This podcast aims to explore what health disparity and equity is, examine their connection to Pharmacoequity and discuss how the P&T committee can address these issues within the formulary review process.
The information presented during the podcast reflects solely the opinions of the presenter. The information and materials are not, and are not intended as, a comprehensive source of drug information on this topic. The contents of the podcast have not been reviewed by ASHP, and should neither be interpreted as the official policies of ASHP, nor an endorsement of any product(s), nor should they be considered as a substitute for the professional judgment of the pharmacist or physician.
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This series focuses on leadership topics within pharmacy practice, including the business of pharmacy, development of leadership skills, career transitions, and more. I'm your host, gift wakay, system manager for medication use and pharmacoeconomics at Novant Health, and I'm joined by our guest, Angela Coella, manager for the enterprise drug policy center at advocate health. We're going to discuss incorporating pharmaco equity and some formulary management. So welcome everyone. Let's turn right into it. Hi, Angela. Could you start us out by explaining the role of pharmacy and therapeutics or P&T committees in healthcare organizations and their significance in addressing health disparities? Certainly. P&T committees consist of actively practicing physicians, pharmacists, and other healthcare professionals. They oversee the drug formulary system, which helps ensure the selection and utilization of medications to meet the health needs of their populations. Pharmacists often lead formulary management processes and provide recommendations that are grounded in robust clinical evidence. Historically, the P&T has been seen primarily only as the keeper of the formulary or having passive oversight of medication use across the hospital or health system. It may be viewed as reactionary to formula requests and focused on financial stewardship, but we're really starting to see this change. Some P&T committees are charged to be proactive to focus on all aspects of medication use proactively, including ensuring equal access and use, and they are tracking the impact of their decisions, not just on costs, but also more so on patient outcomes and safety. They're being challenged to evaluate medication use, not just in an acute care setting or a hospital silo, but across the continuum of care, and to ensure the decisions they are making support the best care delivered to all the patients across the health system. Again, not just in one silo or for one population, and this is a big area where the P&T and formulary system can address health disparities. And what's the difference between a health disparity and health equity? Could you elaborate on that? Yeah, of course. In general, the term health disparities refers to differences in the health outcomes that are generally related to social, economic, and environmental factors. Health equity, by contrast, focuses on ensuring that everyone has an equal opportunity to achieve good health, regardless of their background or circumstances. For a more detailed definition, we can draw from the Healthy People 2030 initiative. It defines the "sparity" as, quote, and stick with me. This is a long quote. A particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage. Health disparities adversely affect groups of people who have systematically experienced greater obstacles to health based on their racial or ethnic group, religion, socioeconomic status, gender, age, mental health, cognitive sensory or physical disability, sexual orientation or gender identity, geographic location, or other characteristics historically linked to discrimination or exclusion. And that's the end of that quote. On the other hand, health equity, again, is defined by Healthy People 2030, is the attainment of the highest level of health for all people. Achieving health equity requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and elimination of health and health care disparities. Very nice. What would you say are some of the factors contributing to the long history of inequitable distribution of pharmacotherapies to minority populations in the United States? The lack of equal access to and really the provision of pharmacotherapies to minority populations in the United States is of course influenced by multiple factors. These include patient related factors such as education, employment, and socioeconomic status, as well as factors within the health care system, such as provider bias and the quality of care provided. Additionally, we see social policies such as transportation and pharmacy access, along with health policies like insurance coverage, drug pricing, research regulation, place significant roles as well. Minority populations, including Black, Latinx, and indigenous communities, are further disadvantaged by lower income levels, lack of private insurance coverage, language barriers, and underutilization of health care resources. Racial and ethnic discrimination, both implicit and explicit, continue to contribute to inequities in health care as well. Adjusting these disparities is crucial in organizations like ASHP have outlined strategies to promote pharmaco-equity, which includes increasing awareness, diversifying the health care workforce, providing culturally competent care, ensuring effective communication, utilizing evidence-based guidelines, and collecting and reporting data on health disparities. Incorporating pharmaco-equity into the formulary review process is one area for health system pharmacists to ensure that the needs of vulnerable patient populations are considered and addressed proactively. You know a lot of us have formulary management down pat, but perhaps are new or to pharmaco-equity and how this can be done. So can you offer any tips on how we can incorporate discussions or considerations about health disparities and inequities into the formulary review process? Yeah, I'd love to. Ideally, discussions on health disparities and inequities should be a standardized component of formula reviews and presentations. Any of us who participated in a formulary review know that it's routine to include information on drug dosing, administration, pharmacology, efficacy, and safety, but along with those elements should also be a discussion on disparities that currently exist or may be impacted by the formulary decision. These are regarding race, ethnicity, gender, geography, socioeconomic status, and social determinants of health. We really need to make that piece of commonplace as a pharmacotherapy review. We're always quick to provide a detailed appraisal of clinical efficacy and safety, critiques of clinical trial design, discussion on placement therapy relative to other therapies, and site of care restrictions. But within each of these elements, we can also include information about health disparities. For example, when we analyze the canonical trials, we can bring forward the data about patient populations represented by enrollment of the clinical trial. When we provide background on the disease state, we can bring forward prevalence breakdowns by populations. When we discuss screening needed prior to therapy, we can highlight access issues. This is a type of information that the formulary review process can incorporate and we can raise this to the P&T level. If we include a call for these types of information in the templates we use for monographs or presentations that we're preparing for P&T and other audiences, then we're really holding ourselves to do it for every drug reviewed. It's such a simple thing to do, but it can make such an important impact. Bringing issues up to the P&T committee and highlighting and the discrepancies in care is a great way to generate discussions. Start to shift focus to improving equitable care and uncovering additional issues. We might not be able to eliminate health disparities during a formulary review, but we certainly can and we absolutely should be highlighting barriers, identifying known issues, and bringing a spotlight to the disparities we know that are in care. Thank you. And what is an example of how a formulary review can impact P&T decisions on medications and also improve formulary? I think a great example. We have a recent FDA approval where inequities in care impact medication use include the new agents for the treatment of Alzheimer's disease. Use of the novel medications is most impactful we've seen early on in the disease state, but we know about disparities in care such as delays and referrals, availability of specialists and access to care. These exist especially for marginalized populations. So this is creating a disadvantage for many patients even before the medication can be considered as an option for them. And adding these novel agents the formulary without considering these issues might create further disadvantages. Evaluation by P&T can highlight the need for increased screening or increased clinic resources. Given the depth and the scope of our P&T committees, they can exert pressure on health system leadership and they may be able to increase funding to create or to expand clinics, create or expand full-time employees and identify other ways to address needs that have been identified. They can also height an awareness of disparities for their colleagues who may just not know. And since we're talking about Alzheimer's disease, I just wanted to circle back to the impact that we can make in the formulary review process by identifying and presenting data about the inequitable race and ethnicity representation in clinical trials. The prevalence of Alzheimer's disease in white patients in the general population is about 10 percent. Whereas in the primary clinical trials, they actually comprise 77 percent. Conversely, we see about a 19 percent of Alzheimer's disease and non-Hispanic lactations in the general population, yet they were only 2.5 percent of the total clinical trial enrollment. We shouldn't be drawing conclusions or making assumptions about clinical outcomes to meet data, but we should be using the data to generate discussions and height and awareness around the concept of pharmaco and health inequities in our health systems and populations. Agreed. We talk a lot about leveraging technology in healthcare these days. So how can informatics and electronic medical records contribute to addressing disparities in healthcare delivery following formulary decisions? Yeah, they can actually play a really crucial role in assuring equitable access to the decisions made for health system formularies. So we can leverage these tools and identify, evaluate, and address discrepancies in healthcare delivery in real time or almost real time. They help us monitor trends related to barriers to care and perhaps highlight sub-optimal drug utilization and specific populations. Identifying risk points during the formulary review helps enable health systems to proactively monitor and build into these medical records the ability to identify inequities of care. We can identify and design dashboards and then we can also routinely generate reports to help identify any discrepancies in care. The proactive approach ensures that formulary decisions align with the goal of providing equitable access to optimal health care for all the individuals impacted. Great. You know, I'd say that we are pretty used to forming multi-disciplinary teams and working with non-pharmacy partners on shared goals. How can additional representation from other departments also contribute to promoting health equity within P&T committees? So including representation from departments such as ethics or diversity equity and inclusion can really play a crucial role in ensuring that health equity is considered and discussed when we're making medication use decisions within the P&T or other committees. These members really bring diverse perspectives as well as unique skill sets that can help identify risks of health disparities that may be inadvertently created by P&T decisions or prevented and also help address barriers and access to care. They might help ask questions such as will all patients have equal access to the specialist equipment and safeguards required to administer medications that are highly complex or novel. What inequities does our P&T committee need to raise awareness of to improve care for all patients? Also the use of the subcommittees prior to P&T can provide recommendations for better addressing pharmaco-equity within their specialties and academic medical centers may have departments or divisions with expertise to assist as well. The multi-disciplinary approach helped ensure that health equity remains essential consideration in all of our formulary decision making. Well great discussion that was my last question for you and I really like this topic because it helps us at least start to brainstorm ways that we can actually apply pharmaco-equity to our formulary management process. So thanks so much for this important topic and those excellent insights Angela. Thank you. Well everyone that's all the time we have for today. I hope you also enjoyed learning more about pharmaco-equity as it relates to formulary management. 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