Introduction

Given pharmacy’s increasing role in research, shaping public policy, and assessing medication use and safety across populations, learning fundamentals of epidemiology and pharmacoepidemiology is a critical component of pharmacy education. This is especially true for pharmacy students interested in pursuing careers in research, industry, administration, or public policy where these skills are consistently required.

Epidemiology is “the study of the distribution and determinants of health-related states or events in specified populations, and the application of this study to the control of health problems.”¹ Pharmacoepidemiology, a subset of epidemiology, is “the study of the use and effects/side-effects of drugs in large numbers of people with the purpose of supporting the rational and cost-effective use of drugs in the population thereby improving health outcomes.”² As drug experts, pharmacists are already routinely responsible for monitoring drug use and safety across various populations. Additionally, the increasing complexity of health systems and push for a more holistic approach to health – not just drugs – necessitates an increased focus on epidemiology training for pharmacists. This is underscored by the fact that research – and by extension epidemiology and pharmacoepidemiology – serves as the tenth and all-encompassing essential service of public health.³

In every professional setting, pharmacists are at least in some part responsible for monitoring diseases and drug use. For some pharmacists, the population may be the patients in their community pharmacy, while for other pharmacists, their population may include serving millions of individuals while working for the FDA. Regardless of the setting, you will work with diverse, often ill or at-risk, populations reinforcing the importance of skills and experience in monitoring disease and medication use across populations. To gain further appreciation for epidemiology and its utility, consider the opioid epidemic. Pharmacists lead the charge in tracking opioid utilization, identifying high-risk patients, exploring the risk/benefit of opioids, and designing/assessing various public health policies aimed at mitigating the crisis (e.g., opioid reversal strategies). Examples of pharmacy-related epidemiology and pharmacoepidemiology duties include:

• Monitoring levels of disease and/or drug utilization
• Guiding distribution of resources
• Discovering exposures that facilitate or mitigate patterns in disease and/or drug use
• Providing useful information on the beneficial and harmful effects of drugs, including risk/benefit information.

Case and Case Questions

You have volunteered to serve as a consultant for a new non-profit agency. The agency’s mission is to “improve the health of the population by promoting safe and effective use of medications”. The agency wants to establish roots in a particular state, but isn’t sure where to go. The agency’s board of trustees has asked you to provide a recommendation as to which state they should go to and start their work. Your task is to compare various state pairs and provide a recommendation (with rationale) as to which you think is the “unhealthier” state in regards to a particular health topic. Utilize the various data (outcomes, risk factors, determinants) available on the Henry J Kaiser Family Foundation (KFF) State Health Facts web site (https://www.kff.org/statedata/) and specific to that particular health issue to make your decision. Your recommendation should be written into a clear, focused format that you will present to the board of trustees.

The board of trustees has provided you with several topics of interest and several state pairings for your analysis (see Table). For each of the eight topics, pick one pairing, and conclude which state is “worse” concerning that particular topic (aka, “which state is in more need of your non-profit agency’s help”). The board has asked that you analyze a different state pair for each topic. Use the outcome data available on KFF State Health Facts website to support your decision.

1. Topic #1: Immunizations

Outcomes to compare located under “Health Status”, subsection “Immunizations

Measures to compare/discuss:

• Percent of Adults Aged 65 and Over Who Have Ever Had A Pneumonia Vaccine
• Percent of Children Age 19-35 Months Who Are Immunized

2. Topic #2: Alcohol and Drug Dependence

Outcomes to compare located under “Health Status”, subsection “Alcohol and Illicit Drug Dependence, Abuse, and Treatment”

Measures to compare/discuss:

• Individuals Reporting Alcohol Dependence or Abuse in the Past Year
• Individuals Reporting Needing but Not Receiving Treatment for Alcohol Use in the Past Year
• Individuals Reporting Illicit Drug Dependence or Abuse in the Past Year
• Individuals Reporting Needing but Not Receiving Treatment for Illicit Drug Use in the Past Year
• Individuals Reporting Nonmedical Pain Reliever Use in the Past Year

3. Topic #3: Opioid Epidemic

Outcomes to compare located under “Health Status”, subsection “Opioid Overdose Deaths”

Measures to compare/discuss:

• Provisional 2017 Opioid Overdose Deaths as a Percent of All Drug Overdose Deaths
• Opioid Overdose Deaths and Opioid Overdose Deaths as a Percent of All Drug Overdose Deaths
• Opioid Overdose Death Rates and All Drug Overdose Death Rates per 100,000 Population (Age-Adjusted)
• Prescription Opioid Overdose Deaths and Death Rate per 100,000 Population (Age-Adjusted)
• Opioid Overdose Deaths by Type of Opioid
• Opioid Overdose Deaths by Race/Ethnicity
• Opioid Overdose Deaths by Age Group
• Opioid Overdose Deaths by Gender

4. Topic #4: Prescription Drugs

Outcomes to compare located under “Health Costs and Budgets”, subsection “Prescription Drugs”

Measures to compare/discuss:

• Number of Retail Prescription Drugs Filled at Pharmacies by Payer
• Retail Prescription Drugs Filled at Pharmacies (Annual per Capita)
• Retail Sales for Prescription Drugs Filled at Pharmacies by Payer
• Number of Mail Order Prescriptions Drugs by Payer
• Number of Mail Order Prescription Drugs Per Capita
• Mail Order Sales of Prescriptions Drugs by Payer

5. Topic #5: HIV/AIDS

Outcomes to compare located under “HIV/AIDS”, subsection “AIDS Drug Assistance Program (ADAP)”

Measures to compare/discuss:

• Total ADAP Budget
• Distribution of ADAP Budget by Source
• Distribution of ADAP Expenditures
• Total ADAP Clients Enrolled and Served
• ADAP Expenditures per Client Served
• ADAP Financial Eligibility as a Percent of the Federal Poverty Level

6. Topic #6: Medicare

Outcomes to compare located under “Medicare”, subsection “Prescription Drug Plans”

Measures to compare/discuss:

• Medicare Prescription Drug Plans: Stand Alone PDP Enrollment
• Medicare Prescription Drug Plans: Stand Alone PDP Enrollees as a Percent of Total Medicare Population
• Medicare Prescription Drug Plans: Number of Medicare Beneficiaries with Creditable Prescription Drug Coverage, by Type
• Medicare Prescription Drug Plans: Percent of Medicare Part D Eligible Beneficiaries with Known Creditable Prescription Drug Coverage
• Medicare Prescription Drug Plans: Number of PDPs that are Low-Income Subsidy Eligible
• Medicare Prescription Drug Plans: Average Premium for PDPs
• Medicare Prescription Drug Plans (PDPs)

7. Topic #7: Medicaid and CHIP

Outcomes to compare located under “Medicaid and CHIP”, subsection “Medicaid Benefits”

Measures to compare/discuss:

• Medicaid Benefits: Prescription Drugs

8. Topic #8: Women’s Health

Outcomes to compare located under “Women’s Health”, subsection “Family Planning”

Measures to compare/discuss:

• Emergency Room Requirements to Offer Emergency Contraception Services to Sexual Assault Survivors
• Pharmacist Provision of Emergency Contraception to Women Without a Doctor’s Prescription
• Mandated Coverage of Infertility Treatment
• Minors’ Authority to Consent to Contraceptive Services
• State Requirements for Insurance Coverage of Contraceptives
• States That Have Expanded Eligibility for Coverage of Family Planning Services Under Medicaid
• Medicaid Coverage of Oral Contraceptives
• Medicaid Coverage of Intrauterine Devices (IUDs) & Implants and Reimbursement Policy
• Medicaid Coverage of Prescription Contraceptives – Injectable, Diaphragm, Patch, Ring
• Medicaid Coverage of Over-the-Counter Contraceptives
• Medicaid Coverage of Emergency Contraceptives

Author Commentary

Epidemiology and pharmacoepidemiology are extremely broad and complex fields, and this activity is only meant as an introduction into these areas. These concepts are crucial to developing an appreciation for population health, its intricacies, and the many factors that contribute to health. As you delve into these comparisons, you should be careful in how you interpret and present the available data. Also, understand that the available data is limited and that you must make the most informed decision you can with imperfect and incomplete information. This closely reflects what happens in the real world. Lastly, when reviewing topics, you will notice many disparities and inequalities across state populations. As you find these differences, especially large differences, begin to consider how state-level policies and culture may contribute to these found differences. In this way, you will be extending the focus of this activity to include additional related epidemiological concepts such as determinants of health and health disparities.

Facilitator Notes

• Although recommended state pairings are provided, you may choose whichever state pairings you’d like. You can also amend the case so as to compare countries or cities instead.
• This activity should be group based.
• Debriefing after the activity is highly recommended. This gives groups the opportunity to share their decision and rationale as well as yourself and other students the chance to comment/critique.
• Feel free to add more pairings or have more than one group per pairing, depending on your class needs.
• Feel free to remove the written report as a requirement or change its length. Also, it’s up to you whether you want students to be able to include graphs/charts in their report.
• In preparation for this activity, you may want to briefly look into these pairings and try to find a particular “nugget” you’d like to talk about for each pairing. This “nugget” is a particular important difference that you’d like to emphasize with the class. You can even keep the “nuggets” secret and tell groups that if they find this “nugget” and include it in their response, they get bonus points or a prize of some sorts. For example, a particular “nugget” would be smoking prevalence in Kentucky vs. California. Kentucky has much larger prevalence than California. You could then talk with the class about how smoking impacts health as well as why Kentucky has a much higher prevalence. What policies or cultural aspects might discourage smoking in California? Other examples of nuggets (depending on which states are being compared) could include employment, Medicaid, insurance, or medication burden. This can help students understand how they can use epidemiological data to better understand the relationship between public health policies and resulting health outcomes.
• The mission of the non-profit agency is purposefully kept ambiguous. Accordingly, students won’t be able to infer what kind of initiatives the non-profit might employ. This is done so that students aren’t restricted to only certain comparisons that align with the non-profits particular focus. If you desire, you can amend the case so that the non-profit agency has a particular focus (i.e. lung cancer). This would then direct the students as to which data points would be most relevant to compare between states (e.g. smoking prevalence).

Patient Approaches and Opportunities

Epidemiology is the “scientific arm” of public health and is essential for assessing trends and patterns of disease and medication use across populations. Pharmacists are responsible for safe and effective medication use, and accordingly, must lead the effort in monitoring medication utilization and safety in populations. A strong foundation in epidemiological concepts is a critical component for pharmacists to have so that they can perform public health research and make sound conclusions when interpreting data. Ultimately, such foundational knowledge will lead to enhanced ability to create effective and meaningful public health programs and policies.