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Use and Monitoring of "Statin" Lipid-Lowering Drugs Compared With Guidelines
Susan A. Abookire, MD, MPH;
Andrew S. Karson, MD;
Julie Fiskio;
David W. Bates, MD, MSc
Arch Intern Med. 2001;161:53-58.
ABSTRACT
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Background In patients with high cholesterol, 3-hydroxy-3-methylglutaryl coenzyme
A reductase inhibitors (or "statins") have been shown to reduce overall mortality
in primary and secondary prevention. The National Cholesterol Education Program
expert panel's guidelines (Adult Treatment Panel II) recommend evaluation
and treatment of high cholesterol based on stratification of patients according
to cardiovascular risk. While evidence suggests that many patients are undertreated,
comparatively few data are available regarding overtreatment.
Objectives To assess the appropriateness of statin therapy compared with national
guidelines and to examine the appropriateness of monitoring for adverse effects.
Methods For all patients at a tertiary medical center, electronic medical records
were evaluated for presence or absence of statin use and for presence of established
coronary heart disease or cardiac risk factors. Therapy was compared with
the recommendations of the National Cholesterol Education Program guidelines.
Our primary outcome measures included, for all patients taking statins, prevalence
of appropriateness vs overuse, and for all patients with coronary heart disease,
prevalence of appropriateness vs underuse.
Results Overuse of statin therapy was found among 69% of patients undergoing
primary prevention, and among 47% of patients undergoing secondary prevention.
In addition, among patients with coronary heart disease who were not taking
statins, 88% were undertreated. Monitoring of liver function varied widely,
and did not correlate with the risk of adverse events secondary to statin
use.
Conclusions Overtreatment and undertreatment for hyperlipidemia were frequent. Decision
support may help physicians improve their performance compared with guidelines.
INTRODUCTION
MANY epidemiologic studies1, 2
over the past several decades have established the relation between an elevated
serum cholesterol level and the development of coronary heart disease (CHD).
In 1993, the expert panel of the National Cholesterol Education Program (NCEP)
proposed guidelines to stratify patients according to risk of CHD, based on
cholesterol values and other risk factors. The guidelines recommend drug therapy
for individuals at greatest risk.3
More recently, controlled trials4, 5, 6, 7, 8
have demonstrated a conclusive reduction in overall mortality and mortality
from CHD among patients whose low-density lipoprotein (LDL) cholesterol values
were lowered with 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitor
("statin") drug therapy. Initial trials4 demonstrated
a survival benefit in patients with established CHD and significantly elevated
serum cholesterol values; these results were later extended to patients with
CHD whose LDL cholesterol levels were only modestly elevated5
and even to patients with CHD who had LDL cholesterol values in the average
range.6 In patients without established CHD,
the benefit of lowering LDL cholesterol levels with statin therapy has been
shown in clinical trials to reduce the incidence of myocardial infarction
and mortality from coronary events, supporting their use in primary prevention.7 These findings were also extended to show a reduction
in coronary events among patients with modest LDL cholesterol elevations,
using aggressive LDL cholesterol lowering.8
Despite the evidence of preventable deaths among patients with CHD,
several studies have suggested undertreatment of this group by primary care
physicians9, 10, 11, 12
and cardiologists.13 In contrast, relatively
little is known about the frequency of overtreatment, particularly among patients
undergoing primary prevention. Furthermore, little is known about how practice
patterns for monitoring the safety of these medications vary or compare with
recommendations. Since primary care physicians hold a strategic position in
the detection and management of health problems, their adherence to standards
such as consensus guidelines may have a widespread effect.
To address these issues, we performed a study with several goals. Our
primary aim was to assess the prevalence of appropriateness of statin therapy
compared with established guidelines. This included the prevalence of overuse
among all patients taking statins and the prevalence of underuse among patients
with established CHD. Similarly, we wanted to assess how patients were monitored
for adverse effects, and the relation of monitoring to previously established
recommendations. Secondary aims included evaluating the impact that monitoring
had on clinical outcomes, estimating the safety of statins in this cohort,
and estimating the financial burden of monitoring. We sought to quantify the
occurrence of less obvious adverse effects, in addition to hepatotoxicity.
We also assessed the potential costs and savings associated with inappropriate
and appropriate statin use and liver function monitoring.
PATIENTS AND METHODS
STUDY SITE AND PATIENTS
This study was performed at a tertiary care center, the Brigham and
Women's Hospital, Boston, Mass, and its affiliated sites. Data were drawn
from an electronic outpatient medical record,14
which is used at most sites affiliated with the hospital, including hospital-based
practices, free-standing community practices, and community health centers.
The electronic medical record includes coded problem lists, medication lists,
and laboratory data.
To assess the accuracy of the electronic medical record,15
we performed manual medical record reviews. In an analysis of 670 records,
we found that if a specific disease state was on the electronic problem list
(coronary artery disease, diabetes, or hypertension), then the problem was
also found on medical record review 98% of the time. Conversely, of 177 patient
records manually reviewed, a disease state found on medical record review
on average had a 94% likelihood of also being on the electronic problem list.
Similarly, if certain drugs (statins or hormone replacement agents) were on
the electronic medication list, then more than 95% of the time these agents
appeared on medical record review; if these drugs were found on medical record
review, then they were found on the electronic medication list roughly 90%
of the time. Demographic variables (age and sex) and laboratory data (LDL
and high-density lipoprotein cholesterol levels and the results of liver function
tests) were 100% accurate. Information regarding certain risk factors (smoking
and family history of heart disease) was variably documented in patient medical
records and electronic problem lists; however, when the risk factor information
appeared, it appeared in both places.
To determine overuse, we evaluated the cohort of all patients taking
statins as of January 1, 1996. Among patients taking statins, records were
further studied to determine the indication for statin use (primary or secondary
prevention), lipid profiles, and contraindications to statin use. In addition,
we evaluated the amount of monitoring for liver function abnormalities, the
impact of monitoring, and coexisting medications or disease conditions that
could increase the risk of adverse effects.
We defined patients as meeting criteria for secondary
prevention if they had CHD; we did not include a broader definition
of athersclerotic disease for this analysis. Patients were identified as having
CHD if their computerized problem lists indicated coronary artery disease,
myocardial infarction, coronary artery bypass graft, angina, or percutaneous
transluminal coronary angioplasty; patients without these problems were considered
to be taking statins for primary prevention. Patients undergoing primary prevention
were examined for the presence of factors widely accepted as conferring risk
for heart disease. These included hypertension; current smoking status; diabetes
mellitus; family history of premature heart disease; male sex and age older
than 45 years; female sex and age older than 55 years, not taking hormone
replacement therapy; and low (<0.91 mmol/L [<35 mg/dL]) high-density
lipoprotein cholesterol values. A high-density lipoprotein cholesterol level
greater than 1.55 mmol/L (>60 mg/dL) was considered a negative risk factor.
The total number of risk factors for each patient was summed. Since established
guidelines stratify patients according to whether they have 2 or more risk
factors3 or less than 2, we also categorized
patients this way.
GUIDELINES
Guidelines for using pharmacological therapy to treat hypercholesterolemia
are based on LDL cholesterol values.3 Thus,
we retrieved the most recent LDL cholesterol value before the initiation of
statin therapy. This value, combined with the indication and number of risk
factors, was compared with guidelines for initiating statin therapy. Patients
were considered appropriate if their risk factor status and LDL cholesterol
value before statin initiation were in accordance with guidelines.
For patients undergoing primary prevention, those with less than 2 risk
factors were considered appropriate if their LDL cholesterol level before
drug initiation was greater than 4.92 mmol/L (>190 mg/dL); those with 2 or
more risk factors were considered appropriate if their prior LDL cholesterol
value was greater than 4.14 mmol/L (>160 mg/dL).
We considered patients with CHD (secondary prevention) to be inappropriately
taking statin therapy if their LDL cholesterol value before drug therapy was
below 2.59 mmol/L (<100 mg/dL). To estimate underuse of statins, we reexplored
our database for patients who met our criteria for CHD and who were not taking
statins. When patients had LDL cholesterol values greater than 2.59 mmol/L
(>100 mg/dL) in the presence of CHD and were not taking statins, we considered
this inappropriate underuse. For the sake of this analysis, patients with
CHD who were taking statins but had not reached the goal LDL cholesterol level
of 2.59 mmol/L (100 mg/dL) were not considered inappropriately treated.
ANALYSIS
Patient demographics, overall lipid values, and the range of lipid and
liver function monitoring were assessed. The proportions of inappropriate
use were calculated, including overuse in primary and secondary prevention
and underuse in secondary prevention. Patient demographics were compared between
those meeting and not meeting guidelines.
Logistic regression modeling was used to identify predictors of overuse
of statin therapy. Indication (primary vs secondary) and patient sex were
binary covariates. The 2 continuous variables—patient age and number
of risk factors—were assessed to determine the most appropriate form
to be used in the model. Both variables, when grouped into categories, showed
a nonlinear relation to overuse when used in a logistic regression model.
Thus, for the final model, age was categorized into clinically relevant groups,
and "number of cardiac risk factors" was collapsed into a binary variable
to correlate with guidelines (<2 vs  2).
Liver function monitoring was reviewed to assess the range and variability
of monitoring frequency compared with recommendations. To evaluate whether
more vigilant monitoring occurred with increased risk of adverse events due
to statin use, Spearman rank correlations were used to compare the degree
of abnormality of the laboratory result with the frequency of monitoring.
The effect of monitoring was further assessed to determine whether the abnormalities
had an impact on therapy, such as discontinuation or replacement of the statin
drug. Records showing patients with abnormal liver function were individually
analyzed to determine the impact of these abnormal results on their statin
therapy and to determine whether these patients had any clinically significant
abnormality.
Patient problem lists, which included medical conditions that would
increase the risk of using statins (such as hepatitis or liver disease), were
individually reviewed to determine if monitoring was appropriate. Records
were also reviewed to determine if the problem preceded or resulted from statin
use.
We also evaluated whether monitoring was more frequent if medications
interacting with statins were being taken concurrently. These medications
were itraconazole, nefazodone hydrochloride (Serzone), gemfibrozil, clofibrate,
cyclosporine, and niacin.
Potential adverse reactions to the statin medications were identified
by searching patient records for problems that might be related to statin
use, including rhabdomyolysis, myositis, sleep disorder or insomnia,16 and thrombocytopenia.17
If any of these problems were present, the individual patient records were
manually reviewed to determine if the problems appeared to have any relation
to use of the statin medication.
We estimated potential annual medication and liver monitoring charges
and savings that might be realized if guidelines for use and monitoring were
followed. To assess the drug costs of overuse, we used weighted averages of
the statin drugs in our cohort and their 1996 average wholesale prices.18 We estimated the drug cost of correcting underuse
by choosing a particular statin (atorvastatin calcium) and calculating the
cost using its 1996 average wholesale price.18
This statin was chosen because its average wholesale price was the lowest
among the statins and would, therefore, result in the most conservative estimate
of the cost of correcting underuse.
The expected cost of liver function monitoring was estimated using an
average of 2 episodes of monitoring per person appropriately undergoing therapy.
Excess cost, due to overmonitoring patients appropriately undergoing therapy
or monitoring patients who were inappropriately undergoing therapy, was estimated
using prices in the Brigham and Women's Hospital laboratory.
All data analyses were performed using SAS statistical software.19
RESULTS
Among 29 543 outpatients who visited their primary care physician
during 1996, 1575 (5%) were taking statins. Patients taking statins were 60%
female, and their mean age was 63 years (Table 1). Among patients taking statins, 69% were treated for primary
prevention, and 31% had established CHD. Total cholesterol values were measured
on average 2.8 times during the 12-month period. There was no correlation
between monitoring frequency and the amount of total cholesterol elevation.
For LDL cholesterol levels, the correlation was modest (Table 2).
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Table 1. Characteristics of 1575 Patients Taking Statin Drugs During
1996*
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Table 2. Range of Monitoring Frequencies
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Based on LDL cholesterol levels and risk factor status, only 336 (31%)
of 1080 patients undergoing primary prevention met NCEP guidelines. Of patients
undergoing secondary prevention therapy, 260 (53%) of 495 met guidelines (Figure 1). Among patients undergoing primary
prevention who did not meet NCEP guidelines, 69% had fewer than 2 risk factors;
this group had a mean total cholesterol level of 6.40 mmol/L (247 mg/dL) before
beginning therapy. The remaining 31% had 2 or more risk factors, and the mean
total cholesterol level for this group was 6.14 mmol/L (237 mg/dL) (Table 3).
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Figure 1. Appropriateness of 3-hydroxy-3-methylglutaryl
coenzyme A reductase inhibitor (statin) use in primary and secondary prevention
for 1575 patients taking statins.
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Table 3. Characteristics of 744 Patients Taking Statins for Primary
Prevention Who Did Not Meet NCEP Guidelines, by Number of Risk Factors*
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In a logistic regression analysis using appropriateness as a binary
outcome, we found that age 70 years or older, being treated for primary prevention,
and having fewer than 2 risk factors were significant (P<.001) predictors of statin overuse, but patient sex was not (Table 4). Reintroducing the covariate of
sex to our model did not reveal confounding.
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Table 4. Results of Logistic Regression*
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Among patients with CHD who were not receiving statin therapy (n = 1459),
88% met the criteria for being able to receive a statin and were thus undertreated.
Among patients with CHD who were taking statins (n = 544), 47% did not meet
the criteria and were, therefore, being overtreated according to guidelines
(Figure 2).
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Figure 2. Overview of patients eligible
for 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitor (statin) therapy.
CAD indicates coronary artery disease.
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We found that liver function monitoring during a 1-year period varied
widely (Table 5). Among approximately
5000 liver function tests performed on the cohort of 1575 patients taking
statins, 37 (2%) of the patients had values greater than 3 times normal. Thirty-five
patients had their statin medication changed or discontinued within 90 days
of an abnormal result; 10 of these were confirmed, on individual record review,
to be related to the abnormal laboratory result. Two patients remained off
statins as a result of abnormal liver values, and none had clinical manifestations
of hepatitis. The frequency of monitoring did not correlate with the level
of test abnormality.
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Table 5. Range of Monitoring Liver Function for 1575 Patients Taking
Statins*
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We also evaluated whether monitoring was more intensive among patients
receiving a drug that interacted with statins. Ninety-eight patients (6%)
were found to be taking other medications with important drug-drug interactions,
including niacin, gemfibrozil, cyclosporine, and itraconazole. However, these
patients were not monitored more frequently. None of these patients had clinically
significant adverse events. Nine patients had other documented problems that
may be considered adverse reactions to the statin drugs, including sleep disorder
and thrombocytopenia, but none required discontinuation of the drug.
One impact of inappropriate overuse and liver function monitoring is
cost. Based on the average wholesale price with weighted averages of specific
statin drugs, from the payer perspective an estimated $1 338 449
in annual cost savings might have been realized if statin use in primary and
secondary prevention were restricted to NCEP guidelines. If recommended liver
function monitoring were followed, we estimated a further potential annual
cost savings of $26 620. The cost of correcting underuse among patients
with CHD would be $841 020.
COMMENT
These data suggest that, despite widely available guidelines for the
use of drug therapy in primary and secondary cardiovascular disease prevention,
use of statin lipid-lowering therapy is often inappropriate. Overuse of statin
therapy was found among 69% of patients undergoing primary prevention, and
among 47% of patients undergoing secondary prevention. Overuse was more prevalent
among patients who were being treated for primary prevention, who were older
than 70 years, or who had fewer than 2 cardiac risk factors. We also found
an 88% rate of underuse among patients undergoing secondary prevention who
were not taking statins. Furthermore, monitoring for safety varied widely,
and was not intensified for patients at highest risk.
The potential pharmacy and laboratory savings that would occur by eliminating
overuse are substantial. Also, the cost of correcting underuse would be more
than offset by the savings of eliminating overuse, and might also reduce the
morbidity of CHD. These cost and savings estimates represent drug and laboratory
charges; they do not include social costs of treatment, such as lost work
days, or costs of treating adverse drug events.
These results are consistent with those of several other studies20, 21, 22 that demonstrate
lack of adherence to available guidelines. Our findings extend prior evidence
of undertreatment to show that overtreatment is also a significant concern,
and that a substantial financial burden is associated with overtreatment.
Moreover, we assessed adherence to the NCEP guidelines, which tend to be aggressive
regarding therapy; use of other guidelines23, 24
might have suggested that overtreatment is even more frequent.
Several studies25, 26, 27
have shown that publication of guidelines without more intensive accompanying
information has little impact on clinical practice. This suggests that research
evidence and consensus statements are not primary determinants of physician
behavior. Practice-based interventions may be more effective at having an
impact on practice behavior.27, 28, 29
Tools for improving compliance, and reducing the number of errors, include
reminders and computerized alerts.30, 31
A growing body of evidence suggests that such computerized decision support,
especially when presented at key times such as when physicians are writing
orders, can modify ordering behavior.32 In
addition, decision support is effective for helping physicians remember to
implement an order that follows from another order, such as ordering laboratory
tests to monitor liver function after the initiation of statin therapy.32
This study also illustrates the power of the electronic medical record
for measuring quality. Although such records are not yet widely used, they
have many benefits,30 and facilitation of quality
measurement is high on the list.
Our study has several limitations. While some misclassifications undoubtedly
occurred because of inaccuracies in the database, they could not account for
these figures; guideline adherence could clearly be improved. We may have
overestimated the amount of underuse among patients undergoing secondary prevention,
since our manual medical record review revealed 1 patient of 20 to be actually
taking a statin. If this is the actual proportion of underascertainment, then
the rate of underuse would fall to 84%, which is still a formidable figure.
Also, some people consider that other populations should be included in the
secondary prevention group, such as patients with a history of cerebrovascular
accident or peripheral vascular disease, but we followed a strict interpretation
of the NCEP guidelines. In addition, we did not address whether patients undergoing
secondary prevention actually achieved the recommended LDL cholesterol values;
many undoubtedly did not. Another limitation is that this study was done at
one site, so our results may not be generalizable to other populations. However,
poor adherence to guidelines has been found in other studies, and is extended
herein to show overtreatment in primary prevention and to show inappropriate
safety monitoring.
One possible explanation of our findings of statin overuse is that physicians
may be extrapolating from recent trials supporting a more aggressive approach
to lipid lowering instead of following the NCEP guidelines. However, our data
are drawn from physician behavior as of January 1, 1996, before many of the
clinical trials, particularly those in primary prevention. An additional implication
may be that the guidelines are outdated, and should be revised to reflect
more current evidence.
We conclude that, taken together, these results suggest a substantial
and costly burden of statin overtreatment and undertreatment, and widely varying
liver function monitoring for adverse effects. Decision support, offered during
the prescribing and laboratory test–ordering processes, may help physicians
optimize use of these medications from the population perspective.
AUTHOR INFORMATION
Accepted for publication June 30, 2000.
This study was supported in part by a grant from Aetna–US Healthcare,
Hartford, Conn.
From the Division of General Medicine, Department of Medicine, Brigham
and Women's Hospital and Harvard Medical School (Drs Abookire, Karson, and
Bates), and Partners Information Systems (Drs Abookire and Bates and Ms Fiskio),
Boston, Mass.
Corresponding author and reprints: Susan A. Abookire, MD, MPH, Division
of General Medicine, Department of Medicine, Brigham and Women's Hospital,
75 Francis St, Boston, MA 02115 (e-mail: sabookire{at}partners.org).
REFERENCES
| |
1. Kannel WB, Castelli WP, Gordon T, McNamara PM. Serum cholesterol, lipoproteins, and the risk of coronary heart disease:
the Framingham study. Ann Intern Med. 1971;74:1-12.
2. Multiple Risk Factor Intervention Trial Research Group. Multiple Risk Factor Intervention Trial: risk factor changes and mortality
results. JAMA. 1982;248:1465-1477.
ABSTRACT
3. Summary of the second report of the National Cholesterol Education
Program (NCEP) expert panel on detection, evaluation, and treatment of high
blood cholesterol in adults (Adult Treatment Panel II). JAMA. 1993;269:3015-3023.
FULL TEXT
|
ISI
| PUBMED
4. The Scandinavian Simvastatin Survival Study Group. Randomised trial of cholesterol lowering in 4444 patients with coronary
heart disease: the Scandinavian Simvastatin Survival Study (4S). Lancet. 1994;334:1383-1389.
5. Cholesterol and Recurrent Events (CARE) Trial Investigators. The effect of pravastatin on coronary events after myocardial infarction
in patients with average cholesterol levels. N Engl J Med. 1996;335:1001-1009.
FREE FULL TEXT
6. The LIPID Study Group. Prevention of cardiovascular events with pravastatin in patients with
coronary heart disease and a broad range of initial cholesterol levels. N Engl J Med. 1998;339:1349-1357.
FREE FULL TEXT
7. West of Scotland Coronary Prevention Study Group. Prevention of coronary heart disease with pravastatin in men with hypercholesterolemia. N Engl J Med. 1995;333:1301-1307.
FREE FULL TEXT
8. Downs JR, Clearfield M, Weis S, et al. Primary prevention of acute coronary events with lovastatin in men
and women with average cholesterol levels: results of AFCAPS/TexCAPS. JAMA. 1998;279:1615-1622.
FREE FULL TEXT
9. McBride P, Schrott H, Plane M, Underbakke G, Brown RL. Primary care practice adherence to National Cholesterol Education Program
guidelines for patients with coronary heart disease. Arch Intern Med. 1998;158:1238-1244.
FREE FULL TEXT
10. Schrott HG, Bittner V, Vittinghoff E, Herrington DM, Hulley S for the HERS Research Group. Adherence to National Cholesterol Education Program treatment goals
in postmenopausal women with heart disease: the Heart and Estrogen/Progestin
Replacement Study (HERS). JAMA. 1997;277:1281-1286.
ABSTRACT
11. Stafford R, Blumenthal D, Pasternak R. Variations in cholesterol management practices of US physicians. J Am Coll Cardiol. 1997;29:139-146.
ABSTRACT
12. Eaton C, McQuade W, Glupczynski D. A comparison of primary vs secondary cardiovascular disease prevention
in an academic family practice. Fam Med. 1994;26:587-592.
PUBMED
13. Cohen M, Byrne M, Levine B, Gutowski T, Adelson R. Low rate of treatment of hypercholesterolemia by cardiologists in patients
with suspected and proven coronary artery disease. Circulation. 1991;83:1294-1304.
FREE FULL TEXT
14. Teich JM, Glaser JP, Beckley RF, et al. Toward cost-effective, quality care: the Brigham Integrated Computing
System. In: Steen EB, ed. Proceedings of the Second Nicholas
E. Daives CPR Recognition Symposium. Chicago, Ill: Computer-Based Patient
Record Institute; 1996:3-34.
15. Wagner MM, Hogan WR. The accuracy of medication data in an outpatient electronic medical
record. J Am Med Inform Assoc. 1996;3:234-244.
FREE FULL TEXT
16. Partinen M, Pihl S, Strandberg T, et al. Comparison of effects on sleep of lovastatin and pravastatin in hypercholesterolemia. Am J Cardiol. 1994;73:876-880.
FULL TEXT
|
ISI
| PUBMED
17. Mantell G, Burke T, Staggers J. Extended clinical safety profile of lovastatin. Am J Cardiol. 1990;66:11B-15B.
18. Choice of lipid-lowering drugs. Med Lett Drugs Ther. 1996;38:67-70.
PUBMED
19. SAS Institute Inc.. SAS, Version 6.12. Cary, NC: SAS Institute Inc; 1997.
20. Thorndike AN, Rigotti NA, Stafford RS, Singer DE. National patterns in the treatment of smokers by physicians. JAMA. 1998;279:604-608.
FREE FULL TEXT
21. Cohen SJ, Robinson D, Dugan E, et al. Communication between older adults and their physicians about urinary
incontinence. J Gerontol A Biol Sci Med Sci. 1999;54:M34-M37.
22. McBride P, Schrott H, Plane M, Underbakke G, Brown R. Primary care practice adherence to National Cholesterol Education Program
guidelines for patients with coronary heart disease. Arch Intern Med. 1998;158:1238-1244.
23. Garber AM, Browner WS, Hulley SB. Cholesterol screening in asymptomatic adults, revisited: part 2. Ann Intern Med. 1996;124:518-531.
FREE FULL TEXT
24. Canadian Consensus Conference on Cholesterol. Final report: the Canadian Consensus Conference on the Prevention of
Heart and Vascular Disease by Altering Serum Cholesterol and Lipoprotein Risk
Factors CMAJ. 1998;139:1-8.
25. Basinski AS. Evaluation of clinical practice guidelines. CMAJ. 1995;153:1575-1581.
ABSTRACT
26. Lomas J, Anderson GM, Domnick-Pierre K, Vayda E, Enkin MW, Hannah WJ. Do practice guidelines guide practice? the effects of a consensus statement
on the practice of physicians. N Engl J Med. 1989;321:1306-1311.
ABSTRACT
27. Davis DA, Thomson MA, Oxman AD, Haynes RB. Changing physician performance: a systematic review of the effect of
continuing medical education strategies. JAMA. 1995;274:700-705.
ABSTRACT
28. Cohen SJ, Halvorson HW, Gosselink CA. Changing physician behavior to improve disease prevention. Prev Med. 1994;23:284-291.
FULL TEXT
|
ISI
| PUBMED
29. Dugan E, Cohen SJ. Changing physician behavior to increase guideline implementation. In: Shumaker SA, Schron E, Ockene J, Mcbee W, eds. Handbook for Health Behavior Change. 2nd ed. New York, NY: Springer
Publishing Co Inc; 1998:283-304.
30. Bates DW, Leape LL, Cullen DJ, et al. Effect of computerized order entry and a team intervention on prevention
of serious medication errors. JAMA. 1998;280:1311-1316.
FREE FULL TEXT
31. Raschke RA, Gollihare B, Wunderlich TA, et al. A computerized alert system to prevent injury from adverse drug events:
development and evaluation in a community teaching hospital. JAMA. 1998;280:1317-1320.
FREE FULL TEXT
32. Overhage JM, Tierney WM, Zhou XA, McDonald CJ. A randomized trial of "corollary orders" to prevent errors of omission. J Am Med Inform Assoc. 1997;4:364-375.
FREE FULL TEXT
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