***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 To strengthen suicide prevention skills in mental health care in The Netherl and s , multidisciplinary teams throughout the country are trained in the application of the new  Dutch guideline on the assessment and treatment of  suicidal behavior . Previous studies have shown beneficial effects of additional efforts for guideline implementation on professionals ’ attitude , knowledge , and skills . However , the effects on patients are equally important , but are rarely measured . The main objective of this study is to examine whether patients of multidisciplinary teams who are trained in guideline application show greater recovery from suicide ideation than patients of untrained teams . Methods / Design This is a multicentre cluster r and omized controlled trial ( RCT ) , in which multidisciplinary teams from mental health care institutions are matched in pairs , and r and omly allocated to either the experimental or control condition . In the experimental condition , next to the usual dissemination of the guideline ( internet , newsletter , books , publications , and congresses ) , teams will be trained in the application of the guideline via a 1-day small interactive group training program supported by e-learning modules . In the control condition , no additional actions next to usual dissemination of the guideline will be undertaken . Assessment s at patient level will start when the experimental teams are trained . Assessment s will take place upon admission and after 3 months , or earlier if the patient is discharged . The primary outcome is suicide ideation . Secondary outcomes are non-fatal suicide attempts , level of treatment satisfaction , and societal costs . Both a cost-effectiveness and cost-utility analysis will be performed . The effects of the intervention will be examined in multilevel models . Discussion The strengths of this study are the size of the study , RCT design , training of complete multidisciplinary teams , and the willingness of both management and staff to participate . Trial registration Netherl and s trial register : Background Interventions design ed to narrow the gap between research findings and clinical practice may be effective , but also costly . Economic evaluations are necessary to judge whether such interventions are worth the effort . We have evaluated the economic effects of a tailored intervention to support the implementation of guidelines for the use of antihypertensive and cholesterol-lowering drugs . The tailored intervention was evaluated in a r and omized trial , and was shown to significantly increase the use of thiazides for patients started on antihypertensive medication , but had little or no impact on other outcomes . The increased use of thiazides was not expected to have an impact on health outcomes . Methods and Findings We performed cost-minimization and cost-effectiveness analyses on data from a r and omized trial involving 146 general practice s from two geographical areas in Norway . Each practice was r and omized to either the tailored intervention ( 70 practice s ; 257 physicians ) or control group ( 69 practice s ; 244 physicians ) . Only patients that were being started on antihypertensive medication were included in the analyses . A multifaceted intervention was tailored to address identified barriers to change . Key components were an educational outreach visit with audit and feedback , and computerized reminders . Pharmacists conducted the visits . A cost-minimization framework was adopted , where the costs of intervention were set against the reduced treatment costs ( principally due to increased use of thiazides rather than more expensive medication ) . The cost-effectiveness of the intervention was estimated as the cost per additional patient being started on thiazides . The net annual cost ( cost minimization ) in our study population was US$ 53,395 , corresponding to US$ 763 per practice . The cost per additional patient started on thiazides ( cost-effectiveness ) was US$ 454 . The net annual savings in a national program was modeled to be US$ 761,998 , or US$ 540 per practice after 2 y. In this scenario the savings exceeded the costs in all but two of the sensitivity analyses we conducted , and the cost-effectiveness was estimated to be US$ 183 . Conclusions We found a significant shift in prescribing of antihypertensive drugs towards the use of thiazides in our trial . A major reason to promote the use of thiazides is their lower price compared to other drugs . The cost of the intervention was more than twice the savings within the time frame of our study . However , we predict modest savings over a 2-y period Abstract Objective : To evaluate the use of a computerised support system for decision making for implementing evidence based clinical guidelines for the management of asthma and angina in adults in primary care . Design : A before and after pragmatic cluster r and omised controlled trial utilising a two by two incomplete block design . Setting : 60 general practice s in north east Engl and . Participants : General practitioners and practice nurses in the study practice s and their patients aged 18 or over with angina or asthma . Main outcome measures : Adherence to the guidelines , based on review of case notes and patient reported generic and condition specific outcome measures . Results : The computerised decision support system had no significant effect on consultation rates , process of care measures ( including prescribing ) , or any patient reported outcomes for either condition . Levels of use of the software were low . Conclusions : No effect was found of computerised evidence based guidelines on the management of asthma or angina in adults in primary care . This was probably due to low levels of use of the software , despite the system being optimised as far as was technically possible . Even if the technical problems of producing a system that fully supports the management of chronic disease were solved , there remains the challenge of integrating the systems into clinical encounters where busy practitioners manage patients with complex , multiple conditions Background A r and omised trial of a multifaceted intervention for improving adherence to clinical practice guidelines for the pharmacological management of hypertension and hypercholesterolemia increased prescribing of thiazides , butdetected no impact onthe use of cardiovascular risk assessment toolsor achievement of treatment targets . We carried out a predominantly quantitative process evaluation to help explain and interpret the trial- findings . Methods Several data - sources were used including :  question  naires completed by  pharmacists  immediately after educational outreach visits  , semi-structured interviews with physicians subjected to the intervention , and data extracted from their electronic medical records . Multivariate regression analyses were conducted to explore the association between possible explanatory variables and the observed variation across practice s for the three main outcomes . Results The attendance rate during the educational sessions in each practice was high ; few problems were reported , and the physicians were perceived as being largely supportive of the recommendations we promoted , except for some scepticism regarding the use of thiazides as first-line antihypertensive medication . Multivariate regression models could explain only a small part of the observed variation across practice s and across trial- outcomes , and key factors that might explain the observed variation in adherence to the recommendations across practice s were not identified . Conclusion This study did not provide compelling explanations for the trial results . Possible reasons for this include a lack of statistical power and failure to include potential explanatory variables in our analyses , particularly organisational factors . More use of qualitative research methods in the course of the trial could have improved our underst and ing BACKGROUND Good blood pressure ( BP ) control reduces the risk of complications in people with type 2 diabetes , yet many do not achieve this . Guidelines for managing hypertension recommend increasing antihypertensive medications until control is achieved , but the effect of such recommendations in routine primary care is unknown . AIM To evaluate the effectiveness of a BP treatment algorithm in primary care patients with type 2 diabetes . DESIGN OF STUDY A cluster r and omised controlled trial of 1534 patients with type 2 diabetes . SETTING Forty-two practice s in Nottingham , UK . METHOD Practice s were r and omised to continue usual care or to use a treatment algorithm design ed so that practice nurses and GPs would increase antihypertensive treatment in steps until the target of 140/80 mmHg was reached . Participants were assessed by a clinical interview and case note review at recruitment and at 1 year . The primary outcome measure was the proportion of participants achieving target BP at 1 year . RESULTS At 1 year there was no difference between the proportions of participants with well controlled BP in the intervention and control arms ( 36.6 % versus 34.3 % ; P = 0.27 ) . Mean systolic and diastolic blood pressures were identical in the two arms ( 143/78 mmHg ) . There was some evidence that participants in the intervention arm were more likely to be receiving higher doses of their antihypertensive drugs , although there was no significant difference in the number of different antihypertensive drugs prescribed . Participants in the intervention arm had a higher rate of primary care BP-related consultations over 12 months than those receiving usual care ( rate ratio = 1.55 , 95 % confidence interval [ CI ] = 1.26 to 1.88 , P<0.001 ) . CONCLUSION Despite increased monitoring and possibly higher doses of medication there was no improvement in blood pressure control . Improvements achieved by specialist nurse-led clinics in secondary care may not translate to people with type 2 diabetes in primary care setting 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 Implementation research is concerned with bridging the gap between evidence and practice through the study of methods to promote the uptake of research into routine practice . Good quality evidence has been summarised into guideline recommendations to show that peri-operative fasting times could be considerably shorter than patients currently experience . The objective of this trial was to evaluate the effectiveness of three strategies for the implementation of recommendations about peri-operative fasting . Methods A pragmatic cluster r and omised trial underpinned by the PARIHS framework was conducted during 2006 to 2009 with a national sample of UK hospitals using time series with mixed methods process evaluation and cost analysis . Hospitals were r and omised to one of three interventions : st and ard dissemination ( SD ) of a guideline package , SD plus a web-based re source championed by an opinion leader , and SD plus plan-do- study -act ( PDSA ) . The primary outcome was duration of fluid fast prior to induction of anaesthesia . Secondary outcomes included duration of food fast , patients ’ experiences , and stakeholders ’ experiences of implementation , including influences . ANOVA was used to test differences over time and interventions . Results Nineteen acute NHS hospitals participated . Across timepoints , 3,505  duration of fasting observations were recorded . No significant effect of the interventions was observed for either fluid or food fasting times . The effect size was 0.33 for the web-based intervention compared to SD alone for the change in fluid fasting and was 0.12 for PDSA compared to SD alone . The process evaluation showed different types of impact , including changes to practice s , policies , and attitudes . A rich picture of the implementation challenges emerged , including inter-professional tensions and a lack of clarity for decision-making authority and responsibility . Conclusions This was a large , complex study and one of the first national r and omised controlled trials conducted within acute care in implementation research . The evidence base for fasting practice was accepted by those participating in this study and the messages from it simple ; however , implementation and practical challenges influenced the interventions ’ impact . A set of conditions for implementation emerges from the findings of this study , which are presented as theoretically transferable propositions that have international relevance .Trial registration IS RCT N18046709 - Peri-operative Implementation Study Evaluation ( POISE ) Abstract Objective To test a multifaceted collaborative quality improvement intervention design ed to promote evidence based surfactant treatment for preterm infants of 23 - 29 weeks ' gestation . Design Cluster r and omised controlled trial Setting and participants 114 neonatal intensive care units ( which treated 6039 infants of 23 - 29 weeks gestation born in 2001 ) . Main outcome measures Process of care measures : proportion of infants receiving first surfactant in the delivery room  , proportion receiving first surfactant more than two hours after birth  , and median time from birth to first dose of surfactant . Clinical outcomes : death before discharge home , and pneumothorax . Intervention Multifaceted collaborative quality improvement advice including audit and feedback , evidence review s , an interactive training workshop , and ongoing faculty support via conference calls and email . Results Compared with those in control hospitals , infants in intervention hospitals were more likely to receive surfactant in the delivery room ( adjusted odds ratio 5.38 ( 95 % confidence interval 2.84 to 10.20 ) ) , were less likely to receive the first do 
    Output:
    
Providing healthcare professionals with a tool to improve implementation of a guideline may lead to little or no difference in costs to the health service .
Implementation tools developed by recognised guideline producers probably lead to improved healthcare professionals ' adherence to guidelines in the management of non-specific low back pain and ordering thyroid-function tests .
There are limited data on the relative costs of implementing these interventions .There are no studies evaluating the effectiveness of interventions targeting the organisation of care ( e.g. benchmarking tools , costing templates , etc .
We could not draw any conclusions about our second objective , the comparative effectiveness of implementation tools , due to the small number of studies , the heterogeneity between interventions , and the clinical conditions that were targeted