***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 effects of a Dutch national prevention programme , aim ed at general practitioners ( GPs ) , on the adherence to organizational guidelines for effective cervical cancer screening  in general practice . To identify the characteristics of general practice s determining success . DESIGN A prospect i ve question naire study with pre- and post-measurement ( before and 15 months after the introduction of the national programme ) . SETTING AND STUDY PARTICIPANTS A r and om sample of one-third of all 4758 Dutch general practice s. One GP was asked to participate per practice . INTERVENTION A national GP prevention programme to improve population -based prevention of cervical cancer combining various methods for quality improvement in general practice , performed on a national , district and practice level . Outreach visitors were a key strategy in bringing about behavioural changes . MAIN OUTCOME MEASURES The proportion of practice s adhering to 10 recommendations ( in four guidelines ) to organize effective cervical cancer screening .  RESULTS After 15 months , all Dutch practice s showed significant improvement in adherence to nine out of 10 recommendations . Two recommendations , in particular ' identifying women who should be medically excluded from screening ' and ' sending a reminder to non-compliers ' showed the largest absolute increases of 26 % and 33 % , respectively . Besides more intensive support of outreach visitors , practice characteristics such as ' computerization ' and ' delegation of many clinical tasks to the practice assistant ' were important in improving the adherence to guidelines . CONCLUSION The national programme , with a combination of various methods for quality improvement , appeared to be effective in improving the organization of cervical screening in general practice . Computerization and , to a lesser extent , delegation of many clinical tasks to the practice assistant and more intensive support to practice s , positively influenced the effectiveness of the national programme Objectives : To evaluate the effect on the process of care of an active strategy to implement clinical guidelines on physiotherapy for low back pain . Design : A cluster r and omised controlled trial comparing an active strategy with st and ard dissemination . Setting : Primary care physiotherapy practice s. Participants : 113 physiotherapists were r and omly allocated to receive the guidelines by mail ( control group ) or to receive an additional active strategy ( intervention group ) which consisted of a multifaceted programme including education , discussion , role playing , feedback , and reminders . Main outcome measures : Adherence to the guidelines was measured by means of individual patients ’ forms recording the treatment completed by the physiotherapist . The forms were assessed using an algorithm based on the number of treatment sessions , treatment goals , interventions , and patient education . Results : Physiotherapists in the intervention group more often correctly limited the number of treatment sessions for patients with a normal course of back pain ( OR 2.39 ; 95 % CI 1.12 to 5.12 ) , more often set functional treatment goals ( OR 1.99 ; 95 % CI 1.06 to 3.72 ) , more often used mainly active interventions ( OR 2.79 ; 95 % CI 1.19 to 6.55 ) , and more often gave adequate patient education ( OR 3.59 ; 95 % CI 1.35 to 9.55 ) . They also adhered more to all four criteria ( OR 2.05 ; 95 % CI 1.15 to 3.65 ) . Conclusions : The active strategy moderately improved adherence to the guidelines . Active strategies are recommended to implement the clinical guidelines on physiotherapy for low back pain BACKGROUND There is still only limited underst and ing of whether and why interventions to facilitate the implementation of guidelines for improving primary care are successful . It is therefore important to look inside the ' black box ' of the intervention , to ascertain which elements work well or less well . AIM To assess the associations of key elements of a nationwide multifaceted prevention programme with the successful implementation of cervical screening guidelines in general practice . DESIGN OF STUDY A nationwide prospect i ve cohort study . SETTING A r and om sample of one-third of all 4,758 general practice s in The Netherl and s ( n = 1,586 ) . METHOD General practitioners ( GPs ) in The Netherl and s were exposed to a two- and -a-half-year nationwide multifaceted prevention programme to improve the adherence to national guidelines for cervical cancer screening . Adherence to guidelines at baseline and after the intervention and actual exposure to programme elements were assessed in the sample using self-administered question naires . RESULTS Both baseline and post-measurement question naires were returned by 988 practice s ( response rate = 62 % ) . No major differences in baseline practice characteristics between study population , non-responders , and all Netherl and s practice s were observed . After the intervention all practice s improved markedly ( P<0.001 ) in their incorporation of nine out of 10 guideline indicators for effective cervical screening into practice . The most important elements for successful implementation were : specific software modules ( odds ratios and 95 % confidence intervalsfor all nine indicators ranged from OR = 1.85 [ 95 % CI = 1.24 - 2.77 ] to OR = 10.2 [ 95 % CI = 7.58 - 14.1 ] ) ; two or more ' practice visits ' by outreach visitors ( ORs and 95 % CIs for six indicators ranged from OR = 1.46 [ 95 % CI= 1.01 - 2.12 ] to OR = 2.35 [ 95 % CI = 1.63 - 3.38 ] ) ; and an educational programme for practice assistants ( ORs and 95 % CIs for four indicators ranged from OR = 1.57 [ 95 % CI = 1.00 - 1.92 ] to OR = 1.90 [ 95 % CI = 1.25 - 2.88 ] ) . CONCLUSION A multifaceted programme targeting GPs , including facilitating software modules , outreach visits , and educational sessions for PAs , contributes to the successful implementation of national guidelines for cervical screening BACKGROUND AND PURPOSE An active strategy was developed for the implementation of the clinical guidelines on physical therapy for patients with low back pain . The effect of this strategy on patients ' physical functioning , coping strategy , and beliefs regarding their low back pain was studied . SUBJECTS One hundred thirteen primary care physical therapists treated a total of 500 patients . METHODS The physical therapists were r and omly assigned to 1 of 2 groups . The control group received the guidelines by mail ( st and ard passive method of dissemination ) . The intervention group , in contrast , received an additional active training strategy consisting of 2 sessions with education , group discussion , role playing , feedback , and reminders .  Patients with low back pain , treated by the participating therapists , completed question naires on physical functioning , pain , sick leave , coping , and beliefs . RESULTS Physical functioning and pain in the 2 groups improved substantially in the first 12 weeks . Multilevel longitudinal analysis showed no differences between the 2 groups on any outcome measure during follow-up . DISCUSSION AND CONCLUSION The authors found no additional benefit to applying an active strategy to implement the physical therapy guidelines for patients with low back pain . Active implementation strategies are not recommended if patient outcomes are to be improved OBJECTIVE To evaluate the feasibility and implementation needs of a cholesterol guideline by assessing the effectiveness of simple dissemination as well as extensive implementation of this guideline on actual performance of general practitioners ( GPs ) . DESIGN R and omized controlled trial . SETTING AND SUBJECTS Thirty-two Dutch GPs in 20 general practice s , 3950 patient records . INTERVENTIONS Guideline dissemination to all 32 GPs , and a 5-month programme for improvement in the intervention group . This programme was developed after barriers to working according to the guideline had been investigated , and consisted of group education , desktop supportive material s , feedback on performance , and face-to-face instruction on location . MAIN OUTCOME MEASURES The outcome parameters were defined as quality of selective case finding and quality of diagnostic procedures , and were measured by chart audit . RESULTS The quality of selective case finding , especially the targeting of cholesterol testing to those with positive cardiovascular risk profiles , did not improve following intervention . Performance of the procedure necessary to diagnose hypercholesterolaemia even deteriorated . The quantity of cholesterol testing increased in both groups , but this was probably explained by the increased availability of desktop cholesterol analysers . CONCLUSIONS Neither simple dissemination nor an intensive programme for improvement had measurable impact on actual performance on working according to the cholesterol guideline . Both the validity and the opinion about feasibility of the guideline in daily practice deserve more attention during guideline development OBJECTIVE : To study the effectiveness of an intensive small group education and peer review programme aim ed at implementing national guidelines on asthma/chronic obstructive pulmonary disease ( COPD ) on care provision by general practitioners ( GPs ) and on patient outcomes . DESIGN : A r and omised experimental study with pre-measurement and post-measurement ( after one year ) in an experimental group and a control group in Dutch general practice . SUBJECTS AND INTERVENTION : Two groups of GPs were formed and r and omised . The education and peer review group ( 17 GPs with 210 patients ) had an intervention consisting of an interactive group education and peer review programme ( four sessions each lasting two hours ) . The control group consisted of 17 GPs with 223 patients ( no intervention ) . MAIN OUTCOME MEASURES : Knowledge , skills , opinion about asthma and COPD care , presence of equipment in practice ; actual performance about peakflow measurement , non-pharmacological and pharmacological treatment ; asthma symptoms ( Dutch Medical Research Council ) , smoking habits , exacerbation ratio , and disease specific quality of life ( QOL-RIQ ) . Data were collected by a written question naire for GPs , by self recording of consultations by GPs , and by a written self administered question naire for adult patients with asthma/ COPD . RESULTS : Data from 34 GP question naires , 433 patient question naires , and recordings from 934 consultations/visits and 350 repeat prescriptions were available . Compared with the control group there were only significant changes for self estimated skills ( + 16 % , 95 % confidence interval 4 % to 26 % ) and presence of peakflow meters in practice ( + 18 % , p < 0.05 ) . No significant changes were found for provided care and patient outcomes compared with the control group . In the subgroup of more severe patients , the group of older patients , and in the group of patients not using anti-inflammatory medication at baseline , no significant changes compared with the control group were seen in patient outcomes . CONCLUSION : Except for two aspects , intensive small group education and peer review in asthma and COPD care do not seem to be effective in changing relevant aspects of the provided care by GPs in accordance with guidelines , nor in changing patients ' health status OBJECTIVE To assess the evidence for the effectiveness of clinical practice guidelines ( CPGs ) in improving  patient outcomes in primary care . DATA SOURCES A search of the MEDLINE , HEALTHPLAN , CINAHL and FAMLI data bases was conducted to identify studies published between Jan. 1 , 1980 , and Dec. 31 , 1995 , concerning the use of guidelines in primary medical care . The keywords used in the search were " clinical guidelines , " " primary care , " " clinical care , " " intervention , " " r and omized controlled trial " and " effectiveness . " STUDY SELECTION Studies of the use of CPGs were selected if they involved a r and omized experimental or quasi-experimental method , concerned primary care , were related to clinical care and examined patient outcomes . Of 91 trials of CPGs identified through the search , 13 met the criteria for inclusion in the critical appraisal . DATA EXTRACTION The following data were extracted , when possible , from the 13 trials : country and setting , number of physicians , number of patients  ( and the proportion followed to completion ) , length of follow-up , study method ( including r and om assignment method ) , type of intervention , medical condition treated and effect on patient outcomes ( including clinical and statistical significance , with confidence intervals ) . DATA SYNTHESIS The most common conditions studied were  hypertension ( 7 studies ) , asthma ( 2 studies ) and cigarette smoking ( 2 studies ) . Four of the studies followed nationally developed guidelines , and 9 used locally developed guidelines . Six studies involved computerized or automated reminder systems , whereas the others relied on small-group workshops and education sessions . Only 5 of the 13 trials ( 38 % ) produced statistically significant results . CONCLUSION There is very little evidence that the use of CPGs improves patient outcomes in primary medical care , but most studies published to date have used older guidelines and methods , which may have been insensitive to small changes in outcomes . Research is needed to determine whether the newer , evidence -based CPGs have an effect on patient outcomes OBJECTIVE To assess the long-term effectiveness of a quality improvement program on care provided and patient outcomes in patients with diabetes . RESEARCH DESIGN AND METHODS A nonr and omized trial was performed with 312 patients with type 2 diabetes in the intervention group and 77 patients with type 2 diabetes in the reference group . The follow-up period was 42 months . The quality improvement program focused on improving both the provision of diabetes care and the patient outcomes . The program consisted of clinical practice guidelines , postgraduate education , audit and feedback , templates to register diabetes care , and a recall system . Data on the care provided were abstract ed from medical records . Main outcomes on the provision of care were annual number of patient visits , blood pressure , and HbA(1c ) and blood lipid levels . Main patient outcomes were blood pressure and H 
    Output:
    
This review demonstrates that Dutch evidence -based clinical guidelines can be effective in improving the process and structure of care .
The high level of variation in effects across recommendations suggests that implementation strategies tailored to individual recommendations within the guideline are needed to establish relevant improvements in healthcare .