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author:("grass, Ines")
1.  A cluster-randomized controlled trial of a computerized antithrombotic risk assessment tool to optimize stroke prevention in general practice: a study protocol 
Therapy for stroke prevention in older persons with atrial fibrillation (AF) is underutilized despite evidence to support its effectiveness. To prevent stroke in this high-risk population, antithrombotic treatment is necessary. Given the challenges and inherent risks of antithrombotic therapy, decision-making is particularly complex for clinicians, necessitating comprehensive risk:benefit assessments. Targeted interventions are urgently needed to support clinicians in this context; the Computerized Antithrombotic Risk Assessment Tool (CARAT) offers a unique approach to this clinical problem.
This study (a prospective, cluster-randomized controlled clinical trial) will be conducted across selected regions in the state of New South Wales, Australia. Fifty GPs will be randomized to either the ‘intervention’ or ‘control’ arm, with each GP recruiting 10 patients (aged ≥65 with AF); target sample size is 500 patients. GPs in the intervention arm will use CARAT during routine patient consultations to: assess risk factors for stroke, bleeding and medication misadventure; quantify the risk/benefit ratio of antithrombotic treatment, identify the recommended therapy, and decide on the treatment course, for an individual patient. CARAT will be applied by the GP at baseline and repeated at 12 months to identify any changes to treatment requirements. At baseline, the participant (patients and GPs) characteristics will be recorded, as well as relevant practice and clinical parameters. Patient follow up will occur at 1, 6, and 12 months via telephone interview to identify changes to therapy, medication side effects, or clinical events.
This project tests the utility of a novel decision support tool (CARAT) in improving the use of preventative therapy to reduce the significant burden of stroke. Importantly, it targets the interface of patient care (general practice), addresses the at-risk population, evaluates clinical outcomes, and offers a tool that may be sustainable via integration into prescribing software and primary care services. GP support and guidance in identifying at risk patients for the appropriate selection of therapy is widely acknowledged. This trial will evaluate the impact of CARAT on the prescription of antithrombotic therapy, its longer-term impact on clinical outcomes including stroke and bleeding, and clinicians perceived utility of CARAT in practice.
Trial registration
Australian New Zealand Clinical Trials Registry: ACTRN12613000060741.
PMCID: PMC3925360  PMID: 24507462
Stroke; Atrial fibrillation; Warfarin; Bleeding; Antithrombotic therapy; General practice; GP; Decision support; Risk assessment
2.  What is patient-centred care? / Que sont les soins axés sur le patient? 
Canadian Pharmacists Journal : CPJ  2013;146(4):177-180.
PMCID: PMC3734919  PMID: 23940463
3.  Understanding the reasons behind the low utilisation of thrombolysis in stroke 
The Australasian Medical Journal  2013;6(3):152-167.
Thrombolysis remains the only approved therapy for acute ischaemic stroke (AIS); however, its utilisation is reported to be low.
This study aimed to determine the reasons for the low utilisation of thrombolysis in clinical practice.
Five metropolitan hospitals comprising two tertiary referral centres and three district hospitals conducted a retrospective, cross-sectional study. Researchers identified patients discharged with a principal diagnosis of AIS over a 12-month time period (July 2009–July 2010), and reviewed the medical record of systematically chosen samples.
The research team reviewed a total of 521 records (48.8% females, mean age 74.4 ± 14 years, age range 5-102 years) from the 1261 AIS patients. Sixty-nine per cent of AIS patients failed to meet eligibility criteria to receive thrombolysis because individuals arrived at the hospital later than 4.5 hours after the onset of symptoms. The factors found to be positively associated with late arrival included confusion at onset, absence of a witness at onset and waiting for improvement of symptoms. However, factors negatively associated with late arrival encompassed facial droop, slurred speech and immediately calling an ambulance. Only 14.7% of the patients arriving within 4.5 hours received thrombolysis. The main reasons for exclusion included such factors as rapidly improving symptoms (28.2%), minor symptoms (17.2%), patient receiving therapeutic anticoagulation (6.7%) and severe stroke (5.5%).
A late patient presentation represents the most significant barrier to utilising thrombolysis in the acute stroke setting. Thrombolysis continues to be currently underutilised in potentially eligible patients, and additional research is needed to identify more precise criteria for selecting patients for thrombolysis.
PMCID: PMC3626030  PMID: 23589739
Tissue Plasminogen Activator (tPA); Alteplase; Thrombolysis; Stroke; Cerebrovascular accident
4.  Community pharmacist attitudes towards collaboration with general practitioners: development and validation of a measure and a model 
Community Pharmacists and General Practitioners (GPs) are increasingly being encouraged to adopt more collaborative approaches to health care delivery as collaboration in primary care has been shown to be effective in improving patient outcomes. However, little is known about pharmacist attitudes towards collaborating with their GP counterparts and variables that influence this interprofessional collaboration. This study aims to develop and validate 1) an instrument to measure pharmacist attitudes towards collaboration with GPs and 2) a model that illustrates how pharmacist attitudes (and other variables) influence collaborative behaviour with GPs.
A questionnaire containing the newly developed “Attitudes Towards Collaboration Instrument for Pharmacists” (ATCI-P) and a previously validated behavioural measure “Frequency of Interprofessional Collaboration Instrument for Pharmacists” (FICI-P) was administered to a sample of 1215 Australian pharmacists. The ATCI-P was developed based on existing literature and qualitative interviews with GPs and community pharmacists. Principal Component Analysis was used to assess the structure of the ATCI-P and the Cronbach’s alpha coefficient was used to assess the internal consistency of the instrument. Structural equation modelling was used to determine how pharmacist attitudes (as measured by the ATCI-P) and other variables, influence collaborative behaviour (as measured by the FICI-P).
Four hundred and ninety-two surveys were completed and returned for a response rate of 40%. Principal Component Analysis revealed the ATCI-P consisted of two factors: ‘interactional determinants’ and ‘practitioner determinants’, both with good internal consistency (Cronbach’s alpha = .90 and .93 respectively). The model demonstrated adequate fit (χ2/df = 1.89, CFI = .955, RMSEA = .062, 90% CI [.049-.074]) and illustrated that ‘interactional determinants’ was the strongest predictor of collaboration and was in turn influenced by ‘practitioner determinants’. The extent of the pharmacist’s contact with physicians during their pre-registration training was also found to be a significant predictor of collaboration (B = .23, SE = .43, p <.001).
The results of the study provide evidence for the validity of the ATCI-P in measuring pharmacist attitudes towards collaboration with GPs and support a model of collaboration, from the pharmacist’s perspective, in which collaborative behaviour is influenced directly by ‘interactional’ and ‘environmental determinants’, and indirectly by ‘practitioner determinants’.
PMCID: PMC3507896  PMID: 22978658
5.  Screening Education And Recognition in Community pHarmacies of Atrial Fibrillation to prevent stroke in an ambulant population aged ≥65 years (SEARCH-AF stroke prevention study): a cross-sectional study protocol 
BMJ Open  2012;2(3):e001355.
Atrial fibrillation (AF) is associated with a high risk of stroke and may often be asymptomatic. AF is commonly undiagnosed until patients present with sequelae, such as heart failure and stroke. Stroke secondary to AF is highly preventable with the use of appropriate thromboprophylaxis. Therefore, early identification and appropriate evidence-based management of AF could lead to subsequent stroke prevention. This study aims to determine the feasibility and impact of a community pharmacy-based screening programme focused on identifying undiagnosed AF in people aged 65 years and older.
Methods and analysis
This cross-sectional study of community-based screening to identify undiagnosed AF will evaluate the feasibility of screening for AF using a pulse palpation and handheld single-lead electrocardiograph (ECG) device. 10 community pharmacies will be recruited and trained to implement the screening protocol, targeting a total of 1000 participants. The primary outcome is the proportion of people newly identified with AF at the completion of the screening programme. Secondary outcomes include level of agreement between the pharmacist's and the cardiologist's interpretation of the single-lead ECG; level of agreement between irregular rhythm identified with pulse palpation and with the single-lead ECG. Process outcomes related to sustainability of the screening programme beyond the trial setting, pharmacist knowledge of AF and rate of uptake of referral to full ECG evaluation and cardiology review will also be collected.
Ethics and dissemination
Primary ethics approval was received on 26 March 2012 from Sydney Local Health District Human Research Ethics Committee—Concord Repatriation General Hospital zone. Results will be disseminated via forums including, but not limited to, peer-reviewed publication and presentation at national and international conferences.
Clinical trials registration number
Article summary
Article focus
Describes the protocol for a community-based screening programme to identify previously undetected AF in adults aged 65 years and older in the community, for stroke prevention.
Key messages
Early identification of AF would allow for timely referral for medical review and subsequent initiation of appropriate evidence-based thromboprophylaxis to prevent stroke.
The efficacy of screening for AF in a community setting is yet to be tested in a well-designed clinical trial.
Strengths and limitations of this study
The main strengths of this study are that it uses a simple community-focused strategy using innovative technology to screen for AF, which may be suitable for widespread implementation. The technology delivers a single-lead electrocardiograph available for immediate interpretation and corroboration by an expert cardiologist remotely.
The sample size of 1000 will inform the design and refinement of a future large-scale intervention and implementation study.
PMCID: PMC3383976  PMID: 22734120
6.  Experiences of community pharmacists involved in the delivery of a specialist asthma service in Australia 
The role of community pharmacists in disease state management has been mooted for some years. Despite a number of trials of disease state management services, there is scant literature into the engagement of, and with, pharmacists in such trials. This paper reports pharmacists’ feedback as providers of a Pharmacy Asthma Management Service (PAMS), a trial coordinated across four academic research centres in Australia in 2009. We also propose recommendations for optimal involvement of pharmacists in academic research.
Feedback about the pharmacists’ experiences was sought via their participation in either a focus group or telephone interview (for those unable to attend their scheduled focus group) at one of three time points. A semi-structured interview guide focused discussion on the pharmacists’ training to provide the asthma service, their interactions with health professionals and patients as per the service protocol, and the future for this type of service. Focus groups were facilitated by two researchers, and the individual interviews were shared between three researchers, with data transcribed verbatim and analysed manually.
Of 93 pharmacists who provided the PAMS, 25 were involved in a focus group and seven via telephone interview. All pharmacists approached agreed to provide feedback. In general, the pharmacists engaged with both the service and research components, and embraced their roles as innovators in the trial of a new service. Some experienced challenges in the recruitment of patients into the service and the amount of research-related documentation, and collaborative patient-centred relationships with GPs require further attention. Specific service components, such as the spirometry, were well received by the pharmacists and their patients. Professional rewards included satisfaction from their enhanced practice, and pharmacists largely envisaged a future for the service.
The PAMS provided pharmacists an opportunity to become involved in an innovative service delivery model, supported by the researchers, yet trained and empowered to implement the clinical service throughout the trial period and beyond. The balance between support and independence appeared crucial in the pharmacists’ engagement with the trial. Their feedback was overwhelmingly positive, while useful suggestions were identified for future academic trials.
PMCID: PMC3439711  PMID: 22709371
Pharmacy; Asthma; Disease management service; Experiences; Feedback
7.  Pharmacy Students' Approaches to Learning in Undergraduate and Graduate Entry Programs 
To compare longitudinal data with previous cross-sectional data regarding Australian undergraduate pharmacy students' approaches to learning, and explore the differences in approaches to learning between undergraduate and postgraduate cohorts.
Longitudinal, repeated measures design using a validated self-report survey instrument were used to gather data.
Undergraduate students' preferences for meaning directed, undirected, and reproduction-directed approaches to learning displayed the same pattern across the 2 studies; however, application-directed scores increased significantly in the second half of the undergraduate degree program. Commencing postgraduate students' approaches to learning were similar to finishing undergraduate students, and this group was significantly more oriented towards meaning-directed learning compared to undergraduate students.
Pharmacy students' maturation in approach to their learning was evident and this bodes well for pharmacists' engaging in life-long learning and capacity to work in increasingly complex health settings.
PMCID: PMC2933015  PMID: 21045948
lifelong learning; learning; Vermunt's Inventory of Learning Styles; longitudinal study
8.  Pharmacy Asthma Care Program (PACP) improves outcomes for patients in the community 
Thorax  2007;62(6):496-592.
Despite national disease management plans, optimal asthma management remains a challenge in Australia. Community pharmacists are ideally placed to implement new strategies that aim to ensure asthma care meets current standards of best practice. The impact of the Pharmacy Asthma Care Program (PACP) on asthma control was assessed using a multi‐site randomised intervention versus control repeated measures study design.
Fifty Australian pharmacies were randomised into two groups: intervention pharmacies implemented the PACP (an ongoing cycle of assessment, goal setting, monitoring and review) to 191 patients over 6 months, while control pharmacies gave their usual care to 205 control patients. Both groups administered questionnaires and conducted spirometric testing at baseline and 6 months later. The main outcome measure was asthma severity/control status.
186 of 205 control patients (91%) and 165 of 191 intervention patients (86%) completed the study. The intervention resulted in improved asthma control: patients receiving the intervention were 2.7 times more likely to improve from “severe” to “not severe” than control patients (OR 2.68, 95% CI 1.64 to 4.37; p<0.001). The intervention also resulted in improved adherence to preventer medication (OR 1.89, 95% CI 1.08 to 3.30; p = 0.03), decreased mean daily dose of reliever medication (difference −149.11 μg, 95% CI −283.87 to −14.36; p = 0.03), a shift in medication profile from reliever only to a combination of preventer, reliever with or without long‐acting β agonist (OR 3.80, 95% CI 1.40 to 10.32; p = 0.01) and improved scores on risk of non‐adherence (difference −0.44, 95% CI −0.69 to −0.18; p = 0.04), quality of life (difference −0.23, 95% CI −0.46 to 0.00; p = 0.05), asthma knowledge (difference 1.18, 95% CI 0.73 to 1.63; p<0.01) and perceived control of asthma questionnaires (difference −1.39, 95% CI −2.44 to −0.35; p<0.01). No significant change in spirometric measures occurred in either group.
A pharmacist‐delivered asthma care programme based on national guidelines improves asthma control. The sustainability and implementation of the programme within the healthcare system remains to be investigated.
PMCID: PMC2117224  PMID: 17251316
9.  Undergraduate and Postgraduate Pharmacy Students' Perceptions of Plagiarism and Academic Honesty 
To assess undergraduate and postgraduate pharmacy students' perceptions of plagiarism and academic honesty.
A questionnaire was administered to undergraduate and postgraduate pharmacy students to determine their levels of awareness of university policy concerning academic honesty; attitudes to plagiarism by rating the acceptability of a range of plagiarizing and cheating practices; and choice of appropriate penalties for a first and second occurrence. The choice of behaviors in response to a scenario about the preparation of a reading-based written assignment and the strategies that students would be prepared to use in order to submit the assignment on time were also assessed.
Findings indicated widespread deficiencies in student knowledge of, and attitudes towards, plagiarism. Students did not perceive plagiarism as a serious issue and the use of inappropriate strategies for sourcing and acknowledging material was common.
The study highlights the importance of achieving a balance among the 3 dimensions of plagiarism management: prevention, detection and penalty.
PMCID: PMC2769527  PMID: 19885074
academic honesty; plagiarism; cheating; Australia
10.  Development of an evidence-based checklist for the detection of drug related problems in type 2 diabetes 
Pharmacy World & Science   2009;31(5):580-595.
Objective To develop an evidence-based checklist to identify potential drug related problems (PDRP) in patients with type 2 diabetes. Setting The evidence based checklist was applied to records of ambulatory type 2 diabetes patients in New South Wales, Australia. Method After comprehensive review of the literature, relevant medication groups and potential drug related problems in type 2 diabetes were identified. All the relevant information was then structured in the form of a checklist. To test the utility of the evidence-based checklist a cross-sectional retrospective study was conducted. The PDRP checklist was applied to the data of 148 patients with established type 2 diabetes and poor glycaemic control. The range and extent of DRPs in this population were identified, which were categorized using the PCNE classification. In addition, the relationship between the total as well as each category of DRPs and several of the patients’ clinical parameters was investigated. Main outcome measure: Number and category of DRPs per patient. Results The PDRP checklist was successfully developed and consisted of six main sections. 682 potential DRPs were identified using the checklist, an average of 4.6 (SD = 1.7) per patient. Metabolic and blood pressure control in the study subjects was generally poor: with a mean HbA1c of 8.7% (SD = 1.5) and mean blood pressure of 139.8 mmHg (SD = 18.1)/81.7 mmHg (SD = 11.1). The majority of DRPs was recorded in the categories ‘therapy failure’ (n = 264) and ‘drug choice problem’ (n = 206). Potentially non-adherent patients had a significantly higher HbA1c than patients who adhered to therapy (HbA1c of 9.4% vs. 8.5%; P = 0.01). Conclusion This is the first tool developed specifically to detect potential DRPs in patients with type 2 diabetes. It was used to identify DRPs in a sample of type 2 diabetes patients and demonstrated the high prevalence of DRPs per patient. The checklist may assist pharmacists and other health care professionals to systematically identify issues in therapy and management of their type 2 diabetes patients and enable earlier intervention to improve metabolic control.
PMCID: PMC2730442  PMID: 19626455
Type 2 diabetes; Drug related problems; Drug therapy; Evidence-based medicine; Evidence-based pharmacy; Diabetes; PCNE DRP classification
11.  Best Practices Assessment to Guide Curricular Change in a Bachelor of Pharmacy Program 
To identify best practices in global pharmacy education and curriculum design as the basis for decisions about major curriculum change in an existing 4-year bachelor of pharmacy curriculum.
We investigated international best-practice standards, conducted semi-structured interviews with faculty members, and used standardized instruments to investigate student perceptions of the existing curriculum and how they approached their learning.
Faculty recommendations included horizontal and vertical integration of curriculum content to replace the previous discipline-based approach; and a theme-based structure underpinned by a detailed statement of learning outcomes that describe the knowledge, skills, and attitudinal milestones to be achieved each year and by the time of graduation. The triangulation of student survey data highlighted issues that needed to be addressed at the individual course unit level, with a particular focus on feedback, assessment, and workload.
The results of the curriculum review provided clear guidance for decisions relating to major curriculum change. An ongoing program of staff development will address the wide range of learning and teaching issues identified by both staff members and students. The results of our investigation of students' approaches to learning will also be used to guide staff development workshops, focusing on strategies to promote “meaningful learning.”
PMCID: PMC2690863  PMID: 19513149
curriculum review; curriculum; bachelor of pharmacy degree; best practices
12.  Pharmacy Students' Approaches to Learning in an Australian University 
To investigate how pharmacy students' approaches to learning change over the duration of a bachelor of pharmacy degree program.
Data were obtained from a cross-sectional, repeated measures design, using a validated self-report survey instrument. Areas examined included processing and regulation strategies, motivational preferences for learning, and the relationship between approaches to learning and academic performance.
Pharmacy students were strongly vocationally oriented in their studies across all year groups. This approach had a significant relationship to academic performance. Overall, students indicated a preference for external regulation strategies. There was little evidence of maturation in approaches to learning as students progressed through the curriculum.
Students' preference for vocationally related strategies can be harnessed to increase both adoption of self-regulation behaviors and motivation for mastery of material. Comparison of our results with other studies indicates that approaches to learning may be influenced more by the learning environment than the discipline of study.
PMCID: PMC2690923  PMID: 19503704
learning, bachelor of pharmacy degree; Vermunt's Inventory of Learning Styles
13.  An Educational Intervention to Train Community Pharmacists in Providing Specialized Asthma Care 
The development, implementation, and evaluation of an educational intervention to facilitate specialized asthma care provision by community pharmacists.
Formative evaluation and a parallel group repeated measures design were used to test the effect of an educational intervention on pharmacist satisfaction and practice behavior as well as patient outcomes. The educational intervention was based on practitioner needs and principles of adult learning using flexible delivery formats.
In the intervention area, 15 pharmacists were trained with the educational intervention, and they provided specialized asthma care to 52 patients over 6 months, while in the control area, 12 pharmacists provided “usual care” to 50 patients. The intervention pharmacists were highly satisfied with the education received and rated most aspects highly. Improvements in patient clinical, humanistic, and economic outcomes in the intervention area were obtained.
The positive results of the educational intervention demonstrate the effectiveness of an educational approach grounded in the theory that inducing behavioral changes in pharmacy practitioners results in improved patient outcomes.
PMCID: PMC1637026  PMID: 17149447
community pharmacists; continuing education; asthma care; patient outcomes

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