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Article |

Influence of the News Media on Diagnostic Testing in the Emergency Department FREE

Vidya Sharma, MBBS, MPH; M. Denise Dowd, MD, MPH; Douglas S. Swanson, MD; Andrew J. Slaughter; Stephen D. Simon, PhD
[+] Author Affiliations

From the Departments of Pediatrics, Children's Mercy Hospital and University of Missouri School of Medicine at Kansas City (Drs Sharma, Dowd, Swanson, and Simon), and Department of Information Services, Children's Mercy Hospital (Mr Slaughter).


Arch Pediatr Adolesc Med. 2003;157(3):257-260. doi:10.1001/archpedi.157.3.257.
Text Size: A A A
Published online

Objective  To examine the association between mass media attention regarding invasive group A streptococcal (GAS) disease and testing for GAS in a pediatric emergency department (ED).

Design, Setting, and Participants  An observational analysis was performed of patients who had GAS tests done in a pediatric ED between December 1, 1999, and November 30, 2001. Data were analyzed by dividing each of the 2 years into 4 consecutive 90-day intervals. Data including age, date of the visit, presenting complaint, primary discharge diagnosis, whether a GAS test was obtained, and the results were collected from an electronic data repository. The date of the news stories, the station, and the duration of the broadcast were collected from electronic archives of the local newspaper and a broadcast monitoring service.

Main Outcome Measure  The rate of GAS tests done per 1000 ED visits and the rate of positive tests per 1000 ED visits.

Results  An average of 103 GAS tests were performed per 1000 ED visits in the December through February period in year 2 compared with 55 GAS tests per 1000 ED visits in a similar period in year 1. This difference was statistically significant (difference, 48 tests; 95% confidence interval, 24-72 tests; P<.001). There were no significant differences in the proportion of positive tests (32% in year 1 vs 20% in year 2; mean difference, −11%; 95% confidence interval, −23% to 1%; P = .07). There were a total of 16 newspaper articles and 34 television stories on GAS during the 2-year study period. The peak in GAS tests and the peak in media events were concomitant.

Conclusion  A surge in news stories regarding GAS disease was associated with an increase in testing for GAS in a pediatric ED.

Figures in this Article

GROUP A streptococci (Streptococcus pyogenes) (GAS), commonly referred to in the lay press as "the flesheating bacteria," causes a variety of illnesses in children ranging from a mild pharyngitis to less common but more severe invasive infections. Clinically, differentiation between viral and GAS pharyngitis is not always possible. Previous reports1,2 have shown that physicians tend to misdiagnose GAS as a cause of pharyngitis. One study showed only a 21% rate of agreement between physicians on the subjective probability estimates of a positive culture.3 To decrease this uncertainty, laboratory confirmation for the presence of GAS is recommended4 and usually accomplished by a rapid test for GAS.

There has been a resurgence of invasive GAS infections since 1987 in the form of streptococcal toxic shock syndrome,510 bacteremia, and necrotizing fasciitis. Such infections have been reported as occurring sporadically, with occasional identification of clusters.1118 The skin or mucous membrane is believed to be the portal of entry in most cases.4 Invasive GAS disease rarely follows GAS pharyngitis.4 There are currently no recommendations and no scientific evidence to support performing a rapid test for GAS to prevent invasive GAS disease.

The influence of the mass media on behavior is well studied.1926 Knowledge of these effects has been used successfully in the commercial sector.27 The public health community has taken advantage of the mass media to influence behavior in the areas of cancer screening and injury prevention.28 Mass media has the capacity to reach and influence millions of people simultaneously. While much is known about the influence of the media on consumer behavior, there are few reports of the influence of the media on use of health services or physician behavior.29,30 In fact, we found one study quantifying the effect of the media on emergency department (ED) visits30 but none on testing in the ED.

This study was undertaken to describe the impact of news coverage of a cluster of invasive GAS cases in the Kansas City, Mo, area on testing for GAS in a large urban referral pediatric emergency department (ED) located in a children's hospital with an annual ED census of 55 000 visits. An observational analysis was performed to determine the association between the number of news media events and the number of rapid tests performed for GAS in a pediatric ED.

This retrospective data analysis examined visits to the ED of an urban midwestern children's hospital. This study was granted exempt status by the Pediatric Institutional Review Board of University of Missouri–Kansas City, as no patient identifiers were collected, patients were not contacted, and their care was not affected.

A database for the study was constructed from 3 data sources. The first data source was the central data repository at the hospital, where all patient encounter data are stored. All visits to the ED for a 2-year period from December 1, 1999, through November 30, 2001, were identified. Variables extracted from this data source included date of the visit, age of the patient, the presenting complaint, the primary discharge diagnosis, whether a rapid test for GAS was done, and the results of the test.

The second data source was the electronic archives of the dominant local newspaper. An electronic search was carried out for all published news stories mentioning GAS disease during the same study period. Specific search terms used were strep, streptococcus, group A beta streptococcus, toxic shock, and flesh-eating bacteria. The date of each news story was noted. If multiple stories occurred on the same date, the number of stories on that day was noted.

The third data source was a commercial broadcast-monitoring service to which the hospital subscribes. This service provides a monthly broadcast list of all news stories on any local television station related to the hospital. Search terms used were children's mercy and CMH. Stories about GAS without these search terms were not included in the search. All summaries were printed and manually reviewed by one of us (V.S.) to include only stories relating to GAS. The date and time of the broadcast, the station that broadcasted it, and the duration of the broadcast story were extracted from this data source.

The study period was divided into two 12-month intervals: year 1 (December 1, 1999, through November 31, 2000) and year 2 (December 1, 2000, through November 31, 2000). This period was chosen because the start of year 2 coincided with the start of media attention. Data were analyzed by dividing each of the 2 years of the study period into 4 consecutive 90-day intervals, for a total of eight 90-day intervals. For each 90-day interval, the total number of ED visits and the number of those visits that included performance of a GAS rapid test were determined. For each period, the rate of GAS rapid tests per 1000 patient visits was calculated. The proportion of positive tests was also noted. The generalized least squares model31 was used to model numbers of children who were tested for GAS and the ratio of positive tests in the different periods during the 2 years. The generalized least-squares model was chosen over the linear model because it accounts for correlation among events in the model. This accounted for the lack of independence among individual observations and the underlying effect of the time trend.

Differences in the frequency of presenting complaints and primary discharge diagnosis during the December through February periods in year 1 and year 2 were tested by means of a 2-sided α-level of .05 using the Fisher exact test (SPSS for Windows, version 11; SPSS Inc, Chicago, Ill). The exact confidence intervals (CIs) for relative risk were computed with StatXact for Windows, version 3.0 (Cytel Software Corporation, Cambridge, Mass).

There were 40 171 ED visits in year 1 and 43 387 ED visits in year 2. A total of 2487 GAS tests were performed in year 1 (62/1000 ED visits) and 3439 were performed in year 2 (79/1000 ED visits) (P = .001). The average (±SD) age of children tested was 7.8 ± 4.3 years in year 1 and 7.9 ± 4.5 years in year 2, which was not statistically significant.

There were a total of 16 newspaper articles and 34 television stories on GAS during the study period. Forty-eight stories (96%) occurred in the December through February period of year 2. Television stories ran for a total duration of 42 minutes 14 seconds. Stories were carried on 4 major networks, with 17 (50%) of the stories carried by 1 network.

An average of 103 GAS tests were performed per 1000 ED visits in the December through February period in year 2 compared with 55 GAS tests per 1000 ED visits during a similar period in year 1. This difference was statistically significant (48 tests; 95% CI, 24-72 tests; P<.001). Comparisons of rates of tests during other intervals did not show statistically significant differences (Table 1).

Table Graphic Jump LocationMean Number of GAS Tests Performed per 1000 ED Visits in 90-Day Intervals During the Study Period (December 1, 1999−November 30, 2001) Mean Number of GAS Tests Performed per 1000 ED Visits in 90-Day Intervals During the Study Period (December 1, 1999−November 30, 2001)

For the 2-year period, the proportion of positive GAS tests was 22%. A comparison of like 90-day intervals for each year showed no significant differences in proportion of positive tests. However, differences between the proportion of positive tests for the December through February intervals for year 1 and year 2 approached significance (32% in year 1 vs 20% in year 2; mean difference, −11%; 95% CI, −23% to 1%; P = .07).

There were no statistically significant differences in the number of children presenting with a chief complaint of "fever" (relative risk, 0.87; 95% CI, 0.74-1.03; P = .09) for the December through February intervals for year 1 and year 2. However, fewer children presented with the chief complaint of "sore throat" during the December through February interval for year 2 (relative risk, 0.69; 95% CI, 0.55-0.86; P = .001). There were no statistically significant differences in the primary discharge diagnosis of "acute pharyngitis" (relative risk, 0.88; 95% CI, 0.69-1.15; P = .32) or "viral infection not elsewhere classified/not otherwise specified" (relative risk, 1.33; 95% CI, 0.94-1.97; P = .09) during the December through February intervals for year 1 and year 2.

The number of news media events and the number of GAS tests done are depicted in Figure 1. Examination of this figure shows that the peak in GAS tests and the peak in media events are concomitant.

Place holder to copy figure label and caption

Number of media events and number of group A streptococcal tests per 1000 emergency department (ED) visits.

Graphic Jump Location

In this study we document an abrupt increase in rapid tests for GAS disease in a pediatric ED concomitant with a large number of news stories about GAS. Furthermore, the ratio of positive tests showed no change or a slight trend toward a decline during this time of media coverage, suggesting no increase in the prevalence of disease during this period of increased testing for GAS disease. There was no difference in the average age of the patients tested, suggesting that increased GAS testing was not limited to any particular age group. The results of this study are similar to those of previous studies32 and a systematic review,33 suggesting that the mass media, including both planned and unplanned coverage, can have an impact on health services utilization.

This observational study of the relationship between media events and GAS testing in the ED demonstrates a strong association; however, causation cannot be established. One possible explanation for the increase in the number of tests is seasonality, but a comparison of similar seasons during the study period made this explanation unlikely. A second explanation may be that the increase in the number of tests is associated with an increase in the number of ED visits. Previous studies have shown a steep increase in patient contacts after extensive media coverage of erectile dysfunction in Germany29 and a decline in ED utilization coinciding with the Super Bowl broadcast.30 We controlled for this by computing a rate of tests per 1000 ED visits. Other possible explanations include an epidemic of viral pharyngitis, or an increase in the presenting complaints of sore throat or fever as a reason for the increased testing. We found no increase in a discharge diagnosis of either "acute phayngitis" or "viral infection." We also found no statistically significant increase in the presenting complaint of "fever." In fact, a presenting complaint of "sore throat" was statistically significantly decreased during the period of greater testing for GAS.

Other factors responsible for the increase could have included increased concern on the part of health care providers regarding aggressive GAS infection. Such concern could have arisen from other nonmedia sources of information, including that from the medical community through journals, the Internet, and an increase in local medical education (grand rounds, health department notices, and intrahospital notices) on the topic. Our retrospective study design did not examine this and other common public sources of medical information, including radio and the Internet, an important source of adult health information.34 Another limitation was that our commercial broadcast-monitoring search did not include any story about GAS that did not mention children's mercy or CMH. This would only underestimate the number of stories on GAS and bias the study toward the null hypothesis. Since only 1 ED experience was examined, generalizability is limited, and we cannot discern whether there was a widespread increase in testing involving other EDs.

The increase in GAS testing is an indication of either an increased demand for the test by the patient or a heightened awareness or concern on the part of the health care provider. Determining whose behavior was changed and how it was changed is beyond the scope of this article. Previous investigators examined the effect of media coverage on the adverse effects of calcium channel blockers.35 They concluded that such coverage led to an "epidemic of anxiety" in a general internal medicine faculty group practice. Such anxiety could have been functioning in the present study, but whether the source of the anxiety was the practitioner or the patient is not known.

In conclusion, our study demonstrates an association between increased media coverage and testing for GAS in an ED. We were unable to demonstrate a concomitant increase in the prevalence of streptococcal or other acute pharyngitis or an increase in the frequency of patients presenting with a chief complaint of sore throat or fever. This increase may represent a change in physicians' practices. Further studies to understand how the media influences patient and physician behaviors are needed. For EDs this is particularly crucial, as surges in health services demand can have the potential to further impact waiting times and staffing in overburdened EDs.

Corresponding author and reprints: Vidya Sharma, MBBS, MPH, Children's Mercy Hospital, 2401 Gilham Rd, Kansas City, MO 64108.

Accepted for publication September 20, 2002.

We acknowledge the contribution of medical student Vijay K. Reddy, who manually entered data on the media stories into a database.

What This Study Adds

The influence of the mass media on the public is well documented, but no data are available regarding its influence on testing in emergency departments. In this study we document an abrupt increase in rapid tests for GAS disease in a pediatric ED concomitant with a large number of news stories about invasive GAS disease, without evidence of an increase in the prevalence of disease during this period of increased testing. Further studies on how the media affects physician and patient behavior are needed, as this has implications for public health education and for resource utilization in EDs.

McIsaac  WJButler  CC Does clinical error contribute to unnecessary antibiotic use? Med Decis Making. 2000;2033- 38
Link to Article
Poses  RMCebul  RDCollins  MFager  SS The accuracy of experienced physicians' probability estimates for patients with sore throats: implications for decision making. JAMA. 1985;254925- 929
Link to Article
Attia  MWZaoutis  TKlein  JDMeier  FA Performance of a predictive model for streptococcal pharyngitis in children. Arch Pediatr Adolesc Med. 2001;155687- 691
Link to Article
American Academy of Pediatrics,Pickering  LK, ed.ed Group A streptococcal infections. 2000 Red Book: Report of the Committee on Infectious Diseases. 25th ed. Elk Grove Village, Ill American Academy of Pediatrics2000;526- 530
Stevens  DL Invasive group A streptococcal infections: the past, present and future. Pediatric Infect Dis J. 1994;13561- 566
Link to Article
Cone  LAWoodard  DRSchilevert  PMTomory  GS Clinical and bacteriologic observations of a toxic shock–like syndrome due to Streptococcus pyogenes. N Engl J Med. 1987;317146- 149
Link to Article
Working Group on Severe Streptococcal Infections, Defining the group A streptococcal toxic shock syndrome: rationale and consensus definition. JAMA. 1993;269390- 391
Link to Article
Begovac  JMarton  ELisic  MBeus  IBozinovic  N Group A streptococcal toxic shock–like syndrome. Pediatr Infect Dis J. 1990;9369- 370
Link to Article
Hoge  CWSchwartz  BTalkington  DFBreiman  RFMacNeill  EMEnglender  SJ The changing epidemiology of invasive group A streptococcal infections and the emergence of streptococcal toxic shock–like syndrome: a retrospective population-based study. JAMA. 1993;269384- 389
Link to Article
Stevens  DLTanner  MNEinship  J  et al.  Severe group A streptococcal infections associated with a toxic shock–like syndrome and scarlet fever toxin. N Engl J Med. 1989;3211- 8
Link to Article
Schwartz  BElliott  JAButler  JC  et al.  Clusters of invasive group A streptococcal infections in family, hospital, and nursing home settings. Clin Infect Dis. 1992;15277- 284
Link to Article
Huang  Y-CHsueh  P-RLin  T-Y  et al.  A family cluster of streptococcal toxic shock syndrome in children: clinical implication and epidemiological investigation. Pediatrics. 2001;1071181- 1184
Link to Article
Centers for Disease Control and Prevention, Outbreak of invasive group A Streptococcus associated with varicella in a child care center—Boston, Massachusetts, 1997. MMWR Morb Mortal Wkly Rep. 1997;46944- 948
DiPersio  JRStevens  DLPetropoulos  GDinsa  K Spread of disease-producing M3 clones of group A streptococcus among family members and health care workers. Clin Infect Dis. 1996;22490- 495
Link to Article
Gamba  MAMartinelli  MSchaad  HJ  et al.  Familial transmission of a serious disease-producing group A streptococcus clone: case reports and review. Clin Infect Dis. 1997;241118- 1121
Link to Article
Cannaday  PMcNitt  THorn  K  et al.  A family outbreak of serious streptococcal infection. JAMA. 1976;236585- 587
Link to Article
Centers for Disease Control and Prevention, Nursing home outbreaks of invasive group A streptococcal infections—Illinois, Kansas, North Carolina, and Texas. MMWR Morb Mortal Wkly Rep. 1990;39577- 579
Davies  HDMcGeer  ASchwartz  B  et al.  Invasive group A streptococcal infections in Ontario, Canada. N Engl J Med. 1996;335547- 554
Link to Article
Villani  S Impact of the media on children and adolescents: a 10-year review of the research. J Am Acad Child Adolesc Psychiatry. 2001;40392- 401
Link to Article
Strasburger  VC Children, adolescents, and the media: five crucial issues. Adolesc Med. 1993;4479- 493
Comstock  G Influences of mass media on health behavior. Health Educ Q. 1981;832- 38
Link to Article
Derksen  DJStrasburger  V Children and the influences of the media. Prim Care. 1994;21747- 758
Otten  AL The influence of the mass media on health policy. Health Aff (Millwood). 1992;11111- 118
Link to Article
Hein  K The impact of mass media on adolescent sexual behavior: the chicken or the egg? AJDC. 1980;134133- 134
Committee on Public Education, American Academy of Pediatrics, Media education. Pediatrics. 1999;104341- 343
Link to Article
Strasburger  VC "Sex, drugs, rock ‘n' roll," and the media—are the media responsible for adolescent behavior? Adolesc Med. 1997;8403- 415
Sithhi-amom  CNgamvithayapongse  J The role of the media and communication in improving the use of drugs and other technologies. Int J Technol Assess Health Care. 1998;1471- 80
Link to Article
Donnerstein  ELinz  D The mass media: a role in injury causation and prevention. Adolesc Med. 1995;6271- 284
Braun  MMathers  MJKlingbiel  J  et al.  "Viagra effect": influence of the mass media on patient behavior. Urol Int. 2001;66145- 148
Link to Article
Reich  NTMoscati  RJehle  DCiotoli  M The impact of a major televised sporting event on emergency department census. J Emerg Med. 1994;1215- 17
Link to Article
Pinheiro  JCBates  DM Mixed Effects Model in S and S-PLUS.  New York, NY Springer-Verlag2000;203- 205
Domenighetti  GGrilli  RLiberati  A Promoting consumers' demand for evidence-based medicine. Int J Technol Assess Health Care. 1998;1497- 105
Link to Article
Grilli  RRamsay  CMinozzi  S Mass media interventions: effects on health services utilization [Cochrane Review on CD-ROM].  Oxford, England Cochrane Library, Update Software2002;issue 1
Not Available, Americans Talk About Science and Medical News: The National Health Council Report: Prepared for the National Health Council.  New York, NY Roper Starch Worldwide1997;
Sulmasy  DP The impact of the media coverage on practice [letter]. J Gen Intern Med. 1996;1162
Link to Article

Figures

Place holder to copy figure label and caption

Number of media events and number of group A streptococcal tests per 1000 emergency department (ED) visits.

Graphic Jump Location

Tables

Table Graphic Jump LocationMean Number of GAS Tests Performed per 1000 ED Visits in 90-Day Intervals During the Study Period (December 1, 1999−November 30, 2001) Mean Number of GAS Tests Performed per 1000 ED Visits in 90-Day Intervals During the Study Period (December 1, 1999−November 30, 2001)

References

McIsaac  WJButler  CC Does clinical error contribute to unnecessary antibiotic use? Med Decis Making. 2000;2033- 38
Link to Article
Poses  RMCebul  RDCollins  MFager  SS The accuracy of experienced physicians' probability estimates for patients with sore throats: implications for decision making. JAMA. 1985;254925- 929
Link to Article
Attia  MWZaoutis  TKlein  JDMeier  FA Performance of a predictive model for streptococcal pharyngitis in children. Arch Pediatr Adolesc Med. 2001;155687- 691
Link to Article
American Academy of Pediatrics,Pickering  LK, ed.ed Group A streptococcal infections. 2000 Red Book: Report of the Committee on Infectious Diseases. 25th ed. Elk Grove Village, Ill American Academy of Pediatrics2000;526- 530
Stevens  DL Invasive group A streptococcal infections: the past, present and future. Pediatric Infect Dis J. 1994;13561- 566
Link to Article
Cone  LAWoodard  DRSchilevert  PMTomory  GS Clinical and bacteriologic observations of a toxic shock–like syndrome due to Streptococcus pyogenes. N Engl J Med. 1987;317146- 149
Link to Article
Working Group on Severe Streptococcal Infections, Defining the group A streptococcal toxic shock syndrome: rationale and consensus definition. JAMA. 1993;269390- 391
Link to Article
Begovac  JMarton  ELisic  MBeus  IBozinovic  N Group A streptococcal toxic shock–like syndrome. Pediatr Infect Dis J. 1990;9369- 370
Link to Article
Hoge  CWSchwartz  BTalkington  DFBreiman  RFMacNeill  EMEnglender  SJ The changing epidemiology of invasive group A streptococcal infections and the emergence of streptococcal toxic shock–like syndrome: a retrospective population-based study. JAMA. 1993;269384- 389
Link to Article
Stevens  DLTanner  MNEinship  J  et al.  Severe group A streptococcal infections associated with a toxic shock–like syndrome and scarlet fever toxin. N Engl J Med. 1989;3211- 8
Link to Article
Schwartz  BElliott  JAButler  JC  et al.  Clusters of invasive group A streptococcal infections in family, hospital, and nursing home settings. Clin Infect Dis. 1992;15277- 284
Link to Article
Huang  Y-CHsueh  P-RLin  T-Y  et al.  A family cluster of streptococcal toxic shock syndrome in children: clinical implication and epidemiological investigation. Pediatrics. 2001;1071181- 1184
Link to Article
Centers for Disease Control and Prevention, Outbreak of invasive group A Streptococcus associated with varicella in a child care center—Boston, Massachusetts, 1997. MMWR Morb Mortal Wkly Rep. 1997;46944- 948
DiPersio  JRStevens  DLPetropoulos  GDinsa  K Spread of disease-producing M3 clones of group A streptococcus among family members and health care workers. Clin Infect Dis. 1996;22490- 495
Link to Article
Gamba  MAMartinelli  MSchaad  HJ  et al.  Familial transmission of a serious disease-producing group A streptococcus clone: case reports and review. Clin Infect Dis. 1997;241118- 1121
Link to Article
Cannaday  PMcNitt  THorn  K  et al.  A family outbreak of serious streptococcal infection. JAMA. 1976;236585- 587
Link to Article
Centers for Disease Control and Prevention, Nursing home outbreaks of invasive group A streptococcal infections—Illinois, Kansas, North Carolina, and Texas. MMWR Morb Mortal Wkly Rep. 1990;39577- 579
Davies  HDMcGeer  ASchwartz  B  et al.  Invasive group A streptococcal infections in Ontario, Canada. N Engl J Med. 1996;335547- 554
Link to Article
Villani  S Impact of the media on children and adolescents: a 10-year review of the research. J Am Acad Child Adolesc Psychiatry. 2001;40392- 401
Link to Article
Strasburger  VC Children, adolescents, and the media: five crucial issues. Adolesc Med. 1993;4479- 493
Comstock  G Influences of mass media on health behavior. Health Educ Q. 1981;832- 38
Link to Article
Derksen  DJStrasburger  V Children and the influences of the media. Prim Care. 1994;21747- 758
Otten  AL The influence of the mass media on health policy. Health Aff (Millwood). 1992;11111- 118
Link to Article
Hein  K The impact of mass media on adolescent sexual behavior: the chicken or the egg? AJDC. 1980;134133- 134
Committee on Public Education, American Academy of Pediatrics, Media education. Pediatrics. 1999;104341- 343
Link to Article
Strasburger  VC "Sex, drugs, rock ‘n' roll," and the media—are the media responsible for adolescent behavior? Adolesc Med. 1997;8403- 415
Sithhi-amom  CNgamvithayapongse  J The role of the media and communication in improving the use of drugs and other technologies. Int J Technol Assess Health Care. 1998;1471- 80
Link to Article
Donnerstein  ELinz  D The mass media: a role in injury causation and prevention. Adolesc Med. 1995;6271- 284
Braun  MMathers  MJKlingbiel  J  et al.  "Viagra effect": influence of the mass media on patient behavior. Urol Int. 2001;66145- 148
Link to Article
Reich  NTMoscati  RJehle  DCiotoli  M The impact of a major televised sporting event on emergency department census. J Emerg Med. 1994;1215- 17
Link to Article
Pinheiro  JCBates  DM Mixed Effects Model in S and S-PLUS.  New York, NY Springer-Verlag2000;203- 205
Domenighetti  GGrilli  RLiberati  A Promoting consumers' demand for evidence-based medicine. Int J Technol Assess Health Care. 1998;1497- 105
Link to Article
Grilli  RRamsay  CMinozzi  S Mass media interventions: effects on health services utilization [Cochrane Review on CD-ROM].  Oxford, England Cochrane Library, Update Software2002;issue 1
Not Available, Americans Talk About Science and Medical News: The National Health Council Report: Prepared for the National Health Council.  New York, NY Roper Starch Worldwide1997;
Sulmasy  DP The impact of the media coverage on practice [letter]. J Gen Intern Med. 1996;1162
Link to Article

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