Pharmacists, providers linking to provide emergency contraception
States eye Washington’s blueprint in designing collaborative practices
Energized by the success of a Washington state pilot project, providers, pharmacists, and other stakeholders in various parts of the United States are sitting down at the table to design their own programs to expand access to emergency contraceptive pills (ECPs).
Representatives from Alaska, California, Connecticut, Idaho, Mary land, Washington, DC, North Carolina, New Jersey, New York, Okla homa, Oregon, Texas, Pennsylvania, and Utah, as well as three Canadian provinces and the Philippines, recently met with partners in the Wash ington state pilot project to learn how they can increase ECP access through direct pharmacist provision. The workshop was hosted by the Program for Appropriate Technology in Health (PATH), with other organizers such as the Washington State Pharmacists Association, the Unive rsity of Washington Department of Pharmacy, the Washington State Board of Pharmacy, and Elgin DDB Needham ad agency, all in Seattle.
During the three-day workshop, participants received an overview of key issues involved in collaborative drug therapy agreements; discussed issues of communication, public relations, collaborative drug therapy agreements, regulation, legislation, training, and service delivery; and brainstormed on key elements needed within individual states to make direct pharmacist provision of ECPs a reality.
"The purpose of the workshop was to share information about what we had done here on the Washington project, and to use that as a starting point or a base for other states who are interested in increasing ECP availability through pharmacists prescribing," says Jane Hutchings, MPH, senior program officer at PATH. (Those who were unable to attend the workshop can download the information from PATH’s Web site: http://www. path.org/html/ec_tools.htm.)
As of May 1999, 130 pharmacies were participating in the Washington project, and more than 800 pharmacists have received training in ECP prescribing, according to PATH. In the first 13 months of the project, 9,333 ECP prescriptions were provided to women directly by a pharmacist.
Pregnancy risk can vary, depending on a variety of factors, but assuming a 10% pregnancy risk and a 75% method-effectiveness rate, PATH estimates that the prescriptions filled in the first 13 months of the project may have prevented between 504 and 2,100 unintended pregnancies, half of which PATH estimates likely would have ended in abortion.
Central Oregon acts
The Central Oregon Independent Practice Association, a group of physicians who cover Crook, Deschutes, Jefferson, Grant, Harney, Lake, and Wheeler counties, is working with several agencies to move toward collaborative agreements for ECP prescribing, reports Mary Jeanne Kuhar, MD, an OB/GYN in Bend, OR, who is involved with organizing the project.
The physicians’ group is collaborating with the Central Oregon Pharmacy Association to put together the pilot project. The project has been approved by the Oregon Medical Association and has been presented to the Oregon Board of Pharmacy for its review.
"Our idea is to do a pilot project which will just be in our seven-county area, so it will not be statewide to start with," reports Kuhar. "We have been very fortunate to be able to work closely with the health division which oversees the different family planning clinics in the counties, and they are very supportive of this."
Changes may need to be made in existing regulations in regard to outpatient collaborative agreements since they have not been used previously in Oregon, says Kuhar.
There is a definite need for expanded access to ECPs in Central Oregon, she explains. Many women are geographically isolated from immediate provider care, and public family planning clinics do not offer weekend hours. According to preliminary user survey data from the Wash ington state project, many women go the pharmacy on weekends or after normal business hours for their ECP prescriptions.
"Judging from the experience that the Seattle group has had, [the weekend] is when over half of the people who need this service access it," Kuhar observes. "That is usually a time when if you call your physician and get that interaction going, it is hard, because people aren’t in their offices, you are dealing with an on-call person who has a lot of other responsibilities, and sometimes that can become quite cumbersome."
Kuhar points to new data indicating that delay of the first dose of ECPs decreases their efficacy. (Reanalysis of data indicates that for both the Yuzpe regimen of combined oral contraceptives, currently in use in the United States, and a progestin-only method, delaying the first dose of ECPs by 12 hours increases the odds of pregnancy by about 50%. See Contraceptive Technology Update, July 1999, p. 75.)
"I really think that the timing issue is crucial, and with that, pharmacists are accessible in a way right now that physicians’ offices are not," Kuhar comments. "It also is kind of a one-stop deal, where you can have the counseling, sign up for the protocol, get the medication, and be done."
California is taking a broad view of the issues surrounding collaborative agreements, reports Jane Boggess, PhD, co-director of the statewide effort. Boggess and co-director Francine Coeytaux, MPH, both with the Pacific Institute for Women’s Health in Los Angeles, have assembled into an access committee state leaders who potentially are concerned not only with expanding ECP access, but access to other contraceptive methods as well.
"I think that the issue really is much broader than emergency contraception," notes Boggess. "It pertains to injectable hormonal contraception, such as the new Lunelle product seeking federal approval that is coming out, to oral contraceptives, to even over-the-counter products." (The new Lunelle product is a combined hormonal injectable contraceptive from Pharmacia & Upjohn of Bridgewater, NJ. See CTU, June 1999, pp. 65-66.)
Boggess’ experience as the former chief of the California State Office of Family Planning gives her expanded knowledge of the myriad logistics involved in distribution and reimbursement of contraceptive products. The partial privatization of the California family planning program has resulted in many women having their contraceptive method prescriptions filled at pharmacies, rather than dispensed through public clinics.
Access barriers are encountered even when Medicaid patients go to retail pharmacies for condoms, Boggess explains. Since pharmacy reimbursement programs rely on an 11-digit code, and condoms are stamped with a 10-digit code, patients must return to public clinics if they want subsidized condoms, she explains.
In addition to the distribution of contraceptive commodities, pharmacists have a role to play in the consultative/management team when it comes to reproductive health care, Boggess says. That belief is shared by fellow access committee member George Pennebaker, PharmD, of Rancho Cordova. Pennebaker works with Plano, TX-based EDS Inc., contractor for the state of California’s Medicaid program, and serves as treasurer of the Sacramento-based California Pharmacy Association.
"The physician’s forte is diagnosis of the symptoms and the situation that the patient presents, coming up with a conclusion of what the diagnosis is, and then the recommendation as to what kind of therapy might be indicated," he explains. "Then the pharmacist starts to get into the equation and deals with the pharmacology and the pharmacokinetics that are the pharmacists’ forte."
This situation is appropriate in the area of emergency contraception because the diagnosis has already been made, he notes. "The condom breaks, or We just didn’t get around to that last night,’ and therefore, the diagnosis is straightforward and clear. Then what is appropriate for the situation is a discussion of the alternatives that are available in those circumstances, and the effects and side effects of the emergency contraceptive, and that is where the pharmacist can do the kind of competent and confidential counseling that is appropriate."
Pharmacists are not interested in encroaching on or replacing the role of clinicians, says Boggess. In moving toward expanded access, each member of the health care community must realize the role he or she will play in making such access a reality, she notes.
"I think it is something that is going to take quite a bit of processing, because it also has the potential to be a pocketbook issue," Boggess says. "Whenever that is the case, I think that it is important for people to remember that where there is consensus around common good issues, to try and keep that as the bottom line."