***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: OBJECTIVE To assess the impact of diverse  continuing medical education ( CME ) interventions on  physician performance and health care outcomes .  DATA SOURCES Using continuing medical education and related phrases , we performed regular search es of the indexed literature ( MEDLINE , Social Science Index , the National Technical Information Service , and Educational Research Information Clearinghouse ) from 1975 through 1991 . In addition , for these years , we used manual search es , key informants , and requests to authors to locate other indexed articles and the nonindexed literature of adult and continuing professional education . STUDY SELECTION From the result ing data base we selected studies that met the following criteria : r and omized controlled trials ; educational programs , activities , or other interventions ; studies that included 50 % or more physicians ; follow-up assessment s of at least 75 % of study subjects ; and objective assessment s of either physician performance or health care outcomes . DATA EXTRACTION Studies were review ed for data related to physician specialty and setting . Continuing medical education interventions were classified by their mode(s ) of activity as being predisposing , enabling , or facilitating . Using the statistical tests supplied by the original investigators , physician performance outcomes and patient outcomes were classified as positive , negative , or inconclusive . DATA SYNTHESIS We located 777 CME studies , of which 50 met all criteria . Thirty-two of these analyzed physician performance ; seven evaluated patient outcomes ; 11 examined both measures . The majority of the 43 studies of physician performance showed positive results in some important measures of re source utilization , counseling strategies , and preventive medicine . Of the 18 studies of health care outcomes , eight demonstrated positive changes in patients ' health care outcomes . CONCLUSION Broadly defined CME interventions using practice -enabling or reinforcing strategies consistently improve physician performance and , in some instances , health care outcomes OBJECTIVE --To evaluate guidelines for general practice management and referral of infertile couples .  Guidelines were implemented with a disease specific reminder at the time of consultation ( the guidelines were embedded within a structured infertility management sheet for each couple ) . DESIGN --Pragmatic r and omised controlled trial . Participating practice s were r and omised to a group that received the guidelines and a control group . SETTING --82 general practice s in Grampian region . SUBJECTS--100 couples referred by general practitioners receiving the guideline and 100 couples referred by control general practitioners . MAIN OUTCOME MEASURES --Whether the general practitioner had taken a full sexual history and examined and investigated both partners appropriately . RESULTS --Characteristics of patients referred by study and control general practitioners did not differ significantly at baseline . Compliance with the guidelines increased for all targeted activities . General practitioners in the study group were more likely to take a sexual history ( for example , couples ' use of fertile period , 85 % v 69 % , p < 0.01 ) ; examine both partners ( female partner , 68 % v 52 % , p < 0.05 ; male partner 39 % v 13 % , p < 0.01 ) ; and investigate both partners ( day 21 progesterone , 72 % v 41 % , p < 0.001 ; semen analysis , 51 % v 41 % , p > 0.05 ) . Improvements were greater when general practitioners used the disease specific reminder . CONCLUSION --Receiving guidelines led to improvements in the process of care of infertile couples within general practice . This effect was enhanced when the guidelines were embedded in a structured infertility management sheet for each couple OBJECTIVE To develop guidelines for laboratory tests ordered before admission for elective surgery . DESIGN A seven-step continuous quality improvement process . SETTING The Departments of Laboratory Medicine , Surgery , and Anesthesia of the University of Massachusetts Medical Center , a 384-bed , teaching , tertiary-care facility . PARTICIPANTS Core group of the Department of Laboratory Medicine and the Laboratory Medical Advisory Committee . INTERVENTION Guidelines were developed for laboratory tests ordered before elective surgery . They were divided into four major groups as well as by age and gender . After an intense educational effort , consent was obtained from the majority of surgeons , who agreed to delegate the ordering of tests to the nurses and anesthesiologists who examine patients before surgery . MAIN OUTCOME MEASURE Charts chosen at r and om by the medical records department for the period prior to implementation of guidelines were review ed and compared with records 1 and 2 years later . RESULTS Reductions of 50 % and 60 % in the first and second years , respectively , in the overall number of tests ordered per patient were demonstrated . An improvement in the appropriateness of tests was also documented : 81 % in the first year and 86 % in the second year , compared with 65 % appropriateness prior to implementation of guidelines . A 1-year savings of $ 66,981 and an overall 2-year savings of $ 75,995 were documented . CONCLUSIONS We have described an approach that involves a sustained educational effort and collaboration of nurses and physicians and have presented specific guidelines for preoperative testing . A major decrease in the number of tests ordered , an increase in their appropriateness , and marked fiscal savings were documented OBJECTIVE To compare the effectiveness of a multifaceted intervention in patients with depression in primary care with the effectiveness of " usual care " by the primary care physician . DESIGN A r and omized controlled trial among primary care patients with major depression or minor depression . PATIENTS Over a 12-month period a total of 217 primary care patients who were recognized as depressed by their primary care physicians and were willing to take antidepressant medication were r and omized , with 91 patients meeting criteria for major depression and 126 for minor depression . INTERVENTIONS Intervention patients received increased intensity and frequency of visits over the first 4 to 6 weeks of treatment ( visits 1 and 3 with a primary care physician , visits 2 and 4 with a psychiatrist ) and continued surveillance of adherence to medication regimens during the continuation and maintenance phases of treatment . Patient education in these visits was supplemented by videotaped and written material s. MAIN OUTCOME MEASURES Primary outcome measures included short-term ( 30-day ) and long-term ( 90-day ) use of antidepressant medication at guideline dosage levels , satisfaction with overall care for depression and antidepressant medication , and reduction in depressive symptoms . RESULTS In patients with major depression , the intervention group had greater adherence than the usual care controls to adequate dosage of antidepressant medication for 90 days or more ( 75.5 % vs 50.0 % ; P < .01 ) , were more likely to rate the quality of the care they received for depression as good to excellent ( 93.0 % vs 75.0 % ; P < .03 ) , and were more likely to rate antidepressant medications as helping somewhat to helping a great deal ( 88.1 % vs 63.3 % ; P < .01 ) . Seventy-four percent of intervention patients with major depression showed 50 % or more improvement on the Symptom Checklist-90 Depressive Symptom Scale compared with 43.8 % of controls ( P < .01 ) , and the intervention patients also demonstrated a significantly greater decrease in depression severity over time compared with controls ( P < .004 ) . In patients with minor depression , the intervention group had significantly greater adherence than controls to adequate dosage of antidepressant medication for 90 days or more ( 79.7 % vs 40.3 % ; P < .001 ) and more often rated antidepressant medication as helping somewhat to helping a great deal ( 81.8 % vs 61.4 % ; P < .02 ) . However , no significant differences were found between the intervention and control groups in the percentage of patients who were satisfied with the care they received for depression ( 94.4 % vs 89.3 % ) , in the percentage who experienced a 50 % or more decrease in depressive symptoms , or in the decrease of depressive symptoms over time . CONCLUSION A multifaceted intervention consisting of collaborative management by the primary care physician and a consulting psychiatrist , intensive patient education , and surveillance of continued refills of antidepressant medication improved adherence to antidepressant regimens in patients with major and with minor depression . It improved satisfaction with care and result ed in more favorable depressive outcomes in patients with major , but not minor , depression We assessed the impact of three conditions on one-year smoking cessation rates .  Physicians in 70 community general practice s were r and omly allocated by practice to one of three groups : In the usual care group , smoking patients were to receive the care they normally would receive . In the gum only group , physicians were asked to speak to patients about smoking cessation and offer nicotine gum . In the gum plus group , physicians were trained in the experimental intervention . This intervention involved advice to stop smoking , the setting of a quit date , the offer of nicotine gum , and four follow-up visits .  Smoking cessation was measured by self-report after one year and vali date d using saliva cotinine measures . Using a criterion of at least three months of abstinence , 8.8 % of the patients of the trained physicians had stopped smoking at the one-year follow-up compared with 4.4 % and 6.1 % of the patients in the usual care and gum only groups , respectively We design ed this study to determine whether an intensive 1-day educational workshop involving family physicians  in establishing essential criteria for hypertension management would significantly affect the short-term outcomes of hypertensive patients in their practice s. Forty r and omly selected physicians were separated into three groups : those who would be involved in establishing the criteria ( 15 ) , those who would receive the criteria by mail ( 15 ) and those who would act as controls and not be aware of the criteria ( 10 ) . We found no significant difference between the three groups in the number of hypertensive patients whose condition remained uncontrolled after the intervention . We conclude that physicians ' participation in the establishment of st and ards of care for conditions such as hypertension or their awareness of such st and ards does not independently result in significantly better patient outcomes . Consequently , we recommend that physicians and health care planners concerned with improving outcomes not rely on any single intervention strategy when planning change OBJECTIVES To improve the initiation of anticoagulation in patients with thrombotic disorders . DESIGN AND SETTING We carried out a preliminary audit in 1991 , developed and implemented strategies to address identified problems , and followed up with another audit in 1993 . Medical records of in patients at The Royal Melbourne Hospital whose anticoagulation therapy was initiated with heparin ( intravenous ) in therapeutic doses and subsequently converted to warfarin were prospect ively assessed over 19-day periods . INTERVENTION Pocket-sized laminated prescriber guidelines for initiating anticoagulation were disseminated after publishing the results of the first audit , together with a single prominent display of two posters in series advocating the use of the guidelines . RESULTS The audits identified 25 eligible patients in 1991 and 27 in 1993 . The mean duration of intravenous heparin therapy was reduced from 150 hours in 1991 to 97 hours in 1993 ( P < 0.002 ) . The mean delay before initiating warfarin therapy after starting heparin therapy was reduced from 69 hours in 1991 to 21 hours in 1993 ( P < 0.002 ) . The mean percentage of time the activated partial thromboplastin time was within the therapeutic range increased from 30 % in 1991 to 44 % in 1993 ( P < 0.05 ) and was above the therapeutic range increased from 13 % in 1991 to 24 % in 1993 ( P < 0.01 ) . Although the number of adverse events was too small to draw definitive conclusions , no difference in adverse haemorrhagic effects was noted between the 1991 and 1993 groups . CONCLUSION There was an improvement in the initiation of anticoagulation and we hypothesise that this was most likely due to a broad acceptance of the guidelines into clinical practice Documentation of unexplained geographic variations in medical practice s [ 1 ] and use of interventions inappropriately [ 2 ] or before their effectiveness has been established [ 3 ] has led to the rapid proliferation of clinical practice guidelines . These systematic ally developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances [ 4 ] are an attempt to discourage ineffective medical practice s , encourage effective practice s , and improve health outcomes [ 5 - 10 ] . Despite increasing enthusiasm for guidelines , evidence exists that guidelines often do not affect clinical practice s or health outcomes [ 11 - 17 ] . One possible obstacle to effective guideline implementation is physician concern about the intent and validity of these documents [ 18 - 22 ] . Many physicians first encounter guidelines in the context of peer review , utilization management , and quality control programs , experiences that they may not perceive positively . Such outsider scrutiny is considered by some to be a challenge to autonomous clinical decision making . Little systematic study of physicians ' attitudes toward guidelines , however , has been done [ 23 , 24 ] . We did a national survey of a r and om sample of American College of Physicians ( ACP ) members to assess ACP members ' familiarity with , confidence in , and attitudes about guidelines issued by ACP and other organizations and members ' perceptions of the effect of ACP and other guidelines on their practice s. Methods Question naire We design ed a practice guidelines question naire that sought information about 1 ) 
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DATA SYNTHESIS The articles showed that CPG dissemination or implementation processes have mixed results .
Variables that affect the adoption of guidelines include qualities of the guidelines , characteristics of the health care professional , characteristics of the practice setting , incentives , regulation and patient factors .
Specific strategies fell into 2 categories : primary strategies involving mailing or publication of the actual guidelines and secondary interventional strategies to reinforce the guidelines .
The interventions were shown to be weak ( didactic , traditional continuing medical education and mailings ) , moderately effective ( audit and feedback , especially concurrent , targeted to specific providers and delivered by peers or opinion leaders ) and relatively strong ( reminder systems , academic detailing and multiple interventions ) .
The evidence shows serious deficiencies in the adoption of CPGs in practice .