***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: Background : The effect of regular and expected printed educational material s on physician prescribing behaviour has not been studied . We sought to measure the impact of a series of evidence -based drug therapy letters mailed to physicians in British Columbia on prescribing to newly treated patients . Methods : A paired , cluster r and omized community design was used . The study population included 499 physicians from 24 local health areas in British Columbia . Local health areas were paired by number of physicians , and 1 of each pair was r and omly selected and its physicians assigned to an intervention group or a control group . The intervention was 12 issues of an evidence -based series called Therapeutics Letter . Physicians in the control group ( n = 241 ) received the letters 3–8 months after physicians in the intervention group ( n = 258 ) . The impact on prescribing to newly treated patients  ( defined as patients who had not previously made a cl aim for any medication from the class of drugs profiled in the letter ) was analyzed using the drug cl aims data base of BC Pharmacare , a publicly funded drug benefits program that covered all seniors and people receiving social assistance . Results : The probability of prescribing a drug recommended in the Therapeutics Letter rather than another drug in the same class increased by 30 % in the 3 months after the mailing of the letter relative to the preceding 3 months , adjusted for any before – after changes in the control group ( relative risk 1.30 ; 95 % confidence interval 1.13–1.52 ) . No letter achieved statistical significance on its own . However , 11 of the 12 letters produced prescribing changes in the predicted direction such that the overall result was significant when their effect was combined . Interpretation : The combined effect of an ongoing series of printed letters distributed from a credible and trusted source can have a clinical ly significant effect on prescribing to newly treated patients Background R and omised controlled trials of implementation strategies tell us whether ( or not ) an intervention results in changes in professional behaviour but little about the causal mechanisms that produce any change . Theory-based process evaluations collect data on theoretical constructs alongside r and omised trials to explore possible causal mechanisms and effect modifiers . This is similar to measuring intermediate endpoints in clinical trials to further underst and the biological basis of any observed effects ( for example , measuring lipid profiles alongside trials of lipid lowering drugs where the primary endpoint could be reduction in vascular related deaths).This study protocol describes a theory-based process evaluation alongside the Ontario Printed Educational Message ( OPEM ) trial . We hypothesize that the OPEM interventions are most likely to operate through changes in physicians ' behavioural intentions due to improved attitudes or subjective norms with little or no change in perceived behavioural control . We will test this hypothesis using a well-vali date d social cognition model , the theory of planned behaviour ( TPB ) that incorporates these constructs . Methods / design We will develop theory-based surveys using st and ard methods based upon the TPB for the second and third replications , and survey a sub sample of Ontario family physicians from each arm of the trial two months before and six months after the dissemination of the index edition of informed , the evidence based newsletter used for the interventions . In the third replication , our study will converge with the " TRY-ME " protocol ( a second study conducted alongside the OPEM trial ) , in which the content of educational messages was constructed using both st and ard methods and methods informed by psychological theory . We will modify Dillman 's total design method to maximise response rates . Preliminary analyses will initially assess the internal reliability of the measures and use regression to explore the relationships between predictor and dependent variable ( intention to advise diabetic patients to have annual retinopathy screening and to prescribe thiazide diuretics for first line treatment of uncomplicated hypertension ) . We will then compare groups using methods appropriate for comparing independent sample s to determine whether there have been changes in the predicted constructs ( attitudes , subjective norms , or intentions ) across the study groups as hypothesised , and will assess the convergence between the process evaluation results and the main trial results .Trial registration numberCurrent controlled trial IS RCT OBJECTIVES To assess the feasibility of a multifaceted strategy to translate evidence -based guidelines for treating nursing home-acquired pneumonia ( NHAP ) into practice using a small intervention trial . DESIGN Pre-posttest with untreated control group . SETTING Two Colorado State Veterans Homes ( SVHs ) during two influenza seasons . PARTICIPANTS Eighty-six residents with two or more signs of lower respiratory tract infection . INTERVENTION Multifaceted , including a formative phase to modify the intervention , institutional-level change emphasizing immunization , and availability of appropriate antibiotics ; interactive educational sessions for nurses ; and academic detailing . MEASUREMENTS Subjects ' SVH medical records were review ed for guideline compliance retrospectively for the influenza season before the intervention and prospect ively during the intervention . Bivariate comparisons-of-care processes between the intervention and control facility before and after the intervention were made using the Fischer exact test . RESULTS At the intervention facility , compliance with five of the guidelines improved : influenza vaccination , timely physician response to illness onset , x-ray for patients not being hospitalized , use of appropriate antibiotics , and timely antibiotic initiation for unstable patients . Chest x-ray and appropriate and timely antibiotics were significantly better at the intervention than at the control facility during the intervention year but not during the control year . CONCLUSION Multifaceted , evidence -based , NHAP guideline implementation improved care processes in a SVH . Guideline implementation should be studied in a national sample of nursing homes to determine whether it improves quality of life and functional outcomes of this debilitating illness for long-term care residents OBJECTIVES . To determine whether we could increase adherence to the Centers for Disease Control and Prevention ( CDC ) recommendations with well-accepted approaches to improving quality of care and adherence to the CDC recommendations result ed in improved outcomes for acute otitis media ( AOM ) . METHODS . A cluster r and omization study was conducted in 12 pediatric practice s ( 6 intervention and 6 control sites ) . The main outcome measures were adherence to the CDC recommendations  ( modified to include 2 additional antimicrobial agents ) and a subsequent antibiotic prescription for AOM within 30 days after diagnosis . RESULTS . Of 3152 patients referred to research assistants , 2584 ( 82 % ) were eligible . Of those eligible , 1368 ( 99 % ) of 1382 at the intervention sites and 1138 ( 99 % ) of 1146 at the control sites consented to participate . Rates of adherence to the CDC recommendations were not significantly higher at the intervention sites than at the control sites , for initial enrollment episodes ( 78.2 % vs 70.6 % ) or second episodes ( 62.6 % vs 59.9 % ) . After controlling for clustering according to site and covariates , children who were not treated in adherence to the CDC recommendations for both episodes had 1.60 times the odds of a subsequent prescription within 12 days , compared with those treated in adherence at both episodes . CONCLUSIONS . Despite using evidence -based approaches that are known to influence physician behavior , we were unable to increase adherence to the CDC recommendations for treatment of AOM . However , we did establish that prescription of antimicrobial therapy consistent with the CDC recommendations for a second episode of AOM was associated with improved outcomes , measured as the need for subsequent antibiotic prescription . Because of the selection of resistant otopathogens , adherence to the CDC recommendations is likely more important in subsequent episodes of AOM than in the initial episode Objectives : To evaluate the impact of using pain assessment scales on the management of musculoskeletal chronic pain . Methods : Cluster-r and omized controlled multicentre trial in French general practice setting s. Practice s were r and omized by region before patient recruitment . The inclusion concerned patients suffering from musculoskeletal chronic pain . General practitioners assigned to the scale group used two vali date d assessment instruments ; those assigned to the control group cared for their patients according to their usual practice . The primary end-point was the level of relief obtained and the secondary changes in prescription of painkilling modalities . Results : A total of 155 general practitioners included 772 successive patients suffering from musculoskeletal chronic pain . The control group reported a mean level of relief of 50.7 % compared with one of 41.1 % in the scale group ( p<0.0001 ) . In the intervention group , physicians decreased significantly their prescription of  level two painkillers .  Conclusions . In general practice , the use of pain assessment scales is not associated with greater pain relief . The lesser level of pain relief obtained in the scale group does provide evidence that using pain assessment scales does not enhance the relief of chronic pain in patients in primary care . Guidelines which recommend the systematic use of scales for the assessment and monitoring of chronic pain are not tailored to either the context or the patients encountered in the primary care setting Background A challenge for implementation research ers is to develop principles that could generate testable hypotheses that apply across a range of clinical context s , thus leading to generalisability of findings . Such principles may be provided by systematic ally developed theories . The opportunity has arisen to test some of these theoretical principles in the Ontario Printed Educational Material s ( OPEM ) trial by conducting a sub-trial within the existing trial structure . OPEM is a large factorial cluster-r and omised trial evaluating the effects of short directive and long discursive educational messages embedded into informed , an evidence -based newsletter produced in Canada by the Institute for Clinical Evaluative Sciences ( ICES ) and mailed to all primary care physicians in Ontario . The content of educational messages in the sub-trial will be constructed using both st and ard methods and methods inspired by psychological theory . The aim of this study is to test the effectiveness of the  TheoRY-inspired MEssage ( ' TRY-ME '  ) compared with the ' st and ard ' message in changing prescribing behaviour . Methods The OPEM trial participants r and omised to receive the short directive message attached to the outside of informed(an ' outsert ' )  will be sub-r and omised to receive either a st and ard message or a message informed by the theory of planned behaviour ( TPB ) using a two ( long insert or no insert ) by three ( theory-based outsert or st and ard outsert or no outsert ) design . The messages will relate to prescription of thiazide diuretics as first line drug treatment for hypertension ( described in the accompanying protocol , " The Ontario Printed Educational Material s trial " ) . The short messages will be developed independently by two research teams . The primary outcome is prescription of thiazide diuretics , measured by routinely collected data available within ICES . The study is design ed to answer the question , is there any difference in guideline adherence ( i.e. , thiazide prescription rates ) between physicians in the six groups ? A  process evaluation survey instrument based on the TPB will be administered pre- and post-intervention ( described in the accompanying protocol , " Looking inside the black box " ) . The second research question concerns processes that may underlie observed differences in prescribing behaviour . We expect that effects of the messages on prescribing behaviour will be mediated through changes in physicians ' cognitions . Trial registration numberCurrent controlled trial IS RCT Background Psychological models can be used to underst and and predict behaviour in a wide range of setting s. However , they have not been consistently applied to health professional behaviours , and the contribution of differing theories is not clear . The aim of this study was to explore the usefulness of a range of psychological theories to predict health professional behaviour relating to management of upper respiratory tract infections ( URTIs ) without antibiotics . Methods Psychological measures were collected by postal question naire survey from a r and om sample of general practitioners ( GPs ) in Scotl and . The outcome measures were clinical behaviour ( using antibiotic prescription rates as a proxy indicator ) ,  behavioural simulation ( scenario-based decisions to managing URTI with or without antibiotics ) and behavioural intention ( general intention to managing URTI without antibiotics ) . Explanatory variables were the constructs within the following theories : Theory of Planned Behaviour ( TPB ) , Social Cognitive Theory ( SCT ) , Common Sense Self-Regulation Model ( CS-SRM ) , Operant Learning Theory ( OLT ) , Implementation Intention ( II ) , Stage Model ( SM ) , and knowledge ( a non-theoretical construct ) . For each outcome measure , multiple regression analysis was used to examine the predictive value of each theoretical model individually . Following this ' theory level ' analysis , a ' cross theory ' analysis was conducted to investigate the combined predictive value of all significant individual constructs across theories . Results All theories were tested , but only significant results are presented . When predicting behaviour , at the theory level , OLT explained 6 % of the variance and , in a cross theory analysis , OLT ' evidence of habitual behaviour ' also explained 6 % . When predicting  behavioural simulation  , at the theory level , the proportion of variance explained was : TPB , 31 % ; SCT , 26 % ; II , 6 % ; OLT , 24 % . GPs who reported having already decided to change their management to try to avoid the use of antibiotics made significantly fewer scenario-based decisions to prescribe . In the cross theory analysis , perceived behavioural control ( TPB ) , evidence of habitual behaviour ( OLT ) , CS-SRM cause ( chance/bad luck ) , and intention entered the equation , together explaining 36 % of the variance . When predicting intention , at the theory level , the proportion of variance explained was : TPB , 30 % ; SCT , 29 % ; CS-SRM 27 % ; OLT , 43 % . GPs who reported that they had already decided to change their management to try to avoid the use of antibiotics had a significantly higher intention to manage URTIs without prescribing antibiotics . In the cross theory analysis , OLT evidence of habitual behaviour , TPB attitudes , risk perception , CS-SRM control by doctor , TPB perceived behavioural control and CS-SRM control by treatment entered the equation , together explaining 49 % 
    Output:
    
Audit and feedback , together with educational outreach visits , were the focus of the majority of recent , high- quality research into prescribing interventions .
These interventions were also the most effective in improving prescribing practice .
There is insufficient recent research into manual reminders to confidently up date earlier review s and there remains insufficient evidence to draw conclusions regarding the effectiveness of local consensus processes or multidisciplinary teams .
Conclusions : Educational outreach as well as  audit and feedback  continue to dominate research into prescribing interventions .
These 2 prescribing interventions also most consistently show positive results .