The Rise of Russia
131 Pages
English
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The Rise of Russia

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Downloading requires you to have access to the YouScribe library
Learn all about the services we offer
131 Pages
English

Description

  • cours magistral - matière potentielle : suggestions
  • expression écrite
Chapter 24 The Rise of Russia Chapter Summary. The rise of the Russian empire, unlike Western colonial empires, although altering power balances through Eurasia involved only limited commercial exchange. After freeing themselves from Mongol domination by 1480, the Russians pushed eastward. Some extension of territory also occurred in eastern Europe. Regional states, many differing from Russia, were present, with Lithuania and Poland rivaling Russia into the 17th century. Russia, with its Byzantine influenced culture, had been unimportant in world affairs before the 15th century.
  • royal authority
  • economic lag
  • peasant discontent
  • russia from the mongols
  • importance of the western european
  • western dress styles
  • military superiority
  • russia
  • land
  • state

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Exrait











NATIONAL PHARMACY DATABASE
PROJECT












CG Berbatis, VB Sunderland, CR Mills and M Bulsara

June 2003








School of Pharmacy
Curtin University of Technology of Western Australia
GPO Box U1987
Perth WA 6845





C Berbatis and V B Sunderland
School of Pharmacy
Curtin University of Technology of Western Australia
GPO Box U1987 Perth
Western Australia 6845



This project was funded under the Third Community Pharmacy Agreement Research and Development Grants
Program for the project titled “Reference data base of Australia’s community pharmacies: Analysis of national
survey”.

































First published in June 2003

Reference database of Australia’s community pharmacies.

Copyright School of Pharmacy, Curtin University of Technology of Western Australia GPO
Box U1987 Perth W Australia 6845.

ISBN: 1 74067 2747.

All rights reserved. This publication may be reproduced with appropriate citation and the prior
informing of the copyright owners and the authors of this report

Table of Contents

Acknowledgements …………...……………………..………………………………………… 3
Executive summary …………...……………………..………………………………………… 4
Recommendations …………...……………………..…………………………………………9
Contact details …………...… 16

1. Introduction …………….……………..………………………………………… 17
1.1 Terms of Reference ………………..………..………………………………………… 17
1.2 Origins of the National Pharmacy Database Project ….………………..……… 17
1.3 Review of pharmacy surveys overseas and in Australia ………..…..……… 18
1.4 Methodology …………………….…..…………………………………………… 19
1.4.1Sample and stratification with PhARIA system ……….…………..……… 19
1.4.1.1 Difficulties with the PhARIA system for stratification ….……..………… 20
1.4.2 Participation rate ……………..…….………………………………………… 20
1.4.3 Response rate ……………………… 21
1.4.4 Questionnaire ………………………………… 22
1.4.5 Implementation and administration of survey …….…………… 22
1.4.6 Analysis ……………..…….………………………………………………... 23
1.4.7 National estimates …..…….…………………………... 24
2. Database (Term of Reference 1, disk attached) …..………………………………..... 25
2.1 Pharmacy activities, facilities, services, PhARIA and estimates …………....... 25
2.2 Pharmacy characteristics and facility/service provision ……………………..... 25
2.3 Pharmacy characteristics and barriers …..………………………………........... 26
3. (Terms of Reference 1, 2 and 5) Discussion by section ……………………........... 27
3.1 Section A Respondent pharmacist details …………………….............. 28
3.2 Section B Enhanced pharmacy services paid or unpaid …………………………. 33
3.3 Section C Barriers to and facilitators of enhanced pharmacy services ………. 37
3.4 Section D Prescription-related activities ............………………………………..... 39
3.5 Section E Medication review processes 47
3.6 Section F Primary health care, pharmacy and pharmacist-only medicines ……. 51
3.7 Section G Preventive services ……………...........……………………………….... 54
3.8 Section H Harm minimisation or reduction ...........………………………………... 59
3.9 Section I Complementary therapies and herbal medicines …………………….. 63
3.10 Section J Information facilities and programs ....………………………………... 66
3.11 Section K Technologies and health communications ………………………….... 68
3.12 Section L Opinion on the use of technical facilities ………………………….... 72
3.13 Section M Pharmacy and staff …………………………....………………………. 75
4. Pharmacy characteristics, facility/service provision (Term Reference 3) …………….. 83
5. Pharmacy characteristics and barriers (Term of Reference 4) 86
5.1 Barriers to extended services .…….……..…..………………….………. 86
5.2 Facilitators of extended services ………..………………..………………… 88
5.3 Opinions on technical facilities .…………….…………………..………………… 90

6. Glossary and definitions ……………………………..……………..……………………….. 92
7. Technical notes ………………………….…………..……………..………………………… 93
8. References ………………………………………………………………………….. 94
9. Appendices ……………….…………..……………..……………………………… 106


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Acknowledgements

We are indebted to the 1131 respondent pharmacists, the following for their investment of
experience and expertise, many others for their valued contribution and our partners.

National advisory panel
A.Prof C Alderman Director Pharmacy, Daw Park VA Hospital, SA; delegate of SHPA
Mr R Brennan Registrar Pharmaceutical Council of WA; delegate of COPRA
Mr W Kelly Deputy CEO ; delegate of Pharmaceutical Society of Australia
Mr T Logan Pharmacy Guild of Australia; Chairman and delegate of QCPP
Dr M Ortiz Researcher, RTI Health, N Carolina, USA ; delegate of APMA
Dr P Passmore Research and Community pharmacist, South Perth, WA
Prof K Raymond LaTrobe University, Ballarat; delegate of CHAPANZ
Dr M Tatchell Director Health Economics; delegate of Pharmacy Guild of Australia,

International specialist and research pharmacists
Dr S Anderson School of Tropical Health and Hygiene, London, England
Mrs A Burns American Pharmacists Association, Washington DC, USA
A Prof L MacKeigan Faculty of Pharmacy, University of Toronto, Canada
Prof J McElnay School of Pharmacy, Queen’s University, Belfast, N Ireland
Mrs G Norheim American Pharmacists Association, Washington DC,USA
Dr C A Pedersen College of Pharmacy, Ohio State University, Columbus, USA
Mrs K Roberts Area pharmacy specialist - drug misuse, Glasgow, Scotland
Dr A Ruston Greenwich University, England
A Prof J Sheridan University of Auckland, New Zealand
Dr J.W.F.van Mijl Quality Institute for Pharmaceutical Care, Kampen, The Netherlands


Specialist and other pharmacists in Australia
Prof M Garlepp School of Pharmacy, Curtin University of Technology of W Australia
Mr J Gibson Research and Practicing Pharmacist, Nedlands, W Australia
Mr P Hannan Webstercare, Mortlake, NSW, Australia
Mr A Lloyd Pharmacy Consultant, Melbourne Victoria
Mr R Manning Chief Pharmacist, Tiwi Islands, NT, Australia
Mr P Muhlheisen Turning Point Alcohol and Drug Centre, Fitzroy, Victoria
Debbie Rigby Consultant Pharmacy, Pharmaceutical Society Australia (Q)
Mr A Saunders Health Communication Network, Melbourne, Victoria
Mr K Sclavos Chairman QCPP 2001, Pharmacy Guild of Australia (Queensland)
Ms H Stark Formerly ACNielsen Consult, Sydney, Australia
Mr G Stevens Webstercare, Mortlake, NSW, Australia

Focus group and pilot test pharmacists
Mr F Grapsas Kardinya Park Shopping Centre Pharmacy, W Australia
Mr G Lowe 7 Day Pharmacy, Leeming Shopping Centre, Leeming, W Australia
Mr D Manuel Amcal Pharmacy, Tuart Hill, W Australia
Mr P Rees Amcal Chemist, Westfield Shopping Centre, Innaloo, W Australia
Mr M Rollings Pharmacity Chemist Supermart , Perth, W Australia
Mr L Souness Guardian Pharmacy, East Victoria Park (medical centre), W Australia

Mrs M Bou-Samra Pharmacy Guild of Australia, Queensland
Mr R Cox Terry White Chemists, Buranda, Queensland
Mrs S Forrester Soul Pattinson, Palmerston, NT
Ms R Guastella Mount Hospital Pharmacy, Perth
Ms S Holzberger School of Pharmacy, University of Queensland
Mr B Horsfall PSA, Victoria
Ms A Hudson Bob Willis Chemist, NSW
Ms J Kagi Boulevard Pharmacy, Mt Newman, W Australia
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Ms A Legg Riverview Pharmacy, NSW
Mr K O’Connor Wishart Pharmacy, Queensland
Mr B Moffatt Manley, NSW
Mr S McCahon Amcal Chemist, Kalgoorlie, W Australia
Mrs L Rushton Mayne Pharmacy, Blacktown, NSW
Ms H Stark Seaforth Pharmacy, NSW

Others who assisted exceptionally
Mr G Bridge QCPP, Pharmacy Guild of Australia, Barton, ACT Australia
Mr A Daniels Australian Pharmacist, Deakin, ACT, Australia
Mr P Dragovic Danica Graphic Design studio, Bayswater, W Australia
Mrs C D’Costa WPO-Receptionist, School of Pharmacy, Curtin University
Mrs D D’Souza Administrative Co-ordinator, School of Pharmacy, Curtin University
Mr M Eton Australian Journal of Pharmacy, Sydney, NSW, Australia
Ms J Gilson RN National Pharmacies, Adelaide, South Australia
Ms V Graham Survey Research Centre, University of Western Australia
Mr B Langham Sign Multimedia, Perth, Western Australia
Dr A Rossouw Survey Research Centre, University of Western Australia

This project was funded by the Commonwealth Department of Health and Ageing as part of
the Third Community Pharmacy Agreement.

The Pharmacy Guild of Australia as managers of the Third Community Pharmacy Agreement
Research and Development Grants (CPA R&D Grants) Program.



































3


Executive Summary

Background
Up to 2002 there was no database of the nature and frequency of general or specialist health-
related activities performed in Australia’s community pharmacies. Without such a database
accurate time-series comparisons of changes occurring in pharmacy practice could not be
made. Pharmacy practice could not be compared with that in other countries. Pharmacy’s
activities could not be measured against Australia’s health priorities. Those making plans or
policies for undergraduate or continuing pharmacy education or training were doing so with
limited data on the pattern and trends of activities in pharmacy practice. National professional
bodies had little idea of the relative utility of the various drug information resources, the
incursion of the internet in pharmacy or even the utilisation of the telephone in pharmacists’
day-to-day communication. These same bodies and state boards wishing to make
submissions on legislative changes to government agencies or Parliamentarians had little
reliable data on the duty of care activities pharmacists do but do not actually report.
Negotiators in the pharmacy-government agreements were often data-poor on fundamental
statistics of the settings of and areas within pharmacies, the characteristics of pharmacy
owners and staff, the composition of national pharmacy sales, let alone the high prevalence of
dose administration aids (DAAs) and the nil fees for DAAs or supervised dosing in
pharmacies. Students or outside parties had no single reference to the range and frequency
of the health-related activities involved in contemporary pharmacy practice in this country.
The construction of a database of community pharmacy practice in Australia together with
data from other sources may partly overcome some of these deficiencies particularly if it is
updated regularly like Australia’s five-yearly national health surveys.
The ‘National Pharmacy Database Project (the ‘project’) officially commenced in January
2002. The national survey of community pharmacies was conducted from 12 July to 9
September. The resulting frequency data were compiled and summarised from September to
November 2002. The results were analysed from January to April 2003. The report was
completed during May and June 2003.

Aims
The terms of reference or aims of the project were :
1. To construct a national database of the most important types and rates of pharmacy
characteristics including facilities, health-related general and specialised including
preventive services in Australia’s community pharmacies for Australian and overseas
reference or comparisons;
2. To make comparisons between pharmacies in the different PhARIA zones;
3. To test relationships between pharmacy characteristics and facility/service provision;
4. To test relationships between pharmacy characteristics and barriers to facility/service
provision; and
5. To make national estimates of a range of pharmacy services and facilities.

Method
The sample of pharmacies was adequate to meet statistically defined margins of error with
prevalence rates of pharmacy services or facilities down to 1%. The PhARIA (i.e. the physical
and professional remoteness of pharmacies within Australia) was used to stratify to ensure
adequate numbers of rural and remote pharmacies. To overcome the skewness due to the
large bulk of pharmacies in Pharia 1, a 20% random of pharmacies in Pharia 1 and a total
sampling of all pharmacies in Pharias 2 to 6 was done. A questionnaire was developed with
most of the 33 questions and 240 items of data requiring numerical data with which statistical
estimates could be made adding a crucial quantitative value. The questions reflected a
balance of the core general and special activities growing in Australia’s pharmacy practice .
These were largely based on demographics trends, changes made to national health policies
since 1997 often arising from results produced by pharmacy researchers, the occurring in this
country and an inexorable evolution in pharmacy practice proceeding overseas and in
Australia. The questionnaire was designed by a professional graphics artist and reflected the
4
contemporary requirements by the pre-eminent survey methodologist, Professor Don A
Dillman. The implementation of the survey closely followed Dillman’s mixed mode survey
guidelines and was conducted and analysed independently by the University of Western
Australia’s Survey Research Centre and its Biostatistician. A 91% participation and over 81%
response rates were achieved hence non-respondent bias was minimal. A website was
constructed which for the first time in Australian pharmacy research posted results for the
participant pharmacies to observe whether they worked furthest north in the Tiwi Islands on
the coast of the Great Australian Bight to the south-west.

Results
The following table summarise the key findings in the following sections A to M following and
the Sections 4 and 5 which analysed statistically the strength of relationships between
pharmacy variables and the activities in community pharmacies. Details may be found in the
attached database.

Table 1. Key findings from the database : for Term of Reference 1,2.3 -
Section Title Key Findings
A. Respondent pharmacist • Respondents were mainly male with
details. one-third aged greater than 50
years.
• Pharmacies outside Pharia 1 have
fewer female, and also older and
less qualified staff.
• Each respondent group reported
much higher continuing professional
education (CPE) hours than their
counterparts in Great Britain.

B. Enhanced pharmacy services. • All 24 nominated enhanced
pharmacy services were
represented to some degree in
Australia’s community pharmacy.
• Enhanced services with trained staff
were evident at high levels for
asthma, diabetes, harm reduction,
herbal medicines, hypertension,
smoking cessation and wound care.
• Attention should be given to the
promotion of weight reduction
services as has already occurred for
wound care.
Many of these enhanced services were
provided with trained staff at no charge.
C. Barriers and facilitators of Greatest barriers were:
enhanced pharmacy services. • lack of time (90.3%), shortage of
pharmacists (78.3%), no extra
remuneration (63.3%) and cannot
find locums (63.2%).
Greatest facilitators were:
• dedicated study time (77.9%)
accreditation (75.6%), closed
counselling areas (72.8%) and
access to patient notes (70.6%).
• The combined resistance and
uncertainty were “appointment
systems” and “clinical testing area.”

5
D. Prescription related activities in • Dose administration aids were
community pharmacies. issued to 9.19 million patients
annually.
• Supervised administration of
individual doses included a range of
analgesics, benzodiazepines,
methadone, buprenorphine and
psychotropic agents and occurred in
community pharmacies for 25,904
patients each week.
• Community pharmacists declined to
dispense 1.075 million prescriptions
annually due to dosages,
interactions, adverse effects or other
problems.
• Counselling occurred in private
locations in the pharmacy on 14.42
million occasions annually.
• CMI computerised formation was
provided on 6.76 million occasions
and other written or printed drug
information to 8.61 million patients
annually.
• 3.71 million patients annually
required special counselling owing
to poor English language.
• compliance interventions by
community pharmacists were
recorded on 14.42 million occasions
annually.

E. Medication review process • 53.7% of community pharmacies
provided medicines to aged care
facilities and 50.8% were approved
for domiciliary medication
management reviews.
• At least 4,600 patients received one
of a range of medication reviews by
community pharmacists each month.
• Most of these reviews were carried
out by a contracted consultant
pharmacist.

F. Primary health care including • 78.2 million consultations occurred
pharmacy and pharmacist only annually in community pharmacies
medicines regarding health and medications.
• At least 4.19 million patients
annually were referred to GPs and
1.77 million to other health workers.
• Misuse of S 2 and S 3 medicines
was suspected in 0.863 million
patients and supply refused on
0.631 million occasions annually.
• Computerised or Self-Care printed
information was provided to patients
on 10.26 million occasions annually.

6
G. Preventive services • 82% of Australia’s community
implemented in this pharmacy pharmacies had a dedicated vaccine
refrigerator.
• Primary prevention actions initiated
by community pharmacists were
annually: 1.452 million nicotine
treatments, 0.687 million low-dose
aspirin , 0.739 million iron
for anaemia, 0.576 million folic
acid in pregnancy, 0.869 million
calcium for osteoporosis.
• 385,288 screening tests were
conducted annually in pharmacies
for undiagnosed chronic conditions
and 25,081 pregnancy tests were
performed.

H. Harm minimisation services • More than 40% of pharmacies are
and detected S4 and S8 active in each of methadone or
forgeries and doctor shopping buprenorphine dosing and needle
in Australia’s pharmacies exchange.
• 18.8% are active in benzodiazepine
or other prescriber contracts.
• 13,519 clients with forged
prescriptions and 23,391 patients
were identified as “doctor shoppers”
annually.

I. Complementary therapies • Community pharmacies refer 44,044
including herbal medicines clients monthly to complementary
practitioners
• Highest referrals were for
naturopathy and homeopathy.

J. Information facilities and • The following information sources
programs were used with a daily frequency in
pharmacies in Australia:
CMI Computerised 23202
CD ROMs (APP/MIMS) 20212
PSA Self Care 11867
MIMS or APP books 10709
AMH 6126
APF 4969

K. Technologies and health • 89.2% pharmacies had a computer
information and with a Pentium processor and 39.8%
communication used the internet and 40.8% email
regularly.
• On average each pharmacy
contacted doctors 3.73 times daily,
patients or their carers 1.95 times
and other health workers 0.68 times
daily by telephone.
L. Opinion on the use of technical • Telephone was strongly agreed to
facilities be the best mode of communicating
with doctors, patients and carers.


7

• There was some concern that
privacy legislation restricted
telephone communication.
• There is a greater concern that
internet sales will depress OTC
prescriptions by 2004.

M. Pharmacy and staff • The majority of pharmacies are
located in a shopping strip and are
open on average 6.18 days and 55.5
hours per week.
• 50.5% of pharmacies are members
of a wide range of “groups”.
• 54.1% of pharmacies responding
were QCPP accredited.
• 57.2% have one owner and 9.6%
have 3 or more owners and 39.5%
owners are aged over 50 years.
• The majority of proprietors work
hours was spent in the dispensary.

Pharia . Pharmacies in Pharia zones 5 and 6 consistently ranked low in the provision of a
range of services but these results need to be standardised for customer flow and other
variables.

Relationships with enhanced (specialised) pharmacy services - Term of Reference 4
Of the pharmacy variables tested the provision of enhanced and certain other services by
pharmacies was consistently and significantly related to the individual characteristics of
turnover, pharmacy size and group membership. But regression analysis is required to
control for effect modification and confounding variables.

Relationships with barriers and facilitators of pharmacy services - Term of Reference 5
For the provision of enhanced pharmacy services Pharia zone location was significantly
related individually to a number of barriers including shortage of time, shortage of
pharmacists, availability of locums, remuneration and opportunity to meet local GPs. But
regression analysis is required to control for effect modification and confounding variables.
For the provision of enhanced pharmacy services QCPP status was significantly related
individually to facilitators including access to patient notes, clinical testing area, appointment
system, and accreditation for these services. . But regression analysis is required to control
for effect modification and confounding variables.
















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