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Associate Professor Beata Bajorek

Biography

A/Prof Bajorek is a registered clinical pharmacist, having practiced in community & hospital and is the inaugural Academic Pharmacist at Royal North Shore Hospital. Previously she has been a Research Fellow at the Clinical Practice Advancement Centre, University Health System Consortium (Chicago, USA), followed by 9 years in academia in the Faculties of Pharmacy and Nursing, University of Sydney (Australia).

She is a highly experienced clinical educator, having supervised countless clinical placements, served as education coordinator for the Society of Hospital Pharmacists of Australia (NSW) and authored over 125 educational articles for clinical practice journals. A/Prof Bajorek has been recognised through awards and nominations for Outstanding Teaching, Support for the Student Experience, and Research Supervision.

She also teaches specialised topics for the University of NSW and College of Nursing and has been an expert speaker/reviewer for various professional organisations including the National Prescribing Service, Pharmaceutical Society of Australia, Australian College of Pharmacy Practice, NSW Therapeutic Assessment Group and National Stroke Foundation. Her clinical research spans the Quality Use of Medicines (QUM), Cardiovascular Health, Medication Safety and pharmacist-led interventions.

She has been a member of teams that have been competitively awarded just over $3 million for research, and is one of a rare few Pharmacy Practice researchers to have been awarded NHMRC Project Grants as a Chief (Lead) Investigator. She has supervised over 35 research students and over 30 QUM research students from a range of national and international universities.

A/Prof Bajorek is an experienced doctoral supervisor and welcomes research degree enquiries via a formal expression of interest (please do not email directly).

Image of Beata Bajorek
Associate Professor, Pharmacy
Core Member, Health Services and Practice Research Strength
Bachelor of Pharmacy, GradCertEdStud(Higher Ed), Diploma in Hospital Pharmacy, Doctor of Philosophy
 
Phone
+61 2 9514 8301
Room
CB07.04.51

Research Interests

A/Prof Bajorek is an experienced doctoral supervisor and welcomes research degree enquiries via a formal expression of interest (please do not email directly).

Can supervise: Yes

Clinical therapeutics
Clinical pharmacology
Professional practice and communication skills
Data handling and statistics
Clinical practice and residencies
Research methods
Dispensing practice
Applied pharmacology for health care professionals and prescribers

Journal articles

Bajorek, B., Lemay, K., Gunn, K. & Armour, C. 2015, 'The potential role for a pharmacist in a multidisciplinary general practitioner super clinic', Australasian Medical Journal, vol. 8, no. 2, pp. 52-63.
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Background The Australian government's General Practitioner (GP) super clinics programme aims to provide well-integrated, multidisciplinary, patient-centred care for people with chronic disease. However, there is no research into the current role of pharmacists in this setting. Aims To explore the perspectives of GP super clinic staff on current and potential (future) pharmacist-led services provided in this setting. Methods Individual interviews (facilitated using a semi-structured interview guide and thematically analysed) were conducted with purposively sampled staff of a GP super clinic in a semirural location in the state of New South Wales, until theme saturation. Participating staff included (n=9): three GPs, one pharmacist, one nurse, one business manager, and three reception staff. Results Three themes emerged conveying perspectives on: working relationships between staff; a pharmacist's current role; and potential future roles for a pharmacist. All clinic staff actively engaged the pharmacist in their 'team approach'. Currently established roles for home medicines reviews (HMRs) and drug information were well supported, but needed to be expanded, for example, with formalised case conferences between GPs, pharmacists, and other staff. New roles needed be explored in auditing medication use, optimising medication records, specialised drug information, dispensing, and prescribing. Although GPs had differing views about opportunities for pharmacists' prescribing in this setting, they saw several benefits to this service, such as reducing the time pressure on GPs to enable more effective consultations. Conclusion Results suggest a pharmacist's services can potentially be better used within the multidisciplinary super clinic model of care to address current gaps within the semi-rural practice setting. Any future role for the pharmacist could be addressed as part of a formalised, strategic approach to creating an integrated healthcare team, with attention to f...
Singh, S. & Bajorek, B. 2015, 'Pharmacotherapy in the ageing patient: The impact of age per se (A review).', Ageing Res Rev.
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A literature search was carried out to review the influence of 'ageing' on pharmacotherapeutic decision-making, specifically how 'age' is defined and considered in the utilisation of medication. Embase, Medline, International Pharmaceutical Abstracts, and Google scholar were canvassed in a three-tiered search according to pre-established inclusion criteria. In tier 1, a total of 22 studies were identified highlighting the underutilisation of medication in elderly patients, with a particular focus on warfarin. Four studies highlighted an age-bias in medication-prescribing for elderly patients, specifically in relation to medicines for rheumatoid arthritis, angina, and hypertension. Tier 2 identified diverse definitions for 'elderly', including biological age, chronological age, physiological age, as well as various descriptions of 'elderly' in clinical trials and guidelines. Finally, medication optimisation tools were identified through the third tier, emphasising the use of chronological age to describe the 'elderly'. Old age influences pharmacotherapeutic decision-making at various levels, however, what complicates the situation is the absence of a comprehensive definition of 'elderly'. Clinical recommendations need to be based more on objective factors known to affect medication effectiveness and safety.
Wang, Y. & Bajorek, B. 2014, 'New oral anticoagulants in practice: Pharmacological and practical considerations', American Journal of Cardiovascular Drugs, vol. 14, no. 3, pp. 175-189.
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Although highly effective, warfarin use is complicated by its unpredictable narrow therapeutic window, genetic heterogeneity in pharmacokinetic response, numerous food and drug interactions, and the need for regular international normalized ratio (INR) monitoring. Currently, several novel oral anticoagulant (NOAC) drugs (dabigatran, rivaroxaban, apixaban) are available on the market as alternatives to warfarin. These agents all feature more predictable pharmacodynamic and pharmacokinetic properties than warfarin. Additionally, the NOACs do not require routine monitoring of coagulation parameters, and have a relatively lower potential for interactions with drug, herb, and dietary constituents, which enhances the convenience of management for both patients and health professionals alike. However, there are other considerations regarding the use of NOACs that must be taken into account during management of therapy. In contrast to warfarin, most NOACs need dosage adjustments in renal impairment and are contraindicated in severe liver impairment, and there are no specific antidotes for treating NOAC-related over-anticoagulation. The more frequent dosing needed for NOACs may reduce adherence, especially in elderly patients with polypharmacy. Furthermore, NOACs, especially dabigatran, are not as well tolerated as warfarin in patients with gastrointestinal diseases. Overall, the availability of the NOACs has expanded the treatment armamentarium, but they are not without risk. Given the limited experience with the NOACs, their limited range of indications, and their cost, the characteristics of each anticoagulant must be carefully considered to carefully select the agent that will provide the optimal risk/benefit profile in the individual patient. © 2014 Springer International Publishing.
Wang, Y. & Bajorek, B. 2014, 'Safe use of antithrombotics for stroke prevention in atrial fibrillation: Consideration of risk assessment tools to support decision-making', Therapeutic Advances in Drug Safety, vol. 5, no. 1, pp. 21-37.
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Clinical guidelines advocate stroke prevention therapy in atrial fibrillation (AF) patients, specifically anticoagulation. However, the decision to initiate treatment is based on the risk (bleeding) versus benefit (prevention of stroke) of therapy, which is often difficult to assess. This review identifies available risk assessment tools to facilitate the safe and optimal use of antithrombotic therapy for stroke prevention in AF. Using key databases and online clinical resources to search the literature (1992-2012), 19 tools have been identified and published to date: 11 addressing stroke risk, 7 addressing bleeding risk and 1 integrating both risk assessments. The stroke risk assessment tools (e.g. CHADS2, CHA2DS2-VASc) share common risk factors: age, hypertension, previous cerebrovascular attack. The bleeding risk assessment tools (e.g. HEMORR2HAGES, HAS-BLED) share common risk factors: age, previous bleeding, renal and liver impairment. In terms of their development, six of the stroke risk assessment tools have been derived from clinical studies, whilst five are based on refinement of existing tools or expert consensus. Many have been evaluated by prospective application to data from real patient cohorts. Bleeding risk assessment tools have been derived from trials, or generated from patient data and then validated via further studies. One identified tool (i.e. Computerised Antithrombotic Risk Assessment Tool [CARAT]) integrates both stroke and bleeding, and specifically considers other key factors in decision-making regarding antithrombotic therapy, particularly those increasing the risk of medication misadventure with treatment (e.g. function, drug interactions, medication adherence). This highlights that whilst separate tools are available to assess stroke and bleeding risk, they do not estimate the relative risk versus benefit of treatment in an individual patient nor consider key medication safety aspects. More effort is needed to synthesize these separat...
Hanna, T., Bajorek, B., Lemay, K. & Armour, C.L. 2014, 'Using scenarios to test the appropriateness of pharmacist prescribing in asthma management', Pharmacy Practice, vol. 12, no. 1.
Objective: To explore the potential for community pharmacist prescribing in terms of usefulness, pharmacists' confidence, and appropriateness, in the context of asthma management. Methods: Twenty community pharmacists were recruited using convenience sampling from a group of trained practitioners who had already delivered asthma services. These pharmacists were asked to complete a scenariobased questionnaire (9 scenarios) modelled on information from real patients. Pharmacist interventions were independently reviewed and rated on their appropriateness according to the Respiratory Therapeutic Guidelines (TG) by three expert researchers. Results: In seven of nine scenarios (78%), the most common prescribing intervention made by pharmacists agreed with TG recommendations. Although the prescribing intervention was appropriate in the majority of cases, the execution of such interventions was not in line with guidelines (i.e. dosage or frequency) in the majority of scenarios. Due to this, only 47% (76/162) of the interventions overall were considered appropriate. However, pharmacists were deemed to be often following common clinical practice for asthma prescribing. Therefore 81% (132/162) of prescribing interventions were consistent with clinical practice, which is often not guideline driven, indicating a need for specific training in prescribing according to guidelines. Pharmacists reported that they were confident in making prescribing interventions and that this would be very useful in their management of the patients in the scenarios. Conclusion: Community pharmacists may be able to prescribe asthma medications appropriately to help achieve good outcomes for their patients. However, further training in the guidelines for prescribing are required if pharmacists are to support asthma management in this way.
Bajorek, B., Magin, P., Hilmer, S. & Krass, I. 2014, 'A cluster-randomized controlled trial of a computerized antithrombotic risk assessment tool to optimize stroke prevention in general practice: A study protocol', BMC Health Services Research, vol. 14.
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Background: 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. Methods/design. 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. Discussion. 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 ...
Singh, S. & Bajorek, B. 2014, 'Defining 'elderly' in clinical practice guidelines for pharmacotherapy', Pharmacy Practice, vol. 12, no. 4.
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Method: Guidelines pertaining to the use of pharmacotherapy, focusing on conditions described in National Health Priority Areas, were identified using databases (Medline, Google Scholar) and organisation websites (Department of Health and Ageing, National Heart Foundation, National Health and Medical Research Council). Guidelines were reviewed and qualitatively analysed to identify any references or definitions of 'elderly' persons.
Alhawassi, T.M., Krass, I., Bajorek, B. & Pont, L.G. 2014, 'A systematic review of the prevalence and risk factors for adverse drug reactions in the elderly in the acute care setting', Clinical Interventions in Aging, vol. 9, pp. 2079-2086.
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Adverse drug reactions (ADRs) are an important health issue. While prevalence and risk factors associated with ADRs in the general adult population have been well documented, much less is known about ADRs in the elderly population. The aim of this study was to review the published literature to estimate the prevalence of ADRs in the elderly in the acute care setting and identify factors associated with an increased risk of an ADR in the elderly. A systematic review of studies published between 2003 and 2013 was conducted in the Cochrane Database of Systematic Reviews, EMBASE, Google Scholar and MEDLINE. Key search terms included: 'adverse drug reactions', 'adverse effects', 'elderly patients and hospital admission', 'drug therapy', 'drug adverse effects', 'drug related', 'aged', 'older patients', 'geriatric', 'hospitalization', and 'emergency admissions'. For inclusion in the review, studies had to focus on ADRs in the elderly and had to include an explicit definition of what was considered an ADR and/or an explicit assessment of causality, and a clear description of the method used for ADR identification, and had to describe factors associated with an increased risk of an ADR. Fourteen hospital-based observational studies exploring ADRs in the elderly in the acute care setting were eligible for inclusion in this review. The mean prevalence of ADRs in the elderly in the studies included in this review was 11.0% (95% confidence interval [CI]: 5.1%–16.8%). The median prevalence of ADRs leading to hospitalization was 10.0% (95% CI: 7.2%–12.8%), while the prevalence of ADRs occurring during hospitalization was 11.5% (95% CI: 0%–27.7%). There was wide variation in the overall ADR prevalence, from 5.8% to 46.3%. Female sex, increased comorbid complexity, and increased number of medications were all significantly associated with an increased risk of an ADR. Retrospective studies and those relying on identification by the usual treating team reported lower prevalence rat...
Eissa, A., Krass, I. & Bajorek, B.V. 2014, 'Use of medications for secondary prevention in stroke patients at hospital discharge in Australia', International Journal of Clinical Pharmacy, vol. 36, no. 2, pp. 384-393.
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Background: Stroke is one of the leading causes of death and disability. Significant proportions (33 %) of stroke presentations are by patients with a previous stroke or transient ischaemic attack. Consequently, the stroke management guidelines recommend that all ischaemic stroke patients should receive three key evidence-based preventive drug therapies: antihypertensive drug therapy, a statin and an antithrombotic drug therapy (anticoagulant and/or antiplatelet). Objective: To determine the rates of utilization of the three key evidence-based drug therapies for the secondary prevention of stroke and to identify factors associated with use of treatment at discharge. Setting: Five metropolitan hospitals in New South Wales, comprising two tertiary referral centres and three district hospitals. Method: A retrospective clinical audit was conducted in the study hospitals. Patients discharged with a principal diagnosis of ischaemic stroke during a 12-month time period (July 2009-2010) were identified for review. Main outcome measure: The rate of utilization of each of the three key evidence-based drug therapies and the factors associated with use of treatment at discharge. Results: A total of 521 medical records were reviewed. Of these, 469 patients were discharged alive with a mean age of 73.6 &plusmn; 14.4 years. Overall, 75.4 % were prescribed an antihypertensive agent at discharge versus only 65.7 % on admission (P < 0.05). Three hundred-sixty patients (77.6 % of the eligible patients) were prescribed a statin at discharge (compared to only 43.9 % on admission, P < 0.05), of whom 74.0 % received monotherapy. Almost all (97.6 %) eligible patients were prescribed an antithrombotic drug therapy at discharge, of whom 68.5 % were prescribed monotherapy and 28.2 % were prescribed dual therapy. Only 60.0 % of eligible patients were discharged on all three key guideline recommended secondary preventive drug therapies. Multivariate logistic regression analyses showed that hyperten...
Eissa, A., Krass, I., Levi, C., Sturm, J., Ibrahim, R. & Bajorek, B. 2013, 'Understanding the reasons behind the low utilisation of thrombolysis in stroke', Australasian Medical Journal, vol. 6, no. 3, pp. 152-163.
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Background Thrombolysis remains the only approved therapy for acute ischaemic stroke (AIS); however, its utilisation is reported to be low. Aims This study aimed to determine the reasons for the low utilisation of thrombolysis in clinical practice. Method 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. Results The research team reviewed a total of 521 records (48.8% females, mean age 74.4 &plusmn;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%). Conclusion 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.
Stafford, L., Van Tienen, E.C., Peterson, G.M., Bereznicki, L.R.E., Jackson, S.L., Bajorek, B.V., Mullan, J.R. & DeBoos, I.M. 2012, 'Warfarin management after discharge from hospital: A qualitative analysis', Journal of Clinical Pharmacy and Therapeutics, vol. 37, no. 4, pp. 410-414.
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What is Known and Objective: Warfarin is recognized as a high-risk medication for adverse events, and the risks are particularly heightened in the period immediately following a patient's discharge from hospital. This qualitative study aimed to explore the experiences of Australian patients and healthcare professionals of warfarin management in the post-discharge period and identify the benefits and deficiencies of existing systems, to inform the development of a model for a new collaborative post-discharge warfarin management service. Methods: Healthcare professionals, professional organization representatives and patients recently discharged from hospital taking warfarin (consumers) were recruited via purposive, criterion-based sampling within two Australian states. Semi-structured telephone interviews were conducted between August and October 2008 using standard discussion guides. Data were manually analyzed to identify emergent themes using a phenomenological approach. Results: Forty-seven participants were involved in the telephone interviews. Three major themes emerged: (i) appropriate warfarin education is integral to effective warfarin management, (ii) problems occur in communication along the continuum of care and (iii) home-delivered services are valuable to both patients and healthcare professionals. Discussion: Although high-quality warfarin education and effective communication at the hospital-community interface were identified as important in post-discharge warfarin management, deficiencies were perceived within current systems. The role of home-delivered services in ensuring timely follow-up and promoting continuity of care was recognized. Previous studies exploring anticoagulation management in other settings have identified similar themes. Post-discharge management should therefore focus on providing patients with a solid foundation to minimize future problems. What is New and Conclusion: Addressing the three identified facets of care within a n...
Nasser, S., Mullan, J. & Bajorek, B. 2012, 'Challenges of Older Patients' Knowledge About Warfarin Therapy', Journal of Primary Care and Community Health, vol. 3, no. 1, pp. 65-74.
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Objective: To review the challenges of warfarin education for older patients (aged 65 years or older) in terms of knowledge, access to warfarin education, and education resources. Methods: A quasi-systematic review of the literature was performed via electronic database searches (eg, Medline, Embase, Cumulative Index to Nursing and Allied Health Literature, International Pharmaceutical Abstracts, Meditext, and Google Scholar) from 1990 to May 2011. Results: The 62 articles reviewed found that improved patient knowledge results in better anticoagulation control. The review also found that between 50% and 80% of older patients have inadequate knowledge about the basic aspects of warfarin therapy (eg, action, benefits and risks, interactions with other drugs or foods, international normalized ratio management). Demographic factors, such as advancing age, lower family income, and limited health literacy, were found to inversely affect patients' warfarin knowledge, and access to warfarin education and information resources were often suboptimal in different practice settings. Finally, a number of educational strategies and resources that could be readily incorporated to improve the effectiveness of current warfarin education programs were extracted from the review. Conclusion: This comprehensive review highlights that education about warfarin in older patients is currently suboptimal and may in part contribute to poor therapeutic outcomes. This review article also acknowledges the need to identify, target, and develop educational strategies and resources to further improve older patients' knowledge about their warfarin therapy. &copy; SAGE Publications 2012.
Bajorek, B.V. & Ren, S. 2012, 'Utilisation of antithrombotic therapy for stroke prevention in atrial fibrillation in a Sydney hospital: Then and now', International Journal of Clinical Pharmacy, vol. 34, no. 1, pp. 88-97.
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Objective Evidence from pivotal clinical trials conducted more than a decade ago supports the use of antithrombotic therapy, particularly warfarin, for stroke prevention in atrial fibrillation (AF). Despite the wide dissemination of this evidence since that time, there is anecdotal evidence that utilisation of therapy remains suboptimal, especially in the target elderly population, which is reflected in the development of practice tools such as the TAG Clinical Indicator ('Antithrombotics in AF' Indicator 1.6, 2007). Therefore, the objective of this study was to determine the current utilisation of antithrombotic therapy for elderly patients with AF in the local setting, and to compare this utilisation with the results of a prior audit (AUDIT 1), as well as against the recommendations of the TAG Clinical Indicator (TAG IND). Setting A major teaching hospital in Sydney, Australia. Method A retrospective audit (AUDIT 2) of medical records of hospital inpatients (aged 65 years, with a significant diagnosis of AF), pertaining to admissions over the 12-month period 1st June 2006-31st May 2007, was conducted. Main outcome measure Proportion of patients receiving antithrombotic therapy at the point of discharge from hospital. Results A total of 201 patients (mean age 79.8 &plusmn; 7.8 years) were reviewed in AUDIT 2. Most (85%) patients received antithrombotic therapy (vs. 79.2%, AUDIT 1), with "warfarin &plusmn; antiplatelets" most frequently (46.3%) used (vs. 34.5%, AUDIT 1), followed by "aspirin &plusmn; other antiplatelet" (33.3% AUDIT 2 vs. 43.1% AUDIT 1). Patients aged 80 years were significantly less likely to receive warfarin therapy, compared to those <80 years (40.2% vs. 52.5%, P = 0.01). Of those patients who were deemed 'eligible' for warfarin according to AUDIT 2 (n = 155), only 55.0% of patients were actually prescribed this treatment. Results obtained by AUDIT 2 and TAG IND were overall comparable. Conclusion Whilst there have been temporal improvements in the overall utilisa...
Bajorek, B.V., Masood, N. & Krass, I. 2012, 'Development of a Computerised Antithrombotic Risk Assessment Tool (CARAT) to optimise therapy in older persons with atrial fibrillation', Australasian Journal on Ageing, vol. 31, no. 2, pp. 102-109.
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Aim: To develop and evaluate a novel Computerised Antithrombotic Risk Assessment Tool (CARAT) to aid clinicians' decision making regarding the risk-benefit of antithrombotic therapy in older patients. Methods: CARAT was developed in an iterative process involving multidisciplinary feedback and computerisation of previously trialled algorithms. Hospital-based clinicians then applied the tool to patient cases, to evaluate its usability. Results: Overall, 94% of clinicians (n= 27 yielding 216 responses) were satisfied with CARAT's format. Most (72%) clinician responses agreed with CARAT recommendations; over two-thirds agreed with estimates of stroke and bleeding risk. However, geriatricians were 3.5 times more likely to disagree with CARAT recommendations than cardiologists, particularly in cases of high fall risk. Overall, 63% responded that CARAT was at least 'somewhat useful' for clinical practice; 22% indicating it was 'very useful'. Conclusion: CARAT has potential as a useful decision-support tool to assist clinicians in decision making regarding appropriate antithrombotic therapy in older patients. &copy; 2011 The Authors. Australasian Journal on Ageing &copy; 2011 ACOTA.
Wright, L., Hill, K.M., Bernhardt, J., Lindley, R., Ada, L., Bajorek, B.V., Barber, P.A., Beer, C., Golledge, J., Gustafsson, L., Hersh, D., Kenardy, J., Perry, L., Middleton, S., Brauer, S.G. & Nelson, M.R. 2012, 'Stroke management: Updated recommendations for treatment along the care continuum', Internal Medicine Journal, vol. 42, no. 5, pp. 562-569.
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The Australian Clinical Guidelines for Stroke Management 2010 represents an update of the Clinical Guidelines for Stroke Rehabilitation and Recovery (2005) and the Clinical Guidelines for Acute Stroke Management (2007). For the first time, they cover the whole spectrum of stroke, from public awareness and prehospital response to stroke unit and stroke management strategies, acute treatment, secondary prevention, rehabilitation and community care. The guidelines also include recommendations on transient ischaemic attack. The most significant changes to previous guideline recommendations include the extension of the stroke thrombolysis window from 3 to 4.5h and the change from positive to negative recommendations for the use of thigh-length antithrombotic stockings for deep venous thrombosis prevention and the routine use of prolonged positioning for contracture management. &copy; 2012 National Stroke Foundation. Internal Medicine Journal &copy; 2012 Royal Australasian College of Physicians.
Bajorek, B., Masood, N. & Krass, I. 2012, 'Development Of A Computerised Antithrombotic Risk Assessment Tool (Carat) To Optimise Therapy In Older Persons With Atrial Fibrillation', Australian Journal of Ageing, vol. 31, no. 2, pp. 102-109.
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Aim: To develop and evaluate a novel Computerised Antithrombotic Risk Assessment Tool (CARAT) to aid clinicians' decision making regarding the riskbenefit of antithrombotic therapy in older patients. Methods: CARAT was developed in an iterative process i
Nasser, S., Mullan, J. & Bajorek, B. 2012, 'Assessing the quality, suitability and readability of internet-based health information about warfarin for patients', Australasian Medical Journal, vol. 5, no. 3, pp. 194-203.
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Background: Warfarin is a high-risk medication where patient information may be critical to help ensure safe and effective treatment. Considering the time constraints of healthcare providers, the internet can be an important supplementary information resource for patients prescribed warfarin. The usefulness of internet-based patient information is often limited by challenges associated with finding valid and reliable health information. Given patients' increasing access of the internet for information, this study investigated the quality, suitability and readability of patient information about warfarin presented on the internet. Method: Previously validated tools were used to evaluate the quality, suitability and readability of patient information about warfarin on selected websites. Results: The initial search yielded 200 websites, of which 11 fit selection criteria, comprising seven non-commercial and four commercial websites. Regarding quality, most of the non-commercial sites (six out of seven) scored at least an 'adequate' score. With regard to suitability, 6 of the 11 websites (including two of the four commercial sites) attained an 'adequate' score. It was determined that information on 7 of the 11 sites (including two commercial sites) was written at reading grade levels beyond that considered representative of the adult patient population with poor literacy skills (e.g. school grade 8 or less). Conclusion: Despite the overall 'adequate' quality and suitability of the internet derived patient information about warfarin, the actual usability of such websites may be limited due to their poor readability grades, particularly in patients with low literacy skills.
Eissa, A., Krass, I. & Bajorek, B. 2012, 'Barriers to the utilization of thrombolysis for acute ischaemic stroke', Journal of Clinical Pharmacy & Therapeutics, vol. 37, pp. 399-409.
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Thrombolysis is currently the only evidence-based pharmacological treatment available for acute ischaemic stroke (AIS); however, its current utilization is suboptimal (administered to <3% of AIS patients). The aim of this article was to identify the potential barriers to the use of thrombolysis via a review of the available literature. Methods: Medline, Embase, International Pharmaceutical Abstracts and Google Scholar were searched to identify relevant original articles, review papers and other literature published in the period 1995-2011. Results and Discussion: Several barriers to the utilization of thrombolysis in stroke have been identified in the literature and can be broadly classified as 'preadmission' barriers and 'post-admission' barriers.The most effective interventions appear to be those comprising several strategies and those that target more than one barrier simultaneously. Therefore, optimal utilization of thrombolysis requires a systematic, integrated multidisciplinary approach across the continuum of acute care.
Nasser, S., Mullan, J. & Bajorek, B. 2012, 'Educating patients about warfarin therapy using information technology: A survey on healthcare professionals' perspectives', Pharmacy Practice, vol. 10, no. 2, pp. 97-104.
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Objective: To explore healthcare professionals' views about the benefits and challenges of using information technology (IT) resources for educating patients about their warfarin therapy. Methods: A cross-sectional survey of both community and hospital-based healthcare professionals (e.g., doctors, pharmacists and nurses) involved using a purpose-designed questionnaire. The questionnaires were distributed using a multi-modal approach to maximise response rates. Results: Of the total 300 questionnaires distributed, 109 completed surveys were received (43.3% response rate). Over half (53.2%) of the healthcare participants were aged between 40-59 years, the majority (59.5%) of whom were female. Fifty nine (54.1%) participants reported having had no access to warfarin-specific IT-based patient education resources, and a further 19 (38.0%) of the participants who had IT-access reported that they never used such resources. According to the healthcare participants, the main challenges associated with educating their patients about warfarin therapy included: patient-related factors, such as older age, language barriers, cognitive impairments and/or ethnic backgrounds or healthcare professional factors, such as time constraints. The healthcare professionals reported that there were several aspects about warfarin therapy which they found difficult to educate their patients about which is why they identified computers and interactive touch screen kiosks as preferred IT devices to deliver warfarin education resources in general practices, hospital-based clinics and community pharmacies. At the same time, the healthcare professionals also identified a number of facilitators (e.g., to reinforce warfarin education, to offer reliable and easily comprehensible information) and barriers (e.g., time and costs of using IT resources, difficulty in operating the resources) that could impact on the effective implementation of these devices in educating patients about their warfarin the...
Eissa, A., Krass, I. & Bajorek, B.V. 2012, 'Optimizing the management of acute ischaemic stroke: A review of the utilization of intravenous recombinant tissue plasminogen activator (tPA)', Journal of Clinical Pharmacy and Therapeutics, vol. 37, no. 6, pp. 620-629.
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What is known and Objective: Thrombolysis using intravenous tissue plasminogen activator (tPA) is the only available evidence-based treatment for acute ischaemic stroke; however, its current utilization is very low. Therefore, the aim of this article is to review the literature regarding the use of intravenous tPA for the treatment of acute ischaemic stroke. The review will also compare utilization rates of thrombolysis in different centres across the world and identify key reasons for the underutilization of thrombolysis in stroke. Methods: MEDLINE, EMBASE, International Pharmaceutical Abstracts (IPA) and Google Scholar were searched for relevant original articles, review papers and other publications over the publication period 1995-2012. Results and Discussion: The National Institute of Neurological Disorders and Stroke (NINDS) (1995, N = 624 patients) and ECASS III (2008, N = 821 patients) are two pivotal randomized controlled trials providing evidence for the use of intravenous tPA within 3 h or 3-45 h from stroke onset, respectively. Both trials have shown that tPA administration decreases disability at 90 days from stroke. Furthermore, a recent pooled analysis of randomized controlled trials (2010, N = 3670 patients) supports these results, highlighting that early stroke treatment is associated with better outcomes, especially when treatment is started within 90 min of stroke onset (but suggesting that the benefit could be afforded within a 45-h time window). Three major observational trials, STARS (2000, N = 389 patients), CASES (2005, N = 1135 patients) and SITS-MOST (2007, N = 6483 patients), have reported acceptable safety and efficacy in clinical practice. However, only a small proportion of acute ischaemic stroke patients receive tPA in clinical practice, because of the limited availability of tPA-utilizing sites and suboptimal use of tPA in sites where it is available. What is new and Conclusion: tPA reduces disability in stroke patients. Moreover...
Nasser, S., Cecchele, R., Touma, S., Han, P., Nair, K., Vizgoft, J., Murdoch, V., Mullan, J. & Bajorek, B. 2012, 'Documentation of warfarin education provided to hospital patients: A clinical audit', Journal of Pharmacy Practice and Research, vol. 42, no. 2, pp. 129-133.
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Background: Effective management of warfarin therapy is often challenged by its complex pharmacology and preventable adverse events. One strategy to ensure safe warfarin use is provision of comprehensive warfarin education to patients. Aim: To review the provision of warfarin education to hospital patients prescribed warfarin and to describe patient characteristics that may impact on warfarin education. Method: A prospective study was undertaken at 2 large Australian metropolitan hospitals. Provision of warfarin education was identified by auditing the medication charts and clinical notes of hospitalised older patients (? 65 years). Patients were also interviewed to confirm whether they recalled receiving warfarin education during their hospital stay. Results: Data were collected for 96 patients with a mean age of 74 (SD 13) years. Most patients (78%) were admitted to medical wards, were taking warfarin for atrial fibrillation (56%), and had started warfarin prior to admission (54%). 36% of patients had provision of warfarin education documented in medication charts and clinical notes, and in most cases warfarin education was provided by a pharmacist. Of the 68 patients available for interview, only 47% recalled receiving warfarin education; in the majority of cases they cited pharmacists as providers of the education. Conclusion: There is a need to improve documentation and provision of warfarin education to hospital patients.
Bassett-Clarke, D., Krass, I. & Bajorek, B. 2012, 'Ethnic differences of medicines-taking in older adults: A cross cultural study in New Zealand', International Journal of Pharmacy Practice, vol. 20, no. 2, pp. 90-98.
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Objectives The literature identifies many barriers to medicines use, including bio-psycho-social issues, but less is known regarding ethno-cultural barriers, which are important in culturally diverse nations. The aim of this study was to explore ethnic differences in attitudes to medicines and medicines-taking, focusing on the main constituents of the New Zealand (NZ) population: NZ European, M?ori (the indigenous people of NZ), Pacific and Asian peoples. Methods A qualitative study involving a series of focus groups was conducted. Participants (>50 years old) taking medicines were recruited from various community-based groups. The focus group discussions were transcribed verbatim and analysed for key themes via manual inductive coding and constant comparison. Key findings Twenty focus groups (n = 100 participants) were conducted. Three key common themes emerged: (1) conception of a medicine; (2) self-management of medication; and (3) seeking further medicines information. In general, NZ European participants had a very narrow view of what a medicine is, were motivated to source medicines information independently and were very proactive in medicines management. At the other end of the spectrum, Pacific peoples expressed a broad view of what constitutes a medicine, were not motivated to source medicines information independently and were not proactive in medicines management, tending to instead rely on healthcare professionals for answers. The findings from the various ethnic groups highlight differences in attitudes to medicines per se and medicines-taking; these influences on medication-taking behaviour need to be considered in the provision of pharmaceutical care. Conclusion Ethnic differences in attitudes to medicines and medicines-taking are apparent, although there are some commonalities in terms of needs regarding support and advice around medicines' use. This will help inform the development of resources and communication tools to assist pharmacists in pr...
Alene, M., Wiese, M.D., Angamo, M.T., Bajorek, B.V., Yesuf, E.A. & Wabe, N.T. 2012, 'Adherence to medication for the treatment of psychosis: rates and risk factors in an Ethiopian population', BMC Clinical Pharmacology, vol. 12.
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Background: Medication-taking behavior, specifically non-adherence, is significantly associated with treatment outcome and is a major cause of relapse in the treatment of psychotic disorders. Non-adherence can be multifactorial; however, the rates and associated risk factors in an Ethiopian population have not yet been elucidated. The principal aim of this study was to evaluate adherence rates to antipsychotic medications, and secondarily to identify potential factors associated with non-adherence, among psychotic patients at tertiary care teaching hospital in Southwest Ethiopia.Methods: A cross-sectional study was conducted over a 2-month period in 2009 (January 15th to March 20th) at the Jimma University Specialized Hospital. Adherence was computed using both a compliant fill rate method and self-reporting via a structured patient interview (focusing on how often regular medication doses were missed altogether, and whether they missed taking their doses on time). Data were analyzed using SPSS for windows version 16.0, and chi-square and Pearsons r tests were used to determine the statistical significance of the association of variables with adherence.Result: Three hundred thirty six patients were included in the study. A total of 75.6% were diagnosed with schizophrenia, while the others were diagnosed with other psychotic disorders. Most (88.1%) patients were taking only antipsychotics, while the remainder took more than one medication. Based upon the compliant fill rate, 57.5% of prescription fills were considered compliant, but only 19.6% of participants had compliant fills for all of their prescriptions. In contrast, on the basis of patients self-report, 52.1% of patients reported that they had never missed a medication dose, 32.0% sometimes missed their daily doses, 22.0% only missed taking their dose at the specific scheduled time, and 5.9% missed both taking their dose at the specific scheduled time and sometimes missed their daily doses. The most common ...
Eissa, A., Krass, I. & Bajorek, B.V. 2012, 'Barriers to the utilization of thrombolysis for acute ischaemic stroke', Journal of Clinical Pharmacy and Therapeutics, vol. 37, no. 4, pp. 399-409.
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What is known and Objective: Thrombolysis is currently the only evidence-based pharmacological treatment available for acute ischaemic stroke (AIS); however, its current utilization is suboptimal (administered to <3% of AIS patients). The aim of this article was to identify the potential barriers to the use of thrombolysis via a review of the available literature. Methods: Medline, Embase, International Pharmaceutical Abstracts and Google Scholar were searched to identify relevant original articles, review papers and other literature published in the period 1995-2011. Results and Discussion: Several barriers to the utilization of thrombolysis in stroke have been identified in the literature and can be broadly classified as 'preadmission' barriers and 'post-admission' barriers. Preadmission barriers include patient and paramedic-related factors leading to late patient presentation for treatment (i.e. outside the therapeutic time window for the administration of thrombolysis). Post-admission barriers include in-hospital factors, such as suboptimal triage of stroke patients and inefficient in-hospital acute stroke care systems, a lack of appropriate infrastructure and expertise to administer thrombolysis, physician uncertainty in prescribing thrombolysis and difficulty in obtaining informed consent for thrombolysis. Suggested strategies to overcome these barriers include public awareness campaigns, prehospital triage by paramedics, hospital bypass protocols and prenotification systems, urgent stroke-unit admission, on-call multidisciplinary acute stroke teams, urgent neuroimaging protocols, telestroke interventions and risk-assessment tools to aid physicians when considering thrombolysis. Additionally, greater pharmacists' engagement is warranted to help identify the people at risk of stroke and support preventative strategies, and provide the public with information regarding the recognition of stroke, as well as facilitate the access and use of thrombolysis. What ...
Castelino, R.L., Bajorek, B.V. & Chen, T.F. 2011, 'Are interventions recommended by pharmacists during Home Medicines Review evidence-based?', Journal of Evaluation in Clinical Practice, vol. 17, no. 1, pp. 104-110.
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Introduction Over the past decade medication review services have been implemented in many countries, including Australia, UK and USA. Although, the attitudes and barriers to the implementation of evidence-based medicine have been investigated, the extent to which medication review recommendations are evidence-based is not known. Objective To determine (1) the extent to which pharmacist's recommendations during medication review services were consistent with the evidence-based guides at the time of the review; and (2) the nature and extent of drug-related problems (DRPs) and the actions recommended by pharmacists to resolve DRPs. Method A retrospective review of Home Medicines Review cases performed on 224 community-dwelling older people (65 years or older). The chi-squared test for categorical variables was used to compare the proportion of recommendations that were evidence-based and recommendations for which no evidence could be identified in the most common Australian information sources. DRPs and the actions recommended to resolve the DRPs were classified according to previously employed criteria. Results Pharmacists made a total of 1114 therapeutic recommendations to general practitioners, of which 964 required supporting pharmacotherapeutic evidence. The majority (94%) of the pharmacists' recommendations were in accordance with the evidence-based guides, as compared with the recommendations for which no evidence could be identified (P < 0.001). Pharmacists reported that 98% of the patients had at least one problem with use of their medication detected. Conclusion The majority of the actions recommended by pharmacists during the medication review process were consistent with the literature embedded in key Australian information sources. Medication management in older people is complex and challenging, as highlighted by the DRPs identified in 98% of our patients. A suitably trained pharmacist, with full access to the patient, medical record and supporting re...
Cao, B.Y., Chow, C., Elliott, P., MacPherson, R.D., Crane, J. & Bajorek, B.V. 2011, 'Implementing a pharmacist charting service in the pre-admission clinic', Journal of Pharmacy Practice and Research, vol. 41, no. 2, pp. 102-107.
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Aim: To implement a pharmacist charting service in the preadmission clinic (PAC) and describe a preparatory process for the initiation of this service. Method: Stage 1: a proposal for a pharmacist charting service in the PAC was devised via an iterative process with an advisory panel. Stage 2: feedback on the proposal was obtained from key staff via a survey comprising 15 linear scale statements (0 = strongly disagree to 10 = strongly agree) and open-ended questions. Stage 3: baseline data were collected on existing PAC service outcomes, e.g. consultation times, accuracy of medication charts. Results: Stage 1: a service protocol was developed following positive feedback. Stage 2: most staff strongly agreed that a pharmacist charting service would improve the efficiency and workflow in the PAC (median 8; n = 19) and that PAC pharmacists were competent and skilled to chart medications (median 9). Pharmacists perceived that the proposed service would increase their workload (median 10), consultation times (median 9) and medicolegal responsibilities (median 7) while the opposite was reported by the doctors (median 2, 2, and 3, respectively). Stage 3: mean baseline consultation times for pharmacists and doctors were 18.6 and 25 minutes, respectively. Most (95%) of the 56 analysed medication charts were incomplete (at least 1 piece of information missing) while 41% had at least one or more inaccuracies. Conclusion: There are benefits of a pharmacist charting service. This is the first step toward exploring models for pharmacist prescribing.
Yip, A. & Bajorek, B.V. 2011, 'Prescribing of anti-arrhythmics for atrial fibrillation', Australian Journal of Pharmacy, vol. 92, no. 1091, pp. 85-87.
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Braidy, N., Bui, K. & Bajorek, B. 2011, 'Evaluating the impact of new anticoagulants in the hospital setting', Pharmacy Practice, vol. 9, no. 1, pp. 1-10.
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The short-comings of current anticoagulants have led to the development of newer, albeit more expensive, oral alternatives. Objective: To explore the potential impact the new anticoagulants dabigatran and rivaroxaban in the local hospital setting, in terms of utilisation and subsequent costing. Method: A preliminary costing analysis was performed based on a prospective 2-week clinical audit (29th June - 13th July 2009). Data regarding current anticoagulation management were extracted from the medical files of patients admitted to Ryde Hospital. To model potential costing implications of using the newer agents, the reported incidence of VTE/stroke and bleeding events were obtained from key clinical trials. Results: Data were collected for 67 patients treated with either warfarin (n=46) or enoxaparin (n=21) for prophylaxis of VTE/stroke. At least two-thirds of all patients were deemed suitable candidates for the use of newer oral anticoagulants (by current therapy: warfarin: 65.2% (AF), 34.8% (VTE); enoxaparin: 100%, (VTE)). The use of dabigatran in VTE/stroke prevention was found to be more cost-effective than warfarin and enoxaparin due to significantly lower costs of therapeutic monitoring and reduced administration costs. Rivaroxaban was more cost-effective than warfarin and enoxaparin for VTE/stroke prevention when supplier-rebates (33%) were factored into costing. Conclusion: This study highlights the potential cost-effectiveness of newer anticoagulants, dabigatran and rivaroxaban, compared to warfarin and enoxaparin. These agents may offer economic advantages, as well as clinical benefits, in the hospital-based management of anticoagulated patients.
Stafford, L., Peterson, G.M., Bereznicki, L.R.E., Jackson, S.L., Van Tienen, E.C., Angley, M.T., Bajorek, B.V., McLachlan, A.J., Mullan, J.R., Misan, G.M.H. & Gaetani, L. 2011, 'Clinical outcomes of a collaborative, home-based postdischarge warfarin management service', Annals of Pharmacotherapy, vol. 45, no. 3, pp. 325-334.
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BACKGROUND: Warfarin remains a high-risk drug for adverse events, especially following discharge from the hospital. New approaches are needed to minimize the potential for adverse outcomes during this period. OBJECTIVE: To evaluate the clinical outcomes of a collaborative, home-based postdischarge warfarin management service adapted from the Australian Home Medicines Review (HMR) program. METHODS: In a prospective, nonrandomized controlled cohort study, patients discharged from the hospital and newly initiated on or continuing warfarin therapy received either usual care (UC) or a postdischarge service (PDS) of 2 or 3 home visits by a trained, HMR-accredited pharmacist in their first 8 to 10 days postdischarge. The PDS involved point-of-care international normalized ratio (INR) monitoring, warfarin education, and an HMR, in collaboration with the patient's general practitioner and community pharmacist. The primary outcome measure was the combined incidence of major and minor hemorrhagic events in the 90 days postdischarge. Secondary outcome measures included the incidences of thrombotic events, combined hemorrhagic and thombotic events, unplanned and warfarin-related hospital readmissions, death, INR control, and persistence with therapy at 8 and 90 days postdischarge. RESULTS: The PDS (n = 129) was associated with statistically significantly decreased rates of combined major and minor hemorrhagic events to day 90 (5.3% vs 14.7%; p = 0.03) and day 8 (0.9% vs 7.2%; p = 0.01) compared with UC (n = 139). The rate of combined hemorrhagic and thrombotic events to day 90 also decreased (6.4% vs 19.0%; p = 0.008) and persistence with warfarin therapy improved (95.4% vs 83.6%; p = 0.004). No significant differences in readmission and death rates or INR control were demonstrated. CONCLUSIONS: This study demonstrated the ability of appropriately trained accredited pharmacists working within the Australian HMR framework to reduce adverse events and improve persistence in pat...
Lee, Y.J.F., Levy, R. & Bajorek, B.V. 2011, 'Restricted antimicrobial use at transitions of care at an Australian hospital', Journal of Pharmacy Practice and Research, vol. 41, no. 4, pp. 283-287.
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Background: The emergence of antimicrobial resistance reinforces the need for antimicrobial stewardship to promote the appropriate and judicious use of antimicrobials. Aim: To quantify restricted antimicrobial use among intensive care unit (ICU) discharges to general wards, and to review appropriateness of antimicrobial use. Method: A prospective clinical audit was conducted over a 2- week period. Medical records for ICU discharges were reviewed, with relevant data extracted (patient characteristics, antimicrobial therapy prescribed, treatment instructions). Appropriateness of restricted antimicrobials used was gauged in accordance with hospital policies and the Therapeutic Guidelines: Antibiotic. Results: 98 patients were discharged from the ICU - 74 (76%) discharged to general wards were on antimicrobials, 15 discharged to general wards were not on antimicrobials and 9 discharged out of the hospital. Of these 74 patients, 31 (42%) were prescribed a total of 57 restricted antimicrobials; only 11 of these 31 (36%) patients had documented approval (from microbiology/infectious diseases teams) for use of restricted antimicrobials. 46 restricted antimicrobials (n = 57; 81%) were deemed clinically appropriate and the remaining 11 were prescribed outside guideline-recommended indications. Conclusion: While most restricted antimicrobials were prescribed according to national guidelines, in only one-third of patients were the restricted antimicrobials 'approved' for use according to hospital policies. Better clinical documentation on treatment plans and review processes for restricted antimicrobial use is needed during the transition from ICU to general wards.
Kumar, N., Knowler, C.B., Strumpman, D. & Bajorek, B.V. 2011, 'Facilitating medication misadventure risk assessment in the emergency medical unit', Journal of Pharmacy Practice and Research, vol. 41, no. 2, pp. 108-112.
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Background: The risk of medication misadventure is heightened in emergency settings. Identifying at-risk patients is integral to minimising medication-related adverse events. Aim: To pilot a medication misadventure risk assessment tool to identify at-risk patients most likely to benefit from targeted intervention by an emergency department pharmacist. Method: A prospective descriptive study was undertaken in an emergency medical unit over 2 weeks (June to July 2009). Patients were included if they were over 70 years of age, took 3 5 regular medications, had 3 3 comorbidities, and/or were newly started on warfarin or had been admitted to the emergency department as a result of a medication-related adverse event. Nurses were encouraged to use the medication misadventure risk assessment tool for all patients admitted to the emergency medical unit. The pharmacist provided targeted interventions to all patients who were identified as being at-risk by the nurses. The pharmacist also verified the accuracy of the risk assessments undertaken by the nurses using this tool. Main outcome measures were the sensitivity and specificity of the tool and the reliability of the nurses' risk assessment. Results: Nurses completed 115 medication risk assessments for 194 patients. The risk assessments were accurately completed in all but 10 patients. Of the 36 (31%) patients assessed as high risk, 18 required pharmacist intervention. Of the 79 patients assessed as low risk, 3 required pharmacist intervention. The tool was useful in identifying at-risk patients (specificity 78%, 95%CI 69-85; sensitivity 83%, 95%CI 60- 94). Conclusion: Nurses in the emergency department used the risk assessment tool to identify patients at risk of medication misadventure and facilitate targeted interventions by pharmacists.
Bajorek, B. 2011, 'A review of the safety of anticoagulants in older people using the medicines management pathway: weighing the benefits against the risks.', Ther Adv Drug Saf, vol. 2, no. 2, pp. 45-58.
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Anticoagulant drugs maintain a high potential for adverse events due to their inherent risk of haemorrhage and/or complex pharmacology. In addition, compromising the safety of these agents is the context in which they are principally used; that is, in the long-term prevention of thromboembolic diseases in an older patient population. These challenges are especially pronounced in the prevention of stroke in older persons with atrial fibrillation (AF), where the need for thromboprophylaxis is paramount and in whom the arrhythmia is most prevalent, but where the target population is simultaneously at high risk of adverse drug events. Essentially, this translates to the use of high-risk therapies on an indefinite basis, in persons who have multiple comorbidities, use polypharmacy, and who may have age-related functional and cognitive decline, culminating in a higher potential for medication misadventure. For this reason, anticoagulants mandate extra pharmacovigilance, and therefore the aim of this review is to address some of the key safety considerations in the use of anticoagulant drugs (warfarin, dabigatran, rivaroxaban), spanning the initiation of therapy to its ongoing management. Using the Medication Management Pathway (MMP) as a framework, in this review we canvas and highlight specific developments in practical strategies to facilitate the safe use of anticoagulants (particularly warfarin) in 'at-risk' elderly patients including: comprehensive risk/benefit assessment using novel risk stratification tools; focused medicines review services; therapeutic drug monitoring services delivered in the primary care setting; and practical education strategies and resources targeting the older patient population. Until newer alternative anticoagulants become viable options for widespread use, clinicians will necessarily need to rely on specific resources and interventions to facilitate the safe use of currently available anticoagulants (i.e. warfarin) in 'at-risk' older ...
Castelino, R.L., Chen, T.F., Guddattu, V. & Bajorek, B.V. 2010, 'Use of evidence-based therapy for the prevention of cardiovascular events among older people', Evaluation and the Health Professions, vol. 33, no. 3, pp. 276-301.
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Evidence-based therapies (EBTs) for the prevention of cardiovascular disease (CVD) are reportedly underutilized in older people. The primary purpose of this study was to evaluate the use of EBTs for the prevention of CVD events in older people and secondarily whether a Home Medicines Review (HMR) service by pharmacists' predicts the use of these medicines. A retrospective cross-sectional audit of HMR reports pertaining to 608 community-dwelling older people (?65 years) was conducted. EBTs considered for this audit included four guideline-recommended therapies for CVD: antithrombotic therapy (warfarin &plusmn; antiplatelet therapy), ?-blockers, statins, and angiotensin agents (angiotensin-converting enzyme inhibitors [ACEI] &plusmn; angiotensin II receptor blockers [ARBs]). The prevalence of EBT use among the older people, mean age (SD) 75.6 (7.5) years, was: 73% for antithrombotic therapy, 75% for statins, 74% for angiotensin therapy, and 35% for ?-blockers. CVD risk factors warranting treatment with these EBTs were frequently associated with use of EBTs. EBTs were least likely to be used in those with coronary interventions like coronary artery bypass grafting (CABG)/stent insertion (all EBTs except angiotensin agents) and angiotensin agents in those with a history of myocardial infarction or chronic heart failure. A pharmacist-led HMR service was significantly associated with the prescribing of all 4 EBTs. The results from this study show good adherence to evidence-based guidelines in general, although there is still room for improvement to further optimize clinical outcomes in these complex patients. The study also adds to the available literature on the effectiveness of pharmacists' collaborative contribution to the care of these high-risk patients. &copy; The Author(s) 2010.
Castelino, R.L., Bajorek, B.V. & Chen, T.F. 2010, 'Retrospective evaluation of home medicines review by pharmacists in older australian patients using the medication appropriateness index', Annals of Pharmacotherapy, vol. 44, no. 12, pp. 1922-1929.
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BACKGROUND: Home Medicines Review (HMR), a community-based collaborative service provided by general practitioners (GPs) and accredited pharmacists in Australia, has demonstrated effectiveness in preventing, detecting, and resolving medication-related problems. The Medication Appropriateness Index (MAI) has been found to be a reliable, valid, standardized instrument for assessment of multiple elements of drug therapy prescribing. OBJECTIVE: To retrospectively evaluate the impact of HMRs on the appropriateness of prescribing, using the MAI as a tool to categorize pharmacists' recommendations. METHODS: A retrospective analysis was performed on a sample of 270 HMR cases pertaining to community-dwelling older people (?65 years) in New South Wales, Australia. The HMRs were collected from 7 accredited pharmacists using purposive sampling. All HMRs were conducted between February 2006 and October 2009. MAI scores were retrospectively calculated at baseline, after the HMR service based on the pharmacist's recommendations to the GP, and following uptake of the pharmacist's recommendations by the GP. RESULTS: The mean &plusmn; SD age of the patients was 75.3 &plusmn; 7.4 years and 55% were female. Overall, almost all (99%; n = 267) patients had at least 1 inappropriate rating at baseline and more than 50% (n = 154) of the patients had a cumulative MAI score >15. The mean MAI score at baseline was 18.6 &plusmn; 11.3, which decreased to 9.3 &plusmn; 7.5 after HMR. The number of patients with a cumulative MAI score ?15 increased to 216 after the HMR service, compared to 116 at baseline. Pharmacists' recommendations documented in the HMR reports and uptake of these recommendations by the GP resulted in a statistically significant decrease in the MAI scores (both p < 0.001). CONCLUSIONS: The study demonstrates that the provision of medication reviews by accredited pharmacists can improve the appropriateness of prescribing as demonstrated by the change in MAI score and, hence, has the potential to improve ...
Yip, A. & Bajorek, B.V. 2010, 'Identifying temporal changes to the prescribing of anti-arrhythmics for atrial fibrillation', Journal of Pharmacy Practice and Research, vol. 40, no. 4, pp. 285-289.
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Background: There are a paucity of data on the use of anti arrhythmics for a trial fibrillation (AF), particularly in view of new treatment guidelines recommending rate control over rhythm control. Aim: To investigate the use of anti-arrhythmics for AF in the local clinical setting. Method: A retrospective clinical audit of the medical records of 174 adult patients with primary or secondary AF was conducted at a large Sydney teaching hospital. Data were collected on patients' characteristics, medical history, factors affecting treatment choice and clinical outcomes. Results: For acute treatment of AF, 38 (22%) patients received rhythm control only, 30 (17%) received rate control only, and 42 (24%) received rate control plus rhythm control. For longterm management of AF, 24 (14%) patients received rhythm control only, 42 (24%) received rate control only, and 28 (16%) received rate control plus rhythm control. The number of patients who attained sinus rhythm was higher in those receiving rhythm control drugs versus rate control drugs (84% vs 31%; p < 0.05). A decrease was observed in the number of patients on digoxin (41% vs 6%; p < 0.01) and amiodarone (26% vs 6%; p < 0.001). Factors identified as influencing treatment choice were age, heart rate, AF characteristics and comorbidities. Conclusion: There has been a temporal change in the use of anti-arrhythmics for AF, reflecting changes to recommendations on the use of rhythm versus rate control drugs. These changes in prescribing patterns are reflective of current guidelines and evidence-based practice.
Castelino, R.L., Hilmer, S.N., Bajorek, B.V., Nishtala, P. & Chen, T.F. 2010, 'Drug burden index and potentially inappropriate medications in community-dwelling older people: The impact of home medicines review', Drugs and Aging, vol. 27, no. 2, pp. 135-148.
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Background: A significant problem in older people (aged ?65 years) is the use of potentially inappropriate medications (PIMs), including those with sedative and anticholinergic properties. However, effective intervention strategies have yet to be identified. The Drug Burden Index (DBI) is an evidence-based tool that measures a persons total exposure to medications with sedative and anticholinergic properties and has been shown to be independently associated with impairment in cognitive and physical function. Objective: The main aim of the study was to investigate whether Home Medicines Review (HMR) services by pharmacists for community-dwelling older people would lead to an improvement in the use of medications, as measured by a decrease in the DBI score. The study also aimed to investigate the (i) distribution of DBI scores and PIMs among older people living in the community, and (ii) impact of pharmacists recommendations on DBI scores and PIMs. Methods: A retrospective analysis of medication reviews was performed for 372 community-dwelling older people (aged ?65 years) who received an HMR service from the pharmacist. The main outcome measure was the total DBI score at baseline and post-HMR. The data were also examined to determine the extent of PIM use (2003 Beers criteria), and the number and nature of pharmacists recommendations. Results: Overall, medications contributing to the DBI (i.e. medications with sedative or anticholinergic properties) and PIMs were identified in 60.5% (n = 225) and 39.8% (n = 148) of the patients, respectively. Following pharmacist recommendations during the HMR service, medications contributing to the DBI were identified in 51.6% (n = 192) of the patients. A statistically &copy; 2010 Adis Data Information BV. All rights reserved.
Perera, V., Bajorek, B.V., Matthews, S.M. & Hilmer, S.N. 2010, 'Response to: Assigning "frailty"', Age and Ageing, vol. 39, no. 3, pp. 405-406.
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Hilmer, S.N., Perera, V., Mitchell, S., Murnion, B.P., Dent, J., Bajorek, B., Matthews, S. & Rolfson, D.B. 2009, 'The assessment of frailty in older people in acute care', Australasian Journal on Ageing, vol. 28, no. 4, pp. 182-188.
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Aim: Develop a measure of frailty for older acute inpatients to be performed by non-geriatricians. Method: The Reported Edmonton Frail Scale (REFS) was adapted from the Edmonton Frail Scale for use with Australian acute inpatients. With acute patients aged over 70 years admitted to an Australian teaching hospital, we validated REFS against the Geriatrician's Clinical Impression of Frailty (GCIF), measures of cognition, comorbidity and function, and assessed inter-rater reliability. Results: REFS was moderately correlated with GCIF (n = 105, R = 0.61, P < 0.01), Mini-Mental State Examination impairment (n = 61, R = 0.49, P < 0.001), Charlson Comorbidity Index (n = 59, R = 0.51, P < 0.001) and Katz Daily Living Scale (n = 59, R = 0.51, P < 0.001). Inter-rater reliability of REFS administered by two researchers without medical training was excellent (kappa = 0.84, n = 31). Conclusion: In this cohort of older acute inpatients, REFS is a valid, reliable test of frailty, and may be a valuable research tool to assess the impact of frailty on prognosis and response to therapy. &copy; 2009 ACOTA.
Perera, V., Bajorek, B.V., Matthews, S. & Hilmer, S.N. 2009, 'The impact of frailty on the utilisation of antithrombotic therapy in older patients with atrial fibrillation', Age and Ageing, vol. 38, no. 2, pp. 156-162.
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Objective: to investigate the impact of frailty on the utilisation of antithrombotics and on clinical outcomes in older people with atrial fibrillation (AF). Design: prospective study of a cohort of 220 acute inpatients aged ?70 years with AF, admitted to a teaching hospital in Sydney, Australia (April-July 2007), with 207 followed up over 6 months. Results: a total of 140 patients (64%) were identified as frail using avalidated tool. Frail patients were less likely to receive warfarin than non-frail on hospital admission (P = 0.002) and discharge (P < 0.001). During hospitalisation, the proportion of frail participants prescribed warfarin decreased by 10.7% and that of non-frail increased by 6.3%. Over the 6-month follow-up, 43 major or severe haemorrhages (20.8%), 20 cardioembolic strokes (9.7%) and 40 deaths (19.2%) were reported. Compared to non-frail, frail participants were significantly more likely to experience embolic stroke (RR 3.5, 95% CI 1.0-12.0, P < 0.05), had a small non-significant increase in risk of major haemorrhage (RR 1.5, 95% CI = 0.7-3.0, P = 0.29) and had greater mortality (RR 2.8, 95% CI 1.2-6.5, P = 0.01). Conclusion: frail older inpatients with AF are significantly less likely to receive warfarin than non-frail and appear more vulnerable to adverse clinical outcomes, with and without antithrombotic therapy. &copy; The Author 2009. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved.
Shaw, E., Tofler, G.H., Buckley, T., Bajorek, B. & Ward, M. 2009, 'Therapy for Triggered Acute Risk Prevention: A Study of Feasibility', Heart Lung and Circulation, vol. 18, no. 5, pp. 347-352.
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Background: Heavy physical exertion, emotional stress, heavy meals and respiratory infection transiently increase the risk of myocardial infarction, sudden death and stroke, however it remains uncertain how to use this information for disease prevention. Aims: We determined the feasibility of taking targeted medication for the hazard duration of a triggering activity to reduce risk. Methods: After a run-in training period over 1 month, 17 healthy subjects recorded for 1 month all episodes of physical and emotional stress, heavy meal and respiratory infection. For each episode, they were instructed to take either aspirin 100 mg and propranolol 10 mg (for physical exertion and emotional stress) or aspirin 100 mg alone (for respiratory infection and heavy meal) and record adherence with taking medication. Subjects performed exertion while wearing a heart rate monitor, once during the run-in period, and once 30 min after taking propranolol and aspirin. Results: Based on study diary subjects reliably documented triggers with 94% adherence. Designated medication was also reliably taken, with 88% adherence. Propranolol taken prior to exertion resulted in a lower peak heart rate (128 &plusmn; 38 versus 149 &plusmn; 21, p < 0.01) compared to similar exercise during the run-in period. Over two-thirds (71%) of subjects considered that it was feasible to continue taking medication in this manner. Conclusions: The study indicates that potential triggers of acute cardiovascular disease can be reliably identified, and it is feasible and acceptable to take targeted medication at the time of these triggers. These findings encourage further investigation of the potential role of this therapeutic strategy. &copy; 2009 Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of Australia and New Zealand.
Bajorek, B.V., Ogle, S.J., Duguid, M.J., Shenfield, G.M. & Krass, I. 2009, 'Balancing risk versus benefit: The elderly patient's perspective on warfarin therapy', Pharmacy Practice, vol. 7, no. 2, pp. 113-123.
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Warfarin theraphy is underused in the target at-risk elderly population. Clinicians perceive that older patients are reluctant to use this theraphy, however the perspective of patients or their carers has yet to be explored. Objective: To explore in-depth the perspectives of elderly patients and/ or their carers regarding the use of warfarin therapy. Method: A qualitative study, using semi-structured group interviews was undertaken. The audio-taped discussions were transcribed verbatim, then thematically analysed to identify emergent themes. Group discussions were conducted at a major Sydney teaching hospital, over a 2-month period. Individuals aged 65 years or older (and/or their carers) who were using long-term (6 months) warfarin therapy were recruited by voluntary response to study flyers. Results: 17 patients and carers (mean age 77.2 SD=7.5 years) participated in one of two focus groups. Five core themes emerged regarding warfarin therapy: inadequate knowledge and understanding about it, patients/carers variable experience of information provision, cycle of reactions to being on it, issues in its practical management, and the spectrum of experiences with it. Overall, participants were very accepting of the therapy, describing a high level of compliance, despite initial fears and anxieties, and a relative lack of knowledge. Patients felt somewhat abandoned in their management of warfarin due to the lack of ongoing support services in the community, and inadequate information provision. Conclusions: Elderly patients and their carers appear to be quite accepting of warfarin therapy, in contrast to the perceptions of health care professionals. More effort is needed, however, in terms of information provision, particularly in the form of community-based services, to assist patients in the long-term management of warfarin.
Bajorek, B.V., Yau, L., Lee, K. & Zulueta, W. 2009, 'Management of over-anticoagulation in warfarinised hospital patients', Journal of Pharmacy Practice and Research, vol. 39, no. 1, pp. 13-18.
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Aim: To determine the number of warfarinised hospital patients experiencing over-anticoagulation; to identify how overanticoagulation is managed and whether local guidelines are adhered to. Method: 2 prospective one-week clinical audits were conducted in 2005 (Audit 1) and 2008 (Audit 2). The medical notes, drug charts and anticoagulation charts of warfarinised patients admitted to hospital were reviewed. The following data were collected: medical histories, warfarin regimen, international non-nalised ratio results, clinical events and over-anticoagulation clinical management and treatment options. Results: Data were collected for 58 patients (Audit 1: n = 30; Audit 2: n = 28). At least one-third of all patients experienced over-anticoagulation (Audit 1: 53%; Audit 2: 36%). Haemorrhagic events occurred in 40% of patients in Audit 1 and 18% in Audit 2 (p = 0.06) - not all were associated with elevated international normalised ratios. Most cases of overanticoagulation were managed by withholding warfarin doses and one case (Audit 2) required Prothrombinex. Drug interactions were the most common risk factor (> 50% of patients) for over-anticoagulation in both audits. Problems with documentation were more prevalent in Audit 1 than in Audit 2. Conclusion: Over-anticoagulation is a common occurrence in warfarinised hospital patients. Hospital over-anticoagulation management practices need to be reviewed to ensure safe and efficacious anticoagulation.
Bajorek, B. 2009, 'Reducing the burden of cardiovascular disease', Australian Journal of Pharmacy, vol. 90, no. 1066, pp. 72-72.
Castelino, R.L., Bajorek, B.V. & Chen, T.F. 2009, 'Targeting suboptimal prescribing in the elderly: A review of the impact of pharmacy services', Annals of Pharmacotherapy, vol. 43, no. 6, pp. 1096-1106.
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OBJECTIVE: To review the currently available literature on the impact of interventions by pharmacists on suboptimal prescribing in the elderly. DATA SOURCES: MEDLINE, EMBASE, and International Pharmaceutical Abstracts databases were searched for studies published between January 1992 and December 2008. Key words included medication review, drug regimen review, pharmaceutical services, pharmaceutical care, pharmacists, medications, appropriateness, suboptimal, underuse, aged, elderly, randomized controlled trial, inappropriate, prescribing, and intervention. STUDY SELECTION AND DATA EXTRACTION: To be included in the review, studies must have been conducted in patients 65 years or older, published in English, randomized and controlled, and must have included an intervention delivered by a pharmacist or had a pharmacist as a member of the intervention team. From each relevant study, the following data were extracted: study duration, country, number of patients, year of publication, objective, type and impact of the intervention, method used to assess suboptimal prescribing, and data concerning the quality of the study. DATA SYNTHESIS: A total of 38 articles were identified, of which 12 matched our inclusion criteria. Seven articles included interventions initiated by pharmacists, and the remaining 5 described interventions in which the pharmacist was a part of the multidisciplinary team. A broad range of tools was used to measure prescribing appropriateness; we found that a consensus on the best approach has not been reached. Most of the studies involving pharmacists showed significant improvement in suboptimal prescribing at one or more time points. However, most of these interventions were directed toward reducing the overuse or misuse of medications. CONCLUSIONS: Pharmacy services to reduce suboptimal prescribing have shown promising and noteworthy improvements. More research is needed to address the underutilization of medications in the elderly and healthcare i...
Perera, V., Bajorek, B.V., Matthews, S. & Hilmer, S.N. 2009, 'Reply', Age and Ageing, vol. 38, no. 6, pp. 763-764.
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Vermeer, N.S. & Bajorek, B.V. 2008, 'Utilization of evidence-based therapy for the secondary prevention of acute coronary syndromes in Australian practice', Journal of Clinical Pharmacy and Therapeutics, vol. 33, no. 6, pp. 591-601.
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Aim: To review and document the current utilization of pharmacotherapy for the secondary prevention of acute coronary syndromes (ACS) in patients discharged from an Australian hospital. Methods: A retrospective cross-sectional study was conducted at a major Sydney teaching hospital. Patients with either a primary or secondary diagnosis of acute coronary syndrome were identified from medical records over a 4-month period (January-April 2007). A range of clinical data was extracted from medical records, including medical history, clinical presentation and pharmacotherapy both on admission and at discharge. This audit focussed on the use of four guideline-recommended therapies: aspirin &plusmn; clopidogrel, beta blockers, statins and ACE-inhibitors (ACE-I), as well as the utilization of multiple antithrombotics. Results: Data pertaining to a total of 169 patients was extracted and reviewed. The mean age of the study population was 65.9 years and 71% of the population was male. Non-ST-segment elevation myocardial infarction (Non-STEMI) accounted for 42% of the admissions, whereas 33.7% and 24.3% of the patients were respectively admitted for ST-segment elevation myocardial infarction (STEMI) or unstable angina. After accounting for reported contra-indications, overall, 96% of the eligible patients received antithrombotics comprising of at least aspirin, and 79% of eligible patients received aspirin plus clopidogrel. Furthermore, 82% of eligible patients received a beta-blocker at discharge, 86% a statin and 79% received either an ACE-I or angiotensin-II receptor antagonist. Compared with patients who presented with myocardial infarction (with or without ST-segment elevation), those presenting with unstable angina were less likely to receive a beta-blocker (OR = 0.19, 95%-CI: 0.08-0.48) or an ACE-agent (OR = 0.15, 95%-CI: 0.06-0.39) at discharge. Patients over 65 years of age were also less likely to receive a beta-blocker (OR = 0.35, 95%-CI: 0.14-0.89) or an ACE-agent (OR =...
Page, M.A., Bajorek, B.V. & Brien, J.-.A.E. 2008, 'Prescribing in teaching hospitals: A qualitative study of social and cultural dynamics', Journal of Pharmacy Practice and Research, vol. 38, no. 4, pp. 286-291.
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Background: General practitioners integrate an array of social and environmental factors into their prescribing decisions. In teaching hospitals, despite the involvement of multiple practitioners in making and acting on prescribing decisions, little is known about the influence of roles, relationships, professional subcultures and underlying beliefs, on prescribing practices. Aim: To explore the social and cultural dynamics of prescribing in teaching hospitals. Method: Consultants, registrars, junior doctors, nurses and pharmacists from 2 large Sydney teaching hospitals were sampled purposively and invited to participate in a qualitative study involving semi-structured interviews. The interview topics explored included: attitudes about prescribing, roles and responsibilities, communication of decisions, influences on prescribing and factors contributing to prescribing errors. Interviews were transcribed verbatim and the content analysed thematically. Results: Participants included 8 consultants, 8 registrars, 9 junior doctors, 7 nurses and 11 pharmacists. 5 distinct sets of social and cultural influences on prescribing behaviours were identified. The dominant set of influences related to the structure of how prescribing took place and chief among these were the strong intra-professional relationships of medical teams. Other social and cultural influences related to how prescribing decisions were communicated, underlying assumptions within medical teams, knowledge acquisition and the hospital environment. Conclusion: Prescribing in teaching hospitals is shaped by a complex web of social and cultural dynamics. An appreciation of these influences may be vital to the success of strategies to improve use of medicines in teaching hospitals.
Su, E.Y., Naganathan, V., Fallah, H., Bajorek, B.V. & McLachlan, A.J. 2008, 'Anticoagulation control in hospitalised patients on warfarin', Journal of Pharmacy Practice and Research, vol. 38, no. 4, pp. 292-295.
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Background: Anticoagulation control is a strong predictor of Iclinical outcomes for patients on warfarin. Aim: To identify instances of excessive anticoagulation in hospitalised patients on warfarin and to determine the causes of international normalised ratios (INRs) of 5 and above and the management strategies used to correct it. Method: An observational descriptive study undertaken at a teaching hospital over a 3-month period. Data were reviewed prospectively and retrospectively to measure the percentage of time patients were maintained within their target INR range while in hospital and to identify cases of excessive anticoagulation. Patients were divided into a control group (INR < 5) and a high INR group (INR ? 5). Possible causes of INRs of 5 and above and its management strategies were recorded. Results: Out of a total of 208 patients on warfarin identified in the geriatric, orthopaedic and cardiology wards, 144 patients met the study criteria. The mean percentage of time spent within, above and below the target INR range by the control group was 60%, 0% and 15%, and by the high INR group was 41%, 33% and 16%, respectively. In the high INR group, 26 possible causes of INRs of 5 and above were identified and the co-administration of roxithromycin and warfarin were implicated in 7 cases. Management strategies for INRs of 5 and above were compared between two stratified groups (INR 5-9 and INR ? 9). The management strategies adopted included warfarin dose reduction (83%; 86%), temporary withholding of warfarin (100%; 100%), administration of vitamin K (58%; 100%), fresh frozen plasma (13%; 43%) and prothrombin complex concentrate (8%; 29%). The time to return to the upper limit of the target INR range was INR 5-9 (1.6 SD 1.5 days) and INR ? 9 (0.5 SD 0.4 days). Conclusion: Anticoagulation control is difficult for hospital patients and drug interactions are an important contributing factor. The management strategies adopted to correct excessive anticoagulatio...
Kung, M.-.S. & Bajorek, B. 2008, 'Medications in pregnancy: Impact on time to lactogenesis after parturition', Journal of Pharmacy Practice and Research, vol. 38, no. 3, pp. 205-208.
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Background: Although the many factors that affect the initiation of lactation have been identified, the impact of medications on lactogenesis remains largely unknown. Aim: To explore the impact of medications used during pregnancy on time to lactogenesis after parturition. Method: Data were collected prospectively from women admitted to a metropolitan Sydney hospital for parturition. Information was obtained via a short interview with each patient, as well as from medical notes, drug charts and infant feeding charts. Results: The average time to lactogenesis was 68.9 hours (range 22.5-126). 39% of women experienced delayed lactogenesis. Observational results showed that the use of some medications during pregnancy may impact on the time to lactogenesis. Cigarette smoking during pregnancy and prolonged stage II vaginal delivery may also increase the time to lactogenesis. Conclusion: Several medications used during pregnancy may impact on time to lactogenesis but the biological plausibility is unknown.
Buchan, D.S. & Bajorek, B. 2008, 'Incidence of venous thromboembolism and thromboprophylaxis after total hip or knee arthroplasty', Journal of Pharmacy Practice and Research, vol. 38, no. 3, pp. 200-204.
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Background: Despite numerous guidelines and consensus statements on venous thromboembolism (VTE) prophylaxis, there appears to be a large gap between evidence and practice. Aim: To identify the incidence of VTE, thromboprophylaxis practice, VTE risk factors, and bleeding complications in patients undergoing elective total hip or knee arthroplasty. Method: Patients who underwent elective total hip or knee arthroplasty from 1 January 2004 to 31 December 2005 were identified retrospectively from medical records at two hospitals. A clinical case audit was performed and data collected on the 3-month incidence of VTE, thromboprophylaxis practice, VTE risk factors and bleeding episodes. Results: VTE incidence was 13% (in-hospital incidence 9.3% and 3-month readmission incidence 3.3%) and was significantly higher at Hospital 1 for unilateral total knee arthroplasty (p= 0.02) and unilateral total hip arthroplasty (p = 0.02). At both hospitals the 3-month incidence of VTE was 16% post unilateral total knee arthroplasty compared to 7.7% post unilateral total hip arthroplasty (p = 0.06). 99% of patients received appropriate pharmacological prophylaxis and of these 87% received an appropriate dose. 17 patients (55%) that developed VTE had one or more risk factors. There were 23 cases (9.30%) of minor bleeding and 4 cases (1.6%) of major bleeding. Conclusion: VTE incidence was higher than that quoted in the literature, which may reflect high usage of pre-discharge deep vein thrombosis screening in the study population. There is a need to develop and disseminate management algorithms for elective total hip or knee arthroplasty in the local setting.
Nguyen, N.-.A. & Bajorek, B.V. 2008, 'Pharmacist prescribing in warfarin therapy: Exploring clinical utility in the hospital setting', Journal of Pharmacy Practice and Research, vol. 38, no. 1, pp. 35-39.
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Background: Managing warfarin therapy can be challenging and a multidisciplinary approach to achieve optimal outcomes can be beneficial. Internationally, extended roles for pharmacists have involved collaborative prescribing privileges. Aim: To explore the clinical utility and capacity of pharmacists to undertake prescribing functions in anticoagulation management in the hospital setting. Methods: Pharmacists were recruited from a large Sydney teaching hospital. A questionnaire was used to simulate a pharmacist prescribing function and to explore their opinion of the usefulness of prescribing and their confidence to undertake such roles. The appropriateness of pharmacists' prescribing decisions was evaluated. Results: Prescribing authority was generally considered useful for pharmacists in the management of warfarin therapy. Pharmacist prescribing in the inpatient setting was thought to enable enhanced pharmacovigilance and be useful when medical staff are unavailable. However, outpatient settings were considered more appropriate. Dependent or collaborative models of prescribing were considered more appropriate than independent models. Despite expressing confidence in their ability to prescribe, the majority of participants' responses (58%) were deemed clinically inappropriate. Lack of training and experience and opposition from the medical team were identified as potential barriers toward pharmacist prescribing. Conclusion: Extended prescribing roles for pharmacists in anticoagulation management may be useful, particularly in the outpatient setting. Training and experience is needed to ensure safe prescribing practices are maintained.
Glover, S. & Bajorek, B.V. 2008, 'Exploring point-of-care testing of capillary blood in warfarin management', Journal of Pharmacy Practice and Research, vol. 38, no. 4, pp. 300-304.
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Background: Long-term warfarin therapy requires intensive laboratory monitoring of venous blood. Reliable and efficient point-of-care testing (POCT) of capillary blood offers an alternative to laboratory monitoring. Aim: To explore the perceptions of health professionals to POCT in warfarin management and to identify the models of monitoring warfarinised patients preferred by health professionals. Method: An exploratory descriptive study that purposively sampled health professionals (hospital pharmacists, specialists, nurses, general practitioners) involved in the management of anticoagulated patients and practising within an area health service. Health professionals were invited to participate in a group discussion on POCT and to then complete a brief survey ranking proposed monitoring models incorporating POCT. Results: 4 group discussions and/or individual interviews with 33 health professionals elucidated several themes, such as lack of knowledge or confidence in POCT, operator accreditation and careful patient selection. An acute post-acute care model and general practice surgery model incorporating POCT was preferred by health professionals in terms of perceived benefits to patients, cost-effectiveness and time efficiency. Conclusion: POCT will be a component in the monitoring and management of warfarinised patients in the future. A drawback to POCT is the perceived inaccuracy of the devices used. Operator training and maintenance of a controlled practice environment were suggested strategies to overcome variability.
Vracar, D. & Bajorek, B.V. 2008, 'Australian general practitioners' views on pharmacist prescribing', Journal of Pharmacy Practice and Research, vol. 38, no. 2, pp. 96-102.
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Aim: To explore Australian general practitioners' views on extending prescribing rights to pharmacists, the appropriateness of pharmacist prescribing models, and the influence of general practitioners' characteristics on their preference for a particular pharmacist prescribing model. Method: The study consisted of two parts. Part A was a scenario-based questionnaire using Likert-scale responses and Part B was a semi-structured interview. General practitioners were randomly recruited from two Sydney divisions of general practice. Data were analysed using descriptive statistics and qualitative responses were thematically analysed. Results: Completed questionnaires were received from 22/150 general practitioners (response rate 15%), with 10 general practitioners providing additional comments. 10/12 (83%) general practitioners participated in the interviews. Repeat prescribing and prescribing by referral were the most favoured models; 53% of general practitioners rated them as appropriate or somewhat appropriate models of pharmacist prescribing. 6 major themes emerged: focus on safety issues, lack of awareness of pharmacist training and capabilities, division of professional/clinical responsibility, conflict in definition of prescribing versus treating, interference with the general practitioner-patient relationship and remuneration. Conclusion: General practitioners favoured the dependent pharmacist prescribing approach, which is the most widespread practice overseas. The issues raised by the general practitioners need to be addressed before pharmacist prescribing can be pursued in Australia.
Hilmer, S.N., Rangiah, C., Bajorek, B.V. & Shenfield, G.M. 2007, 'Failure to weigh patients in hospital: A medication safety risk', Internal Medicine Journal, vol. 37, no. 9, pp. 647-650.
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Often patients are not weighed in hospital. Failure to weigh patients prescribed renally excreted drugs may correlate to adverse drug events. We carried out a cross-sectional study of patients prescribed common renally excreted drugs (heparin, enoxaparin and gentamicin), admitted to two wards at Royal North Shore Hospital, Sydney over 3 months. Of all patients surveyed, 28% (22/78) in the orthopaedic ward and 22% (27/124) in the medical ward were weighed. Among those prescribed therapeutic doses of the study drugs, 25% (3/12) in the orthopaedic ward and 27% (7/26) in the medical ward were weighed. Patients prescribed therapeutic anticoagulation who were not weighed experienced more haemorrhagic complications than patients who were weighed (P = 0.03). Patients prescribed renally excreted drugs in hospital are frequently not weighed. This is associated with reduced medication safety. &copy; 2007 Royal Australasian College of Physicians.
Bajorek, B.V., Ogle, S.J., Duguid, M.J., Shenfield, G.M. & Krass, I. 2007, 'Management of warfarin in atrial fibrillation: Views of health professionals, older patients and their carers', Medical Journal of Australia, vol. 186, no. 4, pp. 175-180.
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Objective: To identify the views of health professionals, patients and their carers on strategies to improve the use and management of warfarin in older patients with atrial fibrillation. Design: Qualitative study based on analysis of group interviews. Setting: A major metropolitan teaching hospital, from 1 March to 30 April 2003. Participants: 14 patients (? 65 years) with established atrial fibrillation and taking warfarin, three carers, 12 specialists, eight general practitioners, six community pharmacists, nine hospital pharmacists, and 11 nurses volunteered in response to flyers promoting the study. Results: Suggested strategies to improve warfarin management targeted support services for GPs and patients. Hospital-based clinicians felt that dissemination of trial evidence to GPs to support treatment recommendations is required, and that GPs need to enlist allied health professionals in the management of patients taking warfarin. GPs preferred access to practical advice from expert colleagues on the day-to-day management. Patients requested more information about warfarin therapy, as access to information is inadequate, particularly from primary sources (GPs, community pharmacists). Verbal and written information are equally important, but a single counselling session or supply of a booklet was viewed as inadequate. Participants identified various interventions for all levels of warfarin management; from the collective input, a framework for management strategies was developed. Conclusions: Health professionals and patients require more customised information to support warfarin use and management.
Bajorek, B.V. 2007, 'In reply', Medical Journal of Australia, vol. 187, no. 6, pp. 371-371.
Bajorek, B.V., Krass, I., Ogle, S.J., Duguid, M.J. & Shenfield, G.M. 2006, 'Warfarin use in the elderly: The nurses' perspective', Australian Journal of Advanced Nursing, vol. 23, no. 3, pp. 19-25.
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Objective: To explore the barriers to warfarin use from the perspective of nurses working in aged care. Design: A qualitative study, involving a semi-structured group interview, during March-April 2001. Setting and Subjects: Eleven nurses, employed within the catchment of the Northern Sydney Area Health Service, who were involved in the care of elderly warfarinised patients. Main outcome measure: Identification, via thematic analysis, of the main themes underpinning the nursing perspective on warfarin use in this setting, with regard to their perceived role/s, experiences with patients, and potential strategies for managing the therapy. Results: Five main themes were identified: perceived patient attitude toward warfarin; barriers to the use of warfarin; expressed lack of confidence in the processes involved; nurses' role in warfarin use; and strategies to improve warfarin use. Nurses were concerned about warfarin use in the elderly, but felt they had a limited capacity to intervene. Conclusion: Nurses are potentially underutilised as a resource and support for both patients and prescribers, in the management of warfarin therapy.
Khoo, A. & Bajorek, B.V. 2006, 'Extended roles for pharmacists in warfarin therapy: Identifying opportunities for pharmacist prescribing', Journal of Pharmacy Practice and Research, vol. 36, no. 3, pp. 190-193.
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Background: Warfarin has traditionally posed a challenge to clinicians because of its narrow therapeutic index. Extended roles for pharmacists may address some of the problems in warfarin management. International experience has involved anticoagulation clinics in which pharmacists have authority to engage in collaborative prescribing activities with physicians. Aim: To identify opportunities for pharmacist prescribing activities in warfarin management within the hospital setting. Method: Pharmacists from a Sydney teaching hospital were recruited. The first stage involved an audit of pharmacists' interventions in patients receiving warfarin. Stage two involved a focus group discussion to further explore these issues. Results: 9 pharmacists saw 41 warfarinised patients over the 5-day data collection period. Pharmacists saw reason to intervene in the warfarin therapy of 19 (46%) of these patients and a prescribing activity was involved in 16 (84%) of these interventions. Despite these ample opportunities to prescribe, pharmacists felt limited in their ability to use these opportunities. Lack of information about the patient, workloads, medicolegal responsibility, and the need for further training and experience, were cited as the main reasons pharmacists were hesitant to prescribe. It was also suggested that the outpatient setting may be more appropriate to trial a pharmacist prescribing role. Conclusion: There are ample opportunities for pharmacist prescribing in the area of warfarin management. However, practice change is needed before such a role can be taken up in the hospital setting.
Kay, O.C., Bajorek, B.V. & Brien, J.-.A.E. 2006, 'Pharmacist prescribing activities - An electronic survey on the opinions of Australian Pharmacists', Journal of Pharmacy Practice and Research, vol. 36, no. 3, pp. 199-203.
Aim: To identify Australian pharmacists' awareness of their international colleagues' prescribing practices and explore their views about the feasibility and utility of pharmacist prescribing privileges within the scope of their current practice. Method: Members of the AusPharmList, Australian Association of Consultant Pharmacy and The Society of Hospital Pharmacists of Australia were invited by e-mail to participate in a community pharmacist, consultant pharmacist or hospital pharmacist electronic survey. These surveys were designed to elicit views concerning: dependent and independent prescribing; resource availability to support pharmacist prescribing; ability to justify prescribing decisions; and limitations of pharmacist prescribing. Results: Of the 268 surveys completed (response rate 6.4%), 45% of respondents were aware of their international colleagues' prescribing activities. 74% agreed that pharmacists should be granted dependent prescribing authority, while 52% agreed that pharmacists should be granted independent prescribing authority. The majority (88%) indicated they could identify their own limitations and 86% believed they could justify their prescribing decisions as dependent prescribers. 73% believed they would benefit from prescribing authority in their daily scope of practice. Conclusion: In 2004, awareness of international developments in pharmacist prescribing was not extensive among the respondents. However, many identified areas where they would benefit from dependent prescribing activities in their daily scope of practice.
Bajorek, B.V., Krass, I., Ogle, S.J., Duguid, M.J. & Shenfield, G.M. 2006, 'Warfarin use in the elderly: the nurses' perspective.', The Australian journal of advanced nursing : a quarterly publication of the Royal Australian Nursing Federation., vol. 23, no. 3, pp. 19-25.
OBJECTIVE: To explore the barriers to warfarin use from the perspective of nurses working in aged care. DESIGN: A qualitative study, involving a semi-structured group interview, during March-April 2001. SETTING AND SUBJECTS: Eleven nurses, employed within the catchment of the Northern Sydney Area Health Service, who were involved in the care of elderly warfarinised patients. MAIN OUTCOME MEASURE: Identification, via thematic analysis, of the main themes underpinning the nursing perspective on warfarin use in this setting, with regard to their perceived role/s, experiences with patients, and potential strategies for managing the therapy. RESULTS: Five main themes were identified: perceived patient attitude toward warfarin; barriers to the use of warfarin; expressed lack of confidence in the processes involved; nurses' role in warfarin use; and strategies to improve warfarin use. Nurses were concerned about warfarin use in the elderly, but felt they had a limited capacity to intervene. CONCLUSION: Nurses are potentially underutilised as a resource and support for both patients and prescribers, in the management of warfarin therapy.
Hanes, C.A. & Bajorek, B.V. 2005, 'Pharmacist prescribing: Views of Australian hospital pharmacists', Journal of Pharmacy Practice and Research, vol. 35, no. 3, pp. 178-180.
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Aim: To explore the views of a sample of Australian hospital pharmacists on prescribing privileges. Method: The study involved a questionnaire and a focus group discussion for hospital pharmacists and teacher practitioners. Participants could participate in either or both of these activities. Results: 15 pharmacists completed the questionnaire and 8 participated in the focus group discussion. Several models of pharmacist prescribing (discharge and specialist settings) were seen to be appropriate and useful to Australian practice. 93% of pharmacists noted that prescribing privileges would enable them to provide more efficient/improved pharmaceutical care; 64% that prescribing would result in reduced healthcare costs; and all noted physician opposition as a barrier. Pharmacists indicated that they already prescribed on an 'unofficial' basis. Training and accreditation beyond registration was deemed necessary by all pharmacists. Conclusion: Hospital discharge or specialist settings may be most appropriate to pilot pharmacist prescribing in Australia. Further research on a larger scale is needed to provide a base of evidence before this practice is pursued.
Bajorek, B.V., Krass, I., Ogle, S.J., Duguid, M.J. & Shenfield, G.M. 2005, 'Optimizing the use of antithrombotic therapy for atrial fibrillation in older people: A pharmacist-led multidisciplinary intervention', Journal of the American Geriatrics Society, vol. 53, no. 11, pp. 1912-1920.
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OBJECTIVES: To develop, implement, and evaluate a pharmacist-led multidisciplinary intervention in a hospital setting that would optimize antithrombotic use in elderly atrial fibrillation patients. The hypothesis that there would be an increase in the proportion of patients receiving antithrombotic therapy at discharge was tested. DESIGN: Evidence-based algorithms were developed to define the criteria (stroke risk vs contraindications) by which an elderly patient's requirement for antithrombotic therapy was assessed. SETTING: A major Sydney teaching hospital. PARTICIPANTS: Two hundred eighteen consecutively admitted elderly patients (mean age 85.2) were recruited over a 6-month period. INTERVENTION: A pharmacist-coordinated multidisciplinary review process was implemented to coordinate risk assessments and subsequently recommend appropriate antithrombotic therapy, as per the algorithms. MEASUREMENTS: The proportion of patients receiving antithrombotic therapy was assessed on admission (preintervention), at discharge (postintervention), and postdischarge (follow-up at 3 and 6 months). RESULTS: As a result of the intervention, 78 patients (35.8%) required changes to their existing antithrombotic therapy. Of these changes, 60 (76.9%) were "upgrades" to more-effective treatment options (e.g., from no therapy to any agent or from aspirin to warfarin). The remaining 18 (23.1%) changes were "downgrades" to less-effective, albeit safer, options. Despite a significant increase in antithrombotic use overall (59.6% vs 81.2%, P < .001), fewer patients received warfarin postintervention, after having been assessed as inappropriate candidates (20.7% vs 17.4%, P = .39). CONCLUSION: A pharmacist-led multidisciplinary process was successfully developed and implemented within the hospital setting to increase overall antithrombotic use. Having addressed some of the known barriers and limitations to warfarin use, these algorithms may allow allied health workers, patients, and clinic...
Valiya, S.N. & Bajorek, B.V. 2005, 'Ximelagatran cost effectiveness for stroke prevention in atrial fibrillation', Journal of Pharmacy Practice and Research, vol. 35, no. 4, pp. 279-283.
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Background: The benefit of warfarin for stroke prevention in non-valvular atrial fibrillation has been demonstrated in various clinical trials. Warfarin has a narrow therapeutic window and carries a significant risk of bleeding. Ximelagatran is a new oral antithrombotic with predictable plasma concentrations and excellent bioavailability. Aim: To compare the costs and benefits of ximelagatran to that of warfarin and aspirin. Method: In a preliminary cost-effectiveness analysis, the costs and clinical consequences of warfarin, aspirin and ximelagatran were compared. The principal outcome was measured in the form of an incremental cost-effectiveness ratio. A decision analysis model was constructed to map the expected outcomes of three treatment alternatives. Sensitivity analysis tested the robustness of the data. Results: Warfarin appeared to be most cost effective in this clinical setting. The incremental cost-effectiveness ratio indicated that the use of ximelagatran in preference to warfarin would cost an additional $272 000/patient/year. Likewise the use of ximelagatran in preference to aspirin would cost an additional $13 000/patient/year. Conclusion: Ximelagatran appears to be cost effective in a small group of high-risk patients. This may have implications for the development of treatment guidelines in this clinical setting.
Hanes, C. & Bajorek, B. 2004, 'Pharmacist prescribing: Is Australia behind the times?', Australian Journal of Pharmacy, vol. 85, no. 1014, pp. 680-681.
Gelgor, L., Bajorek, B. & Chen, T. 2003, 'Evaluating pain management in rural community pharmacy: The importance of HMR and regular pain assessment', Australian Journal of Pharmacy, vol. 84, no. 998, pp. 366-369.
It is estimated that the best practice management of pain in Australia could result in savings (on medications, drug-related hospital admissions, utilisation of ancillary health services, social benefits such as those to the workforce) of approximately $4.8bn per annum.1,5 Pharmacy-based interventions have demonstrated cost savings and increased quality use of medicines, as well as healthcare practitioner satisfaction, in other healthcare priority areas (for example, asthma and diabetes). However, in Australia so far, no pharmacy-based interventions have been evaluated for the management of chronic pain, despite the pharmacist's accessibility and ideal placement to play a significant role in its management.
Bajorek, B.V., Krass, I., Ogle, S.J., Duguid, M.J. & Shenfield, G.M. 2002, 'The impact of age on antithrombotic use in elderly patients with non-valvular atrial fibrillation', AUSTRALASIAN JOURNAL ON AGEING, vol. 21, no. 1, pp. 36-41.
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Bajorek, B., Krass, I., Ogle, S.J., Duguid, M.J. & Shenfield, G.M. 2002, 'The impact of age on antithrombotic use in elderly patients with non-valvular atrial fibrillation', Australasian Journal on Ageing, vol. 21, no. 1, pp. 36-41.
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Aim of study: To investigate the use of antithrombotic therapy in elderly patients with atrial fibrillation (AF). Methods: Data were collected retrospectively from the medical records of 262 AF patients ?65 years, who were admitted to a Sydney teaching hospital over a 12-month period. Results: Overall, 202 (79%) patients were discharged on some antithrombotic therapy. Patients ?80 years were as likely to receive antithrombotic therapy as those <80 years (75.8% versus 81.9%, P=0.23), but a significantly lower proportion received warfarin than did those <80 years (25.5% versus 61.5%, P<0.0001). Definite contraindications to anticoagulation were a significant influence on antithrombotic agent selection (P=0.04), but multivariate analysis indicated that 'old age' was the largest contributing factor: patients ?80 years were 5.46 times more likely to receive aspirin in preference to warfarin than their younger counterparts (P<0.0001). Conclusion: Warfarin is being withheld in AF patients ?80 years for reasons other than recognised contraindications and is, therefore, potentially underutilised in the target elderly population. Further studies are necessary to determine whether this is appropriate.
Bajorek, B.V., Krass, I., Ogle, S.J., Duguid, M.J. & Shenfield, G.M. 2001, 'A survey of long-term antiarrhythmic therapy in elderly patients with atrial fibrillation', Australian Journal of Hospital Pharmacy, vol. 31, no. 2, pp. 93-97.
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Aim: To investigate the use of long-term antiarrhythmic (rhythm-control [RHY] and rate-control [RAC]) therapy for the management of atrial fibrillation (AF) in elderly patients. Method: Data were collected retrospectively from the medical records of 255 patients with AF who were ?65 years of age and were admitted to Royal North Shore Hospital in the period 1 July 1996 to 30 June 1997. Results: Overall, 192 (75%) patients were discharged on antiarrhythmic therapy for the long-term management of AF. Sixty-six patients (26%) received RHY only, 90 (35%) received RAC only, 36 (14%) were prescribed the combination of RHY + RAC therapy, and 63 (25%) received no therapy. Patients ?80 years of age were equally likely to receive long-term antiarrhythmic therapy as those <80 years (74% versus 77%, p = 0.65), but a significantly lower proportion of them received RHY only than in those <80 years (17% versus 34%, p = 0.001). The preferred option in older patients was RAC only (42%). Cardiology patients were more likely to receive RHY &plusmn; RAC therapy (53%) than Aged Care (16%) or General Medicine patients (16%; p < 0.05). Logistic regression analysis indicated that old age and medical specialty were significant predictors for the choice of agent: patients ?80 years were 2.2 times more likely to receive RAC only in preference to RHY only therapy than their younger counterparts (p = 0.044). Conclusion: Long-term rhythm-control therapy (e.g. amiodarone, sotalol) is potentially underutilised in AF patients ?80 years of age. Reliance on the use of rate-controlling agents such as digoxin persists in clinical practice.
Krass, I., Bajorek, B., Bagia, M., Fragoudakis, I., Ozgur, B. & Sy Li, C. 1997, 'An evaluation of three methods used in the prophylaxis of cyclophosphamide-induced haemorrhagic cystitis in bone marrow transplant patients', Journal of Oncology Pharmacy Practice, vol. 3, no. 4, pp. 193-199.
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Background. Bone marrow transplant (BMT) recipi ents, who receive high-dose cyclophosphamide as part of conditioning therapy, are at considerable risk of developing haemorrhagic cystitis (HC). The role of prophylaxis of cyclophosphamide-induced HC is well- established in the literature, however, the literature is inconclusive with respect to the most effective form of prophylaxis. This study was undertaken to evaluate three methods of prophylaxis for HC used in BMT recipients in terms of the rate and severity of HC. The incidence and type of adverse effects attributed to each prophylactic regimen were also documented. Method. A retrospective cohort study was con ducted in four teaching hospitals. During the 5-week data collection period, the medical records of 354 adult BMT patients were reviewed. Routine prophy laxis for cyclophosphamide-induced HC was used in all four hospitals. Three methods of prophylaxis were identified; bladder irrigation, forced diuresis, and Mesna. Results. The incidence of HC (micro- and mac rohaematuria combined) was significantly higher in the hospital using bladder irrigation for prophylaxis than in the hospitals using Mesna or forced diuresis (P < 0.0001). The effect was more pronounced when the incidence of microhaematuria and macrohaema turia were compared separately. Patients receiving bladder irrigation for prophylaxis experienced an approximately threefold higher incidence of micro haematuria (35.4%) than patients receiving either Mesna or forced diuresis. The incidence of macroh aematuria in the bladder irrigation group was approx imately twice as high (21.1%) as in other methods. The difference in the incidence of HC between Mesna and forced diuresis was not statistically significant, with a reported incidence of microhaematuria of 9.6% and 8.9%, respectively, and for macrohaematuria of 13.2% and 8.9%, respectively. Logistic regression anal ysis was performed to examine the relationship be tween potential risk factors, methods...