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Chien-Wen T, Phillips RL, Green LA, Fryer GE, Dovey SM. What physicians need to know about seniors and limited prescription benefits, and why. Am Fam Physician 2002; 66:212. [PMID: 12152958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
Abstract
More and more often, seniors are faced with outpatient prescription benefits that have annual spending limits, and they may be forced to cut back on use of medications when they run out of benefits before the end of the year. Family physicians can play a valuable role by helping seniors choose the best value medications for their budgets and by checking whether or not seniors can afford their prescriptions.
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Okkes IM, Polderman GO, Fryer GE, Yamada T, Bujak M, Oskam SK, Green LA, Lamberts H. The role of family practice in different health care systems: a comparison of reasons for encounter, diagnoses, and interventions in primary care populations in the Netherlands, Japan, Poland, and the United States. THE JOURNAL OF FAMILY PRACTICE 2002; 51:72-73. [PMID: 11927068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
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Green LA, Dovey S, Fryer GE. It takes a balanced health care system to get it right. THE JOURNAL OF FAMILY PRACTICE 2001; 50:1038-1039. [PMID: 11742604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
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Froom J, Culpepper L, Green LA, de Melker RA, Grob P, Heeren T, van Balen F. A cross-national study of acute otitis media: risk factors, severity, and treatment at initial visit. Report from the International Primary Care Network (IPCN) and the Ambulatory Sentinel Practice Network (ASPN). THE JOURNAL OF THE AMERICAN BOARD OF FAMILY PRACTICE 2001; 14:406-17. [PMID: 11757882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
BACKGROUND Treatment of acute otitis media (AOM) differs worldwide. The Dutch avoid antimicrobials unless fever and pain persist; the British use them for 5 to 7 days, and Americans use them for 10 days. If effects of therapies are to be compared, it is necessary to evaluate rates of risk factors, severity of attacks, and their influence on treatment decisions. We wanted to compare the prevalence of risk factors for AOM and evaluate their association with severity of attacks and of severity with antimicrobial treatment. METHODS We undertook a prospective cohort study of 2,165 patients with AOM enrolled by primary care physicians; 895 were enrolled from North America, 571 were enrolled from the United Kingdom, and 699 were enrolled from The Netherlands. The literature was searched using the key words "acute otitis media," "severity," and "international comparisons." RESULTS The prevalence of several AOM risk factors differs significantly among patients from the three country networks; these factors include race, parent smoking habits, previous episodes, previous episodes without a physician visit, tonsillectomy or adenoidectomy, frequency of upper respiratory tract infections, day care, and recumbent bottle-feeding. Dutch children have the most severe attacks as defined by fever, ear discharge, decreased hearing during the previous week, and moderate or severe ear pain. In country-adjusted univariate analyses, increasing age, exposure to tobacco smoke, day care, previous attacks of AOM, previous attacks without physician care, past prophylactic antimicrobials, ear tubes, adenoidectomy, and tonsillectomy all contribute to severity. Only country network, age, history of AOM, previous episode without physician care, and history of adenoidectomy and tympanostomy tubes are independently related to increased severity, while current breast-feeding is protective. Severity of attacks influences treatment decisions. Dutch children are least likely to receive antimicrobials, and even for severe attacks the British and Dutch physicians usually use amoxicillin or trimethoprim-sulfa; North American children with severe attacks are more likely to receive a broad-spectrum second-line antimicrobial. CONCLUSION Dutch children have the highest ratings in all severity measures, possibly reflecting parental decisions about care seeking for earaches. When comparing groups of patients with AOM, it is necessary to adjust for baseline characteristics. Severity of episode affects physician treatment decisions. Adoption of Dutch guidelines restricting use of antimicrobials for AOM in the United States could result in annual savings of about $185 million.
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Phillips RL, Green LA, Fryer GE, Dovey SM. Uncoordinated growth of the primary care work force. Am Fam Physician 2001; 64:1498. [PMID: 11730305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
Family physicians, nurse practitioners and physician assistants are distinctly different in their clinical training, yet they function interdependently. Together, they represent a significant portion of the primary care work force. Training capacity for these professions has increased rapidly over the physician assistant decade, but almost no collaborative work force planning has occurred.
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Chen FM, Feudtner C, Rhodes LA, Green LA. Role conflicts of physicians and their family members: rules but no rulebook. West J Med 2001; 175:236-9; discussion 240. [PMID: 11577049 PMCID: PMC1071568 DOI: 10.1136/ewjm.175.4.236] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To elucidate the difficulties physicians have when a family member becomes ill and to elicit their underlying causes. DESIGN Using a key informant technique, we solicited chairs of family medicine departments for their experiences with the health care provided to seriously ill family members. We then conducted in-depth, semistructured telephone interviews that were then transcribed, coded, and labeled for themes. SUBJECTS 8 senior family physicians whose parents had experienced a serious illness within the past 5 years. All of the subjects reflected on experiences stemming from their fathers' illness. RESULTS These physicians faced competing expectations: at an internal level, those of their ideal role in their family and their ideal professional identity; and at an external level, those originating from other family members and from other physicians. Reconciling these conflicting expectations was made more difficult by what they deemed to be suboptimal circumstances of the modern health care system. CONCLUSIONS Conflicting rules of appropriate conduct, compounded by the inadequacies of modern health care, make the role of physician-family member especially challenging. The medical profession needs a clearer, more trenchant understanding of this role.
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Chen FM, Rhodes LA, Green LA. Family physicians' personal experiences of their fathers' health care. THE JOURNAL OF FAMILY PRACTICE 2001; 50:762-766. [PMID: 11674908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
OBJECTIVES The American health care system is complicated and can be difficult to navigate. The physician who observes the care of a family member has a uniquely informed perspective on this system. We hoped to gain insight into some of the shortcomings of the health care system from the personal experiences of physician family members. STUDY DESIGN Using a key informant technique, we invited by E-mail any of the chairpersons of US academic departments of family medicine to describe their recent personal experiences with the health care system when their parent was seriously ill. In-depth semi-structured telephone interviews were conducted with each of the study participants. The interviews were transcribed, coded, and labeled for themes. POPULATION Eight family physicians responded to the E-mail, and each was interviewed. These physicians had been in practice for an average of 19 years, were nationally distributed, and included both men and women. Each discussed their father's experience. RESULTS All participants spoke of the importance of an advocate for their fathers who would coordinate medical care. These physicians witnessed various obstacles in their fathers's care, such as poor communication and fragmented care. As a result, many of them felt compelled to intervene in their fathers' care. The physicians expressed concern about the care their fathers received, believing that the system does not operate the way it should. CONCLUSIONS Even patients with a knowledgeable physician family member face challenges in receiving optimal medical care. Patients might receive better care if health care systems reinforced the role of an accountable attending physician, encouraged continuity of care, and emphasized the value of knowing the patient as a person.
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Fryer GE, Green LA, Vojir CP, Krugman RD, Miyoshi TJ, Stine C, Miller ME. Hispanic versus white, non-Hispanic physician medical practices in Colorado. J Health Care Poor Underserved 2001; 12:342-51. [PMID: 11475551 DOI: 10.1353/hpu.2010.0811] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The purpose of the study was to extend the scope of earlier research on minority physicians attending to the needs of the poor and their own ethnicity by contrasting practice characteristics of Hispanic doctors in Colorado with those of their white, non-Hispanic counterparts. It was found that Hispanic physicians spent more hours per week in direct patient care, were more likely to have a primary care specialty, and were less often specialty board certified than white, non-Hispanic doctors. Hispanic generalists established practices in areas in which the percentages of the population that were (1) below poverty level, (2) Hispanic, (3) Hispanic and below poverty level, and (4) white, non-Hispanic, and below poverty level were greater than in areas in which white, non-Hispanic primary care physicians practiced. These findings argue for special provision to admit ethnic minorities to undergraduate and graduate medical education programs.
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Zamorski MA, Green LA. NHBPEP report on high blood pressure in pregnancy: a summary for family physicians. Am Fam Physician 2001; 64:263-70, 216. [PMID: 11476271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2023]
Abstract
The National High Blood Pressure Education Program's Working Group on High Blood Pressure in Pregnancy recently issued a report implicating hypertension as a complication in 6 to 8 percent of pregnancies. Hypertension in pregnancy is related to one of four conditions: (1) chronic hypertension that predates pregnancy; (2) preeclampsia-eclampsia, a serious, systemic syndrome of elevated blood pressure, proteinuria and other findings; (3) chronic hypertension with superimposed preeclampsia; and (4) gestational hypertension, or nonproteinuric hypertension of pregnancy. Edema is no longer a criterion for preeclampsia, and the definition of blood pressure elevation is 140/90 mm Hg or higher. Patients with gestational hypertension have previously unrecognized chronic hypertension, emerging preeclampsia or transient hypertension of pregnancy, an obstetrically benign condition. Because distinguishing among these conditions can be done only in retrospect, clinical management of gestational hypertension consists of repeated evaluations to look for signs of emerging preeclampsia. Women with chronic hypertension should be followed for evidence of fetal growth restriction or superimposed preeclampsia. Management options for chronic hypertension in most women include discontinuing antihypertensive medications during pregnancy, switching to methyldopa or continuing previous antihypertensive therapy.
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Green LA. High blood pressure in pregnancy. Am Fam Physician 2001; 64:225, 228. [PMID: 11476270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2023]
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Green LA. Setting the bar for accepting positive findings. THE JOURNAL OF FAMILY PRACTICE 2001; 50:471-474. [PMID: 11350717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
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Fryer GE, Green LA, Dovey S, Phillips RL. Direct graduate medical education payments to teaching hospitals by Medicare: unexplained variation and public policy contradictions. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2001; 76:439-445. [PMID: 11346521 DOI: 10.1097/00001888-200105000-00015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
PURPOSE To comprehensively examine both inter- and intrastate variations in Medicare's cost-rate structure for teaching hospitals and to assess the Medicare payment system for graduate medical education (GME), as presently configured, as an instrument to promote physician workforce reform, specifically sufficient public access to primary care physician services. METHOD Using Public Use Files of hospital cost reports from the Health Care Financing Administration for fiscal year 1997, 648 hospitals that met inclusion criteria for moderate GME volume were identified. The average and range of direct costs of resident training were computed for these teaching hospitals to illustrate differences within and between the 45 states that had at least two teaching hospitals that qualified for comparison. The cost rate upon which direct medical education (DME) payments are based was then correlated with the percentage of a state's counties that were wholly designated primary care health personnel shortage areas (PCHPSAs) in 1997 and with its primary care physician-to-population ratio, as determined from the Area Resource FILE: RESULTS Variations in inter- and intrastate DME costs exist. In some states, the range in DME rates substantially exceeded the mean cost. DME funding policies are more generous toward teaching hospitals in states with greater primary care physician-to-population ratios and smaller proportions of counties wholly designated PCHPSAS: CONCLUSION Inherent inequities in DME funding seriously undermine the current Medicare GME payment system's capacity to contribute to U.S. physician workforce reform and to improve access to care. There is actually a financial incentive to train residents in areas in which there is relatively less need for their services.
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Fryer GE, Green LA, Dovey SM, Phillips RI. The United States relies on family physicians unlike any other specialty. Am Fam Physician 2001; 63:1669. [PMID: 11352277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2023]
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Green LA. The view from 2020: how family practice failed. Fam Med 2001; 33:320-4. [PMID: 11322525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
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Green LA, Dovey SM. Practice based primary care research networks. They work and are ready for full development and support. BMJ (CLINICAL RESEARCH ED.) 2001; 322:567-8. [PMID: 11238139 PMCID: PMC1119774 DOI: 10.1136/bmj.322.7286.567] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Green LA, Culpepper L, de Melker RA, Froom J, van Balen F, Grob P, Heeren T. Tympanometry interpretation by primary care physicians. A report from the International Primary Care Network (IPCN) and the Ambulatory Sentinel Practice Network (ASPN). THE JOURNAL OF FAMILY PRACTICE 2000; 49:932-936. [PMID: 11052167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
BACKGROUND The accuracy of data gathered by primary care clinicians in practice-based research networks (PBRNs) has been questioned. Tympanometry, recently recommended as a means of improving accuracy of diagnosing acute otitis media, was included as an objective diagnostic measure in an international PBRN study. We report the level of agreement of interpretations of tympanograms between primary care physicians in PBRNs and experts. METHODS Primary care physicians in PBRNs in the Netherlands, United Kingdom, United States, and Canada enrolled 1773 children aged 6 to 180 months who contributed 6358 tympanograms during 3179 visits. The physicians were trained in the use and interpretation of tympanometry using the Modified Jerger Classification. We determined the level of agreement between physicians and experts for interpretation of tympanograms. One comparison used the 6358 individual ear tracings. A second comparison used the 3179 office visits by children as the unit of analysis. RESULTS The distribution of expert interpretation of all tympanograms was: 35.8% A, 30% B, 15.5% C1, 12% C2, and 6.8% uninterpretable; for visits, 37.8% were normal (A or C1), 55.6% abnormal (B or C2), and 6.6% could not be classified. There was a high degree of agreement in the interpretation of tympanograms between experts and primary care physicians across networks (kappa=0.70-0.77), age groups of children (kappa=0.69-0.73), and types of visits (kappa=0.66-0.77). This high degree of agreement was also found when children were used as a unit of analysis. CONCLUSIONS Interpretations of tympanograms by primary care physicians using the Modified Jerger Classification can be used with confidence. These results provide further evidence that practicing primary care physicians can provide high-quality data for research purposes.
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Dickinson WP, Stange KC, Ebell MH, Ewigman BG, Green LA. Involving all family physicians and family medicine faculty members in the use and generation of new knowledge. Fam Med 2000; 32:480-90. [PMID: 10916715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
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Green LA. Putting practice into research: a 20-year perspective. Fam Med 2000; 32:396-7. [PMID: 10879320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
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Wyszewianski L, Green LA. Strategies for changing clinicians' practice patterns. A new perspective. THE JOURNAL OF FAMILY PRACTICE 2000; 49:461-464. [PMID: 10836780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
How can we persuade clinicians to adopt proven practices? Education, incentives, feedback, social marketing, and various other change strategies have inconsistent and unpredictable effects. We propose a theoretical framework that can provide a reliable basis for selecting effective change strategies. We divide clinicians into 4 categories on the basis of their responses to new information about the effectiveness of clinical strategies. We similarly divide the universe of practice change strategies into knowledge-oriented and behavior-oriented methods. We then show why specific combinations of these strategies are likely to be consistently effective for each of the 4 categories of clinicians.
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Herschman HR, MacLaren DC, Iyer M, Namavari M, Bobinski K, Green LA, Wu L, Berk AJ, Toyokuni T, Barrio JR, Cherry SR, Phelps ME, Sandgren EP, Gambhir SS. Seeing is believing: non-invasive, quantitative and repetitive imaging of reporter gene expression in living animals, using positron emission tomography. J Neurosci Res 2000; 59:699-705. [PMID: 10700006 DOI: 10.1002/(sici)1097-4547(20000315)59:6<699::aid-jnr1>3.0.co;2-1] [Citation(s) in RCA: 76] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The ability to monitor reporter gene expression in living animals and in patients will permit longitudinal examinations both of somatically transferred DNA in experimental animals and patients and of transgenic constructs expressed in experimental animals. If investigators can non-invasively monitor the organ and tissue specificity, the magnitude and the duration of gene expression from somatically transferred DNA and from transgenes, conceptually new experimental paradigms will be possible. If clinicians can non-invasively monitor the location, extent and duration of somatically transferred genes, they will be better able to determine the correlations between expression of therapeutic genes and clinical outcomes. We have developed two reporter gene systems for in vivo reporter gene imaging in which the protein products of the reporter genes sequester positron-emitting reporter probes. The "PET reporter gene" dependent sequestration of the "PET reporter probes" is subsequently measured in living animals by Positron Emission Tomography (PET). We describe here the principles of PET reporter gene/PET reporter probe in vivo imaging, the development of two imaging systems, and the validation of their ability to non-invasively, quantitatively and repetitively image reporter gene expression in murine viral gene transfer and transgenic models.
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Mold JW, Green LA. Primary care research: revisiting its definition and rationale. THE JOURNAL OF FAMILY PRACTICE 2000; 49:206-208. [PMID: 10735478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
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Green LA, Fryer GE. The development and goals of the AAFP center for policy studies in family practice and primary care. American Academy of Family Physicians. THE JOURNAL OF FAMILY PRACTICE 1999; 48:905-908. [PMID: 10907629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
In this article we describe the creation and role of the Center for Policy Studies in Family Practice and Primary Care established by the American Academy of Family Physicians in Washington, DC, this year. We recount the events leading to the decision to implement the Center, list its guiding assumptions, and explain its initial structure and function. We also identify the 3 themes that will guide the early work of the Center: sustaining the functional domain of family practice and primary care; investing in key infrastructures; and securing universal health coverage.
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Crawford MH, Bernstein SJ, Deedwania PC, DiMarco JP, Ferrick KJ, Garson A, Green LA, Greene HL, Silka MJ, Stone PH, Tracy CM, Gibbons RJ, Alpert JS, Eagle KA, Gardner TJ, Gregoratos G, Russell RO, Ryan TH, Smith SC. ACC/AHA Guidelines for Ambulatory Electrocardiography. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the Guidelines for Ambulatory Electrocardiography). Developed in collaboration with the North American Society for Pacing and Electrophysiology. J Am Coll Cardiol 1999; 34:912-48. [PMID: 10483977 DOI: 10.1016/s0735-1097(99)00354-x] [Citation(s) in RCA: 189] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Crawford MH, Bernstein SJ, Deedwania PC, DiMarco JP, Ferrick KJ, Garson A, Green LA, Greene HL, Silka MJ, Stone PH, Tracy CM, Gibbons RJ, Alpert JS, Eagle KA, Gardner TJ, Gregoratos G, Russell RO, Ryan TJ, Smith SC. ACC/AHA guidelines for ambulatory electrocardiography: executive summary and recommendations. A report of the American College of Cardiology/American Heart Association task force on practice guidelines (committee to revise the guidelines for ambulatory electrocardiography). Circulation 1999; 100:886-93. [PMID: 10458728 DOI: 10.1161/01.cir.100.8.886] [Citation(s) in RCA: 124] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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