Practice-Based Research Syntheses of Child Find, Referral, Early Identifi cation, and Eligibility Practices and Models
Educational Outreach (Academic Detailing)
The use of an educational outreach procedure called academic detailing for changing physician pre-scribing practices was the focus of this research synthesis. The practice is characterized by brief, repeated, face-to-face, informal educational outreach visits to physicians by knowledgeable profes-sionals (academic detailers) in physicians’ offi ces or other practice settings to provide information and materials to change prescribing behavior. The synthesis included 38 studies of more than 5,000 physicians and other health-care providers. Results showed that a number of academic-detailing characteristics were most associated with hypothesized or expected changes in prescribing prac-tices. Characteristics include collecting baseline information on physicians’ current prescribing prac-tices, establishing a motivation to change, establishing the credibility of the message and messenger, repeating a highly focused message, and providing positive reinforcement for changes in prescribing practices. Implications for using these practice characteristics for child fi nd are described.
professionals (academic detailers) in physicians’ offi ces or other practice settings to provide information and
The purpose of this practice-based research materials to change prescribing behavior (Soumerai &
synthesis is to assess the effectiveness of an
educational outreach practice called academic
This particular educational outreach practice was
detailing for changing physician prescribing practices.
the focus of this research synthesis because the prac-
Academic detailing is a well developed and researched
Cornerstonesis a publication of the Tracking, Re-
practice that has been widely used to improve physi-
ferral and Assessment Center for Excellence (TRACE)
cians’ decision-making choices that involve prescribing
funded by the U. S. Department of Education, Offi ce of
medications, diagnostic tests, medical procedures, treat-
Special Education Programs (H324G020002). TRACE is
ments, etc. (Benincasa et al., 1996; Daly et al., 1993;
an organizational unit of the Center for Improving Com-
Ofman et al., 2003; Soumerai & Avorn, 1987; Soumerai
munity Linkages at the Orelena Hawks Puckett Institute (www.puckett.org). All opinions are the responsibility of
et al., 1993). This educational outreach practice is char-
TRACE and do not necessarily refl ect the views of the
acterized by brief, repeated, face-to-face, informal edu-
U.S. Department of Education. Copyright 2005 by the
cational outreach visits to physicians by knowledgeable
Orelena Hawks Puckett Institute. All rights reserved. Cornerstones | Volume One | Number One 1
tice holds promise as a child fi nd strategy for increas-
1. conducting interviews to investigate baseline
ing physician referrals to IDEA Part C early intervention
knowledge and motivations for current pre-
programs (Dunst & Trivette, 2004). More specifi cally,
we examined the features of academic detailing that
2. focusing programs on specifi c categories of
were associated with changes in physician prescribing
physicians as well as on their opinion leaders,
practices with a focus on those characteristics that could
3. defi ning clear educational and behavioral ob-
be used as part of child fi nd to promote physician refer-
rals of children with or at risk for disabilities to early
4. establishing credibility through a respected or-
intervention programs. Physician outreach is a common
ganizational identity, referencing authoritative
child fi nd practice (see Dunst & Trivette, 2004), but no
and unbiased sources of information, and pre-
empirical evidence was found regarding the effective-
senting both sides of controversial issues,
ness of the ways in which this practice is used by early
stimulating active physician participation in
intervention program providers. We therefore conducted
a review and synthesis of studies in health-care settings
6. using concise graphic educational materials,
where an evidence base has been amassed about the ef-
7. highlighting and repeating the essential mes-
fectiveness of physician prescribing behavior. (For pur-
poses of this synthesis, a physician making a referral for
8. providing positive reinforcement of improved
treatment was deemed a prescribing practice.)
The synthesis was conducted using a characteristics
These characteristics were used to develop the 13 aca-
and consequences framework (Dunst, Trivette, & Cut-
demic-detailing variables listed in Table 1 and to code
spec, 2002) where the focus of analysis was the identi-
the studies included in the research synthesis. The fi ve
fi cation of those particular characteristics of academic
Soumerai and Avorn (1990) characteristics that included
detailing that were associated with desired changes in
multiple elements (Numbers 1, 2, 6, 7 and 8 in the above
prescribing practices. This was accomplished by coding
list) were subdivided in order to discern which character-
different academic detailing characteristics and relating
istics were most important. Additionally, we examined
the use of the practice characteristics to variations in
fi ve structural variables as possible determinants of the
study outcomes and as well examined the infl uence of the type of research design on changes in prescribing
For purposes of this synthesis, studies were includ-
Academic detailing has its roots in communications
ed if the academic-detailing procedure was done face-
theory and social marketing (see Smith, 1991; Soume-
to-face in physicians’ practices or another health-care or
rai & Avorn, 1990). It has been used by pharmaceuti-
medical setting (e.g., hospitals). Studies that implement-
cal manufacturers for more than 50 years for infl uencing
ed and evaluated the practice by mail, telephone, or other
physicians’ prescriptions of the manufacturers’ products
non-face-to-face methods were excluded (e.g., McPhee,
(Caplow, 1952; Hawkins, 1959; Hubbard, 1955). In
Bird, Fordham, Rodnick, & Osborn, 1991; Sweet, 1996).
1949, at the point in time where academic detailing was
Additional exclusion criteria are described in the Selec-
recognized as a profession, the U.S. Department of Labor
described an academic detailer as a person who “intro-duces new pharmaceutical products and their methods of
use to physicians, dentists, hospitals, and public-health offi cials, promoting the use of the product rather than
selling it” (cited in Hawkins, 1959, p. 215).
An initial search was done using physician outreach,
marketing or marketing strategies, and educational out-Description of the Practice reach as search terms. Once academic detailing was
There have been various attempts to defi ne academic
identifi ed as the limiting term used for educational out-
detailing and describe the key characteristics of the prac-
reach to physicians, the search for relevant studies was
tice (e.g., Allen, 2004; Dietrich et al., 1992; Klein, 1983;
done using different variations of academic detailing (ac-
Pathak, 1983). Stephen Soumerai and his colleagues by
ademic detail,*academic and detail*) as search terms.
far have been the leaders in attempting to disentangle,
unpack, and identify the principles and components of
The following databases were searched for relevant
the practice (e.g., Soumerai, 1998; Soumerai & Avorn,
studies: Psychological Abstracts online (PsycINFO),
1990). According to Soumerai and Avorn (1990), aca-
Social Sciences Citation Index, Educational Resources
Information Center (ERIC), MEDLINE, Cumulative In-
2 Cornerstones | Volume One | Number One
dex to Nursing and Allied Health Literature (CINAHL),
in the experimental or intervention groups and 2,435 in
Health Source: Nursing/Academic Edition, The Co-
the control or comparison groups. The number of partici-
chrane Library, Academic Search Elite, Dissertation
pants in two studies (Avorn et al., 1992; Landgren et al.,
Abstracts International, OCLC PapersFirst, ABI Inform
1988) were not reported (see footnote b in Table 2 for an
(ProQuest), Ingenta, Business Source Elite, and World-
Cat. Hand searches were conducted of relevant review
The majority of participants were physicians (86%).
articles, book chapters, books, and a Cochrane review
The remaining participants were nurse practitioners
(O’Brien et al., 2001) to locate additional studies. In ad-
(5%), residents (5%), physician assistants (2%), and in-
dition, the reference lists of the studies identifi ed through
the above searches were also examined.
Participant ages were reported in only six studies
and averaged between 38 and 51 years. Years of experi-
ence of the study participants was reported in only four
Studies were included if at least three of the eight
studies and averaged between 13 and 40 years. In the 11
Soumerai and Avorn (1990) academic detailing char-
studies that reported the gender of the study participants,
acteristics were described, mentioned, or could be dis-
cerned, and Cohen’s d effect sizes (Dunst, Hamby, & Trivette, 2004) could be calculated for pretest/posttest
or experimental vs. comparison group differences. In a
The academic-detailing interventions were imple-
number of instances, the data presented in the research
mented in physicians’ practices (61%), HMOs, MCOs,
reports were reanalyzed to produce fi ndings that were di-
or clinics (21%), hospitals (13%), or nursing homes
rectly comparable across studies. In so doing, there were
(5%). In all cases, the interventions were implemented
cases where the study investigators reported positive
on a face-to-face basis with an individual study partici-
fi ndings but our analyses found small effects. In other
pant (76%) or with a small group of participants all prac-
cases, study investigators reported no signifi cant results
but our analyses found large effect sizes.
Studies were excluded from the synthesis if too
few academic-detailing characteristics could be dis-
The 38 studies employed 48 individuals as interven-
cerned (e.g, Kim et al., 1999; van Eijk, Avorn, Porsius,
tionists. The persons implementing the academic-detail-
& de Boer, 2001; Zwar, Wolk, Gordon, & Sanson-Fisher,
ing interventions were mostly physicians (41%) or phar-
2000), the outcomes in a study did not include a measure
macists (41%) (Table 3). In eight instances (16%), the
of physician prescribing behavior (e.g., Gorin et al., 2000;
profesional backgrounds of the academic detailers were
Hearnshaw, Khunti, & Robertson, 2000; Ross-Degnan et
al., 1996), the intervention was not done on a one-on-one or small group basis (e.g., Bernal-Delgado, Galeote-
Mayor, Pradas-Arnal, & Peiro-Moreno, 2002; Ferguson
Table 3 shows the research designs used by the in-
et al., 2003; Mahloch, Taylor, Taplin, & Urban, 1993),
vestigators and the types of analyses performed on the
the intervention was called academic detailing but the
data. The majority of the investigations were random-
description of practice did not match the academic-de-
ized clinical trials (60%) or other types of controlled trial
tailing characteristics in Table 1 (e.g., Blackstien-Hirsch,
studies (29%). The remaining four studies (10%) used
Anderson, Cicutto, McIvor, & Norton, 2000; Markey &
Schattner, 2001; McCormick et al., 1999) or effect sizes
In the largest number of cases, the investigators col-
could not be calculated from the data included in the re-
lected both pretest and posttest measures of physician
search reports (e.g., Benincasa et al., 1996; Daly et al.,
prescribing behavior or practices (84%). In six studies
(16%), only posttest data were collected. Search Results Outcomes
The 38 studies included nine different types of pre-
Thirty eight (38) studies met the inclusion criteria
scribing practices (see Table 3). In most of the studies
for the synthesis. Table 2 shows selected characteristics
(60%), the outcome was a change in prescribing some
of the study participants and the settings where the edu-
type of drug or medication. Prescribing patient treat-
ments (18%) or diagnostic tests or screenings (18%) were the second most frequent outcomes. In two studies
(5%), referrals to other professionals or programs were
The 38 studies included 5,102 participants, 2,667
Cornerstones | Volume One | Number One 3
The outcomes were considered either targeted
tors may have conducted pretest/posttest differences for
(26%) or nontargeted (74%). Outcomes were considered
the experimental and comparison groups separately. In
targeted if hypothesized or expected change in prescrib-
the majority of studies (79%) we were able to compute
ing practices was focused and precise (e.g., decreasing
the posttest difference effect sizes.
the use of the antibiotic tetracycline for treating respira-
Ninety three (93) effect sizes were computed from
tory infections). Outcomes were considered nontargeted
the fi ndings in the 38 studies. Effect sizes were calculat-
if the hypothesized or expected changes in prescribing
ed only on outcomes that were hypothesized or expected
practices included both increases and decreases of two
to change as a result of the interventions. In all cases,
or more prescribing behaviors (e.g., increasing prescrip-
these included the prescribing practices of the study
tions for beta-blockers and decreasing prescriptions for
participants. Effect sizes were not computed on study
ace-inhibitors) or included two or more conditions con-
participants’ nonprescribing practices (e.g., physician
stituting the focus of intervention (e.g., decreasing pre-
requests for information), patient outcomes (e.g., blood
scriptions for treating hypertension or depression).
pressure), or for prescriptions that were not the targets of
The sources of the outcome data were either the
the interventions. In a number of studies, the investiga-
direct observation or measurement of the study partici-
tors reported results for individual prescriptions and for
pants’ prescribing practices (50%) or changes in pre-
all prescriptions combined. The latter were not included
scription counts or rates found in databases including the
in our analyses to reduce confounds associated with du-
physicians’ prescriptions (50%). Direct observation or
measurement included, for example, the number of times
Table 5 summarizes the expected and observed ef-
a physician in a study prescribed or did not prescribe a
fects in the 38 studies. The table includes the targets of
targeted drug. Indirect outcome measures included, for
the study participants prescribing practices, the outcome
example, average daily doses of prescriptions from an
measures constituting the focus of investigation, the
hypothesized or expected increase or decrease in pre-scriptions, and the effect sizes for the pretest/posttest or
posttest group differences. The effect size signs show the
Table 4 shows the particular academic-detailing
direction of effect of the independent variables on the
characteristics that were part of the interventions con-
dependent variables (e.g., if there was a hypothesized
stituting the focus of investigation. The presence of each
decrease in prescriptions and this was found, the result is
characteristic was discerned by descriptions included in
the research reports and checked by two or more of the
authors of this synthesis. Individual studies included an
shown in Table 6. Because the posttest comparison
average of 5.60 characteristics (SD = 2.29, Range = 3 to
group studies produced more effect sizes, they are used
13). The use of an opinion leader to implement the inter-
as the principle fi ndings for interpretative purposes. The
ventions was used in the fewest studies (11%), and the
academic-detailing characteristics are ordered (for the
provision of concise educational materials to the study
posttest group difference analyses) from the largest to
participants was done in the majority of studies (89%).
smallest average size of effect. The confi dence intervals
The interventions themselves occurred during a sin-
(CI) for the effect sizes are also included and provide a
gle session (45%) or had one or more follow-up contacts
basis for ascertaining the relative importance of the aca-
(55%). The number of follow-up contacts ranged from
demic-detailing characteristics and structural variables.
as few as one or two (47%) to as many as four or fi ve
(For interpretative purposes, if the lower bound is at least
.25, then the true effect may be considered at least this large.)
Synthesis Findings Academic Detailing
The relationship between both the academic-detail-
All of the academic-detailing characteristics, except
ing characteristics (Tables 1 and 4) and the study struc-
the use of an opinion leader as an interventionist, have
tural variables (Tables 1) and the study participant pre-
average effect sizes greater than .25 for the pretest/post-
scribing practices (Table 3) was ascertained by calculat-
test comparisons. Seven characteristics emerged as rela-
ing effect sizes for either pretest/posttest differences or
tively more important as evidenced by lower bound con-
posttest differences between the experimental/interven-
fi dence levels being about .25 or larger. These charac-
tion groups and control/comparison groups (Dunst et al.,
teristics are collecting baseline prescribing information,
2004). In the latter studies, information available in the
establishing credibility, repeating the intended message,
research reports was used to calculate the posttest differ-
providing positive reinforcement, establishing a motiva-
ences between groups even though the study investiga-
tion to change, having clear intervention objectives, and
4 Cornerstones | Volume One | Number One
using concise educational materials for reinforcing the
with relatively small differences for the within variable
intended change or desire to change.
contrasts. These results indicate that where, who, and
A comparison of the average effect sizes from the
how academic detailing is done matters less than what is
two different types of analyses (posttest vs. pretest/post-
test) shows, with a few exceptions, similar results. Al-
In contrast to the fi ndings for the practice-related
though the magnitude of effect is generally smaller for
structural variables, both outcome-related variables were
pretest/posttest studies compared to the posttest group
associated with differences in the average effect sizes
comparison studies. The exception is the single study
where the patterns were identical for both types of analy-
that yielded an average effect size of .82 for three aca-
ses. Measuring the prescribing practices of the study par-
demic-detailing characteristics, which should be inter-
ticipants directly produced an average effect size almost
preted with caution. The fi ndings taken together indicate
twice as large as when the effects of the interventions
that a combination of academic-detailing characteristics
were discerned using indirect or unobtrusive measures.
are associated with desired changes in prescribing prac-
This was expected because the use of a larger database as
a source of outcome data includes prescriptions of physi-
Exploratory cluster and factor analyses were per-
cians who were not participants in the studies.
formed on the use/nonuse of the academic-detailing
fi ndings for the targeted vs. nontargeted out-
characteristics (Table 4) to discern if there were unique
comes were unexpected inasmuch as one would predict
combinations of practice characteristics. The cluster and
a larger size of effect for prescriptions that were specifi -
factor analyses were done for all 38 studies combined
cally the focus of behavior change. The results suggest
and for the pretest/posttest and the experimental vs. com-
that the effects of the interventions were broader based
parison group studies separately. A consistent pattern of
fi ndings emerged (regardless of type of analysis or set of data) showing there were four clusters or groupings of
• Building rapport and credibility by establishing
Findings from this practice-based research synthe-
physician baseline knowledge, ascertaining the
sis indicate that most of the academic detailing charac-
motivation to change prescribing practices, and
teristics constituting the focus of analysis are associated
establishing credibility and delivering a cred-
with expected or hypothesized changes in the study par-
ticipants’ prescribing behavior and that a combination
• Fostering change by establishing specifi c behav-
of the practice characteristics best represented the key
ioral objectives, highlighting and repeating the
features and components of the practice. Results also
reason(s) why a change in prescribing practices
show that the practice-related structural variables con-
is warranted, actively involving the physicians
stituting the focus of analysis were not confounds and
in the change process, and reinforcing the phy-
that academic detailing is similarly effective regardless
sicians for changing their practices.
of setting, interventionist, or the type of intervention
• Using explanatory materials by using concise and
(see Table 6). Moreover, the patterns of fi ndings of the
graphic written materials for describing and ex-
structural variable analyses are nearly the same for the
plaining the benefi ts of changing prescribing
posttest group comparison and pretest/posttest studies.
Results from this practice-based research synthesis are
• Maintaining change by making repeated follow-
similar to those reported elsewhere (e.g., Davis, Thom-
up visits to answer questions, reinforcing be-
son, Oxman, & Haynes, 1995; Smith, 2000).
havior change, and providing additional infor-mation. Implications for Practice
The reader is referred to Moser, Dorsch, and Kellerman
The educational outreach practice constituting the
(2004) for a similar categorization of academic-detailing
focus of this Cornerstones was targeted for review and
synthesis because it holds promise as a child fi nd strat-egy for increasing physician referrals of infants and tod-
dlers with disabilities or at risk for developmental delays
The structural variables constituting the focus of
to early intervention programs. The current landscape of
analysis included three practice-related factors (setting,
health-care practices makes it very diffi cult for physi-
academic detailer, and type of session) and two out-
cians to take time out of their busy schedules to attend
come-related factors (type and source of outcome data).
training sessions promoting their understanding of early
All three practice-related factors have average effect
intervention and the benefi ts to their patients and them-
sizes of .27 or higher for the posttest comparison studies
selves. Because of its brief and highly focused emphasis
Cornerstones | Volume One | Number One 5
on communicating a credible message, features of aca-
& Fields, D. (1992). A randomized trial of a pro-
demic detailing would seem especially useful for im-
gram to reduce the use of psychoactive drugs in
proving the effectiveness of child fi nd.
nursing homes. New England Journal of Medicine,
Physician outreach is a commonly used strategy
for promoting referrals to early intervention (Dunst &
Baran, R. W., Duchane, J., Parker, L., Cornwell, S.,
Trivette, 2004). The extent to which outreach to phy-
Franic, D., & Erwin, W. G. (1996). Effectiveness
sicians is likely to be effective can be strengthened by
of academic detailing in the managed care envi-
considering key characteristics of academic detailing as
ronment: Improving prescribing of lipid-lowering
part of planning and implementing child fi nd activities.
agents. Journal of Managed Care Pharmacy, 2,
The use of academic detailing as a child fi nd strategy in-
dicates a need to include a reason (motivation) for mak-
Benincasa, T. A., King, E. S., Rimer, B. K., Bloom, H.
ing a referral (prescription) to early intervention with an
S., Balshem, A., James, J., & Engstrom, P. F. (1996).
explicit focus (message) on the benefi ts to a physician
Results of an offi ce-based training program in clini-
and his or her patients. The message needs to be clear,
cal breast examination for primary care physicians.
concise, and credible, as well as highly focused. Estab-
Journal of Cancer Education, 11, 25-31.
lishing the credibility of the message and messenger is
Bernal-Delgado, E., Galeote-Mayor, M., Pradas-Arnal,
accomplished by reference to relevant and respected
F., & Peiro-Moreno, S. (2002). Evidence based edu-
sources (e.g., the American Academy of Pediatrics for
cational outreach visits: Effects on prescriptions of
pediatricians and the American Academy of Family
non-steroidal anti-infl ammatory drugs. Journal of
Physicians for family physicians). The message needs
Epidemiology & Community Health, 56, 653-658.
to be communicated orally during visits to physicians’
Blackstien-Hirsch, P., Anderson, G., Cicutto, L., McIvor,
practices, reinforced using concise and graphic written
A., & Norton, P. (2000). Implementing continuing
materials (e.g., brochures) left with the physicians, and
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Brown, J. B., Shye, D., McFarland, B. H., Nichols, G.
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Findings from this practice-based research synthe-
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Puckett Institute, Morganton ([email protected]). Cornerstones | Volume One | Number One 9
Table 1 Characteristics and Variables Coded for Each Study Included in the Synthesis
Collect baseline information about the physicians’ knowledge influencing current practices.
Explicit effort made to identify physicians’ motives for the practice targeted for change.
Intervention targets specific category of physicians.
Use an opinion leader to introduce the targeted prescribing practice.
Opinion leader conducts the academic-detailing session(s).
Clear behavioral objectives are established for changing physician prescribing practices.
Establish credibility for targeted practice change with reference to respected and
Physicians are actively involved in the “change process.”
Concise written materials about the targeted practice are used to increase knowledge.
Graphic materials include explicit description of practice benefits.
Intervention highlights and repeats a focused message.
Physicians are reinforced for their responsiveness and willingness to change their
Academic detailer makes follow up visit to reinforce message delivered during initial
One-on-one or a group of physicians in the same practice
Physician practice (including HMOs, MCOs, clinics) vs. hospital or nursing home
Individual physicians prescribing vs. data in a larger database
Pretest/posttest or experimental vs. comparison group
a Developed based on descriptions in Soumerai and Avorn (1990).
10 Cornerstones | Volume One | Number One
Table 2 Selected Characteristics of Study Participants Cornerstones | Volume One | Number One 11
aType of setting: HMO = health maintenance organization, MCO = managed care organization, Practice =
private or group practice, Clinic = health-care center or county clinic.
bIndividual number of physicians receiving academic detailing intervention is not reported. Numbers are for
cNumber of participants in the experimental and control groups is not reported. Numbers are estimates of indi-
dMedian age of participant reported. eNR = Not reported.
12 Cornerstones | Volume One | Number One
Table 3 Research Designs and Outcome Measures Used in the Studies
follow-up care for patients with depression
Number of physicians report- Use of smoking cessation
Drugs prescribed Prescribing antibiotics
New diagnoses of depression Diagnosis of depression
Cornerstones | Volume One | Number One 13
Peterson & Sugden (1995) Controlled trial Pre Post
Prescribing of non-steroidal anti-inflammatory drugs and paracetamol
Prescribing of antibiotics for urinary tract infection
drugs, non-steroidal anti-inflammatory drugs, procholorperazines
Avorn & Soumerai (1983) ontrolled trial
14 Cornerstones | Volume One | Number One
Table 4 Characteristics of Academic Detailing Constituting the Focus of Intervention Cornerstones | Volume One | Number One 15
Table 5 Outcome Measures and Major Findings of the Studies
Lipid lowering drugs (overall prescribing rate)
Medication for treatment of depression (average daily dose)
Screening for (DES) cancer risk (double intervention)
Screening for (DES) cancer risk (single intervention)
Patient care following hypertension guidelines
Use of guidelines to treat patients with aspirin as anti-platelet
Use of guidelines to treat patients with NSAIDs for pain
Overall - patient treated according to guidelines
Patient treated according to guidelines (small practices)
Patient treated according to guidelines (large practices)
Physicians requests excessive alcohol use screening
kit: Academic detailing vs. mail/phone intervention
Physicians uses >1 AUDIT kit: Academic detailing
16 Cornerstones | Volume One | Number One
Adequate antidepressant drug intervention:
Heliocobacter testing for ulcer diagnosis
Drugs for gout and kidney stones treatment
Number of patients with long term diazepam use
Total number of patients with antipsychotics
Cornerstones | Volume One | Number One 17
Compliance with guidelines for sigmoidoscopy
Average number of days of unnecessary antibiotics
Antibiotic (cephalexin), Vasodialators, and pain
management drug propoxyphene (darvon) (prescribing of
Transfusions ordered compliant with guidelines
Transfusions ordered non-compliant with guidelines
ACE inhibitors per guidelines for heart failure
Smoking patients’ medical records document
Patients medical records indicate physician
a SMA-12 = Sequential Multiple Analysis lab test panel for 12 measures used to screen patients. b SMA-6 = Sequential Multiple Analysis lab test panel for 6 measures used to monitor patients. c CBC = Complete blood count test.
18 Cornerstones | Volume One | Number One
Table 6 Average Effect Sizes for the Academic-Detailing Characteristics and Structural Variables Constituting the Focus of AnalysisCornerstones | Volume One | Number One 19
Tout cela n’a pas échappé aux colons blancs. Eux aussi se servent de l’échinacée, contre lasyphilis notamment, selon un texte datant dumilieu du XIXe siècle. Une trentaine d’années L ’ é c h i n a c é e plus tard, aux alentours de 1880, un immigréallemand établi dans l’Ohio, H.C.F. Meyer, entire un médicament qu’il préconise contre lesmaux de tête, les névralgies,
C l i n i c a l C a r e / E d u c a t i o n / N u t r i t i o n / P s y c h o s o c i a l R e s e a r c h O R I G I N A L Relationships Between Daily Acute Glucose Fluctuations and Cognitive Performance Among Aged Type 2 Diabetic Patients ARIA ROSARIA RIZZO, MD, PHD FRANCESCO VESTINI, MD AFFAELE MARFELLA, MD, PHD BIAGIO LETTIERI, MD tions is still difficult. Considering that t