title: Rural access to clinical pharmacy services.
abstract: OBJECTIVE
  To examine the impact of rural residence and primary care site on use of clinical pharmacy services (CPS) and to describe the use of clinical telepharmacy within the Veterans Health Administration (VHA) health care system.
  
  
  METHODS
  Using 2011 national VHA data, the frequency of patients with CPS encounters was compared across patient residence (urban or rural) and principal site of primary care (medical center, urban clinic, or rural clinic). The likelihood of CPS utilization was estimated with random effects logistic regression. Individual service types (e.g., anticoagulation clinics) and delivery modes (e.g., telehealth) were also examined.
  
  
  RESULTS
  Of 3,040,635 patients, 711,348 (23.4%) received CPS. Service use varied by patient residence (urban: 24.9%; rural: 19.7%) and principal site of primary care (medical center: 25.9%; urban clinic: 22.5%; rural clinic: 17.6%). However, in adjusted analyses, urban-rural differences were explained primarily by primary care site and less so by patient residence. Similar findings were observed for individual CPS types. Telehealth encounters were common, accounting for nearly one-half of patients receiving CPS. Video telehealth was infrequent (<0.2%), but more common among patients of rural clinics than those receiving CPS at medical centers (odds ratio [OR] = 9.7; 95% CI 9.0-10.5).
  
  
  CONCLUSIONS
  We identified a potential disparity between rural and urban patients' access to CPS, which was largely explained by greater reliance on community clinics for primary care than on medical centers. Future research is needed to determine if this disparity will be alleviated by emerging organizational changes, including expanding telehealth capacity and integrating pharmacists into primary care teams, and whether lessons learned at VHA translate to other settings.
authors.forename: Brandon J
authors.initials: BJ
authors.lastname: Patterson
authors.forename: Peter J
authors.initials: PJ
authors.lastname: Kaboli
authors.forename: Traviss
authors.initials: T
authors.lastname: Tubbs
authors.forename: Bruce
authors.initials: B
authors.lastname: Alexander
authors.forename: Brian C
authors.initials: BC
authors.lastname: Lund
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D054625:Healthcare Disparities / Q000706:statistics & numerical data; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D010607:Pharmacy Service, Hospital / Q000458:organization & administration / Q000706:statistics & numerical data*; D011320:Primary Health Care / Q000458:organization & administration / Q000706:statistics & numerical data; D019035:Rural Health Services / Q000458:organization & administration / Q000706:statistics & numerical data*; D012424:Rural Population; D017216:Telemedicine / Q000706:statistics & numerical data*; D014481:United States; D014493:United States Department of Veterans Affairs; D019037:Urban Health Services; D014505:Urban Population