Full Text HS-92-03 THE STUDY OF PATIENT OUTCOMES ASSOCIATED WITH PHARMACEUTICAL THERAPY NIH GUIDE, Volume 21, Number 12, March 27, 1992 RFA: HS-92-03 P.T. 34 Keywords: Chemotherapy Therapy Evaluation Agency for Health Care Policy and Research Application Receipt Date: July 15, 1992 PURPOSE The purpose of this announcement is to solicit applications from non- profit organizations to conduct research on the outcomes of pharmaceutical therapy. The Agency for Health Care Policy and Research (AHCPR) is encouraging innovative and timely health services research on the effectiveness of pharmaceutical therapy and care. This Request for Applications (RFA) is an activity of the research component of the Medical Treatment Effectiveness Program (MEDTEP) in the Department of Health and Human Services, to assess the appropriateness and effectiveness of alternative strategies to prevent, diagnose, treat, and manage clinical conditions. P.L. 101-239, which established the AHCPR in December 1989, refers specifically to the need to study the appropriate use of prescription drugs. The RFA benefited from extensive formal discussion with representatives from government, academia, and industry. HEALTHY PEOPLE 2000 The Public Health Service (PHS) is committed to achieving the health promotion and disease prevention objectives of "Healthy People 2000," a PHS-led national activity for setting priority areas. This RFA, The Study of Patient Outcomes Associated with Pharmaceutical Therapy, is related to the section on "Food and Drug Safety" (Objectives 12.5 and 12.6). Potential applicants may obtain a copy of "Healthy People 2000" (Full Report: Stock No. 017-001-00474-0) or "Healthy People 2000" (Summary Report: Stock No. 017-001-00473-1) through the Superintendent of Documents, Government Printing Office, Washington, DC 20402-9325 (telephone 202-783-3238). ELIGIBILITY REQUIREMENTS Applications may be submitted by domestic and foreign non-profit organizations, public and private, including universities, clinics, units of State and local governments, non-profit firms, and non-profit foundations. For-profit institutions are not eligible for AHCPR grants. Applications from women members of minority population groups are encouraged. MECHANISM OF SUPPORT This RFA will use the research grant mechanism (R01). Responsibility for the planning, direction, and execution of the proposed project will be solely that of the applicant. This RFA is a one-time solicitation. If the AHCPR determines that there is a sufficient continuing program need, the AHCPR may announce a request for new and competitive continuation applications. The total project period for applications submitted in response to this RFA may not exceed five years. The continuation of each awarded project will depend on an annual progress review by the AHCPR and the availability of funds. FUNDS AVAILABLE The AHCPR expects to commit up to $3 million in competitive awards for outcomes research associated with pharmaceutical therapy in Fiscal Year 1993. Approximately six to ten awards are expected to be made, at the earliest, in February 1993. The issuance of awards will be contingent on the availability of funds and the quality of the applications. RESEARCH OBJECTIVES The enabling legislation for the AHCPR (P.L. 101-239) authorizes the study of the appropriateness and effectiveness of the use of services and procedures in the prevention, diagnosis, treatment, and management of clinical conditions. Priority is given to the study of conditions and treatment strategies that affect large numbers of people; that result in substantial expense; that are important in the Medicare and Medicaid programs; and for which there are significant variations in patterns of care, implying uncertainty of effectiveness. The law recognizes drug therapy as an important form of treatment and refers specifically to the need to investigate the appropriate use of prescription drugs. The purpose of this RFA is to encourage studies on the patient outcomes of pharmaceutical therapy as part of the ongoing work supported under MEDTEP. The Food and Drug Administration (FDA) requires pharmaceutical manufacturers to provide evidence of safety and efficacy as a condition for the marketing of drugs. The FDA's laws and regulations for drug approval do not contain a requirement for studies of comparative drug effectiveness (although comparison with a control, which is often a placebo but may be an active drug, is required to demonstrate efficacy), alternative therapies (e.g., drug versus surgery), or cost. The FDA may require comparative studies of drug safety. An approved drug may enter the market with relatively little information available for the practitioner, the third party payer, or the patient about how the drug compares with the array of other therapies available. The same indication may be shared by a multitude of drugs or classes of drugs. Serious, but rare, adverse reactions, as well as unique benefits, may remain unknown at the time the drug is introduced into the market. After marketing, especially after the expiration of a product's patent, there may be limited incentive for continued study of the positive or negative effects of the drug relative to other competing products or other competing treatment modalities (including non-treatment). Patient outcomes research has been driven by the increasing need for information on appropriateness and effectiveness, as the number of alternative clinical strategies and related costs increase. Relatively new methods, such as decision analysis, meta-analysis, and small area analysis of practice variations, have emerged as major contributors to the study of patient outcomes. Research designs and approaches suitable for the analysis of large computerized claims databases, and other secondary and primary data sources, have been further developed, as have tools and instruments that facilitate the measurement and comparison of risks, benefits, costs, and patient preferences. This methodological and design work, however, is in its infancy with regard to the study of the outcomes of pharmaceutical treatment and care. In order to generate information useful for the development of an agenda on this area of outcomes research, AHCPR convened a series of meetings with representatives from government, academia, and industry. Many sessions with groups and individuals with expertise in drug-related research and policy resulted in a list of topics recommended for study. This list was categorized into five general research areas: o drug utilization review o pharmacists' cognitive services o patient factors o data and information needs o research methods This RFA emphasizes the relationship between prescription drugs, pharmaceutical services, and patient outcomes in ambulatory care settings. Of particular importance is the need to increase the availability and the use of data and empirical methods in all areas of research on the outcomes of pharmaceutical therapy. For this RFA, the original five categories were aggregated into three general areas of research: o data and analytic methods o factors affecting the appropriateness of prescribing o the role of the patient These areas are described below, including sample questions for research. The issues and questions raised, however, are illustrative only, and other study topics relevant to this RFA are welcome. Data and Analytic Methods There is a critical need for comprehensive, comparative assessment of the appropriateness and effectiveness of alternative pharmaceutical therapies. Current state-of-the-art methodology for the study of marketed drugs includes the use of large, linked, administrative databases (e.g., those used by Medicaid programs); non-randomized, Phase IV studies (e.g., post-marketing studies by pharmaceutical firms); registries of adverse events (e.g., the FDA Adverse Drug Reaction Reporting System); and multi-center, large-scale clinical trials (e.g., the NIH Cardiac Arrhythmia Suppression Trials). There are few comprehensive evaluations of the validity, reliability, sensitivity/specificity, and generalizability of findings from post-marketing data. In order to study alternative pharmaceutical therapies, researchers should consider using existing data collected for either administrative or research purposes. Examples of data sources include State Medicaid program data, computerized medical and pharmacy records found in managed care settings, and data recorded in long-term clinical trials. These sources can be supplemented with primary data collection. Data sources should allow for the detection, measurement, and/or control of: drug exposure, indication for drug use, severity of illness, co-morbidities, relevant confounders, and the actual costs of care. Appropriate outcomes measures and pre-treatment health status information are required. Emphasis is to be given to the study of clinical conditions that meet the following criteria: o the predominant mode of therapy is pharmaceutical; o a large number of patients are affected; o the use of health care resources is substantial, especially for Medicaid and/or Medicare beneficiaries; and o a variety of therapeutic choices exist. Examples of clinical conditions relevant for study include: cardiovascular disease; asthma and allergies; bacterial infections; psychiatric conditions; endocrine diseases; and arthritis. However, studies of any conditions treated in an ambulatory care setting that meet the above criteria are welcome. The AHCPR encourages studies of the following: o What is the feasibility of using and/or developing comprehensive databases to address questions concerning the outcomes of pharmaceutical therapy? How can multiple data sources, such as insurance claims for medical and pharmaceutical services and other administrative records linked for research purposes, provide valid measures of drug exposure and outcomes? Which methodological approaches can be used to increase the utility of these data sources? What additional information is needed to complement information from these sources in order to address hypotheses on relationships between alternative therapies and patient outcomes? o In order to relate drug therapy to specific patient outcomes, the accurate ascertainment of drug exposure is essential. Markers or surrogate measures of drug exposure are often used (e.g., numbers of prescriptions filled). How valid are currently used measures of drug exposure at the individual and/or population level? o Current therapeutic practice frequently includes pharmacological treatment to achieve surrogate clinical endpoints. The example often cited where treatment and surrogate measures have been linked with outcomes successfully is the treatment of hypertension for the prevention of stroke and myocardial infarction. For other clinical conditions, how can the association between pharmaceutical treatment to achieve surrogate endpoints and patient outcomes be validated? o Evaluation of the cost effectiveness of a drug therapy is not required for FDA's approval to market drugs in the United States. The results from cost-effectiveness studies are used in drug advertising and in third-party reimbursement decisions. However, the relative technical quality and objectivity of cost- effectiveness analyses have been questioned. Separate economic analyses of the same interventions can lead to very different conclusions because of differences in methodology. In addition, because of inter-study methodological differences, it is difficult to compare the cost effectiveness or net benefits of a variety of interventions examined in separate studies, limiting the usefulness of cost-effectiveness analyses for policymakers. The process of developing a standard methodology requires that comparisons between various approaches be undertaken, and that they be evaluated using patient outcomes as an indicator of the appropriateness of the tool. Comparative cost-effectiveness studies that can be used by the industry and research community as models or standards for analysis would be especially useful. What are the conceptual and methodological issues that merit attention in comparative cost-effectiveness studies of alternative drug therapies? o In some countries (e.g., Canada and the United Kingdom) there are computerized databases that record drug utilization for the entire population. What hypotheses about the outcomes associated with pharmaceutical therapy can be tested using these international sources of data? Factors Affecting the Appropriateness of Drug Prescribing Previous studies have explored the effects of policy and educational interventions on the appropriateness of drug prescribing. For example, Soumerai (1991) reported that the imposition of a cap on the number of Medicaid prescriptions per month, per patient increased the number of admissions to long-term care facilities. Bloom (1985) demonstrated that hospital admissions for ulcer disease rose when the State Medicaid program reduced access to H-2 antagonists. Shaffner (1983) documented the relative success of academic detailing in discouraging the prescribing of tetracycline for children. Many questions remain, however, about the long-term effects of private and public programs that monitor and intervene in the prescribing process. Existing and new programs need to be evaluated to determine whether or not they actually affect patient outcomes. The AHCPR is interested in new research on the effects on patient outcomes of programs designed to improve the appropriateness of drug prescribing. Examples of these studies include assessment of drug utilization review (DUR) programs within States or health maintenance organizations (HMOs); analysis of the relationships among pharmacists' cognitive services, prescriber behavior, and patient outcomes; and the comparative long-term success of academic detailing or other educational interventions aimed at the health care provider in the managed care setting. Emphasis will be placed on studies involving existing programs that have available a comprehensive, longitudinal database including generalizable patient information, diagnostic data, and data on the use of prescription drugs. Primary data collection can be used to augment existing data sources and to develop and evaluate patient outcomes data that combine objective and subjective measures, and may be necessary to validate existing information. The AHCPR encourages studies of the following: o Drug utilization review refers to programs that are expected to assess and promote the quality of pharmaceutical therapy, minimize unnecessary expenditure, and intervene whenever inappropriate choice or actions have been identified. The Omnibus Budget Reconciliation Act of 1990 requires State Medicaid programs to implement a comprehensive DUR program by January 1, 1993. The DUR program is to have a prospective component in which pharmacists monitor drug therapy; a retrospective component in which previous patterns of inappropriate drug prescribing are identified; and an educational component in which health care providers are targeted for remedial action. Each State is required to develop explicit criteria for use by Medicaid DUR programs. Of particular interest for this RFA are questions dealing with the linkage between DUR and patient outcomes in this authorized Medicaid program and other DUR programs in the private ambulatory care setting. What is the effect of variation in drug prescribing patterns on patient outcomes? Are differences in the criteria used for monitoring quality of pharmaceutical therapy associated with different outcomes? What specific therapeutic issues should DUR focus on to optimize the clinical and cost effectiveness of the review process? o The Omnibus Budget Reconciliation Act of 1990 also authorizes demonstrations of the cost effectiveness of pharmacists' cognitive services for Medicaid recipients. These services involve the use of specialized knowledge by the pharmacist to maintain or improve the quality of drug therapy. Examples of pharmacists' cognitive services include patient counseling and education; provider education; the monitoring of medication profiles and compliance; the development and enforcement of formularies; and the detection and correction of prescribing errors. While demonstrations are not within the scope of this RFA, several evaluative questions are appropriate for study. The focus of these questions should be on the relationships between the provision of pharmaceutical care, including cognitive services, the appropriateness of prescribing behavior, and patient outcomes. How do organizational, legal/regulatory, reimbursement, and other market or system factors affect the type and level of available services, the pattern of prescribing behavior, and related patient outcomes? What are the data needs and problems involved in designing and implementing databases for evaluating the cost effectiveness of cognitive services? o Interventions to change prescribing behavior range from face-to-face academic detailing to less costly computer-generated messages and letters with specific prescribing information. Further study of the effects of these interventions on prescribing behavior and on patient outcomes is needed. What are the level and duration of these effects? Can varying the setting, mechanism, or targeted population lead to more cost-effective interventions? The Role of the Patient Therapeutic goals are condition- and patient-specific, and desired outcomes will vary by disease, severity of illness, consequences of therapy, and associated treatment costs. In addition to objectively measured consequences of treatment, such as morbidity, mortality, and hospital readmissions, outcomes of importance include subjective measures of the patients' quality of life, satisfaction, and perceived functional status. Both provider and patient perspectives, including patient preferences, need to be considered in defining optimal treatment and outcomes. Studies on the medication-taking behavior of patients typically focus on self-care and compliance with a prescribed regimen, with little or no attention to outcomes. Self-treatment includes self-diagnosis, home remedies, over-the-counter (OTC) medications, and often the use of prescribed medications obtained through unconventional sources (e.g., shared by a friend or relative). Estimates of patient compliance or cooperation with a prescribed regimen range from thirty to eighty percent, varying by medical condition, data source, and measures used. Many tools and strategies have been devised to increase patient compliance, but the effects on outcomes have not been evaluated. The AHCPR is interested in studies that will address the following: o How does patient compliance with a prescribed drug regimen vary with respect to changes in perceived quality of life and functional status, controlling for factors such as access to care and costs of care? How do organizational and administrative barriers (e.g., waiting lists, lack of continuity of care) affect patient outcomes? To what extent do health care provider services such as counseling and medication profile monitoring affect patient outcomes? How does this effect vary by type of provider (e.g., physician, nurse, or pharmacist) and by patient characteristics (e.g., sociodemographic, economic, and behavioral)? o For many conditions, objective indicators are the primary choice for measuring patient outcomes. For other conditions, for which objective measures are less precise, subjective measures, such as quality of life and patient satisfaction, may be more appropriate indicators of effectiveness. What is the association between objective and subjective measures for specific conditions? How can both types of measures be used in conjunction with existing administrative databases to improve the analysis of comparative effectiveness of alternative therapies? o To what extent can existing databases or new primary data be used to examine the relationship between self-care and patient outcomes? What are the factors that motivate self-care, and how are outcomes differentially affected by this practice versus the use of a prescribed regime? o Models and instruments have been developed to measure patient satisfaction, quality of life, functional status, and utility. To what extent can these tools be used to compare outcomes among alternative pharmaceutical therapies? What analytical tools and instruments are most effective in measuring patient preference, knowledge, and practices with respect to drug therapy? SPECIAL REQUIREMENTS Applications should specifically address the appropriateness and/or effectiveness of pharmaceuticals or related services. Appropriateness signifies care for which the benefit (or probability of benefit) exceeds the negative consequences (or risk) by an acceptable margin. Effectiveness refers to the results of clinical interventions provided in typical, "real world" patient-provider situations, in contrast to the controlled, "laboratory" settings in which efficacy may be assessed. Projects should include investigator(s) and key staff who reflect the multidisciplinary nature of outcomes research, including, as appropriate: health care providers, such as physicians, pharmacists, nurses, physical therapists, and relevant specialists; health services researchers; statisticians, biostatisticians, and epidemiologists; and individuals whose expertise includes health economics, policy, and/or decision theory. SPECIAL INSTRUCTIONS TO APPLICANTS REGARDING IMPLEMENTATION OF NIH POLICIES CONCERNING INCLUSION OF WOMEN AND MINORITIES IN STUDY POPULATIONS The AHCPR adheres to NIH and ADAMHA policy that requires applicants for research grants and cooperative agreements to include minorities and women in study populations, so that research findings can be of benefit to all persons. Additional emphasis, however, must be placed on the need to include minorities and women of all ages in studies of diseases, disorders, and conditions that affect them specifically. If minorities or women are excluded or inadequately represented in proposed health services research, particularly in proposed population-based studies, a clear compelling rationale must be provided. The composition of any proposed population group for study must be described in terms of gender and racial/ethnic group. In addition, gender and racial/ethnic issues must be addressed in developing a research design and sample size appropriate for the scientific objectives of the study. This information must be included in the form PHS 398 in Section 2, 1-4 of the Research Plan and summarized in Section 2, E, Human Subjects. All applications for outcomes research associated with pharmaceutical therapy submitted to the AHCPR are required to address this policy with respect to the inclusion of minorities and women as subjects of their research. The AHCPR will not award grants for applications that do not comply. If the required policy is not reflected in the application, the application will be returned without review. APPLICATION PROCEDURES The research grant application form PHS 398 (rev. 9/91) is to be used in applying for these grants. State and local government agencies may use form PHS 5161 and follow those requirements for copy submission. These forms are available from: Office of Scientific Review Agency for Health Care Policy and Research 2101 East Jefferson Street, Suite 602 Rockville, MD 20852 Telephone: (301) 227-8449 The RFA label available in the PHS 398 application form must be affixed to the bottom of the face page of the application. Failure to use this label could result in delayed processing of the application such that it may not reach the review committee in time for review. In addition, the RFA title and number must be typed on line 2a of the face page of the application form and the YES box must be marked. The completed original, signed application and four legible copies of PHS form 398 must be sent or delivered to: Division of Research Grants National Institutes of Health Westwood Building, Room 240 Bethesda, MD 20892** Completed applications must be received at the Division of Research Grants on or before the receipt date specified in this announcement. One copy labeled "Advance Copy" is to be submitted simultaneously to: Center for Medical Effectiveness Research Agency for Health Care Policy and Research 2101 East Jefferson Street, Suite 605 Rockville, MD 20852 Conference for Prospective Applicants The AHCPR plans to convene a conference in Chicago on April 20, 1992. At this conference, AHCPR staff will discuss the programmatic and administrative details of this RFA and respond to questions concerning this announcement. Attendance is not a prerequisite for applying. Individuals with questions concerning this announcement, or unable to attend the conference, may call or write the AHCPR staff members listed below for further technical and/or administrative assistance. The AHCPR will make available to interested parties a listing of key questions and answers concerning the program that are addressed at the conference. Those interested in attending the conference should forward their addresses and telephone numbers to Drs. Bosco or Perfetto at the address listed below under INQUIRIES. The AHCPR will inform interested parties of the specific time and location of the conference. All personal travel costs and accommodations are the responsibility of the attendees. REVIEW PROCEDURES Upon receipt, applications will be reviewed by AHCPR staff for completeness and responsiveness. Incomplete applications will be returned to the applicant without further consideration. If the application is not responsive to the RFA, AHCPR staff will contact the applicant to determine whether to return the application to the applicant or submit it for review in competition with unsolicited applications at the next review cycle for grant applications. All responsive applications will undergo peer review for scientific merit by an AHCPR chartered review committee of non-Federal experts. Applications that are recommended for further consideration and that request total direct costs in excess of $250,000 will subsequently be reviewed by the National Advisory Council for Health Care Policy, Research, and Evaluation. Peer review will take into account the following review criteria: o significance and originality of the goals of the project from a scientific or technical standpoint; o adequacy of the methodology proposed to carry out the project; o availability of data or the proposed plan to collect data required in the analysis; o adequacy and appropriateness of the plan for organizing and carrying out the project; o qualifications of the Principal Investigator and proposed staff; o reasonableness of the proposed budget in relation to the project; o adequacy of the facilities and resources available to the applicant; and o adequacy of the proposed means for protecting against or minimizing adverse effects of project-related activities upon humans, animals, or the environment. AWARD CRITERIA The following will be considered in making funding decisions: o recommendations of the peer review committee and the National Advisory Council; o assurance provided in the research application and the fiscal plan that effective use will made of grant funds; o business management capability of the applicant; o competence and skill of the staff, especially the senior personnel, in light of the scope of the project; o probable utility of findings for dealing with concerns of this RFA and MEDTEP; and o relative priority of the proposed project in light of other established priorities. INQUIRIES Written and telephone inquiries concerning this RFA are encouraged. The opportunity to clarify any issues or to address questions from potential applicants is welcome. Direct inquiries regarding programmatic issues to: Lynn Bosco, M.D., M.P.H. Center for Medical Effectiveness Research Agency for Health Care Policy and Research 2101 East Jefferson Street, Suite 605 Rockville, MD 20852 Telephone: (301) 227-8485 or Eleanor M. Perfetto, Ph.D., R.Ph. Center for Medical Effectiveness Research Agency for Health Care Policy and Research 2101 East Jefferson Street, Suite 605 Rockville, MD 20852 Telephone: (301) 227-8485 Direct inquiries regarding administrative and budgetary matters to: Ralph L. Sloat Chief, Grants Management Branch Office of Planning and Resource Management Agency for Health Care Policy and Research 2101 East Jefferson Street, Suite 601 Rockville, MD 20852 Telephone: (301) 227-8447 AUTHORITY AND REGULATIONS This program is described in the Catalog of Federal Domestic Assistance No. 93.180. Awards are made under authority of Title IX of the Public Health Service Act (42 U.S.C. 299-299c-6) and section 1142 of the Social Security Act (42 U.S.C. 1320b-12); and administered in accordance with PHS grants policies, program regulations (42 CFR, Part 67, Subpart A), and other applicable Department regulations. The requirements of Executive Order 12372, "Intergovernmental Review of Federal Programs," are not applicable to AHCPR research grant programs. Selected References Agency for Health Care Policy and Research. (1990, March). Program Note: Medical Treatment Effectiveness Research. (Publication No. OM90-0059) Rockville, MD: Public Health Service. Agency for Health Care Policy and Research. (1990, September). AHCPR Purposes and Programs. (Publication No. OM90-0096) Rockville, MD: Public Health Service. Agency for Health Care Policy and Research. (1991, April). Report to Congress: The Feasibility of Linking Research-Related Data Bases to Federal and Non-Federal Medical Administrative Data Bases. (Publication No. 91-0003) Rockville, MD: Public Health Service. American Academy of Orthopedic Surgeons, Subcommittee on Outcomes Studies. (1991, January). Fundamentals of Outcomes Research. Park Ridge, IL: American Academy of Orthopedic Surgeons. Avorn, J.L. and S.B. Soumerai. (1983). Improving Drug Therapy Decisions Through Educational Outreach: A Randomized Controlled Trial for Academically Based "Detailing." New England Journal of Medicine 308, pp. 1457-63. Bloom B.S. and J. Jacobs. (1985, July). Cost Effects of Restricting Cost-Effective Therapy. Medical Care 23, pp. 872-80. Echt D.S., P.R. Liebson, L.B. Mitchell, et al. (1991, March 21) Mortality and Morbidity in Patients Receiving Encainide, Flecainide or Placebo. The Cardiac Arrhythmia Suppression Trial. New England Journal of Medicine 324(12), pp.781-8. FDC Reports, Inc. (1991, December 16). FDA to Stress Rx Patient Information With Publicity Effort in Upcoming Months. FDC Reports ("The Pink Sheet"), p. 7. Hepler C.D. and L.M. Strand. (1990, March). Opportunities and Responsibilities in Pharmaceutical Care. American Journal of Hospital Pharmacy 47, pp. 533-43. Hillman, A.L., J.M. Eisenberg, M. V. Pauly, et al. (1991, May 9). Avoiding Bias in the Conduct and Reporting of Cost-Effectiveness Research Sponsored by Pharmaceutical Companies. New England Journal of Medicine 324 (19), pp. 1362-1365. Lipton, H.L. and J.A. Bird. (1991, December). Drug Utilization Review: State-of-the-Science and Directions for Outcomes Research. Unpublished manuscript prepared for AHCPR. Payne, S.M.C. (1987, December). Identifying and Managing Inappropriate Hospital Utilization: A Policy Synthesis. Health Services Research 22:5, pp. 709-769. Raskin, I.E. and C.W. Maklan. (1991, June). Medical Treatment Effectiveness Research: A View From Inside the Agency for Health Care Policy and Research. Evaluation and the Health Professions, pp. 161-186. Ray, W.A. and M.R. Griffin. (1991, November). Pharmaceutical Effectiveness Research: Meeting Information Needs of Clinical and Policy Decision Making. Unpublished manuscript prepared for AHCPR. Reeder, C.E., W.M. Dickson, C.M. Kozma, et al. (1991, October). Patient Factors Influencing the Utilization of Pharmaceuticals and Pharmaceutical Care. Unpublished manuscript prepared for AHCPR. Schaffner, W., W.A. Ray, C.F. Federspiel, and W.O. Miller. (1983). Improving Antibiotic Prescribing in Office Practice: A Controlled Trial of Three Educational Methods. Journal of the American Medical Association 250, pp.1728-32. Soumerai, S.B., D. Ross-Degnan, J. Avorn, et al. (1991, October 10). Effects of Medicaid Drug-Payment Limits on Admission to Hospital and Nursing Homes. New England Journal of Medicine 325(15), pp. 1072-1077. Strand, L.M. and P.C. Morley. (1991, November). Pharmacists' Cognitive Services. Unpublished manuscript prepared for AHCPR. Stergachis A., J.S. Gardner, and T.D. Koepsell. (1991, November). Methodological Issues in Pharmaceutical Outcomes Research. Unpublished manuscript prepared for AHCPR. .
Return to NIH Guide Main Index
Office of Extramural Research (OER) |
National Institutes of Health (NIH) 9000 Rockville Pike Bethesda, Maryland 20892 |
Department of Health and Human Services (HHS) |
||||||||
Note: For help accessing PDF, RTF, MS Word, Excel, PowerPoint, Audio or Video files, see Help Downloading Files. |