***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 Although for more than a decade healthcare systems have attempted to provide evidence -based mental health treatments , the availability and use of psychotherapies remains low . A significant need exists to identify simple but effective implementation strategies to adopt complex practice s within complex systems of care . Emerging evidence suggests that facilitation may be an effective integrative implementation strategy for adoption of complex practice s. The current pilot examined the use of external facilitation for adoption of cognitive behavioral therapy ( CBT ) in 20 Department of Veteran Affairs ( VA ) clinics . Methods The 20 clinics were paired on facility characteristics , and 23 clinicians from these were trained in CBT .  A clinic in each pair was r and omly selected to receive external facilitation . Quantitative methods were used to examine the extent of CBT implementation in 10 clinics that received external facilitation compared with 10 clinics that did not , and to better underst and the relationship between individual providers ' characteristics and attitudes and their CBT use . Costs of external facilitation were assessed by tracking the time spent by the facilitator and therapists in activities related to implementing CBT . Qualitative methods were used to explore context ual and other factors thought to influence implementation . Results Examination of change scores showed that facilitated therapists averaged an increase of 19 % [ 95 % CI : ( 2 , 36 ) ] in self-reported CBT use from baseline , while control therapists averaged a 4 % [ 95 % CI : ( -14 , 21 ) ] increase . Therapists in the facilitated condition who were not providing CBT at baseline showed the greatest increase ( 35 % ) compared to a control therapist who was not providing CBT at baseline ( 10 % ) or to therapists in either condition who were providing CBT at baseline ( average 3 % ) . Increased CBT use was unrelated to prior CBT training . Barriers to CBT implementation were therapists ' lack of control over their clinic schedule and poor communication with clinical leaders . Conclusions These findings suggest that facilitation may help clinicians make complex practice changes such as implementing an evidence -based psychotherapy . Furthermore , the substantial increase in  CBT usage among the facilitation group was achieved at a modest cost Abstract Objective : To investigate the feasibility of improving screening for carriers of haemoglobin disorders in general practice by using a nurse facilitator to work with primary care teams and the relevant haematology laboratories ; to identify problems in communication between all those involved in delivering the service , and to implement solutions . Design : Two year , practice based r and omised controlled trial . Setting : North London area where 29 % of residents and 43 % of births are in ethnic groups at risk for haemoglobin disorders . Subjects : 26 of the 93 practice s using the services of the area 's haematology laboratory agreed to take part and were r and omly divided into control and intervention practice s. Main outcome measure : Change in number of requests for screening tests for haemoglobin disorders made by control and intervention practice s in baseline and intervention years . Results : The number of screening tests requested varied from 0 - 150 in the 93 practice s in the baseline year . Study practice s tended to have made a moderate number of requests ( 10 - 50 ) during this period . During the intervention year intervention practice s made 292 more requests ( 99 % increase ) and control practice s made 74 fewer requests ( 23 % decrease ; P=0.001 for difference in median change ) . Four practice s , three of which were singleh and ed , accounted for 75 % of the increase . The number of requests from intervention practice s , adjusted for baseline requests , was 3.2 times higher than control practice s ( P<0.0001 ) . Conclusion : General practitioners and practice nurses are willing to undertake a new genetic screening service ( or exp and an existing one ) if they are persuaded that it benefits the health of a significant proportion of their practice population . They need appropriate tools ( for example , information material s for carriers and groups at risk ) , and the laboratory must be sensitive to their needs . Preconceptional carrier screening and counselling need to be coupled with antenatal screening AIM To study the effects of a team-based model for continuous quality improvement ( CQI ) on primary care practice management . DESIGN OF STUDY R and omised controlled trial . SETTING Twenty-six intervention and 23 control primary care practice s in the Netherl and s. METHOD Practice s interested in taking part in the CQI project  were , after assessment of their practice organisation , r and omly assigned to the intervention or control groups . During a total of five meetings , a facilitator helped the teams in the intervention group select suitable topics for quality improvement and follow a structured approach to achieve improvement objectives . Checklists completed by an outreach visitor , question naires for the GPs , staff and patients were used to assemble data on the number and quality of improvement activities undertaken and on practice management prior to the start of the intervention and 1 year later . RESULTS Pre-test and post-test data were compared for the 26 intervention and 23 control practice s. A significant intervention effect was found for the number of improvement objectives actually defined ( 93 versus 54 , P<0.001 ) and successfully completed ( 80 versus 69 % of the projects , P<0.001 ) . The intervention group also improved on more aspects of practice management , as measured by our practice visit method , than the control group but none of these differences proved statistically significant . CONCLUSION The intervention exerted a significant effect on the number and quality of improvement projects undertaken and self-defined objectives met . Failure of the effects of the intervention on the other dimensions of practice management to achieve significance may be due to the topics selected for some of the improvement projects being only partly covered by the assessment instrument OBJECTIVE --To test the impact of physician education and facilitator assisted office system interventions on cancer early detection and preventive services . DESIGN --A r and omised trial of two interventions alone and in combination . SETTING AND SUBJECTS -- Physicians in 98 ambulatory care practice s in the United States . INTERVENTIONS --The education intervention consisted of a day long physician meeting directed at improving knowledge , attitudes , and skills relevant to cancer prevention and early detection . The office system intervention consisted of assistance from a project facilitator in establishing routines for providing needed services . These routines included division of responsibilities for providing services among physicians and their staff and the use of medical record flow sheets . MAIN OUTCOME MEASURES --The proportions of patients provided the cancer prevention and early detection services  indicated annually according to the US National Cancer Institute . RESULTS --Based on cross sectional patient surveys , the office system intervention was associated with an increase in mammography , the recommendation to do breast self examination , clinical breast examination , faecal occult blood testing , advice to quit smoking , and the recommendation to decrease dietary fat . Education was associated only with an increase in mammography . Record review for a patient cohort confirmed cross sectional survey findings regarding the office system for mammography and faecal occult blood testing . CONCLUSION --Community practice s assisted by a facilitator in the development and implementation of an office system can substantially improve provision of cancer early detection and preventive services Systematic review s provide the best evidence on the effectiveness of healthcare interventions including quality improvement strategies . The methods of systematic review of individual patient r and omised trials of healthcare interventions are well developed . We discuss method ological and practice issues that need to be considered when undertaking systematic review s of quality improvement strategies including developing a review protocol , identifying and screening evidence sources , quality assessment and data abstract ion , analytical methods , reporting systematic review s , and appraising systematic review s. This paper builds on our experiences within the Cochrane Effective Practice and Organisation of Care ( EPOC ) review group OBJECTIVES The authors estimate separately contributions of each component intervention to overall effectiveness of quality assurance cycles used to improve practice performance . METHODS In a r and omized , controlled trial , experimental cycles of quality assurance were conducted for eight patient-care guidelines , with two experimental cycles assigned to each of 16 group practice s. For three separate interventions per cycle , practitioners : ( 1 ) were notified of the name of the experimental guideline , ( 2 ) discussed criteria of conformance to the guideline , and ( 3 ) received feedback on performance . Actions taken in response to interventions were documented . Using medical records data for a baseline year and for 3 months after each intervention and an additional 9 months , the authors scored each practice for conformance to two experimental guidelines and to control guidelines . RESULTS For all patient-care guidelines combined , and for four of five guidelines showing improvement , knowledge of guidelines and review criteria alone produced no change . After feedback , performance improved and improvement persisted for at least 9 months . The number of corrective actions implemented contributed significantly to effectiveness of quality assurance . CONCLUSIONS Feedback to providers of data on their performance is a more powerful stimulus for quality improvement than is knowledge of guidelines or discussion of review criteria OBJECTIVE To assess the impact of a quality improvement ( QI ) intervention on the quality of diabetes care at primary care clinics . RESEARCH DESIGN AND METHODS Twelve primary care medical practice s were matched by size and location and r and omized to intervention or control conditions . Intervention clinic staff were trained in a seven-step QI change process to improve diabetes care . Surveys and medical record review s of 754 patients , surveys of 329 clinic staff , interviews with clinic leaders , and analysis of training session videotapes evaluated compliance with and impact of the intervention . Mixed-model nested analyses compared differences in the quality of diabetes care before and after intervention . RESULTS All intervention clinics completed at least six steps of the seven-step QI change process in an 18-month period and , compared with control clinics , had broader staff participation in QI activities ( P = 0.04 ) , used patient registries more often ( P = 0.03 ) , and had better test rates for HbA(1c ) ( A1C ) , LDL , and blood pressure ( P = 0.02 ) . Other processes of diabetes care were unchanged . The intervention did not improve A1C ( P = 0.54 ) , LDL ( P = 0.46 ) , or blood pressure ( P = 0.69 ) levels or a composite of these outcomes ( P = 0.35 ) . CONCLUSIONS This QI change process was successfully implemented but failed to improve A1C , LDL , or blood pressure levels . Data suggest that to be successful , such a QI change process should direct more attention to specific clinical actions , such as drug intensification and patient activation OBJECTIVES : To assess the effects of outreach visits by trained nurse facilitators  on the organisation of services used to prevent cardiovascular disease . To identify the characteristics of general practice s that determined success . DESIGN : A non-r and omised controlled trial of two methods of implementing guidelines to organise prevention of cardiovascular disease : an innovative outreach visit method compared with a feedback method . The results in both groups were compared with data from a control group . SETTING AND SUBJECTS : 95 general practice s in two regions in The Netherl and s. INTERVENTIONS : Trained nurse facilitators visited practice s , focusing on solving problems in the organisation of prevention . They applied a four step model in each practice . The number of visits depended on the needs of the practice team . The feedback method consisted of the provision of a feedback report with advice specific to each practice and st and ardised instructions . MAIN OUTCOME MEASURES : The proportion of practice s adhering to 10 different guidelines . Guidelines were on the detection of patients at risk , their follow up , the registration of preventive activities , and teamwork within the practice . RESULTS : Outreach visits were more effective than feedback in implementing guidelines to organise prevention . Within the group with outreach visits , the increase in the number of practice s adhering to the guidelines was significant for six out of 10 guidelines . Within the feedback group , a comparison of data before and after intervention showed no significant differences . Partnerships and practice s with a computer changed more . CONCLUSION : Outreach visits by trained nurse facilitators proved to be effective in implementing guidelines within general practice s , probably because their help was practical and design ed for the individual practice , guided by the wishes and capabilities of the practice team PURPOSE The objective of this study was to eluci date the effect of facilitation on practice outcomes in the 2-year patient-centered medical home ( PCMH ) National Demonstration Project ( NDP ) intervention , and to describe practice s ’ experience in implementing different components of the NDP model of the PCMH . METHODS Thirty-six family practice s were r and omized to a  facilitated intervention group or a self-directed intervention group . We measured 3 practice -level outcomes : ( 1 ) the proportion of 39 components of the NDP model that practice s implemented , ( 2 ) the aggregate patient rating of the practice s ’ PCMH attributes , and ( 3 ) the practice s ’ ability to make and sustain change , which we term adaptive reserve . We used a repeated- measures analysis of variance to test the intervention effects . RESULTS By the end of the 2 years of the NDP , practice s in both facilitated and self-directed groups had at least 70 % of the NDP model components in place . Implementation was relatively harder if the model component affected multiple roles and processes , required coordination across work units , necessitated additional re sources and expertise , or challenged the traditional model of primary care . Electronic visits , group visits , team-based care , wellness promotion , and proactive population management presented the greatest challenges . Controlling for baseline differences and practice size , facilitated practice s had greater increases in adaptive reserve ( group difference by time , P = .005 ) and the proportion of NDP model components  implemented ( group difference by time , P=.02 ) ; the latter increased from 42 % to 72 % in the facilitated group and from 54 % to 70 % in the self-directed group . Patient ratings of the practice s ’ PCMH attributes did not differ between groups and , in fact , diminished in both of them . CONCLUSIONS Highly motivated practice s can implement many components of the PCMH in 2 years , but apparently at a 
    Output:
    
CONCLUSION Practice facilitation has a moderately robust effect on evidence -based guideline adoption within primary care .