***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 
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    Input: Background and Purpose — We developed a new postdischarge system of care comprising a structured assessment covering longer-term problems experienced by patients with stroke and their carers , linked to evidence -based treatment algorithms and reference guides ( the longer-term stroke care system of care ) to address the poor longer-term recovery experienced by many patients with stroke . Methods — A pragmatic , multicentre , cluster r and omized controlled trial of this system of care . Eligible patients referred to community-based Stroke Care Coordinators were r and omized to receive the new system of care or usual practice . The primary outcome was improved patient psychological well-being ( General Health Question naire-12 ) at 6 months ; secondary outcomes included functional outcomes for patients , carer outcomes , and cost-effectiveness . Follow-up was through self-completed postal question naires at 6 and 12 months . Results — Thirty-two stroke services were r and omized ( 29 participated ) ; 800 patients ( 399 control ; 401 intervention ) and 208 carers ( 100 control ; 108 intervention ) were recruited . In intention to treat analysis , the adjusted difference in patient General Health Question naire-12 mean scores at 6 months was −0.6 points ( 95 % confidence interval , −1.8 to 0.7 ; P=0.394 ) indicating no evidence of statistically significant difference between the groups . Costs of Stroke Care Coordinator inputs , total health and social care costs , and quality -adjusted life year gains at 6 months , 12 months , and over the year were similar between the groups . Conclusions — This robust trial demonstrated no benefit in clinical or cost-effectiveness outcomes associated with the new system of care compared with usual Stroke Care Coordinator practice . Clinical Trial Registration — URL : http://www.controlled-trials.com . Unique identifier : IS RCT N 67932305 OBJECTIVE To assess the effects of a facilitator enhanced multifaceted intervention to implement a locally adapted guideline on the shared care for people with type 2 diabetes . METHODS During 1 year a cluster-r and omized trial was performed in 30 general practice s. In the intervention group , nurse facilitators enhanced guideline implementation by analysing barriers to change , introducing structured care , training practice staff and giving performance feedback . Targets for HbA1c% , systolic blood pressure as well as indications for angiotensin converting enzyme/angiotensin receptor blocking agent prescription differed from the national guidelines . In the control group , GPs were asked to continue the care for people with diabetes as usually . Generalized estimating equations were used to control for the clustered design of the study . RESULTS In the intervention group , more people were seen on a 3-monthly basis ( 88 % versus 69 % , P < 0.001 ) and more blood pressure and bodyweight measurements were performed every 3 months ( blood pressure 83 % versus 66 % , P < 0.001 and bodyweight 78.9 % versus 48.5 % , P < 0.001 ) . Apart from a marginal difference in mean cholesterol , differences in HbA1c% , blood pressure , body mass index and treatment satisfaction were not significant . CONCLUSION Multifaceted implementation of locally adapted shared care guidelines did improve the process of diabetes care but hardly changed intermediate outcomes . In the short term , local adaptation of shared care guidelines does not improve the cardiovascular risks of people with type 2 diabetes Background and objectives Many clinical management guidelines for chronic diseases have been published , but they have not been put into practice by busy clinicians at primary care levels . This study evaluates the implementation of national guidelines incorporated within a structured diabetes and hypertension clinical record ( SR ) in Cape Town in a r and omised controlled trial ( RCT ) . Methods Eighteen public sector community health centres ( CHC ) were r and omly selected and allocated as intervention or control CHC . At each clinic , 25 patients with diabetes and 35 patients with hypertension were enrolled at baseline . Question naires were completed , blood sample s were collected , blood pressure ( BP ) and anthropometric measures were taken and patient records were audited . SR with clinical guideline prompts were introduced at the intervention clinics after training doctors in their use and suggestions to incorporate them in regular patient records . Contact was maintained during the year of intervention with the clinic staff . A follow-up survey was conducted 1 year later to assess BP and HbA1c , and the patient records were examined to ascertain the extent of use of the SR in the intervention clinics . In-depth interviews were conducted with doctors and nurses to record their response to the intervention . Results The intervention evaluated in this RCT had no impact on either diabetes or hypertension control . In the intervention clinics , less than 60 % of the patient folders contained the SR and when present was seldom used . Although the staff were well disposed to the research team , their workload prohibited them from undertaking a true evaluation of the SR , and overall they did not perceive the SR as supporting their current process of patient care . Conclusions No benefit to diabetes of hypertension care by introducing and availability of the staff in the use of the SR was shown in this RCT . The process measures suggest that the SR was not widely used by the healthcare provided in the primary care clinics IMPORTANCE Pay for performance is intended to align incentives to promote high- quality care , but results have been contradictory . OBJECTIVE To test the effect of explicit financial incentives to reward guideline -recommended hypertension care . DESIGN , SETTING , AND PARTICIPANTS Cluster r and omized trial of 12 Veterans Affairs outpatient clinics with 5 performance periods and a 12-month washout that enrolled 83 primary care physicians and 42 nonphysician personnel ( eg , nurses , pharmacists ) . INTERVENTIONS Physician-level ( individual ) incentives , practice -level incentives , both , or none . Intervention participants received up to 5 payments every 4 months ; all participants could access feedback reports . MAIN OUTCOMES AND MEASURES Among a r and om sample , number of patients achieving guideline -recommended blood pressure thresholds or receiving an appropriate response to uncontrolled blood pressure , number of patients prescribed guideline -recommended medications , and number who developed hypotension . RESULTS Mean ( SD ) total payments over the study were $ 4270 ( $ 459 ) , $ 2672 ( $ 153 ) , and $ 1648 ( $ 248 ) for the combined , individual , and practice -level interventions , respectively . The unadjusted baseline and final percentages and the adjusted absolute change over the study in patients meeting the combined blood pressure/appropriate response measure were 75 % to 84 % and 8.84 % ( 95 % CI , 4.20 % to 11.80 % ) for the individual group , 80 % to 85 % and 3.70 % ( 95 % CI , 0.24 % to 7.68 % ) for the practice -level group , 79 % to 88 % and 5.54 % ( 95 % CI , 1.92 % to 9.52 % ) for the combined group , and 86 % to 86 % and 0.47 % ( 95 % CI , -3.12 % to 4.04 % ) for the control group . The adjusted absolute estimated difference in the change between the proportion of patients with blood pressure control/appropriate response for individual incentive and control groups was 8.36 % ( 95 % CI , 2.40 % to 13.00 % ; P=.005 ) . The other incentive groups did not show a significant change compared with controls for this outcome . For medications , the unadjusted baseline and final percentages and the adjusted absolute change were 61 % to 73 % and 9.07 % ( 95 % CI , 4.52 % to 13.44 % ) , 56 % to 65 % and 4.98 % ( 95 % CI , 0.64 % to 10.08 % ) , 65 % to 80 % and 7.26 % ( 95 % CI , 2.92 % to 12.48 % ) , and 63 % to 72 % and 4.35 % ( 95 % CI , -0.28 % to 9.28 % ) , respectively . These changes in the use of guideline -recommended medications were not significant in any of the incentive groups compared with controls , nor was the incidence of hypotension . The effect of the incentive was not sustained after a washout . CONCLUSIONS AND RELEVANCE Individual financial incentives , but not practice -level or combined incentives , result ed in greater blood pressure control or appropriate response to uncontrolled blood pressure ; none of the incentives result ed in greater use of guideline -recommended medications or increased incidence of hypotension compared with controls . Further research is needed on the factors that contributed to these findings . TRIAL REGISTRATION clinical trials.gov Identifier : NCT00302718 BACKGROUND Although high blood pressure is associated with significant morbidity and mortality , the proportion reaching the goal blood pressures as outlined in the Seventh Report of the Joint National Committee on Prevention , Detection , Evaluation , Treatment of High Blood Pressure ( JNC 7 ) is low . We conducted a r and omized trial in primary care practice s of a multifactorial intervention targeted to improve providers ' adherence to hypertension guidelines . METHOD A total of 61 primary care practice s in North Carolina were r and omized to receive either a multifactorial intervention ( guideline dissemination via a continuing medical education session , academic detailing sessions , audit and feedback on preintervention rates of adherence , and automated blood pressure machines ) or an attention control of similar magnitude but targeted at a different guideline . Outcomes were determined through review of patient charts conducted by an independent masked quality assurance organization . RESULTS We found no difference between the 2 groups in any of the adherence measures including no difference in the percentage of patients at goal ( intervention 49.2 % , control 50.6 % ) , with undiagnosed hypertension  ( 18.1 % vs 13.6 % ) , average systolic ( 126 vs 125.1 mm Hg ) , or diastolic blood pressure ( 73.1 vs 73.4 mm Hg ) . Similarly , there was no difference in provider adherence to treatment recommendations ( use of thiazide-type diuretic as first-line therapy : 32 % vs 29.5 % ; use of 2-drug therapy in stage 2 hypertension : 11.3 % vs 10.4 % ) . CONCLUSION An intensive , multifactorial intervention did not improve adherence to national hypertension guidelines among community-based primary care . Efforts should be focused on other types of interventions to improve rates of control of hypertension Background Chronic ( systolic ) heart failure ( CHF ) is a common and disabling condition . Adherence to evidence -based guidelines in primary care has been shown to improve health outcomes . The aim was to explore the impact of a multidisciplinary educational intervention for general practitioners ( GPs ) ( Train the trainer = TTT ) on patient and performance outcomes . Methods This paper presents the key findings from the trial and discusses the lessons learned during the implementation of the TTT trial . Primary care practice s were r and omly assigned to the TTT intervention or to the control group .  37 GPs ( 18 TTT , 19 control ) were r and omised and 168 patients diagnosed with ascertained CHF ( 91 TTT , 77 control ) were enrolled . GPs in the intervention group attended four meetings addressing clinical practice guidelines and pharmacotherapy feedback . The primary outcome was patient self-reported quality of life at seven months , using the SF-36 Physical Functioning scale . Secondary outcomes included other SF-36 scales , the Kansas City Cardiomyopathy Question naire ( KCCQ ) , total mortality , heart failure hospital admissions , prescribing , depressive disorders ( PHQ-9 ) , behavioural change ( European Heart Failure Self-Care Behaviour Scale ) , patient-perceived quality of care ( EUROPEP ) and improvement of heart failure using NT-proBNP-levels . Because recruitment targets were not achieved an exploratory analysis was conducted . Results There was high baseline achievement in both groups for many outcomes . At seven months , there were no significant mean difference between groups for the primary outcome measure ( -3.3 , 95%CI -9.7 to 3.1 , p = 0.30 ) . The only difference in secondary outcomes related to the prescribing of aldosterone antagonists by GPs in the intervention group , with significant between group differences at follow-up ( 42 vs. 24 % , adjusted OR = 4.0 , 95%CI 1.2–13 ; p = 0.02 ) . Conclusion The intervention did not change the primary outcome or most secondary outcomes . Recruitment targets were not achieved and the under-recruitment of practice s and patients alongside a selection bias of participating GPs , prohibit definite conclusions , but the CI indicates a non-effectiveness of the intervention in this sample . We describe the lessons learned from conducting the trial for the future planning and conduct of confirmatory trials in primary care . Trial registration IS RCT N08601529 BACKGROUND Studies have demonstrated that blood pressure ( BP ) control can be improved when clinical pharmacists assist with patient management . The objective of this study was to evaluate if a physician and pharmacist collaborative model in community-based medical offices could improve BP control . METHODS This was a prospect i ve , cluster r and omized , controlled clinical trial with clinics r and omized to a control group ( n = 3 ) or to an intervention group ( n = 3 ) . The study enrolled 4 
    Output:
    
Conclusions Many interventions show promise to improve practitioner adherence to CVD guidelines .