CERTs EducationProjects

P R O G R A M B R I E F

AHRQ’s mission is to improve the quality,safety, efficiency, and effectiveness of healthcare by:

• Using evidence to improve health care.

• Improving health care outcomes throughresearch.

• Transforming research into practice.

Background

The mission of the Centers forEducation and Research onTherapeutics (CERTs) is to conductresearch and provide education that willadvance the best use of therapeutics(drugs, medical devices, and biologicalproducts). The CERTs seek to increaseawareness of the benefits and risks ofnew, existing, and combined uses oftherapeutics, thereby improving theeffectiveness and safety of their use.

The program is administered as acooperative agreement by the Agencyfor Healthcare Research and Quality(AHRQ), in consultation with the U.S.Food and Drug Administration (FDA).The CERTs receive funds from bothpublic and private sources, with AHRQproviding core financial support. TheCERTs network currently comprises 11research centers (see box, next page), aCoordinating Center, a SteeringCommittee, and numerouspartnerships with public and privateorganizations. Collectively, the CERTshave more than 40 unique data sourcesand serve as a national resource ofexperienced researchers.

All CERTs seek to advance knowledge;inform health care providers, patients,and policymakers about thatknowledge; and improve aspects of thehealth care system related totherapeutics. Since the inception of theCERTs program in September 1999,the centers have developed a portfolioof over 200 completed and ongoingstudies with results that have addressedthe safe and effective use oftherapeutics. Many projects focus oneducation. Audiences include patients,providers, and policymakers. Thefollowing CERTs projects exemplifythese educational efforts.

Improving Clinician Training inTherapeutics

Curriculum in Clinical Pharmacology1,2

Each year, adverse drug events causenumerous injuries and a significantnumber of deaths. Educatingproviders, including medical studentsand residents, in clinical pharmacologycan help prevent adverse events byimproving understanding of how drugswork and how they should be used.The University of Arizona center

Advancing Excellence in Health Care • www.ahrq.govAgency for Healthcare Research and Quality

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conducted a survey of internal medicineclerkship and residency programsaround the country to assess theamount of time invested in clinicalpharmacology curriculum at theschools. Their survey found that whilemost institutions allotted time forclinical pharmacology training in theircurricula, there was a great desire foradditional training.

Based on this survey, the Arizona centerdeveloped a new core curriculum inclinical pharmacology for fourth-yearmedical students. The course wasconducted at Georgetown University.It addressed seven major objectivesrelated to medication prescribing,including evaluation of medications,identification of medications andalternative therapies used by patients,effective pain management, recognitionand reporting of adverse drug reactions,and recognition and treatment ofsubstance abuse and poisoning. Twohundred medical students participatedin the course each time it was offered.The course’s effect was measured usingmedical student ratings provided in amedical school graduationquestionnaire. According to studentratings, instruction improved in theareas of clinical pharmacology, painmanagement, and managed care whenthe course was offered. Currently, thereare plans to adapt the curriculum foruse in health education interventions.

Curriculum in Women’s Health

There is a lack of information abouttherapeutics used by women. Toaddress this information gap, theArizona center developed a curriculumfor therapeutics in women’s health. Thecurriculum addresses health andwellness as it pertains to women,diseases commonly found in women,and issues surrounding menstruation,pregnancy, lactation, and menopause.

The women’s health curriculum wasdesigned for pharmacy students and isavailable on the American Associationof Colleges of Pharmacy Web site,www.aacp.org.

Training Programs

Pharmacoepidemiology fellowship.Pharmacoepidemiology is the study ofthe effects of drugs in large numbers ofpeople. The University of Pennsylvaniacenter has developed an ongoingtraining program in clinicalpharmacoepidemiology to help healthpractitioners develop skills in this field.Thus far, 11 fellows have receivedpartial support provided by the CERTsfor training in pharmacoepidemiology.Most have earned master of science inclinical epidemiology degrees.Graduates of the fellowship programhave continued their work aspharmacoepidemiologists in variousacademic positions.

Clinical research fellowship. TheDuke University center conducts afellowship training program incardiovascular medicine. Inconjunction with the Duke ClinicalResearch Institute (DCRI), thecardiovascular fellowship programprovides a well-rounded program forfellows interested in clinical research.Fellows are recruited on an annualbasis. Between July 2004 and July2005, nine cardiovascular fellowsreceived clinical research training at theDCRI. For additional formal training,these fellows can enroll in the DukeUniversity master of science in clinicalresearch program. This trainingprovides cardiovascular fellows with thenecessary education to undertakecareers in clinical research related todiseases including heart failure, stroke,heart attack, atherosclerosis, and otherserious heart- and blood-vessel-relatedillnesses.

CERTs Research CentersUniversity of Texas MD AndersonCancer Center and Baylor College ofMedicine,* Houston, TXRisk and health communication; patient,consumer, and professional education;health decisionmaking and decisionsupport; therapeutic adherence

Duke University Medical Center, Durham, NCTherapies for disorders of the heart andblood vessels

HMO Research Network, Boston, MAUse, safety, and effectiveness studies oftherapeutics, using health plans that servedefined populations

Rutgers, The State University of NewJersey* New Brunswick, NJTherapies for mental health

University of Alabama at Birmingham,Birmingham, ALTherapies for musculoskeletal disorders

University of Arizona, Tucson, AZDetection and prevention of adverse druginteractions

University of Iowa,* Iowa City, IATherapies for older adults and the effectsof aging

University of North Carolina at ChapelHill, Chapel Hill, NCTherapies for children

University of Pennsylvania School ofMedicine, Philadelphia, PATherapies for infection; reduction inantibiotic resistance

Vanderbilt University Medical Center,Nashville, TNPrescription drug use in Medicaid andveteran populations

Weill Medical College of CornellUniversity,* New York, NYTherapeutic medical devices

*New center as of April 2006. This brief doesnot include work from the four new centers.

Courses on Antimicrobial-ResistantPathogens and Emerging InfectiousDiseases

Antibiotic-resistant bacterial infectionsand emerging infectious diseases aretwo complex issues in modern healthcare. As bacteria become resistant toantibiotics, previously treatableinfections can become life threateningand death from antimicrobial-resistantinfections may result. Additionally,emerging diseases can cause seriousillness. They are poorly understood andno standard treatments exist to combatthem.

In order to train clinicians and publichealth professionals in the managementof these serious health threats, theUniversity of Pennsylvania center, inconjunction with the Department ofHealth of the Commonwealth ofPennsylvania, taught courses onantimicrobial-resistant pathogens andemerging infectious diseases. Eightcourses were presented in 2005 at thesemiannual Pennsylvania Public HealthInstitute. The University ofPennsylvania center also posted thecurriculum materials to a secure Web-based management learning systemmaintained by the PennsylvaniaDepartment of Health so that they canbe used in training additional cliniciansand public health officials.

Community-associated methicillin-resistant Staphylococcus Aureus.Methicillin-resistant StaphylococcusAureus (MRSA), a form of antibiotic-resistant bacteria, can cause seriousinfections, typically in hospitals.Recently, a nonhospital community-associated MRSA (CA-MRSA) emergedthat can cause serious skin infections.Community-based prevention andtreatment of CA-MRSA have becomewidespread public health concerns.

To educate those who may encounterpeople with CA-MRSA infections, theUniversity of Pennsylvania centertaught two courses in 2005 that wereattended by 120 professionals,including sports medicine physicians,pediatricians, school nurses, publichealth officials, college and high schoolathletic directors, coaches, andcorrectional officers. The coursesdiscussed both sporadic cases andoutbreaks of CA-MRSA among prisoninmates, previously healthy children,and competitive sports participants.They also covered the treatment ofMRSA infections of the skin and softtissue. The fall 2005 course receivedcoverage by the television and printmedia in Pennsylvania.

Emerging infectious diseases. Bothunderstanding how various infectionsarise and staying abreast of emergingdiseases are critical to managingemerging diseases and antimicrobial-resistant infections. The University ofPennsylvania center, in conjunctionwith the Department of Health of theCommonwealth of Pennsylvania,conducted a course, “Modern Plagues,”at the Pennsylvania Public HealthInstitute. Fifty professionals, includingphysicians, community health nurses,and laboratorians, attended. Thecourse covered factors associated withthe emergence of infectious diseases,antimicrobial resistance of food-bornepathogens of animal origin, andhospital-associated antimicrobial-resistant infections. It also introducedfactors that can lead to the emergenceof a new disease and discussed theemergence of health-care-associatedantibiotic-resistant pathogens, especiallythose resistant to the fluoroquinoloneclass of antibiotics.

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Web-based course on antibioticresistance. The University of NorthCarolina center is developing a Web-based course about antibiotic resistancefor residents, house staff, and primarycare physicians. The course providesinformation about community-acquiredantibiotic resistance and antibiotic-resistant infections. It emphasizescommunity-acquired antibioticresistance in children.

Modifying Provider Behavior ToImprove Patient Care

Decision Support for PhysicianPrescribing

Poor prescribing practices are often acause of adverse drug events. Patientsmay receive prescriptions for productsthat interact with each other or that arenot appropriate because of risk factorssuch as age. The HMO ResearchNetwork center took advantage of anatural experiment and also designeddecision-support modules to testwhether custom, computerizedelectronic medical record (EMR) alertsreduced inappropriate use.

Diminished kidney function and otherphysiologic changes that come with agemay cause older people to responddifferently to medications. Thelessening of kidney function slows themetabolism of some drugs, leading topossibly harmful blood levels. Toreduce potentially harmful prescribing,a health plan created a drug-specificcomputerized alert for two drugs—tricyclic antidepressants and long-actingbenzodiazepines—which wasimplemented in 15 physician practices.The analysis of this natural experimentshowed that alerts to preventprescribing of the two drugs in theelderly were quite effective, resulting inan immediate 22-percent reduction inthe rate of use of the medications.

Subsequent work by the HMOResearch Network center createdcustom alerts that were patient specificto reduce clinician “alert burden.”Although the number of alerts wasreduced by about 75 percent, thedesired lower level of prescribing wasmaintained.

Another EMR alert interventionaddressed the coprescribing of theblood-thinning drug warfarin with anyof five classes of medications known tointeract with it. Before theintervention, almost one-third ofpatients on warfarin had a druginteraction event each month. Twelvemonths after implementation of thecomputerized alerts, these druginteractions had decreased by 14.9percent. Computerized decisionsupport may prove to be a useful toolfor physicians.

The intervention improved little withthe addition of face-to-face groupsessions (group detailing) withprescribers.

Vitamin D Supplementation3-5

Vitamin D is crucial for childhooddevelopment. A deficiency of vitaminD causes rickets, a serious conditionthat can cause skeletal abnormalitiesand failure to thrive. Vitamin Dsupplementation prevents rickets.Breastfed infants may requiresupplementation, as breast milk cancontain an inadequate amount ofvitamin D. In recent years, ricketscaused by vitamin D deficiency hasbeen on the rise in infants and toddlersin the United States. Despite thisincrease, a study conducted by theUniversity of North Carolina (UNC)center found that 44.5 percent ofphysicians did not recommend vitaminsfor any infants. Using the UNC center’swork as well as other research, theAmerican Academy of Pediatrics (AAP)

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developed new guidelines for physiciansin 2003 recommending vitamin Dsupplementation for all breastfedinfants. To assess the effect of theseguidelines on physician behavior,researchers at the UNC center sent asurvey to a nationwide sample ofmembers of the AAP and the AmericanAcademy of Family Physicians, withhalf of the sample receiving aninformation sheet outlining the newrecommendations. Forty-two percentof the recipients responded to thesurvey. The UNC team found thatpediatricians and, to a lesser extent,family practitioners who receivedinformation about the new guidelineswere more likely to beginrecommending vitamin Dsupplementation for all breastfedinfants. The UNC center concludedthat clear, useful, and targetedinformation can change providerbehavior.

Use of Antibiotics6

Antibiotics should be chosen withcaution. These drugs kill or damagebacteria but are ineffective against otherinfective agents, such as viruses. Inaddition, each antibiotic will kill onlycertain kinds of bacteria. If not usedproperly, antibiotics may causepersistent or progressive infection,emerging resistance to treatment, andincreased medical costs. In order toimprove the appropriate use ofantibiotics by physicians, the Universityof Pennsylvania center designed aprogram to restrict the use of certainantibiotics. The restrictions wereenacted to encourage physicians to useantibiotics that killed only the type ofbacteria causing the infection, were lessexpensive, and had the least number ofside effects. The program compared theeffectiveness of two groups in makingrecommendations for effective

antibiotic treatment regimens. Onegroup, the Antimicrobial ManagementTeam (AMT), consisted of a clinicalpharmacist and an infectious diseases(ID) physician; the other groupconsisted of fellows currently beingtrained in ID medicine. To comparethe performance of the two groups,researchers measured theappropriateness of recommendations,cure rate, number of treatment failures,and cost of care. The AMT showedsuperior performance to the ID fellowsin the measures of recommendationappropriateness (87 percent vs. 47percent), cure rate (64 percent vs. 42percent), and number of treatmentfailures (15 percent vs. 28 percent).

Quality Measures at Discharge forHeart Patients

The Vanderbilt center designed acomputerized provider order entry(CPOE) intervention tool to determineif the prescription of medications anddissemination of instructions forpatients with the common conditionsheart failure (HF) and heart attack (oracute myocardial infarction, AMI)could be improved. During patientdischarge, physicians receivedcomputerized alerts that providedinformation about drug prescribing andpatient counseling for HF and AMIpatients. Various outcomes weremeasured, including the use ofappropriate drugs, the provision ofsmoking cessation counseling forpatients who smoked, and the provisionof written discharge instructions for HFpatients. After implementation of theCPOE intervention, the percentage ofpatients receiving smoking cessationcounseling significantly increased forboth AMI patients (from 21 percent to62 percent) and HF patients (from 1percent to 43 percent). The number ofHF patients who received written

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instructions also increased significantly,from 3 percent before CPOE to 56percent after the intervention. Thestudy found that CPOE did notsignificantly change the already highrates of heart medication prescriptions.

Beta-Blockers for Patients With HeartFailure

The use of beta-blocker drugs by heartfailure patients improves survival andreduces hospitalization. However, theyare often not prescribed. The Dukecenter designed an educationalintervention targeting both physiciansand patients to increase beta-blockeruse. All medical practices participatingin the study received brochures toprovide to their HF patients. Allproviders received an information sheetabout the evidence for beta-blocker usein heart failure. A subset of thepractices received both brochures andvideo tapes for their HF patients. Thephysicians in this group were alsoinvited to participate in a live Webcastpresentation led by cardiology expertsabout HF management and beta-blocker use. Additionally, thesephysicians received information onwhich of their HF patients were or werenot taking beta-blockers. The studyfound that beta-blocker use increased inboth groups. The practices thatreceived the more intensive interventionhad a greater proportion of patientstaking beta-blockers, although thedifference was not statisticallysignificant.

Using the Internet as anEducational Medium7

Continuing Medical Education

The University of Alabama atBirmingham (UAB) center conducted asurvey of physicians to understand howthey use the Internet for professional

and educational purposes. UAB faxedthe survey to a random sample ofoffice-based physicians in all specialtiesnationwide and received 2,200responses.

Survey results indicated that physicianInternet use is widespread. Eightypercent of respondents said they use theInternet to find medical information.Additionally, physicians indicated theybelieve that the Internet is ofprofessional value to them. The factorscited by physicians as being mostimportant when seeking information onthe Internet include credibility of theinformation source, quick andimmediate access to information, andease of searching. Slightly less thanone-third of survey participantsreported that they used the Internetseveral times a year or more foraccessing continuing medical education(CME) activities. Factors deemedimportant to the physicians when usingan online CME course includeaccessibility, relevance, credibility, andease of use. Eighty-four percent ofrespondents anticipated increasedInternet use over the next year.

These results informed development ofan Internet-based educational resourceto prevent adverse effects associatedwith glucocorticoids. Glucocorticoids,including the drug prednisone, suppressthe immune system in diseases such asasthma, where the immune system maybe overactive. However, they may causeglucocorticoid-induced osteoporosis(GIOP), which can lead to fractures.

The UAB center conducted a study thatshowed the utilization of preventivetreatment for GIOP was less thanoptimal, with only 42 percent of at-riskpatients receiving proper care. A three-module Internet-based interventioncalled Challenging Cases inMusculoskeletal Medicine was designed

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to help physicians improve GIOPmanagement. It included personalizedpractice-based feedback, case-basedCME, and a quality improvementtoolbox with information aboutosteoporosis risk assessment, diagnosis,and treatment. Physicians wererecruited to use the intervention withmailings of three color brochures, sixfaxes, and four e-mails. Of the 153participants, 81 percent finished at leastone computer module and 45 percentvisited the Web site repeatedly andcompleted more than one module. Theinformation from the modules can beapplied by physicians in their practicesto better prevent and treat GIOP.

Harry Guess Research Community

Harry Guess, M.D., Ph.D., was thePrincipal Investigator of the Universityof North Carolina center from 2003until his death in January 2006. Hewas a pediatrician, a leader in the fieldof pharmacoepidemiology, and anoutstanding mentor, enthusiasticallyimparting knowledge to everyone fromgraduate students to senior scientistsand colleagues. The University ofNorth Carolina center has created theWeb site HarryGuess.unc.edu—theHarry Guess Research Community—asa tribute to his dedication to the idealsof learning. HarryGuess.unc.edu servesas a repository for educational materialsabout pharmacoepidemiology, pediatrictherapeutics, and patient-reportedoutcomes. The Web site acceptscontinuous additions of new tools andresources. All who share the vision ofHarry Guess are welcome to offereducational and research tools for freedissemination through the Web site.

Drug-Induced Arrhythmia

The QT interval is a measurement ofthe electrical activity of the heart thatcan be quantified using anelectrocardiogram. Various drugs can

lengthen the QT interval. This canlead to a dangerous and potentially fatalheart rhythm called torsades de pointes.To prevent this adverse event,physicians should measure the QTinterval before and during the use ofany medication that can prolong it.

The Duke center conducted a series ofsurveys of physicians in cardiovascularmedicine, internal medicine, andpsychiatry to assess their understandingof the QT interval and medications thatmay alter the QT interval. They foundthat, while most physicians reported theneed to measure the QT interval beforeand during the use of a QT-prolongingdrug, only 42 percent of respondentswere able to correctly measure the QTinterval. In addition, many physicianswere unable to correctly identify drugsand combinations of drugs that canlengthen the QT interval.

To educate physicians about the QTinterval, the Duke center designed anInternet module about both the QTinterval and QT-prolonging drugs. Themodule contains a didactic session andtwo case studies designed to improveunderstanding of the importance of theQT interval and its monitoring. It isaccessible through the Duke CERTsWeb site and the American HeartAssociation Web site.

The Arizona center also provides aWeb-based educational resource forproviders about the QT interval of theelectrocardiogram and drug-inducedarrhythmias. Drugs that prolong theQT interval have caused serious life-threatening arrhythmias and deaths.The use of these drugs is a major safetyconcern, and there are more than 30marketed drugs listed on the ArizonaWeb site. The Web site also containsarticles describing the QT interval, thesymptoms that arise from lengtheningof the QT interval, and how peopletaking QT-interval-lengthening drugs

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should be monitored. In addition, itcontains a comprehensive list of drugsthat can lengthen the QT intervaland/or cause torsades de pointes alongwith a printable drug list for patientsand health care providers.

Drug Interactions

The administration of interacting drugsis a common cause of adverse drugevents. In collaboration with the FDA,the Arizona center developed a Web-based educational module that focuseson drug interactions and how they canbe prevented. The module includes aPowerPoint presentation, written text toaccompany each slide in thepresentation, self-assessment questions,and a laminated pocket guide as a quickreference for how to prevent theprescription of drugs capable of causingadverse events due to interactions.

A related project is a virtual medicinecabinet showing various over-the-counter drugs. Visitors can click onvarious types of over-the-counter drugsto learn how they can interact withprescription drugs. In addition, theArizona center Web site has a DrugInteraction Advisory that lists links toarticles about various topics related todrug interactions.

Providing and DisseminatingInformation Resources

New Cardiovascular Information

The Duke center, in conjunction withthe American College of Cardiology(ACC) and the FDA, identified a needto provide health professionals with up-to-date information on cardiovasculardrugs and devices. To address thisneed, the ACC’s Cardiosource Web sitebegan including key recalls and alertson cardiovascular drugs and devices forits members. When necessary,cardiology experts comment on the

implications of such alerts. FDA’sCenter for Devices and RadiologicalHealth recently made another advancein this arena by launching a new,improved Web site to consolidate andcommunicate device safety informationfor health care professionals.

Issue Briefs

The University of Pennsylvania centerdevelops Issue Briefs in conjunction withthe University of Pennsylvania LeonardDavis Institute of Health Economics.Each four-page brief covers a singleissue and provides highlights ofacademic studies in a simple, easy-to-read format. Some past issues coveredby the Issue Briefs include tensions inantibiotic prescribing; adherence toHIV drug therapy; and antibiotics,acne, and upper respiratory tractinfections. These briefs conciselysummarize public policy and publichealth issues for a broad audience.

ADHD Toolkit

Attention-deficit/hyperactivity disorder(ADHD) can cause severe behavioralproblems in children. AlthoughADHD is not a new phenomenon, ithas become increasingly common, or atleast is more frequently diagnosed, inrecent years. The University of NorthCarolina center, in conjunction withthe American Academy of Pediatrics,has developed a toolkit that helps giveproviders a thorough understanding ofbest practices in the diagnosis andmanagement of ADHD. The toolkit,based on AAP guidelines, providesresources for diagnosis and treatment ofADHD. It can be found on the AAPWeb site at http://aap.org/healthtopics/adhd.cfm.

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Educating Patients

Beta-Blocker Use After a Heart Attack

Beta-blockers are often prescribed topatients after a heart attack to reducethe chances of having another heartattack and to improve survival.Although most patients take theirmedications shortly after leaving thehospital, they may stop taking themonce they begin to feel better. Thisincreases the risk of future heartproblems.

The HMO Research Network center, incollaboration with the Duke center,designed an education program forpatients to improve the long-termadherence to beta-blocker therapy. Thecenter identified a group of heart attackpatients from four HMOs and mailed acustomized information sheet to thepatients explaining the importance oftaking a beta-blocker long termfollowing a heart attack; a followupmailing reinforced the messages. Themailing also included a card for patientsto take to their physician that outlinedimportant questions to ask about beta-blockers. The study compared beta-blocker use after 1 year in the groupthat received the information and agroup that did not receive aneducational mailing. Specific findingsof this study will be known soon. It ispredicted that providing patients withinformation about beta-blocker therapywill increase the number of people whocontinue to take the drug.

Living With Arthritis

Arthritis is a common and debilitatingcondition. The joint pain and swellingthat accompany arthritis may limit aperson’s activities severely. The UABcenter developed a Web-basededucational module entitled “TakingCare of Yourself With Arthritis,” which

teaches arthritis patients to cope withthe illness. The module focuses on siximportant topics related to arthritiscare: getting needed care,communicating with the doctor, takingmedication properly, monitoringarthritis symptoms, self-care, anddealing with stress. Patients answer aseries of questions on each topic. Basedon the answers, they are given a seriesof tips containing specific advice aboutdealing with arthritis. By using thismodule, patients can become betterinformed and incorporate theknowledge into their daily lives,improving their quality of life.

Looking to the Future

The CERTs will continue to developmethods, tools, and resources dedicatedto education about the safety, efficacy,and use of therapeutics. The Universityof Arizona center is developing a“Webliography”—an annotated list ofrecommended Web sites that willprovide reliable drug information forpatients and caregivers. TheWebliography provides a table showingfeatures of various Web sites, links tothose Web sites, and printablebrochures and patient informationsheets describing the Web sites in bothEnglish and Spanish. The University ofPennsylvania center is designing acomputerized game based on “SpaceInvaders” that will teach children howand when antibiotics should be used.The Vanderbilt University center isimplementing a computerized supporttool for physicians to improve thegastrointestinal safety of NSAID(nonsteroidal anti-inflammatory drug)prescribing in Veterans Affairs (VA)facilities. Future educational projectsfrom the CERTs will be used topromote the optimal use of therapeuticsfor the improvement of health.

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For More Information

The CERTs welcome input about thetypes of research and education neededto better address costs, effectiveness,and safety issues related to the use oftherapeutics. More information on theCERTs program is available atwww.certs.hhs.gov.

References1. Rosebraugh CJ, Honig PK, Yasuda

SU, et al. Centers for Education andResearch on Therapeutics report:survey of medication errorseducation during undergraduate andgraduate medical education in theUnited States. Clin Pharmacol Ther2002 Jan; 71(1):4-10.

2. Flockhart DA, Yasuda SU, PezzulloJC, et al. Teaching rationalprescribing: a new clinicalpharmacology curriculum formedical schools. Naunyn-Schmeideberg’s Arch Pharmacol2002; 366:33-43.

3. Kreiter SR, Schwartz RP, KirkmanHN Jr., et al. Nutritional rickets inAfrican American breast-fed infants.J Pediatr 2000; 137:153-7.

4. Davenport ML, Uckun A, CalikogluAS. Physician patterns ofprescribing vitamin supplementationfor infants: do they contribute torickets? Pediatrics 2004;113(1):179-80.

5. Calikoglu AS, Davenport ML.Prophylactic vitamin Dsupplementation. Endocr Dev 2003;6:233-58.

6. Gross R, Morgan AS, Kinky DE, etal. Impact of a hospital-basedantimicrobial management programon clinical and economic outcomes.Clin Infect Dis 2001 Aug;33(3):289-95.

7. Casebeer L, Bennett N, Kristofco R,et al. Physician Internet medicalinformation seeking and on-linecontinuing education use patterns. JContin Educ Health Prof 2002Winter; 22(1):33-4.

CERTs Resources

Curriculum in Women’s Health (forproviders)www.aacp.org/site/page.asp?TRACKID=&VID=1&CID=879&DID=5620

Challenging Cases in MusculoskeletalMedicine: Online Educational Coursefor Providers (for providers)www.giop.certs.cme.uab.edu/

Harry Guess Educational Web Site(for providers, patients, public)http://HarryGuess.unc.edu/

Understanding the QT Interval (forproviders)http://qtmodule.mc.duke.edu/

Practical Approach to Long QTSyndrome and Torsades de Pointes(for providers)http://www.azcert.org/medical-pros/education/practical-approach.htm

Drugs That Prolong the QT Intervaland/or Induce Torsades de PointesVentricular Arrhythmia (forproviders, patients, public)www.azcert.org/medical-pros/drug-lists/drug-lists.htm

Over the Counter MedicationInteraction Medicine Cabinet (forpatients, public)http://www.azcert.org/consumers/MCsurvey/router.asp

Preventable Adverse Drug Reactions:A Focus on Drug Interactions (forproviders)http://www.azcert.org/medical-pros/education/module01.htm

Drug Interaction Advisory (forpatients, public)www.azcert.org/consumers/interaction-advisory.htm

ADHD Toolkit (for providers,parents, patients, public)www.aap.org/pubserv/adhdtoolkit

Beta Blockers For Heart Failure (forproviders, patients)http://dukecerts.dcri.duke.edu/resources/bb/index.html#bb_brochure

Taking Care of Yourself WithArthritis (for patients)www.arthritispatient.cme.uab.edu/

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www.ahrq.gov

AHRQ Pub. No. 06-P019September 2006