Putting Policy into Practice: Contraception Care in San Francisco Pharmacies

Contraception Care in San Francisco Pharmacies

What makes some pharmacies more successful than others at implementing pharmacist-prescribed contraception care? To answer this question, we conducted a study to determine the extent of hormonal contraceptive prescribing, also referred to as furnishing in California, among San Francisco community pharmacies, and identify the factors that led to successful implementation.

Implementation in San Francisco pharmacies 

After calling all 113 community and independent pharmacies located in San Francisco, we identified 21 locations (19%) that furnished hormonal contraception. Only one of these was an independent pharmacy; the rest were chain community pharmacies. Half or more of Costco, CVS, and Safeway locations furnished hormonal contraception, while less than 5% of Walgreens and independent pharmacies did so. 

Factors associated with successful adoption

Within the control of pharmacies

We identified three main factors that led to successful implementation that were within pharmacy control. The first was a company protocol—respondents stated that having an established precedent and administrative support, and paying for pharmacists’ training, was crucial for successful implementation. The second was advertising, due to the community’s limited awareness of this service. Lastly, the accessibility of pharmacists played a role in increasing access to services and to hormonal contraception. 

Relating to the setting or larger community

We also identified factors leading to successful implementation outside the control of pharmacies. These included the location of the pharmacy and its patient population, as well as collaboration with local clinics. Pharmacies in proximity to students and other younger and short-term residents found there was more need for hormonal contraceptive furnishing services. One pharmacy had an existing collaboration with a local clinic and its providers that acted as a bridge to the service. 

Barriers to service adoption 

Respondents also reported several barriers to successful implementation. The cost of consultation for patients was a widespread concern. Lack of time was another barrier reported by many pharmacists, which could be resolved through scheduled appointments or more overlaps of pharmacist shifts. The last identified barrier was patient privacy. Many respondents expressed a need for a private consultation room in order to provide a confidential service, and those that had a private consultation room acknowledged this as a benefit. 

Effect of COVID-19 on furnishing 

Our data collection began in April 2020, shortly after the introduction of San Francisco’s shelter-in-place order. We asked study participants to comment on whether practices or demand for hormonal contraception had changed under the shelter-in-place order and responses were mixed. While some pharmacies reported an increase in demand for hormonal contraceptive furnishing, others reposted a decrease. 

Implications for the future

We found an increase in participation among pharmacies in San Francisco that were furnishing hormonal contraception than previously reported in California overall; 19% in San Francisco in 2020 versus 11% statewide in 2017. This finding could reflect either pharmacies adding this service gradually over time or a local phenomenon. However, CVS pharmacists reported that a new corporate protocol was initiated in 2020, suggesting the higher rate of furnishing we identified could be reflected statewide. Our results detailed successful strategies used by San Francisco community pharmacies that could serve as a model for expanding this service to other pharmacies. In the words of one respondent:

“The pharmacist is the most overtrained and underutilized health care professional we have.”

With more widespread implementation of this service, community pharmacists can increase their scope of practice, improve quality and continuity of care for patients, and expand access to hormonal contraception to improve reproductive health.

Link to the full paper.

References

  1. California Board of Pharmacy 1746.1: Protocol for pharmacists furnishing self- administered hormonal contraception. Link.
  2. Chen L, Lim J, Jeong A, & Apollonio D. Implementation of hormonal contraceptive furnishing in San Francisco community pharmacies, 2020. Journal of American Pharmacists Association. doi:https://doi.org/10.1016/j.japh.2020.07.019
  3. Gomez AM. Availability of pharmacist-prescribed contraception in California, 2017. JAMA. 2017;318(22):2253e2254. 

Chen Lim Jeong ApollonioAbout the Authors

Lauren Chen, Julie Lim, and Asher Jeong are third-year doctoral students at the University of California San Francisco (UCSF) School of Pharmacy. Dorie Apollonio is a professor in the UCSF Department of Clinical Pharmacy.

Should We Offer Preconception Services in Community Pharmacies?

Why is preconception care important?

Roughly 4 million pregnancies occur in the United States annually.1 A common misconception is that preconception care is only a health care need when there is an intention to become pregnant. However, because nearly half of all pregnancies in the United States are unplanned, most birth defects occur within the first 3 months of pregnancy, and nearly one-fifth of pregnant women in in the United States receive no prenatal care before the end of their first trimester, preconception care is a serious population health issue deserving of attention.2-4

Why should pharmacists consider being involved?

Although preconception care is recommended to be routinely provided to all women of reproductive potential, gaps exist. With an estimated 90% of Americans living within 5 miles of a community pharmacy, community pharmacists have been proposed as an ideal provider of selected preconception care services to help fill these gaps and support preconception care initiatives.5,6

Where do we even start?

My PGY-1 community pharmacy residency was an incredible year filled with many great experiences that truly helped sculpt my professional practice during my first year as a pharmacist. One of the requirements was to develop and implement a research project; the topic chosen was preconception care. In full disclosure, I did not know much about it when I started the project and quickly found I had more questions than answers. However, I rapidly realized how deserving it is of continued attention.

Our primary objective was to perform a needs assessment using modified evidence-based core indicators:

Preconception Services in the Pharmacy

The above parameters were assessed with the use of a 1-page patient survey, retrospective chart review, and vaccine database review.3,7

Of the 110 patients who were asked to complete the survey, 99 patients took the survey and were included in the study for analysis. More than 75% of the patient population reported being sexually active and only about 50% of participants indicated they used some form of contraception, highlighting a large proportion of the population with the potential to become pregnant, as well as for unplanned pregnancy.

96% of study participants were found to have at least one health concern that could adversely affect a pregnancy if she were to become pregnant. The majority of study participants reported at least one of the following:

  • Abnormal BMI
  • Missing documentation of at least one assessed vaccination
  • No form of daily multivitamin that contained folic acid

Additionally, roughly half of survey participants were on at least one medication with potentially teratogenic effects.

Not only was preconception care need established across the majority of survey participants, but needs were found to span multiple preconception care parameters as well as differing demographics. However, despite the demonstrated need, 78.8% of the survey participants indicated they were not interested in receiving more information on preconception care. Therefore, pharmacists must play an active role in identifying and educating eligible patients.

Are you ready to begin implementing preconception care services within the community pharmacy setting?

If the answer is yes — and I hope it is — what are the next steps?

In identifying these concerns, we hoped that the results could be used in developing new clinical services to support preconception care needs.

Pharmacists already provide non-dispensing services via multiple service models, therefore preconception care services may be built within existing frameworks.6,8,9,10 This support can include:

  • Screening for preconception parameters
  • Optimizing pharmaceutical care plans for adequate disease state management
  • Counseling for prescription and over-the-counter (OTC) products to assist in family planning
  • Prescription contraception via statewide protocol or collaborative practice agreement (depending on state/scope of practice)

As we continue to learn more about the need for and how preconception care fits into community pharmacy practice, I leave you with one final question:

Where might preconception care services fit within your pharmacy workflow and how might you implement these types of services to better the health of the patients you serve?

References

For the original research article, please visit: https://www.ncbi.nlm.nih.gov/pubmed/31010784

  1. Centers for Disease Control and Prevention. Births and natality. Available at: https://www.cdc.gov/nchs/fastats/births.htm; March 31, 2017. 
  2. Centers for Disease Control and Prevention. Preconception health and healthcare. Available at: https://www.cdc.gov/preconception/index.html; February 13, 2017. 
  3. Johnson K, Posner SF, Biermann J, et al. Recommendations to improve preconception health and health caredUnited States. A report of the CDC/ATSDR Preconception Care Work Group and Select Panel on Preconception Care. MMWR Morb Mortal Wkly Rep. 2006;55(RR06):1e23.
  4. Korenbrot CC, Steinberg A, Bender C, Newberry S. Preconception care: a systematic review. Matern Child Health J. 2002;6(2):75e88.
  5. Frederick J. By the numbers: how community pharmacists measure up. Drugstore News;March 13, 2015. Available from:http://www.drugstorenews. com/article/numbers-how-community-pharmacists-measure. 
  6. DiPietro NA, Bright DR. Medication therapy management and preconception care: opportunities for pharmacist intervention. Inov Pharm. 2014;5(1):141.
  7. Frayne DJ, Verbiest SV, Chelmow D, et al. Health system measures to advance preconception wellness: consensus recommendations of the Clinical Workgroup of the National Preconception Health and Health Care initiative. Obstet Gynecol. 2016;127:863e872.
  8. DiPietro Mager NA. Fulfilling an unmet need: roles for clinical pharmacists in preconception care. Pharmacotherapy. 2016;36(2): 141e151.
  9. El-Ibiary SY, Raney EC, Moos MK. The pharmacist’s role in promoting preconception health. J Am Pharm Assoc. 2014;54:e288ee303.

Birth Control Pharmacist HeadshotsAbout the Author

Mollie Reidenbach, PharmD is a clinical care coordinator with SpartanNash, a chain community pharmacy primarily based in Michigan, embedded within a physician group to provide medication therapy support for both their patients and providers.

Teratogenic Medications and Contraception Management

Teratogenic Medications and Contraception

The use of prescription medications by pregnant women has increased over the past 30 years and with the usage comes an increased associated risk of exposing the fetus to the drugs. These medications can cause fetal abnormalities during a pregnancy. Often, for unique reasons, women are not concomitantly prescribed contraception or are not educated regarding the importance of using contraception while taking these high risk medications. Although, the use of teratogenic medications may be necessary for a woman’s health it is important to use birth control while on these drugs to prevent exposure during a pregnancy. 

What are teratogenic medications?

Teratogens are agents that interfere with fetal development when exposed during pregnancy and cause abnormalities. Examples of these teratogens include, but are not limited to alcohol, smoking, and various prescription medications. 

The thalidomide tragedy is an unfortunate example of what teratogenic drugs can do to the development of fetuses. In the late 1950s and early 1960s, thalidomide was widely used for the treatment of nausea in pregnant women soon after, it became apparent that the treatment caused malformations of the arms and legs. Currently, the drug is limited to use for the treatment for various conditions such as skin lesions caused by leprosy and multiple myeloma.

Why is it important to take contraception while on these medications?

Many women take potentially teratogenic medications for health conditions such as hypertension, diabetes, cholesterol, etc. and taking these medications while pregnant increases the risk of fetal malformations and spontaneous abortions. The use of contraception while taking these medications reduces the risk of having pregnancies with abnormalities. 

A study was conducted to evaluate teratogenic medications and associated prescription of contraception in the primary care setting. They found that 25% of the patients that participated in the study were prescribed at least 1 high risk medication from Table 1 and of those patients over half did not have contraceptive management. Ondansetron, often used for nausea in pregnancy, was excluded from the second analysis resulting in 10% of the patients on a high-risk medication and 61.9% of those patients were found to be without any use of contraception management.

The table below summarizes the medications that were used in a study and the teratogenic risks associated with them.

Table 1. Common teratogenic medications and related potential fetal effects

Medication Name Potential Fetal Effects
Atorvastatin, Simvastatin, Pravastatin Congenital abnormalities in infants and skeletal malformations in rats and mice
Topiramate Cleft lip/palate and hypospadias
Valproic Acid Facial dysmorphology, congenital heart defects, spina bifida, cleft lip/palate, development delays
Ondansetron Cardiac malformations
Paroxetine Cardiac malformations and pulmonary hypertension
Lisinopril Spontaneous abortion, oligohydramnios, newborn renal dysfunction

Who is at risk? 

Women who were less than 25 years of age had a low probability of receiving contraception when prescribed a teratogenic medication compared to patients who were of advanced maternal age (over 35 years old). Demographically, among all women who participated in the study, 60% belonged to a minority group compared to the 40% who were not in a minority group which suggests that minorities may be prescribed teratogenic medications more frequently compared to their non-minority counterparts.

Why is this a problem?

The study did not explore why this trend was seen. There are multiple challenges that family physicians face regarding contraception and teratogenic medication management. The first is that physicians may not be able to identify their patients’ family planning intentions, making appropriate counseling challenging. Second, they may experience difficulty finding clinically relevant information on the teratogenic medications. Additionally, while some medications are monitored strictly such as isotretinoin (Accutane), most are not, which makes it difficult for the provider to regularly re-evaluate reproductive plans when patients do not make frequent office visits. Lastly, specialists might prescribe these medications and fail to communicate with the primary care physician leaving the management of contraception up to the patient.

What can pharmacists do? 

It is important to practice interprofessional collaboration which results in safer prescribing practices. Pharmacists are now able to prescribe birth control in some states and can educate patients about contraception use while on teratogenic medications and directly provide contraception if needed and document it.

References

  1. Panchal, BD, Cash, R, Moreno, C, et al. (2019). High-Risk Medication Prescriptions in Primary Care for Women Without Documented Contraception. The Journal of the American Board of Family Medicine 2019;32(4):474–480.
  2. Kim, JH, Scialli, AR. “Thalidomide: The Tragedy of Birth Defects and the Effective Treatment of Disease.” Toxicological Sciences 2011;122(1):1–6.
  3. “Thalidomide: Research Advances in Cancer and More.” Mayo Clinic, Mayo Foundation for Medical Education and Research, 25 May 2019. Available at: https://www.mayoclinic.org/diseases-conditions/cancer/in-depth/thalidomide/art-20046534

About the Author

Sara Shaikh, PharmD Candidate is a pharmacy student at the University of California San Francisco School of Pharmacy in San Francisco, California.