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Encouraging physician appropriate prescribing of non-steroidal anti-inflammatory therapies: protocol of a randomized controlled trial [ISRCTN43532635]
© Doupe et al; licensee BioMed Central Ltd. 2004
Received: 25 March 2004
Accepted: 24 August 2004
Published: 24 August 2004
Traditional non-steroidal anti-inflammatory drugs (NSAIDs) are a widely used class of therapy in the treatment of chronic pain and inflammation. The drugs are effective and can be relatively inexpensive thanks to available generic versions. Unfortunately the traditional NSAIDs are associated with gastrointestinal complications in a small proportion of patients, requiring costly co-therapy with gastro-protective agents. Recently, a new class of non-steroidal anti-inflammatory agents known as coxibs has become available, fashioned to be safer than the traditional NSAIDs but priced considerably higher than the traditional generics. To help physicians choose appropriately and cost-effectively from the expanded number of anti-inflammatory therapies, scientific bodies have issued clinical practice guidelines and third party payers have published restricted reimbursement policies. The objective of this study is to determine whether an educational intervention can prompt physicians to adjust their prescribing in accordance with these expert recommendations.
This is an ongoing, randomized controlled trial. All primary care physicians in Manitoba, Canada have been randomly assigned to a control group or an intervention study group. The educational intervention being evaluated consists of an audit and feedback mechanism combined with optional participation in a Continuing Medical Education interactive workshop. The primary outcome of the study is the change, from pre-to post-intervention, in physicians' appropriate prescribing of non-steroidal anti-inflammatory therapies for patients requiring chronic treatment. Three classes of non-steroidal anti-inflammatory therapies have been identified: coxib therapy, traditional NSAID monotherapy, and traditional NSAID therapy combined with gastro-protective agents. Appropriate prescribing is defined based on international clinical practice guidelines and the provincial drug reimbursement policy in Manitoba.
Traditional non-steroidal anti-inflammatory drugs (NSAIDs) are a widely prescribed class of therapy used to relieve pain and inflammation. The drugs have been shown to be effective for a variety of common disorders (hence their widespread use), most notably chronic osteoarthritis and rheumatoid arthritis. They are relatively inexpensive due to the available generic versions, but unfortunately have clinically important drawbacks related to their gastrointestinal (GI) toxicity . Each year, about 1% to 1.5% of patients taking traditional NSAIDs experience serious GI side effects such as perforations, ulcers, and bleeding [2–5]. When multiplied by the total number of NSAID users this translates into significant patient morbidity and mortality [1, 6] and is associated with considerable health care costs related to hospitalizations or to the prescribing of expensive gastro-protective agents (GPAs) [7–12]. The cause of this GI toxicity is the "non-selective nature" of traditional NSAIDs that block both cyclo-oxygenase-2 (Cox-2), an enzyme involved in the production of inflammation and pain, and Cox-1, a related molecule that functions in GI tract mucosal protection and platelet function .
In the last five years, a new class of non-steroidal anti-inflammatory agents has become available to physicians, fashioned specifically to be safer than the traditional NSAIDs but priced at least two to three times higher than the generic versions of traditional NSAIDs . The new drugs preferentially inhibit Cox-2 enzymes as compared to COX-1 molecules, and therefore have been christened "Cox-2 selective inhibitors" or "coxibs" for short. Large clinical trials comparing the use of coxibs to traditional NSAIDs have lent support to the concept that the new agents offer an improved GI safety profile while maintaining comparable analgesic efficacy in patients with chronic arthritis [3, 4, 15]. The trials, however, have also hinted that the improved GI safety may be compromised by concomitant use of low-dose aspirin  and may come at the expense of some cardiovascular safety, although these data remain controversial [16, 17]. Regardless, the introduction of these new anti-inflammatory agents has prompted the question: when is it appropriate and cost-effective to prescribe coxibs versus traditional NSAID monotherapy or traditional NSAIDs in combination with GPAs?
To assist physicians in selecting from the different classes of anti-inflammatory agents, various scientific bodies have published clinical guidelines and third party payers have issued restricted reimbursement criteria [18–24]. These guidelines and reimbursement criteria in general propose that, for the treatment of chronic osteoarthritis and rheumatoid arthritis, coxibs should be used in lieu of traditional NSAID monotherapy when patients have an elevated risk for serious GI events. Traditional NSAID therapy in combination with certain GPAs (misoprostol or proton pump inhibitors) is also recommended as an alternative for most high-risk patients. High-risk patients are identified as individuals who have one or more of the following clinical characteristics: a history of peptic ulcer disease; advanced age (over 65 years); concomitant use of corticosteroids or anticoagulants; multiple comorbid conditions; or use of high doses or multiple NSAIDs [1, 5, 6, 25, 26]. These high-risk patients are considered to benefit from the improved GI safety of coxibs or from the GI protection afforded by GPAs. Furthermore, coxibs and GPA co-therapy have been shown to be cost-effective in such high-risk patients, as the increased cost of the drugs is partially offset by significant reductions in morbidity and mortality and related expenses [14, 27–29].
With these guidelines and policies on prescribing in place, it is now important for physicians to adjust their prescribing practices accordingly. This is true both for rheumatology specialists and for physicians in the primary care setting where osteoarthritis patients are frequently managed. Unfortunately, experience and educational research show that simply making guidelines available does not elicit behavioural change from physicians [30–33]. In the case of anti-inflammatory drug prescribing, there is already evidence showing that despite the availability of guidelines and reimbursement policies, physicians' choices of drugs remain suboptimal both in terms of the inappropriate use of traditional NSAIDs and the non-cost-effective use of coxibs [34–38].
The current use of anti-inflammatory drugs suggests a need for strategies that will prompt physicians to change their prescribing practice in accordance with the expert recommendations. Preferably, strategies should be investigated that have proved successful at altering physician behaviour in other settings.
In this paper, we describe a randomized controlled study, which we are presently conducting, to evaluate the impact of an educational intervention on primary care physicians' prescribing of non-steroidal anti-inflammatory therapies. The study, being conducted in the province of Manitoba, Canada, tests the hypothesis that this intervention will significantly improve physician appropriate prescribing of anti-inflammatory drugs in compliance with international clinical practice guidelines and Manitoba's restricted drug reimbursement policy [18–22]. The intervention being tested is modelled on proven approaches to changing physician behaviour; it consists of an audit and feedback mechanism with optional participation in a Continuing Medical Education (CME) interactive workshop. This manuscript summarizes Phases II to V of a larger initiative entitled the Manitoba Appropriate Anti-Inflammatory Utilization Initiative (MAAUI). The study began in November 2000 and is currently in the data analysis stage. In this paper, we relate in detail the protocol of this randomized controlled study.
MAAUI is a province-wide population-based study. All primary care physicians (non-specialists) registered with the College of Physicians and Surgeons of Manitoba and practicing in Manitoba since July 1995 were eligible to enter MAAUI. The study excluded residents, new physician graduates, physicians registered as specialists, and physicians who started practicing in the province of Manitoba after July 1995. The eligible study population thus totalled approximately 884 physicians.
All eligible physicians were automatically entered into the MAAUI protocol. Physicians who were randomized to intervention group of the research were given the option to withdraw from the study. Six family physicians who agreed to act as facilitators for the MAAUI CME workshop were not included in the study population.
This study design was chosen for several reasons. First, it offered the scientific rigour that is associated with randomization and the use of a control group. It also ensured that both rural and urban Manitoban physician groups had an equal opportunity to take part in and learn from the study intervention. The study design was also particularly amenable to testing an intervention that required physicians to congregate in common locations (i.e. for the CME workshop). The 1:2 ratio of study groups helped to ensure that there were a sufficient number of study participants who would consider attending the CME workshops.
The educational intervention
Physicians allocated to the intervention arm of MAAUI were mailed a package that included an introduction to the study, audit and feedback material, and an invitation to participate in a CME workshop. Physicians in the control arm received no package.
Audit and feedback material
The Personalized Prescribing Profiles were generated by Manitoba Health and the Manitoba Centre for Health Policy (MCHP) at the University of Manitoba, using administrative data from the Population Health Research Data Repository. This repository contains anonymized encounter-based records of individuals' interactions with the provincial health care system and is derived from information received by the Department of Health, Province of Manitoba, as part of the routine provision of health care in the province. The repository includes Physician Registry files, Medical Claims and Hospital discharge files, as well as Drug Programs Information Network (DPIN) files. The DPIN contains records of all drugs dispensed by Manitoba pharmacies, regardless of who is responsible for payment.
Because of the sensitive nature of the Personalised Prescribing Profiles, the individualized profiles were not seen by the MAAUI research team. Instead the packages containing the profiles were assembled and mailed out by Manitoba Health with the assistance of an independent researcher, hired by the MAAUI research team, who signed a confidentiality agreement with Manitoba Health.
The CME workshop for MAAUI was entitled "The Utilization and Prescribing of Anti-inflammatory Drugs in Osteoarthritis". The workshop focused specifically on the prescribing for osteoarthritis, as it was felt that people with this disease account for a large proportion of the chronic non-steroidal anti-inflammatory use by primary care practices .
Eleven CME workshops were held throughout Manitoba (four within Winnipeg and seven outside of Winnipeg) and physicians in the intervention group were invited to voluntarily attend one of the 11. The workshops were free of charge and were approved for 3.0 hours of MAINPRO-M1 credits (continuing education credits awarded by the College of Family Physicians of Canada for group learning activities). Each workshop was facilitated by a trained family physician.
The workshops included three components: an introductory video, a decision tree, and a case study portion. The introductory video provided the history and rationale of MAAUI, explained aspects of the Personalised Prescribing Profile, and introduced the decision tree. The decision tree depicted a stepwise approach to the diagnosis and treatment of osteoarthritis. This aid was designed by a rheumatologist on the MAAUI research team specifically for use in the study and was based on international clinical practice guidelines and Manitoba's drug reimbursement policy [18–22]. A take-home copy of the decision tree was provided to each workshop participant (see Additional file 1). Finally, the case study portion of the workshop consisted of studies exploring both the diagnosis and appropriate treatment of osteoarthritis. These case studies were supplied from an existing CME curriculum entitled "Clinical Scenarios in Osteoarthritis" .
The overall MAAUI educational intervention, including both the audit and feedback material and the optional CME interactive workshop, was chosen by the MAAUI research team based on the success of similar interventions in the past. Audit and feedback mechanisms have shown moderate success in changing physician behaviour in past studies . Equally, the addition of a continuing education workshop to an existing intervention has been shown to increase the impact on physician behaviour . Workshops with interactive elements, such as case studies, have also been found to be more successful at influencing physician behaviour than purely didactic lectures . Affordability, practicality, and reproducibility were also considered when designing the intervention.
The primary goal of MAAUI is to evaluate the impact of the educational intervention on physician appropriate prescribing of non-steroidal anti-inflammatory therapies for patients requiring long-term treatment. To this end, four principal outcome measures have been developed:
the change in appropriate prescribing of all non-steroidal anti-inflammatory therapy (including coxibs, traditional NSAIDs, and traditional NSAID/GPA combination therapy) from pre-to post-intervention;
the change in appropriate prescribing of coxibs from pre-to post-intervention;
the change in appropriate prescribing of traditional NSAID/GPA combination therapy from pre-to post-intervention; and
the change in appropriate prescribing of traditional NSAID monotherapy from pre-to post-intervention.
These primary outcomes will be evaluated at the level of the individual physician and will be calculated using administrative data similar to that used to create the Personalised Prescribing Profiles. The change in appropriate prescribing (AP) for a given physician will be calculated by the physician's rate of appropriate prescribing during a 6-month period post-intervention (October 1st 2001 to March 31st 2002) minus this rate during a 10-month period immediately pre-intervention (October 1st, 2000 to July 31st, 2001). The rate of appropriate prescribing will be defined as the number of patients prescribed long-term treatment in whom the treatment was appropriate, divided by the total number of patients prescribed long-term treatment, multiplied by 100%. Otherwise expressed:
Physician's ΔAP = Post-intervention AP - Pre-intervention AP
Appropriateness of prescribing will be calculated by a researcher who is blinded to participants' study-arm allocation, and will be based on the same criteria as listed in the Personalised Prescribing Profiles (see Figure 2a). In the event that a physician has fewer than five patients on long-term treatment in either the pre- or post-intervention period, that physician's data will be withheld from analysis to ensure confidentiality of the patients.
In addition to the four principal outcomes, the MAAUI study has a number of prospectively-defined secondary outcomes:
The study will re-evaluate the primary outcomes in the following two physician subgroups: physicians who received the audit and feedback material and attended the CME workshop; physicians who received the audit and feedback material and chose not to attend the CME workshop. This analysis will help to determine the impact that the different components of the educational intervention had on physician behaviour.
Specifically in the subgroup of physicians who attended the CME workshop:
The study will measure the change in physician knowledge of osteoarthritis from pre-CME workshop to immediately post-CME workshop and the change in knowledge from pre-CME workshop to five months post-CME workshop. These two outcomes should provide insight into physicians' retention of information following a CME workshop and will allow us to examine any relationship between change in physician knowledge and change in physician prescribing behaviour.
The study will also survey physicians' perceived change in prescribing behaviour at five months post-intervention. This outcome, compared with the principal study outcomes, will provide insight into the accuracy with which physicians' discern their own prescribing practices.
The study will collect process-related measures in order to mark areas for improvement in the study interventions. Specifically, physicians' impressions of the Personalised Prescribing Profile and CME workshop will be surveyed using the questionnaire distributed immediately following the CME workshop and using focus-group discussions at the end of the study follow-up. All workshop participants will be invited to attend a follow-up focus group (one for urban participants and one for rural participants). A separate focus group will be held for the workshop facilitators.
Baseline data collection
The following data were collected at baseline (October 1st, 2000 to July 31st, 2001) as control measurements: i) physician demographics including sex, urban or rural practice location, and the number of years in practice; ii) physician volume of non-steroidal anti-inflammatory therapies prescribed annually for patients requiring chronic therapy; and iii) physician rate of appropriate prescribing of NSAIDs. These latter two measures were assessed for each of coxibs, traditional NSAID/GPA combination therapy, and traditional NSAID monotherapy.
Sample size and statistics
Sample size was calculated based on the need to detect at least a 10% improvement in physician practice patterns associated with the intervention, for clinical significance. Alpha error was set at 1% because of the multiple primary outcomes and power was set at 80%. It was also assumed in the sample size calculation that physician baseline demographic measures and baseline practice patterns would contribute an additional 10% variation to the outcomes. Based on these figures and using sample size techniques for multivariate regression analysis , we estimated the need for a minimum of 116 physicians in the control group and intervention group respectively.
Multivariate regression analysis will be used to determine if the study intervention has a significant impact on the primary outcomes. Baseline data will be included as control measures and interaction effects between these baseline data and the intervention will also be evaluated.
The MAAUI protocol has been approved by the Health Research Ethics Board, Faculty of Medicine, University of Manitoba, and by the Health Information Privacy Committee of Manitoba Health which is responsible for approving research projects that use personal health information held by a government department.
We are indebted to Health Information Management, Manitoba Health for providing data and to the Manitoba Centre for Health Policy for their maintenance and development of the database. We would also like to acknowledge Manitoba Health for their role on the MAAUI steering committee. The results and conclusions in this paper, however, are those of the authors and no official endorsement by Manitoba Health was intended or should be implied.
- Wolfe MM, Lichtenstein DR, Singh G: Gastrointestinal toxicity of nonsteroidal antiinflammatory drugs. N Engl J Med. 1999, 340: 1888-1899. 10.1056/NEJM199906173402407.View ArticlePubMedGoogle Scholar
- Laine L: Gastrointestinal effects of NSAIDs and coxibs. J Pain Symptom Manage. 2003, 25: S32-S40. 10.1016/S0885-3924(02)00629-2.View ArticlePubMedGoogle Scholar
- Bombardier C, Laine L, Reicin A, Shapiro D, Burgos-Vargas R, Davis B, et al: Comparison of upper gastrointestinal toxicity of rofecoxib and naproxen in patients with rheumatoid arthritis. VIGOR Study Group. N Engl J Med. 2000, 343: 1520-8,2. 10.1056/NEJM200011233432103.View ArticlePubMedGoogle Scholar
- Silverstein FE, Faich G, Goldstein JL, Simon LS, Pincus T, Whelton A, et al: Gastrointestinal toxicity with celecoxib vs nonsteroidal anti-inflammatory drugs for osteoarthritis and rheumatoid arthritis: the CLASS study: A randomized controlled trial. Celecoxib Long-term Arthritis Safety Study. JAMA. 2000, 284: 1247-1255. 10.1001/jama.284.10.1247.View ArticlePubMedGoogle Scholar
- Silverstein FE, Graham DY, Senior JR, Davies HW, Struthers BJ, Bittman RM, et al: Misoprostol reduces serious gastrointestinal complications in patients with rheumatoid arthritis receiving nonsteroidal anti-inflammatory drugs. A randomized, double-blind, placebo-controlled trial. Ann Intern Med. 1995, 123: 241-249.View ArticlePubMedGoogle Scholar
- Singh G: Recent considerations in nonsteroidal anti-inflammatory drug gastropathy. Am J Med. 1998, 105: 31S-38S. 10.1016/S0002-9343(98)00072-2.View ArticlePubMedGoogle Scholar
- Rahme E, Joseph L, Kong SX, Watson DJ, LeLorier J: Cost of prescribed NSAID-related gastrointestinal adverse events in elderly patients. Br J Clin Pharmacol. 2001, 52: 185-192. 10.1046/j.1365-2125.2001.00348.x.View ArticlePubMedPubMed CentralGoogle Scholar
- Rahme E, Joseph L, Kong SX, Watson DJ, LeLorier J: Gastrointestinal health care resource use and costs associated with nonsteroidal antiinflammatory drugs versus acetaminophen: retrospective cohort study of an elderly population. Arthritis Rheum. 2000, 43: 917-924. 10.1002/1529-0131(200004)43:4<917::AID-ANR25>3.0.CO;2-F.View ArticlePubMedGoogle Scholar
- Bloom BS: Direct medical costs of disease and gastrointestinal side effects during treatment for arthritis. Am J Med. 1988, 84: 20-24. 10.1016/0002-9343(88)90250-1.View ArticlePubMedGoogle Scholar
- Chevat C, Pena BM, Al MJ, Rutten FF: Healthcare resource utilisation and costs of treating NSAID-associated gastrointestinal toxicity. A multinational perspective. Pharmacoeconomics. 2001, 19 (Suppl 1): 17-32.View ArticlePubMedGoogle Scholar
- Herings RM, Klungel OH: An epidemiological approach to assess the economic burden of NSAID-induced gastrointestinal events in The Netherlands. Pharmacoeconomics. 2001, 19: 655-665.View ArticlePubMedGoogle Scholar
- Sturkenboom MC, Romano F, Simon G, Correa-Leite ML, Villa M, Nicolosi A, et al: The iatrogenic costs of NSAID therapy: a population study. Arthritis Rheum. 2002, 47: 132-140. 10.1002/art.10268.View ArticlePubMedGoogle Scholar
- Hawkey CJ: Non-steroidal anti-inflammatory drug gastropathy: causes and treatment. Scand J Gastroenterol Suppl. 1996, 220: 124-127.View ArticlePubMedGoogle Scholar
- Maetzel A, Krahn M, Naglie G: The cost effectiveness of rofecoxib and celecoxib in patients with osteoarthritis or rheumatoid arthritis. Arthritis Rheum. 2003, 49: 283-292. 10.1002/art.11121.View ArticlePubMedGoogle Scholar
- Simon LS, Smolen JS, Abramson SB, Appel G, Bombardier C, Brater DC, et al: Controversies in COX-2 selective inhibition. J Rheumatol. 2002, 29: 1501-1510.PubMedGoogle Scholar
- Mukherjee D, Nissen SE, Topol EJ: Risk of cardiovascular events associated with selective COX-2 inhibitors. JAMA. 2001, 286: 954-959. 10.1001/jama.286.8.954.View ArticlePubMedGoogle Scholar
- Solomon DH, Glynn RJ, Levin R, Avorn J: Nonsteroidal anti-inflammatory drug use and acute myocardial infarction. Arch Intern Med. 2002, 162: 1099-1104. 10.1001/archinte.162.10.1099.View ArticlePubMedGoogle Scholar
- Tannenbaum H, Peloso PM, Russell AS, Marlow B: An evidence-based approach to prescribing NSAIDs in the treatment of osteoarthritis and rheumatoid arthritis: The Second Canadian Consensus Conference. Can J Clin Pharmacol. 2000, 7 (Suppl A): 4A-16A.PubMedGoogle Scholar
- National Institute for Clinical Excellence: Guidance on the use of cyclo-oxygenase (Cox) II selective inhibitors, celecoxib, rofecoxib, meloxicam and etodolac for osteoarthritis and rheumatoid arthritis. Technology Appraisal Guidance. 2001, 27: 1-14. [http://www.nice.org.uk/pdf/coxiifullguidance.pdf]Google Scholar
- Recommendations for the medical management of osteoarthritis of the hip and knee: 2000 update. American College of Rheumatology Subcommittee on Osteoarthritis Guidelines. Arthritis Rheum. 2000, 43: 1905-1915. 10.1002/1529-0131(200009)43:9<1905::AID-ANR1>3.0.CO;2-P.Google Scholar
- Guidelines for the management of rheumatoid arthritis: 2002 Update. Arthritis Rheum. 2002, 46: 328-346. 10.1002/art.10148.Google Scholar
- Manitoba Health: Prescription Drugs Cost Assistance Act Regulation (Parts 1 and 2). 2003, [http://www.gov.mb.ca/health/mdbif/]Google Scholar
- Ministry of Health: Ontario Drug Benefit Formulary / Comparative Drug Index Edition no. 38. 2003, [http://www.health.gov.on.ca/english/providers/program/drugs/odbf_mn.html]Google Scholar
- VHA Pharmacy Benefits Management Strategic Health Care Group and the Medical Advisory Panel: Summary of the criteria for non-formulary use of Cyclooxygenase 2 (COX-II) inhibitors in high-risk veteran patients. 2001, [http://www.vapbm.org/criteria/coxcriteria.pdf]Google Scholar
- Hernandez-Diaz S, Rodriguez LA: Association between nonsteroidal anti-inflammatory drugs and upper gastrointestinal tract bleeding/perforation: an overview of epidemiologic studies published in the 1990s. Arch Intern Med. 2000, 160: 2093-2099. 10.1001/archinte.160.14.2093.View ArticlePubMedGoogle Scholar
- Gabriel SE, Jaakkimainen L, Bombardier C: Risk for serious gastrointestinal complications related to use of nonsteroidal anti-inflammatory drugs. A meta-analysis. Ann Intern Med. 1991, 115: 787-796.View ArticlePubMedGoogle Scholar
- Schwappach DL, Koeck CM: Selective COX-2 inhibitors: a health economic perspective. Wien Med Wochenschr. 2003, 153: 116-122.View ArticlePubMedGoogle Scholar
- Spiegel BM, Targownik L, Dulai GS, Gralnek IM: The cost-effectiveness of cyclooxygenase-2 selective inhibitors in the management of chronic arthritis. Ann Intern Med. 2003, 138: 795-806.View ArticlePubMedGoogle Scholar
- Maetzel A, Ferraz MB, Bombardier C: The cost-effectiveness of misoprostol in preventing serious gastrointestinal events associated with the use of nonsteroidal antiinflammatory drugs. Arthritis Rheum. 1998, 41: 16-25. 10.1002/1529-0131(199801)41:1<16::AID-ART3>3.3.CO;2-W.View ArticlePubMedGoogle Scholar
- Lomas J: Words without action? The production, dissemination, and impact of consensus recommendations. Annu Rev Public Health. 1991, 12: 41-65. 10.1146/annurev.pu.12.050191.000353.View ArticlePubMedGoogle Scholar
- Oxman AD, Thomson MA, Davis DA, Haynes RB: No magic bullets: a systematic review of 102 trials of interventions to improve professional practice. CMAJ. 1995, 153: 1423-1431.PubMedPubMed CentralGoogle Scholar
- Davis DA, Taylor-Vaisey A: Translating guidelines into practice. A systematic review of theoretic concepts, practical experience and research evidence in the adoption of clinical practice guidelines. CMAJ. 1997, 157: 408-416.PubMedPubMed CentralGoogle Scholar
- Grimshaw JM, Shirran L, Thomas R, Mowatt G, Fraser C, Bero L, et al: Changing provider behavior: an overview of systematic reviews of interventions. Med Care. 2001, 39: II2-45. 10.1097/00005650-200108002-00002.View ArticlePubMedGoogle Scholar
- Cutts C, LaCaze A: Nonsteroidal anti-inflammatory drugs and potential risks in a convenience sample of general practitioners. Aust Fam Physician. 2002, 31: 590-592.PubMedGoogle Scholar
- Cox E: The Drug of Choice Among Boomers – Cox-2 Inhibitors: Here's What You May Not Know. 2002, [http://www.express-scripts.com/other/news_views/outcomes2002/outcomes_conf_2002_pres_summaries.htm]Google Scholar
- Mamdani M, Rochon P, Laupacis A, Anderson G: Initial patterns of use of COX-2 inhibitors by elderly patients in Ontario: findings and implications. CMAJ. 2002, 167: 1125-1126.PubMedPubMed CentralGoogle Scholar
- Marra CA, Esdaile JM, Sun H, Anis AH: The cost of COX inhibitors: how selective should we be?. J Rheumatol. 2000, 27: 2731-2733.PubMedGoogle Scholar
- Landsberg PG, Pillans PI, Radford JM: Evaluation of cyclooxygenase 2 inhibitor use in patients admitted to a large teaching hospital. Intern Med J. 2003, 33: 225-228. 10.1046/j.1445-5994.2003.00392.x.View ArticlePubMedGoogle Scholar
- Cullen DJ, Seager JM, Holmes S, Doherty M, Wilson JV, Garrud P, et al: Pharmacoepidemiology of non-steroidal anti-inflammatory drug use in Nottingham general practices. Aliment Pharmacol Ther. 2000, 14: 177-185. 10.1046/j.1365-2036.2000.00700.x.View ArticlePubMedGoogle Scholar
- Davis P, Hughes S, Low S, Sholter D, Homik J, Juby A, et al: Clinical Scenarios in Osteoarthritis: Interactive Problem-Based Case Studies. 2000, Prepared by the Division of Continuing Medical Education, Faculty of Medicine and Dentistry, University of Alberta, in Edmonton, in partnership with Patient Health – CME Merck Frosst Canada & Co.Google Scholar
- Jamtvedt G, Young JM, Kristoffersen DT, Thomson O'Brien MA, Oxman AD: Audit and feedback: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2003, CD000259.Google Scholar
- Richards D, Toop L, Graham P: Do clinical practice education groups result in sustained change in GP prescribing?. Fam Pract. 2003, 20: 199-206. 10.1093/fampra/20.2.199.View ArticlePubMedGoogle Scholar
- Thomson O'Brien MA, Freemantle N, Oxman AD, Wolf F, Davis DA, Herrin J: Continuing education meetings and workshops: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2001, CD003030.Google Scholar
- Cohen J: Statistical power analysis. 1988, Hillsdale: Lawrence Erlbaum Associates, Inc, 2Google Scholar
- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6963/4/21/prepub
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