***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 Chronic obstructive pulmonary disease ( COPD ) is a health problem that is becoming increasingly attended-to in Primary Care ( PC ) . However , there is a scarcity of health-care programs and studies exploring the implementation of Clinical Practice Guidelines ( CPG ) . The principal objective of the present study is to evaluate the effectiveness of a combined strategy directed towards health-care professionals and patients to improve the grade of clinical control and the quality -of-life ( QoL ) of the patients via a feedback on their state-of-health . A training plan for the health-care professionals is based on CPG and health education . Method / Design Multi-centred , before-after , quasi experimental , prospect i ve study involving an intervention group and a control group of individuals followed-up for 12 months . The patients receive attention from urban and semi-urban Primary Care Centres ( PCC ) within the administrative area of the Costa de Ponent ( near Barcelona ) . All the pacients corresponding to the PCC of one sub-area were assigned to the intervention group and patients from the rest of sub- areas to the group control . The intervention includes providing data to the health-care professionals ( clinician/nurse ) derived from a clinical history and an interview . A course of training focused on aspects of CPG , motivational interview and health education ( tobacco , inhalers , diet , physical exercise , physiotherapy ) . The sample r and om includes a total of 801 patients ( ≥ 40 years of age ) , recorded as having COPD , receiving attention in the PCC or at home , who have had at least one clinical visit , and who provided written informed consent to participation in the study . Data collected include socio-demographic characteristics , drug treatment , exacerbations and hospital admissions , evaluation of inhaler use , tobacco consumption and life-style and health-care re sources consumed . The main endpoints are dyspnoea , according to the modified scale of the Medical Research Council ( MRC ) and the QoL , evaluated with the St George 's Respiratory Question naire ( SGRQ ) . The variables are obtained at the start and the end of the intervention . Information from follow-up visits focuses on the changes in life-style activities of the patient . Discussion This study is conducted with the objective of generating evidence that shows that implementation of awareness programs directed towards health-care professionals as well as patients in the context of PC can produce an increase in the QoL and a decrease in the disease exacerbation , compared to st and ard clinical practice .Trial Registration Clinical Trials.gov Identifier : NCT00922545 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 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 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 Background Anxiety and depressive disorders are highly prevalent disorders and are mostly treated in primary care . The management of these disorders by general practitioners is not always consistent with prevailing guidelines because of a variety of factors . Design ing implementation strategies tailored to prospect ively identified barriers could lead to more guideline -recommended care . Although tailoring of implementation strategies is promoted in practice , little is known about the effect on improving the quality of care for the early recognition , diagnosis , and stepped care treatment allocation in patients with anxiety or depressive disorders in general practice . This study examines whether the tailored strategy supplemented with training and feedback is more effective than providing training and feedback alone . Methods In this cluster r and omised controlled trial , a total of 22 general practice s will be assigned to one of two conditions : ( 1 ) training , feedback , and tailored interventions and ( 2 ) training and feedback . The primary outcome measure is the proportion of patients who have been recognised to have anxiety and /or depressive disorder .  The secondary outcome measures in patients are severity of anxiety and depressive symptoms , level of functioning , expectation towards and experience with care , quality of life , and economic costs . Measures are taken after the start of the intervention at baseline and at three- and six-month follow-ups . Secondary outcome measures in general practitioners are adherence to guideline -recommended care in care that has been delivered , the proportion of antidepressant prescriptions , and number of referrals to specialised mental healthcare facilities . Data will be gathered from the electronic medical patient records from the patients included in the study . In a process evaluation , the identification of barriers to change and the relations between prospect ively identified barriers and improvement interventions selected for use will be described , as well as the factors that influence the provision of guideline -recommended care . Discussion It is hypothesised that the adherence to guideline recommendations will be improved by design ing implementation interventions that are tailored to prospect ively identified barriers in the local context of general practitioners . Currently , there is insufficient evidence on the most effective and efficient approaches to tailoring , including how barriers should be identified and how interventions should be selected to address the barriers . Trial registration Background Most quality improvement programs in diabetes care incorporate aspects of clinician education , performance feedback , patient education , care management , and diabetes care teams to support primary care physicians . Few studies have applied all of these dimensions to address clinical inertia . Aim To evaluate interventions to improve adherence to evidence -based guidelines for diabetes and reduce clinical inertia in primary care physicians . Design Two-arm cluster r and omized controlled trial . Participants Primary care physicians in Belgium . Interventions Primary care physicians will be r and omly allocated to ' Usual ' ( UQIP ) or ' Advanced ' ( AQIP ) Quality Improvement Programs . Physicians in the UQIP will receive interventions addressing the main physician , patient , and office system factors that contribute to clinical inertia . Physicians in the AQIP will receive additional interventions that focus on sustainable behavior changes in patients and providers . Outcomes Primary endpoints are the proportions of patients within targets for three clinical outcomes : 1 ) glycosylated hemoglobin < 7 % ; 2 ) systolic blood pressure differences ≤130 mmHg ; and 3 ) low density lipoprotein/cholesterol < 100 mg/dl . Secondary endpoints are individual improvements in 12 vali date d parameters : glycosylated hemoglobin , low and high density lipoprotein/cholesterol , total cholesterol , systolic blood pressure , diastolic blood pressure , weight , physical exercise , healthy diet , smoking status , and statin and anti-platelet therapy . Primary and secondary analysis Statistical analyses will be performed using an intent-to-treat approach with a multilevel model . Linear and generalized linear mixed models will be used to account for the clustered nature of the data , i.e. , patients clustered withinimary care physicians , and repeated assessment s clustered within patients . To compare patient characteristics at baseline and between the intervention arms , the generalized estimating equations ( GEE ) approach will be used , taking the clustered nature of the data within physicians into account . We will also use the GEE approach to test for differences in evolution of the primary and secondary endpoints for all patients , and for patients in the two interventions arms , accounting for within-patient clustering . Trial Registration number : NTR 1369 BACKGROUND AND AIMS Clinical inertia is considered a major barrier to better care . We assessed its prevalence , predictors and associations with the intermediate outcomes of diabetes care . MATERIAL S AND METHODS Baseline and follow-up data of a Dutch r and omized controlled trial on the implementation of a locally adapted guideline were used . The study involved 30 general practice s and 1283 patients . Treatment targets differed between study groups [ HbA1c < or= 8.0 % and blood pressure ( BP ) < 140/85 % versus HbA1c < or= 8.5 % and BP < 150/85 ] . Clinical inertia was defined as the failure to intensify therapy when indicated . A complete medication profile of all participating patients was obtained . RESULTS In the intervention and control group , the percentages of patients with poor diabetes or lipid control who did not receive treatment intensification were 45 % and 90 % , approximately . More control group patients with BP levels  above target were confronted with inertia ( 72.7 % versus 63.3 % , P < 0.05 ) . In poorly controlled hypertensive patients , inertia was associated with the height of systolic BP at baseline [ adjusted odds ratio ( OR ) 0.98 , 95 % confidence interval ( CI ) 0.98 - 0.99 ] and the frequency of BP control ( adjusted OR 0.89 , 95 % CI 0.81 - 0.99 ) . If a practice nurse managed these patients , clinical inertia was less common ( adjusted OR 0.12 , 95 % CI 0.02 - 0.91 ) . In both study groups , cholesterol decreased significantly more in patients who received proper treatment intensification . CONCLUSION GPs were more inclined to control blood glucose levels than BP or cholesterol levels . Inertia in response to poorly controlled high BP was less common if nurses assisted GPs BACKGROUND Changes in management of COPD in primary care were studied following a training exercise among Spanish general practitioners ( GPs ) . The exercise involved dissemination of the Spanish Society for Pulmonology and Thoracic Surgery ( SEPAR ) guidelines . The use of a portable device to perform spirometry tests was evaluated to adequately categorize COPD and reduce other diagnostic intervent 
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Moreover , the results are not consistent in showing which strategy is the most appropriate to facilitate their implementation .