***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: The methods of evaluating change and improvement strategies are not well described . The design and conduct of a range of experimental and non-experimental quantitative design s are considered . Such study design s should usually be used in a context where they build on appropriate theoretical , qualitative and modelling work , particularly in the development of appropriate interventions . A range of experimental design s are discussed including single and multiple arm r and omised controlled trials and the use of more complex factorial and block design s. The impact of r and omisation at both group and individual levels and three non-experimental design s ( uncontrolled before and after , controlled before and after , and time series analysis ) are also considered . The design chosen will reflect both the needs ( and re sources ) in any particular circumstances and also the purpose of the evaluation . The general principle underlying the choice of evaluative design is , however , simple — those conducting such evaluations should use the most robust design possible to minimise bias and maximise generalisability OBJECTIVES We sought to determine whether a multidisciplinary outpatient management program decreases  chronic heart failure ( CHF )  hospital readmissions and mortality over a six-month period . BACKGROUND Hospital admission for CHF is an important problem amenable to improved outpatient management . METHODS Two hundred patients hospitalized with CHF at increased risk of hospital readmission were r and omized to a multidisciplinary program or usual care . A study cardiologist and a CHF nurse evaluated each patient and made recommendations to the patient 's primary physician before r and omization . The intervention team consisted of a cardiologist , a CHF nurse , a telephone nurse coordinator and the patient 's primary physician . Contact with the patient was on a prespecified schedule . The CHF nurse followed an algorithm to adjust medications . Patients in the nonintervention group were followed as usual . The primary outcome was the composite of the number of CHF hospital admissions and deaths over six months , compared by using a log transformation t test by intention-to-treat analysis . RESULTS The median age of the study patients was 63.5 years , and 39.5 % were women . There were 43 CHF hospital admissions and 7 deaths in the intervention group , as compared with 59 CHF hospital admissions and 13 deaths in the nonintervention group ( p = 0.09 ) . The quality -of-life score , percentage of patients on target vasodilator therapy and percentage of patients compliant with diet recommendations were significantly better in the intervention group . Cost per patient , in 1998 U.S. dollars , was similar in both groups . CONCLUSIONS This study demonstrates that a six-month , multidisciplinary approach to CHF management can improve important clinical outcomes at a similar cost in recently hospitalized high-risk patients with CHF Objective : To evaluate the effects of a nurse based outpatient management programme for elderly patients discharged with heart failure from a university hospital . Design : Patients with heart failure ( New York Heart Association class II – IV ) and left ventricular systolic dysfunction aged 60 years or more were r and omly assigned to follow up within the management programme or to conventional follow up , usually in primary care . Of the 208 participants , 58 % were men , mean age was 75 years , and mean ejection fraction 34 % . All patients were scheduled for three observational study visits at six month intervals . The primary end point was quality of life ( QoL ) and secondary end points were hospitalisation and mortality . Results : More patients achieved target doses of angiotensin converting enzyme ( ACE ) inhibitors in the intervention group than in the control group ( 82 % v 69 % , 88 % v 69 % , and 88 % v 74 % of recommended target doses at 6 , 12 , and 18 months of follow up , respectively , p < 0.05 for all ) . Patients with initial low QoL had a poor prognosis . After a mean 1122 days of follow up , 82 % of all patients had been readmitted . There were on average 4.7 readmissions per patient and 66 % were due to non-cardiac diagnoses . There were no differences in QoL or health care consumption between the two study groups during follow up . Conclusion : A nurse based management programme is more effective than follow up in primary care in optimising medication for elderly patients with heart failure . However , such a programme does not seem to have a favourable influence on QoL or readmission rate during long term follow up Objective : To evaluate the effects of feedback reports combined with outreach visits from trained non-physicians on the clinical decision making of general practitioners ( GPs ) in cardiovascular care . Design : Pragmatic cluster controlled trial with r and omisation of practice s to support ( intervention group ) or no special attention ( control group ) ; analysis after 2 years . Setting : 124 general practice s in The Netherl and s. Participants : 185 GPs . Main outcome measures : Compliance rates for 12 evidence -based indicators for the management of patients with hypertension , hypercholesterolaemia , angina pectoris , or heart failure .  The evaluation relied on the prospect i ve recording of patient encounters by the participating GPs . Results : The GPs reported 30 101 clinical decisions at baseline and 22 454 decisions after the intervention . A significant improvement was seen for five of the 12 indicators : assessment of risk factors in patients with hypercholesterolaemia ( odds ratio 2.04 ; 95 % CI 1.44 to 2.88 ) or angina pectoris ( 3.07 ; 1.08 to 8.79 ) , provision of information and advice to patients with hypercholesterolaemia ( 1.58 , 1.17 to 2.13 ) or hypertension ( 1.55 , 1.35 to 1.77 ) , and checking for clinical signs of deterioration in patients with heart failure ( 4.11 , 2.17 to 7.77 ) . Single h and ed practice s , non-training practice s , and practice s with older GPs gained particular benefit from the intervention . Conclusions : Intensive support from trained non-physicians can alter certain aspects of the clinical decision making of GPs in cardiovascular care . The effect is small and the strategy needs further development Introduction The uptake of Clinical Practice Guideline ( CPG ) recommendations that improve outcomes in heart failure ( HF ) remains suboptimal . We will conduct a systematic review to identify implementation strategies that improve physician adherence to class I recommendations , those with clear evidence that benefits outweigh the risks . We will use American , Canadian and European HF guidelines as our reference . Methods and analysis We will conduct a literature search in the data bases of MEDLINE , EMBASE , HEALTHSTAR , CINAHL , Cochrane Library , Campbell Collaboration , Joanna Briggs Institute Evidence Based Practice , Centre for Review s and Dissemination and Evidence Based Practice Centres . We will include prospect i ve studies evaluating implementation interventions aim ed at improving uptake of class I CPG recommendations in HF . We will extract data in duplicate . We will classify interventions according to their level of application ( ie , provider , organisation , systems level ) and common underlying characteristics ( eg , education , decision-support , financial incentives ) using the Cochrane Effective Practice and Organisation of Care Taxonomy . We will assess the impact of the intervention on adherence to the CPGs . Outcomes will include proportion of eligible patients who were : prescribed a CPG-recommended pharmacological treatment ; referred for device consideration ; provided self-care education at discharge ; and provided left ventricular function assessment . We will include clinical outcomes such as hospitalisations , readmissions and mortality , if data is available . We will identify the common elements of successful and failing interventions , and examine the context in which they were applied , using the Process Re design context ual framework . We will synthesis e the results narratively and , if appropriate , will pool results for meta- analysis . Discussion and dissemination In this review , we will assess the impact of implementation strategies and context ual factors on physician adherence to HF CPGs . We will explore why some interventions may succeed in one setting and fail in another . We will disseminate our findings through briefing reports , publications and presentations . Trial registration number CRD42015017155 Background — A treatment gap exists between heart failure ( HF ) guidelines and the clinical care of patients . The Registry to Improve the Use of Evidence -Based Heart Failure Therapies in the Outpatient Setting ( IMPROVE HF ) prospect ively tested a multidimensional practice -specific performance improvement intervention on the use of guideline -recommended therapies for HF in outpatient cardiology practice s. Methods and Results — Performance data were collected in a r and om sample of HF patients from 167 US outpatient cardiology practice s at baseline , longitudinally after intervention at 12 and 24 months , and in single-point-in-time patient cohorts at 6 and 18 months . Participants included 34 810 patients with reduced left ventricular ejection fraction ( ≤35 % ) and chronic HF or previous myocardial infa rct ion . To quantify guideline adherence , 7 quality measures were assessed . Interventions included clinical decision support tools , structured improvement strategies , and chart audits with feedback . The performance improvement intervention result ed in significant improvements in 5 of 7 quality measures at the 24-month assessment compared with baseline : & bgr;-blocker ( 92.2 % versus 86.0 % , + 6.2 % ) , aldosterone antagonist ( 60.3 % versus 34.5 % , + 25.1 % ) , cardiac resynchronization therapy ( 66.3 % versus 37.2 % , + 29.9 % ) , implantable cardioverter-defibrillator ( 77.5 % versus 50.1 % , + 27.4 % ) , and HF education ( 72.1 % versus 59.5 % , + 12.6 % ) ( each P<0.001 ) . There were no statistically significant improvements in angiotensin-converting enzyme inhibitor/angiotensin receptor blocker use or anticoagulation for atrial fibrillation . Sensitivity analyses at the patient level and limited to patients with both baseline and 24-month quality measure data yielded similar results . Improvements in the single-point-in-time cohorts were smaller , and there were no concurrent control practice s. Conclusions — The Registry to Improve the Use of Evidence -Based Heart Failure Therapies in the Outpatient Setting , a defined and scalable practice -specific performance improvement intervention , was associated with substantial improvements in the use of guideline -recommended therapies in eligible patients with HF in outpatient cardiology practice s. Clinical Trial Registration — URL : http://www . clinical trials.gov . Unique identifier : NCT00303979 AIMS To evaluate how recommendations of European guidelines regarding pharmacological and non-pharmacological treatments for heart failure ( HF ) are adopted in clinical practice . METHODS AND RESULTS The ESC-HF Long-Term Registry is a prospect i ve , observational study conducted in 211 Cardiology Centres of 21 European and Mediterranean countries , members of the European Society of Cardiology ( ESC ) . From May 2011 to April 2013 , a total of 12,440 patients were enrolled , 40.5 % with acute HF and 59.5 % with chronic HF .  Intravenous treatments for acute HF were heterogeneously administered , irrespective of guideline recommendations . In chronic HF , with reduced EF , renin-angiotensin system ( RAS ) blockers , beta-blockers , and mineralocorticoid antagonists ( MRAs ) were used in 92.2 , 92.7 , and 67.0 % of patients , respectively . When reasons for non-adherence were considered , the real rate of undertreatment accounted for 3.2 , 2.3 , and 5.4 % of the cases , respectively . About 30 % of patients received the target dosage of these drugs , but a documented reason for not achieving the target dosage was reported in almost two-thirds of them . The more relevant reasons for non-implantation of a device , when clinical ly indicated , were related to doctor uncertainties on the indication , patient refusal , or logistical/cost issues . CONCLUSION This pan-European registry shows that , while in patients with acute HF , a large heterogeneity of treatments exists , drug treatment of chronic HF can be considered largely adherent to recommendations of current guidelines , when the reasons for non-adherence are taken into account . Observations regarding the real possibility to adhere fully to current guidelines in daily clinical practice should be seriously considered when clinical practice guidelines have to be written BACKGROUND Treatment with specific beta-blockers and doses recommended by guidelines is often not achieved in practice . We evaluated an intervention directed to the pharmacy to improve prescribing . METHODS AND RESULTS We conducted a pragmatic cluster-r and omized trial , where facilities ( n = 12 ) with patients ( n = 220 ) were the clusters . Eligible patients had a beta-blocker prescription that was not guideline concordant . Level 1 intervention included information to a pharmacist on facility guideline concordance . Level 2 also provided a list of patients not meeting guideline goals . Intervention and follow-up periods were each 6 months . Achievement of full concordance with recommendations was low ( 4%-5 % ) in both groups , primarily due to lack of tolerability . However , compared with level 1 , the level 2 intervention was associated with 1.9-fold greater odds of improvement in prescribing ( 95 % confidence interval [ CI ] 1.1 - 3.2 ) . Level 2 patients also had greater odds of a higher dose ( 1.9 , 95 % CI 1.1 - 3.3 ) . The intervention was aided by the patient lists provided , the electronic medical record 
    Output:
    
Clinical pathways , multidisciplinary teams and multifaceted interventions were most consistently successful in increasing physician uptake of guidelines .
Among r and omised controlled trials ( RCT ) ( n=10 ) , pharmacist and nurse-led interventions improved target dose prescriptions .
Baseline assessment of barriers , staff training , iterative intervention development , leadership commitment and policy/financial incentives were associated with intervention effectiveness .
Clinical pathways , multidisciplinary teams and multifaceted interventions appear to be most consistent in increasing guideline uptake .
However , improvements in process outcomes were rarely accompanied by improvements in clinical outcomes .