The passage of the Affordable Care Act in 2010 triggered a massive overhaul of the U.S. healthcare system by expanding insurance access to millions of people while simultaneously reforming how healthcare services are both delivered and paid for (1,2). The influx of the newly insured, coupled with an aging population, advancing technologies, and more rigorous healthcare standards exposed entrenched weaknesses in the new system(1–3). The U.S. healthcare system was ill prepared to respond to this transformative new policy, leaving countless Americans without convenient, timely, and quality access to healthcare providers. Nearly 20% of Americans live in areas with a limited number of accessible doctors, especially in rural areas, and The American Association of Medical Colleges projects that by 2030, the demand for new primary care physicians will exceed the supply by over 120,000 (4,5). When unmet, this increased demand for physicians leads to a decline in quality of care, an increase in utilization of high-cost measures, and potential impacts on mortality and morbidity in patients living in these areas (6,7).
With the looming need for accessible health care services, a wide range of solutions must be sought to broaden the range of professionals that can safely deliver needed care. One solution that has been effective in times of increased healthcare demand, such as during the worldwide COVID-19, or Coronavirus Disease 2019, pandemic, has been to expand scope of practice laws for certain healthcare professionals. Scope of practice dictates the services that a healthcare professional can provide to patients, and in the United States, this policy is usually dictated at the state level. During the COVID-19 pandemic, for example, state expansions in scope of practice for healthcare professionals have increased access to testing and treatment, and have allowed states to prepare for future preventive interventions through early licensing to provide the COVID vaccine (8,9). Expansions in scope of practice policy allow healthcare practitioners the ability to practice at the top of their field while expanding access to healthcare services.
As evidenced by the pandemic and impact of physician shortages, scope of practice policy falls under the realm of public health policy due to its potential to influence population health and achieve desirable health goals— the definition of public health policy (10,11). Though professional practice legislation is influenced by a multitude of political, financial, and economic factors, evidence-based policymaking is critical to creating safe and impactful public health policy changes, and it should be also be utilized in scope of practice policy because of its implications for population health (11,12). Despite ample precedent showing the benefits of translating research evidence into policy, it is well documented that there are numerous barriers between evidence knowledge and policy implementation(11,13–16). However, these barriers have not been explored in scope of practice policy, specifically in pharmacist scope of practice.
Pharmacists, while historically viewed as simply dispensers of medicine, have been progressively adopting roles as clinical providers due to their expert knowledge in pharmacology and drug treatment (17,18). In many states, pharmacists are permitted to perform advanced services, including wellness testing and preventive health measures such as flu testing and immunizations, manage illnesses, perform medication management, administer medications, and provide other transitions of care services (19,20). Increasing bodies of literature show that pharmacists practicing in these capacities -- and beyond the traditional dispensing role – lead to improved health outcomes, such as increased access to public health services, improved chronic disease outcomes, and reduction of complications and acute care costs (19,21,30–32,22–29). Pharmacist prescribing is just as effective as physician prescribing in hitting certain chronic disease parameters such as lowering blood pressure or cholesterol (33). However, despite nationally standardized education and training, their potential to engage in these services and improve healthcare access and outcomes varies based on state scope of practice policy. Studies at both the single-site clinic and state level demonstrate broader expansion of scope of practice in these areas, such as pharmacist prescribing and disease management, experience greater access in healthcare and improvements in clinical outcomes (34,35).
Despite the ample evidence supporting the effectiveness and safety of pharmacists, inconsistent state-to-state restrictions on pharmacy practice demonstrate a gap between research and effective policy. Not only do these discrepancies between states hinder pharmacists from performing at the top of their training to improve patient care, but it has the potential to create impactful discrepancies in health care access (36). One potential way to reconcile these discrepancies is by improving the dissemination of research and engagement of research by stakeholders in pharmacy policy (37). Leveraging this research supporting advanced pharmacy services can create an opportunity to broaden scope of practice and create evidence-based health policy.
This study aims to characterize these approaches by investigating the utilization of evidence in formulating scope of practice policy. Specifically, this research explores how policymakers, including legislators and other members of government entities, and pharmacist advocates interact with evidence when developing and implementing autonomous pharmacist prescriptive authority policies. Autonomous prescriptive authority describes the lawful ability for pharmacists to prescribe certain medications based on their own licensing and training requirements, rather than under the license of another prescriber (28,38). Allowing pharmacists to prescribe independent of physicians provides a benchmark for other elements of pharmacist scope of practice. Within this realm, the National Alliance of State Pharmacy Associations (NASPA), which advocates for broadening prescriptive authority, identified three areas of existing expanded pharmacist prescriptive authority: (1) contraception access, (2) tobacco cessation, and (3) naloxone access (39–41). These three category-specific examples are the focus of this study. Understanding how research was utilized in and influenced these existing policies can illuminate effective methods for disseminating evidence for the creation of new evidence-based scope of practice policies.