Why is Antibiotic Stewardship Important?


Antibiotics are commonly prescribed. In 2021, there were 211.1 million oral antibiotic prescriptions given by healthcare professionals in the outpatient setting. In other terms, that is an estimated 636 oral antibiotic prescriptions per 1000 individuals. To compare this to previous year’s statistics, in 2020, there were 201.9 million oral antibiotic prescriptions given by healthcare professionals in the outpatient setting, meaning 613 oral antibiotic prescriptions per 1000 individuals. Clearly, this shows that the number of antibiotic prescriptions keeps increasing.

Figure 1. Unnecessary Antibiotic Prescribing

According to the Centers for Disease Control (CDC), about 30 % of antibiotics are prescribed unnecessarily in the outpatient setting (See Figure 1). With that being said, it is crucial to discuss and understand the issue of antimicrobial resistance. Due to increased unnecessary prescribing of antibiotics, antimicrobial resistance is on the rise and it has become a serious matter and threat to not just local health, but also global public health. Since the pharmaceutical industry isn’t providing new drugs on the market to make up for the increase in antibiotic resistance, then what has been done to address this growing problem? One answer to that question is antibiotic stewardship programs. 

According to CDC 2021 annual report, the top 5 most common oral antibiotic classes prescribed in the United States were:
Figure 2. Percentages of the Top 5 Most Commonly Prescribed Oral Antibiotics

Due to antimicrobial resistance, antibiotics lose their effectiveness in fighting off infections. This has led to other implications, such as prolonged hospital stays, increased costs, treatment failures, and much more. On average, patients will be in the hospital for 13 days due to antimicrobial resistance. Therefore, multidrug resistance (MDR) has become a significant challenge in healthcare and has worsened the antimicrobial resistance issue. For example, globally, 500,000 new cases of MDR tuberculosis are diagnosed yearly. On top of everything, it has been shown that the COVID-19 pandemic has set to increase the threat of antimicrobial resistance as well. Overall, pharmaceutical companies have drifted away from this drug development area, which is why there has been a decrease in new antibiotic development for many years.

Antibiotic stewardship programs aim to help this growing problem by improving the use of antibiotics. Physicians and pharmacists have led the majority of antibiotic stewardship programs. These programs ensure that clinicians prescribe antibiotics only when it is necessary, prescribe antibiotics that cover the necessary infection, and do not expose patients to unnecessary antibiotics. To be in accordance with the Centers for Medicare and Medicaid Services, the Joint Commission made it a requirement for hospital settings to have antibiotic stewardship programs implemented. This is a huge win in reducing inappropriate antibiotic use. Antibiotic stewardship programs can be found in various settings, such as hospital settings, outpatient settings, nursing homes, and resource-limited settings. The CDC website has a page with core elements designated to each antibiotic stewardship program setting to understand that each program may differ depending on its location.

Antibiotic resistance has been on the uptrend for quite a while. It is important to know why antibiotics must be carefully prescribed. Antibiotic stewardship programs are one way that this growing problem is being addressed. Hopefully, we will see that antibiotic stewardship efforts have decreased the issue of antibiotic resistance over time.


  1. Majumder MAA, Rahman S, Cohall D, et al. Antimicrobial Stewardship: Fighting Antimicrobial Resistance and Protecting Global Public HealthInfect Drug Resist. 2020;13:4713-4738. Published 2020 Dec 29. doi:10.2147/IDR.S290835
  2. Barlam TF. The state of antibiotic stewardship programs in 2021: The perspective of an experienced stewardAntimicrob Steward Healthc Epidemiol. 2021;1(1):e20. Published 2021 Aug 5. doi:10.1017/ash.2021.180
  3. Measuring outpatient antibiotic prescribing. Centers for Disease Control and Prevention. Published October 5, 2022. Accessed December 1, 2022.
  4. Outpatient antibiotic prescriptions — United States, 2021. Centers for Disease Control and Prevention. Published October 7, 2021. Accessed December 1, 2022.
  5. Outpatient Antibiotic Prescriptions – United States, 2020. Centers for Disease Control and Prevention. Published October 7, 2021. Accessed December 1, 2022.
  6. Core elements of antibiotic stewardship. Centers for Disease Control and Prevention. Published April 7, 2021. Accessed December 1, 2022.

Common Beta Blockers: A Refresher


There are roughly 30 million adults on a beta blocker in the United States. Beta-blockers have been around for a very long time. This class of medications has both been used for on and off-label purposes. Over the years, their usage has evolved and has been seen in various disease states. Overall, the indications that this class of medications have been utilized in, are heart failure, glaucoma, hypertension, anxiety, migraines, and many others. This beta blocker refresher will provide you with the overview that will potentially spark your interest to dive deeper into each medication discussed.

Most common beta-blockers have been recognized for being either selective beta blockers or non-selective beta-blockers:

Depending on which specific beta-blocker a patient is prescribed, it is important to provide education on that specific drug’s adverse effects. Individuals taking non-selective beta blockers may experience some side effects that are not seen with selective beta blockers due to their mechanism of action. For example, sotalol has a risk for QT prolongation because it blocks potassium channels. The adverse effects are dependent on the specific drug, but there are overall common side effects seen within this class of medications, such as fatigue, hypotension, dizziness, and bradycardia. The less common side effects that individuals should be aware of are insomnia, weight gain,  hepatotoxicity, and bronchospasm. Historically, beta-blockers have been contraindicated in patients with asthma due to their mechanism of action. Also, beta-blockers may mask the signs of hypoglycemia. Patients who have diabetes should be educated on what to do when on a beta blocker just in case they experience hypoglycemia. Beta-blockers, however, have their useful places in therapy. To illustrate, this class of medication has been utilized for its anxiolytic effect. An example is propranolol, which is often prescribed off-label for anxiety or to help with stage performance to reduce some peripheral symptoms associated with anxiety.

Other beta-blocker class pertinent details:
  • Individuals should monitor their blood pressure and heart rate while on this medication.
  • There are multiple formulations available on the market.
    • The most common routes of administration are oral, intravenous, or ophthalmic.
  • The dosage of these medications depends on the specific drug.
    • Some of these medications come in immediate release or extended release.
    • For example, propranolol ranges from 80 mg/day to 320 mg/day, which can be split into multiple doses daily due to its half-life.
  • Patients can be on this medication for an extended period of time.

Overall, this class of medication has been on the market for a long time; it is well-established compared to other classes of medications in terms of indications and side effect profiles. It is important to differentiate between selective and non-selective beta-blocker medications to understand their mechanism of action and their respective indications. A large patient population utilizes this class of medications, so it is extra important to keep up with new findings and updates. Hopefully, this refresher on beta-blockers has helped to provide you with beneficial information to continue delivering the best care in your own pharmacy setting.

Dagmara Zajac

RxPharmacist Team


  1. Beta-blockers: Types, uses and side effects. Cleveland Clinic. Accessed November 28, 2022.
  2. What you should know about beta blockers. Mayo Clinic. Published August 13, 2021. Accessed November 28, 2022.
  3. Oliver E, Mayor F Jr, D’Ocon P. Beta-blockers: Historical Perspective and Mechanisms of Action. Rev Esp Cardiol (Engl Ed). 2019;72(10):853-862. doi:10.1016/j.rec.2019.04.006
  4. LiverTox: Clinical and Research Information on Drug-Induced Liver Injury [Internet]. Bethesda (MD): National Institute of Diabetes and Digestive and Kidney Diseases; 2012-. Beta Adrenergic Blocking Agents. [Updated 2018 Jun 3]. Available from:
  5. Farzam K, Jan A. Beta Blockers. [Updated 2022 Jul 21]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from:
  6. Srinivasan AV. Propranolol: A 50-Year Historical Perspective. Ann Indian Acad Neurol. 2019;22(1):21-26. doi:10.4103/aian.AIAN_201_18

How Pharmacists Navigate Through Drug Shortages: An Overview


An ample drug supply is important to ensure that patients receive the medications they need. What happens if the drugs patients need are not able to be supplied for reasons that are out of our control? Drug shortages are more common than individuals think. Since 2018, there have been more than 200 ongoing drug shortages on average yearly. Pharmacists can truly help make drug shortages less of an identifiable problem. Everything that pharmacy school teaches pharmacists and pharmacy students is crucial in utilizing and strategizing the temporary or long-term solutions for these drug shortages. The figure below from the American Society of Health System Pharmacists (ASHP) website shows just how many new drug shortages are identified yearly.

Figure 1. New drug shortages between January 2001 to September 2022
Source: ASHP website
Reasons for Current Drug Shortages

Drug shortages can occur for various reasons. Some of those reasons are due to manufacturing issues, the increase in demand for the product, regulatory issues, voluntary or involuntary recalls, shortage of raw materials, and economic issues. Historically, pharmacies sometimes would start to compound a product, but that is only if a product has such a solution for its shortage. For example, some chain hospitals can borrow between their sites to help relieve some of their shortages because depending on a patient population or patient volume for a given hospital, they can have a higher demand for one product over another and have the luxury to loan products between their sites.

Drug Shortages in the Workplace

Depending on certain workplaces, there can be protocols in place for what to do in case a drug becomes unavailable. Sometimes the shortage can be solved temporarily by using an alternative product, but the problem starts when there is no alternative for a given product.  For example, in an inpatient pharmacy setting in a large hospital, there can be weekly meetings in place for staff from different areas of the hospital at various administration levels to discuss drug shortages. During these drug shortage situations, it is important to have transparency between staff members. Clear communication helps create a collaborative environment which can help identify more solutions to situations. Each individual drug in shortage may need its individualized solution. Those solutions depend on the product in shortage, the facility that utilizes that product, the reason for the shortage, the return to market date, and many other factors.

Resources for Drug Shortages:
  • ASHP has a whole section on its website dedicated to the drug shortage topic. It is very helpful to utilize it to stay up to date on new drug shortages. Depending on the product, it can list the reason for the shortage, and the estimated resupply dates as well. Also, ASHP has a section on the drug shortage trends that have been seen over the years. ASHP has a section on the website for resolved drug shortage items, which perhaps can be helpful to gain historical knowledge about a given product or its history with shortages.
  • The Food and Drug Administration (FDA) has a whole section of its website dedicated to drug shortages. The FDA has a whole database that details breakdowns for each product on shortage in detail by the manufacturer name, shortage duration, specific NDC numbers, and anything else that might be relevant to that given product. The FDA created an app for quicker access and information regarding drug shortages as well.

Drug shortages are clearly complex and not as simple as some may think. They can be caused by various reasons. The solutions for them sometimes can be easy because there is an alternative on the market, but sometimes require a team to figure out temporary strategies and protocols such as compounding the product in pharmacies. It is important for pharmacists everywhere to have these discussions and continually educate other healthcare professionals to prepare for current and future drug shortages. Overall, drug shortages require our immediate attention and responding to the call will ensure that our patients have fewer disruptions to their treatments.

Dagmara Zajac

RxPharmacist Team


  1. Center for Drug Evaluation and Research. Drug shortages. U.S. Food and Drug Administration. Accessed November 23, 2022.
  2. Drug Shortages Statistics. ASHP. Accessed November 23, 2022.
  3. Drug Shortages. ASHP. Accessed November 23, 2022.
  4. Ventola CL. The drug shortage crisis in the United States: causes, impact, and management strategies. P T. 2011;36(11):740-757.

Pharmacy provider status – Are we there yet?

The advancement of the pharmacy profession has allowed pharmacists to take on various roles and provide services that extend well beyond what people think. Often times, people think the role of a pharmacist may be assumed as the stereotypical 12-hour workday, consisting of only dispensing medications. However, pharmacists have gone to school for much more than to just dispense, and the magnitude of education and training received throughout school is pertinent to providing exceptional patient care throughout all types of pharmacy. As fellow pharmacists and pharmacy students, we all know too well that we have to go through a rigorous 4-year doctorate program. Pharmacists are now involved with advanced patient-centered services that include transitions of care, medication management, medication reviews with thorough monitoring, chronic disease management, disease education, prevention and wellness services, and patient education. To reinforce how essential they are, pharmacists have been amongst the frontline workers who have played a significant role in reducing the spread of the coronavirus disease 2019 (COVID-19). The extent to which accessibility of a pharmacist in one’s community took national stage when the Department of Health and Human Services (HHS) authorized state-licensed pharmacists to order and administer, and state-licensed or registered pharmacy interns under the supervision of the pharmacist to administer, coronavirus disease 2019 (COVID-19) vaccines to individuals ages 3 or older. Without the efforts of implementing mobile testing facilities, composing response plans, providing curbside delivery, compounding hand sanitizers, and educating the public on methods to prevent spread, the nation’s population may have been much more vulnerable to its virulence. Their highly talented skills, in addition to reasonable accessibility, allows pharmacist to be trusted amongst patients. In fact, pharmacists are rated among the top 5 most trusted professionals year after year by Gallup.

What is provider status?

According to the Social Security Act (SSA), obtaining provider status means pharmacists can participate in Medicare Part B programs and bill Medicare for services under their scope of practice. However, at this time, and despite all their expertise, pharmacists are omitted from this status as the federal government does not consider these health care professionals as medical providers. Currently, those with provider status are professionals employed as physicians, physician’s assistants, certified nurse practitioners, qualified psychologists, clinical social workers, certified nurse midwives, and certified registered nurse anesthetists.

While a large component of this battle surrounds pharmacists fighting to gain provider status under Medicare Part B, reimbursement from Part D also appears to be controversial. Although Medicare Part D reimburses pharmacies for providing medication therapy management to select patients, the program includes only a small set of services that pharmacists are capable of supplying.

What barriers hold pharmacists from reaching this level of authority?

  • Congress members direct their focus towards the nation’s spending and other issues, including immigration.
    • Due to financial pressures, those making decisions are more focused on reducing health care expenditure, rather than adding new spending costs.
  • Congress equates provider status with the “fee-for-service” (FFS) payment model.
    • FFS is a model in which payment is contingent to the quantity of care, over quality.
    • Legislators may be unwilling to pursue old payment reform as newer payment models evolve.
  • Health care professionals with provider status who bill Medicare through the fee-for-service payment model are in a position of strength, both politically and financially.
    • These individuals may oppose the pharmacy provider status initiative.

While these barriers may impede the ultimate goal of gaining provider status, the American Pharmacist Association (APhA) is taking initiative by contacting health care providers, consumer organizations, payers, and policy makers, all in an effort to educate on the health and economic benefits a pharmacist provides.

What does this mean?

“Provider status is shorthand for ensuring that patients can get access to the clinical services that pharmacists provide and that pharmacists get reimbursed for providing those services” noted vice president of policy for the National Alliance of State Pharmacy Associations, Krystalyn K. Weaver, PharmD. Therefore, this exclusion limits Medicare beneficiaries from accessing pharmacist services.

Tom Menighan, EVP and CEO of APhA, also addressed this concern by stating: “Beyond being unfair to our profession, this lack of federal recognition restricts the contributions pharmacists can make to improving patient care.”

Why is this important?

There is an absolute need to improve health outcomes. In 2016, a released report revealed that the United States spends approximately $1.1 trillion annually on treatment for chronic health conditions, equivalent to almost 6% of the country’s GDP. Additional statistics include the following:

  • 1.5 million cases of preventable medication related side effects
  • $290 billion spent annually to treat preventable medication related side effects
  • $100 billion spent annually towards hospitalizations

Improvements in disease state management through proper medication use would not only go a long way in reducing these costs but will also advance patient quality of life in a cost-efficient manner. Who can serve this role and provide comprehensive education to help treat, manage, and prevent diseases? Pharmacists. All evidence through studies and practice-based experience has shown that pharmacists have all the tools to improve health outcomes and reduce health care costs; however, the absence of provider status and proper payment models have obstructed patients and health care providers from accessing full benefits received through pharmacist services. Provided below are opportunities that pharmacists have taken upon to increase health outcomes:

So, is now the time to gain provider status?

Amidst the ongoing global pandemic we face in today’s world, now is certainly the best time to gain full provider status. As of October 2020, there are only 37 states that have pharmacists classified as “medical providers” under the provisions of Medicare Part B, resulting in a lack of reimbursement for the clinical services provided. Being such an integral part of health care, pharmacists are well-equipped to take on much healthcare challenges, and COVID-19 is reassuring that certainty.


The Pharmacy and Medically Underserved Areas Enhancement Act (H.R. 2759/ S. 1362) is a bipartisan bill that will recognize pharmacists as providers under Medicare Part B. Furthermore, this bill will:

  • Allow Medicare beneficiaries to access the services provided by a pharmacist
  • Focus on providing pharmacist care and services to Medicare beneficiaries in medically underserved communities
  • Provide Medicare reimbursement for pharmacist services in medically underserved communities

The Equitable Community Access to Pharmacist Services Act (H.R. 7213) is also a bipartisan legislation that was introduced in March 2022. This ensures Medicare beneficiary access to pharmacist pandemic-related care without the need for the COVID-19 public health emergency.

Pharmacists have been a vital part of patient care. It is important to recognize healthcare professionals for what they do on an everyday basis. Provider status for pharmacists has been a conversation for a long period of time and with the new legislation in place, the conversation continues. Be a patron, support the cause, because now is the time to reward pharmacists for their purposeful work.


Dagmara Zajac

RxPharmacist Team


  1. Gebhart, F. (2019, June 13). On the Road to Provider Status. Retrieved October 08, 2020, from
  2. Provider Status for Pharmacists. (2017, March). Retrieved October 10, 2020, from
  3. Provider status: What pharmacists need to know now. (2013, August). Retrieved October 07, 2020, from
  4. The Costs of Chronic Disease in the U.S. (2020, September 02). Retrieved October 07, 2020, from
  5. Weitzman, D. (2020, October 07). Provider Status for Pharmacists: It’s About Time. Retrieved October 08, 2020, from
  6. Pharmacy and medically underserved areas enhancement act. ASHP. Accessed November 18, 2022.
  7. Pharmacy’s Top Priority: Medicare Provider Status Recognition. American Pharmacists Association. Accessed November 19, 2022.
  8. Campos P. National Coalition urges Congress to ensure access to essential pharmacist services for Medicare beneficiaries during American Pharmacists Month. Future of Pharmacy Care Coalition. Published October 25, 2022. Accessed November 19, 2022.

Pharmacist market saturation and career outlook – An overview

One of the main obstacles that recent PharmD graduates face is the challenge of finding a job right out of school. Whether it is due to saturation or a lack of experience, the dynamic field of pharmacy appears to raise concern for many, and statistics appear to support this concern. According to the U.S. Bureau of Labor Statistics (BLS), which is responsible for publishing employment trends and projections, there is an estimated 2% increase in pharmacist employment between 2021 and 2031. In 2021, there were 323,500 Pharmacist jobs, it is projected by 2031 that number will increase to 331,100 pharmacists jobs. Pharmacist median pay in 2021 was $128,570 per year. While the career outlook of a pharmacist may vary by industry, it is quite evident that most of the decline comes from the chain and independent pharmacies (Table 1).

Table 1. Employment projections for pharmacists in a retail versus non-retail setting.

Table 1 above accounts for 81% (or 261,200 of 323,500) of jobs that pharmacists have held in 2021, while the remaining 19% come from other industries that have a positive effect on the pharmaceutical workforce. A more detailed look at employment projections can be found here.

What can we take home from observing these statistics?

The demand for pharmacists who work in non-retail settings, such as hospitals and ambulatory care facilities, is set to increase over the next decade as the number of jobs are expected to grow. Alternatively, all retail positions, which make up over half of all pharmacy jobs, is projected to take a significant hit and decline over the next 10 years. Why might this be the case? This branch of pharmacy is expected to expand the role of pharmacy technicians and transition to greater use of mail order and online pharmacies. For example, Amazon has expanded its pharmacy by acquiring PillPack and then two years after, it debuted its own Amazon pharmacy. This online service is offered in all 50 states, and it offers most medications except Schedule II controlled substances.

How could you respond and move forward?

  • Build connections: Use platforms such as LinkedIn to expand your social network and connect and communicate with those in the same profession. Reach out to your school’s alumni network as you already have a shared connection of your alma mater to start off the conversation.
  • Be comfortable with being uncomfortable: Often you may find more opportunities outside of your city or state of preference. While this may seem unfavorable to begin with, coming out of you comfort zone will always pay off.
  • Be innovative and embrace change: Demonstrate your passion for excelling the pharmacy profession and show your willingness to flourish. Opportunities will come by with the right mindset.

Overall, pharmacist employment is on the uptrend. Even though some job settings have been seeing downtrends, it’s important to do your research to be well-rounded in knowing what your options are with your pharmacy degree for added job security and flexibility. There are ways to become a competitive individual for the pharmacy job market. It is important to identify areas you want to pursue to know the skills or the experiences you need in order to be a good candidate for your dream job.  

As always, best of luck!

Dagmara Zajac

RxPharmacist Team


  1. National Employment Matrix_occ_29-1051. U.S. Bureau of Labor Statistics. Accessed November 15, 2022.
  2. Pharmacists: Occupational outlook handbook. U.S. Bureau of Labor Statistics. Published September 8, 2022. Accessed November 15, 2022.
  3. Alam S, Ly S. How to combat job market saturation. The Journal of the American Pharmacists Association. Accessed November 21, 2022.

NAPLEX or MPJE… Which one first?

One of the most substantial fears that PharmD graduates face upon completion of pharmacy school surrounds the next step in their professional development: becoming a licensed pharmacist. With the exception of some states that require an additional practical exam, such as Georgia and New York, the main two exams that are required from state to state to become licensed to practice are the North American Pharmacist Licensure Examination (NAPLEX) and the Multistate Pharmacy Jurisprudence Examination (MPJE). The NAPLEX and MPJE are both pass or fail examinations. While the MPJE exam results do not provide a performance report, the NAPLEX does provide a performance report to reflect on the areas you did well and the areas you might need to review once more. This is an example of the NAPLEX performance report:

Source: NABP Website

While some have no preference in the order of when to take their exams, others may be challenged with a relatively common dilemma – do I take the NAPLEX or MPJE first? This article will not necessarily state why you should pick one option over the other, but instead uncover things to consider when scheduling your exams.

Reason to take the NAPLEX first:Coming out of school, you may feel like a lot of what you have learned in class and during rotations is still relatively fresh in your mind. Before you switch gears to a completely different area of focus, you may want to tackle something you are more familiar with first. Also, depending on the school you have graduated from, you may have been required to register for RxPrep and take on assignments throughout your fourth-year rotations, ultimately keeping your mind engaged on all clinical modules. Another reason is perhaps you have covered your law course during your third year instead of your fourth year of pharmacy school. Lastly, if your school does not provide any law prep course or support before you graduate. 
Reason to take the MPJE first:Based on the plethora of disheartening comments surrounding the exam, many previous exam takers can agree that the MPJE is a more difficult exam. Individuals who take the NAPLEX first may often feel burnt out after extensive preparation, thus leaving those who still have to take the MPJE mentally exhausted and devoid of motivation. Remember, pharmacy law is naturally perceived as a drier topic to begin with. Another reason is if your pharmacy school had you take a law course during your fourth year instead of your third year, making the content fresher in your mind. Lastly, if your pharmacy school does provide a law prep course or support before you graduate. 

Our advice?

Ultimately, what you decide is based on where you stand with respect to how comfortable you are with the content of each exam and even the urgency of addressing your financial situation. Also, depending on the institution, you may be a part of a residency or fellowship program that grants you an additional couple of months of flexibility to become licensed. While it is fine to space out both exams to ensure adequate preparation, you should still be conscious of not distancing your exams too far apart. Remember, the goal is to promptly eliminate the last barrier that stands in the way of you becoming a licensed pharmacist and begin the take down of those horrifying student loans. This was why RxPharmacist was created in supporting pharmacy graduates and pharmacists to overcome the barrier of their licensure exams. Even more so, we also provide state-specific MPJE guides which is a unique offering among other known test-prep companies such as RxPrep which only offers NAPLEX and very minimal (and general) federal MPJE reviews. For more in-depth analysis and advice on each exam, please be sure to check out our previous blogs that provide excellent tips, things to consider, and resources to use to help you overcome your upcoming board exams:

Good luck!

Dagmara Zajac

RxPharmacist Team


  1. NAPLEX Prep Opportunities & Study Guide: NAPLEX exam. National Association of Boards of Pharmacy. Published November 11, 2022. Accessed November 10, 2022.
  2. Multistate Pharmacy Jurisprudence Examination (MPJE): NABP. National Association of Boards of Pharmacy. Published October 6, 2022. Accessed November 10, 2022.

Future of the Profession? Review of new and unique pharmacy careers

It is undeniable that the role of a pharmacist has advanced from the traditional “pill counter” to trusted health care professionals who contribute to patient outcomes through extensive management of drug therapy. According to a published study by the American Association of Colleges of Pharmacy (AACP), the primary practice that PharmD graduates wish to pursue upon graduation is community pharmacy. To outline why this is relevant, the Bureau of Labor Statistics (BLS) anticipates a decline in employment for pharmacists within a traditional retail environment, thus posing a threat to many who wish to follow this route (our full post entitled, “Pharmacist market saturation and career outlook“ can be found here). While all of this may be concerning, pharmacists are fortunately well-equipped with suitable skills that allow them to rise above orthodox practice and pursue nontraditional opportunities while maintaining impactful frontline care. Favorably, the American Society of Health-System Pharmacists (ASHP) has acknowledged this matter and launched its Practice Advancement Initiative (PAI), providing pharmacists with future practice models that may act as an option for those exploring alternative career paths. The campaign advocates for advancing the role of a pharmacist by establishing changes to current pharmacy resources, ultimately promoting career opportunities and patient care simultaneously.

While the number of PharmD graduates continue to increase and advancement of traditional pharmacy begins to slow, you may be asking yourself “what other roles can be filled by pharmacists?” This article will dive into more nontraditional and innovative roles that remain both unique and effective in our dynamic health care world today.

Non-traditional career opportunities:

TypeDescriptionWhere to find information
Nuclear Pharmacy  Nuclear pharmacists focus on the preparation, monitoring, drug information, storage, and handling of radioactive medications. In addition to this, pharmacists in this role provide quality control, patient safety, and counseling to those who require a more unique class of medications. The need for a pharmacist within a nuclear medicine team is impeccable as it allows for a boost in pharmaceutical care to patients.  National Association of Nuclear Pharmacies (NANP)
Specialty PharmacySpecialty medications are typically referred to as high-cost medications that focus more on intricate disease states such as cancer, transplant, hepatitis, HIV, and multiple sclerosis. The prevalence of patients who require specialty medication is increasing, thus necessitating an increased demand for specialty pharmacists who can provide comprehensive care and close management.   Due to the increased complexity in the delivery of specialty pharmaceuticals, many health plans have established approaches to help with the obstacles associated with the distribution of these drugs to patients (classified as insourcing and outsourcing):

Insourcing: Staff are hired to manage the high demand and cost of these medications. These pharmacists are responsible for purchasing, handling, educating physicians and patients, and monitoring patient outcomes.

Outsourcing: Contracting with pharmacies that have established specialty pharmaceutical services to access its expertise, technologies, and resources. Regardless of the approach a managed care organization wishes to pursue, both insourcing and outsourcing have identical requirements that include: Negotiating discounted prices, employing staff with specific expertise (with respect to administration, utilization, and monitoring of specialty medications), and accessing centralized distribution points for specialty pharmaceutical manufacturers  
National Association of Specialty Pharmacy

Academy of Managed Care Pharmacy (AMCP)
Veterinary Pharmacy  While veterinary pharmacy is not a new area of pharmacy practice, it is expected to expand each year and become classified as a more unique career opportunity. Veterinary pharmacists may establish a career with veterinary schools, pharmaceutical companies, manufacturers, and a variety of regulatory agencies (including the FDA through the Center of Veterinary Medicine). An individual interested in working with animals may make this a suitable option; however, additional education and training through residency is required and opportunities are limited usually to academic institutions or professional organizations.  Society of Veterinary Hospital Pharmacists
Compounding Pharmacy  What originally began as physicians taking on both the prescribing and compounding role of patient medication has now evolved to become the responsibility of a pharmacist since the late 19th century. At one point, during the early progression of the 20th century, the manufacturing of mass medications monopolized the service of compounding pharmacies. Today due to the increased need to formulate patient-specific drugs to tailor drug therapy, there appears to be a resurgence in the demand for compounding pharmacists. Compounding services allow pharmacists to prepare medications that target pain management, dermatology, pediatrics, geriatrics, and hormone replacement therapy.  Alliance for Compounding Pharmacy   

APhA National Community Pharmacists Association
Toxicology  Pharmacists in this role can serve as toxicology specialists within poison control centers. In these centers, they facilitate patients who have ingested or otherwise have been exposed to medications or household chemicals. Pharmacists will direct patients to the proper course of action and will subsequently follow-up with them depending on the severity of the situation.  American Association of Poison Control Centers
TelepharmacyTelepharmacy aims to meet the needs of today’s healthcare consumers through the use of telecommunication. The application of this tool covers a wide and diverse scope, including drug review and monitoring, dispensing, sterile and non-sterile compounding verification, medication therapy management, patient assessment, patient counseling, clinical consultation, outcomes assessment, decision support, effective drug information, and electronic prescription filling. Telepharmacy technology allows pharmacists to provide communication and remote care delivery. It significantly improves quality of patient care and medication process and safety by increasing accessibility and efficiency through reducing the need to travel. Especially during the ongoing pandemic, telepharmacy has established itself as an attractive tool to positively impact patient outcomes. Individuals who have been tested for COVID-19 could have a consultation with the pharmacist on the phone or video conferencing platforms such as Skype or zoom for follow-up care. Telepharmacy aims to improve U.S. economy and healthcare efficiency.  ASHP’s Statement on Telepharmacy

2019 NIH Study on Telepharmacy
Regulatory Sciences  Pharmacists also play a huge role in regulatory drug and biologic development at the Food and Drug Administration (FDA). Many pharmacists work at the FDA and if you are lucky, you may score a rotation site at the FDA to learn more what they do from drug labels, to drug reviews and ensuring regulations are met.  FDA Regulatory Fellowships  

Regulatory Affairs Professionals Society (RAPS)  
Long-Term Care PharmacyPharmacists can pursue consultant pharmacy jobs, such as long-term care pharmacy or home health care pharmacy. This is usually in the setting of hospice, nursing home facilities, group homes, etc. Pharmacists can speak with family members and patients about their treatments. Also, pharmacists can take care of patients with various disease states, such as multiple sclerosis, developmental challenges, etc.American Society of Consultant Pharmacists
Pharmaceutical IndustryIn the industry setting, pharmacists have many opportunities to be involved in. They can strive for research and development, quality assurance, marketing, sales, medical affairs, pharmacovigilance, regulatory affairs, and many other areas. These opportunities can be in the U.S. or global settings. Pharmacists can be involved in many different disease states dependent on the pipeline of a given company.Industry Pharmacists Organization

While additional opportunities may require fellowship or residency training, pharmacists can pursue many different career areas. Doing research on career options can help prepare you early on in your career development in deciding which post-graduation path to prepare for in order to be a great candidate when application season arrives. There are still many other pockets of careers we did not dive into such as hospital pharmacy, medication therapy management (MTM), consulting, and data analytics. The PharmD degree is versatile and allows the flexibility of pharmacists to create their own unique careers outside the ‘box’ of retail and hospital pharmacy. As health care transforms, pharmacy roles will also grow, allowing pharmacists to take on new and unique roles. The American Pharmacist Association (APHA) does a great job of specifically listing many career options for pharmacists, so if you are in a predicament about which career to choose, visit the APHA career option website to learn about the various fields in which pharmacists can utilize their degree.

Best of luck in your career searches!

Dagmara Zajac

RxPharmacist Team


  1. 6 Things to Know About Telepharmacy During COVID-19. (n.d.). Retrieved September 26 2020, from
  2. ASHP Statement on Telepharmacy. (n.d.). Retrieved September 26 2020, from
  3. Bai, S., Hertig, J. B., & Weber, R. J. (2016). Nontraditional Career Opportunities for Pharmacists. Hospital pharmacy, 51(11), 944–949.
  4. Kramer, M.H. (2019, January 14). Retrieved September 22, 2020, from
  5. Specialty Pharmaceuticals. (July 18, 2019). Retrieved September 27 2020, from
  6. What is compounding? (n.d.). Retrieved September 22, 2020, from
  7. Pharmacy career pathways: Pharmacy is right for me. Pharmacy for me. Published March 26, 2019. Accessed November 3, 2022.
  8. Career Option Profiles. American Pharmacists Association. Accessed November 5, 2022.

How to Pass Your MPJE Exam the First Time

Each year, the NABP composes a list of MPJE pass rates for each school and college of pharmacy in the United States and compares these results to previous years. While the goal is to observe an upward and promising trend in pass rates, the data obtained between 2019-2021 indicates otherwise, as illustrated in the figure below. Cumulative pass rates across the United States have declined from 83% to 80% over the last couple of years and while the difference may not appear significant, any outcome that does not demonstrate improvement is unfavorable and must be addressed.

Table: MPJE First-Time Pass Rate 2019-2021
Data Reference: NABP website

What could be the result for the decline in performance? Increased burnout? Increased competition? Poor pharmacy coverage of law? Regardless of what the case may be, studying for the MPJE is a tedious process. You may not know what to do or where to begin; however, there are many tips and resources that may be useful to make you feel more prepared for your upcoming exam.

There are no shortcuts, and a lot of time and effort must be devoted to preparing. In this article, we attempt to help you understand the highlights of the MPJE and how to pass it the first time.

Know what the exam is about.

The MPJE results are reported as either Pass or Fail. It is constructed as a 2.5-hour exam that is composed of 120 questions. If you complete at least 107 questions, you will receive your results, but you will get a penalty for not completing all 120 questions.

Currently, these are the areas of focus on the MPJE:

  • Area 1: Pharmacy Practice (~ 83%)
  • Area 2: Licensure, Registration, Certification, and Operational Requirements (~ 15%)
  • Area 3: General Regulatory Requirements (~ 2%)

If individuals are planning to take the MPJE exam after January 1, 2023, these will be the four areas of focus:

  • Area 1: Licensure/Personnel (~ 22%)
  • Area 2: Pharmacist Practice (~ 33%)
  • Area 3: Dispensing Requirements (~ 24%)
  • Area 4: Pharmacy Operations (~ 21%)

The exam aims to assess an individual’s competency by testing their knowledge and skills in evaluating situations and applying relevant federal and state laws. Knowing the build-up of the exam can be a useful marker in indicating how much time should be devoted to each section. A greater breakdown of each area of focus can be found on NABP’s website here. All questions are in multiple-choice, select all that apply, K-type (I only, II and III, or I, II, and III), and ranking format. Be prepared to choose the best answer(s).

Use appropriate study materials.

Unlike preparing for the NAPLEX, which is typically associated with review of one extensive guide, preparation for the MPJE is a little different in that it does not have its own “go-to” guide. RxPharmacist noticed this concern and took action by erasing the dilemma of what resource to use. Here are some tools to help you pass on your first try:

  • Both the state laws and rules can be found on your Board of Pharmacy website. We recommend going to your Board of Pharmacy website first, and if you need help, then pursue study guides as another resource.
    • If you choose to review all the content on the Board’s website, be sure to take notes while you read. The material can be quite extensive as a whole but reducing it into your own writing will serve as an excellent source when the time comes to do your final review before your exam.
  • RxPharmacist provides detailed study guides (in both online and print format) that target key points the MPJE generally focuses on. These comprehensive guides cover both federal and state pharmacy law while providing plenty of questions for practice. To see if a guide is available for your state, check out all the courses provided here.
  • Guide to Federal Pharmacy Law, 9th Edition provides an excellent review of federal law applicable to the exam. The limited use of legal jargon allows for a smoother read while focusing on the most pertinent information.

Whether you choose to study all the material from your Board of Pharmacy’s website or purchase a study guide for a smoother ride, there are a series of topics that must be focused on and highlighted, such as the following:

  • Prescription/labeling requirements
  • Controlled substances
    • DEA forms
    • Classification of controlled substances
    • Prescribing authority and filling
    • Emergency/partial fills
    • Expiration
    • Transfers
    • Refills
  • Other
    • Compounding
    • Continuing education
    • Drug utilization reviews
    • Adulterated vs. misbranded
    • LTCF/hospice facilities
    • Emergency kits
    • Immunizations

Practice, Practice, and Practice!

It’s one thing to study all the material, but it’s an entirely different element to apply all the content you learned to patient scenarios. You won’t realize how challenging it is to distinguish between multiple answer choices until you practice, and thus application is crucial. Some of the highlighted study material listed above can provide you with practice questions; however, additional resources to maximize your practice can be found on NABP’s website.

Another great way to test yourself is with the use of flash cards!

Additional tips:

  • Create a schedule and routine for yourself. Every person is different, thus being aware of your study habits is critical in allowing yourself appropriate time to prepare.
  • Remember to put aside your biased work experience and not depend on everything you see during your workdays such as in the retail pharmacy setting. Sometimes there are differences between what the law states and what your company’s policy is.
  • As the exam does not specify between state and federal law, always pick whichever law is stricter.

Keep in mind the questions on the MPJE can be detailed and require thorough reading. Be sure to not rush through the exam and be mindful of what the question is asking.

Good luck!

Dagmara Zajac

RxPharmacist Team


  1. Multistate Pharmacy Jurisprudence Examination (MPJE): NABP. National Association of Boards of Pharmacy. Published October 6, 2022. Accessed October 28, 2022. 
  2. Multistate Pharmacy Jurisprudence examination passing rates for … – NABP. Accessed October 28, 2022.
  3. Section 8: Exam results and other outcomes. Digital Content Experience Platform. Accessed October 28, 2022.

How to pass your NAPLEX the first time

Congratulations, you made it through pharmacy school and officially graduated! Now, you may find yourself consistently browsing through articles and student forums across the web, all in hopes of finding the best tips for succeeding in your upcoming licensure exam(s). The NAPLEX has undeniably become more challenging over the years and therefore undergoes a review every five years. Historical data demonstrated that the 2016 changes to the NAPLEX decreased the first-time NAPLEX pass rates (Table 1).

YearPassing Rate (%)
Table 1. First-time NAPLEX Pass Rates for 2014-2016

With the exception of the brief increase in passing rates seen in 2018, scores remain consistently low since 2016 (Table 2). Effective January 2021, new revisions were released, and new competencies were introduced. Based on 2021 NAPLEX statistics, the passing rate has decreased even more (Table 3). It’ll be important to watch the statistics in the upcoming years to identify if these NAPLEX revisions were beneficial or not for students to pass their NAPLEX exams on the first try.

YearPassing Rate (%)
Table 2. First-time NAPLEX Pass Rates for 2017-2021

Based on the trend seen over time, there are questions that many of us began to wonder. Is the exam becoming more clinical? Are school curriculums becoming outdated? Or are exam writers simply burning out due to the extended length and duration of the NAPLEX? There could be a variety of reasons as to why pass rates have dropped, and while preparing for an exam that covers up to 4 years of material may feel overwhelming, this article will pinpoint everything you need to know to overcome these statistics and take down your NAPLEX exam (also be sure to check out tips on how to pass your MPJE from our RxPharmacist blog here).

The first step in preparing for any exam is familiarizing yourself with it.

The NAPLEX is 6 hours long and contains 225 questions; 200 count towards your score, while the remaining 25 questions anonymously serve as experimental questions and will have no effect on your score. Many of the questions you’ll come across will be written as patient cases and will require you to piece together multiple elements of the information provided. Questions are presented in multiple-choice, select all that apply, fill-in-the-blank (for calculations), ordered response, and hot-spot (using a diagram to identify the answer) format.

The NAPLEX is broken into these six areas:

  • Area 1: Obtain, Interpret, or Assess Data, Medical, or Patient Information (~ 18%)
  • Area 2: Identify Drug Characteristics (~ 14%)
  • Area 3: Develop or Manage Treatment Plans (~ 35%)
  • Area 4: Perform Calculations (~ 14%) 
  • Area 5: Compound, Dispense, or Administer Drugs, or Manage Delivery Systems (~ 11%)
  • Area 6: Develop or Manage Practice or Medication-Use Systems to Ensure Safety and Quality (~ 7%)

Each one of these areas are further broken down into more detailed subcategories that are listed as part of the NAPLEX competency statements found here from NABP’s website.

  • Once you know the basis of the exam, the next important item on your checklist is to implement a study schedule that strictly predetermines your daily and weekly goals. As much we’d like to provide an estimate on how much time you should set aside to study, the only person who is best aware of their tendencies and abilities is you. Be realistic and fair with your timeline and be sure create an effective study environment by setting aside all distractions during study periods.
  • In terms of study resources, Rxprep has become well-reputable throughout its time and many have relied on the course book as it covers each topic in depth and provides effective illustrations. Rxprep can definitely be a primary tool for studying, but not the only one.

Other helpful resources include:

  • Quizlets: Online flash cards that can serve to enhance and encourage quick recall.
  • RxPharmacist’s practice questions: One of the most updated guides that contains over 700 NAPLEX practice questions that highly mimic the actual exam.
  • Medication and disease state charts: Will help condense information down to the most important material you need to know – excellent tool to use for review. Our RxPharmacist CPJE exam guide provides a nice review of all of the major clinical topics with visuals and easy to read charts.
  • NAPB offers a NAPLEX practice exam that you can purchase, which is made up of previously used NAPLEX exam questions.

One thing we’d like to place emphasis on is the importance of practicing calculations. A considerable portion of the exam contains calculations, which are typically easier to answer if you’re familiar with the formulas and procedures. Consistent practice will help make you an expert in calculations, allowing for a little more leeway when you come across the more tedious and difficult clinical questions. This is why our RxPharmacist NAPLEX guide has a heavy amount of difficult practice calculations so you can easily breeze through the calculation portion to score as high as possible in boosting your overall score.

Similar to the MPJE, the questions on the NAPLEX can be detailed and require thorough reading. Be sure not to rush through the exam and be mindful of what the question is asking.

Best of luck!

-Dagmara Zajac

RxPharmacist Team


  1. Score Results. (n.d.). Retrieved August 27, 2020, from
  2. Welch, A. C., & Karpen, S. C. (2018). Comparing Student Performance on the Old vs New Versions of the NAPLEX. American journal of pharmaceutical education, 82(3), 6408.
  3. Competency statements: North American Pharmacist Licensure Examination. National Association of Boards of Pharmacy. Published October 30, 2020. Accessed October 22, 2022.
  4. NABP Staff. NAPLEX blueprint improvements coming in January 2021. National Association of Boards of Pharmacy. Published October 19, 2020. Accessed October 21, 2022.
  5. North American Pharmacist Licensure Examination passing rates … – NABP. Accessed October 23, 2022.

Common Checkpoint Inhibitors and Their Role in Cancer



Multiple medications have been discovered to target cell surface receptors. These are programmed death-1 (PD-1) and programmed death ligand-1 (PD-L1). These receptors are specifically selected because they are important targets for cancer therapy. There are some similarities between these receptors, but there are differences to note. For example, the PD-1 receptor is expressed on T cells, B cells, monocytes, dendritic cells, natural killer T cells, and regulatory T cells. On the other hand, PD-L1 is expressed on T cells, B cells, dendritic cells, macrophages, bone marrow-derived mast cells, and a few non-immune cells.  

T-cell exhaustion is commonly characterized by the presence of PD-1. PD-1 expression is found in cancers such as tumor infiltrating lymphocytes. PD-L1 is commonly overexpressed in many different types of tumors, such as tumor-associated macrophages.

To understand how PD-1 and PD-L1 work in the human body, it is best to look at each medication’s mechanism of action. The similarities between PD-1 and (PD-L1) medications are that they are monoclonal antibodies, (MAB) and are all available in an injection dosage form. The doses utilized are specific to the indication that the medication is being used for. Here, we will go into specifics to provide an overview of these medications that target cancer cells.


Nivolumab is a human IgG4 MAB and was approved by the FDA in 2014. This medication binds to the PD-1 and stops the PD-L1 and programmed death ligand-2 (PD-L2) from interacting with each other, which ultimately allows the PD-1 pathway inhibition to occur. Nivolumab is commonly indicated for:

  • Melanoma
  • Non-small cell lung cancer (NSCLC)
  • Malignant pleural mesothelioma
  • Renal cell carcinoma (RCC), hepatocellular carcinoma (HCC), and urothelial carcinoma
  • Classical Hodgkin lymphoma (cHL)
  • Squamous cell carcinoma of the head and neck (SCCHN)
  • Esophageal, gastric, colorectal, and gastroesophageal junction cancer
  • Esophageal adenocarcinoma

Nivolumab’s dose strengths are 40 mg/4 mL, 100 mg/10 mL, 120 mg/12 mL, and 240 mg/24 mL solution in a single-dose vial. The common dosages of this medication are 240 mg every two weeks and 480 mg every four weeks. It is important to be aware of the immune-mediated adverse reactions, infusion-related reactions, complications of allogeneic HSCT, and embryo-fetal toxicity associated with this medication. Multiple adverse reactions can occur such as fatigue, rash, musculoskeletal pain, nausea, vomiting, etc. Also, if it is being used with another agent, there are other adverse reactions to consider compared to when it’s being used as a single agent.

Pembrolizumab (approved by the FDA in 2014) is a human IgG4 kappa that targets the PD-1 receptor which is why it has a similar mechanism of action to nivolumab, as well as a similar adverse reaction profile. Pembrolizumab and nivolumab differ in their indications. Some pembrolizumab indications are:

  • Melanoma
  • NSCLC and (cHL)
  • HCC, RCC, Merkel cell, cutaneous squamous cell, urothelial, and endometrial carcinoma
  • Esophageal and gastric cancer
  • Primary mediastinal large B-cell lymphoma (PMBCL)
  • Head and neck squamous cell cancer (HNSCC)
  • Microsatellite instability-high or mismatch repair deficient and colorectal cancer
  • Cervical, tumor mutational burden-high (TMB-H), and triple-negative breast cancer

Typical doses in practice are 200 mg every 3 weeks or 400 mg every 6 weeks. The strengths of this medication offered are also 100 mg/4 mL (25 mg/mL) solution in a single-dose vial. The adverse effects profile is similar to nivolumab.

Atezolizumab was granted FDA approval in 2014 and is phage-derived human IgG1 MAB that blocks PDL1. This medication works by blocking the interaction between PD-1 and B7.1, but it doesn’t induce antibody-dependent cytotoxicity. Some of its indications are:

  • Urothelial carcinoma
  • NSCLC, SCLC, and HCC
  • Melanoma

Some of the dosage forms available are 840 mg/14 mL (60 mg/mL) and 1200 mg/20 mL (60 mg/mL) solution in a single-dose vial. Routinely, doses of 840 mg every 2 weeks, 1200 mg every 3 weeks, or 1680 mg every 4 weeks are utilized in practice. It is important to be aware of the immune-mediated adverse reactions, infusion-related reactions, complications of allogeneic HSCT, and embryo-fetal toxicity which is similar to PD-1 precautions. The common adverse effects seen are fatigue, decreased appetite, nausea, and cough.

Avelumab is IgG1 human MAB anti-PD-L1. This medication was FDA approved in 2016, and is indicated for:

  • Merkel cell carcinoma (MCC)
  • Urothelial carcinoma (UC)
  • RCC

This medication does warrant premedication and is used as needed thereafter. The common doses seen utilized are 800 mg every 2 weeks. The adverse effect profile is dependent on the indication that it is used for, but it is similar to what patients on atezolizumab experience. The common dosage form seen is 200 mg/10 mL (20 mg/mL) solution in single-dose vial.

Durvalumab is a human MAB that targets PD-L1 and was given FDA approval in 2017. Some of this medication’s indications are:

  • Unresectable, Stage III NSCLC
  • Extensive-stage small cell lung cancer (ES-SCLC)
  • Locally advanced or metastatic biliary tract cancer (BTC)

Some of the injection dosage forms available are in a 500 mg/10 mL (50 mg/mL) and 120 mg/2.4 mL (50 mg/mL) solution in a single-dose vial. Commonly, patients receive either a weight-based dose that is dependent on their current weight, or a fixed dose of 1,500 mg every four weeks. The common adverse effects that patients experience are cough, fatigue, nausea, pneumonitis, and upper respiratory tract infections.

Table: PD-1 vs. PD-L1 Medications

Overall, when comparing PD-1 and PD-L1 medications, examining their different indications, dosage strengths, and side effect profiles can be useful in determining the right therapy for the right patient. The over-expression of PD-1 and PD-L1 in cancer cells is the reason why these receptors have been targeted in studies to identify new medication options for different cancer types. It is important to continue to stay up to date with the latest developments in literature because new and old medications are continuously being studied to find new indications and breakthrough therapies.

-Dagmara Zajac

RxPharmacist Team


  1. Tecentriq (atezolizumab) [prescribing information]. South San Francisco, CA: Genentech Inc; January 2022.
  2. Bavencio (avelumab) [prescribing information]. Rockland, MA: EMD Serono Inc; July 2022.
  3. Imfinzi (durvalumab) [prescribing information]. Wilmington, DE: AstraZeneca Pharmaceuticals LP; September 2022.
  4. Opdivo (nivolumab) [prescribing information]. Princeton, NJ: Bristol-Myers Squibb Company; March 2022.
  5. Keytruda (pembrolizumab) [prescribing information]. Whitehouse Station, NJ: Merck & Co Inc; March 2022.
  6. Jiang Y, Chen M, Nie H, Yuan Y. PD-1 and PD-L1 in cancer immunotherapy: clinical implications and future considerations. Hum Vaccin Immunother. 2019;15(5):1111-1122. doi:10.1080/21645515.2019.1571892