to pay up to

Table IV. Pharmaceutical care skills self-assessment by respondents

Pharmaceutical care skills

Total meana

(n=373)

Rural mean (n=176)

Urbanmean (n=197)

Using ethical decision-making skills 3.23 3.21 3.25 Using problem-solving skills 3.15 3.02b 3.26b Communicating information to

health provider 3.12 3.05 3.17 Counseling patient or care-giver 3.03 3.03 3.03 Monitoring drug therapy 2.89 2.86 2.92 Using drug therapy decision-

making skills 2.85 2.81 2.89 Referring to another health

provider 2.84 2.81 2.87 Therapeutic substitution 2.82 2.76 2.87 Writing skills 2.75 2.66 2.77 Assessing patient’s medication

compliance 2.72 2.67 2.77 Eliciting medication history

information 2.57 2.47b 2.67b Conducting drug utilization

review 2.55 2.58 2.53 Interpreting physical assessment

data, including signs and symptoms 2.36 2.39 2.34

Pharmacokinetics skills 2.27 2.17b 2.36b Performing physical assessments

(e.g., pulse, blood pressure) 1.83 1.82 1.85 Other, specify:

Communications skills (5) Compounding skills (2) Computer skills (2) Third party (2) Documentation (2) Patient assessment skills (2)

aPharmaceutical care skills arranged by total means in ascending order each skill rated on scale from 1 = poor, to 4 = outstanding.

bSignificant difference between rural and urban groups (P < 0.05).

$3,000 for the PC skills certificate program. Thirty-five percent of rural pharmacists and 29.9 percent of urban pharmacists were willing to pay this $3,000 cost. Another four percent of pharmacists were willing to pay up to $6,000 for this program. In an open-ended response format, re-spondents were asked to suggest how the training program should be adequately structured to serve their needs. The most common response was home study at 16.1 percent, followed by a combination of home study and distance learning (9.7 percent), and home study and clinical training (4.3 percent). Nontraditional PharmD Program Needs

Pharmacists were also asked five items concerning the need by Nebraska pharmacists for a nontraditional program leading to the Doctor of Pharmacy degree (PharmD) (Table VI). Those who do have the PharmD degree (30.6 percent or 114 of 373) were excluded from this analysis that consisted of 23.9 percent (42 of 176) of rural pharmacists and 36.6 percent (72 of 197) of urban pharmacists. If a program was offered by UNMC, the number of pharmacists that ex-pressed an interest in a nontraditional PharmD program was 93 of 259 (35.9 percent). Interest was expressed by 34.3 percent (46 of 134) of pharmacists from rural areas and 36.8 percent (46 of 125) of pharmacists from urban areas. Only

American Journal of Pharmaceutical Education Vol. 62, Fall 1998 247

Table V. Respondents’ perceptions whether there is a need to develop a certificate program to enhance the pharmaceutical care skills of pharmacists No. pharmacists (n=373) Rural (n=176) Urban(n=197) Variable n Percent n Percent n Percent Interest in program:

No 113 30.3 43 24.4 70 35.5 Yes 249 66.8 128 72.7 121 61.4 Missing 11 2.9 5 2.8 6 3.1

Program perceived as a: Wantb 164 44.0 78 44.3 86 43.7 Need0 159 42.6 74 42.0 85 43.2 Missing 50 13.4 24 13.7 26 13.2

Proposed program structure Home study 60 16.1 24 13.6 3 18.3 Home study and distance learning 36 9.7 20 11.4 16 8.1 Home study and clinical training 16 4.3 9 5.1 7 3.6 All of the above 18 4.8 8 4.6 10 5.1 Distance learning 5 1.3 4 2.3 1 0.5 Training session 3 0.8 2 1.1 1 0.5 Missing 235 63.0 109 61.9 126

aComparison of rural and urban pharmacists (chi-square = 5.04, d.f. = 1, P = 0.025). bWant defined as I want these PC skills but I choose not to pursue them. cNeed defined as I want these PC skills and I am willing to sacrifice the time and cost to obtain them.

Table VI. Respondents’ perceptions whether there is a need to develop a nontraditional PharmD program for Nebraska pharmacists

No. pharmacists (n=259)a Rural (n=134)a Urban (n=125)a

Variable n Percent n Percent n Percent If offered, I am interested in attending this

program: No 156 60.2 81 60.5 75 60.0 Yes 93 35.9 46 34.3 46 36.8 Missing 10 3.9 7 5.2 4 3.2

PharmD degree: I am not interested in such a program

at this time 15 5.8 4 3.0 11 8.8 Wantb 35 13.5 18 13.4 17 13.6 Needc 43 16.6 25 18.7 18 14.4 Missing 166 64.1 87 64.9 79 63 2

Desired structure of this program Home study and distance learning 13 5.0 9 6.7 4 3.2 Home study 12 4.6 5 3.7 7 56 Home study and clinical training 6 2.3 5 3.7 1 0.8 All of the above 8 3.1 3 2.2 5 4.0 Distance learning 3 1.2 3 2.2 — — Missing 217 83.8 109 81.3 108 86.4

aRespondents with a PharmD degree responses (no. pharmacists n=l 14, 30.6 percent; rural pharmacists n=42, 23.9 percent; urban pharmacists n= 72, 36.6 percent) were removed for this analysis.

bWant defined as I want these PC skills but I choose not to pursue them. cNeed defined as I want these PC skills and I am willing to sacrifice the time and cost to obtain them.

16.6 percent (43 of 259) of pharmacists perceived the PharmD degree as a need (I need the degree and I am willing to sacrifice the time and cost to obtain it), as stated by 18.7 percent (25 of 134) of pharmacists in rural areas and 14.4 percent (18 of 125) of pharmacists in urban areas. Pharma-cists’ response to this item suggests that while some pharma-cists perceive the PharmD degree as a wanted degree, relatively few pharmacists are willing to sacrifice the time and cost to obtain it. Pharmacists were asked how this nontraditional PharmD program should be structured and

39 pharmacists reported home study alone, or in a combina-tion of home study and another technique. Thirteen phar-macists chose home study and distance learning, 12 chose home study, and six chose home study and clinical training.

Current Pharmaceutical Care Assessment Pharmacists were asked what percent of their time was

spent on each of nine activities. Dispensing accounted for 43 percent of their time and was the primary category of time use. Commonly cited activities and percentage of their daily

248 American Journal of Pharmaceutical Education Vol. 62, Fall 1998

Table VII. Respondents’ viewpoints on pharmaceutical care assessment and reimbursement

No. pharmacists (n=373)a Rural (n=176) Urban(n=197)a Variable n Percent n Percent n Percent Reimbursement by PBM or third-party

payer for pharmaceutical care: No 305 81.8 147b 83.5 158b 80.2 Yes 46 12.3 23b 13.1 22b 11.2 Missing 22 5.9 6 3.4 17 8.6

Pharmacist charged patients for pharmaceutical care 21 6.0 10c 5.7 11c 5.6

Diseases/medications needing more PC timea

Diabetes 70 18.8 31d 17.6 39d 19.8 Asthma 23 6.2 14d 7.8 9d 4.6 Cardiac medications 13 3.5 3d 1.7 10d 5.1 Hypertension 12 3.2 5d 2.8 7d 3.6 Chemotherapy 10 2.7 ld 0.6 9d 4.6 Antibiotics 7 1.9 2 1.1 5 2.5 Psycho tropic drugs 6 1.6 4 2.3 2 1.0 Anticoagulant 5 1.3 4 23 1 0.5

aRespondents may have answered more than once, so total percent will total more than 100.0. bComparison of rural and urban pharmacists (chi-square = 0.03, d.f. =1, P = 0.854). cComparison of rural and urban pharmacists (chi-square = 0.04, d.f. =1, P= 0.837). dfor first five conditions, a comparison of rural and urban pharmacists (chi-square = 4.94, d.f. =3, P= 0.177).

time spent in that activity were on monitoring drug therapy (i.e., dosage regimen, contraindications, drug interactions, and adverse effects) (12.9 percent), on counseling patient or patient’s care-giver (10.8 percent), on communicating with the health care provider (9.2 percent), and on request for drug information from patient or a health provider (6.7 percent). Frequently cited write-in responses were manage-ment and administration (n=24), paper work (n=5), educa-tion (n=4), nonprescription drugs (n=3), and research (n=2).

Pharmaceutical Care Reimbursement To assess this area, respondents were asked to assume

that PC include nondispensing activities (e.g., patient coun-seling, contacting physician for drug interaction, drug use review, drug therapy monitoring, disease state manage-ment, etc.). Respondents were asked if they were reim-bursed by any pharmacy benefit manager (PBM) or third-party payer for PC. Overall, 12.3 percent of pharmacists (46 of 373) have been reimbursed with the rural area pharma-cists higher (13.1 percent or n=23) compared with the urban group (11.2 percent or n=22). Six percent (n=21) of the respondents have charged private paid patients for PC, 10 were from rural areas and 11 were from urban areas. An average amount of $31.33 (median - $25.00) was charged with a range from $2.00 to $ 120.00. The average amount of time for PC was estimated to be 5.5 minutes per encounter with a range from one to 60 minutes. While the range of responses was large, 77.2 percent said the response was between one and five minutes.

In an open-ended response format, pharmacists were asked whether certain diseases or medications need more time than others for PC. Based on analysis of themes, diabetes was most commonly cited by 18.8 percent of phar-macists with similar distribution in rural and urban groups (Table VII). Other frequently mentioned diseases and medi-cations were: asthma (6.2 percent), cardiac medications (3.5 percent), hypertension (3.2 percent), and chemotherapy (2.7 percent). Asthma was mentioned more frequently by

rural pharmacists (7.8 percent) than by urban pharmacists (4.6 percent). Urban pharmacists more frequently men-tioned cardiac medications and chemotherapy than did rural pharmacists.

DISCUSSION Sample Characteristics

In our sample, independent pharmacists were more common in rural areas and chain store pharmacists more prevalent in urban areas. Urban area pharmacists are more likely to have less than 10 years of experience, are female, come from urban areas, have a PharmD degree and practice in a chain store pharmacy. Rural area pharmacists were more likely to have a baccalaureate degree, reared in a rural area, have more than 10 years of experience, are male, and practice in an independent community pharmacy. Nation-ally, we are seeing a dramatic decline in the number of independent practitioners with a concomitant increase in chain store pharmacists. However, both groups are increas-ingly engaging in pharmaceutical care activities. Pharma-cists with a doctor of pharmacy degree were more common in urban areas than rural areas. Since 1976, UNMC has offered the PharmD program as the sole degree, however, these findings suggest that despite the collegiate clinical orientation, rural areas have not benefited as much as was hoped. These data suggest that a rapid infusing of clinical expertise is needed to salvage and maintain the practice of independent pharmacists especially in rural areas. Sample characteristics were similar to the pharmacist work force study(11). Our sample represents a microcosm of the United States and so our results may have some implications on a national basis.

Cognitive Services Reimbursement Nondispensing activities account for 57 percent of phar-

macist time. Of those who filed for PC reimbursement, only 12.3 percent received payment, and it is unknown from these

American Journal of Pharmaceutical Education Vol. 62, Fall 1998 249

results whether reimbursement was in full or partial. Only six percent of pharmacists have charged private-pay pa-tients for PC, with the median charge of $25.00 for an average of 5.5 minutes. While the 12.3 percent PC reim-bursement rate is low, it is favorable compared with the 6.9 percent reimbursement rate that health insurance company respondents had reported for pharmacist-provided cogni-tive services(14). Given the decreasing gross margins for prescription drugs, PC reimbursement must continue to improve in order for pharmacy to remain a viable profes-sion, regardless of their urban or rural setting.

Nontraditional PharmD or PC Certificate Program Nebraska pharmacists preferred the certification pro-

gram versus a nontraditional PharmD program. Perhaps this translates into their desire to achieve certain skills and less concern for the formality of a degree. University of Nebraska has offered exclusively the doctor of pharmacy degree since 1976. Of the respondents, 30.6 percent re-ported having a PharmD degree, so baccalaureate degree pharmacists comprise seven of ten Nebraska pharmacists. While the desire for the nontraditional PharmD degree could have been confounded by inclusion of respondents with a PharmD degree, their responses were removed for this analysis. Only 43 baccalaureate degree pharmacists perceived the PharmD degree as a need and reported they were willing to sacrifice the time and cost to obtain it. If this result is extrapolated from the 40 percent of Nebraska pharmacists surveyed to the total number of pharmacists, then approximately 108 pharmacists are willing to undergo the opportunity cost and time to obtain this degree. Of these 43 pharmacists, fifteen pharmacists would be willing to pay up to $6,000 and only seven pharmacists were willing to pay more than $6,000 to obtain the PharmD degree. This is less than the $16,000 for all four years of study currently charged for UNMC’s four-year PharmD program. This represents a significant disparity between want and willingness to pay.

Meanwhile, 66.8 percent of pharmacists expressed in-terest and 42.6 percent (159 of 373) perceived the certificate programs as a need. If extrapolated to the population of Nebraska pharmacists, then approximately 375 pharmacists are willing to sacrifice the time and cost to obtain the PC certificate program. This distribution was nearly equal in both urban and rural areas. Both baccalaureate and PharmD degree pharmacists perceive a need for PC training. One-third of the respondents were willing to pay up to $3,000 for the PC program. When asked how this certificate program should be structured, most respondents preferred home study. This does not necessarily translate into good clinical skills. While considerable therapeutics and pharmacokinet-ics knowledge can be obtained through self-study, we doubt that most patient care skills can be learned in a home environment. Some pharmacists argued that pharmacists practice these skills in their practice environment. However, pharmacists reported that 43 percent of their day was spent on dispensing-related activities rather than cognitive ser-vices. This disparity represents the discordance between present practice activities, future practice needs, requisite training and willingness to engage in the training, from both time and financial aspects.

Rural areas in Nebraska and throughout the United States are facing substantial changes in financing and deliv-ery of health care. Combined effects of troubled rural eco-

nomics, difficulties recruiting and retaining physicians and pharmacists, changes in health services utilization patterns, cutbacks in third party reimbursement, and reliance on increasingly expensive technology threaten the prospects for continued accessibility of health services in rural ar-eas(15). Despite these factors, the investigators note that rural practice offers unique opportunities for pharmacists to provide pharmaceutical care and make a substantive impact on patients’ health. Many of our rural pharmacists are the first primary care providers seen and are often the only health care providers consistently and continuously avail-able in the community. With only weekly or biweekly avail-ability of physicians or physician assistants, these rural pharmacists are crucial in meeting the daily health care needs of the community both from a statewide and national level. Gangeness stated that education for rural practices such as these are largely overlooked in current pharmacy curricula(10). He also states that national leadership must develop a sensible workforce policy that considers the needs of ruralpatients(10) and must acknowledge the pharmacist’s role in these rural communities. Pharmaceutical care oppor-tunities abound in these rural settings. Not to address the educational needs of these rural pharmacists is not only to miss a treasure of opportunities, but may also mean the rapid demise of these independent pharmacy practitioners. UNMC and the College of Pharmacy have been devel-oping clerkship and training programs to improve the health of rural Nebraska citizens. Pharmacist response has been positive, however, time and financial constraints have lim-ited these efforts. Educational implications for pharmacy educators are important. While pharmacists desire PC train-ing in both urban and rural areas, most training programs have overlooked rural practice. The need and opportunities for PC in rural areas are substantial. We suggest that col-leges and schools of pharmacy deal with this issue through prioritized training of rural practitioners. We further sug-gest that this issue be addressed in a timely manner to help salvage the dwindling number of rural independent phar-macy practitioners.

Pharmacy Student Pharmaceutical Care Skills Training. Pharmacists were asked to rate a 15-item list of desired

PC skills needed by pharmacy students. Both rural and urban pharmacists had similar ratings for the top five rated skills. Counseling patients was the highest rated need. Phar-macists cited communication skills as the most popular open-ended response. This suggests that UNMC and other colleges of pharmacies should place greater emphasis on communication skills in pharmacy students and offer more opportunities earlier in the curriculum to practice clinical skill building. Some suggestions include a communication skills laboratory, expansion of the APhA/ASP Patient Coun-seling Competition to all students, development of precep-tor counseling role models, and greater clerkship emphasis on counseling. “Performing physical assessment” was rated the lowest item on the 15-item list. “Interpreting physical assessment data” was rated the second lowest item. This is disconcerting as it represents a lack of insight from these practitioners as to the future of pharmacy. Effective drug therapy monitoring is closely linked with basic physical assessment competencies. As pharmacists progress to func-tioning as mid-level practitioners, we must acquire and refine our physical assessment skills.

250 American Journal of Pharmaceutical Education Vol. 62, Fall 1998

Current Pharmaceutical Care Skills Assessment Pharmacists were asked to self-assess their own level of

PC skills. Both rural and urban pharmacists assessed their ethical decision-making skills as highest and this concurs with public opinion as evidenced by the Gallup poll. “Coun-seling of patients” was rated very high in this self-assessment section, and in the desired PC skills section needed by pharmacy students. In accordance with the pharmacy stu-dent PC skills training assessment “performing physical assessment skills” was the lowest rated item on this assess-ment as well. These findings suggest that pharmacists do not value this activity. However, this PC skill is considered a crucial component of community practice by some phar-macy practitioners and pharmacy educators. Physical as-sessment is also listed as a curriculum content area for the Doctor of Pharmacy degree model program(16,17). One supposition for this low rating is that pharmacists view physical assessment as the exclusive domain of the physi-cian. While this may be the perception of some pharmacists, nurse practitioners and physician assistants are routinely conducting physical assessment and have also secured pre-scribing rights. Rephrasing this survey item from “perform-ing physical assessments” to “performing patient assess-ment” may have received a more favorable response. “Pa-tient assessment skills” were a write-in response by two pharmacists, and may suggest that some pharmacists feel apprehensive about calling these PC skills “physical assess-ment skills.” While pharmacists do not have to be experts at performing complicated physical assessments, they should be able to conduct basic skills (e.g., pulse, blood pressure monitoring). All pharmacists should be able to help deter-mine whether changes in the patient’s health are due to the use of medications. If PC becomes a broad-based move-ment, then the pharmacist must assume responsibility for monitoring the patient’s drug therapy. Accordingly, this requires the pharmacist to “lay hands” on patients by doing basic physical assessment.

Considerable efforts have been made to design and implement PC training programs, however, there are few published reports where a need’s assessment has been con-ducted(8,9,18). Schommer and Cable surveyed Ohio phar-macists to compare current PC practices between respon-dents categorized by practice setting. Their instrument mea-sured four overall dimensions: drug information source, information gathering, patient counseling, and drug moni-toring. Overall, pharmacists were more involved in “pas-sive” PC activities such as a drug information source. How-ever, pharmacists were less likely to engage in “active” PC activities such as patient counseling and drug monitoring activities. Community pharmacists were more involved in patient counseling, whereas institutional pharmacists more frequently engaged in drug monitoring activities. Their results showed that pharmacists engaged in passive pharma-ceutical care activities more frequently than active ones. They concluded that pharmacists and students need appro-priate training and professional socialization to encourage a more active type of practice in which comprehensive PC is provided(18). In our study, Nebraska pharmacists reported being more active in patient counseling, but less likely to be interested in physical assessment activities.

As pharmacy educators review these data, the PC edu-cational need of the rural practitioners is clearly critical. With an ongoing dramatic decline in independent, rural practitioners, a rapid infusion of PC skills is needed to

maintain these rural pharmacy practices to served this rural population. If these pharmacy practices do not survive, it is unlikely that they will be replaced with chain pharmacies that require a larger patient population base. So, it is likely that rural populations could face a lack of pharmaceutical care. With pharmacists frequently the solitary, primary care provider in these settings, this translates into a severe medi-cal care deficiency. Without these pharmacy practitioners, the health care crisis in rural communities will assume an entirely different dimension. Pharmacy educators need to seize this acute situation and assist both the rural pharma-cists and rural communities in securing pharmaceutical care as the standard for rural patients.

Study Limitation. One limitation is the self-reported nature of the study.

The percent of the pharmacist’s day spent in dispensing and performing cognitive services is an approximation. Actual time can be determined using direct observation techniques or a work sampling technique but was beyond the scope of this study.

CONCLUSION Pharmaceutical care is needed by our patients and by our profession in order for us to advance into the 21st century. Additional education is needed regarding PC by most prac-titioners. The training mode most wanted and needed by Nebraska pharmacists is through a PC certificate program and perhaps this is the most expedient mode especially for rural practitioners. While a certificate program would be best received, home-study should represent only a compo-nent and not the entirety of such a program. It is unlikely that a competent mid-level practitioner can be developed through a certificate program. However, such a program will provide a start and a strong base for the motivated pharmacist clinician to build upon. Given the crucial nature of rural pharmacy, such certificate programs should be implemented immediately and should initially target rural pharmacy prac-titioners.

Am. J. Pharm. Educ., 62, 243-252(1998); received 9/8/97, accepted 4/23/98.

References (1) Hepler, CD. and Strand, LM., “Opportunities and responsibilities in

pharmaceutical care,” Am. J. Hosp. Pharm., 47, 533-543(1990). (2) Tomechko, M.A., Strand, L.M., Morley, P.C. and Cipolle, R.J., “Q

and A from thepharmaceutical care project in Minnesota,” Am. Pharm., NS35, 30-39(1995).

(3) Penna, R.P., “Pharmaceutical care: Pharmacy’s mission for the 1990s,” Am. J. Hosp. Pharm., 47, 543-549(1990).

(4) Pew Health Professions Commission, “Critical challenges: Revitaliz-ing the health professions for the twenty-first century,” USCF Center for Health Professions. San Francisco CA (1995).

(5) Sapienza, A.M. and Broeseker, A., “Health care professionals and interdisciplinary care,” in Introduction to Health Care Delivery: A Primer for Pharmacists. (edit., McCarthy, R.L.), Aspen Publication, Inc. Gaithersburg MD (1998) pp. 31-61.

(6) Broeseker, A. and Janke, K.K., “The evolution and revolution of pharmaceutical care,” in Introduction to Health Care Delivery: A Primer for Pharmacists. (edit., McCarthy RL.), Aspen Publication, Inc. Gaithersburg MD (1998) pp. 393-416.

(7) Miller, L.G. and Narducci, W.A., “Nebraska drug information net-work: Educational model for community sites,” Am. J. Pharm. Educ., 60, 131-135(1996).

(8) Scott, D.M., Neary, T.J., Thilliander, T. and Ueda, C.T., “Factors affecting pharmacists’ selection of rural or urban practice sites in Nebraska,” Am. J. Hosp. Pharm., 49, 1941-1945(1992).

(9) Miller, L.G., Jungnickel, P.W. and Scott, D.M., “Pharmaceutical care

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in rural community pharmacy clerkships: Emphasis on developing computer skills to enhance patient education. Am. J. Pharm. Educ. 60, 249-256(1996).

(10) Gangeness, D.E., “Pharmaceutical care for rural patients: Ominous trends,” J. Am. Pharm. Assoc., NS37, 62-65, 84(1997).

(11) Commission to Implement Change in Pharmaceutical Education, “Background Paper II: Entry-evel, curricular outcomes, curricular content and educational processes,” Am. J. Pharm. Educ., 57, 374 376(1993).

(12) Braden, J. and Beauregard, K., “Health status and access to care of rural and urban populations,” AHCP Publication No. 94-0031. Na-tional Medical Expenditure Survey Research Findings. Agency for Health Care Policy and Research, Public Health Service, Rockville MD(1994).

(13) SAS/STAT User’s Guide. Version 6, Fourth Edition. Cary NC, SAS Institute, 859, 1634(1988).

(14) Scott, D.M., Miller, L.G., “Reimbursement for pharmacy cognitive services: Insurance company assessment,” J. Managed Care Pharm., 3, 46-51(1997).

(15) Comer, J. and Mueller, K., “Access to health care: Urban-rural comparisons from a Midwestern agricultural state,” J. Rural Hlth., 11, 128-136(1995).

(16) da Camara, C.C., D’Elia, R.P. and Swanson, L.N., “Survey of physical assessment course offerings in American colleges of pharmacy,” Am. J. Pharm. Educ., 60, 343-347(1996).

(17) Commission to Implement Change in Pharmaceutical Education, “Entry-level education in pharmacy: A commitment to change,” ibid., 57, 366-374(1993)

(18) Schommer, J.C. and Cable, G.L., “Current status of pharmaceutical care practice: Strategies for education,” ibid., 60, 36-42(1996).

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