***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 This study tests whether a managed behavioral health care organization can influence adherence to practice guidelines for the treatment of  major depression  in a r and omized trial of guideline dissemination . Guidelines were disseminated to mental health clinicians ( N=443 ) under one of three conditions : ( 1 ) a general mailing of guidelines to clinicians , ( 2 ) a mailing in which guidelines were targeted to a patient starting treatment with the clinician , and ( 3 ) no mailing of guidelines . The results showed no effects of guideline dissemination as measured by self-report of patients and clinicians and through episode characteristics derived from cl aims data , despite sentinel effects . Results also showed high rates of clinician-reported guideline adherence that were not detected in the cl aims data , indicating significant undertreatment of depression . Results suggest that mental health systems must look to other dissemination strategies to improve adherence to st and ards of care and raise the performance of independent practicing Little is known about incorporation of new knowledge from r and omised clinical trials into clinical practice . Thrombolytic therapy was shown to reduce the mortality of acute myocardial infa rct ion in several large trials published during 1986 - 88 . To examine the effect of these data on clinical practice , we analysed the supply of thrombolytic drugs in a representative English region ( population 4.7 million ) in 1987 - 92 . During the study period there were over 10,000 hospital admissions per year in the region for acute myocardial infa rct ion . From a very low initial level ,  thrombolytic drug use rose slowly for several years after publication of the trial results and reached a plateau in 1991 - 92 . Rates of use per 1000 patients admitted with myocardial infa rct ion varied almost six-fold between districts in 1989 - 90 and over two-fold in 1991 - 92 . Level of use attained by districts in the latter period was strongly associated with the extent of their previous participation in multicentre trials of thrombolysis ( p = 0.003 ) ; we estimate that 35 - 50 % of patients admitted with acute myocardial infa rct ion were receiving thrombolytics . The full potential of thrombolytic treatment has still not been achieved in routine care and the limiting factors need to be defined Study Design . Back‐injured workers with high disability risk scores on a predictive question naire participated in a r and omized , controlled trial of physician notification , with outcomes follow‐up 3 months after injury . Objectives . To test whether physician intervention improves return to work and self‐ assessment outcomes for people at relatively high risk for disability . Summary of Background Data . Only a small number of back‐injured workers suffer significant disability . Ouick identification of these people would facilitate more efficient targeting and trials of interventions . Controlling variations in practice through practice guidelines has been recommended as a promising strategy for improving care and reducing disability . Methods . Workers filing back injury reports responded to a disability prediction question naire . Those with high risk scores were r and omly assigned to control or intervention groups . Patient‐ design ated physicians in the intervention group received two letters identifying the patient 's risk and making recommendations for care , including the Agency for Health Care Policy and Research 's algorithms for acute low back pain . Predictive accuracy of the question naire and efficacy of physician intervention were evaluated on the basis of work status and self‐ assessment s 3 months after injury . Results . Of the 268 workers completing the question naire portion of the study , 32 ( 12 % ) were out of work because of back pain 3 months after injury . The question naire 's predictive accuracy included maximum κ of 0.277 and a receiver operating curve area of 0.78 . Fifty‐three people completed the physician intervention trial . The intervention had no significant impact on return to work , self‐assessed pain , or satisfaction with health care . Conclusions . Stratification of back‐injured people according to disability risk can can increase intervention efficiency by identifying those who require treatment and sparing those who do not . The apparent failure of risk notification and practice guidelines to reduce disability in this study may be improved by different application methods in the future BACKGROUND Public agencies responsible for implementing health care policies often adapt and disseminate clinical practice guidelines , but the effectiveness of mass dissemination of guidelines is unknown . AIM To study the effects of guideline dissemination on physicians ' prescribing practice s for the treatment of stable angina pectoris . DESIGN R and omized controlled trial . METHODS A sample of 3293 Quebec physicians were r and omly assigned to receive a one-page summary of clinical practice guidelines on the treatment of stable angina ( in February 1999 ) , to receive the summary and a reminder ( in February and March 1999 , respectively ) , or to receive no intervention ( controls ) . The prescribing profiles of participants , as well as sociodemographic characteristics of the physicians and their patients , were examined for June-December 1999 . RESULTS The intervention had no effect on prescription rates of beta-blockers , antiplatelet agents , or hypolipaemic drugs . Compared to 1997 data for the same physicians , there was an overall 10 % increase in appropriate prescription rates , irrespective of the intervention . DISCUSSION In-house production and dissemination of clinical practice guidelines may not improve physicians ' practice patterns if there is pre-existing substantial scientific consensus on the issue Health risk appraisal ( HRA ) remains one of the most widely used health promotion tools despite only equivocal evidence for its effectiveness . Theories of behavior change predict conventional HRA 's ineffectiveness because risk information alone is seldom sufficient to change complex behaviors . In this study , a r and omized trial compared the effects of feedback from an enhanced HRA with a typical HRA and a control group among adult patients from eight family medicine practice s. The enhanced HRA assessed behavior-specific psychosocial factors and provided patients with computer-generated , individually-tailored behavior change information in addition to typical HRA risk feedback . Changes in seven behaviors were assessed at a 6 month follow-up . Overall , patients receiving enhanced HRA feedback were 18 % more likely to change at least one risk behavior than were patients receiving typical HRA feedback or no feedback ( OR = 1.18 , 95 % CI = 1.00 , 1.39 ) . The enhanced HRA feedback appeared to promote changes in cholesterol screening , dietary fat consumption and physical activity , but not in smoking , seat belt use , mammography and Pap smears . We conclude that the addition of theory-based , individually-tailored behavior change information may improve the effectiveness of HRA The cost-effectiveness of quality assurance programs is often poorly documented , especially for innovative approaches . The authors analyzed the economic effects of an experimental educational outreach program design ed to reduce inappropriate drug prescribing , based on a four-state r and omized controlled trial ( N = 435 physicians ) . Primary care physicians r and omized into the face-to-face group were offered two individualized educational sessions with clinical pharmacists , lasting an average of 18 minutes each , concerning optimal use of three drug groups that are often used inappropriately . After the program , expenditures for target drugs prescribed by these physicians to Medicaid patients decreased by 13 % , compared with controls ( P = 0.002 ) ; this effect was stable over three quarters . Implementation of this program for 10,000 physicians would lead to projected drug savings ( to Medicaid only ) of $ 2,050,000 , compared with re source costs of $ 940,000 . Net savings remain high , even after adjustment for use of substitution medications . Although there was a ninefold difference in average preintervention prescribing levels between the highest and lowest thirds of the sample , all groups reduced target drug expenditures at the same rate . Targeting of higher-volume prescribers would thus further raise the observed benefit-to-cost ratio from approximately 1.8 to at least 3.0 . Net benefits would also increase further if non-Medicaid savings were added , or if the analysis included quality -of-care considerations . Although print material s alone may be marginally cost-effective , print plus face-to-face approaches offer greater net benefits . The authors conclude that a program of brief , face-to-face “ detailing ” visits conducted by academic rather than commercial sources can be a highly cost-effective method for improving drug therapy decisions . Such an approach makes possible the enhancement of physicians ' clinical expertise without relying on restriction of drug choices In order to increase physicians ' adherence to recommended st and ards of medical care and to examine factors presumed to contribute to such changes , we conducted a r and omized , controlled trial using reading material s targeted to specific practice recommendations . Seventy-nine internal medicine residents completed baseline question naires stating their intentions to follow 13 common preventive care actions . They were r and omly assigned to receive one of two different sets of readings covering these care actions . Thus , each physician was in the experimental group for one set of readings ( A or B ) while serving as a control for the other set . The impact of the reading was determined by : the physicians ' knowledge of the recommended care actions detailed in the combined readings , their post-reading intentions , and clinical behavior when faced with patients having indications for the recommended actions . The 73 residents ( 92 % ) who read the material judged 39 % of the information to be new and 72 % useful . Residents had significantly better performance on the knowledge questions based on their own readings than did their control group peers for both sets of readings . For the Group A physicians , reading significantly ( P less than 0.05 ) increased intentions to follow one of the seven clinical actions while Group B residents increased their intentions in three out of six . Step-wise multiple regression analyses were used to predict physicians ' post-reading adherence to the recommended actions . For the Group A actions , pre-reading actions accounted for most of the variance in their post-reading actions . ( ABSTRACT TRUNCATED AT 250 WORDS BACKGROUND Radiological tests are often used by general practitioners ( GPs ) . These tests can be overused and contribute little to clinical management . We aim ed to assess two methods of reducing GP requests for radiological tests in accordance with the UK Royal College of Radiologists ' guidelines on lumbar spine and knee radiographs . METHODS We assessed audit and feedback , and educational reminder messages in six radiology departments and 244 general practice s that they served . The study was a before- and -after , pragmatic , cluster r and omised controlled trial with a 232 factorial design . A r and om subset of GP patients ' records were examined for concordance with the guidelines . The main outcome measure was number of radiograph requests per 1000 patients per year . Analysis was by intention to treat . FINDINGS The effect of  educational reminder messages  ( ie , the change in request rate after intervention ) was an absolute change of -1.53 ( 95 % CI -2.5 to -0.57 ) for lumbar spine and of -1.61 ( -2.6 to -0.62 ) for knee radiographs , both relative reductions of about 20 % . The effect of audit and feedback  was an absolute change of -0.07 ( -1.3 to 0.9 ) for lumbar spine of 0.04 ( -0.95 to 1.03 ) for knee radiograph requests , both relative reductions of about 1 % . Concordance between groups did not differ significantly . INTERPRETATION 6-monthly feedback of audit data is ineffective but the routine attachment of educational reminder messages to radiographs is effective and does not affect quality of referrals . Any department of radiology that h and les referrals from primary care could deliver this intervention to good effect Documentation of unexplained geographic variations in medical practice s [ 1 ] and use of interventions inappropriately [ 2 ] or before their effectiveness has been established [ 3 ] has led to the rapid proliferation of clinical practice guidelines . These systematic ally developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances [ 4 ] are an attempt to discourage ineffective medical practice s , encourage effective practice s , and improve health outcomes [ 5 - 10 ] . Despite increasing enthusiasm for guidelines , evidence 
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Evidence from this review showed that PEMs appear to have small beneficial effects on professional practice .
The results of this review suggest that when compared to no intervention , PEMs when used alone may have a beneficial effect on process outcomes but not on patient outcomes .
Despite this wide of range of effects reported for PEMs , clinical significance of the observed effect sizes is not known .
There is insufficient information about how to optimise educational material s. The effectiveness of educational material s compared to other interventions is uncertain