key: cord-0917629-9o6qcj9w
authors: Patel, Janelle; Christofferson, Nikki; Goodlet, Kellie J.
title: Pharmacist-provided SARS-CoV-2 testing targeting a majority-Hispanic community during the early COVID-19 pandemic: results of a patient perception survey
date: 2021-08-19
journal: J Am Pharm Assoc (2003)
DOI: 10.1016/j.japh.2021.08.015
sha: ed686a186babce8aaef9de8ba5fd4f9c93398ecf
doc_id: 917629
cord_uid: 9o6qcj9w

Background Racial and ethnic minority groups are disproportionally represented among U.S. COVID-19 cases, owing to long-standing systemic inequities in the social determinants of health. Among Hispanic populations, lack of access to testing sites has resulted in delayed time to diagnosis, risking increased spread within high-risk communities. The accessibility and expertise of community pharmacists support expanded pharmacist roles in public health and pandemic response, including point-of-care (POC) diagnostic testing. Objective To determine the local impact of community pharmacist-provided COVID-19 testing among a majority-Hispanic, lower income population during the early COVID-19 pandemic, as assessed via a patient satisfaction survey. Methods A 10-question Likert-type questionnaire was administered in English and Spanish to patients who received a pharmacist-provided POC COVID-19 test at a large-chain community pharmacy in Arizona between 5/1/20 and 6/14/20. Questions surrounded patient perceptions of the testing process and subsequent pharmacist counselling on their test results. Results At total of 622 patients completed the survey (94.1% participation rate among successful contacts, representing 28.3% of all eligible patients). The mean age was 42 years, 51% were female, and 64% of patients identified as Hispanic. Over 97% of surveyed patients either agreed or strongly agreed that receiving a pharmacist-provided COVID-19 test at a community pharmacy was a comfortable experience, expanded their access to care, and allowed them to receive their test results in a timely manner. Additionally, over half of surveyed patients “did not know” where they would have alternatively sought testing if the community testing site was not available. Overall, the results of this study demonstrated highly favorable patient perceptions of pharmacist-provided POC testing for COVID-19, with over 99% of surveyed patients satisfied with their testing experience. Conclusion Among patients in a lower-income majority-Hispanic community, pharmacist-provided POC testing services for COVID-19 were well-received and expanded patient access to testing during the early pandemic.

subsequent pharmacist counselling on their test results. 48 49 Results: At total of 622 patients completed the survey (94.1% participation rate among successful 50 contacts, representing 28.3% of all eligible patients). The mean age was 42 years, 51% were female, and 51 64% of patients identified as Hispanic. Over 97% of surveyed patients either agreed or strongly agreed 52 that receiving a pharmacist-provided COVID-19 test at a community pharmacy was a comfortable 53 experience, expanded their access to care, and allowed them to receive their test results in a timely 54 manner. Additionally, over half of surveyed patients "did not know" where they would have alternatively 55 sought testing if the community testing site was not available. Overall, the results of this study 56 demonstrated highly favorable patient perceptions of pharmacist-provided POC testing for COVID-19, 57 with over 99% of surveyed patients satisfied with their testing experience. 18-49, who are 4.5 times more likely than non-Hispanic white patients to be hospitalized for COVID-19. 9 95

Hispanic patients may additionally be at increased risk for in-hospital mortality. 10,11 During public health 96 emergencies, when allocation of resources is often limited, diagnostic testing is needed for triage 97 assessment to prevent the spread of illness within high-risk communities. Delayed diagnosis of COVID-98 19 is associated with increased hospital visits, poor health outcomes, and increased viral transmission. 12 99

Thus, outreach to highly impacted minority communities is essential for detecting cases quickly and 100 controlling virus spread. Among a low-income Latinx community in San Francisco, the median time from 101 COVID-19 symptom onset to time of testing was four days, with 25% of patients having a delay of nine 102 days or longer. 13 Lack of access to a testing site was identified as the most common barrier to obtaining 103 testing, as well as not knowing where or how to make an appointment and lacking insurance or a primary 104 care provider. 13 105 pharmacies are a highly accessible resource for patients, particularly in underserved and rural 110 communities where patients may not have their own physician. During the pandemic, the Department of 111

Act, expanded pharmacists' scope of practice authorizing the ordering and administration of COVID-19 113 diagnostic tests across various communities. 14 In an effort to increase the accessibility of timely testing 114 for at-risk communities, Walgreens partnered with the DHHS and initiated no-cost COVID-19 testing to 115 patients by late April of 2020, during the time a stay-at-home order was active across Arizona. 15 During 116 this period of early first-wave pandemic activity, routine health services were restricted as facilities 117 worked to transition from traditional care delivery models to limited occupancy appointments and 118 telemedicine, with patients potentially experiencing increased barriers to care during this time, 119 particularly among lower-income communities. Local pharmacies have the opportunity to mitigate some 120 of these barriers with services such as point-of-care (POC) testing for COVID-19 and pharmacist 121 counselling, which may expand healthcare access to underserved communities and help alleviate the 122 increased burden on the healthcare system. Previous literature has supported the public health role of 123 community pharmacists, including during national emergencies, through services such as immunization, 124 disease state management, and POC testing, with more patients successfully linked to care. 16-18 However, 125 whether or not patients would perceive these pharmacy services favorably is underexplored within the 126 literature, particularly given the mistrust of government and healthcare systems among some Hispanic 127 groups due to factors such as perceived discrimination. 19 128 129

The objective of this study was to determine the local impact of community pharmacist-provided COVID-131 19 testing among a majority-Hispanic, lower income population during the early COVID-19 pandemic, as with 60% identifying as Hispanic or non-white. 21 Thirteen percent of residents are foreign-born, and over 146 one-third speak a language other than English at home. 21 The median household income is 10% lower 147 than that for Maricopa County, while the median per capita income is 36% lower, reflective of a higher The COVID-19 testing site was located within the parking lot of a closed Walgreens retail space in 157 addition to drive-thru COVID-19 testing services. Advertising for this location consisted of posted 158 signage. Bilingual team members were available at the site to assist primarily Spanish-speaking patients. 159

Pharmacists were trained to operate the COVID-19 testing site and facilitate the ordering and 160 administration of COVID-19 diagnostic tests to patients after attending a live training workshop provided at no cost to the patient. Patients were not required to list insurance information, but were required to 163 provide identification in order for team members to verify the age criteria and lab order matched the 164 patient being tested. At each testing site, patients performed a pharmacist-guided nasal self-swab 165 collection and specimen samples were processed onsite within 30 minutes via Abbott Diagnostic's ID 166 NOW rapid molecular device. 23 The ID NOW device by Abbott Diagnostics obtained Emergency Use 167

Authorization approval by the Food and Drug Administration on March 27 th 2020, and COVID-19 testing 168

in El Mirage began on April 1 st 2020. In compliance with city ordinances issued to avoid crowding and 169 maximize testing capacity, patients were instructed to exit the testing site directly following test testing site available expanded their access to healthcare services, including 62% of patients who 228 "strongly agreed" with this statement. This was reflected in the patient comments as well, which stated 229 that the testing site was easy to access and that they liked having the site available in the community. 230

Some patients noted living 30-45 minutes away from the pharmacy, but making the drive as it was their 231 nearest available testing site, such as a patient who said that it was "located far from my house but I was 232 glad to have found a place to get tested since there was no available locations near me." Several also 233 expressed appreciation for having a non-appointment testing option, including a patient who stated "I am 234 elderly and do not know how to make an appointment online, so it was nice that the testing site took me in 235 without an appointment." While a few patients did comment that their testing results were delayed, over 236 98% of patients agreed that they received their COVID-19 test result quickly, with 66% of patients 237 strongly agreeing. Nearly 100 patients specifically praised the fast turnaround time of the testing site in the test results were given so quickly" and a first-responder who "appreciated being able to get back to 240 to cope with everything," while a grandmother testing positive for COVID-19 said that "the pharmacist 255 was great as she explained everything I needed to do after testing positive to make my grandkids safe." 256 One patient shared that she "was hospitalized two days after receiving my covid test, and was thankful 257 that I knew when to call 911." Of the approximately 10% of patients who disagreed that they felt more 258 knowledgeable after speaking with the pharmacist, most stated that they had never received a post-visit 259 phone call and therefore did not have a conversation with the pharmacist, or said that they did not 260 remember the counselling given the months that had passed from their initial testing date. 261 multiple times, including a patient who stated that since testing she had referred over 20 friends and 266 family members. Similarly, 98% of patients agreed or strongly agree that pharmacist-provided testing 267 services benefit the community, stating that "this is a necessary resource that needs to be in the 268 communities for people" and that they "wish there were more locations open since there is a great need 269 for them." Multiple patients noted the pervasive fear and anxiety that was present during the early 270 pandemic, and that "a testing site was really needed in the community at the start of the pandemic" and 271 (Table 3) . Older adults were less likely to have a positive COVID-19 test result than younger 277 patients (6.1% versus 18.7%, p=0.008), while Hispanic patients were more likely to have a positive test 278 result than non-Hispanic patients (22.9% versus 7.6%, p<0.001). Across all subgroups, perceptions of the 279 pharmacist-guided POC COVID-19 testing experiences were broadly similar with respect to the percent 280 of strongly agree/agree responses, with the exception that older adults were less likely to report feeling 281 more knowledgeable after receiving pharmacist counselling on potential signs and symptoms of COVID-282 19 infection (82% versus 91%, p=0.018) and when to seek medical attention (77% versus 89%, p=0.004). 283

A significantly higher proportion of Hispanic patients, by contrast, reported feeling more knowledgeable 284 (> 92% agreement, Table 3) . likely as any other racial or ethnic group to be uninsured, and less than half identified having an office-295 based healthcare provider for routine care, highlighting the importance of utilizing alternative care 296 delivery models to provide effective outreach, particularly during public health emergencies. Notably, the 297 availability of non-appointment testing options was also highlighted by the surveyed patients as a positive 298 feature of the site, which may expand access to care. Many Hispanic persons work frontline jobs such as 299 within grocery stores, construction, food delivery, and cleaning and sanitation services, which in addition 300 to increasing COVID-19 exposure risk may have inconsistent schedules or lack paid time off, limiting the 301 ability of these workers to schedule appointments. 25 Non-appointment options also increase access for 302 patients without reliable internet or technology to schedule the appointment, or who may hesitate to call 303 to make an appointment due to language barriers. 304

The high observed COVID-19 positivity rate at the El Mirage site is consistent with existing data 306 demonstrating the disproportionate impact of the pandemic on Hispanic communities in the U.S. The 307 pandemic has created fear and anxiety among Hispanic families as many of them face language barriers 308 and limited access to health information in their communities. A national survey conducted by the Pew 309

Research Center revealed Hispanic adults were more likely to view COVID-19 as a major threat to the 310 health of the U.S. population (65% versus 47%) as well as a major threat to their personal health (39% 311 versus 27%). 26 In addition to work-related exposures, about 25% of Hispanic persons live in 312 multigenerational households compared to only 15% of non-Hispanic whites, which can make it difficult 313 for families to take precautions, maintain social distancing, and care for sick loved ones without risking importance of developing interpersonal relationships and earning patient trust. The patients who did not 325 report feeling more knowledgeable after their conversation with the pharmacist largely were those who 326 did not receive the intended follow-up counselling phone call, for example because they did not answer 327 their phone or their provided contact number was not in service. Pharmacist counselling was delivered 328 during the follow-up call to streamline the testing process and to allow the counselling to be tailored 329 based on the patient's test result. However, providing general counselling during the testing visit itself 330 may have allowed for better capture of the 10% of patients who missed out on this information. The lower 331

proportion of older adults who reported feeling more knowledgeable after receiving pharmacist 332 counselling is also worthy of consideration for future health outreach efforts. pharmacists' contributions to disease management during the COVID-19 pandemic highlighted the 339 significant structural health disparities that challenge the current U.S. healthcare system, stressing the 340 importance of interfacing public health with other sectors of the healthcare system, including community perceptions of pharmacist-provided healthcare services revealed in the present study has broad 343 implications beyond the current pandemic. Virtually all patients agreed that community pharmacy testing 344 benefits their community, with calls for additional sites and expansion into rural areas. This supports 345 increased pharmacist roles in providing preventative services in the community including POC testing, 346 primary care services, and select prescription authority to not only strengthen the U.S. healthcare system, 347 but to make it more inclusive, accessible, and effective for the most vulnerable. 

The study results support the local impact of community pharmacy testing sites on expanding healthcare 362 access to underserved and vulnerable populations who are most impacted by healthcare disparities. 363

Community pharmacists may provide added benefit in alleviating the burden on the healthcare system 364 during public health emergencies, including via the provision of pharmacist counselling and patient 365 education. 366 J o u r n a l P r e -p r o o f 

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Acknowledgements: The authors would like to thank the following students from Midwestern University