Geographic Disparities in Board-Certified Ambulatory Care Pharmacists in Appalachia.

Background
The Appalachian region experiences persistent health disparities and limited access to health care services. Ambulatory care pharmacists, including Board-Certified Ambulatory Care Pharmacists (BCACPs), can help address these gaps, but their distribution in Appalachia is not well described.
Objective
To evaluate the distribution and population density of BCACPs in the United States, the Appalachian region, and rural Appalachian counties.
Methods
This cross-sectional study used publicly available data from the Board of Pharmacy Specialties (BPS) and the Appalachian Regional Commission (ARC). BCACP data, including ZIP codes, were obtained from the BPS registry in August 2025. Counties were classified as Appalachian and further categorized as rural or non-rural using ARC definitions. BCACP density per 1,000,000 residents was calculated and compared across regions. Rate ratios (RRs) with 95% confidence intervals (CIs) were calculated using Poisson regression, with U.S. density as the reference.
Results
BCACP density was lower in the Appalachian region compared to the United States overall and was lowest in rural Appalachian counties. Compared with the national BCACP density, the BCACP rate was 24% lower in Appalachia (RR 0.76, 95% CI 0.69–0.85; P < 0.001) and 73% lower in rural Appalachian counties (RR 0.27, 95% CI 0.15–0.47; P < 0.001).
Conclusions
BCACPs are underrepresented in Appalachia, highlighting a gap in access to specialized ambulatory care services. Addressing this gap will require targeted recruitment and retention strategies, including early pipeline development, financial incentives such as loan forgiveness, and ensuring practice sites are ready to support pharmacist integration. Expanding access to ambulatory care pharmacists may help improve care delivery and reduce health disparities in these communities.