TRANSLATING RESEARCH INTO PRACTICE

Release Date:  January 8, 1999

RFA:  HS-99-003

P.T.

Agency for Health Care Policy and Research

Letter of Intent Receipt Date:  February 5, 1999
Application Receipt Date:  April 22, 1999

PURPOSE

The Agency for Health Care Policy and Research (AHCPR) invites applications to
conduct research related to implementing evidence-based tools and information in
diverse health care settings among practitioners caring for diverse populations.
Applications are sought for studies that apply innovative strategies for
implementing evidence-based tools and information and demonstrate improved
clinical practice and sustained practitioner behavior change.

Evidence-based tools and information include findings from rigorously conducted
research and from clinical practice guidelines, algorithms, treatment protocols,
practice parameters, quality indicators, and continuous quality improvement
initiatives that are developed using a systematic approach to evidence synthesis.

This Request for Applications (RFA) is one in a series of RFAs to support
research on quality of health care being issued by AHCPR over the next several
weeks.  These initiatives respond to the report, Quality First, The President"s
Commission on Consumer Protection and Quality in the Health Care Industry
(Commission), which called for a significant investment in the further
development of research, tools, and information for patients, practitioners,
purchasers, and payers.

The three RFAs are: 1) Translating Research into Practice- to generate new
knowledge about approaches, both innovative and established, which are effective
and cost-effective in promoting the use of rigorously derived evidence in
clinical settings and lead to improved health care practice and sustained
practitioner behavior change (with particular interest in studies that implement
AHCPR-supported evidence-based tools and information), 2) Quality Measurement for
Vulnerable Populations- to develop and test new quality measures which can be
used in the purchase or improvement of health care services for populations
identified as vulnerable in the Commission report, and 3) Assessment of Quality
Improvement Strategies in Health Care- to rigorously evaluate strategies for
improving health care quality which are currently in widespread use by organized
quality improvement systems (projects that would expand the conceptual and
methodological basis for improving clinical quality and analyze the relative
utility and costs of various approaches to quality improvement).

In addition to their common context and theme, these three initiatives are also
designed to help build capacity in the field of health services research.  This
is accomplished through the inclusion of specific incentives to attract
applications from qualified minority and junior faculty health services
researchers.

AHCPR is especially interested in studies that implement AHCPR-supported
evidence-based tools and information, including Patient Outcome Research Team
(PORT) and other research findings, AHCPR-supported clinical practice guideline
recommendations, and evidence reports and technology assessments produced by the
AHCPR Evidence-based Practice Centers.

The goal of this RFA is to improve the translation and use of research findings
and evidence-based tools and information into practice by developing and
validating innovative principles, methods, and tools that work in diverse
settings, populations, and payment systems. Applicants are encouraged to form
public-private partnerships or consortia, such as between academic and other
research organizations and health plans and purchasers, to perform this research.
Such partnerships may help to more quickly translate research findings into
actual practice settings.  Applicants may also seek collaborative funding for
projects funded under this RFA.  Roles of collaborators should be clearly defined
in the application.  AHCPR encourages minority institutions to apply for funding
under this solicitation, and encourages collaboration on projects between
minority institutions and majority institutions.  Minority institutions have had
a significant role in delivering health care to underserved communities and
represent a valuable resource to facilitate collaboration with those communities.

AHCPR is committed to achieving the goals of the President"s Race and Health
Disparities Initiative: Eliminating by the year 2000 the differences in outcomes
and health status for racial and ethnic minority populations in six clinical
areas (infant mortality, cancer screening and management, cardiovascular disease,
diabetes, HIV infection, and child and adult  immunization). Many of these
disparities are not due to gaps in knowledge regarding disease processes, but are
largely the result of provider factors, patient factors, and organizational
factors which impair the implementation of existing knowledge. AHCPR seeks
research projects which will advance the implementation of existing research
findings in order to assist in achieving this ambitious goal. For further
information on this Initiative, see:  http://raceandhealth.hhs.gov.

HEALTHY PEOPLE 2000

The Public Health Serviced (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. AHCPR encourages applicants to submit grant
applications with relevance to the specific objectives of this initiative.
Potential applicants may obtain a printed copy of "Healthy People 2000" (Full
Report: Stock No. 017-001-00474-0 or Summary Report: Stock No. 017-001-00473-1)
through the Superintendent of Documents, Government Printing Office, Washington,
D.C. 20402-
9325, telephone: 202/512-1800.

ELIGIBILITY REQUIREMENTS

Applications may be submitted by public or private non-profit  organizations,
including universities, clinics, units of State and local governments, non-profit
firms, and non-profit foundations. For-profit organizations may participate as
members of consortia or subcontractors if the applicant is non-profit.
Organizations described in section 501(c)4 of the Internal Revenue Code that
engage in lobbying are not eligible.

AHCPR encourages women, members of minority groups and persons with disabilities
to apply as Principal Investigators.

MECHANISM OF SUPPORT

This RFA will use the research project grant (R01) mechanism. Responsibility for
the planning, direction, and execution of the proposed project will be solely
that of the applicant.

The total project period for an application submitted in response to this RFA may
not exceed three years. The anticipated award date is September 30, 1999.  This
RFA is a one-time solicitation. 

Because the nature and scope of the research proposed in response to this RFA may
vary, it is anticipated that the size of an award will vary also.

Future unsolicited competing continuation applications will compete with all
investigator-initiated applications and be reviewed according to customary peer
review procedures.

FUNDS AVAILABLE

AHCPR expects to award up to $2 million in fiscal year 1999 to support the first
year of up to 4 to 6 projects under this RFA. AHCPR will set-aside approximately
$500,000 of the $2 million to support projects which address one or more of the
six clinical areas identified in the President"s Race and Health Disparities
Initiative (infant mortality, cancer screening and management, cardiovascular
disease, diabetes, HIV infection, and child and adult  immunization) with regard
to racial and ethnic minority population groups.

Funding beyond the initial budget period will depend on annual progress reviews
by AHCPR and the availability of funds. 

RESEARCH OBJECTIVES

Background

A continuing challenge in health services research is to improve the translation
and use of research findings for practitioners, patients, consumers and other
decisionmakers to effect needed health care changes. Evidence-based decision
making, the use of current best evidence in making decisions about individual
patients, is an effective method for translating research into practice in order
to effect sustained practitioner, patient, and organizational behavior change.
This approach requires that research results be compiled in a systematic manner
and made available to decision makers. But the evidence base is rapidly
expanding, with more than 3800 biomedical journals indexed in MEDLINE and
approximate 7300 citations added weekly.  Health care practitioners are besieged
with information, some of it evidence-
based such as findings from clinical trials, but some irrelevant to clinical
care. The lag period between publication of research findings demonstrating
clinical effectiveness and the subsequent implementation in clinical practice is
well recognized, and practitioners continue to base clinical decisions on
outdated training and on experience with individual patients. Determining the
best strategies for implementing evidence-based tools and information is crucial
for translating evidence into practice.

A wide range of strategies for implementing evidence into practice to accomplish
behavior change has been proposed. These strategies include continuing medical
education (CME), self-instructed learning, academic detailing, audit and
feedback, provider reminder systems, incentives, local opinion leaders, outreach
visits, continuous quality improvement initiatives, clinical information systems,
and computer decision support systems.  Some of these strategies have been the
focus of research. In a systematic review of trials of interventions to improve
medical practice, outreach visits and local opinion leaders were found to be
effective.(Oxman, 1995) Soumerai and colleagues demonstrated the benefit of
combining local opinion leaders with performance feedback to improve adoption of
effective treatments in practice. (Soumerai, 1998) A systematic review of trials
of CME pointed out educational strategies that may be effective and Soumerai and
Avorn showed that academic detailing could be effective in some cases.(Davis,
1995, Soumerai, 1990)

Taken together, these and other studies do not suggest a single superior strategy
but show that different strategies may be effective in achieving behavior change
depending on the target group, health care setting, desired behavior change, and
identified barriers to implementation. For example, conducting audits and
providing feedback may be effective in improving prescribing habits and
diagnostic test ordering but not another behavior. Computer decision support
systems enhance clinical performance for drug dosing and preventive care, but
have been tested in a limited range of settings.(Hunt, 1998) Generally, academic
detailing, reminders, and multifaceted approaches seem to be more successful,
opinion leaders and audit and feedback to be variably effective, and didactic
educational sessions and written educational materials are largely
ineffective.(Bero, 1998) As pointed out by Greco and Eisenberg, the impact of
implementation strategies depends on the context in which they are applied, and
is influenced by health care settings, practitioner perceptions, and the desired
behavior change.(Greco, 1993)

Too little is known about which combinations of implementation strategies are
effective in which clinical contexts and for which clinical conditions. Barriers
to successful implementation of evidence-based information have been proposed,
but research that includes identification of barriers and demonstration of
effective strategies to overcome these barriers has generally not been conducted.
Applications are encouraged to address these issues.

Important to the design of implementation research studies is consideration of
a conceptual framework for behavior change. For example, the "Precede/Proceed"
model specifies three categories of factors that support behavior
change.(Green,1991) Predisposing factors are the skills, knowledge, attitudes,
and beliefs of individual practitioners. Enabling factors are practice setting
and organization factors that make change possible, such as reminders,
checklists, and clinical information systems. Reinforcing factors are those that
reward and strengthen behavior change and include rewards, incentives, and
feedback. Applications are strongly encouraged to describe a conceptual framework
supporting the proposed implementation project and include multifaceted
implementation strategies that address factors important to effect behavior
change.

Methodological Considerations

The effect of implementation of evidence-based tools and information on the
health status of patients may be difficult to measure directly. Focus on
intermediate health outcomes in addition to provider knowledge and behavior,
service delivery, resource use and cost, quality, and patient satisfaction is
appropriate. Studies that compare the cost and/or cost-
effectiveness of implementation strategies are encouraged.

Methods can include rigorous qualitative studies, quantitative research, and
empirical work. In order to monitor and account for secular changes in practice
patterns, studies employing control group designs are strongly encouraged.

Research Questions

A broad array of research questions is relevant to implementation of evidence-
based tools and information. The following questions are AHCPR priorities:

o  What are effective approaches that apply multifaceted strategies to
implementation of evidence-based tools and information?

o  How does the structure of health care organizations affect implementation of
evidence-based tools and information?

o  What strategy or combination of strategies consistently demonstrates improved
behavior change and can be generalized to a range of providers, health care
systems and settings, and geographic areas?

o  What is the effect of implementation of evidence-based tools and information
on health care organizations in terms of resource use and cost?

o  What are the effects of implementation of evidence-based tools and information
on health outcomes, cost, and quality of life?

o  What are strategies for identifying, validating, and addressing barriers to
implementation of evidence-based tools and information?

o  What are the effects of evidence-based clinical information on patient and
consumer quality of life, satisfaction with care, behavior, knowledge, and
attitudes?

o  What is the comparative cost-effectiveness of various strategies for
implementing evidence-based tools and information?

o  Is the effective implementation of evidence-based tools and information
specific to racial/ethnic minority populations?  For which populations? To what
degree?

o  Is there a measurable difference in the effectiveness of evidence-based tools
and information depending on the match of the race/ethnicity of providers and
patients?

o  Are the existing racial/ethnic categories meaningful in identifying the
effectiveness of evidence-based tools and information? Is the identification of
sub-populations necessary? Is culture a more valid variable than race/ethnicity?

SPECIAL REQUIREMENTS

Research applications submitted in response to this RFA should describe how the
proposed project will build on current implementation research findings. Projects
should describe the evidence-based tools or information that will be implemented
and the implementation strategies to be studied. Strategies for implementing
evidence into practice that may be studied include:

o  continuing medical education (CME)
o  self-instructed learning
o  academic detailing
o  audit and feedback
o  provider reminder systems
o  incentives
o  local opinion leaders and outreach visits
o  continuous quality improvement initiatives
o  clinical information and computer decision support systems

Projects should also describe the health care settings in which care is provided
(such as provider networks, ambulatory clinics, managed care organizations, and
other health care delivery systems) and the patient populations served, the
target audience for implementation, behaviors to be changed, and the specific
processes and outcomes being measured (e.g., practitioner knowledge and behavior,
health outcomes, service delivery, resource use and cost, patient satisfaction,
and quality). Applications should clearly identify the unit of analysis, which
can be patients, individual providers (physicians, nurses, nurse practitioners,
physician assistants, and others), provider groups, or health care systems.
Applications are encouraged that propose taking evidence-based implementation
interventions studied and shown effective in one setting and studying them in
other settings or with other types of health care providers.

CONDITIONS OF AWARD

In addition to other applicable grants policies and requirements, the following
conditions apply to all AHCPR grant awards. Applicants should also be familiar
with the agency"s grant regulations, 42 CFR Part 67 Subpart A, and particularly
sections 67.18-67.22.

Data Privacy

Information obtained in the course of this study that identifies an individual
or entity must be treated as confidential in accordance with section 903(c) of
the Public Health Service Act. Applicants must describe in the Human Subjects
section of the application procedures for ensuring the confidentiality of
identifying information. The description of the procedures should include a
discussion of who will be permitted access to the information, both raw data and
machine readable files, and how personal identifiers will be safeguarded.

Rights in Data

AHCPR grantees may copyright or seek patents, as appropriate, for final and
interim products and materials including, but not limited to, methodological
tools, measures, software with documentation, literature searches, and analyses
that are developed in whole or in part with AHCPR funds. Such copyrights and
patents are subject to a Federal government license to use and permit others to
use these products and materials for AHCPR purposes. In accordance with its
legislative dissemination mandate, AHCPR purposes may include, subject to
statutory confidentiality protections, making research materials, data bases, and
algorithms available for verification or replication by other researchers, and
subject to AHCPR budget constraints, final products may be made available to the
health care community and the public by AHCPR, or its agents, if such
distribution would significantly increase access to a product and thereby produce
public health benefits. Ordinarily, to accomplish distribution, AHCPR publicizes
research findings but relies on grantees to publish in peer-reviewed journals and
to market grant-supported products.

INCLUSION OF WOMEN, MINORITIES, AND CHILDREN IN RESEARCH STUDY POPULATIONS
INVOLVING HUMAN SUBJECTS

It is the policy of AHCPR that women and members of minority groups be included
in all AHCPR-supported research projects involving human subjects, unless a clear
and compelling rationale and justification are provided that inclusion is
inappropriate with respect to the health of the subjects or the purpose of the
research.

All investigators proposing research involving human subjects should read the
"NIH Guidelines on the Inclusion of Women and Minorities as Subjects in Clinical
Research," which was published in the Federal Register of March 28, 1994 (FR 59
14508-14513), and printed in the NIH GUIDE of March 18, 1994. AHCPR follows the
NIH Guidelines, as applicable.

Investigators may obtain copies from these sources or from the AHCPR contractor,
Equals Three Communications, Inc., listed under INQUIRIES.

AHCPR is also encouraging investigators to consider including children in study
populations, as appropriate. AHCPR announced in the NIH Guide of May 9, 1997,
that it is developing a policy and implementation plan on the inclusion of
children in health services research. This Notice is available through the AHCPR
web site http://www.ahcpr.gov (Funding Opportunities) and InstantFAX (see
instructions under INQUIRIES).

AHCPR program staff may also provide information concerning these policies (see
INQUIRIES).

LETTER OF INTENT 

Prospective applicants are asked to submit, by February 5, 1999, a letter of
intent that includes the names, addresses, and telephone numbers, of the proposed
Principal Investigator and other key personnel, a descriptive title of the
application, and the number and title of this RFA. Although a letter of intent
is not required, is not binding, and does not enter into the consideration of any
subsequent application, the information allows AHCPR staff to estimate the
potential review workload and avoid conflicts of interest in the review. AHCPR
will not provide responses to letters of intent.

Letters of intent are to be addressed to:

Francis D. Chesley, Jr., M.D.
Center for Practice and Technology Assessment
Agency for Health Care Policy and Research
6010 Executive Boulevard, Suite 300
Rockville, MD 20852
Email:  [email protected]

APPLICATION PROCEDURES

Applicants should use the research grant application form PHS 398 (rev. 4/98) in
applying for these grants. State and local government applicants may use form
PHS-5161-1, Application for Federal Assistance (rev. 5/96), and follow those
requirements for copy submission.

Application kits are available at most institutional offices of sponsored
research. Also they may be obtained from the Division of Extramural Outreach and
Information Resources, National Institutes of Health, 6701 Rockledge Drive, MSC
7910, Bethesda MD 20892-7910, telephone 301/710-0267, E-mail/Internet:
[email protected].

AHCPR applicants can also obtain application materials from the AHCPR contractor:
Equals Three Communications, Inc. (see INQUIRIES)

The RFA label available in the PHS 398 (rev. 4/98) application form must be
affixed to the bottom of the face page of the original 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 2 of the face page of the application form
and the YES box must be marked.

The PHS 398 type size requirements (p.6) will be enforced rigorously and non-
compliant applications returned.

Submit a signed, typewritten original of the application, including the
Checklist, and four signed photocopies, in one package to:

Center for Scientific Review
National Institutes of Health
6701 Rockledge Drive, Room 1040, MSC 7710
Bethesda, MD 20892-7710
Bethesda, MD 20817 (for express/courier service)

At the time of submission, one additional copy, labeled "Advanced Copy," must
also be sent to:

Francis D. Chesley, Jr., M.D.
Center for Practice and Technology Assessment
Agency for Health Care Policy and Research
6010 Executive Boulevard, Suite 300
Rockville, MD 20852

Applications submitted under this RFA must be received in the Center for
Scientific Review, NIH, by April 22, 1999. If an application is received after
that date, it will be returned to the applicant without review.

For research proposals over $500,000 in direct costs for any year, investigators
must have received written agreement from AHCPR that it will accept the
applications (NIH Guide, August 22, 1997). This RFA is available through the
AHCPR Web site http://www.ahcpr.gov (Funding Opportunities) and from the AHCPR
contractor Equals Three Communications, Inc.

Application Preparation (for Using HCFA Data)

For applications that propose to use Medicare or Medicaid data that are
individually identifiable, applicants should state explicitly in the "Research
Design and Methods" section of the Research Plan (for PHS 398) the specific
files, time periods, and cohorts proposed for the research. In consultation with
HCFA, AHCPR will use this information to develop a cost estimate for obtaining
the data. This estimate will be included in the estimated total cost of the grant
at the time funding decisions are made.

Applicants should be aware that for individually identifiable Medicare and
Medicaid data, Principal Investigators and their grantee institutions will be
required to enter into a Data Use Agreement (DUA) with HCFA to protect the
confidentiality of data in accordance with OMB circular a-130, Appendix III -
"Security of Federal Automated Information Systems."  The use of the data is
restricted to the purposes and time period specified in the DUA.  At the end of
this time period, the grantee is required to return the data to HCFA, or certify
that the data has been destroyed.  Grantees must also comply with the
confidentiality requirements of Section 903(c) of the PHS Act.

REVIEW CONSIDERATIONS

Applications that are complete and responsive to the RFA will be evaluated for
scientific and technical merit by an appropriate peer review group convened in
accordance with AHCPR peer review procedures. If the application is not
responsive to the RFA, Referral staff may 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. As part of
the merit review, all applications will receive a written critique, and also may
undergo a process in which only those applications deemed to have the highest
scientific merit will be discussed and assigned a priority score.

General Review Criteria

Review criteria for AHCPR grant applications are: significance and originality
from a scientific and technical viewpoint, adequacy of the method(s),
availability of data or proposed plans to collect data required for the project,
adequacy of the plan for organizing and carrying out the project, qualification
and experience of the Principal Investigator and proposed staff, reasonableness
of the proposed budget and duration, adequacy of the proposed facilities and
resources available to the applicant, the extent to which women, minorities and
children (as appropriate), are adequately represented in study population, and
when applicable, the adequacy of the proposed means for protecting human
subjects.

Special Review Criteria

In addition to the review criteria above, to determine eligibility for minority
set-aside funds, applications will be evaluated on the following criteria:

1.  The significance of the project in addressing one or more of the six
conditions identified in the President"s Race and Health Disparities Initiative
(infant mortality, cancer screening and management, cardiovascular disease,
diabetes, HIV infection, and child and adult immunization) in one or more of the
four identified racial/ethnic minority population groups (Black, Hispanic,
American Indian and Alaska Native, Asian American and Pacific Islander).

2.  The degree to which the project demonstrates a meaningful collaboration
between a minority institution and a majority institution.

AWARD CRITERIA

Applications will compete for available funds with all other applications under
this RFA. Applications deemed eligible for set-aside funds will compete with all
other eligible applications for set-aside funds, and if not funded, will compete
with all other applications under this RFA. The following will be considered when
making the funding decisions: quality of the proposed project as determined by
peer review, program balance, and availability of funds.

Special preference will be accorded to applications from principal investigators
who are not recent (within 2 years) or current AHCPR-funded principal
investigators of an AHCPR grant for research in quality.

The anticipated award date is September 30, 1999.

INQUIRIES

Copies of this RFA are available from:

Equals Three Communications, Inc.
7910 Woodmont Avenue, Suite 200
Bethesda, MD 20814-3015
Telephone:  301/656-3100
FAX:  301/652-5264

The RFA is also available on AHCPR"s Web site, http://www.ahcpr.gov (Funding
Opportunities) and through AHCPR InstantFAX at 301/594-2800. To use InstantFAX,
you must call from a facsimile (FAX) machine with a telephone handset. Follow the
voice prompts to obtain a copy of the InstantFAX table of contents, which has the
document number (not the same as the RFA number). The RFA will be sent at the end
of the ordering process. AHCPR InstantFAX operates 24 hours a day, 7 days a week.
For questions about this service, call Judy Wilcox, Office of Health Care
Information, at 301/594-1364, ext. 1389.

AHCPR welcomes the opportunity to clarify any issues or questions from potential
applicants. Written and telephone inquiries are encouraged. Direct inquiries
regarding programmatic issues including information on the inclusion of women,
minorities, and children in study populations, as well as additional information
about AHCPR supported work pertaining to evidence-based practice and translating
research into practice to:

Francis D. Chesley, Jr., M.D.
Center for Practice and Technology Assessment
Agency for Health Care Policy and Research
6010 Executive Boulevard, Suite 300
Rockville, MD 20852
Telephone:  301/594-4021
Email:  [email protected]

The National Institute of Mental Health also supports research on the
dissemination of evidence-based knowledge designed to promote the adoption of
research-based change in clinical practice and policy dealing with mental health
and behavioral issues.  Studies range from psychological and social factors
influencing decision-making by practitioners and consumers, to investigations
targeting large-scale service systems and funding sources.  Emphasis is placed
upon the testing of interventions and strategies that will change practice and
policy dealing with mental health and behavioral issues.

Programmatic inquiries may be direct to:

Harold Goldstein, Ph.D.
Division of Services and Intervention Research
National Institute of Mental Health
6001 Executive Boulevard, Room 7146, MSC 9631
Bethesda, MD  20892-9631
Telephone:  (301) 443-3747
FAX:  (301) 443-4045
Email:  [email protected]

Direct inquiries regarding fiscal matters to:

Joan Metcalfe
Grants Management Specialist
Agency for Health Care Policy and Research
2101 East Jefferson Street, Suite 601
Rockville, MD 20852
Telephone:  301/594-1841
FAX:  301/594-3210
Email: [email protected]

AUTHORITY AND REGULATIONS

This program is described in the Catalog of Federal Domestic Assistance, Number
93.226. Awards are made under authorization 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) as applicable. Awards are administered under PHS Grants
Policy Statement and Federal regulations 42 CFR 67, Subpart A, and 45 CFR Parts
74 and 92. This program is not subject to the intergovernmental review
requirements of Executive Order 12372 or Health Systems Agency review.

The PHS strongly encourages all grant and contract recipients to provide a smoke-
free workplace and promote the non-use of all tobacco products. In addition,
Public Law 103-227, The Pro-Children Act of 1994, prohibits smoking in certain
facilities (or in some cases, any portion of a facility) in which regular or
routine education, library, day care, health care, or early child development
services are provided to children. This is consistent with the PHS mission to
protect and advance the physical and mental health of the American people.

References

Bero LA, Grilli R, Grimshaw JM, Harvey E, Oxman AD, Thompson MA, 1998. Closing
the gap between research and practice: an overview of systematic reviews of
interventions to promote the implementation of research findings. BMJ, 317:465-
68.

Davis DA, Thomson MA, Oxman AD, Haynes RB, 1995. Changing physician performance:
a systematic review of the effect of continuing medical education strategies.
JAMA, 274:700-05.

Greco PJ, Eisenberg JM, 1993. Changing physicians" practice. N Engl J Med,
329:1271-73.

Green L, Kreuter M, 1991. Application of PRECEDE/PROCEED in Community Settings:
Health Promotion Planning: An Educational and Environmental Approach. Mountain
View, Calif: Mayfield.

Hunt DL, Haynes RB, Hanna SE, Smith K, 1998. Effects of computer-
based decision support systems on physician performance and patient outcomes.
JAMA, 280:1339-46.

Oxman AD, Thomson MA, Davis DA, Haynes RB, 1995. No magic bullet: a systematic
review of 102 trials of interventions to improve professional practice. Can Med
Assoc J, 153:1423-1431.

Soumerai SB, Avorn JA, 1990. Principles of education outreach ("academic
detailing") to improve clinical decision making. JAMA, 263:549-56.

Soumerai SB, McLaughlin TJ, Gurwitz JH, Guadagnoli E, Hauptman PJ, Borbas C,
Morris N, McLaughlin B, Gao X, Willison DJ, Asinger R, Gobel F, 1998.  Effect of
local medical opinion leaders on quality of care for acute myocardial infarction:
a randomized controlled.  JAMA  279:358-63.

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