Trends in hormone therapy use before and after publication of the Women's Health Initiative trial: 10 years of follow-up. Changes in pattern of use, clinical characteristics and persistence rate of hormone replacement therapy among postmenopausal women after the WHI publication. Synergy between publication and promotion: comparing adoption of new evidence in Canada and the United States. Prescriptions for estrogen replacement therapy in Ontario before and after publication of the Women's Health Initiative Study. Impact of a multipronged education strategy on antibiotic prescribing in Quebec, Canada. Impact of the pravastatin or atorvastatin evaluation and infection therapy-thrombolysis in myocardial infarction 22/Reversal of Atherosclerosis with Aggressive Lipid Lowering trials on trends in intensive versus moderate statin therapy in Ontario, Canada. Changes in prescribing patterns following publication of the ALLHAT trial. The impact of the Women's Health Initiative study on incident clonidine use in Ontario, Canada. Effect of distributing an evidence-based guideline for prevention of osteoporosis on health education programs in municipal health centers: a randomized controlled trial. National use of postmenopausal hormone therapy: annual trends and response to recent evidence. Impact of a drug-use review program intervention on prescribing after publication of a randomized clinical trial. What impact have NICE guidelines had on the trends of hip arthroplasty since their publication? The results from the Trent Regional Arthroplasty Study between 1990 and 2005. Chest radiography guidelines for general practitioners: a practical approach. Changes in the use of postmenopausal hormone therapy after the publication of clinical trial results. Effect of an education program on decreasing catheter-related bloodstream infections in the surgical intensive care unit. Modified guidelines impact on antibiotic use and costs: duration of treatment for pneumonia in a neurosurgical ICU is reduced. Use of the statins in patients after acute myocardial infarction: does evidence change practice? The effect of the ACOG guideline on vaginal births after cesarean. Effect of periodic letters on evidence-based drug therapy on prescribing behaviour: a randomized trial. Impact of a drug bulletin on the knowledge, perception of drug utility, and prescribing behavior of physicians. Implementing a guideline for the treatment of type 2 diabetics: results of a cluster-randomized controlled trial (C-RCT). Primary care guidelines on consultation practices: the effectiveness of computerized versus paper-based versions. A cluster randomized controlled trial among newly qualified primary care physicians. Implementation of guidelines for sequential therapy with fluoroquinolones in a Belgian hospital. The impact of national guidelines for the prophylaxis of venous thromboembolism on the complications of arthroplasty of the lower limb. A randomized trial to increase smoking intervention by physicians. Doctors Helping Smokers, Round I. Drug treatment of stable angina pectoris and mass dissemination of therapeutic guidelines: a randomized controlled trial. Improving drug-therapy decisions through educational outreach. A randomized controlled trial of academically based "detailing". Change in clinical practice after publication of guidelines on breast cancer treatment. Lack of effect of guideline changes on LDL cholesterol reporting and control for diabetes visits in the U.S., 1995-2004. The impact of evidence-based guideline dissemination for the assessment and treatment of major depression in a managed behavioral health care organization. Impact of clinical trial results on national trends in alpha-blocker prescribing, 1996-2002. Promotion and prescribing of hormone therapy after report of harm by the Women's Health Initiative. Effects of mailed dissemination of the Royal College of Radiologists' guidelines on general practitioner referrals for radiography: a time series analysis. Trends in the use of lipid-lowering medications at discharge in patients with acute myocardial infarction: 1998 to 2006. New use of rosiglitazone decreased following publication of a meta-analysis suggesting harm. Reduction in the use of surgery for glue ear: did national guidelines have an impact? Results of a randomized controlled trial on statin use in dialysis patients had no influence on statin prescription. Primary care prescribing patterns in Ireland after the publication of large hypertension trials. Impact of effective health care bulletin on treatment of persistent glue ear in children: time series analysis. Randomized controlled trial of the effect of the Royal College of Radiologists' guidelines on general practitioners' referrals for radiographic examination. Guidelines and educational outreach visits from community pharmacists to improve prescribing in general practice: a randomised controlled trial. Predictors for prophylactic antithrombotic prescribing in ischaemic heart disease and the impact of national guidelines. Rates of hyperkalemia after publication of the Randomized Aldactone Evaluation Study. Cluster randomized clinical trial (ISRCTN23732000) to evaluate the effectiveness of a diagnosis recognition and treatment guide for depressive disorders in primary care.
The aim of this study was to assess the impact of the scientific evidence reported by Women's Health Initiative (WHI) trial on hormone therapy (HT) use in a 10-year follow-up retrospective cohort of women participating in a breast cancer screening program.
                Between 1998 and 2007, a retrospective cohort of participants in a population-based breast cancer screening program in the city of Barcelona (Catalonia, Spain) was assessed. The study population consisted of 50,918 women. Trends in current HT use and the annual rate of new users were analyzed by age group.
                From 1998, successive annual increases were found in the prevalence levels of HT use in all age groups. In 2002, the prevalence peaked at 11% in 50- to 54-year-olds and at 10.1% in 55- to 59-year-olds, followed by a sudden reversal and a progressive decrease. In 2007, 5 years after the publication of the WHI trial, the HT use decreased by 89.1% in 50- to 54-year-olds, 87.5% in 55- to 59-year-olds, 84.6% in 60- to 64-year-olds, and 66.0% in 65- to 69-year-olds. The percentage of new users also fell substantially after 2002.
                HT use decreased during the 5 years after the publication of the WHI. This reduction was especially marked in the first 2 years, when the decrease in new treatments exceeded the number of continuations. In the following 3 years, the decrease was approximately equal in both groups. The WHI was stopped prematurely because of an increased risk of breast cancer, stroke and cardiovascular diseases (CVD) in the hormone replacement therapy (HRT) arm of the trial. Changes in the use of HRT are expected.
                To assess the impact of the Women's Health Initiative (WHI) publication on the rate of HRT prescription, and the clinical characteristics and persistence rate of new users and its determinants.
                From the RAMQ databases, the total numbers of HRT prescriptions, and of new HRT's users were calculated between 2 January 1998 and 31 May 2003. To assess the clinical characteristics of women, two retrospective cohorts of new HRT's users were constructed before (pre-WHI) and after (post-WHI) the WHI study publication. The persistence rate after 1 year of follow-up was estimated using a Kaplan-Meier analysis. Cox regression models were used to estimate the rate ratio of HRT cessation.
                The total numbers of HRT users and of new users declined respectively by 28% and 50% in post-WHI. The standard dosage of HRT was significantly less used, while the proportion of women with risk factors of CVD or at very high risk of coronary artery disease (CAD) did not change. The rate of persistence in the pre-WHI cohort was 59% compared to 45% in the post-WHI (p < 0.0001), and women with risk factors of CVD or at very high risk of CAD were less likely to cease their HRT.
                One year after publication, significant changes had already occurred in the trends of use, women's characteristics and estrogen dosage. No change in the proportion of new users with CVD risk factors or at very high risk of CAD was seen.
                Copyright (c) 2006 John Wiley & Sons, Ltd. Few studies have examined the effect of new evidence from clinical trials on physician practice. We took advantage of differences in promotional activity in Canada and the United States for the Heart Outcomes Prevention and Evaluation (HOPE) study and the Randomized Aldactone Evaluation Study (RALES) to determine if publication of new evidence changes practice, and the extent to which promotion influences adoption of new evidence.
                We used longitudinal dispensing data, collected from 1998 to 2001, to examine changes in prescribing patterns for ramipril and other angiotensin-converting enzyme (ACE) inhibitors before and after the HOPE study. We also obtained estimates for promotional expenditures. We stratified analyses by country, to isolate the effect of promotion, and used interrupted time series methods to adjust for pre-existing prescribing trends. Similar analyses were conducted for spironolactone use before and after RALES.
                Publication of the HOPE study results was associated with rapid increases in the use of ramipril. After adjusting for pre-existing prescribing trends, ramipril prescribing increased by 12% per month (P = 0.001) in Canada versus 5% per month (P = 0.001) in the United States after the study results were presented and published. One year later, ramipril accounted for 30% of the ACE inhibitor market in Canada versus 6% in the United States. The year before publication of these results, expenditures for detailing increased by 20% in Canada (to 18 US dollars per physician) but decreased by 7% in the United States (to 13 US dollars per physician); the year after publication, spending increased to 27 US dollars per physician in Canada versus 23 US dollars per physician in the United States. In the absence of promotional activity for RALES in either country, publication of results was associated with more modest but similar increases of 2% per month (P = 0.001) in spironolactone use in both countries.
                Publication of new evidence is associated with modest changes in practice. Promotional activity appears to increase the adoption of evidence. Rather than relying on the publication of articles and creation of guidelines, those wishing to accelerate the adoption of new evidence may need to undertake more active promotion. nan Antibiotic overuse and resistance have become a major threat in the last 2 decades. Many programs tried to optimize antibiotic consumption in the inpatient setting, but the outpatient environment that represents the bulk of antibiotic use has been challenging. Following a significant rise of Clostridium difficile infections, all the health care stakeholders in the province of Quebec, Canada initiated a global education program targeting physicians and pharmacists.
                A bundle approach was used; 11 user-friendly guidelines were produced by a group of experts and sent to all physicians and pharmacists in Quebec in January 2005. Downloadable versions of guidelines were posted on a dedicated Web site. They were promoted by professional organizations, universities, and experts during educational events, and there was strong acceptance by the pharmaceutical industry with a willingness to follow the recommendations in their marketing. The Intercontinental Medical Statistics (IMS) database was used to analyze and compare Quebec's total outpatient prescriptions per 1000 inhabitants with those in the other Canadian provinces for 2 time periods: preintervention (January 2003 to December 2004), and postintervention (February 2005 to December 2007).
                In 2004, antibiotic consumption per capita was 23.3% higher in Canada generally than in Quebec. After the guidelines dissemination, the gap between Quebec and the other Canadian provinces increased by 4.1 prescriptions/1000 inhabitants (P = .0002), and the trend persisted 36 months later. Antibiotic costs fell $134.5/1000 inhabitants in Quebec compared with the rest of Canada (P = .054).
                The implementation of guidelines significantly reduced antibiotic prescriptions in Quebec compared with the rest of the country, and there was a strong trend toward significant cost reduction. In March 2004, the Reversal of Atherosclerosis with Aggressive Lipid Lowering (REVERSAL) trial demonstrated that intensive lipid-lowering therapy (atorvastatin 80 mg/d) reduced progression of coronary atherosclerosis compared with moderate lipid-lowering therapy (pravastatin 40 mg/d). The following month, the Pravastatin or Atorvastatin Evaluation and Infection Therapy-Thrombolysis In Myocardial Infarction 22 (PROVE IT-TIMI 22) study demonstrated the superiority of intensive (atorvastatin 80 mg/d) versus moderate (pravastatin 40 mg/d) lipid-lowering therapy for reducing death or cardiovascular events in patients suffering from an acute coronary syndrome. We sought to determine the impact of these 2 trials on trends in intensive versus moderate statin therapy in Ontario, Canada.
                This is a retrospective time-series analysis of statin prescribing between June 1997 and September 2004 in Ontario, Canada, for all residents age 65 years and older. The publication of the PROVE IT-TIMI 22 and REVERSAL trials was associated with a sustained and statistically significant increase in the number of prescriptions dispensed for atorvastatin 80 mg (range, 272 to 635 additional prescriptions per month), whereas the number of prescriptions filled for pravastatin 40 mg did not change. Similarly, it resulted in a temporal increase in the relative market share of atorvastatin at a dose of 80 mg versus that of atorvastatin at a dose of 40 mg. However, the proportion of simvastatin prescriptions for 80 mg relative to 40 mg did not change over time, implying a drug-specific effect rather than a class effect in prescribing practice.
                The publication of the PROVE IT-TIMI 22 and REVERSAL trials resulted in a significant sustained increase in the use of intensive compared with moderate statin therapy. This shift was evident primarily in an increased use of high-dose atorvastatin and did not appear to be generalizable to other statins. nan Following publication of the Women's Health Initiative (WHI) study, many women discontinued use of estrogen replacement therapy. There is some evidence that the antihypertensive agent clonidine can reduce the frequency of hot flashes associated with menopause.
                To determine the impact of the WHI study on incident use of clonidine in elderly women in Ontario, Canada.
                Retrospective, population-based administrative database design. Data on all residents of Ontario over the age of 65 years were included. Time series methods were used to analyze change in incident clonidine use following publication of the WHI study.
                Following publication of the WHI study, incident use of clonidine increased substantially among elderly women in Ontario, Canada. Similar trends were not observed for incident use of other antihypertensive medications.
                During a period of time in which a large proportion of women discontinued estrogen replacement therapy, incident use of clonidine increased. There is some evidence that a small number of women may have sought alternative relief from menopausal symptoms using other pharmacological therapies. Current health education programs for osteoporosis prevention are not strictly evidence-based. We assessed whether distribution of an evidence-based guideline improved such programs at municipal health centers.
                This randomized controlled trial evaluated 100 municipal health centers throughout Japan that were randomly selected from those that planned to revise osteoporosis prevention programs. The implementation status of educational items recommended by the guideline was assessed before and after the intervention by evaluators blinded to the allocation. After the pre-intervention assessment, centers were randomly allocated in a 1:1 ratio to intervention and control groups by a minimization method defining region and city/town as stratification factors. Centers in the intervention group were given copies of the guideline; centers in the control group were instructed to use any information except the guideline. Analyses were performed on an intention-to-treat basis.
                The guideline was used by 50% of the intervention group. Before the intervention, there was no significant difference in the evidence-based status of health education between the groups. The post-intervention assessment showed that the implementation rates of health education on dietary calcium intake for postmenopausal women and exercise for elderly persons were higher in the intervention group. Specific advice on intakes of calcium and vitamin D and exercise became more evidence-based in the intervention group.
                The findings suggest that the guideline helped healthcare professionals to improve health education programs by making them more evidence-based. However, the improvements seemed to be limited to items that the professionals felt prepared to improve. Postmenopausal hormone therapy use increased dramatically during the past 2 decades because of a prevailing belief in its health benefits. Recent evidence from randomized trials published in July 2002 demonstrated adverse cardiovascular disease events and other risks with hormone therapy in the form of oral estrogen combined with progestin.
                To describe patterns of hormone therapy use from 1995 until July 2003, including the impact of recent evidence.
                Two databases were used to describe national trends in hormone therapy use from January 1995 to July 2003. The National Prescription Audit database provided data on the number of hormone therapy prescriptions filled by retail pharmacies and the National Disease and Therapeutic Index database provided data on patient visits to office-based physicians during which hormone therapy was prescribed.
                Annual number of hormone therapy prescriptions and characteristics of visits to physicians during which hormone therapy was prescribed.
                Annual hormone therapy prescriptions increased from 58 million in 1995 to 90 million in 1999, representing approximately 15 million women per year, then remained stable through June 2002. Adoption of new oral estrogen/progestin combinations, primarily Prempro, accounted for most of this growth. Obstetrician/gynecologists provided more than 70% of hormone therapy prescriptions, and more than one third of patients were older than 60 years. Following the publication of trial results in July 2002, hormone therapy prescriptions declined in successive months. Relative to January-June 2002, prescriptions from January-June 2003 declined by 66% for Prempro and 33% for Premarin. Small increases were observed in vaginal formulations and in new prescriptions for low-dose Premarin. If prescription rates observed through July 2003 remain stable, a decline to 57 million prescriptions for 2003, similar to the rate in 1995, is projected.
                Clinical practice responded rapidly to recent evidence of harms associated with hormone therapy. Since July 2002, many patients have discontinued hormone therapy or are tapering to lower doses. The effect of a drug-use review (DUR) program intervention on physician prescribing after the results of a randomized clinical trial were published was studied. A Veterans Administration (VA) cooperative study published in June 1986 showed that congestive heart failure (CHF) patients who had hydralazine and isosorbide added to their drug therapy had less mortality than patients given digoxin and diuretics with or without prazosin. Physicians with at least one CHF patient who was receiving the less effective therapy were randomly assigned to intervention and control groups. In September 1986, intervention-group physicians (n = 288) were mailed a letter and questionnaire from the DUR program coordinator, the journal article, and a drug history profile of a CHF patient who might benefit from the information. Control physicians received no mailing. The questionnaire asked whether the physicians already knew about the VA study, intended to alter their prescribing, and could identify factors that would affect their decision. Two thirds of intervention-group physicians were already aware of the VA study. One third indicated that they intended to alter drug therapy based on the study results; factors significantly associated with the intent to adopt a change were physician training and experience, comments by peers, new drug availability, and the size of the reduction in mortality. During four months after the intervention, only 5 physicians in the two groups switched their patients to both hydralazine and isosorbide (full change); 23 switched them to at least one of the drugs or discontinued prazosin (partial change). There was no significant difference in the number of full or partial changes between groups.(ABSTRACT TRUNCATED AT 250 WORDS) The National Institute for Clinical Excellence (NICE) published the guidelines on the selection of prostheses for primary hip replacement in 2000. They supported the use of cemented hip prostheses to the exclusion of uncemented and hybrid implants. The information from the Trent (and Wales) Regional Arthroplasty Study has been examined to identify retrospectively the types of hip prostheses used between 1990 and 2005, and to assess the impact that the guidelines have had on orthopaedic practice. The results show that the publication of the NICE guidelines has had little impact on clinical practice, with the use of uncemented prostheses increasing from 6.7% (137) in 2001 to 19.2% (632) in 2005. The use of hybrid prostheses has more than doubled from 8.8% (181) to 22% (722) of all hips implanted in the same period. The recommendations made by NICE are not being followed, which calls into question their value. An intensive programme of guideline development and dissemination is not always practical. We designed general practitioner guidelines for chest radiography and disseminated them to a group of 33 practices selected randomly from the practices that refer more than five patients for chest radiography annually. The subsequent 2500 requests were analysed and demographic data, the referring practice and the relevant history noted. We documented a reduction in the proportion of referrals that were contrary to the guidelines by 30.5% (from 8.2% to 5.7%, P = 0.016), a reduction in referral rate with an inadequate history by 29.7% (from 15.5% to 10.9%, P = 0.0008) and an increase in the frequency that a presumptive diagnosis was stated by 14.5% (from 42.9% to 49.1%, P = 0.0025). There was no overall reduction in referral rate in the study group and the reasons for this are discussed. We conclude that guidelines for chest radiography are effective in reducing inappropriate requests and can also improve the clinical information provided. The recent publication of clinical trial results has led to a dramatic shift in the evidence about postmenopausal hormone therapy.
                To examine whether the publication of clinical trial results, specifically the Heart and Estrogen/progestin Replacement Study (HERS) in 1998 and the Women's Health Initiative (WHI) in 2002, has influenced the use of hormone therapy among postmenopausal women.
                Observational cohort (1997 to 2003).
                San Francisco Mammography Registry, San Francisco, California.
                Postmenopausal women between the ages of 50 and 74 years without a personal history of breast cancer who underwent mammography (151862 mammograms).
                Self-reported current use of hormone therapy.
                Among menopausal women who had mammography, it was estimated that 41% were currently using hormone therapy in 1997. Before the publication of HERS, the use of hormone therapy was increasing at a rate of 1% (95% CI, 0% to 2%) per quarter. After the publication of HERS, use decreased by 1% (CI, -3% to 0%) per quarter. In contrast, the publication of the WHI in 2002 was associated with a more substantial decline in the use of hormone therapy of 18% (CI, -21% to -16%) per quarter. Similar associations were observed for most subgroups of women, including women older than 65 years of age; women with a previous hysterectomy; and women who described their race or ethnicity as white, African American, Latina, Chinese, or Filipina.
                The release of the HERS data was temporally associated with a modest decline in the use of hormone therapy. In contrast, the release of the principal findings from the WHI was associated with a more substantial decline in use by postmenopausal women. The reason for the differences in decline may relate to the fact that the WHI results were widely publicized or were more applicable to most postmenopausal women because the WHI study was performed in healthy women. The purpose of the study was to determine whether an education initiative aimed at improving central venous catheter insertion and care could decrease the rate of primary bloodstream infections.
                Pre- and postintervention observational study.
                Eighteen-bed surgical/burn/trauma intensive care unit (ICU) in an urban teaching hospital.
                A total of 4,283 patients were admitted to the ICU between January 1, 1998, and December 31, 2000.
                A program primarily directed toward registered nurses was developed by a multidisciplinary task force to highlight correct practice for central venous catheter insertion and maintenance. The program consisted of a 10-page self-study module on risk factors and practice modifications involved in catheter-related infections as well as a verbal in-service at staff meetings. Each participant was required to take a pretest before taking the study module and an identical test after its completion. Fact sheets and posters reinforcing the information in the study module were also posted throughout the ICU.
                Seventy-four primary bloodstream infections occurred in 6874 catheter days (10.8 per 1000 catheter days) in the 18 months before the intervention. After the implementation of the education module, the number of primary bloodstream infections fell to 26 in 7044 catheter days (3.7 per 1000 catheter days), a decrease of 66% (p < .0001). The estimated cost savings secondary to the decreased infection rate for the 18 months after the intervention was between $185,000 and $2.808 million.
                A focused intervention primarily directed at the ICU nursing staff can lead to a dramatic decrease in the incidence of primary bloodstream infections. Educational programs may lead to a substantial decrease in cost, morbidity, and mortality attributable to central venous catheterization. To evaluate the impact of an intervention to reduce the duration of antibiotic treatment for pneumonia in a neurosurgical intensive care unit (ICU). The usage of antibiotics and the resultant costs were examined using interrupted time series analysis while resistance and device-associated infection rates are also described.
                In January 2004, revised guidelines for the use of antibiotics were implemented. As a consequence of this, the duration of antibiotic therapy for nosocomial pneumonia was reduced from 14 to 7 days, while for community-acquired pneumonia the period fell from 10 to 5 days. The effect on the antibiotic use density [AD; expressed as defined daily doses (DDD) per 1000 patient days (pd)] was calculated by segmented regression analysis of interrupted time series for the 24 months prior to (2002 and 2003) and after the intervention (2004 and 2005).
                The intervention was associated with a significant decrease in total AD from 949.8 to 626.7 DDD/1000 pd after the intervention. This was mainly due to reduced consumption of second-generation cephalosporins (-100.6 DDD/1000 pd), imidazoles (- 100.3 DDD/1000 pd), carbapenems (-33.3 DDD/1000 pd), penicillins with beta-lactamase inhibitor (-33.5 DDD/1000 pd) and glycopeptides (-30.2 DDD/1000 pd). Glycopeptide reduction might be associated with a significant decrease in the proportion of methicillin-resistant Staphylococcus aureus (8.4% before and 2.9% after the intervention). Similarly, total antibiotic costs/pd (Euro) showed a significant decrease from 13.16 Euro/pd before to 7.31 euro/pd after the intervention. This is a saving of 5.85 Euro/pd. The incidence of patients dying with pneumonia did not change significantly.
                The most conservative estimate of segmented regression analysis over a 48 month period showed that halving the duration of treatment for pneumonia results in a reduction of over 30% in antibiotic consumption and costs. Because respiratory infections are most common in ICU patients, interventions targeting a reduction in the duration of treatment of pneumonia might be extremely worthwhile. To compare the use of lipid-lowering agents in 42 628 elderly patients (aged > or =65 years) after acute myocardial infarction, before and after the publication of the Scandinavian Simvastatin Survival Study (4S), using the Ontario Myocardial Infarction Database.
                Multivariate regression models were created to estimate changes in the rate of statin use over time in monthly cohorts of elderly patients after acute myocardial infarction in Ontario from April 1, 1992, to March 31, 1997. Changes in the rate of statin use over time were estimated using patient and prescriber characteristics.
                We found a 3.6-fold significant increase in the monthly rate of statin use after the publication of 4S compared with before the publication of 4S (P<.001); specifically, the rate of increase in simvastatin and pravastatin sodium use was higher after the publication of 4S (P<.001 for each). Before the publication of 4S, the rate of increase in statin use in younger patients (aged 65-74 years) was 2.7 times higher than in older patients (aged > or =75 years) (P =.02), while after the publication of 4S, the rate of increase in statin use was only 1.8-fold higher in the younger group (P<.001). After the publication of 4S, there was a 1.6-fold higher rate of increase in statin use in male compared with female patients (P =.006). Also after the publication of 4S, specialists (cardiologists and internists) had a 2-fold higher rate of increased use of the statins than did generalists (P<.001).
                It is possible to shift practice if the evidence of benefit is strong, the intervention is easy to implement, and the intervention is marketed aggressively. nan The effect of regular and expected printed educational materials on physician prescribing behaviour has not been studied. We sought to measure the impact of a series of evidence-based drug therapy letters mailed to physicians in British Columbia on prescribing to newly treated patients.
                A paired, cluster randomized community design was used. The study population included 499 physicians from 24 local health areas in British Columbia. Local health areas were paired by number of physicians, and 1 of each pair was randomly selected and its physicians assigned to an intervention group or a control group. The intervention was 12 issues of an evidence-based series called Therapeutics Letter. Physicians in the control group (n = 241) received the letters 3-8 months after physicians in the intervention group (n = 258). The impact on prescribing to newly treated patients (defined as patients who had not previously made a claim for any medication from the class of drugs profiled in the letter) was analyzed using the drug claims database of BC Pharmacare, a publicly funded drug benefits program that covered all seniors and people receiving social assistance.
                The probability of prescribing a drug recommended in the Therapeutics Letter rather than another drug in the same class increased by 30% in the 3 months after the mailing of the letter relative to the preceding 3 months, adjusted for any before-after changes in the control group (relative risk 1.30; 95% confidence interval 1.13-1.52). No letter achieved statistical significance on its own. However, 11 of the 12 letters produced prescribing changes in the predicted direction such that the overall result was significant when their effect was combined.
                The combined effect of an ongoing series of printed letters distributed from a credible and trusted source can have a clinically significant effect on prescribing to newly treated patients. The impact of a drug bulletin was tested in a randomized controlled trial that included 186 family physicians. The length of the trial was six months. It was hypothesized that printed information, such as in drug bulletins, influences physician prescribing behavior by changing their knowledge of drug efficacy and adverse effects and their perceptions of drug utility. Therefore, the impact of a drug bulletin was evaluated on these domains of influence. Interview data were used to assess changes in knowledge, perceived drug utility, and stated prescribing. Health insurance funds' records were used to collect actual prescribing data. Information in the bulletin on the treatment of renal colic changed physicians' knowledge as well as perceived utility of drugs used for renal colic (p less than 0.05). Significant changes in stated prescribing were also found. On the other hand, advice in the same bulletin on the treatment of the irritable bowel syndrome (IBS) had no impact at all. It did not even improve the knowledge of the physicians about the drugs used for IBS. Apparently, the message about the treatment of IBS failed to gain the attention of the physicians. It is suggested that some messages are sufficiently transmitted through written information, and others that are seen as less relevant or too difficult to implement need more intensive strategies. In Italy many diabetics still lack adequate care in general practice. We assessed the effectiveness of different strategies for the implementation of an evidence-based guideline for the management of non-complicated type 2 diabetes among General Practitioners (GPs) of Lazio region.
                Three-arm cluster-randomised controlled trial with GPs as units of randomisation (clusters). 252 GPs were randomised either to an active strategy (training module with administration of the guideline), or to a passive dissemination (administration of the guideline only), or to usual care (control). Data on prescriptions of tests and drugs were collected by existing information systems, whereas patients' data came from GPs' databases. Process outcomes were measured at the cluster level one year after the intervention. Primary outcomes concerned the measurement of glycosilated haemoglobin and the commissioning of micro- and macrovascular complications assessment tests. In order to assess the physicians' drug prescribing behaviour secondary outcomes were also calculated.
                GPs identified 6395 uncomplicated type 2 patients with a high prevalence of cardiovascular risk factors. Data on GPs baseline performance show low proportions of glycosilated haemoglobin assessments. Results of the C-RCT analysis indicate that the active implementation strategy was ineffective relating to all primary outcomes (respectively, OR 1.06 [95% IC: 0.76-1.46]; OR 1.07 [95% IC: 0.80-1.43]; OR 1.4 [95% IC:0.91-2.16]. Similarly, passive dissemination of the guideline showed no effect.
                In our region compliance of GPs with guidelines was not enhanced by a structured learning programme. Implementation through organizational measures appears to be essential to induce behavioural changes.
                ISRCTN80116232. To compare the effects of computerized and paper-based versions of guidelines on recently qualified physicians' consultation practices.
                Two arm cluster randomized controlled trial. Physicians were randomized to receive computerized or textbook-based versions of the same guidelines for a 4-week study period. Physicians' compliance with guideline recommendations about laboratory, radiological, physical and other examinations, procedures, nonpharmacologic and pharmacologic treatments, physiotherapy, and referrals were measured by case note review.
                There were 139 recently qualified physicians working in 96 primary healthcare centers in Finland who participated in the study. Data on 4,633 patient encounters were abstracted, of which 3,484 were suitable for further analysis. Physicians' compliance with guidelines was high (over 80% for use of laboratory, radiology, physical examinations, and referrals). There were no significant differences in physicians' consultation practices in any of the measured outcomes between the computerized and textbook group.
                Guidelines are a useful source of information for recently qualified physicians working in primary care. However, the method of presentation of the guidelines (electronic or paper) does not have an effect on guideline use or their impact on decisions. Other factors should be considered when choosing the method of presentation of guidelines, such as information-seeking time, ease of use during the consultation, ability to update, production costs, and the physician's own preferences. This study measured the impact of three interventions for physicians, in order to implement guidelines for sequential therapy (intravenous to oral conversion) with fluoroquinolones.
                A Belgian university hospital with 1,065 beds. Method The first intervention consisted of the hospital-wide publication of guidelines in the local drug letter towards all prescribers. The consumption of fluoroquinolones was measured by means of an interrupted time-series (ITS) analysis 21 months before (period A) and 24 months after publication (period B). The second intervention was an educational interactive session, by infectious disease specialists, to the medical staff of orthopaedics and endocrinology. The third intervention comprised a proactive conversion programme on the abdominal surgery, gastro-enterology and plastic surgery wards, where pharmacists attached a pre-printed note with a suggestion to switch to an oral treatment every time a patient met the criteria for switching. The second and third intervention took place 6 months after the first intervention. Fluoroquinolone treatments were evaluated during a 2 month period before (group 1) and after the introduction of the second (group 2) and third (group 3) intervention.
                The monthly ratio of intravenous versus total fluoroquinolone consumption (daily defined doses per 1,000 bed days) was measured to assess the impact of the first intervention. The impact of the second and third intervention was measured in relation to the number of days that intravenous therapy continued beyond the day that the patient fulfilled the criteria for sequential therapy and the antibiotic cost.
                The ITS demonstrated a reduction of 3.3% in the ratio of intravenous versus total consumption after the publication of the guidelines (P = 0.011). In group 1, patients were treated intravenously for 4.1 days longer than necessary. This parameter decreased in group 2 to 3.5 days and in group 3 to 1.0 day (P = 0.006). The mean additional cost for longer intravenous treatment decreased from 188.0 euro in group 1, to 103.0 euro in group 2 and 44.0 euro in group 3 (P = 0.037).
                This study demonstrated that active implementation of guidelines is necessary. A proactive conversion programme by a pharmacist resulted in a reduction in the duration of the intravenous treatment, and the treatment cost. The National Institute for Clinical Excellence (NICE) produces recommendations on appropriate treatment within the National Health Service (NHS) in England and Wales. The NICE guidelines on prophylaxis for venous thromboembolism in orthopaedic surgery recommend that all patients be offered a low molecular weight heparin (LMWH). The linked hospital episode statistics of 219 602 patients were examined to determine the rates of complications following lower limb arthroplasty for the 12-month periods prior to and following the publication of these guidelines. These were compared with data from the National Joint Registry (England and Wales) regarding the use of LMWH during the same periods. There was a significant increase in the reported use of LMWH (59.5% to 67.6%, p < 0.001) following the publication of the guidelines. However, the 90-day venous thromboembolism events actually increased slightly following total hip replacement (THR, 1.69% to 1.84%, p = 0.06) and remained unchanged following total knee replacement (TKR, 1.99% to 2.04%). Return to theatre in the first 30 days for infection did not show significant changes. There was an increase in the number of patients diagnosed with thrombocytopenia, which was significant following THR (0.11% to 0.16%, p = 0.04). The recommendations from NICE are based on predicted reductions in venous thromboembolism events, reducing morbidity, mortality and costs to the NHS. The early results in orthopaedic patients do not support these predictions, but do show an increase in complications. Sixty-six physicians were randomized to three groups to conduct a 1-month campaign to help their patients stop smoking. The workshop group received free patient education materials and a 6-hour training workshop. The materials group received free patient education materials, and the no-assistance group received nothing. A telephone interview was completed with 89% of the 6767 eligible adult patients seen during the month of the campaign. The brief training program and patient education materials marginally increased the smoking intervention activities of volunteer physicians in private practice. Both workshop and materials physicians asked 54% of their smoking patients to stop; no-assistance physicians asked 40%. One year later, 36% of patients who had not even been asked by their doctors if they smoked reported that they had tried to stop smoking. If the physician had asked the patient if he or she smoked, the probability of a quit attempt was 47%. Patients who had been asked if they smoked were more likely to claim to have stopped (13%) than patients who had not been asked (9%). However, the proportion of patients claiming continued abstinence (range, 12% to 14%) was not related to the group of the physician. Public agencies responsible for implementing health care policies often adapt and disseminate clinical practice guidelines, but the effectiveness of mass dissemination of guidelines is unknown. Aim: To study the effects of guideline dissemination on physicians' prescribing practices for the treatment of stable angina pectoris.
                Randomized controlled trial.
                A sample of 3293 Quebec physicians were randomly assigned to receive a one-page summary of clinical practice guidelines on the treatment of stable angina (in February 1999), to receive the summary and a reminder (in February and March 1999, respectively), or to receive no intervention (controls). The prescribing profiles of participants, as well as sociodemographic characteristics of the physicians and their patients, were examined for June-December 1999.
                The intervention had no effect on prescription rates of beta-blockers, antiplatelet agents, or hypolipaemic drugs. Compared to 1997 data for the same physicians, there was an overall 10% increase in appropriate prescription rates, irrespective of the intervention.
                In-house production and dissemination of clinical practice guidelines may not improve physicians' practice patterns if there is pre-existing substantial scientific consensus on the issue. Improving precision and economy in the prescribing of drugs is a goal whose importance has increased with the proliferation of new and potent agents and with growing economic pressures to contain health-care costs. We implemented an office-based physician education program to reduce the excessive use of three drug groups: cerebral and peripheral vasodilators, an oral cephalosporin, and propoxyphene. A four-state sample of 435 prescribers of these drugs was identified through Medicaid records and randomly assigned to one of three groups. Physicians who were offered personal educational visits by clinical pharmacists along with a series of mailed "unadvertisements" reduced their prescribing of the target drugs by 14 per cent as compared with controls (P = 0.0001). A comparable reduction in the number of dollars reimbursed for these drugs was also seen between the two groups, resulting in substantial cost savings. No such change was seen in physicians who received mailed print materials only. The effect persisted for at least nine months after the start of the intervention, and no significant increase in the use of expensive substitute drugs was found. Academically based "detailing" may represent a useful and cost-effective way to improve the quality of drug-therapy decisions and reduce unnecessary expenditures. Several studies raise questions about whether clinical practice guidelines actually guide practice. We evaluated patterns of use of breast-conserving surgery (BCS) over time to examine the effect of guideline publication.
                Retrospective analysis of time-series data on breast cancer treatment. Multiple logistic regression analysis was performed, adjusting for covariates including the patient's age, comorbidity status and admission year, to assess whether the use of BCS was higher after publication of treatment guidelines.
                Five teaching hospitals participating in the Quality Improvement/Indicator Project (QIP) in Japan.
                Female breast cancer patients who received surgical treatment at five teaching hospitals from January 1996 through December 2007 (n = 2199).
                Rates of use of BCS.
                The proportion of BCS use increased from 26.4% before guideline publication to 59.9% after guideline publication in Japan. After controlling for other characteristics, the use of BCS has increased significantly over time, especially since 2001. Women aged 70 years and older (P=0.004) and those with any comorbidity (P < 0.001) were significantly less likely to receive BCS.
                This study demonstrated that the adjusted proportion of BCS has increased dramatically since 2001, 2 years after guideline publication in Japan and this is consistent with a relationship between guideline publication and a change in this clinical practice. nan This study tests whether a managed behavioral health care organization can influence adherence to practice guidelines for the treatment of major depression in a randomized trial of guideline dissemination. Guidelines were disseminated to mental health clinicians (N = 443) under one of three conditions: (1) a general mailing of guidelines to clinicians, (2) a mailing in which guidelines were targeted to a patient starting treatment with the clinician, and (3) no mailing of guidelines. The results showed no effects of guideline dissemination as measured by self-report of patients and clinicians and through episode characteristics derived from claims data, despite sentinel effects. Results also showed high rates of clinician-reported guideline adherence that were not detected in the claims data, indicating significant undertreatment of depression. Results suggest that mental health systems must look to other dissemination strategies to improve adherence to standards of care and raise the performance of independent practicing clinicians. Research on factors that influence prescribing patterns and the extent of change produced by clinical trial findings is limited.
                To examine the changes in prescribing of alpha-blockers for hypertension treatment before and after the April 2000 publication of the unfavorable Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) early termination involving the study's doxazosin mesylate arm. Changes in prescribing were considered in the context of other potential concurrent influences on medication use between 1996 and 2002, including changes in alpha-blocker drug prices, generic conversion, drug promotion, and competition.
                Using 2 national pharmaceutical market research reports published by IMS HEALTH, alpha-blocker prescription orders reported in the National Prescription Audit-a random computerized sample of about 20 000 of 29 000 retail, independent, and mail order pharmacies and mass merchandise and discount houses--and office-based physician alpha-blocker prescribing patterns reported in the National Disease and Therapeutic Index--a random stratified sample of about 3500 physician offices--were tracked.
                Trends in physician-reported use of alpha-blockers and alpha-blocker prescribing and dispensing by US pharmacies.
                There were steady increases in alpha-blocker new prescriptions, dispensed prescriptions, and physician drug use from 1996 through 1999. There was a moderate reversal in these trends following ALLHAT early termination and subsequent publications in early 2000. Between 1999 and 2002, new annual alpha-blocker prescription orders declined by 26% (from 5.15 million to 3.79 million), dispensed prescriptions by 22% (from 17.2 million to 13.4 million), and physician-reported drug use by 54% (from 2.26 million to 1.03 million). Other potential influences did not appear to have contributed significantly to this decline although cessation of alpha-blocker marketing may have hastened the decline.
                Modest yet statistically significant declines in the use of doxazosin and other alpha-blockers coincided with the early termination of the ALLHAT doxazosin arm. Although physicians responded to this new evidence, strategies to augment the impact of clinical trials on clinical practice are warranted. Little is known about how the pharmaceutical industry responds to evidence of harm associated with its products, such as the publication in July 2002 of the Women's Health Initiative Estrogen Plus Progestin Trial (WHI E+P) report demonstrating that standard-dose Prempro produced significant harm and lacked net benefits.
                To examine pharmaceutical industry response to the WHI E+P results by analyzing promotional expenditures for hormone therapy before and after July 2002.
                Nationally representative and prospectively collected longitudinal data (January 2001 through December 2003) on prescribing and promotion of hormone therapies were obtained from IMS Health and Consumer Media Reports.
                Trends in quarterly prescriptions for hormone therapy and expenditures on 5 modes of drug promotion: samples, office-based detailing, hospital-based promotion, journal advertisements, and direct-to-consumer advertising.
                Prior to the WHI E+P report, prescribing rates and promotional spending for hormone therapy were stable. In the quarter before the WHI E+P report (April-June 2002), 22.4 million prescriptions for hormone therapy were dispensed and 71 million dollars was spent on promotion (in annual terms, 350 dollars per year per US physician). Within 9 months of the report's publication (quarter 1 of 2003), there was a 32% decrease in hormone therapy prescriptions, and a nadir had been reached for promotional spending (37% decrease compared with pre-WHI E+P levels). Spending decreased for all promotional activities and most hormone therapies. Overall, the greatest declines were for samples (36% decrease as of quarter 1 of 2003) and direct-to-consumer advertising (100% decrease). The greatest declines in promotion occurred for standard-dose Prempro (61% decrease as of quarter 1 of 2003), the agent implicated by the WHI E+P report. More recently, promotional efforts have increased, particularly for lower-dose Prempro, a resurgence associated with modestly increased prescriptions for this newer agent.
                Concordant with its widespread use, hormone therapy was among the most heavily promoted medications prior to the WHI E+P report. Following reporting of the evidence of harm from this trial, there was a substantial decline in promotional spending for hormone therapy, particularly for the agents most directly implicated in the trial. Interrelated with the impact of the trial results themselves and the ensuing media coverage, reduced promotion may have contributed to a substantial decline in hormone therapy prescriptions. To evaluate the effect of postal dissemination of the third edition of the Royal College of Radiologists' (RCR) guidelines on general practitioner referrals for radiography.
                An interrupted time series using monthly data for 34 months before and 14 months after dissemination of the guidelines was employed. Data were abstracted for the period April 1994 to March 1998 from the computerized administrative systems of open access radiological services provided by two teaching hospitals in one region of Scotland. The time series results are contrasted with those obtained by using a simple before and after design.
                A total of 117 747 imaging requests from general practice were received in the two departments. There were no significant effects of disseminating the guidelines on the total number of requests, or on requests for individual examinations. If a simple before and after study had been used, then we would have erroneously concluded that significant changes had occurred in referral practice for 11 of the 18 procedures concerned.
                Mailing of copies of the RCR guidelines had a small effect on general practitioners' use of X-ray investigations of uncertain clinical significance. Additional dissemination and implementation strategies appear necessary to promote the use of guidelines.
                Copyright 2002 The Royal College of Radiologists. Compelling evidence demonstrates that certain lipid-lowering medications improve outcomes after acute myocardial infarction (AMI), but to what extent national utilization has increased in response to trials and guidelines has not been well studied. The objective of this study is to determine trends in the use of lipid-lowering medications at discharge for AMI.
                A time trend analysis was conducted on treatment rates with lipid-lowering medications from 1998 to 2006 in 996,364 patients with AMI hospitalized in 1,669 hospitals participating in the National Registry of Myocardial Infarction (NRMI) 3, 4, and 5.
                Between 1998 and 2006, use of lipid-lowering medications at discharge increased from 29.3% to 83.8%, (relative risk [RR] 2.86, 95% CI 2.84-2.89, P < .0001). Increased use was observed in men (RR 2.71) and women (RR 3.17); age younger than 65 years (RR 2.32) and 65 years or older (RR 3.46); teaching (RR 2.47) and nonteaching hospitals (RR 2.96); and in all regions of the country. After adjusting for multiple other independent predictors, the temporal increase in use of lipid-lowering medications remained highly significant (RR 2.70, 95% CI 2.68-2.73, P < .0001). A significant upward jump in the rate of lipid-lowering medication use was observed most notably in month 72, corresponding to the publication on the PROVE-IT trial (Pravastatin or Atorvastatin Evaluation and Infection Therapy trial).
                Use of lipid-lowering medications in patients hospitalized with AMI has increased substantially in the United States in the past 8 years. The increase in the lipid-lowering medication use was possibly accelerated by certain randomized clinical trial evidence demonstrating improved outcomes in this high-risk population. It is uncertain whether meta-analyses lead to changes in prescribing practices. We studied trends in the prescribing of glucose-lowering therapy before and after the publication of a meta-analysis suggesting harm from rosiglitazone.
                We examined the prescription records of all residents of Ontario, Canada, aged > or = 66 years. For each week between January and December 2007, we identified new users of five categories of glucose-lowering medications: rosiglitazone, pioglitazone, metformin, glibenclamide (glyburide) and insulin. The effect of the meta-analysis was assessed using interventional autoregressive integrated moving-average models.
                Following the release of the meta-analysis, there was a sudden decline in new users of rosiglitazone (P = 0.01), mirrored by a nearly identical but transient increase in new users of pioglitazone (P < 0.001). There was also a net decline in new users of thiazolidinediones as a class (P < 0.001). The number of new users of other glucose-lowering medications did not change.
                A highly-publicized meta-analysis regarding rosiglitazone's potential harms led to an abrupt decline in new users of the drug, as well as a transient surge in new use of pioglitazone. It is widely accepted that the passive dissemination of national clinical guidance has little or no impact on practice.
                To assess the impact in England of an Effective Health Care bulletin on childhood surgery for glue ear issued in 1992 and to understand the reasons for any change (or lack of change) in practice that ensued.
                Time series analysis of the rate of use of surgery by children under 10 years of age from 1975 to 1997/8 in 13 English health districts.
                Following a rise in the rate of surgery in public (National Health Service) hospitals from 1975 to 1985, the rate declined by 1.6% a year from 1986 to 1992/3. Following publication of the guidelines in November 1992, the rate of decline increased to 10.1% a year. Even after allowing for a slight increase in the use of independent (private) hospitals between 1992/3 and 1997/8, the overall rate of decline was at least 7.9%. It appears that the rate of referral of cases by primary care physicians (general practitioners) halved during this period. Several contextual factors are thought to have contributed to the effect of the guidelines, including pre-existing professional concern about the value of surgery, the introduction of an internal market into the NHS, and growing apprehension among parents fuelled by scepticism in the mass media. During this unprecedented period of rapid change in usage, staff delivering the service remained unaware of the alterations in their own practice.
                Passive dissemination of national guidelines can accelerate an existing trend in clinical practice if the context is hospitable. Policy makers should identify and target such situations. Randomized trials provide high-quality evidence for patient care. The Der Deutsche Diabetes Dialyse Studie (4D), a randomized study which demonstrated no benefit of statins among diabetic patients receiving hemodialysis, was published in July 2005. To determine effects of this study we conducted a retrospective, population-based, time series analysis with change-point regression to see if the rate of statin prescription to dialysis patients had been modified. We linked health administrative data for all diabetic hemodialysis patients living in Ontario, Canada, with similar characteristics to the 4D patient cohort. During the nearly 11-year period prior to study publication, the rate of statin use increased almost 14-fold, from 43 to 597 per 1000 patients. For 2.5 years after study publication, rather than diminish, statin use continued to rise to an absolute rate of 676 per 1000 patients. These temporal patterns in statin use closely mimicked trends in the diabetic population not receiving dialysis. The 4D trial had no impact on statin use when we restricted the analysis to incident statin prescriptions or expanded the characteristics of the dialysis patients considered for study. Thus, we found that publication of a large, expensive, randomized controlled trial in patients receiving hemodialysis had no immediate impact on clinical practice. The use of a common cardiovascular medication in this patient population appears to be influenced by other factors. This study assessed prescribing patterns of antihypertensive therapies (AHT) before and after the publication of the LIFE, ALLHAT and VALUE trials between 2000 and 2005.
                The Irish HSE-PCRS prescribing database was used to identify those initiated any AHT. Any change 12 months before and after the trial publications was examined using a segmented regression analysis.
                There was little or no effect of any of the trials on new AHT prescribing, except for ALLHAT where there was an increase in new prescriptions for ACE inhibitors, and VALUE with a slight increase in prescriptions for calcium channel blockers.
                Our findings show that there was little or no effect of any of the three clinical trials studied on new AHT prescribing patterns in Irish general practice. Future studies should assess any underlying barriers to implementing new evidence into clinical practice. nan The Royal College of Radiologists' guidelines aim to encourage more appropriate use of diagnostic radiology and so reduce the use of clinically unhelpful x-ray examinations.
                The object of this study was to conduct a randomized controlled trial of the introduction of the guidelines into general practice.
                A total of 62 practices (170 general practitioners) referring patients to St George's Hospital, London for diagnostic radiology were randomly allocated into two groups. Guidelines were sent to the 30 practices in the intervention group. Radiological referral patterns were compared in both groups before and after the introduction of guidelines.
                Practices which had received guidelines requested significantly fewer examinations of the spine, and made a significantly higher proportion of requests which conformed to the guidelines compared with practices which had not received the guidelines. There were no significant differences in the proportion of forms giving physical findings or in the proportion of positive findings at radiology.
                Introduction of guidelines can influence general practitioners' radiological referrals in the short term. Wider use of guidelines might help to reduce unnecessary irradiation of patients. To evaluate the effectiveness of guidelines with or without one-to-one educational outreach visits by community pharmacists in improving general practice prescribing for non-steroidal anti-inflammatory drugs (NSAIDs).
                Cluster randomised trial of 20 general practices within Avon, England. Practices were randomised to three groups: control; mailed guidelines; mailed guidelines plus educational outreach visits. General practitioners (GPs) in the latter group received two one-to-one outreach visits from community pharmacists. Changes in prescribing were measured using outcomes derived from prescribing analysis and cost (PACT) data. The primary outcome measure was change in the volume of prescribing for ibuprofen, diclofenac and naproxen as a percentage of total NSAID prescribing. Six secondary outcomes included other measures of prescribing quality and volume. A cost-benefit analysis was performed.
                No significant differences were observed for the primary outcome measure: practices receiving outreach visits prescribed only 2.1% [95% confidence interval (CI): -0.8 to 5.0] more of the three recommended NSAIDs than the control practices did and 1.6% (95% CI: -1.4 to 4.7) more than practices that received guidelines only. Following adjustment for multiple comparisons, only one secondary outcome showed a statistically significant difference between the groups: the proportion of prescribing of the five most frequently used drugs was 2.2% (95% CI: 0.9 to 3.6) higher in the educational outreach group compared with the control group. A net increase in costs was shown with both interventions.
                Although good prescribing at baseline in the participating practices limited the capacity for improvement, this trial provides no evidence that guidelines with or without educational outreach visits from community pharmacists lead to substantial improvements in prescribing behaviour. Assessment of predictors for initiating prophylactic antithrombotic prescribing for patients newly diagnosed with ischaemic heart disease (IHD) and the impact of the introduction of national guidelines.
                A retrospective case-control study was performed using pharmacy prescription data from 120,000 Dutch patients over a 5-year period. IHD patients were identified using as a marker multiple nitrate prescriptions [anatomical-chemical-therapeutic (ATC) code CO1D] indicating chronic use. Initiation of antithrombotic therapy was likewise identified using ATC codes B01AA and B01AC (oral anticoagulants and thrombocyte aggregation inhibitors), prescribed within 6 months following the first nitrate prescription. Statistically significant (P<0.05) predictors were assessed using multivariable analysis considering patient, prescriber and medication characteristics.
                Of the 2598 patients who met specified inclusion criteria for newly diagnosed IHD, approximately 35% was not prescribed any type of antithrombotic therapy. Male patients [odds ratio (OR) 2.4, 95% confidence interval (CI) 2.0-2.9], patients with cardiovascular (other than IHD) and diabetic co-morbidity (OR 6.4, 95% CI 4.8-7.9 and OR 1.6, 95% CI 1.1-2.1, respectively) and patients using isosorbide mononitrate rather than isosorbide dinitrate as anti-ischaemic main therapy (OR 2.1, 95% CI 1.3-2.5) were most likely to be prescribed antithrombotic therapy. Furthermore, initiating antithrombotic prescribing was more likely after the introduction of national guidelines (OR 1.4, 95% CI 1.1-1.7).
                Initiating antithrombotic prescribing in newly diagnosed IHD patients can be predicted by patient gender, certain co-morbidity and main type of nitrate therapy. The introduction of national guidelines has resulted in an increase of prophylactic antithrombotic prescribing in accordance with their contents. The Randomized Aldactone Evaluation Study (RALES) demonstrated that spironolactone significantly improves outcomes in patients with severe heart failure. Use of angiotensin-converting-enzyme (ACE) inhibitors is also indicated in these patients. However, life-threatening hyperkalemia can occur when these drugs are used together.
                We conducted a population-based time-series analysis to examine trends in the rate of spironolactone prescriptions and the rate of hospitalization for hyperkalemia in ambulatory patients before and after the publication of RALES. We linked prescription-claims data and hospital-admission records for more than 1.3 million adults 66 years of age or older in Ontario, Canada, for the period from 1994 through 2001.
                Among patients treated with ACE inhibitors who had recently been hospitalized for heart failure, the spironolactone-prescription rate was 34 per 1000 patients in 1994, and it increased immediately after the publication of RALES, to 149 per 1000 patients by late 2001 (P<0.001). The rate of hospitalization for hyperkalemia rose from 2.4 per 1000 patients in 1994 to 11.0 per 1000 patients in 2001 (P<0.001), and the associated mortality rose from 0.3 per 1000 to 2.0 per 1000 patients (P<0.001). As compared with expected numbers of events, there were 560 (95 percent confidence interval, 285 to 754) additional hyperkalemia-related hospitalizations and 73 (95 percent confidence interval, 27 to 120) additional hospital deaths during 2001 among older patients with heart failure who were treated with ACE inhibitors in Ontario. Publication of RALES was not associated with significant decreases in the rates of readmission for heart failure or death from all causes.
                The publication of RALES was associated with abrupt increases in the rate of prescriptions for spironolactone and in hyperkalemia-associated morbidity and mortality. Closer laboratory monitoring and more judicious use of spironolactone may reduce the occurrence of this complication.
                Copyright 2004 Massachusetts Medical Society nan
The results of this review suggest that when used alone and compared to no intervention, PEMs may have a small beneficial effect on professional practice outcomes. There is insufficient information to reliably estimate the effect of PEMs on patient outcomes, and clinical significance of the observed effect sizes is not known. The effectiveness of PEMs compared to other interventions, or of PEMs as part of a multifaceted intervention, is uncertain.