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Factors influencing pharmacists' selection of their first practice setting.

Factors that influenced the choice of initial practice setting among pharmacists who had completed the majority of their experiential training in a hospital setting were determined. A questionnaire was mailed to all eligible pharmacists who successfully completed the Ohio pharmacist licensure examination in June or September 1987. Respondents were asked to (1) provide demographic data, (2) rate the importance of 23 factors that a pharmacist might consider when choosing a practice site, and (3) rate the desirability of a pharmacist position in their major hospital internship site, as well as positions they had considered in other hospitals and in community pharmacies. The predictive accuracy of four decision-making models--the weighted compensatory choice model, the unweighted compensatory choice model, the lexicographic model, and the conjunctive model--also was determined. Of 105 pharmacists surveyed, 53 returned usable questionnaires. Twenty-five had chosen to practice in hospital settings, and 28 had chosen community settings. The factor "is personally rewarding" was mentioned most often by hospital and community pharmacists as the factor that was most important when choosing their first position. The lexicographic model, which postulates that a pharmacist will choose the practice site with the highest performance rating for the most important factor, was the most accurate predictor of respondents' initial practice sites. Pharmacists' perception of how practice sites would rate in terms of the single job-related factor most important to them was the best predictor of whether they chose hospital or community practice initially and whether they chose to work in the hospital in which they served their internship, another hospital, or a community pharmacy.

Attitude of Health Personnel↗

Pharmacists' evaluations of the nonprescription availability of metaproterenol, cimetidine, ibuprofen, and nystatin.

The relative importance of six switch evaluation criteria in pharmacists' evaluations of the appropriateness of switching four drugs from prescription to nonprescription status was assessed. A questionnaire was constructed for three potential switch candidates (metaproterenol, cimetidine, and nystatin) and one already switched drug (ibuprofen 200 mg). Pharmacists were asked to judge (1) the overall appropriateness of switching these four drugs and (2) the appropriateness of switching these drugs based on the FDA switch criteria of safety, effectiveness, and labeling and two other proposed criteria: the need for oral counseling about the product and perceived market need for the product. Additionally, pharmacists were asked to rate whether they believed the study drugs would be profitable to their pharmacies if the drugs were switched to nonprescription status. A total of 1161 pharmacists were reached by the mailings, of whom 417 (34.8%) responded. Only ibuprofen 200 mg received a positive overall switch approval rating from the pharmacists; cimetidine received the lowest rating. The six evaluation criteria were tested for significant association with pharmacists' overall judgment of the appropriateness of switching each drug. The three most influential criteria were safety, labeling, and market need for the product, respectively. Profitability to the pharmacy was not significantly associated with pharmacists' overall judgment of switch appropriateness. Regression analysis identified safety, labeling, and market need as important in the evaluation of all four drugs, and pharmacists' evaluation of the relative importance of these criteria was a predictor of their overall judgment of the appropriateness of a switch. Consumer safety, not personal economic interests, most influenced pharmacists' judgment of the appropriateness of a switch from prescription to nonprescription status for four drugs.

Attitude of Health Personnel↗

Comparative usefulness of MEDLINE searches performed by a drug information pharmacist and by medical librarians.

The usefulness of MEDLINE searches conducted by a drug information pharmacist who had received online training was compared with the usefulness of searches conducted by medical librarians. Searches for literature pertinent to select drug information requests received at a university drug consultation service during a three-month period were conducted independently by the pharmacist and one of three reference librarians. The three librarians had received extensive online search training and were experienced in conducting MEDLINE searches; the pharmacist was trained by a fourth experienced librarian-searcher using National Library of Medicine (NLM) training materials. For each drug information request, the pharmacist and the librarian searched two MEDLINE files on the NLM service. The printouts generated by the two searchers were evaluated by two drug information pharmacists in terms of how useful each list of citations would be in enabling the drug information pharmacists to answer the related question. The majority of printouts in 48 sets of searches were judged to be useful. Of the 96 possible "best search" votes (two votes for each of the 48 sets of printouts), the pharmacist's searches received 34 votes, the librarians' searches received 28 votes, and there were 34 tie votes. The numbers of useful primary and alternate citations were found to be the best predictors of whether a given printout would receive the "best search" rating. MEDLINE searches performed by a drug information pharmacist with online training, in response to drug information requests, were judged by drug information pharmacists to be as useful as searches performed by librarians.

Drug Information Services↗

Establishing a rehabilitation program for impaired pharmacists.

The Texas Pharmaceutical Association (TPA) rehabilitation program for impaired pharmacists and pharmacy students is described. Since its inception in 1983, the TPA Pharmacists Rehabilitation Program has provided assistance to impaired pharmacists and pharmacy students, as well as their families, friends, customers, and coworkers. The program uses a carefully developed intervention process designed to assist impaired pharmacists and pharmacy students in obtaining evaluation and treatment of their condition. After a referral, an appointment is made for the impaired person at 1 of 15 regional evaluation and referral centers across the state, where arrangements for appropriate treatment are made. After treatment, the Committee on Pharmacists Rehabilitation aids the pharmacist or student in reentering the profession or returning to school. Intervenors are pharmacists registered in the state of Texas who have participated in TPA's training sessions; TPA also provides an intervenor's workbook. Amendments to the Texas Pharmacy Act passed in 1983 and 1985 provide protection for intervenors who are working with pharmacists and pharmacy students with impairment problems. Referrals are made by means of a 24-hour, toll-free hotline funded by a pharmaceutical manufacturing company. Other funding comes from individual donors, member associations affiliated with TPA, chain drugstores, wholesalers, and the Texas State Board of Pharmacy. A successful rehabilitation program for impaired pharmacists and students must be carefully designed and implemented, with attention paid to legal, financial, and intervention-related issues associated with substance abuse.

Drug and Narcotic Control↗

Pharmacist management of antiemetic therapy under protocol in an oncology clinic.

The development of a program for pharmacist prescribing of antiemetic agents for nausea and vomiting induced by antineoplastic agents given to ambulatory patients is described. The oncologist and the pharmacists developed a protocol and submitted it to the Washington State Board of Pharmacy, which can authorize a pharmacist to initiate or modify drug therapy in accordance with written guidelines or protocols. The protocol was approved and the pharmacists developed algorithms for antiemetic therapy, based on the emetic potential of the various antineoplastic agents. The oncologist writes an order for the pharmacist to prescribe antiemetic therapy for an individual patient, and the pharmacists selects an algorithm for each patient based on the antineoplastic agent that has the highest potential for causing emesis. The pharmacist writes orders for antiemetic agents to be administered in the clinic and at home, phones the patient 24 hours after antineoplastic drug therapy, and, if necessary, modifies the antiemetic therapy. Pharmacists have managed antiemetic therapy for more than 1200 patient visits and were able to use the first-line therapy in the selected algorithm in 78% of the cases without serious adverse effects. Pharmacist management of antiemetic therapy for nausea and vomiting associated with antineoplastic drug treatment has been well accepted by patients and professionals in this oncology clinic.

Antiemetics↗

Job-related stress experienced by hospital pharmacists and nurses.

Pharmacists' and nurses' perceptions of job-related stress and its relationship to career satisfaction were surveyed. A questionnaire was developed and mailed in 1987 to pharmacists and nurses whose names were randomly selected from national mailing lists. Subjects were asked to rate, on a five-point scale (4 = very often), how often they found 39 situations to be stressful. The first 30 situations composed the Health Professions Stress Inventory (HPSI), which was created for this study; the remaining nine questions were included for validation of the HPSI. Respondents were also asked whether they would choose the same profession again. Usable questionnaires were returned by 107 pharmacists and 263 nurses practicing in hospitals. Of the potentially highest stress score of 120, overall mean scores were significantly higher for nurses (63) than for pharmacists (57). Statistical analysis indicated that the sample size was adequate and the HPSI was valid and reliable. Both pharmacists and nurses found situations that dealt with interruptions, poor opportunities for advancement, inadequate staffing levels, excessive workload, and inadequate pay to be the most stressful. Pharmacists viewed not feeling challenged as a significantly more stressful situation than did nurses. Career satisfaction was significantly related to job stress for both pharmacists and nurses; 45% of the pharmacists and 37% of the nurses said they would not choose the same profession again, and those with the highest scores on the stress scale were least likely to choose the same profession again. These hospital nurses and pharmacists reported moderate job-related stress.(ABSTRACT TRUNCATED AT 250 WORDS)

Humans↗

Pharmacist competency certification in aminoglycoside dosing.

A pharmacist competency-certification program was developed to train and evaluate newly hired pharmacists, provide continuing education and skills development for staff pharmacists, and standardize clinical pharmacy practice at a 940-bed teaching hospital. A pretest, self-teaching module, and written final examination were developed; the total program can be completed in approximately one month. The self-teaching module contains 37 pages of factual material on the pharmacology, pharmacokinetics, antimicrobial spectra, cost, relative toxicities, and dosing and monitoring techniques for aminoglycoside antibiotics. The pretest and final examination consist of 20 multiple-choice questions based on actual patient cases. Following its initial implementation, 21 of 49 staff pharmacists elected to complete the program. There was an equal representation of pharmacist trainees, novice pharmacists, and experienced clinical pharmacists. All three groups demonstrated improvement over pretest scores. The trainees and novice pharmacists showed the greatest improvement. This program defines a standard of practice and provides a continuing-education tool. Because of its success, the program has been mandated in the orientation of all clinical pharmacists.

Aminoglycosides↗

Achieving pharmacist proficiency in pharmacokinetic dosage adjustments.

A pharmacokinetics training and certification program for staff pharmacists in a community hospital is described. A pharmacokinetics committee consisting of six pharmacists with extensive clinical experience in pharmacokinetics was formed to implement the program. A self-teaching module incorporating basic pharmacokinetic concepts and sample problems was developed. Specific guidelines for calculating dosages of the aminoglycosides and theophylline were also developed, as were indications for the appropriate ordering and serum sampling of these drugs. These guidelines were used in the didactic training of pharmacists, and their knowledge of this information was evaluated by written examinations. Pharmacists were also required to calculate drug dosages for patients in the hospital. These pharmacokinetics calculations were evaluated by the pharmacokinetics committee at periodic meetings. Of the 12 pharmacists included in the training program initially, 9 completed the entire training and certification process. All new pharmacists are now required to obtain certification in pharmacokinetics; yearly recertification of all pharmacists is obtained by participation in patient case presentations involving calculation of drug dosages. This pharmacokinetics training program ensures a standard level of competency among staff pharmacists and may increase physicians' reliance on pharmacists for adjusting drug dosages.

Aminoglycosides↗

Levels of satisfaction among hospital pharmacists.

Hospital pharmacists in a Midwestern, metropolitan area were surveyed to determine levels of job satisfaction. Of the 195 pharmacists who received the 120-item questionnaire, 132 (68%) responded. The questionnaire included facet-free questions which reflect the overall satisfaction of an individual with his job. Results to these questions were compared to those for professional, managerial and nonprofessional workers in two University of Michigan Surveys of Working Conditions. Also included in the survey were facet-specific job satisfaction measures from the Minnesota Job Satisfaction Questionnaire. The study found an overall pattern of less satisfaction among hospital pharmacists than among workers included in the Michigan surveys. The data indicate that hospital pharmacists might be less committed to their jobs and more likely to change jobs than other employees. Compared to other employees, hospital pharmacists showed a greater commitment to the work ethic and were more dissatisfied with their general life situation. The average general job satisfaction score of the respondents was 2.53, on a five-point scale, indicating something less than "satisfied". Pharmacists were least satisfied with the lack of opportunity for advancement, staffing practices, employer's policies and practices, and compensation practices. Compensation relative to others and amount of compensation were the sources of greatest satisfaction. Staff pharmacists had the lowest level of satisfaction; clinical pharmacists the highest--other personnel categories compared were directors, associate and assistant directors, and supervisors. The profession of pharmacy should decide whether or not to be concerned with the general low level of satisfaction among hospital pharmacists.

Attitude↗

Palliative care for patients with cancer: what are the educational needs of community pharmacists?

AIMS: The objective of this study was to determine the educational needs of community pharmacists in Australia related to palliative cancer care, to guide the development of an online educational program for pharmacists. METHODS: Questionnaires were posted to a random sample of community pharmacies in Australia. The questionnaire sought information pertaining to pharmacists': demographics; educational needs by rating the importance of learning more about 18 palliative cancer care topics and self-perceived level of knowledge of them; preference for format(s) for the program; willingness to participate in the program; and perception regarding their practice of palliative cancer care. Results were analysed using Statistical Package for the Social Sciences (SPSS) version 11.5 software. MAIN RESULTS: A questionnaire return rate of 10.3% was achieved. The characteristics of respondents were reflective of community pharmacy practice in Australia when compared with the latest available labour force figures by the Australian Institute of Health and Welfare. Pharmacists rated all 18 topics as "important/essential", and their level of knowledge of them as "poor/good". Pharmacists preferred information provided in these formats: text (89.8%), case studies (80.6%) and multi-choice questions (69.4%). Most pharmacists (85.2%) indicated that they would participate in the program. The majority of pharmacists (71.3%) reported that they deliver palliative cancer care services; usually less-than-monthly (24.1%) or weekly (21.3%). CONCLUSIONS: Educational needs of community pharmacists in palliative cancer care were identified. The information gathered will assist in guiding the development of an online educational program for pharmacists to improve their knowledge and skills in palliative cancer care.

Adult↗

Use of labor economic theory to examine hours worked by male and female pharmacists.

PURPOSE: The objectives of this study were to develop a theoretically derived model of hours worked by pharmacists and estimate the model separately for male and female pharmacists. METHODS: A systematic random sample of 1,600 pharmacists from four states was mailed a survey asking about current and past employment information. Two dependent variables were studied: weekly hours worked and annual hours worked. Independent variables were categorized as economic variables (hourly wage rate, other income, total debt) and demographic variables (employment position, age, degree earned, marital status, number of children at home). A two equation multiple regression model was estimated with two-stage least squares regression. RESULTS: A total of 541 pharmacists responded to the survey and data from 442 of the respondents were used in the analysis. Hourly wage rates were negatively associated with weekly hours worked for males. Other income and total debt were significantly negatively and positively associated, respectively, with annual hours worked by female pharmacists. The number of young children at home significantly reduced weekly and annual hours worked by female pharmacists. Female pharmacists earning a Pharm.D. degree worked significantly more hours weekly and annually. Age was significantly negatively associated with male pharmacists weekly and annual hours worked. CONCLUSIONS: Economic variables had a relatively small effect on hours worked by male and female pharmacists suggesting that increased wage rates may not increase hours worked. Strategies to increase hours worked by females likely should focus on benefits to help females handle childcare issues.

Female↗

Quality of pharmacists' documentations in patients' medical records.

Training pharmacists to appropriately document patient-specific problems and recommendations in patients' medical records and subsequent monitoring of pharmacist-written documentation are described. The medical staff of a tertiary care teaching hospital recommended that pharmacists be allowed to write in the permanent portion of patients' medical records. A six-month pilot program was approved to train pharmacists in writing chart notes. Notes would be assessed according to the following criteria: necessity (i.e., a chart note was the appropriate means of communication), clarity, legibility, completeness, correct format, and lack of judgmental language. Initial training was by physicians from the pharmacy and therapeutics committee, with more extensive training by a committee composed of clinical and administrative pharmacists. After training ended, each pharmacist's first few notes were reviewed by a member of the pharmacy committee. The quality of pharmacist-written notes is reviewed quarterly. The first quarterly evaluation and another review 1 1/2 years later showed that all pharmacist notes met all of the established criteria. A multidisciplinary approach was effective in training pharmacists to document interventions appropriately in patients' permanent records. Ongoing monitoring ensures the continuing quality of such documentation.

Documentation↗

Predicting the rate of physician-accepted interventions by hospital pharmacists in the United Kingdom.

Pharmacists' clinical interventions in a group of British hospitals were counted, and a model to determine factors that affected the intervention rate was developed. All pharmacists who visited patient wards in 27 acute care hospitals recorded their daily ward visits and their clinical interventions during five consecutive days (Monday through Friday) in June 1993. An intervention was defined as any recommendation made with the intent of changing drug treatment. Mixed-model Poisson regression was used to try to explain variations in the intervention rate, defined as the number of physician-accepted interventions divided by the number of occupied-bed days. Possible predictors of intervention rate considered were characteristics of the hospitals, the wards, and the pharmacists. During the study period, 248 pharmacists visited 10,478 beds and proposed 3,501 interventions. Of these interventions, 3371 were accepted, 56 were rejected, and 74 were unresolved. The most frequent reasons for the interventions involved the dose (29%), the need for therapy (21%), the choice of drug (14%), and the route (12%). Ward type, pharmacist grade, and the total time the pharmacist spent on the wards were significant predictors of the intervention rate. To validate the model, data were collected during the same period in 1994; the model predicted the number of interventions within 1 of the actual number in 82% of cases. In a model explaining the factors that affected the rate of physician-accepted pharmacist interventions in acute care hospitals in the United Kingdom, ward type, pharmacist grade, and total time spent on the ward by the pharmacist were significant predictors of the intervention rate.

Drug Monitoring↗

Practical, reliable, comprehensive method for characterizing pharmacists' clinical activities.

A method for rating the value of pharmacists' clinical services was studied. An instrument was developed to measure the severity of medication errors and the value of pharmacists' clinical interventions. Pharmacists at a hospital pharmacy department used the instrument at the time they made an intervention. A single pharmacist reviewed and adjusted the scores assigned by the pharmacist who made the intervention. An expert panel consisting of two clinical pharmacists and two physicians also scored all the interventions using the same instrument. All rankings were compared using kappa (kappa) and weighted kappa statistics, and symmetry tests were applied to examine whether specific raters consistently rated higher or lower than other raters. Data were extracted from the pharmacy department's intervention database to rate 300 interventions. Agreement between the raters was substantial, both overall and for each dimension individually. However, the physicians rated severity of error and value of service lower than their pharmacist counterparts. The study indicated that severity of error and value of service are clearly related, but not linearly. Services can be identified as high value even when there are no prescribing errors. Pharmacists found the instrument usable and practical. A literature-based instrument for simultaneously assessing the severity of errors in medication orders and the value of pharmacists' interventions was constructed, tested in a hospital, and determined to be reliable.

Humans↗

Patients' use of GPs and community pharmacists in minor illness: a cross-sectional questionnaire-based study.

BACKGROUND: Despite pharmacists having increased involvement in managing minor illness, many patients continue to attend their GP with problems that could be managed by community pharmacists. OBJECTIVE: Our aim was to investigate the prevalence of visits to the GP that GPs felt could be managed by a pharmacist, and to explore patients' reasons for such visits. METHODS: This cross-sectional questionnaire study was conducted at 13 general practices in West Sussex, UK. A questionnaire was given to all patients attending appointments with their GP in these practices over a 1-week period, asking what the presenting problem was and whether the advice of a pharmacist had been sought. If patients had not sought the advice of a pharmacist, they were asked why not. The GP was then asked to indicate whether, in their opinion, the patient's problem could have been managed by a community pharmacist. RESULTS: The response rate was 94% (3984), representing 87% of all patients consulting their doctor during the week of the study. GPs felt that only 7% (260) of these visits could have been managed by a community pharmacist. The proportion of 'unnecessary' visits was significantly higher (P < 0.001) amongst young adults, those presenting with new medical problems and those consulting about a child's health. Skin and musculoskeletal problems were the most common causes of 'unnecessary' visits to the GP. The majority of patients making 'unnecessary' visits (59%) disagreed with the GP and felt that the pharmacist would not have been appropriate for their problem. CONCLUSIONS: GPs and patients were, on the whole, in agreement over which conditions were appropriate for GP attention. There is, however, a need for education to increase awareness of the roles of pharmacists, aimed particularly at young adults and at those with children.

Adult↗

Effects of pharmacist monitoring on patient satisfaction with antidepressant medication therapy.

OBJECTIVE: To examine the effects of pharmacist monitoring on patient satisfaction with and adherence to antidepressant medication therapy. DESIGN: In this prospective field study, we interviewed patients starting an antidepressant after a new prescription was dispensed and again 2 months later. The first interview assessed patients' characteristics, antidepressant medication history, knowledge of antidepresant medications and their use, and beliefs about antidepressant medications. The second interview focused on pharmacist monitoring behavior and satisfaction with the antidepressant medication. SETTING AND PARTICIPANTS: From 23 community pharmacies, we enrolled 100 patients, 59 of whom were taking an antidepressant for the first time. MAIN OUTCOME MEASURES: Patient satisfaction with and reported adherence to their antidepressant medication regimen. RESULTS: Pharmacist monitoring of patients' antidepressant medication use varied. More than 70% of patients reported that pharmacists asked about medication concerns; 53% and 54% of patients, respectively, said pharmacists encouraged their questions and listened to their concerns; and 32% found pharmacists helpful in solving problems related to the antidepressant. Fifty-seven percent of patients reported feeling better a lot of the time since taking the antidepressant, 40% said the antidepressant did not bother them, and 83% reported missing doses, adding doses, or stopping the antidepressant during the study period. Initial beliefs about antidepressants were a strong predictor of patient outcomes. Pharmacist monitoring was predictive of satisfaction and adherence for individuals taking an antidepressant for the first time. CONCLUSION: Pharmacists can play a critical role in monitoring medication concerns at the beginning of use, allowing for problem solving, reinforcement, and greater patient satisfaction with and adherence to medication therapy. Obstacles to effective pharmacist monitoring and follow-up need to be identified and addressed in future improvement efforts.

Adult↗

Counseling Spanish-speaking patients: Atlanta pharmacists' cultural sensitivity, use of language-assistance services, and attitudes.

OBJECTIVE: To document the types of language-assistance services available in pharmacies and the perceptions of pharmacists regarding the effectiveness of these services, and to measure the attitudes toward counseling Spanish-speaking patients and cultural sensitivity of pharmacists. DESIGN: Cross-sectional assessment. SETTING: Metropolitan Atlanta, Ga. PARTICIPANTS: Registered Georgia pharmacists residing in metropolitan Atlanta. INTERVENTIONS: Mailed survey, with repeat mailing 2 weeks later. MAIN OUTCOME MEASURES: 38 survey items measuring demographic and practice-site characteristics, types of language-assistance services available with an assessment of the effectiveness of each measured on a nominal scale, and attitudinal items concerning counseling of Spanish-speaking patients and pharmacists' cultural sensitivity using a 5-point Likert-type response scale. RESULTS: Of 1,975 questionnaires mailed, 608 were returned, a 30.8% response rate. Nearly two thirds of the pharmacists had recently counseled a Spanish-speaking patient, but only one fourth of those respondents considered their interactions effective. Nearly all pharmacists, 88.0%, worked in pharmacies with language-assistance services. Of seven types of these services, a mean of 2.19 were available in pharmacies, and the majority of pharmacists (84.4% or more) identifying a service considered it to be effective. The pharmacists were neutral about counseling Spanish-speaking patients (mean = 2.94) and indifferent toward other cultures (mean = 3.28); however, they agreed they had a responsibility to counsel Spanish-speaking patients, and they believed that use of language-assistance services would constitute a reasonable effort to counsel these patients. CONCLUSION: Pharmacists have an opportunity to address barriers to communication with the Spanish-speaking population through use of language-assistance services and educational measures within the profession.

Adult↗

[Diffusion of pharmacist interventions within the framework of clinical pharmacy activity in the clinical ward].

BACKGROUND: Computerised physician order entry (CPOE) and the integration of a pharmacist in clinical wards have been shown to prevent medication errors. OBJECTIVES: The objectives were to describe interventions performed by a clinical pharmacist integrated into clinical wards with CPOE, to assess the acceptance of interventions by prescribers, and to describe factors associated with acceptance. METHODS: A 3-week prospective study was conducted in five wards of a 2000-bed French teaching hospital. RESULTS: During pharmacist review of medication orders and participation on physician rounds, six resident pharmacists provided interventions either conveyed orally to prescribers, using the computer system, or combining both methods. There were 221 pharmacist interventions concerning drug-drug interactions (27%), drug monitoring (17%) and computer-related problems (16%). Pharmacist interventions consisted of change of drug choice or dose adjustment (49%), drug monitoring (17%) and administration modality optimisation (14%). Interventions were provided solely via computer systems in 67% of cases. The rate of intervention acceptance was 47.1%. In multivariate analysis, acceptance was significantly associated with oral transmission (odds ratio [OR] = 6.46; 95% confidence interval [95% CI] [1.65-25.24]; p < 0.01), change of drug choice or dose adjustment recommendations (OR = 3.81; 95% CI [1.63-8.86]; p < 0.01) and administration modality optimisation recommendations (OR = 9.51; 95% CI [3.02-29.93]; p < 0.01). CONCLUSION: Communication method and nature of recommendation are factors associated with pharmacist intervention acceptance. CPOE is necessary to develop clinical pharmacy practice. However, only the integration of the pharmacist on the ward can guarantee a high level of acceptance of pharmacist interventions by prescribers.

France↗