9 The ‘state’ of things: epidemiologic comparisons across populations

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

2. Topic #2: Alcohol and Drug Dependence

3. Topic #3: Opioid Epidemic

4. Topic #4: Prescription Drugs

5. Topic #5: HIV/AIDS

6. Topic #6: Medicare

7. Topic #7: Medicaid and CHIP

8. Topic #8: Women’s Health

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.

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.