Assessment of pharmacy manpower and services in West Virginia

Article Outline

• Abstract
• 1. Introduction
• 2. Background
• 3. Methods
• 4. Results
  • 4.1. Respondent demographics
  • 4.2. Pharmacy practice
  • 4.3. Pharmacist staffing
• 5. Discussion
• 6. Conclusion
• References
• Copyright

Abstract 

Background

The shortage of pharmacists across the nation has been much publicized and has been identified as one of the reasons for new schools of pharmacy to open or for existing colleges and schools of pharmacy to increase their class sizes. This article represents the assessment of a new school of pharmacy's evaluation of staffing and practice in its geographic area.

Objective

This survey represents the first data point within the School of Pharmacy assessment plan and will be repeated at several intervals after the program opens to longitudinally evaluate its impact on pharmacy staffing and services within West Virginia.

Methods

Using a modified Dillman survey methodology a random sample of 548 pharmacists in West Virginia, approximately one-third the active roster, were surveyed regarding staffing and services in West Virginia.

Results

A response rate of 32.78% was achieved and findings indicated that there is a staffing shortage of pharmacists within West Virginia, that staffing impacts the services pharmacists provide, and that more pharmacists would be willing to offer disease management services if staffing levels were at appropriate levels.

Conclusions

A shortage of pharmacists does exist in West Virginia and it has implications on patient care. Longitudinal evaluation of the impact of a new pharmacy program will be conducted and the staffing and services within West Virginia should be continued to be studied.

Keywords: Pharmacist staffing, West Virginia, New schools of pharmacy

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1. Introduction 

The shortage of pharmacists across the nation has been much publicized and has been projected to worsen throughout the next decade.¹ The pharmacist shortage has also been identified as one of the reasons for new schools of pharmacy to open or for existing colleges and schools of pharmacy to increase their class sizes. While the shortage is not uniform from state to state, West Virginia has consistently been identified in the Pharmacy Manpower Project as a high demand area.² As of November 2005, West Virginia was the only state in the United States with an aggregate demand score of 5, indicating a high demand and difficulty filling open positions.² This article addresses the shortage in West Virginia specifically and the impact of this shortage has on patient care issues such as disease management.

The School of Pharmacy at the University of Charleston was started based upon the needs for pharmacy services within West Virginia. To determine if the School of Pharmacy impacts patient care and pharmacist staffing after it opens in the fall of 2006, a baseline understanding of the current manpower and practice activities within West Virginia is necessary. This survey represents the first data point within the School of Pharmacy assessment plan and will be repeated at several intervals after the program opens to longitudinally evaluate its impact on pharmacy staffing and services within West Virginia.

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2. Background 

An unpublished study by the West Virginia Board of Pharmacy in 2003 reported approximately 925 full-time pharmacists actively practicing in the State of West Virginia, or 5/10 000 population while the current average in the United States being 9.0 pharmacists/10 000 population. This is also less than the ratio of pharmacists in rural areas, which is 6.6/10 000.³ The need for pharmacists within West Virginia has been characterized by the State Board as a shortage in 2003 with a projected shortfall of 75 to 100 pharmacists this year and growing annually. This is further supported by Cooksey et al⁴ who identified in 1999 that West Virginia had only 4.2 graduates per 100 000 of the state population, which demonstrates the great need for pharmacists within the state.⁴

West Virginia is located in the Appalachian region of the United States. Appalachia, as defined in the legislation from which the Appalachian Regional Commission derives its authority, is a 200 000-square-mile region that follows the spine of the Appalachian Mountains from southern New York to northern Mississippi. It includes all of West Virginia and parts of 12 other states: Alabama, Georgia, Kentucky, Maryland, Mississippi, New York, North Carolina, Ohio, Pennsylvania, South Carolina, Tennessee, and Virginia. About 23 million people—or 8% of the entire U.S. population—live in the 406 counties of the Appalachian Region; 42% of the Region's population is rural, compared with 20% of the national population.⁵, ⁶ The rural nature of the Appalachian region (including West Virginia) can be seen as representative of the United States, which according to the U.S. Office of Management and Budget is categorized as rural.⁷

The challenges regarding the provision of pharmaceutical care can be compounded in rural areas where pharmacy services may exist less frequently than in urban settings. In addition, the rurality of West Virginia has significant implications for patient care. In rural communities, pharmacists not only are significant contributors to local health care, but are also a critical part of the community. More so than urban counterparts, rural pharmacists are on a first-name basis with their patients and are a readily accessible source of medical information, whether in the pharmacy or in other social settings. They are a part of the social fabric of the areas they serve. The challenge is that in rural settings the pharmacist may not only be an integral part of the health care team, but may in fact be the only available, certainly the most accessible, health care provider. According to a study of pharmacy practice in West Virginia that evaluated the barriers to providing pharmaceutical care in rural environments, pharmacists surveyed indicated a willingness to engage in pharmaceutical care and that educational interventions should be considered to improve practitioner confidence to render pharmaceutical care.⁸

According to census data, West Virginia is older in many categories than U.S. average. Noted within the 2004 Census Bureau information was that West Virginia exceeded the national average for individuals over 65 years of age (15% vs 12%), individuals over 18 years of age (78.3% vs 74.5%), and median age (40.3 vs 36.2 years).⁹ Based on the increasing number of prescriptions used by an aging population, it is easy to understand why there will be profound shortages of pharmacists in the next 2 decades. Unfortunately, current numbers of pharmacists are insufficient to safely dispense prescribed drugs and monitor the effects of drugs on their patients. The Department of Health and Human Services in a congressionally mandated report states that the demand for pharmacists far outpaces the supply, and the public's health may be compromised because of the reduced time a pharmacist may have to deliver comprehensive patient-centered pharmacy care.¹⁰

Unfortunately, the citizens of West Virginia exhibit several unhealthy practices that would benefit from patient-centered pharmacy care if available. Smoking, obesity, diabetes, and lung-related issues are commonplace in West Virginia and when combined with the fact that the state has a higher than average median age, there is a prominent need for care. The unanswered question is what could be done if there were an adequate number of pharmacists within West Virginia to implement the services that would result in positive health outcomes for these patients. The success of the Asheville Project demonstrates what can be accomplished if pharmacists are appropriately educated to manage patient outcomes and the positive outcomes that can result.¹¹ The success of the Asheville Project, while not explicitly stated, is dependent upon adequate staffing so the services can be offered and continued.

Finally, shortages may also contribute to increased salaries for pharmacists. According to the 2005 Drug Topics Annual Salary Survey, salary levels within the southern region of the United States, of which West Virginia is included, are among the highest in the country. Chain pharmacists in the southern region were the highest paid in the country.¹² One possible reason for the higher salaries is the amount of rural environments in the southern region, the lower number of pharmacists in these regions, and the increased demands on pharmacist from a more aged patient population. It might be possible to encourage pharmacy students to leave and return after graduation to their hometown communities or encourage pharmacy students to practice in rural areas. A study of pharmacy student perspectives of rural pharmacy practice found that students would be willing to work in rural environments if the practice opportunities were consistent with their interests.¹³

For these reasons, it was important to evaluate pharmacist staffing and practice within West Virginia. The specific objectives of this study were to identify pharmacist staffing levels within West Virginia, identify pharmacy care being provided within West Virginia, identify the impact of pharmacist staffing levels on patient care, and identify pharmacy technician staffing levels in West Virginia.

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3. Methods 

A 32-question survey, 1 page front and back, was developed for the purposes of the study. A 5-point Likert scale was chosen to give the respondent a neutral response versus using a 4-point forced choice scale. The literature is mixed regarding the use of even versus odd numbered scales and the researchers chose the former.¹⁴ The survey was pilot tested on 4 local pharmacists to determine face validity, content validity, and to assess readability and time-to-complete. The pharmacists selected for the pilot study were predominantly retail pharmacists with more than 5 years of experience. Minor changes were made to the survey based upon the pilot test and included clarification of questions and responses. No questions were added or deleted as a result of the pilot test.

During survey development, the list of registered pharmacists within West Virginia was obtained from the West Virginia Board of Pharmacy. According to the Board in the fall of 2004, there were 1644 pharmacists on the active roster. Using random sampling 548 pharmacists, approximately one-third of the active roster, were selected for the study and all had mailing addresses within West Virginia.

This study used a survey methodology that was modified from the procedures recommended by Salant and Dillman¹⁵ with the mailing sequence being comprised of 2 parts. The initial mailing was the survey, a personalized cover letter, and a self-addressed postage-paid return envelope. The second mailing was a nonpersonalized reminder postcard sent to nonresponders to increase the response rate approximately 2 weeks after the initial mailing. The first mailing took place the week of November 15, 2004 and the reminder postcard was sent the week of November 29, 2004.

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4. Results 

Out of the 548 surveys mailed, 8 were returned because of inaccurate mailing addresses decreasing the sample size to 540. As a result of the 2 mailings, a total of 177 surveys were returned, yielding a response rate of 32.78%. The following results section is broken down into 3 subsections, which are respondent demographics, pharmacy practice, and pharmacist staffing levels.

4.1. Respondent demographics 

The findings for the respondent demographics can be found in Table 1. Specific findings included that sex was evenly split, 79% of respondents were working full time, 80% had a B.S. in Pharmacy, and 58% were board certified.

Table 1. Demographic information; n=177 (indicates %)

4.2. Pharmacy practice 

As can be seen in Table 2, pharmacists within West Virginia are engaged in disease management practices, but in every disease state a higher percent of pharmacists wanted to be offering services than currently are. Questions within this section were specific to the practice of pharmacy in West Virginia as defined through services offered by the respondents in his or her primary place of employ.

Table 2. Disease management programs offered and like to offer (n=177)

Five barriers were given as examples to the pharmacists as to what prevented them from offering disease management services. The barrier identified most was staffing (70%) with the barrier identified least was that respondents would not be interested in participating in disease management (5%). The remainder of the results can be found in Table 3.

Table 3. Barriers to offering DSM (n=177)

DSM=disease management.

4.3. Pharmacist staffing 

Questions within this section were specific to staffing level for pharmacists in West Virginia and its impact on patient care. In addition to asking about pharmacist staffing levels, the survey also asked about pharmacy technician staffing levels as well.

One aspect of pharmacist and pharmacy technician staffing levels was to identify how many open positions had occurred within the respondent's primary place of employ. As indicated in Table 4 for both pharmacists and pharmacy technicians, over 55% of respondents indicated a vacant position within the past 12 months. The results were lower for more than 1 vacant position but still above 30% for both pharmacists and pharmacy technicians.

Table 4. Vacant pharmacist and pharmacy technician positions at primary place of employ (n=177)

With respect to specific questions about the pharmacist shortage within West Virginia, respondents were asked to answer using a 5-point Likert scale from “Strongly Agree” to “Strongly Disagree” and the detailed results can be found in Table 5. These findings indicate a perceived shortage of pharmacists by respondents in West Virginia consistent with national data. According to the findings, 81.5% of respondents strongly agreed or agreed that there is a shortage of pharmacists in West Virginia and 75.7% strongly agreed or agreed that the shortage was worse in the rural areas of the state. According to respondents, 97.1% strongly agreed or agreed that pharmacist levels impact patient care and 85.8% indicated that pharmacists staffing levels impact the ability to counsel patients. The data were also evaluated with respect to the perceived shortage by retail pharmacists versus nonretail pharmacists and no difference was found.

Table 5. Pharmacist staffing levels and impact on patient care

Note: S.A.=strongly agree; A=agree; N=neutral; D=disagree; S.D.=strongly disagree.

Data were also collected regarding the staffing levels of pharmacy technicians because they have an integral role in patient care. According to the findings, 54% of respondents strongly agreed or agreed that there was a shortage of pharmacy technicians and 44% strongly agreed or agreed that the shortage was greater in rural areas. Also noted in the findings were that 85.8% of respondents strongly agreed or agreed that pharmacy technician staffing levels impact patient care. The detailed results can be found in Table 6.

Table 6. Pharmacy technician staffing levels and impact on patient care

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5. Discussion 

Based on the results, the number of pharmacists providing disease management services is lower than the number who would like to offer services. As indicated in Table 2, only 5% of respondents did not want to engage in disease management services, and 70% of respondents indicated that they were not staffed to offer disease management services. This compares to a recent study in California where only 18% cited limited staffing as a barrier to offering disease management.¹⁶ Of the 9 specific disease states mentioned in Table 1, an average of 31.37% of respondents would like to offer these specific services. With respect to the number of pharmacists interested in providing disease management services, it was recently reported that 20% of pharmacists in California interested.¹⁶ This comparison is interesting just on the basis of the population for the different states as well as the number of mature pharmacy programs that have been graduating potential pharmacists. While the question did not ask what staffing, pharmacist or pharmacy technician, the respondent felt contributed, subsequent questions asserted that shortages of either pharmacists or pharmacy technicians impacted patient care. It should also be noted that 75.7% of respondents strongly agreed or agreed that the shortage was worse in the rural areas of the state and over half of the respondents reported either vacant pharmacist and/or pharmacy technician positions at primary place of employment.

The key issue is staffing as it relates to the time that can be spent on patient care related issues. Of particular importance to respondents is the relationship between pharmacist staffing levels and its relationship to patient care and patient counseling. According to the results, 97.1% strongly agree or agree that pharmacist staffing impacts patient care and 85.9% strongly agree or agree that it impacts patient counseling, what should be considered is the minimum level of patient education interventions. If staffing is indeed related to the success of counseling patients, then these findings are very troublesome in that it demonstrates the potential impact on patient care that can result from a shortage of pharmacists.

The shortage of pharmacy technicians within West Virginia has serious implications for patient care as well. Findings indicated that 54% of respondents strongly agreed or agreed that there was a shortage of pharmacy technicians in West Virginia. This was supported by the fact that 68.3% of respondents indicated that their primary place of employ tried to fill 1 vacant pharmacy technician position within the past 12 months and 45.2% indicated trying to fill more than 1 position in the same time frame.

The role of the pharmacy technician has evolved and in combination with the use of technology pharmacies have been able to mitigate the problems, in some instances, caused by the shortage of pharmacists. The findings of this study indicate that the shortage of pharmacy technicians could well be hindering patient care, and over 85% of respondents strongly agreed or agreed that pharmacy technician staffing impacted patient care. More needs to be done to ensure the adequate preparation, training, and certification of pharmacy technicians to ensure their role in patient care in states like West Virginia that have a demonstrated shortage.

The opening of new schools of pharmacy in Charleston, West Virginia, Grundy, Virginia, Johnson City, Tennessee and at the time this article was developed 2 new programs were proposed in Kentucky may help over time as these programs begin producing graduates, but graduating pharmacists is only part of the solution. Unless recruitment and retention issues targeting rural areas are addressed, such as recruiting rural students seeking to go to school and then return home, the shortage in rural areas will not be resolved. Recruitment programs targeting rural area students and unique tuition assistant programs might help increase the number of pharmacists in these rural areas, but these are only 2 possible solutions and others need to be explored.

As the staffing issues are resolved because of an increased number of pharmacy graduates, disease management programs dealing with these unhealthy lifestyles should become more commonplace. Unfortunately, the demographics within West Virginia combined with the fact that a new influx of graduates will not occur until 2010 means that the shortage may not go away any time soon. While it could be considered that the increased use of pharmacy technicians and technology could help ameliorate the problem, previously stated findings from this study indicate a shortage of pharmacy technicians as well.

No study is without limitations and several were identified. First, the response rate could have been increased if a third mailing was conducted. At the time the survey was conducted, other things regarding the start-up of the pharmacy program precluded the third mailing from occurring. Second, the survey did not identify who was practicing in rural versus urban environments and this may have been helpful in evaluating the shortage in these different settings with less reliance on pharmacist perceptions. This change will be made in subsequent surveys. Regarding the survey itself, while the survey was pilot studied for face and content validity, no psychometric analysis was conducted to evaluate the instrument.

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6. Conclusion 

Based upon the data from this survey, there is a shortage of pharmacists within West Virginia and that shortage is affecting patient care. A significant number of respondents indicated their desire to provide a variety of disease management services and that they lacked the expertise or staffing to do so. A possible implication of the lack of expertise is that the lack of staffing is preventing currently practicing pharmacists from attending programming and gaining the credentials necessary to offer disease management services.

Part of the mission of the school of pharmacy is to provide a comprehensive educational program for the education of entry-level practitioners. The repetition of this survey will enable the school of pharmacy to assess if it is meeting this mission. Providing a comprehensive educational program should correct not only the staffing issues but also the expertise issues preventing pharmacists in West Virginia from providing disease management programs. An increase in well-trained pharmacists should lead to an increase in these programs being offered in West Virginia.

The opening of a new pharmacy school in southern West Virginia should lead to better health care for the residents of that area by alleviating a portion of the shortage. This will allow pharmacists who desire to implement disease management programs, the opportunity to do so and impact change within the community. Further follow-up will be needed to determine the effect this has on the lifestyle choices of West Virginians.

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