Chapter 3. Findings (continued)

3.2. Portfolio Outputs and Dissemination

The CERTs program strives to increase awareness of the risks and appropriate uses of therapeutics. It values making available CERT information to relevant audiences.²⁰ The understanding of the process of diffusion of research into practice is a complex process.²¹ Awareness is "when potential users learn about the products, tools, or findings and gain some understanding about how they work."²² As described by Rogers, diffusion is "a passive process by which an innovation is communicated through channels over time in a social system²³ and "dissemination involves a more active, tailored process of communication, with a goal of persuading users to adopt the innovation."⁴⁰ In this section we begin with a description of Portfolio research outputs and conclude with an overview of Portfolio dissemination initiatives.

3.2.1. Research Outputs

The research outputs of the Portfolio include publications, presentations, conferences, workshops, proceedings, committee roles, and testimony to federal agencies.²⁴ Descriptive statistics describing such outputs of the CERTs and individual grants are provided below, and some additional outputs are also described (e.g. registries).

CERTs Publications

The CERTs program had 383 publications. The breakdown of the publications by individual CERT was: Vanderbilt (177); Penn (55); UNC (55); HMO Research Network (41); UAB (24); Duke (19); and Arizona (12). Of the seven CERTs Vanderbilt University had the most (177) publications, while Arizona had the fewest (12) publications. The number of publications produced by four of the seven CERTs rose during the period 2002 through 2005: HMO Research Network, UAB, Penn, and Vanderbilt. Of these the HMO Research Network displayed the most marked increase, rising from five publications in 2002 to nineteen in 2005. The Vanderbilt University CERT also saw a substantial increase in publications, rising from thirty-nine publications in 2002 to fifty-three publications in 2005. The UNC CERT publication volume rose from thirteen publications in 2002 to fifteen publications in 2005. Two CERTs had fewer publications over the four-year period. The Duke University CERT displayed a marked decrease in its number of publications between 2002 and 2005, with its publications dropping from five in 2002 to three in 2005 after rising to seven in 2003. The Arizona CERT saw a small decrease in its number of publications, dropping from four publications in 2002 to three publications in 2005 (Exhibit 6).

Publication counts represent only one measure of CERT output. Several factors likely impact the quantity of publications a CERT produced over the study period. For example, the first four CERTs that were funded (Duke, UNC, Vanderbilt, and Arizona) have had more time to develop a critical mass of research, data, and investigators. Additionally the nature of a CERTs specialty seems to impact the quantity of publications as well. For example, the Arizona CERT appears to have focused on education and the creation of an inter-disciplinary team, which may explain the smaller number of publications compared to other CERTs. The research foci of the CERTs may also influence publication counts, with some types of studies taking longer to complete and submit to journals than others. The number of investigators at each CERT may correlate with the quantity of publications, however that information was not consistently available from the individual CERTs.

As expected at primarily academic research institutions, the majority of the publications produced by each CERT were journal articles. Of the seven CERTs, the Vanderbilt, Penn, UAB, UNC, Arizona, and Duke CERTs publication lists were comprised entirely of journal articles. The UNC CERT publications were the most heterogeneous, with a publication list comprised of journal articles, abstracts, and book chapters (and items coded "other").²⁵

Of the seven CERTs, the Vanderbilt University CERT published the greatest number (177) of articles, and 55 (31%) of these appeared in high impact journals. The HMO Research Network published the greatest percentage of its journal articles in high impact journals. 40% of thirty-five articles were coded as high impact. The remaining high impact percentage totals are as follows: Vanderbilt (31%); Penn (18%); UNC (9 %); UAB (29%); Arizona (17%); HMO Research Network (40%); and Duke (32%). Exhibit 7 shows the number of publications for each CERT by publication type — journal article, high impact journal article, book chapter, and abstract.

CERTs Projects

The CERTs Coordinating Center maintains a database of the projects and publications of the CERTs program and individual centers. An entry in the database is defined as a project if it is a "core" CERTs project, i.e. funded at least in part by an AHRQ CERTs grant or supported at least in part by the administrative core funded by an AHRQ CERTs grant.²⁶ As of January 2006, the CERTs had 288 projects consisting of completed (127), ongoing (137), proposed (21), and discontinued (3) projects. Exhibit 8 shows the distribution across the CERTs of the 264 completed and ongoing projects.

Exhibit 8: Total Projects by CERT

CERT	Total	Percent
Coordinating Center	4	1.5%
Duke University Medical Center	43	16.3%
HMO Research Network	32	12.1%
University of Alabama at Birmingham	27	10.2%
University of Arizona Health Sciences Center	20	7.6%
University of North Carolina at Chapel Hill	28	10.6%
University of Pennsylvania School of Medicine	78	29.5%
Vanderbilt University Medical Center	32	12.1%
Total	264	100.0%

Of the projects that were ongoing or completed, the Penn CERT had the most projects and the Arizona CERT had the fewest. The mean number of projects per research center was 37. The individual CERTs varied in terms of what constituted a project. One of Arizona's projects, the QT registry, already had 12 publications from it—in contrast to other CERTs which typically had only 1 publication per project. Some CERTs had multiple projects that were subsumed under a project number in the CC database of projects. Additionally, labeling a project "complete" was at the discretion of the individual CERT. The database did not include dates so all completed and ongoing projects were included. Therefore, the differences in definitions across the individual CERTs make interpreting the apparent variability in projects difficult to assess. In addition, the project database does not attribute a date to each project.

Coordinating Center staff indicated: "Generally projects are considered complete when the analysis is done and the results are presented and manuscripts written/ published." The CERTs indicated that "the project status categorization recognizes the variability of projects, e.g. education projects, multi-component research projects, evolving research projects."

The CERTs Coordinating Center publication database included the project number with which the publication is associated. Of the 235 publications, 230 had CERT project numbers attributed to them. The range of publications per CERT project was from 0 to 12. Of the ones that had publications associated, some had more than one publication attributed to the project. The 230 publications are attributed to 134 projects, with an average of 1.71 publications per project.²⁷

CERTs Presentations

CERTs investigators made presentations for various purposes, including dissemination of findings, educational purposes, and policy or regulatory purposes. From 2002 through 2005 the CERTs program as a whole made 206 presentations at professional meetings, clinical conferences, research conferences, hospital grand rounds, government advisory board meetings, invited professorships, academic medical centers, among other venues. Within this list of presentations was the John M. Eisenberg Memorial Lectureship on Therapeutics Research, presented at academic medical centers across the United States. The average number of presentations per year was 51.5. The trend in the number of presentations over the evaluation period (2002-2005) was upward the first three years, then more than halved from 2004 (64) to 2005 (28). Exhibit 9 displays this trend.

The HMO Research Network and the Vanderbilt CERT conduct research that leverages their clinical databases. These centers can focus on numerous topics and therapeutic areas as a result. In contrast, the UAB and Duke CERT focus on clinical areas, musculoskeletal disorder therapies and cardiovascular therapies respectively, so the scope of their research is more varied and includes intervention studies and education outside their centers. UNC focuses on research on therapeutics in the pediatric population and Arizona focuses on therapeutics drug events relating to women.

Grant Outputs

The Portfolio grants for the period 1999–2005 examined antibiotic prescribing, use, and resistance (4); adherence (1), drug cost sharing (1), quality indicators (1), prescribing (1); formularies (1); and medication errors (1). Of the 12 non-CERT grants (center awards and key projects—risk series and prescribing safety were excluded from this analysis because they are counted in the CERTs publications), only four were completed by the time period covered by this evaluation. One of the four grants was for a conference with two products—one on the conference proceedings and the other a psychotropic drug fact sheet. Another grantee had not fully completed the analysis and findings of the grant so had not published, although he self-reported two or more presentations at professional meetings. A third grantee reported an intervention study that the investigator reported presenting at one professional meeting. He also had submitted for publication and was rejected, and was revising for resubmission to another journal. He noted: "This is the kind of material that doesn't lead to journal articles. These are dissemination strategies that occur in a non-academic setting." The grantee is referring to how interventions like a media campaign or educational intervention employed in a specific metropolitan area are not seen as generalizable and are therefore less likely to be accepted for publication in traditional journals. These studies may better reach the appropriate audience through dissemination efforts like a newsletter. The fourth grantee had published in six peer-reviewed journals, presented five abstracts and reported preparing two additional manuscripts for publication. The differences in the publications were related to the type of grant funded and the type of research. Conference grants, for example, would not be expected to result in as many publications as a research award. Additionally, a randomized trial might generate more publications than a non-randomized study due to greater interest.

3.2.2. Dissemination

The CERTs have employ numerous dissemination activities including the use of traditional academic vehicles of presenting at professional meetings and publishing in scholarly journals. CERTs maintain Web sites that are one means of potentially increasing awareness of CERTs findings. All but Vanderbilt maintain a Web site that is linked to the CERTs Web site. The CERTs, particularly in their progress reports to AHRQ, provided measures that illustrate the extent to which they are distributing materials:

• "Abbreviated versions of the table are published in Harriet Lane's Pediatric Manual and the Washington Manual, two of the most popular pocket manuals for interns and residents... 50,000 laminated copies have been requested." (AZ PR01-02).
• Draft toolkit for diagnosing and treating ADHD. Made available to 1000 pediatricians. After evaluating components, put toolkit into final form and available to all 55,000 American Academy of Pediatrics members in fall 2002. Disseminated at the National Initiative for Children's Healthcare Quality national summit (UNC PR 01-02).
• "Over the last 12 months, we have received over 94,000 contacts to our Web site and approximately 3 to 5 requests weekly from pharmacists, physicians, nurses, students, and the public for information about the cardiac safety of particular drugs" (AZ PR 04-05).

CERTs have employed other dissemination channels to tailor their efforts toward their audience. For example, the Penn CERT is associated with an institute that creates issue briefs on important research topics and provides them to different stakeholders, including policymakers. One progress report describes how and the extents to which these issue briefs are distributed.

• In conjunction with the Leonard Davis Institute of Health Economics, issue briefs have been sent to a mailing list of more than 4,000 people (Penn PR 02-03).
• Literature review completed of interventions to improve medication use in HMOs. "Access database has been created to house abstracts and full bibliographic references" (HMO PR 01-02).

Some CERTs research has attracted media attention and additional Internet sources. For example, a Penn investigator explained that, after a report was published, it was, "disseminated in a dozen or so articles worldwide via the newspaper, radio (NPR), evening news, and by many Web-based news organizations" There were other examples within the CERTs where the research was picked up by the media. One stated that this was positive because "the message goes out farther and more widely."

The Coordinating Center has developed a system that "will combine improvements of existing systems and that will provide additional tools to replace what is now being done manually. The system will track projects, publications and other products, contacts, and partners, and it will provide a vehicle to automate what has been a manual process. A Coordinating Center member further described this CERTs Information Tracking (CIT) system.

Duke is developing a computer-based dissemination support system. There are formal processes, and in between those formal processes they get updates. What they are hoping to do with this) project is to have connected with this database all information about partnerships and products that anyone can add to and take information out of. For instance, AHRQ could pull out a search on Diabetes. A part of moving towards this system is refining how data are collected because current variability. They hope the system will be applicable beyond the CERTs to external parties on a case-by-case basis.

Dissemination efforts to consumers are particularly difficult. One CERT described a first step to achieve this, "translate the research into tools that can really make a difference out in the world where patients live and providers practice." As the director of education at a CERT stated, "the work I do is revolves around finding the best way to disseminate information on prescription drug safety." Additionally, a staff member at the Coordinating Center focuses on the dissemination of CERTs work and efforts. A special effort that expands the dissemination of CERTs research "government day," which a Steering Committee member described:

It is quite unusual for a federally funded independent program of research centers to undertake an environmental scan to try to move the field forward, but that's what we do..., one of our government agency members said, "well, that's nice but if you're coming to Washington you ought to brief our government, our power agency." This was our FDA representative... and that then created a second major conclave where all of the PIs and the Steering Committee got together with leadership from NIH, VA, AHRQ, FDA, and others to create "government day."

CERTs respondents identified dissemination as a key mission of the CERTs; they therefore identified dissemination as a key aspect of some of their projects or the component of the project that was financially supported by their CERT. A recent publication on the use of ACE inhibitors in pregnant women was anticipated to have a big impact and the investigator described the support he received from AHRQ and the CERTs regarding dissemination:

I presented that at a steering committee meeting last year and got good feedback on dissemination efforts.... AHRQ staff through CERTs really helped to facilitate a lot of our dissemination efforts... helping to... shape our message to allow consumers to understand a little bit about what the potential implications might be for them... We ended up with a theme message. Whenever the reporter would ask "what do you want people to understand?" the answer would be "A woman who is on blood pressure medicine should talk to her doctor about the medicine she's on and come up with another medicine that she might use." It was really helpful to have the AHRQ staffers and press office give us input.

The grantee respondents also described their dissemination efforts. It was evident that dissemination was a key focus of their efforts:

We're up to six papers published and two others submitted and some of those were papers we planned, and some of those were papers that these findings encouraged us to write….we wrote a piece for the member newsletter that went to approximately 800,000 enrollees. ... there was already a lot of lay press about antibiotic resistance, and there were fewer requests for our materials than we had expected…. AHRQ was very good about publicizing these important results.... AHRQ put out press releases and got attention for the findings.

This grant recipient, a member of one of the CERTs, stated, "we took seriously AHRQ's mandate not only to do research and publish it in academic journals but to try to get the products of the research out there as much as we could." The investigator attributed to his involvement with the CERT his additional effort to seek a vehicle to disseminate the materials to an even broader audience than his State. Another grant recipient described in her final report the extent of the dissemination efforts:

The proceedings were published by the Center for Health and Health Care in schools and by Spring 2005, 2,500 copies had been distributed (mail or conference)... to key leaders and the report was posted on the Center Web site where a large number of visitors viewed it. Although not anticipated in the original grant application, concerns registered by conference participants about the specific issue of psychotropic drugs at school led the Center to prepare a fact sheet. This publication has been well received by state policymakers and building-based school nurses. The Center has mailed out 4,400 copies of the fact sheet and 23,134 visitors have viewed the publication on the Center web site.

Another grant recipient described submitting publications; however he also stated "journal articles are not an effective way to disseminate your message to the people who are really going to make something happen with it. That's my feeling at least."

Among the outside individuals who were contacted to provide external feedback, one individual who praised the CERTs products (i.e. QT registry) indicated that it was not always apparent that these products were CERTs-related. This comment, although from just one individual, could indicate the lack of association of products and publications with the CERTs and/or AHRQ.

The distinction between awareness, diffusion, and dissemination are important to consider. If effective dissemination implies targeting the appropriate audience, than Portfolio intervention studies and educational efforts may best be disseminated not only though traditional channels like journals, but also through channels that are targeted toward highly specific audiences.

3.2.3. Educational Outputs

Of the five Pharmaceutical Outcomes Portfolio program goals, three directly reflect an emphasis on education: to better understand risks and benefits of therapeutics; to help consumers derive maximum benefit; and support to providers, researchers, and students. Portfolio grants and CERTs research affirmed a commitment to these educational goals, although there was considerable perceived variability across centers. Two of the individual grants were R13 or conference grants that inherently focus on education.

One researcher summed up the need:

"We need centers with a critical mass of seasoned investigators to train younger people."

Part of the CERT mission is to provide education to advance the optimal use of drugs, medical devices, and biological products. Therefore, the CERTs have provided education on clinical topics and research methods in therapeutics to researchers, practitioners, patients, and policymakers; developed educational resources (e.g. toolkits, continuing education), fostered the development of future researchers and practitioners; and initiated educational initiatives. The focus on both research and on education was designed "to develop a field that would perpetuate itself," stated an AHRQ representative. The educational outputs and outcomes of the CERTs are in two primary categories, within the CERTs and beyond the CERTs (i.e. public, patients, providers).

CERTs Educational Outputs

Education beyond the CERTs, including consumers, patients, practitioners, and policymakers is a focus of the CERTs program generally, but not all of the Centers appear to share those priorities. Most CERTs have contributed to educational outputs of the Portfolio, but some have contributed far more educational resources than others. For example, the Arizona CERT is a Center that demonstrates a steadfast commitment to educating the public, particularly providers, patients, and consumers by having an Educational Core as one of three cores within their organization. The Arizona CERT also has aimed to develop educational tools aimed at consumers with low health literacy. The Arizona CERT has a multidisciplinary team that assists with their ability to provide educational tools by having a social scientist in their CERT. Similarly, the development of the QT interval educational module at Duke was a collaboration between a psychologist and other social scientists. The production of educational tools and a commitment to educational materials focused on the consumer requires a skill set different from that of the typical clinician in practice or research. This has implications for the CERTs program on Education Projects, because some needed skills may be lacking at the CERTs.

Exhibit 10 includes a sample list of educational outputs produced to date from the CERTs and the primary audience for each.

All of the CERTs centers are located at colleges and universities, and many of the investigators are also professors, lecturers, and involved in the formal or informal training of students. The CERTs are likely contributing to formal education beyond what is considered CERTs work, although potentially on CERTs related research and topics. For example, six of the seven research centers have a Web site for their CERT and each of the six has educational information on the Web site both for consumers and practitioners. A brief description of some of the educational products includes: curricula, educational modules, Web-based resources, printed resources, toolkits, workshops, and other educational interventions.

Curricula and Educational Modules

In their AHRQ progress reports, the Arizona, Penn, UAB, and UNC CERTs described having developed curricula. The Arizona CERT developed course materials on therapeutics for the clinical pharmacology curriculum which led to the development of an educational module for health care practitioners and students that is now available on the Arizona CERT Web site. The Arizona CERT collaborated with the FDA to develop the first of several planned educational modules that will be shared with medical student and residency training directors in the US. The product of this partnership was a three ring notebook containing a CD with a PowerPoint® presentation entitled Preventable Adverse Drug Interactions: A Focus on Drug Interactions, and a printout of the PowerPoint slides with lecture notes to guide an instructor (AZ PR01-02).

The Alabama CERT reported providing lectures at various health professional schools, as well developing continuing medical education (CME) materials on osteoporosis management for pharmacists and nurses. Alabama also collaborated with the Alabama Department of Public Health and the National Arthritis Action Plan to create a tailored Web site focused on patient education in arthritis (http://www.arthritispatient.cme.uab.edu/) (AB PR02-03).

The Penn CERT has developed and implemented courses to improve knowledge and skills in the use of therapeutics by future physicians for use in medical school as well as in a course on Pharmacoepidemiology Research Methods taught for the first time in summer 2003 (Penn PR02-03).

The UNC CERT described local presentations, including an invited "Meet the Expert" session on aminoglycoside monitoring at a national infectious disease meeting (UNC PR03-04).

Educational Web Resources, Toolkits

The CERTs have developed Web-based educational resources on the Web, some of which are described below.

The Arizona CERT has developed many Web-based tools for both clinicians and patients including:

• http://medicine.iupui.edu/flockhart/ predicts clinically relevant drug interactions based upon their metabolism by specific cytochrome P450 enzymes. Abbreviated versions of the table are published in Harriet Lane's Pediatric Manual and the Washington Manual described under "Dissemination" above (AZ PR01-02).
• A pilot interactive Web-based module to educate consumers about potential interactions between over-the-counter (OTC) drugs and prescribed medications www.arizonacert.org/index.html (AZ PR03-04).
• The Education Core has developed a consumer-targeted medication "Webliography" — an annotated list of Web sites that have met specific evaluation criteria — to serve as a trustworthy and reliable source of medication information for consumers.
• The Education Core is addressing practice-based factors associated with prescribing outcomes by developing a Web-based interactive causal diagram showing causal pathways of factors that contribute to adverse drug events in community settings (AZ PR04-05).

An external respondent associated with a medical center praised the Arizona CERT's clinical resource of the list of drugs that can cause arrhythmias. He stated that the tool is a key trusted, and used resource.

Duke and the HMO CERT have produced and posted resources on the Web, including:

• An Internet-based educational module on the QT interval was developed as part of the Duke CERTs patient safety supplement. The American Heart Association expressed interest in posting this module on their Web site (Duke PR03-04).
• With the American College of Cardiology (ACC) Duke developed methods to disseminate medication, device alerts, and recalls to practitioners, and implemented 2 programs. The first was the addition of selected FDA alerts related to cardiovascular issues to the Cardiosource.com Web site. The second is a MedWatch PDA application available through Skyscape.com or the ACC Web site (Duke PR 04-05).
• The HMO CERT's—Chronic Disease Score—SAS programs and drug tables were posted to AHRQ Patient Safety Web site for public use of a chronic disease score program.
• The Duke CERT developed print materials, an online Web session, and an educational video to inform caregivers about beta-blocker use for heart failure patients (Duke PR 01-02).
• Duke reported working with professional societies (AAFP, AHA, ACC) to create English and Spanish language brochures on beta-blockers and heart attacks.

The UNC CERT has also developed educational products related to pediatrics, including:

• A pilot toolkit for diagnosing and treating ADHD was made available to approximately 1000 pediatricians. After evaluation of the pilot, the kit was revised and made available to all American Academy of Pediatrics members in Fall 2002. Disseminated at the National Initiative for Children's Healthcare Quality national summit (UNC PR 01-02).
• UNC collaborated with the North Carolina Statewide Asthma Improvement Project (jointly funded by another foundation). Held educational programs that provided clinicians with practical tools and effective strategies for improving the care of children with asthma. Approximately 600 physicians participated. Due to the positive response to the asthma sessions, the NC Division of Medical Assistance expressed support for more intensive improvement efforts involving a specific number of practices in the Access I Medicaid network. AAP will use several key concepts and tools as a template for its online CME/QI program targeted at improving the care of children with asthma (UNC PR 01-02).

In addition to the educational products, a UNC investigator described how their CERT was trying to leverage educational efforts:

We've decided that we should work with existing national organizations (AAP, American Board of Pediatric Medicine) and help them do better getting educational material into practice... Our goal with the Board is to try to get our findings inserted into guidelines and the practitioner re-certification process...

Educational Interventions

Beside the traditional educational outputs the CERTs have also developed educational interventions with the aim of changing behavior of health care professionals and patients. For example, Arizona reported completing three educational interventions including: a program for provider education, a program for ancillary staff education, and a program for patient education (Over the Counter/Supplement Use and Therapeutic Interactions). The Alabama CERT is working on a multi-modal intervention applicable to administrators, physicians, nurses, and patient care technicians in the nursing home setting. They have completed the educational module, toolbox, and educational teleconferences (AB PR 03-04). Alabama implemented a three-module physician intervention aimed at improving the prevention and treatment of glucocorticoid-induced osteoporosis and the safe use of glucocorticoids. In addition to the educational interventions, the Penn CERT also developed and validated an instrument for evaluating educational processes targeted at children with regard to appropriate antibiotic use (Penn PR 04-05).

Workshops and Think Tanks

The individual CERTs and the CERTs program as a whole have held workshops and convened key stakeholders. The CERT research centers described in progress reports hosting workshops with different stakeholders on a variety of topics. Some examples include:

The Duke CERTs with several partners sponsored a workshop attended by more than 50 clinicians, government, and industry representatives. Conference participants reached consensus on six principles related to post marketing surveillance of cardiovascular devices (Duke PR01-02).

UNC held a Summer Institute on "Using the Evidence on Therapeutics to Enhance Quality" for private practitioners across North Carolina (UNC PR 01-02).

Besides the efforts of individual CERT, the CERTs program as a whole has supported educational events. The CERT network sponsored the John M. Eisenberg Memorial Lectureship on Therapeutics Research that was established by AHRQ and the CERTs leverage the CERTs network through a variety of educational and translation of research into modalities.²⁹ As part of this initiative, representative of the CERTs presented seven lectures at different institutions during 2003-2004.

The CERTs program collaborated for the AHRQ conference grant "Risk Series"—five think tanks held between 2001 and 2003 on: risk communication, risk assessment, benefit assessment, risk communication and the media, and risk management. The risk series was an initiative developed by the CERTs and included a partnership with AHRQ, the Center for Drug Evaluation and Research (CDER) of the Food and Drug Administration (FDA), and the Pharmaceutical Research and Manufacturers of America (PhRMA). It convened health care providers, researchers,³⁰ experts from government and industry, and representatives of the media and consumer groups. A few CERTs PIs identified the Risk Series as among their most important advances as a group. Two of these PIs described the Series:

The Series helped to shape national views about risk, and importantly, we were able to work as a group. Demonstrating how one can work with professional societies is an important component of the evolving fabric of therapeutics.

We had meetings with diverse people and achieved consensus about what research was needed. There has not yet been a sufficient response to what has been agreed upon for research needs, such as statistical approaches and measuring adverse reactions. What should be the role of the press in risk communication?

Another PI continued:

The Risk series was a great example... it turned out to have a major impact... It lead to the idea that we don't know how much is being spent on post-approval drug safety, benefit assessment, and risk management... it [included] voting on unifying principles at a time when the FDA was developing risk assessment guidelines for industry. The FDA staff drafting these guidelines were at the CERT think tank, which was a completely CERT PI- initiated effort.

In summary, the CERTs program has developed various initiatives focused on education in therapeutics for providers and patients. Most centers demonstrated an effort to educate providers, but only a few centers demonstrated a commitment beyond the traditional development of continuing education. The CERTs focused less on patient education than on provider education, although five of seven CERTs maintain Web sites that have information for consumers/patients. Similarly, some CERTs focused more on developing educational tools and products for consumers than did others.

Portfolio Grants

Of the four individual grantees who were respondents for the evaluation, one held a conference and two other grants involved educational interventions. The two grants on antibiotic resistance included educational interventions and media campaigns that involved the development and dissemination of educational materials. One grant was awarded to convene a conference on medication management in school systems. The grantee explained:

We invited 35-40 people to participate with the goal of providing documentation on what actually happens in the school setting, what the issues are, and what some of the recommendations one might make about how to strengthen the process. It was really less about prescribing than about improving quality... a follow-up was a fact sheet on psychotropic drugs.

As the grantee described, she made publicly available the proceedings of the conference. She also in response to conference attendees' stated needs, developed a fact sheet on psychotropic medications because the need was identified in the conference, which demonstrated responsiveness. The selection of a fact sheet format was intended to accommodate the school nurses' schedules.

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