Background
I am proud to receive the inaugural Eric Kirk Award for my work
in research and teaching since 1972 .
I wish to thank the Pharmaceutical Society of Western Australia
for providing the award, the distinguished nominators Professor
Michael Garlepp , John Gibson and Richard Plumridge , professional
colleagues overseas and in Australia.
May I single out Dr George Eckert who from 1975-85 was the clinical
pharmacologist in Sydney Hospital and guided me into a new career
in research at a time I had other callings and over the past decade
Professor Bruce Sunderland in Curtin University's School of Pharmacy
whose support was crucial to the work carried out since 1990.
And of course my biggest debts are owed to my dear wife Rita and
my late mother Despina.
We are fortunate Eric Kirk was at his peak in the 1970s when hospital
pharmacy was booming.
He had built an elite pharmacy department by 1974 in Sir Charles
Gairdner Hospital before becoming the president of the Society of
Hospital Pharmacists of Australia and then the Pharmaceutical Council
of Western Australia.
The fruits of his efforts can be seen in the robust pharmacy structures
he shaped during the 1970s and his many protégés who
became leaders in pharmacy practice, education and administration.
Eric was always good to me and he was ever busy thinking how best
to apply findings from clinical research generally including ours
at the time from Sydney Hospital.
Population
approach to research
The Kirk Award work can be divided into the two most active phases
of my pharmacy research : the first seven years from 1975 to 1982
and the last seven years to 2003.
The continuing element in my research has been the population
approach to research which refers to methods which produce statistics
demonstrating pharmacy's contribution to health or some aspect
of health which help guide National and State pharmacy and other
decision makers.
The population approach is complementary to the clinical approach
whose main feature is individualised patient care.
It is simply illustrated in universities by departments or schools
of public or population health where the basic disciplines are
epidemiology and bio-statistics.
Phase
1 in hospital research : 1975 to 1982
In 1975 I began work in the clinical pharmacology unit at Sydney
Hospital with a Roche national fellowship granted by the Society
of Hospital Pharmacists of Australia .
In our first studies we categorised patients by their a) demographics
or gender and age, b) disease or pathology markers, or by c) the
main therapeutic drug group they received.
We soon found serious toxicities in many patients with impaired
renal function due largely to inappropriate drugs or excessive
dosage regimens .
We produced the creatinine program where biochemistry results
were sent immediately to pharmacy departments in addition to wards
allowing pharmacists to promptly assess the results and prepare
advice on drug and dosage changes before their ward rounds according
to patients' clinical results at no added cost to the hospital.
The program with additional pathology results was adapted in hospitals
nationwide and saved thousands of patients adverse effects and
even their lives. Clinical pharmacy then in its infancy in Australia
became streamlined almost overnight by this simple population
approach. I was awarded a Winston Churchill fellowship in 1976
to study the prevention of adverse drug effects overseas on the
basis of this work.
In 1978 I came back to work at Fremantle Hospital as Australia's
first official clinical pharmacist.
We quickly applied an expanded creatinine program.
We also developed in the pharmacy department attractive monthly
hospital drug bulletins with feedback to doctors on their prescribing
patterns to compare with contemporary standards became recognised
nationally .
We proved the bulletins were significantly effective in 1980 using
a quasi-experimental technique 'mini-time series analysis' then
new to pharmacy and an underutilised form of evaluation in pharmacy
to this time .
The 'Australian Prescriber', 'Current Therapeutics' , other new
nationally distributed therapeutics journals and hospital drug
bulletins contained mainly drug information of a general nature.
The 'Fremantle Hospital Drug Bulletin' was a new agent of therapeutic
change adopted by others.
In 1979 and 1980 I wrote editorials on drug safety (adverse drug
reactions) and improving drug usage in hospitals for the 'Medical
Journal of Australia' .
These may be the first or only times a pharmacist has written
editorials for a medical journal at least in Australia.
The above work led to many reports and papers published up to
1982. Curtin University's Dr Stan Kailis and I wrote a chapter
on 'Anaemias' in 1978 which continued until 1996 in later editions
of the international clinical pharmacy textbook entitled 'Textbook
of therapeutics: drug and disease management' ( Sixth edition.
Williams and Wilkins,1996)
This was a tribute to the international status of our clinical
pharmacy work in Australia.
The national Kodak fellowship awarded to me by the Pharmaceutical
Society of Australia in 1978 to study sources of drug and morbidity
data by state in Australia and my election to the Pharmaceutical
Council of Western Australia in 1980 marked the start of my subsequent
research into community drug usage, health and pharmacy's health-related
activities
Phase
2 in community research : 1996-2003
From 1996 to 2003 we developed three areas of important pharmacy
research and innovation.
First, the national evaluation of pharmacy services in Australia's
methadone programs from January 1999 to June 2000.
This stemmed from our 1996 studies of the transition in Western
Australia of methadone programs into primary care from the William
Street specialist clinic in the midst of the 1990s heroin epidemic.
We found high satisfaction with pharmacists, lower operating costs
and higher retention in those programs involving community prescribers
and pharmacists who dispensed methadone as maintenance treatment
for heroin addiction the main type of opioid dependence.
We also noticed the high concurrent misuse of licit opioids and
amphetamines which led to two landmark papers in November 2000
and 2002 on international and jurisdictional analyses of licit
opioids and licit psychostimulants most frequently prescribed
for ADHD.
The high per capita levels of use and evidence of diversion we
found in Australia and in this state rang alarm bells for the
profession and governments.
Our work was recognised in an invited chapter written with Professor
Sunderland and the University of Western Australia's biostatistician
Max Bulsara in the international reference in this area entitled
'Drug misuse and community pharmacy' ( editors J Sheridan and
J Strang. London: Taylor and Francis, 2003).
Our second contribution in this phase began in 1997 when our Pharmacy
department was the first in Australia to formally train pharmacists
in clinical testing .
The need to accredit pharmacists for screening blood pressure,
glucose, cholesterol and other forms of testing to prevent obesity,
diabetes, cardiovascular and other lifestyle or chronic diseases
is now compelling.
Thirdly, we are finishing our report of the national pharmacy
database project (January 2002 to April 2003) the first national
study of health-related activities and facilities occurring in
Australia's community pharmacies.
The data from 1131 pharmacies equating to an unprecedented 81%
response we received from the randomised stratified nationwide
sample of community pharmacies have led so far to over 900 tables
of statistical analysis in this four volume report we are near
completing. Our comprehensive review of the literature and my
meetings with national pharmacy bodies and leading academics during
January 2003 in London, the USA and Canada showed the great value
of this project both internationally and nationally.
The methods and results will form international and national benchmarks
for all future large-scale studies of pharmacies.
Most importantly the report will provide crucial data for the
Fourth Government Pharmacy Agreement negotiations to start in
2003 as well as providing a reference base for national and state
pharmacy decision makers and educators
Concluding
pleas:
May I conclude with two pleas.
First, that the Minister for Health facilitate far better access
by our researchers to data on licit opioids and psychostimulants
held by State government agencies because of the indisputable
evidence of diversion and misuse revealed in our 2002 and 2002
papers in the Medical Journal of Australia.
We have found it very difficult to obtain these data.
By inhibiting access for their careful analysis, the surges in
licit opioid and psychostimulant drug misuse will continue in
this State, to the detriment of this society and our profession.
Second, our state pharmacy bodies should involve our educators
more in their decisions affecting health related activities in
pharmacies.
Curtin University's School of Pharmacy has shown by its achievements
in research and educational initiatives since 1990 that the profession
will be richer if it has it continuously contributes to the decision-making
process in pharmacy providing health care and disease prevention.
Constantine
G Berbatis
14 March 2003.
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