The passing of California Senate Bill 493 in 2013 granted pharmacists provider status and created the Advanced Practice Pharmacist license (APh), which aims to expand pharmacists’ scope of practice. However, three years after the implementation of the APh license, achievement of this goal has not been documented.
In a web-based cross-sectional survey, participants answered 30 multiple-choice questions. These questions assessed the impact of the APh license on pharmacists’ ability to practice APh-authorized responsibilities. Other questions assessed respondents’ practice background and opinions on the APh license. Advanced Practice Pharmacists (APP) were categorized as benefiting with respect to a specific responsibility if they were able to perform that responsibility only after licensure.
Ninety-six complete survey responses were received and analyzed. The APPs did not report benefiting from licensure regarding expansion of scope of practice for any of the five specific APh-authorized responsibilities (p<0.001). On average across all five responsibilities, 5.2% ± 1.5% of APPs achieved benefit for any given responsibility.
Most pharmacists who obtained the APh license already held these responsibilities and thus benefited little from licensure. Due to the license’s recent implementation, the reasons for its lack of benefit are unknown.
Nationwide, there is an anticipated increased demand for clinical care from pharmacists due to an increasing aging population, the move towards community-based care, and the increased expenditures on medications for chronic disease management.(1) While the 2021 House of Representatives Bill 2759, which proposed granting pharmacists provider status on a national level, has not passed Congress, many individual states created provider status legislation to promote expansion of pharmacy professional practice.(2,3)
Pharmacists in California were granted provider status via Senate Bill 493 (2013), which effectively created the Advanced Practice Pharmacist license (APh).(4–6) The APh license intended to authorize pharmacists to perform five responsibilities that previously required a collaborative practice agreement (CPA), expanding pharmacists’ scope of practice as outlined in SB 493 (Figure 1).(4–6)
Eight years after the bill passed and three years after the implementation of the license, there are concerns as to whether the APP designation achieves its goal of expanding pharmacists’ scope of practice.(7) Over 500 APPs have been licensed in California since 2016; however, there are no California-specific studies on the impact of the APh license on expanding pharmacists’ scope of practice.(4) This study aimed to determine the expansion of practice for APh licensed pharmacists in California and whether the APh license is achieving its intended goal.
For this cross-sectional study, a 30-question survey was developed on the Qualtrics platform. A survey invitation was sent via mail to all 541 APPs listed. The survey link was distributed to APPs in California by QR codes, using online groups, electronic newsletters, and listservs. Responses received between July 3, 2019, and January 3, 2020, were analyzed.
The Qualtrics survey consisted of five multiple-choice questions to assess the impact of the APh license on APh-authorized responsibilities, eight multiple-choice questions that assessed APPs’ opinions on the APh license with six optional follow-up questions, and eleven questions that collected participants’ demographic information.
To determine the change in APPs’ scope of practice since obtaining the APh license, each of the five APh-authorized responsibilities were evaluated by the survey. This was followed by questions assessing their opinion on licensure and information about their practice background.
Descriptive statistics were used to analyze demographic information, motivations and barriers to licensure, and future expectations of the APh license. Participants were provided an option for explanations or additional comments when relevant.
Based on the responses, the practice of APh-authorized responsibilities before and after acquiring the APh license were assessed and stratified responses into two groups, with pharmacists either achieving “benefit” or “no benefit” from the license. “Benefit” was defined as pharmacists who were previously unable to perform an APh-authorized responsibility but able to do so after APh licensure. A Fisher’s exact test was performed on the stratified data using an online calculator to determine the statistical significance of benefit or no benefit for each APh-authorized responsibility.(8)
Practice Background Characteristics
Of the 541 licensed APPs in California at the time of survey distribution, 138 responses (25.5%) were received between July 3, 2019 and January 3, 2020. However, only 96 respondents (17.7%) completed all required questions and only complete responses were analyzed. Practice backgrounds of respondents are described in Table 1.
The most common practice setting was clinic or ambulatory care pharmacy (45.8%) and the least common setting was outpatient or dispensing pharmacy (7.3%). While 82.3% had practiced under a CPA prior to obtaining the APh license, 75.0% still practice under a CPA after obtaining APh licensure. Furthermore, a greater percentage of respondents involved in a CPA prior to obtaining the APh (25.3%) reported a benefit with the APh license compared to those who did not previously work under a CPA (17.6%).
Assessment of the APh License on Pharmacy Practice
The majority of APPs did not report benefiting from obtaining APh licensure regarding expansion of scope of practice for any of the five specific APh-authorized responsibilities (p<0.00001, Table 2). On average only 5.2% ± 1.5% of respondents reported benefiting from the APh license.
For outpatient or dispensing pharmacists, benefit was only experienced for performing patient assessments by one of the seven pharmacists responding.
Current Perceptions of APPs on the APh License
The most endorsed goal or motivation for licensure was to support the expansion of the pharmacy profession (Table 3).
A total of 66.7% of APPs held a general expectation that the APh license will further the pharmacy profession within the next 10 years. By a smaller margin, 59.4% of APPs reported an expectation that the license will eventually increase pharmacists’ scope of practice and 44.8% believed the license will increase respect for pharmacists. Overall, 74% of respondents plan to renew their APh license upon expiration.
Only 38.5% of APPs believe that their initial goal or motivation for licensure has been achieved, and only 17.7% believe that their personal scope of practice has expanded (Table 4). In total, 71.9% of respondents encountered at least one barrier when utilizing the APh license. Billing was endorsed by 44.8% of respondents, making it the largest reported barrier across all practice settings. Administrative barriers and lack of time were also reported barriers with 21.9% and 17.7% of respondents endorsing them, respectively.
The creation of the APh license was intended to further expand pharmacists’ scope of practice in California.(4–6) This study assessed both the actual impact of the license and the extent of its utilization in comparison to its intended goal. The aim of the APh license was met with limited success.
Outpatient or dispensing pharmacists were the least represented subgroup of survey respondents—a population that would likely have benefited from APh licensure the most in terms of scope of practice expansion.(9) The role of the community pharmacist has primarily consisted of processing or verifying prescriptions; however, the passing of legislation such as SB 493 has expanded that role by allowing all pharmacists in California to furnish select medications and administer immunizations.(6,10) With APh licensure, outpatient or dispensing pharmacists could have more independence in assessing patients and optimizing their medication therapy, allowing pharmacists to better utilize their training.
The license was disproportionately obtained by those who already held APh responsibilities and thus had less to gain from APh licensure. While the results demonstrated that APPs did not report benefiting from being APh-licensed, most responses were from pharmacists working under a CPA and/or in a clinic, ambulatory care, or acute care setting which allowed them to perform the APh-authorized responsibilities before licensure.
The lack of perceived benefit derived from the APh license may also be attributed to findings from barriers endorsed by respondents. Billing was the most reported barrier, which suggests that a lack of proper compensation may hinder the utility of the license. Some respondents specified that they have not had the opportunity to utilize their APh license due to a lack of recognition of the license by non-pharmacy professionals or a lack of necessity given the abundance of CPAs within the survey population. Pharmacists wrote that the license “didn’t change anything” or is “not relevant in the...setting where [they] practice.” These barriers highlight some challenges the APh license faces and can guide future reform to maximize its utility.
Despite the lack of perceived benefit by the participants in this survey, many pharmacists are still planning for renewal. Two-thirds of respondents anticipate that the license will further the pharmacy profession and increase pharmacists’ scope of practice in the next 10 years. Comments included expectations for “increase[d] access to care for patients,” and “more reimbursement...per patient session.” Additionally, most respondents endorsed supporting the expansion of the pharmacy profession as one of their initial goals or motivations for APh licensure. This highlights the desire to further the profession and the belief among respondents that the license may become increasingly relevant in pharmacy practice. Furthermore, according to the 2011 U.S. Surgeon General report, there is more diversity in pharmacy practice scope and setting than previously reported.(11) With this overall shift in both the expansion and perception of the profession nationwide, it is plausible to anticipate benefit from the APh license in California on pharmacists’ scope of practice in the upcoming decade.(11)
There were several limitations to this study. Firstly, the survey had a low response rate (~18%) and the demographics of the larger target population have not been characterized, impairing generalizability of study findings. Moreover, only seven responses were received from pharmacists practicing in outpatient or dispensing pharmacies, which limits the ability to extrapolate those responses as representative of outpatient pharmacists. Secondly, for a given APh-authorized responsibility, 45% to 57% of respondents indicated only their ability to perform the responsibility only prior to receiving the license. It is unlikely that the license narrowed pharmacists’ scope of practice. Thus, these responses may be attributed to misinterpretation of survey questions and were stratified during data analysis into the “no benefit” group. Thirdly, due to the anonymity of the survey design, the APP status of the respondents or the number of times a single person responded could not be verified. Lastly, since the license became active two years prior to when the survey was released (2017), it is possible that not enough time has elapsed for the license to have made a measurable impact. Despite these limitations, this is one of the first studies to assess the impact of the APh license on scope of practice among California pharmacists. These findings provide new information regarding the effect of the license in achieving its intended goal, and the barriers that need to be addressed to make a substantial impact on pharmacists’ scope of practice in California.
The APh license was initially created to expand the field of pharmacy by enabling APPs to perform certain responsibilities that are not typically within pharmacists’ scope of practice. However, a majority of survey respondents did not report benefiting from the APh license because they were already performing these APh-authorized responsibilities through a CPA prior to APh licensure.
The recent implementation of the APh license may require more time for the desired impacts to manifest. Thus, the lack of perceived benefit in this survey may be due to its relatively new status, an inconsistent understanding of the license, a lack of licensure in community pharmacists, or a mixture of these reasons. Considering the relatively recent launch of the APh license, future research could reevaluate its perceived impact after an extended duration and thus allow for a more comprehensive and timely analysis.
About the Authors
Monica Lomanto, PharmD, is a PGY1 resident at VA Northern California Health Care System. She is a 2021 graduate of the UC San Francisco School of Pharmacy and was a student representative on the UCSF California Pharmacy Student Leadership (CAPSLEAD) team. Dr. Lomanto has no conflicts of interest to report.
Holly Ly, PharmD, is a Biopharmaceutics Research Fellow at U.S. Food and Drug Administration (FDA). She is a 2021 graduate of the UC San Francisco School of Pharmacy and was a student representative on the UCSF CAPSLEAD team. Dr. Ly has no conflicts of interest to report.
Jordan Brooks, PharmD, is a Clinical Pharmacology and Therapeutics Fellow at UC San Francisco. He is a 2021 graduate of the UCSF School of Pharmacy and was a student representative on the UCSF CAPSLEAD team. Dr. Brooks has no conflicts of interest to report.
Angela Chang, PharmD, is a PGY1 Pharmacy Resident at Loyola University Medical Center in Maywood, IL. She is a 2021 graduate of the UC San Francisco School of Pharmacy and was a student representative on the UCSF CAPSLEAD team. Dr. Chang has no conflicts of interest to report.
Alice La, PharmD, is a PGY1 Resident at the Legacy Emanuel Medical Center. She is a 2021 graduate of the UC San Francisco School of Pharmacy and was a student representative on the UCSF CAPSLEAD team. Dr. La has no conflicts of interest to report.
Kevin Le, PharmD, is a PGY1 Pharmacy Resident at VA San Diego. He is a 2021 graduate of the UC San Francisco School of Pharmacy and was a student representative on the UCSF CAPSLEAD team. Dr. Le has no conflicts of interest to report.
Manuel Seraydarian, PharmD, is a PGY1 Resident at Zuckerburg San Francisco General. He is a 2021 graduate of the UC San Francisco School of Pharmacy and was a student representative on the UCSF CAPSLEAD team. Dr. Seraydarian has no conflicts of interest to report.
Colette Truong, PharmD, is a PGY1 Resident at Rady’s Childrens Hospital. She is a 2021 graduate of the UC San Francisco School of Pharmacy and was a student representative on the UCSF CAPSLEAD team. Dr. Truong has no conflicts of interest to report.
Crystal Zhou, PharmD, APh, AHSCP-CHC, BCACP, is an Assistant Clinical Professor of Pharmacy in the Department of Clinical Pharmacy at UCSF School of Pharmacy. Dr. Zhou’s clinical practice is with the Division of Cardiology at UCSF in both general cardiology and cardiac rehabilitation. Dr. Zhou has been an Advanced Practice Pharmacist since 2018. Dr. Zhou has no conflicts of interest to report.