Student Paper

PRACTICE-BASED RESEARCH

Accessibility to Essential Medicines in New York City by Zip Code Income Levels and Boroughs
1

Yan Aronson, PharmD , Joyce Addo-Atuah, PhD

1
Was a PharmD candidate, 2013, at the Touro College of Pharmacy, New York, at the time of this study which was the required
2
students Capstone Project. Associate Professor of Pharmacy & Health Outcomes and the students Capstone Project Advisor.
Keywords: Access to medicines, medication access, prescription drugs, medication costs, medication prices, frequently prescribed
medicines, availability of medicines, New York City.
Abstract
Access to essential medicines is fundamental to medication adherence, continuity of care and hence population health outcomes and
overall quality of life. Disparities in the availability and the cost of these medications in New York City, especially for low income
neighborhoods, would compound the underlying health disparities in these neighborhoods. This study examined the physical and
financial accessibility to 8 of the 150 Most Frequently Prescribed Drugs in New York, 2 each for Asthma, Diabetes, Hypertension, and
Hyperlipidemia, 4 conditions that are among the top 10 most costly conditions in the United States. The study did not find any
significant differences in mean drug prices between the high, medium, and low income neighborhoods in the City. However, the
significantly different income levels and uninsured rates across neighborhood income strata in the City (p<0.001 for both), coupled
with the high disease burden and other underlying disparities in low income neighborhoods, would point to potential affordability
challenges for needed medications in these neighborhoods. On the other hand, significant differences in mean prices between the 5

City boroughs were found for 3 of the study drugs: Advair , p=0.009; Amlodipine 10mg, p<0.001; and Lisinopril 10mg, p=0.046. No

such significant differences were observed for the mean prices of the other 5 study drugs-Proventil HFA, Metformin HCL 500mg,
Glipizide ER 5mg, Simvastatin 20mg, and Atorvastatin 10mg. The study findings did not also suggest that drug prices are dictated by
the number of pharmacies in a neighborhood.
Further studies would be needed to better understand the complexities associated with the accessibility of essential medicines in New
York City. These studies could include qualitative ones which would examine the perceptions and experiences of City residents with
respect to the accessibility of prescribed medications as the basis for targeted interventions directed at promoting access to needed
medications for all New Yorkers.

Introduction
Essential medicines have been defined as those that satisfy
1
the priority health care needs of the population. In the
2-5
6
7
United States as a whole and also in the State and City of
New York, the high morbidity and mortality associated with
costly health conditions such as asthma, diabetes,
hypertension, hyperlipidemia and their complications, qualify
the medicines for the treatment of these conditions to be
1
labeled as essential medicines. Access to essential
medicines have been defined as their continuous availability
and affordability in public or private health facilities or
pharmacies within a reasonable distance from the homes of
8
those who need them. Equitable access to safe and
affordable medicines is considered to be of the utmost
9
importance by the global health community.
Four main dimensions of access to essential medicines,

Corresponding Author: Yan Aronson, PharmD

4742 Burnet Ave, Sherman Oaks, CA 91403
Phone: (818) 398-8818; Email: yan624@yahoo.com
http://z.umn.edu/INNOVATIONS

2013, Vol. 4, No. 3, Article 127

vaccines, and other health commodities have been identified

10
and operationalized. They consist of: (a) Physical
Availability, (b) Affordability [financial accessibility], (c)
10
Geographic Accessibility, and (d) Acceptability [satisfaction].
Physical availability has been defined as the relationship
between the type and quantity of product(s) or service(s)
needed and the product(s) or service(s) actually provided.
Some of the key indicators proposed for physical availability
include: percentage of a set of unexpired key items in stock,
10
percentage of time out of stock for a set of key items.
Affordability defines the relationship between prices of the
products or services and the users ability to pay for them.
Key indicators proposed for affordability include the average
price differential between a generic and brand product for
the treatment of key health conditions; and public and
private sector prices as compared to the median international
10
prices of drugs for those conditions.
Geographic accessibility on the other hand describes the
relationship between the location of the product or service
and the location of the eventual user of the product or
10
service. Some key indicators include the percentage of

INNOVATIONS in pharmacy

Student Paper

PRACTICE-BASED RESEARCH

households located more than five kilometers from a health

facility or pharmacy that has a set of key items in stock at all
10
times. Acceptability (or satisfaction), defines the
relationship between the users attitudes and expectations
about the products and services and the actual
characteristics of products and services. Key indicators for
this dimension include clients satisfaction with outcome of
their most recent visit to the pharmacy or other outlets for
10
their medications.
Barriers to accessing needed medications are a global public
health concern. Reports from global monitoring indicate that
only 51.8% of public and 68.7% of private health facilities in
developing countries were able to provide essential
9
medicines to their populations in 2012. High medicine prices
have been identified as one such barrier to medication access
in these countries. Essential medicines, when available, were
found to have prices that were between 2.5-6.5 times those
9
of their international reference prices (IRPs). Although
generic equivalent drugs are much cheaper than their
innovator brands, they may not always be available,
9
especially in the private sector in these countries.
The 8 Millennium Development Goals (MDGs), which provide
a framework for promoting global health in the context of
development, has a specific target-Target 8E of MDG 8-which
11
addresses access to essential medicines. Target 8E seeks to
promote access to essential medicines for the populations in
developing countries through global cooperation between
pharmaceutical companies and the governments of these
11
countries. The indicator for monitoring progress for this
target is, Proportion of the population with access to
11
affordable essential medicines on a sustainable basis.
Medication access is also very relevant to the United States
population; several factors can create gaps in the accessibility
to medications for those who need them. These include
affordability challenges arising from lack of health insurance
coverage which necessitates people having to pay for their
12
medications out-of-pocket However, even individuals with
health insurance coverage may face prescription drug
accessibility challenges as a result of the use of various
prescription drugs utilization management strategies by their
13-14
health plans.
These strategies include prior authorization,
stepped therapy, with increasing out-of-pocket payments for
higher tier drugs, full payment for non-formulary drugs, and
13-14
utilization reviews.
. Seniors in America faced affordability
challenges for their outpatient prescription drugs before the
15
implementation of the Medicare Part D program in 2006. It
is important to note however, that the Part D program was
designed such that Medicare beneficiaries would have to pay
for their full outpatients prescription drug costs out-of-pocket
http://z.umn.edu/INNOVATIONS

2013, Vol. 4, No. 3, Article 127

once they hit the coverage gap, commonly referred to as the

16
donut hole. This could have serious implications for
prescription drugs accessibility, and hence by inference
medication adherence and outcomes, for the Medicare
population in most need of medications. Fortunately, this
accessibility challenge is being addressed by the Affordable
Care Act of 2010 with the ultimate aim of eliminating the
17
donut hole in the Part D Program.
With the goal of addressing the escalating expenditures on
prescription drugs for public programs like Medicaid, many
states have been promoting generic prescribing and
empowering pharmacists to substitute generically equivalent
drugs for branded products in the absence of any
18-21
contraindication.
Although generic drugs can bring
consumers significant savings, they may not be as readily
21
available as their brand-name innovator equivalents. People
in neighborhoods where needed generics are not available
would have no option but to pay the higher prices for brand
name drugs; those with the means may have to travel
distances to obtain needed generics. However, generic drug
shortages in the United States are increasingly becoming
problematic; about 251 such shortages were recorded in
22
2011 alone. In a study by Baumer et al on drug shortages in
23
acute care hospitals, nearly all pharmacy directors surveyed
believed that shortages had changed practice and had
compromised patient care. Their results suggested that
shortages increase the acquisition cost of pharmaceuticals in
23
the United States by over $99 million annually. In another
study which looked at the impact of drug shortages on U.S.
health systems, most respondents surveyed felt that the
information resources available to manage drug shortages
were not adequate, costing the U.S. $216 million annually in
24
labor costs to manage the shortages.
High prescription drug prices are a significant barrier to
appropriate medication use especially among populations
with limited resources. This can potentially compromise
medication adherence and thus the health outcomes of
vulnerable and under-served populations.
In the state of New York, the Drug Retail Price List Law
mandates pharmacies to (1) maintain a price list for the 150
Most Prescribed Medicines in the state, (2) update this list
weekly, (3) post a sign in the pharmacy informing clients of
the availability of this list, and (4) make copies available to
25
consumers upon request. This Law was intended to make
the above information available to consumers so that they
could lower their drug costs by shopping around for
25
competitive prices. However, studies by the New York City
Council Investigation Division in both 2002 and 2004 reported
widespread noncompliance to the Law; more importantly,
there was no indication of any serious enforcement-

INNOVATIONS in pharmacy

Student Paper

PRACTICE-BASED RESEARCH
25

enhancing changes between the 2 year period. The 2004

City investigation, for example, found gross disparities
between drug prices within and between New York City
boroughs; some drug price differences ranged from $30 to
25
$80. Furthermore, only about 28% of pharmacies had actual
Drug Price Lists and 70% of pharmacies did not comply with
the requirement to make their Drug Price Lists available to
25
consumers on request. The researchers recommended that
properly enforcing the State Law on Drug Retail Price Lists
and making these prices available online could potentially
make drug prices in the City become more transparent and
25
competitive for the benefit of consumers. Another study in
New York City has reported significant disparities in
geographic access to neighborhood pharmacies and the
availability of commonly-prescribed medications across
26
neighborhood income levels. Commonly-prescribed
medications were found to be more likely out of stock ,
OR=1.24; 95% CI (1.02-1.52) in poorer neighborhoods than in
26
the medium and higher income ones. Entire neighborhoods
could be described as medication deserts because both
geographic access to pharmacies and the availability of
common medications were very poor in these communities,
26
according to this study. Significant differences were also
reported in the relative proportion of independent to chain
26
pharmacies across neighborhood incomes in the City.
Another study conducted by Gellad et al in Florida, using
available state drug prices data, sought to determine whether
there were significant differences in retail drug prices based
27
on neighborhood income strata. Their findings indicated
that mean drug prices were 9% above the statewide average
27
in the poorest zip codes. More importantly, mean drug
prices in the independent pharmacies in the poorest zip
codes were about 15% higher than those in the chain
27
pharmacies.
In the context of the Healthy People 2020 goal of achieving
health equity, eliminating disparities, and improving the
28
health of all population groups, and given the great
disparities in incomes among the very diverse populations of
NYC, examination of the accessibility to essential medicines in
the City is of important public health relevance. This study
therefore sought to evaluate 2 dimensions of accessibility
(physical availability and drug prices/financial) to essential
medicines in New York City by answering the following
research questions:
1)

2)

Are there significant differences in mean drug prices

across neighborhood income levels and boroughs in
New York City?
Are drug prices in a zip code associated with the
number of pharmacies in the zip code?

http://z.umn.edu/INNOVATIONS

2013, Vol. 4, No. 3, Article 127

Methods
This was a cross sectional study of mean drug prices by zip
code income levels and boroughs (The Bronx, Brooklyn,
Manhattan, Queens, and Staten Island) in New York City. Zip
code definitions of New York City Neighborhoods available
on the website of the New York State Department of Health
was used to identify the zip codes in the 5 New York City
29
boroughs. The NYC Census Fact Finder website and the
EpiQuery search engine of the New York City Department of
Health and Mental Hygiene provided neighborhood
characteristics including the mean household income, the
predominant racial/ethnic group of the resident population
based on the 2000 and 2010 census data, and the percentage
30-31
of the population uninsured in the neighborhoods.
For the purposes of this study and in an effort to adequately
cover the wide range of mean household incomes reported
for the neighborhoods in NYC, zip codes or neighborhoods
were categorized as high income ones if the mean household
incomes were greater than or equal to $80,000; medium
income ones were those below $80,000 but above $57,000;
and low income neighborhoods were those with mean
household incomes below $57,000. Within each NYC
borough, 2 zip codes each were randomly selected from the
high, medium, and low income neighborhoods, yielding a
total of 30 zip codes (6 per borough) for the study.
Two prescription medications each for Asthma, Diabetes,
Hypertension, and Hyperlipidemia were targeted for the
study. The targeted medical conditions are among the most
costly conditions in the United States according to the
5
Medical Expenditure Panel Survey.
The specific study drugs, selected from the 150 Most
Frequently Prescribed Drugs in New York State, which is
published annually by the New York State Board of
32
Pharmacy, were:
Asthma: Advair Diskus 250/50 (GlaxoSmithKline)
[Fluticasone propionate 250 mcg & Salmeterol 50 mcg] and
Proventil HFA Inhaler 6.7gm (MERCK & Co) [Albuterol
sulfate]
Diabetes: Metformin HCL 500mg and Glipizide ER 5mg
Hypertension: Amlodipine 10mg and Lisinopril 10mg
Hyperlipidemia: Atorvastatin 10mg and Simvastatin 20mg
The Prescription Drug Prices in New York State search
engine on the New York State Department of Healths
33
webpage was used to collect data on drug prices. The
search engine allows for the selection of drugs of interest,
target zip code(s), and the distance around the zip code(s) in
order to generate a list of the names and number of
pharmacies, along with their drug prices, in the selected zip

INNOVATIONS in pharmacy

Student Paper

PRACTICE-BASED RESEARCH

code(s). We chose a 2-mile radius around the target zip codes

for the search on drug prices in this study. From the list of
available pharmacies in each zip code so generated, we
calculated the mean prices for the study drugs in that zip
code by averaging drug prices from 2 randomly-selected
chain (Rite Aid and Walgreens) and 2 independent
pharmacies from that neighborhood. The mean drug prices so

determined were for 1 inhaler each (Advair and Proventil

HFA ) and for 30 tablets each of Glipizide ER 5mg, Amlodipine

10mg, Lisinopril 10 mg, Simvastatin 20, Atorvastatin 10mg
32
and for 60 tablets of Metformin HCL 500mg. Advair and

Proventil are listed as such on the list of 150 Most Prescribed

Drugs; the other 6 drugs have been listed by their generic
32
names with an indication of their innovator brand names.
Data Analysis
Data collected for each zip code included neighborhood
demographics, drug prices, and the number of pharmacies
available within a 2-miles radius of each zip code.
Neighborhood data covered zip codes with their associated
cities and boroughs. Zip code demographic data consisted of
population size, predominant racial/ethnic group, socioeconomic status (expressed as mean household income) and
percent of population uninsured in 2010.
To determine whether there were significant differences in
mean drug prices by zip code household income in NYC, we
pooled the mean drug prices in the 3 zip code income levels
across the City, coming out with City-wide mean prices for
each drug in the high, medium, and low City neighborhoods
and compared them for significant differences using One Way
Analysis of Variance (ANOVA). We also used ANOVA to
analyze differences in mean drug prices across the 5 NYC
boroughs. The strength and the direction of the relationships
between the number of pharmacies in a neighborhood and
mean drug prices were examined by Pearson ProductMoment Correlation. All statistical tests were performed
using IBM SPSS Statistics 19 software package (IBM
Corporation, Armonk, NY). P-values for statistical test results
0.05 were taken as indicative of statistically-significant
differences or relationships between the study variables.
Results
Table 1 gives the demographic characteristics of the
populations in the 30 study zip codes in New York City and
the number of pharmacies within a 2-mile radius of each zip
code. The information in Table 1 is summarized in Table 2.
Mean prices of the study drugs with their corresponding zip
codes and NYC boroughs, household income levels, and the
number of pharmacies are presented in Table 3.
The mean (95% CI) prices of the study drugs across
neighborhood income levels in the City have been presented
http://z.umn.edu/INNOVATIONS

2013, Vol. 4, No. 3, Article 127

in Table 4. Mean prices (95% CI) of Advair250/50 inhaler

was found to be $290.44($284.62-$296.26), $293.02
($284.75-$301.29), and $295.15($286.92-$303.38) in the
high, medium, and low income neighborhoods, respectively.
No statistically significant differences in these prices were
observed (p=0.689). Similarly, the mean prices of the
remaining 7 study drugs were not found to be significantly
different across neighborhood income strata in the City
(Table 4). Table 5 presents the mean drug prices across the 5
NYC boroughs. Among the 8 study drugs, only 3 of them

(Advair 250/50 inhaler, Amlodipine 10mg, and Lisinopril

10mg), were found to have mean prices that varied
significantly across the boroughs. Whereas

Advair 250/50mgs mean price was $289.36($281.86$296.96) in the Bronx, it was $294.39 ($284.14-$304.62),
$299.05 ($290.20-$307.90), $280.74($ 272.61-$288.11), and
$301.03($298.30-$304.10) in Brooklyn, Manhattan, Queens,
and Staten Island, respectively (p=0.009). Similarly, 30 tablets
of Amlodipine 10mg ranged from $44.48 ($$42.75-$46.21) in
the Bronx to $63.49 ($62.19-$64.79) in Staten Island
(p<0.001). Furthermore, Lisinopril 10mg prices were found to
differ significantly across boroughs (p=0.0406).
26

Given that an earlier study by Amstislavski et al had

reported significant disparities in geographic access to
neighborhood pharmacies across neighborhood income
strata in the City, this study further sought to determine
whether there were significant correlations between mean
drug prices in New York City neighborhoods and the number
of pharmacies within a 2-mile radius of the neighborhood.
Positive linear relationships of varying strengths were
observed between the number of pharmacies and the mean
prices of 4 of the study drugs but none achieved statistical

significance-Advair (r=0.53; p=0.643); Proventil HFA (r=0.62;

p=0.575); Glipizide ER 5mg (r=0.086; p=0.945); and
Simvastatin 20mg (r=0.394; p=0.742). The mean prices of the
remaining 4 study drugs were negatively correlated to the
number of pharmacies in the neighborhood but again, none
of these relationships were found to be statistically
significant.
Discussion
Prices of essential medicines determine their affordability
(financial accessibility) which in turn may have major
implications for medication adherence, continuity of care,
and hence population health outcomes. Significant price
differences for frequently-prescribed medications for 4 of the
most common and costly medical conditions in the United
States-asthma, diabetes, hypertension, and hyperlipidemiawill undoubtedly compound the challenges of health
disparities which the United States is already grappling with.
Such drug price variations in NYC, with its very diverse

INNOVATIONS in pharmacy

Student Paper

PRACTICE-BASED RESEARCH

racial/ethnic, income, and uninsured rates, among others, will

be even more problematic.
It is gratifying therefore to note that, unlike the Florida study
27
of mean drug prices by Gellad et al, the findings in this
current study, of mean drug prices by neighborhood income
levels and boroughs in NYC, did not reveal any significant
differences in drug prices between the high, medium, and low
income neighborhoods in the City. However, attention
should be drawn to the differences in the mean household
income levels across the 3 neighborhood income strata in the
City. Whereas a low income neighborhood (10453) in Morris
Heights in the Bronx has a mean household income of $37,
383, that of a similar neighborhood (10303) in Mariners
Harbor in Staten Island is $54,956. Similarly, a high income
neighborhood (10464) in Pelham Bay in the Bronx has a mean
household income of $81,856, compared to that of a similar
neighborhood (10038) in Seaport, Manhattan of $124, 271.
More importantly, mean household income levels, especially
in the low income strata, in Staten Island were found to be
outliers when compared with those in the other 4 boroughs
in the City. For example, a low income zip code (10302) in
Staten Island has a mean household income of $56,518,
which is equivalent to that of a medium income ($56,838) zip
code (10466) in the Bronx. These income differences were
statistically significant (p<0.001). In addition to these income
differences, the percentage of the population without health
insurance coverage in the high, medium, and low income
neighborhoods were also significantly different (p<0.001);
12
they were 8.80%, 15.76% and18.74%, respectively, in 2010.
Unlike the insured populations, those uninsured would have
to pay for their needed medications at the full undiscounted
retail prices out of pocket, in the absence of any other
assistance. Health insurance plans normally negotiate with
drug manufacturers for discounted prices; a benefit that will
not be available to the uninsured.
Another factor for consideration is the differences in the
predominant racial/ethnic composition of the resident
populations in the 3 neighborhood income levels of the City.
With the exception of Elm Park (10302) in Staten Island, Table
1 indicates that the predominant racial/ethnic populations in
the low income neighborhoods in all 5 boroughs of the City
are African Americans or Hispanics. Hence, low income, along
with lack of health insurance, in the context of
disproportionately high disease burden, poor access to health
34-35
care, and poor health outcomes,
would suggest a
potential for medications affordability challenges for these
populations, even though no significant drug price differences
were observed across neighborhood income levels in the City.

http://z.umn.edu/INNOVATIONS

2013, Vol. 4, No. 3, Article 127

On the other hand, mean drug prices differed significantly

across the boroughs for 3 of the 8 study drugs- Advair ,

Amlodipine 10mg and Lisinopril 10mg. However, the price
differences observed for these drugs in this study did not
25
reach the ranges ($30-$80) reported in the City in 2004.
Those researchers suggested that City residents could shop
for competitive drug prices across boroughs and hence make
25
substantial savings. It is also important to note that
26
although the study of Amstislavski et al reported significant
disparities in the geographic access to neighborhood
pharmacies and the availability of commonly-prescribed
medications across neighborhood income levels in the City,
the findings in this study would suggest that mean prices of
prescription medications are not dictated by the number of
neighborhood pharmacies in NYC.
This study has a number of limitations. Since the New York
City Council Investigations Division found serious compliance
challenges with the State Drug Retail Price List Law in 2
25
consecutive studies conducted in the City, it is possible that
similar challenges still persist, which would mean that the
drug prices data used in this study may not reflect the most
current ones in use in the respective pharmacies. Thus
primary data collection from pharmacies would be important
to authenticate the reported medication prices. Another
possible limitation is that only 4 pharmacies per zip code
were randomly selected for computing the mean prices for
the 8 study drugs, given the limited time period available for
the study. A more representative sample of pharmacies,
systematically selected per zip code may yield a more
representative data on drug prices in the City.
Conclusion
Accessibility to essential medicines is fundamental to desired
medication adherence and optimum outcomes with respect
to therapeutic benefits of drug treatment and population
health. Disparities in the geographic access to neighborhood
pharmacies and also in the physical availability of medications
and in their costs have been reported in earlier studies
25-26
conducted in NYC.
A Florida study has also reported
significant disparities in mean drug prices across
neighborhood income strata and between independent and
27
chain pharmacies. Although this current study did not find
any significant differences in drug prices across neighborhood
income levels in the City, the fact still remains that medicines
in the United States, especially branded products such as

36
Advair and Proventil HFA are not cheap. Whereas insured
people benefit from their health plans negotiated discounted
drug prices, populations without health insurance coverage
do not enjoy this luxury. This can be especially problematic
for, minority, under-served populations already facing
33-34
significant health disparity challenges,
and hence the

INNOVATIONS in pharmacy

Student Paper

PRACTICE-BASED RESEARCH

public health importance and relevance of this study.

Medicines affordability (financial accessibility) challenges
could have implications for prescription filling and re-filling,
medication adherence, and general continuity of care for the
chronic diseases and conditions targeted in this study, thus
adversely affecting the health outcomes and quality of life of
minorities and low income populations in the City.
Accessibility challenges to the medications targeted in this
study would have a special public health relevance given that
they are among the most frequently prescribed for 4 of the
top 10 most costly conditions among the noninstitutionalized
5
adult population 18 years and above in the United States.
Further studies, using a more representative sample of NYC
zip codes and which also examine differences in mean drug
prices between chains versus independent pharmacies,
would be useful. Follow up studies could also be enriched if
resources would allow for the collection of primary data from
a representative sample of pharmacies in the City in line with
26
the study protocol of Amstislavski et al.
Furthermore, a qualitative study examining New Yorkers
perceptions of the accessibility of essential medicines and
their personal experiences of accessing needed prescription
medications would be needed to assist policy makers,
healthcare providers and drug manufacturers and distributors
in taking the requisite steps to promote access to essential
medications for all populations irrespective of race/ethnicity,
socio-economic status, and geographic residence in the City.
Similar qualitative studies on access to medicines, such as the
37
one carried out in Ghana, could be replicated elsewhere in
and outside the United States to inform policy and promote
access. Finally, studies which examine the relationships
between access to medicines, medication utilization and
adherence, and health outcomes would be very useful
towards promoting population health.

http://z.umn.edu/INNOVATIONS

2013, Vol. 4, No. 3, Article 127

References
1. World Health Organization. Essential Medicines.
Available at:
http://www.who.int/medicines/services/essmedicines_d
ef/en/index.html Accessed 6/20/2013.
2. CDC National Center for Health Statistics. National
Surveillance of Asthma: United States, 2001-2010.
Available at:
http://www.cdc.gov/nchs/data/series/sr_03/sr03_035.p
df Accessed 6/20/2013.
3. Centers for Disease Control & Prevention. National
Diabetes Fact Sheet: National Estimates and General
Information on Diabetes & Prediabetes in the United
States, 2011. Available at:
http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf
Accessed 6/20/2013.
4. Centers for Disease Control and Prevention. High Blood
Pressure Facts, Available at:
http://www.cdc.gov/bloodpressure/facts.htm Accessed
6/15/2013.
5. Soni, A. Top 10 Most Costly Conditions among Men and
Women, 2008: Estimates for the U.S. Civilian
Noninstitutionalized Adult Population, Age 18 and Older.
Statistical Brief #331. July 2011. Agency for Healthcare
Research and Quality, Rockville, MD. Available at:
http://www.meps.ahrq.gov/mepsweb/data_files/publica
tions/st331/stat331.shtml Accessed 6/15/2013.
6. New York State Department of Health. Leading Causes of
Death, New York State 2001-2010. Available at:
http://www.health.ny.gov/statistics/leadingcauses_deat
hs/nys_by_year.htm Accessed 6/15/2013.
7. New York State Department of Health. Leading Causes of
Death, New York City, 2001-2010. Available at:
http://www.health.ny.gov/statistics/leadingcauses_deat
hs/nyc_by_year,htm Accessed 6/15/2013.
8. World Health Organization. Access to Medicines.
Available at:
http://www.who.int/trade/glossary/story002/en/
Accessed 6/20/2013.
9. World Health Organization. Access to Affordable
Essential Medicines. Available at:
http://www.who.int/medicines/mdg/MDG08ChapterEM
edsEn.pdf Accessed 6/20/2013.
10. Center for Pharmaceutical Management. Defining and
Measuring Access to Essential Drugs, Vaccines, and
Health Commodities. Available at:
http://www.msh.org/seam/reports/Access_Meeting_Fer
ney_Voltaire_1.pdf Accessed 6/20/2013.

INNOVATIONS in pharmacy

Student Paper

PRACTICE-BASED RESEARCH

11. United Nations. Millennium Development Goal 8. The

Global Partnerships for Development: Making Rhetoric
a Reality-MDG Gap Task Force Report 2012. Available at:
http://www.un.org/millenniumgoals/2012_Gap_Report/
MDG_2012Gap_Task_Force_report.pdf Accessed
6/20/2013.
12. New York City Department of Health and Mental
Hygiene. NYC Community Health Survey 2010.
Percentage with No Insurance by Neighborhood.
Available at: https://a816healthpsi.nyc.gov/SASStoredProcess/guest?_PROGRAM=
%2FEpiQuery%2FCHS%2Fchs2&year=2010&var=insure5&
strat1=allsex2&strat2=none&qtype=neighbor&bivar=gen
hlt4. Accessed 4/11/2013.
13. Horizon Blue Cross Blue Shield of New Jersey. Pharmacy
& Prescriptions Utilization Management. Available at:
http://www.horizonblue.com/members/services/pharm
acy-prescriptions/utilization-management Accessed
6/15/2013.
14. AARP Public Policy Institute. Strategies to Increase
Generic Drug Utilization and Associated Savings.
Available at:
http://assets.aarp.org/rgcenter/health/i16_generics.pdf
Accessed 6/20/2013.
15. Millett C, Everett CJ, Matheson EM, Bindman AB,
Mainous AG. Impact of Medicare Part D on Seniors' Outof-pocket Expenditures on Medications. Arch Intern Med.
2010; 170(15):1325-1330.
doi:10.1001/archinternmed.2010.208.
16. Medicare. Prescription Drug Coverage: Things to
Consider. Available at: http://www.medicare.gov/pdpthings-to-consider.asp Accessed: 3/8/2013.
17. Centers for Medicare & Medicaid (CMS). Closing the
Coverage Gap-Medicare Prescription Drugs Are
Becoming More Affordable. Available at:
http://www.medicare.gov/Pubs/pdf/11493.pdf
Accessed 6/20/2013.
18. Kaiser Family Foundation. Prescription Drug Trends, May
2010. Available at:
http://www.kff.org/rxdrugs/upload/3057-08.pdf
Accessed 4/11/2013.
19. Jesse CV. Generic-Substitution Laws. US Pharm.
2008;33(6) (Generic Drug Review):30-34. Available at:
http://www.uspharmacist.com/content/s/44/c/9787/
Accessed 4/11/2013.
20. Shrank, WH, Choudhry, NK, Agnew-Blais, J. Federman,
AD, Liberman JN, Liu J et al. State Generic Substitution
Laws can Lower Drug Outlays Under Medicaid . Health
Affairs. 2010; 29(7):1383-1390.doi:
10.1377/hlthaff.2009.0424.

http://z.umn.edu/INNOVATIONS

2013, Vol. 4, No. 3, Article 127

21. National Conference of State Legislatures. Use of Generic

Prescription Drugs and Brand-Name Discounts. Available
at:
http://www.ncsl.org/portals/1/documents/health/GENE
RICS-2010.pdf Accessed 4/20/2013.
22. Thomas K. The New York Times. Drug Shortages Persist in
U.S., Harming Care. Available at:
http://www.nytimes.com/2012/11/17/business/drugshortages-are-becoming-persistent-inus.html?pagewanted=all&_r=0 Accessed 3/13/2013.
23. Baumer AM, Clark AM, Witmer DR, Geize SB, Vermeulen
LC, Deffenbaugh JH. National Survey of the Impact of
Drug Shortages in Acute Care Hospitals. American Journal
of Health-System Pharmacy. 2004; 61(19):2015-22.
24. Kaakeh R, Sweet BV, Reilly C, Bush C, DeLoach S, Higgins
B. Impact of Drug Shortages on U.S. HealthSsystems.
American Journal of Health-System Pharmacy. 2011;
68(19):1811-1819. doi: 10.2146/ajhp110210.
25. The Council of the City of New York. Prescription Drug
Prices: All Over the Map. Available at:
http://www.nyc.gov/html/records/pdf/govpub/859presc
drugs.pdf Accessed 4/11/2013.
26. Amstislavski P, Matthews A, Sheffield S, Maroko AR, and
Weedon J. Medication Deserts: Survey of Neighborhood
Disparities in Availability of Prescription Medications.
International Journal of Health Geographics 2012;11:48.
27. Gellad WF, Choudhry NK, Friedberg MW, Brookhart MA,
Haas JS, Shrank WH. Variation in Drug Prices at
Pharmacies: Are Prices Higher in Poorer Areas? Health
Services Research online. 2009; 44(2p1): 606
617.doi: 10.1111/j.1475-6773.2008.00917.
28. Department of Health & Mental Hygiene. Healthy People
2020 Framework. Available at:
http://www.healthypeople.gov/2020/consortium/HP202
0Framework.pdf Accessed 6/20/2013.
29. New York State Department of Health. Zip Code
Definitions of New York City Neighborhoods. Available at:
http://www.health.ny.gov/statistics/cancer/registry/app
endix/neighborhoods.htm Accessed 4/11/2013.
30. NYC Government. NYC Census FactFinder Available at:
http://maps.nyc.gov/census/ Accessed 4/11/2013.
31. NYC Department of Health & Mental Hygiene. EpiQuery:
NYC Interactive Health Data. Available at: https://a816healthpsi.nyc.gov/epiquery/ Accessed 7/4/2013.
32. New York State Department of Health. 150 Most
Frequently Prescribed Drugs. Available at:
https://apps.health.ny.gov/pdpw/DrugInfo/DrugInfo.acti
on Accessed 6/20/2013.
33. New York State Department of Health. Prescription Drug
Prices in New York State. Available at:
https://apps.health.ny.gov/pdpw/SearchDrugs/Home.act
ion Accessed 6/20/2013.

INNOVATIONS in pharmacy

Student Paper

PRACTICE-BASED RESEARCH

34. AHRQ. Addressing Racial and Ethnic Disparities in Health

Care. April 2013. Agency for Healthcare Research and
Quality, Rockville, MD. Available at:
http://www.ahrq.gov/research/findings/factsheets/mino
rity/disparit/index.html. Accessed 6/15/2013.
35. Kawachi I, Daniels N, and Robinson DE. Health Disparities
by Race and Class: Why Both Matter. Health Affairs.
2005; 24(2):343-352.
36. Lopert R and Gleeson D. The High Prices of Free Trade:
U.S. Trade Agreements and Access to Medicines. The
Journal of Law, Medicine & Ethics. Special Issue:
Symposium-Global Health & the Law. 2013;41(1):199223.
37. Addo-Atuah J, Gourley D, Gourley G, White-Means SI,
Womeodu RJ, Faris RJ, Addo NA. Accessibility of
Antiretroviral Therapy in Ghana: Convenience of Access.
Journal of Social Aspects of HIV/AIDS. 2012;9 (2):74-87.

http://z.umn.edu/INNOVATIONS

2013, Vol. 4, No. 3, Article 127

INNOVATIONS in pharmacy

Student Paper

PRACTICE-BASED RESEARCH
Table 1. Demographic Characteristics of Populations in the Study Zip Codes

Zip Code

City

Borough

Income
Status

10471
10466
10453
10464
10461
10454
11231
11204
11212
11217
11235
11239
10025
10026

Riverdale
Edenwald
Morris Heights
Pelham Bay
Morris Park
Mott Haven
Carroll Gardens
Borough Park
Brownsville
Boerum Hill
Brighton Beach
Starrett City
Upper West Side
Morningside
Heights
East Harlem
South Street
Seaport
Alphabet City
Upper
Manhattan
Breezy Point
Flushing
Arverne
Little Neck
Astoria
Jamaica
Tottenville
Arrochar
Elm Park
Bay Terrace
St. George
Mariners Harbor

Bronx
Bronx
Bronx
Bronx
Bronx
Bronx
Brooklyn
Brooklyn
Brooklyn
Brooklyn
Brooklyn
Brooklyn
Manhattan
Manhattan

10035
10038
10009
10039
11697
11355
11692
11362
11106
11433
10307
10305
10302
10308
10301
10303

http://z.umn.edu/INNOVATIONS

Population

Predominant
Race/Ethnicity

High
Medium
Low
High
Medium
Low
High
Medium
Low
High
Medium
Low
High
Medium

Mean
Household
Income ($)
104,139
56,838
37,383
81,856
63,417
33,417
101,734
59,739
38,168
111,074
62,842
34,784
115,200
64,751

22,922
67,813
78,309
4,534
50,502
37,337
33,336
78,134
84,500
35,881
79,132
13,393
94,600
34,003

White
African American
African American
White
White
Hispanic
White
White
African American
White
White
African American
White
African American

%
Uninsured
(2010)
13.8
13.2
21.5
11.7
18.1
21.5
5.5
16.9
18.4
5.5
15.9
14.5
8.6
20.5

Manhattan
Manhattan

Low
High

45,516
124,271

33,969
20,300

Hispanic
White

17.6
12.9

Manhattan
Manhattan

Medium
Low

83,700
43,417

61,347
24,527

White
African American

13.8
25.0

Queens
Queens
Queens
Queens
Queens
Queens
Staten Island
Staten Island
Staten Island
Staten Island
Staten Island
Staten Island

High
Medium
Low
High
Medium
Low
High
Medium
Low
High
Medium
Low

105,975
59,124
44,816
95,762
61,476
41,274
113,102
79,425
56,518
104,300
74,852
54,956

4,079
85,871
37,337
17,823
38,875
32,687
14,096
41,749
19,088
27,357
39,706
26,337

White
Asian
African American
White
White
African American
White
White
White
White
White
African American

8.1
14.9
12.4
9.1
21.1
21.7
5.4
11.6
17.4
7.4
11.6
17.4

2013, Vol. 4, No. 3, Article 127

INNOVATIONS in pharmacy

Student Paper

PRACTICE-BASED RESEARCH

Table 2. Summary Demographic Information and Number of Pharmacies Per Zip Code Income Levels in NYC
Borough

Income Status

Bronx

High
Medium
Low
High
Medium
Low
High
Medium
Low
High
Medium
Low
High
Medium
Low

Brooklyn

Manhattan

Queens

Staten Island

Mean
Household
Income ($)
92,998
60,128
35,400
106,404
61,291
36,476
119,736
74,226
44,467
100,869
60,300
43,045
108,701
77,139
55,737

Total Population

27,456
118,315
115,646
69,217
157,266
97,893
114,900
95,350
58,496
21,902
124,746
70,024
41,453
81,455
45,425

% Uninsured
(2010)
12.8
15.3
21.5
5.5
16.4
16.4
10.8
17.3
21.3
8.6
18.0
17.1
5.9
11.6
17.4

# Pharmacies

56
116
329
174
284
149
301
399
367
186
204
70
29
41
27

High Income=Mean Household Income$80,000; Medium Income =Mean Household Income (X) $57,000 X<$80,000; Low
Income=Mean Household Income <$57,000.

http://z.umn.edu/INNOVATIONS

2013, Vol. 4, No. 3, Article 127

INNOVATIONS in pharmacy

10

Student Paper

PRACTICE-BASED RESEARCH
Table 3. Mean Drug Prices ($) by Zip Code

Zip
Code
10471
10466
10453
10464
10461
10454
11231
11204
11212
11217
11235
11239
10025
10026
10035
10038
10009
10039
11697
11355
11692
11362
11106
11433
10307
10305
10302
10308
10301
10303

Income
Level
High
Medium
Low
High
Medium
Low
High
Medium
Low
High
Medium
Low
High
Medium
Low
High
Medium
Low
High
Medium
Low
High
Medium
Low
High
Medium
Low
High
Medium
Low

Number of
Pharmacies
40
53
184
16
63
145
68
184
103
106
100
46
142
168
177
159
231
190
164
68
8
22
136
62
17
19
16
12
22
11

http://z.umn.edu/INNOVATIONS

Advair
250/50
293.85
306.96
284.29
284.57
282.71
283.76
272.47
308.94
302.50
289.56
292.55
300.31
304.46
298.55
306.64
283.74
288.48
312.40
284.45
267.84
272.81
295.75
279.64
281.69
295.43
304.67
301.79
300.09
299.87
305.34

Proventil
HFA
53.74
55.96
53.23
59.63
60.31
70.76
51.88
49.82
55.29
54.45
52.98
65.47
55.65
66.62
55.12
57.43
54.58
56.98
53.54
59.36
58.73
55.70
51.51
57.73
48.79
51.52
50.44
49.39
58.28
48.75

Metformin
HCL 500mg
40.65
28.37
31.89
28.23
38.62
40.35
27.76
48.23
32.96
40.14
41.10
33.32
40.03
29.41
36.04
37.33
35.95
44.12
41.11
28.76
28.41
38.28
28.12
24.54
28.68
32.11
35.39
24.65
22.38
22.37

2013, Vol. 4, No. 3, Article 127

Glipizide
ER 5mg
13.78
13.35
16.94
13.46
21.00
17.97
13.42
17.71
21.45
17.21
14.13
19.93
20.43
14.63
13.80
16.41
17.47
18.11
14.59
17.84
17.71
17.77
15.92
17.86
17.21
16.88
17.54
15.79
18.44
17.30

Amlodipine
10mg
44.79
44.61
40.68
46.51
46.52
43.76
52.73
53.76
66.47
61.25
64.78
48.17
40.03
41.16
46.68
43.84
43.13
58.18
51.57
40.52
44.37
44.97
39.93
52.73
61.59
62.10
65.45
65.39
63.21
63.21

Lisinopril
10 mg
22.86
23.77
23.99
21.07
21.08
22.15
24.51
28.89
25.32
28.11
29.15
32.22
19.97
29.84
36.46
22.02
22.27
28.41
28.35
18.95
22.16
25.66
18.57
18.32
24.62
25.33
24.28
25.66
19.13
24.52

Simvastatin
20mg
84.80
84.80
84.21
81.15
81.15
94.57
95.10
91.34
90.43
81.32
85.25
89.73
64.28
90.03
90.78
80.40
81.44
92.32
85.26
79.84
84.75
81.54
90.28
79.35
86.20
93.15
92.77
91.40
77.94
90.12

INNOVATIONS in pharmacy

Atorvastatin
10mg
141.80
145.15
146.60
141.81
142.36
144.49
144.13
146.44
154.06
145.46
145.67
146.79
140.36
149.42
148.51
141.88
145.77
148.69
142.73
140.52
142.66
152.04
147.33
146.42
143.49
141.76
141.80
147.61
138.91
139.48

11

Student Paper

PRACTICE-BASED RESEARCH

Table 4. Mean Drug Prices (95%CI) Across Neighborhood Household Income Levels in NYC
Drug

High Income

Medium Income

Low Income

Advair 250/50

ANOVA
F (p-values)
0.377 (0.689)

$290.44
$293.02
$295.15
($284.62-$296.26)
($284.75-$301.29)
($286.92-$303.38
Proventil 6.7gm
$54.02
$56.09
$57.25
0.983 (0.387)
($51.93-$56.11)
($52.90-$59.28)
($53.14-$61.36)
Metformin HCL
$34.67
$33.31
$57.25
0.171 (0.843)
500mg
($30.64-$38.70)
($28.57-$38.05)
($28.81-$$37.07)
Glipizide ER 5mg
$16.01
$16.74
$17.76
1.830 (0.180)
($14.61-$17.41)
($15.32-$18.16)
($16.64-$19.08)
Amlodipine 10mg
$51.27
$49.97
$52.97
0.250 (0.781)
($45.83-$56.71)
($43.73-$56.21)
($46.97-$58.97)
Lisinopril 10mg
$24.28
$23.70
$25.78
0.624 (0.543)
($22.54-$26.02)
($20.96-$26.44)
($22.50-$29.06)
Simvastatin 20mg
$83.15
$85.52
$88.90
2.128 (0.139)
($78.09-$88.21)
($82.18-$88.86)
($86.00-$91.80)
Atorvastatin 10mg
$144.13
$144.13
$145.95
0.802 (0.459)
($141.97-$146.29)
($141.97-$146.29)
($143.39-$148.51)
High Income=Mean Household Income $80,000; Medium Income = Mean Household Income (X) $57,000 X< $80,000;
Low Income=Mean Household Income < $57,000.

Table 5.Mean Drug Prices (95% CI) Across New York City Boroughs
Drug

Bronx

Brooklyn

Manhattan

Queens

Staten Island

Advair250/50

$289.36
($281.76$296.96)
$58.93
($53.75-$64.13)
$34.69
($29.99-$39.99)
$16.09
($13.60-$18.56)
$44.48
($42.75-$46.21)
$22.49
($21.47-$23.51)
$85.12
($81.16-$89.06)
$143.71
($142.09$145.31)

$ 294.39
($284.14$304.62)
$54.98
($50.59-$59.37)
$37.25
($31-39-$43.11)
$17.31
($14.80-$19.82)
$52.76
($51.97-$63.75)
$28.03
($25.79-$30.27)
$88.86
($84.97-$92.75)
$147.10
($144.26$149.92)

$299.05
($290.20$307.90)
$57.66
($54.14-$61.32)
$37.15
($33.24-41.06)
$16.81
($14.87-$18.75)
$45.51
($40.20-$50.80)
$28.03
($21.51-$31.49)
$83.21
($74.77-$91.65)
$145.77
($142.70$148.84)

$280.74
($272.61$288.11)
$56.10
($53.63-$58.58)
$31.54
($26.29-$36.79)
$16.95
($15.85-$18.05)
$45.68
($41-35-$50.01)
$22.00
($18.64-$25.36)
$83.50
($80.20-$86.80)
$145.29
($141.94$148.62)

$301.03
($298.30$304.10)
$51.10
($48.30-$54.10)
$27.60
($23.29-$31.91)
$17.19
($16.49-$17.89)
$63.49
($62.19-$64.79)
$23.93
($21.99-$25.83)
$88.60
($83.97-$93.23)
$142.18
($139.66$144.70)

Proventil HFA
6.7gm
Metformin HCL
500mg
Glipizide ER 5mg
Amlodipine 10mg
Lisinopril 10mg
Simvastatin 20mg
Atorvastatin 10mg

http://z.umn.edu/INNOVATIONS

2013, Vol. 4, No. 3, Article 127

INNOVATIONS in pharmacy

ANOVA
F (p-values)
4.23 (0.009)

2.311 (0.08)
2.745
(0.051)
0.249
(0.907)
16.907
(<0.001)
2.823
(0.046)
1.060
(0.397)
1.851
(0.151)

12