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Self-Study from Web-Based and Printed Guideline Materials: A Randomized, Controlled Trial among Resident Physicians

Douglas S. Bell, MD; Gregg C. Fonarow, MD; Ron D. Hays, PhD; and Carol M. Mangione, MD, MSPH
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From University of California, Los Angeles, School of Medicine, Los Angeles, California.

Presented in part at the Society for General Internal Medicine Annual Meeting, 30 April–1 May 1999, San Francisco, California.

Acknowledgments: The authors thank the SAGE trial participants and the following chief residents, program directors, and administrators who were instrumental in their residents' participation: David Graham, MD, Oregon Health Sciences University, Portland, Oregon; Jodi Friedman, MD, and Roland Sakiyama, MD, University of California, Los Angeles, Los Angeles, California; Harry Hollander, MD, and Jill Thomas, University of California, San Francisco, San Francisco, California; Stephanie Silas, MD, H. James Williams, MD, Ita M. Killeen, MD, and Judi Weston, University of Utah, Salt Lake City, Utah. They also thank LuAnn Wilkerson, PhD, Anju Relan, PhD, and Martin Shapiro, MD, PhD, for insightful critical review of the instructional design and the trial design.

Grant Support: In part by a National Research Service Award (T32 PE19001-09) from the Health Resources and Services Administration of the U.S. Department of Health and Human Services. Additional project support was provided by the University of California, Los Angeles, Stein–Oppenheimer Fund and by the GTE Foundation through the University of California, Los Angeles, Center for Digital Innovation. Dr. Mangione was partially supported by the Robert Wood Johnson Foundation as a Generalist Faculty Scholar (award no. 029250).

Requests for Single Reprints: Douglas S. Bell, MD, University of California, Los Angeles, Division of General Internal Medicine and Health Services Research, 911 Broxton Plaza, Room 218, Los Angeles, CA 90095-1736; e-mail, sagequery@gim.med.ucla.edu.

Requests To Purchase Bulk Reprints (minimum, 100 copies): the Reprints Coordinator; phone, 215-351-2657; e-mail, reprints@mail.acponline.org.

Current Author Addresses: Drs. Bell, Hays, and Mangione: Department of Medicine, Division of General Internal Medicine and Health Services Research, University of California, Los Angeles, 911 Broxton Plaza, Los Angeles, CA 90095-1736.

Dr. Fonarow: Department of Medicine, Division of Cardiology, University of California, Los Angeles, CHS 67-130A, Los Angeles, CA 90095-1679.

Author Contributions: Conception and design: D.S. Bell, G.C. Fonarow, R.D. Hays, C.M. Mangione.

Analysis and interpretation of the data: D.S. Bell, G.C. Fonarow, R.D. Hays, C.M. Mangione.

Drafting of the article: D.S. Bell, G.C. Fonarow, R.D. Hays, C.M. Mangione.

Critical revision of the article for important intellectual content: D.S. Bell, G.C. Fonarow, R.D. Hays, C.M. Mangione.

Final approval of the article: D.S. Bell, G.C. Fonarow, R.D. Hays, C.M. Mangione.

Provision of study materials or patients: D.S. Bell, G.C. Fonarow, C.M. Mangione.

Statistical expertise: D.S. Bell, R.D. Hays, C.M. Mangione.

Obtaining of funding: D.S. Bell, C.M. Mangione.

Administrative, technical, or logistic support: D.S. Bell, C.M. Mangione.

Collection and assembly of data: D.S. Bell.

Ann Intern Med. 2000;132(12):938-946. doi:10.7326/0003-4819-132-12-200006200-00003
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Many primary care physicians have not learned about key advances in caring for patients after acute myocardial infarction, including the use of β-blockers (1) and angiotensin-converting enzyme inhibitors (2). Although professional organizations have disseminated guidelines for the care of acute myocardial infarction (34), important therapies continue to be underused (5). Physicians read guidelines to stay up-to-date (6), but reading without additional interaction is relatively ineffective for learning (7) and has little effect on practice (8). Physicians therefore need better methods for learning from guidelines. Self-assessment tests are often used to enhance self-study of printed materials (910), but physicians can now choose from a growing number of World Wide Web sites that offer on-line self-study (11).

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Grahic Jump Location
Figure 1.
The SAGE (Self-Study Acceleration with Graphic Evidence) randomized trial viewer.

When guidelines refer to landmark clinical trials, users can select an “evidence link” to open the randomized trial viewer, displaying a standard graphic view of the trial's results in terms of absolute risks and relative risks. If the trial reported subgroup results for an outcome, a “Subgroups” pop-up menu is shown below the outcome label. Selecting a subgroup variable, such as “Age,” starts an animation sequence in which the absolute risk bar for each treatment splits into a separate risk bar for each subgroup. The bars then rearrange, ending with adjacent treatment and control bars and new relative risk estimates for each subgroup. ACE = angiotensin-converting enzyme; tid = three times per day.

Grahic Jump Location
Grahic Jump Location
Figure 2.
Flow of participants.

SAGE = Self-Study Acceleration with Graphic Evidence.

Grahic Jump Location




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Summary for Patients

Doctors' Experience in Learning from Web-Based Compared with Print-Based Materials

The summary below is from the full report titled “Self-Study from Web-Based and Printed Guideline Materials. A Randomized, Controlled Trial among Resident Physicians.” It is in the 20 June 2000 issue of Annals of Internal Medicine (volume 132, pages 938-946). The authors are D.S. Bell, G.C. Fonarow, R.D. Hays, and C.M. Mangione.


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