The randomized controlled trial will begin during year 2. The education intervention and the dissemination of the PORRT tool and guidelines will occur only in the selected 75 RCT practices. The RCT will compare passive distribution of guidelines by mail to an in-office intervention consisting of guideline distribution combined with educational outreach providing training in guideline use and patient mediated information provided by the risk and referral assessment tool (PORRT). The three-arm trial will consist of 25 medical practices that have never participated in IMB and 25 practices that are currently participating, both of which will receive the guidelines through the mail, and 25 practices currently participating in IMB that will receive the more intense in-office training intervention. We hypothesize that effect measures (guideline implementation, and referral quantity, quality and effectiveness) will be most favorable in those practices with the intense intervention, least favorable in those practices that have not participated in the IMB program and somewhat effective for those practices that are participating in IMB but only receive the passive dissemination of guidelines.