July 26, 2012 — Summary of, "Direct Pharmacy Access to Hormonal Contraception: California Physician and Advanced Practice Clinician Views," Rafie et al., Contraception, June 18, 2012.
Streamlining delivery of effective contraceptive methods -- including direct access to hormonal contraceptives at pharmacies -- has been suggested by experts as a way to expand access and reduce the unintended pregnancy rate in the U.S., according to Sally Rafie of the University of California-San Diego Health System and colleagues.
Previous research has shown that women "can successfully screen themselves for contraindications" to birth control pills, Rafie and colleagues noted. Further, surveys have found that 68% of women would choose to obtain their contraceptive method directly from a pharmacist if it was an option and that 85% of pharmacists are interested in providing hormonal contraceptive services.
Rafie and colleagues developed a study to "explore the opinions of physicians and advanced practice clinicians providing reproductive health care services on expanded access to hormonal contraception through pharmacists."
The researchers conducted in-depth interviews with 20 clinicians, including medical doctors, doctors of osteopathy, certified nurse-midwives, nurse practitioners and physician assistants who provide reproductive health services.
Prior to the interviews, participants were given a list of definitions of various models of access to medications in the U.S. and were asked to fill out a demographic questionnaire. The interviews included a series of 18 questions aimed at eliciting "providers' opinions on increased access to the following hormonal contraceptives: oral tablets, transdermal patch, vaginal ring and injectables."
About 80% of participants said the current prescription-only access model is too restrictive. About 33% of respondents said pharmacy access would be most appropriate, while 28% favored over-the counter access. Some participants said the type of hormonal contraceptive should affect the model of access; for example, two participants said tablets, patches and ring contraceptives should be sold over-the-counter, while injectables should be behind-the-counter.
Almost all study participants said increased access to hormonal contraceptives would be a benefit of pharmacy access. The majority of respondents said "continuation and compliance" would improve with pharmacy access, and many also cited increased convenience for women. Only one participant said there would be no benefits to pharmacy access.
"The most commonly reported concern of participants was potential refusal of care by pharmacists," the researchers wrote. The second most common concern was the possibility of inadequate counseling by pharmacists, especially on other forms of contraception, such as intrauterine devices.
Some participants cited concerns about patients' out-of-pocket costs, particularly if pharmacists were to charge a service fee that health insurers would not cover. Adolescent health care providers also "stressed the nuances that go into providing reproductive health services to youth," and some were "especially critical of the prescription-only and pharmacy access models, where they mentioned that pharmacists tend to refuse contraception more often to teens than they do adult patients."
More than 50% of study participants said their professional provider roles would improve if pharmacists were more involved in providing contraception. For example, they predicted that they would perform fewer abortions, deal with fewer prescription refill requests and have more time to address patients' other reproductive health needs if pharmacists were able to handle contraception requests.
The survey also assessed participants' recommendations for implementing a pharmacy access model. All participants said the evaluation for hormonal contraceptives at pharmacies should include a blood pressure measurement and medical history review in accordance with the World Health Organization's Medical Eligibility Criteria for Contraceptive Use. Participants felt competent that pharmacists could capably perform these evaluations.
The researchers found that participants were more divided in their perceptions of training for pharmacists to provide hormonal contraceptive screening, prescribing and counseling. Many were unfamiliar with pharmacist education and training, while about one-third said pharmacists were adequately trained to provide contraceptive services and one-fourth said they would be capable with more training. About 94% said they would feel comfortable referring their patients to a pharmacist for hormonal contraceptives, while 100% said they would feel comfortable accepting referrals from pharmacists for patients who need additional care.
The respondents recognized the additional time it would take for pharmacists to provide contraceptive services. Nearly all participants said pharmacists should be reimbursed accordingly, though a few were unsure.
"When asked what pharmacists can be doing under the current prescription-only model to help increase access to hormonal contraceptives," participants most frequently said pharmacists should "not refuse care based on personal beliefs" and also felt that they should "offer contraceptive counseling to all appropriate patients." When asked about other health services, most participants said they would support allowing pharmacists to prescribe sexually transmitted infection partner treatment with antibiotics, and all but two providers said pharmacists should not be granted unrestricted prescriptive authority.
Nearly all participants supported pharmacy access, the researchers wrote. They "believed that counseling and screening by a trained provider are important parts of the provision of contraceptives, and therefore tended to support the pharmacy access model over the behind-the-counter and over-the-counter models of access," the researchers noted.
The researchers concluded, "[I]ncreased access to hormonal contraception is supported by the majority of providers." They noted that many providers "expressed concerns about possible pharmacists' refusal of care," but "little data exist on the extent to which refusal of care is or would be a problem." Further, participants' concern about pharmacist training can be addressed through targeted training programs, including specific training regarding adolescent health.
The researchers noted the study was limited in that it included a small sample of participants from the San Francisco area. The researchers called for additional studies "capturing a broader practitioner population" in order to "represent the general opinions of providers across the country."