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Translational research ‘practice based research in health promotes the study of the process of care, raises new questions, includes patient knowledge and preferences - and is the final common pathway for improving individual patient care and outcomes ‘ Westfall, Mold, Fagnan 2007 A shift in paradigm? ‘practice-based research provides the laboratory that will help generate new knowledge and bridge the chasm between recommended care and improved health ‘ ‘Practice-based research is a crucial scientific step - between the great advances of the next 25 years and the millions who want to live a long and healthy life’ Westfall, Mold, Fagnan 2007 Mortality in Stroke survivors at 10 yrs = 82% Recurrent stroke leads to a stepwise decline into dependency. “Risk for stroke recurrence lowered by 80% if risk factors are managed correctly” Hachinski 2002 Management of risk factors In stroke survivors Attempts to address problem CHAMP (cardiac) PROTECT (stroke)--initiation in hospital Get with the Guidelines (stroke) --web page CASPR (stroke)--standardized orders Can Telemedicine assist in reaching this goal? Study Type Reference RCT Mayo NE, et al, 2007 Cohort Study Bosworth HB, et al, 2000 Weimar C, et al, 2002 Cohort Study Comparative Study Randomise d Study Kawas C, et al, 1995 Duncan P, et al 2005 Validation Study Kwon S, et al, 2006 Telemedicine Intervention Telephon e calls by nursing care coordinator ove r 6 weeks after discharge, and at 6 months Telephon e interviews at 1, 6 and 12 months Telephon e follow-up at 100 days and 1 year post discharge. Targe t population 190 post-stroke patients 1073 post-stroke patients 4264 Post-stroke patients fro m 30 hospitals Use of Telephone and in-person 84 subjects to test cognitive abilities Measuring strok e impact using 458 patients with telephone intervi ews compared stroke to mail a t 12 weeks post stroke Measuring strok e impact using 136 post stroke telephone intervi ews at 12 and patients fro m 13 16 weeks post stroke VA hospitals Study Type Reference Telemedicine Intervention RCT Grant JS et al, 2002 * Telephon e contact strategy for problem solving therapy o ver 18 months. 74 Stroke Survivors and Caregivers RCT Boter H, 2004 * Outreach care included 3 telephone calls an d a home visit within 5 months of discharge. Qualitative study Pierce 2004 Internet based education and support Needs Study Demeris G, Shigaki CL, Schopp LH, 2005 Buckley KM, Tran BQ, Prandoni CM, 2004 Lutz BJ , Chumble r NR, Roland K, 2007 Assessment of needs for client Š oriented ru ral teleh ealth network by intervi ew Tele-health nurse s use videophones to contact caregiver s 536 Post Hospital Stroke Patients and Informal Care Giver s. 9 Caregivers of patients with stroke 43 health professionals Descriptive Study Needs Study Interviews to identify unmet post-discharge needs for existing care coordination and home-teleh ealth services Stroke Survivors and Caregivers 21 family caregiver s of stroke patients 22 post stroke patients (3mths to 5 years) and carers Elements Integration of hospital and primary care Surveillance of risk factor management Long-term sustainability of the process Track record GPEP randomized control trial 2000-2005 HARP program 2006 Systolic blood pressure sBP 138 136 mmHg 134 Treatment 132 Control 130 128 126 Discharge (mmHg): Treatment 12 months 5.1 Control T-test ANCOVA 6.0 -1.0 p = .07 p = .03 Change scores -2.1 p = .01 • 12-month target of <140 mmHg: 66/89 (74%) of treatment group, 52/89 (58%) of control group (p < .05). Systolic BP sBP 140 138 136 mm Hg 134 IC 132 SC 130 128 126 124 Discharge 12 months Change scores: 6.0 (IC) vs –1.8 (SC) T-test: p = 0.02 ANCOVA (age, sex, Rankin, baseline sBP): p = 0.04 BMI BMI 30 29 IC 28 SC 27 26 Discharge 12 months Change scores: 0.5 (IC) vs –0.3 (SC) T-test: p = 0.04 ANCOVA (age, sex, Rankin, baseline BMI): p = 0.007 Walks Walks per week 6 5 4 IC 3 SC 2 1 0 Discharge 12 months Change scores: 0.8 (IC) vs –0.7 (SC) T-test: p = 0.001 ANCOVA (age, sex, Rankin, baseline walks per week): p < 0.001 Risk factor advice Patients receiving risk factor advice 100 90 80 70 % 60 IC SC 50 40 30 20 10 0 BP Cholesterol Smoking Alcohol Salt intake/weight Physical activity Blood glucose Significant group differences: BP, cholesterol, alcohol, physical activity and blood glucose. Depression Patients depressed at 12 months 100 90 80 70 % 60 IC 50 SC 40 30 20 10 0 12 months PHQ-9 score of 5 or greater reflected depressive symptoms. At 12 months, 30/91 (33%) IC patients exhibited depressive symptoms, compared to 52/95 (55%) SC patients (χ2 = 8.9, p = 0.003). AQoL AQoL 31 30 29 28 IC 27 SC 26 25 24 23 Discharge 12 months Higher score indicates lower quality of life. Change scores – T-test: p = 0.002 – ANCOVA (age, sex, Rankin, baseline AQoL): p = 0.012 Disability Rankin 2.5 2 1.5 IC SC 1 0.5 0 Discharge 12 months Higher score indicates greater disability. Change scores – T-test: p = 0.012 – ANCOVA (age, sex, baseline Rankin): p = 0.003 Weight BMI 30 29 Treatment 28 Control 27 26 Discharge Change scores (BMI): 12 months Treatment 0.50 Control -0.32 T-test p = .04 ANCOVA p = .03 Depression Patients with depressive symptoms 100 90 80 70 % 60 Treatment 50 Control 40 30 20 10 0 12 months Score of 5 or above on PHQ-9: Treatment Control 31/92 (34%) 51/94 (54%) χ2 = 8.0, p < .01 Questions How can we promote translation of evidence-based recommendations? How can we take these items of transferrable knowledge and make them culturally and health services appropriate for other systems? What works and how can we maintain the key elements? Diversity--not a problem but an asset. How can long-term sustainability be promoted? Adapted, streamlined model ICARUSS Integrated Care for Risk Reduction in Stroke Survivors ICARUSS An integrated model of care The translation of evidence-based recommendations for secondary stroke prevention into practice Traditional model Dichotomy hospital and primary care system Defective information flow between two systems Passive role of patient and carer Integrated care model ( ICARUSS) Ongoing information and data transfer between GP,coordinator, carer and patient, sharing of expertise (Telemedicine) Propelled by informed carer/patient Ongoing educational aspect Availability of advice (shared care element) Sustainability maintained by Chronic Disease Management Model, combines Recommendations commenced in hospital Protocols for management Ongoing surveillance Long-term sustainability Components of the ICARUSS model Patient risk profile established in hospital Identifiction of Carer Patient and carer education begins in hospital, continuing as groups in community. Patient and carer assume responsibility role Telephone tracking ( stratified according to patient profile) Patient/carer-held document (guidelines, documentation) Bi-directional information flow (Hospital, coordinator, GP, patient and carer) Data base entry and surveillance Clear guidelines for GP ( Flow-chart) mirrored in patient/carer-held document GP access to telephone advice from specialist ( Shared Care component) Model of Chronic Disease Management ( Long-term patient and carer support and involvement, continued data return, surveillance and coordinator contact) Patient and carer empowerment Encouraging assumption of responsibility by patient and/carer Based on “active” Epilepsy model Guided by hand-held document mirroring that of GP Telephone tracking According to risk stratification Semi-structured interview Educational aspect 3-monthly pre-and post GP visit relationship) Structured interview Data to GP Post-call --?data faxed Inexpensive Outlook (only if regular GP Bi-directional information transfer Traditional model was unidirectional Integrated care model is bi-directional Clear directions on flow chart to both patient and primary care doctor 3 monthly information to GP (if available) Serial data transfer back to coordinator Surveillance of data Reaction to persistent discrepancies Chronic Disease Management model Groups (8-10 patients) Selected on locality/culture/language Leader ( patient, carer or volunteer) Structured personal education by coordinator Telephone contact networking with group Monthly telephone report to coordinator Meet as individual group and as part of the educational sessions run by coordinator Leader to continue telephone contact and surveillance during and after exit from one year program Leader to continue ensuring data return after exit POST DISCHARGE HOSPITAL Stratified telephone tracking related to patient risk profile High Medium Low CO-ORDINATOR Coordinator makes contact with patient or carer PATIENT Patient is discharged from hospital or rehabilitation facility. Pre Visit Call Post Visit Call Pre Visit Call Post Visit Call GP folder, clinical summary and letters sent to GP. Pre Visit Call Post Visit Call Pre Visit Call Home Visit v 3-month visit Randomisation and baseline data collection 6-month visit 9-month visit 12-month visit GENERAL PRACTITIONER See Fig 2. For detail. Ongoing support and medical advice to GP’s NEUROLOGIST Discharge information review and telephone contact with GP Independent Patient Review at Stroke Follow-up Clinic Fig. 1. Diagrammatic Representation of the Integrated Care Model HOSPITAL 3-MONTH POST DISCHARGE VISIT DISCHARGE CO-ORDINATOR Stratified telephone tracking related to risk factor profile. Pre Visit Call Data Faxed to Coordinator Post Visit Call PATIENT 3-month visit GENERAL PRACTITIONER Data Faxed to GP Support to GP NEUROLOGIST Fig. 2. Diagrammatic Representation of 3–monthly Visit Flow EDC Generated Document Folders Control Patient 12month Follow-up Letter Pre-Printed Risk Factor Brochures David Jackson Senior Stroke Research Coordinator Department of Neurology The Royal Melbourne Hospital Parkville VIC 3052 Phone: +61 3 9342 7598 Fax: +61 3 9342 7444 David Jackson Senior Stroke Research Coordinator Department of Neurology The Royal Melbourne Hospital Parkville VIC 3052 Phone: +61 3 9342 7598 Fax: +61 3 9342 7444 Intervention Patient 12month Follow-up Letter 3-month Worksheet Reducing Risk For Stroke Recurrence By An Integrated, Multimodal Model Of Care Reducing Risk For Stroke Recurrence By An Integrated, Multimodal Model Of Care The ICARUSS Program The ICARUSS Program 1/05/2007 31/01/2008 David Jackson Senior Stroke Research Coordinator Department of Neurology The Royal Melbourne Hospital Parkville VIC 3052 Phone: +61 3 9342 7598 Fax: +61 3 9342 7444 Dear Dr. Thank you for agreeing to participate in this study. The National Ageing Research Institute the Royal Melbourne Hospital and the National Stroke Research Institute have initiated this research project to address the benefit of a structured, shared care model in the management of vascular risk factors and depression for patients discharged from hospital after stroke. . Reducing Risk The process consists of: Dear Dr. Thank you for agreeing to participate in this study. ICARUSS Program Dear Dr. It is hoped that this process will facilitate the management and follow-up of stroke patients with particular reference to modifiable vascular risk factors and post-stroke depression. Thank you for agreeing to participate in this study. Attached, please find a clinical summary, which includes a risk factor profile, medications, plans for management and an ability profile that depicts function in the areas of: David Jackson Senior Stroke Research Coordinator Department of Neurology The Royal Melbourne Hospital Parkville VIC 3052 Phone: +61 3 9342 7598 Fax: +61 3 9342 7444 An indication of the presence (or not) of depression/anxiety inReducing the patient post discharge Risk For Stroke Recurrence By An Integrated, Multimodal Model Of Care If you have any queries, please contact David Jackson at 9342 7598 or fax: 9342 7444 It is hoped that this process will facilitate the management and follow-up of stroke patients with particular reference to modifiable vascular risk factors and post-stroke depression. Yours sincerely, David Jackson Senior Stroke Research Coordinator Jacques Joubert MB CHB, MRCP, FRACS 6-month Worksheet 6-month Worksheet Incorporation of a patient held risk factor worksheet into follow-up visits by the general practitioner Regular telephone tracking of the patient for visits and the appropriate blood tests An indication of the presence (or not) of depression/anxiety in the patient post discharge It is hoped that this process will facilitate the management and follow-up of stroke patients with particular reference to modifiable vascular risk factors and post-stroke depression. Attached, please find a clinical summary, which includes a risk factor profile, The National Ageing Research Institute the Royal Melbourne Hospital and the medications, plans for management and an ability profile that depicts function in the National Stroke Research Institute have initiated this research project to address areas of: the benefit of a structured, shared care model in the management of vascular risk factors and depression for patients discharged from hospital after stroke. mental status . motor function The process consists of: verbal expression understanding Incorporation of a patient held risk factor worksheet into follow-up visits by incontinence the general practitioner Regular telephone tracking of the patient for visits and the appropriate The project manager will forward you a patient status report on a regular basis. blood tests The study will in no way interfere with your management of the patient. v The National Ageing Research Institute the Royal Melbourne Hospital and the National Stroke Research Institute have initiated this research project to address the benefit of a structured, shared care model in the management of vascular risk factors and depression for patients discharged from hospital after stroke. . The process consists of: Control Patient Letter of Thanks For Stroke Recurrence By An Integrated, Multimodal Model Of Care Incorporation of a patient held risk factor worksheet into follow-up visits by the general practitioner The Regular telephone tracking of the patient for visits and the appropriate blood tests 1/05/2007 An indication of the presence (or not) of depression/anxiety in the patient post discharge The ICARUSS Program Intervention Patient Letter of Thanks Attached, please find a clinical summary, which includes a 1/05/2007 risk factor profile, medications, plans for management and an ability profile that depicts function in the areas of: Dear Dr. mental status Thank you for agreeing to participate in this study. motor function verbal expression The National Ageing Research Institute the Royal Melbourne Hospital and the understanding National Stroke Research Institute have initiated this research project to address incontinence the benefit of a structured, shared care model in the management of vascular factors and depression for patients discharged from hospital after stroke. The project manager will forward you a patient status report onrisk a regular basis. . The process consists of: The study will in no way interfere with your management of the patient. For Stroke Recurrence By An Multimodal Model Of Care v 9-month Worksheet 9-month Worksheet Yours sincerely, v 12-month Worksheet 12-month Worksheet ICARUSS Program Attached, please find a clinical summary, which includes a risk factor profile, medications, plans for management and an ability profile that depicts Dear function Dr. in the areas of: Thank you for agreeing to participate in this study. mental status mental status motor function verbal expression understanding incontinence The study will in no way interfere with your management of the patient. If you have any queries, please contact David Jackson at 9342 7598 or fax: 9342 7444 David Jackson Senior Stroke Research Coordinator Jacques Joubert MB CHB, MRCP, FRACS David Jackson Senior Stroke Research Coordinator Department of Neurology The Royal Melbourne Hospital Parkville VIC 3052 Phone: +61 3 9342 7598 Fax: +61 3 9342 7444 7444 Incorporation of a patient held risk factor worksheet into follow-up visits by If you have any queries, please contact David Jackson at 9342 7598 or fax: 9342 the general practitioner Regular telephone tracking of the patient for visits and the appropriate Yours sincerely, Reducing Risk blood tests Integrated, An indication of the presence (or not) of depression/anxiety in the patient post discharge The David Jackson Senior Stroke Research Coordinator It is hoped that this process will facilitate the management and follow-up of stroke patients Jacques Joubert MB CHB, MRCP, FRACS with particular reference to modifiable vascular risk factors and post-stroke1/05/2007 depression. The project manager will forward you a patient status report on a regular basis. motor function The National Ageing Research Institute the Royal Melbourne Hospital and the verbal expression National Stroke Research Institute have initiated this research project to address understanding the benefit of a structured, shared care model in the management of vascular incontinence risk factors and depression for patients discharged from hospital after stroke. . The project manager will forward you a patient status report on a regular basis. The process consists of: The study will in no way interfere with your management of the patient. vv Incorporation of a patient held risk factor worksheet into follow-up visits by the general practitioner If you have any queries, please contact David Jackson at 9342 7598 or fax: 9342 7444 Regular telephone tracking of the patient for visits and the appropriate blood tests Yours sincerely, An indication of the presence (or not) of depression/anxiety in the patient post discharge It is hoped that this process will facilitate the management and follow-up of stroke patients with particular reference to modifiable vascular risk factors and post-stroke depression. David Jackson Senior Stroke Research Coordinator Jacques Joubert MB CHB, MRCP, FRACS Attached, please find a clinical summary, which includes a risk factor profile, medications, plans for management and an ability profile that depicts function in the areas of: 12-month Follow-up Letter mental status motor function verbal expression understanding incontinence The project manager will forward you a patient status report on a regular basis. The study will in no way interfere with your management of the patient. If you have any queries, please contact David Jackson at 9342 7598 or fax: 9342 7444 Yours sincerely, David Jackson Senior Stroke Research Coordinator Department of Neurology The Royal Melbourne Hospital Parkville VIC 3052 Phone: +61 3 9342 7598 Fax: +61 3 9342 7444 David Jackson Senior Stroke Research Coordinator Jacques Joubert MB CHB, MRCP, FRACS Pre-visit Datasheet Reducing Risk For Stroke Recurrence By An Integrated, Multimodal Model Of Care The ICARUSS Program 1/05/2007 Dear Dr. Thank you for agreeing to participate in this study. David Jackson Senior Stroke Research Coordinator Department of Neurology The Royal Melbourne Hospital The National Ageing Research Institute the Royal Melbourne Hospital and the National Stroke Research Institute have initiated this research project to address the benefit of a structured, shared care model in the management of vascular risk factors and depression for patients discharged from hospital after stroke. . The process consists of: Parkville VIC 3052 Phone: +61 3 9342 7598 Fax: +61 3 9342 7444 Incorporation of a patient held risk factor worksheet into follow-up visits by the general practitioner Risk For Stroke Recurrence By An Regular telephone tracking of the patient for Reducing visits and the appropriate blood tests Integrated, Multimodal Model Of Care An indication of the presence (or not) of depression/anxiety in the patient post discharge The ICARUSS Program Pre-visit Letter It is hoped that this process will facilitate the management and follow-up of stroke patients with particular reference to modifiable vascular risk factors and post-stroke depression. 23/07/2007 Attached, please find a clinical summary, which includes a risk factor profile, medications, plans for management and an ability profile that depicts function in the areas of: Dear Dr Einstein, mental status motor function verbal expression understanding incontinence RE: Jed Carter. 3-month after discharge Integrated Care Visit. After my telephone conversation with your patient and carer the following have been determined Current Problems The project manager will forward you a patient status report on a regular basis. Distance walked with ease at one time The study will in no way interfere with your management of the patient. = 200m Times walked per day If you have any queries, please contact David Jackson at 9342 7598 or fax: 9342 7444 = 2 Reducing Risk For Stroke Recurrence By An = 7 Integrated, Multimodal Model Of Care Days walked per week Yours sincerely, David Jackson Senior Stroke Research Coordinator Jacques Joubert MB CHB, MRCP, FRACS Standard drinks /day / week = 0 Cigarettes smoked per day = 40 Clinical Summary The ICARUSS Program 1/05/2007 Depression David Jackson Senior Stroke Research Coordinator Department of Neurology The Royal Melbourne Hospital Parkville VIC 3052 Phone: +61 3 9342 7598 Fax: +61 3 9342 7444 Dear Dr. Depression screening assessment (PHQ-9) score: = 6 Thank you for agreeing to participate in this study. According to scoring criteria for the PHQ-9, the patient is mildly moderately severely The National Ageing Research Institute the Royal Melbourne Hospital and the depressed National Stroke Research Institute have initiated this research project to address the benefit of a structured, shared care model in the management of vascular th The patient has an appointment with you risk on 16 April 2007 at 10:00am factors and depression for patients discharged from hospital after stroke. . The process consists of: Yours sincerely, Reducing Risk For Stroke Recurrence By An Integrated, Multimodal Model Of Care Incorporation of a patient held risk factor worksheet into follow-up visits by the general practitioner Regular telephone tracking of the patient for visits and the appropriate blood tests An indication of the presence (or not) of depression/anxiety in the patient CLINICAL post discharge The ICARUSS Program SUMMARY Patient Name: Jed Carter It is hoped that this process will facilitate the management and follow-up of stroke patients with particular reference to modifiable vascular risk factors and post-stroke depression. Admission date: 12/01/2007 Discharge date: 13/01/2007 GP Letter of Thanks Attached, please find a clinical summary, which includes a risk factor profile, medications, plans for management and an ability General profile Practitioner: that depicts Dr function in the Frank Einstein areas of: mental status motor function verbal expression understanding incontinence Diagnosis: Left Middle Cerebral Territory Infarction. Presentation: Awoke with right sided facial droop, slurred speech, sensory changes right upper and lower limbs, significant weakness right upper and lower limbs Clinical status on discharge The project manager will forward you a patient status report on Alert a regular basis. Conscious state: Mental state: Oriented The study will in no way interfere with your management of the patient. Speech: Mild dysarthria Weakness: Right arm 2/5. Right leg no movement. Neglect: None Gait: Impaired in relation to weakness Continence: Continent If you have any queries, please contact David Jackson at 9342 7598 or fax: 9342 7444 Yours sincerely, David Jackson Senior Stroke Research Coordinator Jacques Joubert MB CHB, MRCP, FRACS Known risk factors for stroke Hypertension Hyperlipidemia Smoking Obesity Social circumstances: Lives with supportive wife and one adult child. David Jackson Senior Stroke Research Coordinator Department of Neurology The Royal Melbourne Hospital Parkville VIC 3052 Phone: +61 3 9342 7598 Fax: +61 3 9342 7444 Reducing Risk For Stroke Recurrence By An Integrated, Multimodal Model Of Care The ICARUSS Program Relevant Investigations; CT (Brain): Nil significant abnormalities detected. 1/05/2007 Carotid Doppler study: 75% stenosis left ICA. 0-15% right ICA Fasting Blood sugar: 7.5mmol/L Cholesterol: 6 mmol/L Triglycerides: 4.8 mmol/L HDLC: 5 mmol/L LDLC: 6 mmol/L INR: Not applicable Discharge medication: Aspirin 100mg orally daily Lipitor 40mg orally daily Atenolol 25 mg orally daily Frusemide 40 mg orally bd Dear Dr. v Thank you for agreeing to participate in this study. The National Ageing Research Institute the Royal Melbourne Hospital and the National Stroke Research Institute have initiated this research project to address the benefit of a structured, shared care model in the management of vascular risk factors and depression for patients discharged from hospital after stroke. . The process consists of: Telmisartan 40mg orally daily Incorporation of a patient held risk factor worksheet into follow-up visits by the general practitioner Regular telephone tracking of the patient for visits and the appropriate Discharge planning: For discharge to Broadmeadows Health Service forblood approximately 3 tests Anand indication weeks of inpatient rehabilitation. Social work arranging supports for patient carer. of the presence (or not) of depression/anxiety in the patient post discharge It is hoped that this process will facilitate the management and follow-up of stroke patients with particular reference to modifiable vascular risk factors and post-stroke depression. Attached, please find a clinical summary, which includes a risk factor profile, medications, plans for management and an ability profile that depicts function in the areas of: mental status motor function verbal expression understanding incontinence The project manager will forward you a patient status report on a regular basis. The study will in no way interfere with your management of the patient. If you have any queries, please contact David Jackson at 9342 7598 or fax: 9342 7444 Yours sincerely, David Jackson Senior Stroke Research Coordinator Jacques Joubert MB CHB, MRCP, FRACS Fig. 3 . ICARUSS Document Gallery. v Login Screen Acknowledgement of ‘Musee des Beaux-Arts et de la Dentelle d’Alencon – France’ for use of the ICARUSS Logo Image will appear in Phase 2 Example Patient Details Screen Patient fields will be customised to ICARUSS Team Requirements Drop down list of forms available for each patient, as well as ability to add forms The fields shown here will be how the customised ICARUSS EDC Patient Fields will be displayed Research Design Randomized Controlled Trial Comparing “usual care” to the ICARUSS model Telemedicine features Telephone contact (stratified Telephone follow-up, Specialist-GP contact) Fax (information to GP) Web-based EDC (data surveillance) (Radiological data transfer) (Videoconferencing) Australian collaborators Royal Melbourne Hospital Austin Hospital Western Hospital Royal Perth Hospital Hunter New England Health Area Service National Ageing Research Institute National Stroke Research Institute University of Melbourne Monash University National Stroke Foundation Neuroscience Trials Australia North Western Division General Practice Current Participating Sites in Australia Royal Melbourne Hospital Western Hospital St Vincents Austin Hospital John Hunter Hospital Royal Perth Hospital Investigators and Scientific Advisory Committee Geoffrey Donnan Stephen Davis Graeme Hankey David Ames Helen Dewey Chris Reid Peter Hand John Barlow Sue Hookey David Jackson Lynette Joubert Jacques Joubert Christine Kilpatrick Erin Lalor Chris Levi Colin Masters Michael Murray Debra O’Connor Carolyn Searle Robyn Smith Christine Walker Tissa Wijeratne Bob Williamson Ingrid Winship International collaborating centres France Singapore India Sri Lanka