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Doctors' perception of pertinent information. Results of a survey of a random sample of French general practitioners. GEP (Groupe d'Etude de la Prescription)
Abstract
The results of a survey aimed at investigating which tools prescribers have at hand to help them to identify pertinent information from a background of “noise” are reported. A questionnaire was sent to 250 general practitioners randomly selected from a list of those practicing in the Rhône-Alpes region in France, of whom 117 (46.8%) replied. The questionnaire consisted of three sections, the first explored how they dealt with intermediate and clinical outcomes in trials, the second presented a series of statements to identify what would make them prescribe a new drug, and the third looked at their knowledge of therapy assessment methodology.
It was found that most general practitioners had not been trained to identify the most salient information for selecting the best treatment. This implies that both medical students and qualified doctors should be taught to recognise pertinent information.
... Las revistas científicas son, probablemente, las fuentes de información más objetivas e independientes de las que dispone el facultativo; no obstante, su influencia no parece ser acorde con su calidad [28][29][30] . En Francia, por ejemplo, aunque un 45% de los médicos afirmó que la existencia de ensayos clínicos era la principal consideración a la hora de valorar la eficacia de un fármaco, otro 45% consideró que eran sus propias impresiones las más consideradas 31 . Un artículo, publicado por Gené et al 29 en 1988 sobre el consumo de cinarizina en nuestro país, muestra cómo a pesar de que a partir de 1985 distintos artículos vinieron asociando parkinsonismo y cinarizina, la prescripción de este principio activo no disminuyó significativamente. ...
... Las revistas científicas son, probablemente, las fuentes de información más objetivas e independientes de las que dispone el facultativo; no obstante, su influencia no parece ser acorde con su calidad [28][29][30] . En Francia, por ejemplo, aunque un 45% de los médicos afirmó que la existencia de ensayos clínicos era la principal consideración a la hora de valorar la eficacia de un fármaco, otro 45% consideró que eran sus propias impresiones las más consideradas 31 . Un artículo, publicado por Gené et al 29 en 1988 sobre el consumo de cinarizina en nuestro país, muestra cómo a pesar de que a partir de 1985 distintos artículos vinieron asociando parkinsonismo y cinarizina, la prescripción de este principio activo no disminuyó significativamente. ...
Unwanted random variability in day-to-day decision making referred to as ‘noise’ is associated with unhelpful variation that affects both the reproducibility and quality of decision making. Although this is described in other fields, the prevalence of noise in medical decision making and its effects on patient outcomes and the process and efficiency of care have not been reported and are unknown. This review sought to explore noise as a feature of medical decision making, as well as explore potential sources of noise in this setting. The search generated 2,082 results. Analysis of 14 studies included in the review (11 PubMed, 3 reference mining) suggests noise is a driver of unhelpful practice variation and may have important effects on care efficiency and reproducibility. 7 of the 14 studies demonstrated pattern noise, 3 demonstrated occasion noise, and 5 demonstrated stable pattern noise. The decision making in 8 studies demonstrated level noise, and lastly the decision making in 4 of the studies demonstrated system noise, a combination of both pattern and level noise. Additional study is required to ascertain how to measure and mitigate noise in medical decision making, as well as better understand the sources of noise present. Clinical trial number not applicable.
Results are presented in the most varied ways in medical publications and advertising material. The reader should be able to interpret the results of such studies accurately. In the present investigation our interest focused on whether a physician learns to analyse results correctly in medical school or in his subsequent clinical career. We also investigated whether the interpretation of therapeutic data differs as between students in the 4th year of medical school, students of the 6th year and physicians. In a questionnaire, one result from the Helsinki Heart Study was presented in for different ways: (a) absolute risk reduction, (b) relative risk reduction, (c) NNT (number needed to treat) and (d) percentage of patients without a cardiovascular event during the monitoring period. To each group we assigned a different drug. We interviewed students in the 4th and 6th years of medical school, physicians during a continuing education course and physicians before and after an evidence-based medicine (EBM) course. They replied by stating which drug they would select for therapy. Evaluation of the questionnaire showed that the majority regarded the drug for relative risk reduction as the most effective. Physicians taking part in the EBM course analysed the statistical data better than the other groups interviewed, and their answers even improved significantly after the EBM course. There was no difference in the interpretation of therapeutic results between students and physicians who had not taken part in an EBM course. The study also found that in all the groups interviewed the presentation of the results of scientific studies has a marked influence on their interpretation. We conclude that interpretation of medical studies should form part of every student's and physicians's training, either in medical school or continuing education courses. On the other hand, the results of studies should be uniformly expressed in absolute figures, to make it easier to compare different results.
This article describes and analyzes decision-making by patients, physicians, and drug information providers about registered medical drugs. Based on a cognitive psychology perspective, cognitive variables (the individual's mediating system) are assumed to be critical factors determining both patient and physician behavior. The individual's psychological functioning is seen as a continuous reciprocal interaction between behavioral, cognitive, and environmental influences; i.e., an interactional paradigm is applied. The importance of research models including cognitive and situation variables to guide the search for appropriate research methods is stressed. An intensive research strategy with a small sample of respondents will often be necessary. Also, respondents should be asked to describe their reactions to specific medical situations. The drug information sender has to select a set of goals for disseminating information to patients. Among the goals most often selected are: message comprehension, receiver satisfaction, changes in knowledge, attitudes, and drug behavior, as well as health effects. More research is needed on how the patient's mediating system, the actual situation, and the perceived situation steer his search for the use of new drug information. A different set of factors influence the patient's decision to start a medicinal or drug treatment than the factors that influence his decision to continue a treatment. The latter factors include forgetfulness, misunderstandings, and the patient's interpretation of physiological signs. More cognitive-oriented research about drug compliance must be undertaken. In such studies the mediating systems of a group of patients could be considered before and after intervention. There are a great number of types of inappropriate (irrational) prescribing. However, a physician may prescribe rationally in one area but irrationally in another. Face-to-face education of physicians has been shown to be effective in reducing inappropriate prescribing in a number of studies. "Overprescribing" of benzodiazepine has been an issue of intensive professional debate during the last decades. The two groups who criticize and defend the existing use of benzodiazepines build their views on different assumptions about the interaction between mind and brain as well as making different value assumptions regarding the use of a psychotropic drug. There is a need for prescription studies where a cognitive and interactional perspective is combined with an information-processing and a normative perspective. The benzodiazepines dependency problem has provoked lively discussion among professionals and the general public. Long-term benzodiazepine use and personality disorders increase the risk of the patient becoming dependent. A great number of research models have been suggested for the analysis of prescription drug dependency and as guides to the treatment of dependency.(ABSTRACT TRUNCATED AT 400 WORDS)
Clinical trials may lead to conflicting results. We studied how different ways of reporting results affected physicians' recommendations. A questionnaire distributed to 148 general practitioners presented results of a clinical trial where a reduction of cardiac events and an increase of mortality was reported. Results were shown in four different ways--relative risk reduction, absolute risk reduction, percentages of event-free patients, number needing to be treated to prevent an event--as if they derived from different trials. A fifth presentation was the reduced rate of cardiac events along with the increased rate of mortality. Physicians were asked to estimate how much they would be willing to prescribe each drug. The mean agreement of physicians' decisions was 77 (28)% for relative risk reduction, 24 (28)% for absolute risk reduction, 37 (37)% for different percentages event-free patients, 34 (34)% for number need to treat, and 23 (28)% for events reduction and mortality for increase (p < 0.001 relative risk vs others). The method of reporting trial results and the completeness of information in the case of controversial results affects physicians willingness to prescribe.
To study how satisfactory the contents of introductory courses in cardiovascular therapeutics, given to medical students in France, are with respect to the concepts of evidence-based medicine.
Medical school lecturers were asked to provide written course material used as part of medical school courses. Best-available evidence was classified as existent (including two therapeutic subclasses: indicated and contraindicated), and nonexistent. Four scores (from 0 to 10) were given, according to conformity with best-available evidence, and citation of randomized clinical trials (RCT), meta-analyses and therapeutic objectives.
Thirty-four written documents were obtained from 43 faculties. Although the score (mean +/- SEM) of conformity with best-available evidence was 5.43 +/- 0.28 for the existent best-available evidence class, the corresponding scores for the citation of RCT, meta-analyses, and therapeutic objectives were, respectively, 1 +/- 0.2, 0.16 +/- 0.07, and 2.7 +/- 0.3. The four scores were highest when the best-available evidence belonged to the indicated class, intermediate when best-available evidence was nonexistent, and lowest for the contraindicated class (P < .05). These scores were significantly higher when the printed material was intended for specialists.
Despite some limitations, the extent of agreement with the best-available evidence is only moderate. Pathophysiologic reasoning is largely preferred to justify the choice of therapeutics recommended to medical students.
Commonly used methods for identifying the training needs of general practitioners do not enable the real needs felt during interviews with patients during office visits to be detected. In this study, the authors evaluate how physicians' use of a personal-office-visit diary affects the level of specificity of their expressed training needs. In 1999, the authors carried out a controlled intervention trial using a random sample of 1,038 general practitioners from a region of France, randomized to intervention and control groups. The practitioners in the intervention group were asked to identify their training needs using a personal-office-visit diary. The level of specificity for their expressed needs was compared with that of the expressed needs of the practitioners in the control group. The use of the diary was associated with a significantly higher level of specificity in the training needs identified by the general practitioners who participated. Independent of the intervention, practitioners under 40 years of age, those in urban practice, and those who were members of a continuing medical education (CME) association expressed their training needs with higher specificity. The personal-office-visit diary would seem to be a simple, inexpensive, and useful tool for more specifically identifying training needs, which could help establish more appropriate and better-targeted training programs. However, it should be assessed further by those involved in CME for general practitioners.
The general practitioner plays an essential role in the rational strategy of drug-use by the quality of his prescription which translates the validity and the relevance of his pharmaceutical information. The objective of this work is to study the different means of pharmaceutical information used by general practitioners in the region of Sousse (Tunisia). We conducted a transversal, descriptive, exhaustive survey of 140 general practitioners in private (68) and public (72) practice during 1999. Data were collected through a questionnaire. This study, with a participation rate of 78%, showed that pharmaceutical dictionaries are the major source of information for 86% of general practitioners, that medical delegates have a positive image for 84% of them and that 36% of general practitioners do not subscribe to any medical journal. Thus, general practitioners are exposed to relatively unreliable pharmaceutical information coming generally from the pharmaceutical industry.
Bringing all available evidence on therapy efficacy to users is a necessary step in the evidence-based medicine paradigm. Today, the needs of physicians in medical information, including therapeutic information, are not met. Further, the information reaching the doctors is rarely consistent with the available evidence. The growth rate of emerging evidence and its increasing complexity make the doctors unable to cope with it within the current medical information system. So, there is a real need to sort out a new way for transferring therapeutic information to doctors and patients. We conceived a new paradigm and designed an Internet process based on it by which unbiased evidence is brought to doctors in such a format that it can be accessed and used during the visit.
The spontaneous reporting of adverse drug reactions (ADRs) through the yellow card and made concrete by the knowledge and attitudes of doctors, has been rousing a great deal of bibliographical interest in recent years. However, there does not seem to be any actual revision in the theme on which the theoretical models that explain the process of decision in reporting are proposed. In this work an explanatory model of the factors that condition reporting is proposed and a revision of the literature on the subject has also been carried out.
The proposed model is centralized in the medical professional and it considers the habit of reporting as the result of the doctor's formation and his interaction with the environment. The combination of knowledge-attitudes-practices and the theory of the satisfaction of needs seemed very adequate for ADR systematization.
The results also indicate that, to improve the participation of health professionals in surveillance systems through spontaneous reporting, it might be necessary to design combined strategies that modify both intrinsic (knowledge, attitudes) and extrinsic (relationship between health professionals and their patients, the national health system and pharmaceutical companies) factors.
The therapeutic knowledge of physicians is the corner stone to the rational use of medicines; however information about medicines is generally obtained from the pharmaceutical industry via their sales representatives (reps). We aimed to identify general practitioners' (GPs) attitudes to pharmaceutical reps and the information they provide. We surveyed 140 GPs using a self-administered questionnaire. The response rate was 78% (72 GPs from the public sector and 68 from the private sector). About 10% of the GPs said they received daily visits from pharmaceutical reps; 84% of GPs considered them an efficient source of information and 31% said they might change their therapeutic prescribing following visits from these reps. Because of their positive perception of pharmaceutical reps, GPs are susceptible to the information they provide. Controlling the validity of the therapeutic information imparted by the pharmaceutical industry is thus a fundamental component of the programme for the rational use of medicines.
In order to test the efficacy of under-graduate and post-graduate medical education on pharmacology and drug information in France two variables were surveyed from 1974 until 1979: 1. Sales of four classes of cardio-vascular drugs (beta-blocking agents, 'long-acting' nitrates, platelet modifying drugs - aspirin excluded -, fibrates); 2. supply of clinical controlled trial reports to the medical community, which were considered as the input function of the system under scrutiny. Sales represented the output function. They were assumed to be closely dependent on prescriptions. The expected correlation between conclusions of reports - positive, negative, dubious - and sales of the corresponding drug was seldom observed. In most instances sales were independent of controlled clinical trial results. It was concluded that prescribers were not satisfactorily informed. In addition this study produced some hypotheses on the possible defects of the system. Monitoring of prescribers' habits was shown to be possible and useful.
We conducted a statewide controlled trial of three methods to improve antibiotic prescribing in office practice: a mailed brochure, a drug educator visit, and a physician visit. Educational topics were three antibiotics contraindicated for office practice and oral cephalosporins. Medicaid prescribing data were used to select doctors who needed education. The effect of the methods was evaluated by comparing the change in prescribing (the year before the intervention v the year after the intervention) for the doctors receiving education with the prescribing of comparable doctors chosen as controls. The mailed brochure had no detectable effect, and the drug educator had only a modest effect. The physician visits produced strong attributable reductions in prescribing of both drug classes. For the contraindicated antibiotics, the reductions were 18% in number of doctors prescribing, 44% in number of patients per doctor receiving these drugs, and 54% in number of prescriptions written per doctor. For the oral cephalosporins, both number of patients and number of prescriptions per doctor were reduced by 21%. Doctors responded equally well to recommendations designed to improve the quality of care and to reduce the cost of care.
(JAMA 1983;250:1728-1732)
Dissemination of new medical information to the practicing physician is a complex and often faulty process. To examine the magnitude of this problem, we surveyed primary care physicians to determine their knowledge of the results of the cooperative trial of photocoagulation in diabetic retinopathy. Despite the acknowledged relevance to their practice, only 28% (38/137) of family physicians and 46% (42/91) of internists were aware of the study results (P<.001). Respondents were asked to manage two patient problems involving diabetic retinopathy. Only 33% (75/229) handled both correctly, although the retinopathy photocoagulation study had been published 18 months earlier. These findings indicate that results from clinical trials may not be disseminated to practicing physicians and, therefore, not incorporated into practice. Greater attention should be directed toward making findings from clinical trials available to practitioners.
(JAMA 241:2622-2624, 1979)
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Dissemination of new medical information to the practicing physician is a complex and often faulty process. To examine the magnitude of this problem, we surveyed primary care physicians to determine their knowledge of the results of the cooperative trial of photocoagulation in diabetic retinopathy. Despite the acknowledge relevance to their practice, only 28% (38/137) of family physicians and 46% (42/91) of internists were aware of the study results (P less than .001). Respondents were asked to manage two patient problems involving diabetic retinopathy. Only 33% (75/229) handled both correctly, although the retinopathy photocoagulation study had been published 18 months earlier. These findings indicate that results from clinical trials may not be disseminated to practicing physicians and, therefore, not incorporated into practice. Greater attention should be directed toward making findings from clinical trials available to practitioners.
A survey was run on a sample of 134 French GPs from the Rhône-Alpes region, in an attempt to investigate the way they recollect important clinical trials that should have an impact on their practice. It was found that 1) most of them did not remember these trials (however, the awareness score did vary throughout the trials); 2) the correlation between prescription claims and awareness score was very poor.
The randomized clinical trial (RCT) is the most powerful tool available to assess the effectiveness of a medical procedure. It complies with the fundamentals of scientific human experimentation and it is accepted, as such, by the researchers as the yardstick of medical progress. Therefore RCTs should have had a major impact on current medical practices through health policy makers and prescribers. Though they are limited in number and they have investigated few medical fields, studies on the impact of RCTs on medical practice have shown large and frequent discrepancies between scientific data made available from RCTs and current prescription practices in France, the United States, Finland, Holland, and elsewhere. Hence the above expectation is frustrated because doctors are not trained to weigh the evidence on treatment benefit-risk ratios, to read clinical research reports, or to select the appropriate information. In addition, the number of pending problems addressed by RCTs are too few, too slow to give the answers, inadequately sized, and their outcome measures are more often than not inappropriate. Doctors are reluctant to participate in clinical trials despite such participation being one of their duties. Governmental agencies barely fund clinical trials. Researchers do not formulate the right questions.
In the process of deciding whether to fund a clinical trial, the sponsor weighs the investment of dollars, effort, and time against the information the trial is likely to generate. Varying objectives are reflected in the trial design. For example, a new drug goes through several phases of development, from dose-response studies to large, randomized clinical trials. Industry-sponsored, large-scale trials are primarily designed to document an anticipated beneficial effect, while federal agencies or foundations may have a broader interest in determining whether an intervention effect is beneficial, indifferent, or even harmful. It is important to distinguish between these goals in any analysis of the impact of clinical trials on medical practice. Moreover, it should be recognized that clinical practice itself cannot be measured directly. Indirect measures such as number of patient visits by clinical diagnosis as well as drug prescriptions or sales can indicate the impact of clinical trials. Physician interviews can provide additional information in terms of knowledge, prescription habits, perceived effectiveness, and safety. However, this approach has drawbacks, including cost.
Professional Standards Review Organizations will presumably employ peer review committees to set standards. It is unclear whether such committees will rely more on the results of clinical trials or on the 'usual practice of the community'. For this study several techniques have been employed to assess the use by physicians in practice of therapies whose efficacy has been brought into question by clinical trials. The sales of oral hypoglycemic agents have continued to rise since 1970 in spite of the suggestion in the university group diabetes program studies that they cause increased deaths from cardiovascular disease. For 15 yr physicians continued to prescribe stilbestrol for roughly 50,000 pregnant women a year in spite of the fact that 6 reasonably well controlled studies in the early 1950's showed it to be totally ineffective. A review of hospital records reveals that strict bed rest continues to be prescribed for patients with acute viral hepatitis, and the Sippy and related bland diets for patients with peptic ulcer, in spite of the fact that all controlled trials conducted have shown both therapies to be worthless. It is suggested that physicians who wish to continue to employ therapies that have been found by peer review to be ineffective, or more toxic than efficacious, should be expected, as in the case of investigative procedures and drugs, to submit their plans to peer review and to obtain truly informed consent from their patients.
We conducted a statewide controlled trial of three methods to improve antibiotic prescribing in office practice: a mailed brochure, a drug educator visit, and a physician visit. Educational topics were three antibiotics contraindicated for office practice and oral cephalosporins. Medicaid prescribing data were used to select donors who needed education. The effect of the methods was evaluated by comparing the change in prescribing (the year before the intervention v the year after the intervention) for the doctors receiving education with the prescribing of comparable doctors chosen as controls. The mailed brochure had no detectable effect, and the drug educator had only a modest effect. The physician visits produced strong attributable reductions in prescribing of both drug classes. For the contraindicated antibiotics, the reductions were 18% in number of doctors prescribing, 44% in number of patients per doctor receiving these drugs, and 54% in number of prescriptions written per doctor. For the oral cephalosporins, both number of patients and number of prescriptions per doctor were reduced by 21%. Doctors responded equally well to recommendations designed to improve the quality of care and to reduce the cost of care.
Improving precision and economy in the prescribing of drugs is a goal whose importance has increased with the proliferation of new and potent agents and with growing economic pressures to contain health-care costs. We implemented an office-based physician education program to reduce the excessive use of three drug groups: cerebral and peripheral vasodilators, an oral cephalosporin, and propoxyphene. A four-state sample of 435 prescribers of these drugs was identified through Medicaid records and randomly assigned to one of three groups. Physicians who were offered personal educational visits by clinical pharmacists along with a series of mailed "unadvertisements" reduced their prescribing of the target drugs by 14 per cent as compared with controls (P = 0.0001). A comparable reduction in the number of dollars reimbursed for these drugs was also seen between the two groups, resulting in substantial cost savings. No such change was seen in physicians who received mailed print materials only. The effect persisted for at least nine months after the start of the intervention, and no significant increase in the use of expensive substitute drugs was found. Academically based "detailing" may represent a useful and cost-effective way to improve the quality of drug-therapy decisions and reduce unnecessary expenditures.
Large, multicenter clinical trials are expensive to design and to carry out. In spite of the magnitude of expenditures for such endeavors during the past two decades, little attention has been given to evaluating the impact of findings from these trials on those who are expected to benefit from them, i.e., future patients to whom trial findings apply. The implications of failure to demonstrate that results from these large medical experiments have been accepted by medical practitioners and policy makers and applied appropriately to patients must be of concern to all advocates and practitioners of controlled trials. Of the 20 evaluation studies reviewed in this paper, 6 were directed at assessing dollar benefits to the patient or to society. The remaining 14 studies were concerned primarily with physician knowledge and acceptance of trial findings. Investigators and sponsors of each large trial have a responsibility to develop an evaluation strategy during the planning phase of the trial, to publicize findings from the trial, to evaluate the impact of the findings on future patients, to act in response to the results of the evaluation, and to foster integration of findings into patient care policy.
The use of cimetidine in general practice was studied in relation to the guidelines approved by the Dutch National Drug Regulatory Agency (DRA). National and regional figures showed that the frequency with which cimetidine was prescribed in general practice was greater than could be explained on the basis of approved indications alone. Analysis of its employment in 14 hypothetical cases suggested however, that general practitioners in The Netherlands chose their indications for cimetidine and the duration of cimetidine treatment according to the guidelines for its use approved by the DRA; only 12.7% of the prescriptions related to indications that had not been approved in The Netherlands, the most prominent finding being the case of a possible gastric carcinoma. It was estimated that less than half of all cimetidine prescriptions in general practice will be issued for indications approved by the Dutch DRA. Some discrepancy exists with regard to the dose employed; contrary to the recommendations of the DRA, the dose chosen varied little from indication to indication.
This paper provides a review of available funding sources for clinical trials, with emphasis on trials funded via the National Institutes of Health. Data from the NIH Inventory of Clinical Trials are used to summarize the cost and key design characteristics of NIH trials. The paper concludes with a discussion of some of the factors which add to the cost of trials.
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