human
***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: OBJECTIVE To provide access to professional development opportunities for health care professionals , especially in rural Australian regions , consistent with recommendations in the Australian National Pain Strategy and state government policy . DESIGN AND SETTING A preliminary prospect i ve , single-cohort study design , which aligned health policy with evidence -informed clinical practice , evaluated the implementation and effectiveness of an interprofessional , health care provider pain education program ( hPEP ) for management of nonspecific low back pain ( nsLBP ) in rural Western Australia . INTERVENTION The 6.5-hour hPEP intervention was delivered to 60 care providers ( caseload nsLBP 19.8 % ± 22.5 ) at four rural WA regions . OUTCOME MEASURES Outcomes were recorded at baseline and 2 months post-intervention regarding attitudes , beliefs ( modified Health Care Providers Pain and Impairment Relationship Scale [ HC-PAIRS ] ) , Back Pain Beliefs Question naire [ BBQ ] ) , and self-reported evidence -based clinical practice ( knowledge and skills regarding nsLBP , rated on a 5-point Likert scale with 1 = nil and 5 = excellent ) . RESULTS hPEP was feasible to implement . At 2 months post-hPEP , responders ' ( response rate 53 % ) improved evidence -based beliefs were indicated by HC-PAIRS scores : baseline mean ( SD ) [ 43.2 ( 9.3 ) ] ; mean difference ( 95 % CI ) [ -5.9 ( -8.6 to -3.1 ) ] ; and BBQ baseline [ 34.3 ( 6.8 ) ] ; mean difference [ 2.1 ( 0.5 to 3.6 ) ] . Positive shifts were observed for all measures of clinical knowledge and skills ( P < 0.001 ) and increased assistance with planning lifestyle changes ( P < 0.001 ) , advice on self-management ( P = 0.010 ) , and for decreased referrals for spinal imaging ( P = 0.03 ) . CONCLUSIONS This policy-into- practice educational program is feasible to implement in rural Western Australia ( WA ) . While preliminary data are encouraging , a further r and omized controlled trial is recommended 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 AND PURPOSE An active strategy was developed for the implementation of the clinical guidelines on physical therapy for patients with low back pain . The effect of this strategy on patients ' physical functioning , coping strategy , and beliefs regarding their low back pain was studied . SUBJECTS One hundred thirteen primary care physical therapists treated a total of 500 patients . METHODS The physical therapists were r and omly assigned to 1 of 2 groups . The control group received the guidelines by mail ( st and ard passive method of dissemination ) . The intervention group , in contrast , received an additional active training strategy consisting of 2 sessions with education , group discussion , role playing , feedback , and reminders .  Patients with low back pain , treated by the participating therapists , completed question naires on physical functioning , pain , sick leave , coping , and beliefs . RESULTS Physical functioning and pain in the 2 groups improved substantially in the first 12 weeks . Multilevel longitudinal analysis showed no differences between the 2 groups on any outcome measure during follow-up . DISCUSSION AND CONCLUSION The authors found no additional benefit to applying an active strategy to implement the physical therapy guidelines for patients with low back pain . Active implementation strategies are not recommended if patient outcomes are to be improved Study Design . Cost-effectiveness analysis alongside a cluster r and omized controlled trial . Objective . To study the cost-effectiveness of 2 low back pain guideline implementation ( GI ) strategies . Summary of Background Data . Several evidence -based guidelines on management of low back pain have been published . However , there is still no consensus on the effective implementation strategy . Especially studies on the economic impact of different implementation strategies are lacking . Methods . This analysis was performed alongside a cluster r and omized controlled trial on the effectiveness of 2 GI strategies ( physician education alone [ GI ] or physician education in combination with motivational counseling [ MC ] by practice nurses)-–both compared with the postal dissemination of the guideline ( control group , C ) . Sociodemographic data , pain characteristics , and cost data were collected by interview at baseline and after 6 and 12 months . low back pain – related health care costs were valued for 2004 from the societal perspective . Results . For the cost analysis , 1322 patients from 126 general practice s were included . Both interventions showed lower direct and indirect costs as well as better patient outcomes during follow-up compared with controls . In addition , both intervention arms showed superiority of cost-effectiveness to C. The effects attenuated when adjusting for differences of health care utilization prior to patient recruitment and for clustering of data . Conclusion . Trends in cost-effectiveness are visible but need to be confirmed in future studies . Research ers performing cost-evaluation studies should test for baseline imbalances of health care utilization data instead of judging on the r and omization success by review ing non-cost parameters like clinical data alone Background Evidence -based clinical practice guidelines may improve treatment quality , but the uptake of guideline recommendations is often incomplete and slow . Recently new low back pain guidelines are being launched in Denmark . The guidelines are considered to reduce personal and public costs . The aim of this study is to evaluate whether a complex , multifaceted implementation strategy of the low back pain guidelines will reduce secondary care referral and improve patient outcomes compared to the usual simple implementation strategy . Methods / design In a two-armed cluster r and omised trial , 100 general practice s ( clusters ) and 2,700 patients aged 18 to 65 years from the North Denmark region will be included . Practice s are r and omly allocated 1:1 to a simple or a complex implementation strategy . Intervention practice s will receive a complex implementation strategy , including guideline facilitator visits , stratification tools , and quality reports on low back pain treatment . Primary outcome is referral to secondary care . Secondary outcomes are pain , physical function , health-related quality of life , patient satisfaction with care and treatment outcome , employment status , and sick leave . Primary and secondary outcomes pertain to the patient level . Assessment s of outcomes are blinded and follow the intention-to-treat principle . Additionally , a process assessment will evaluate the degree to which the intervention elements will be delivered as planned , as well as measure changes in beliefs and behaviours among general practitioners and patients . Discussion This study provides knowledge concerning the process and effect of an intervention to implement low back pain guidelines in general practice , and will provide insight on essential elements to include in future implementation strategies in general practice .Trial registration Registered as NCT01699256 on Clinical Trials.gov Background Low back pain ( LBP ) is one of the most prevalent and expensive health care problems in industrialised countries . LBP leads to high health care utility and productivity losses ; leaving the individual , the employer , and society with substantial costs . To improve the care for LBP patients and reduce the high societal and financial burden of LBP , in 2010 the ‘ Multidisciplinary care guideline for nonspecific low back pain ’ was developed in the Netherl and s. The current paper describes the design of a study aim ing to evaluate the ( cost- ) effectiveness of a multifaceted strategy to implement this guideline . Methods In a cluster-r and omised controlled trial , the ( cost- ) effectiveness of a multifaceted implementation strategy will be compared to passive guideline dissemination . Using a stepped-wedge approach , participating general practitioners , physiotherapists , and occupational physicians are allocated into clusters and will attend a multidisciplinary continuing medical education training session . The timing these clusters receive the training is the unit of r and omisation . LBP patients visiting the participating health care providers are invited to participate in the trial and will receive access to a multimedia intervention aim ed at improving beliefs , cognitions , and self-management . The primary outcome measure of this study is patient back beliefs . Secondary outcome measures on patient level include pain , functional status , quality of life , health care utility , and productivity losses . Outcome measures on professional level include knowledge and attitude towards the guideline , and guideline adherence . A process evaluation for the implementation strategy will be performed among the health care providers and the patients . Furthermore , a qualitative subgroup analysis among patients with various ethnic background s will be performed . Discussion This study will give insight into the ( cost- ) effectiveness of a multifaceted implementation strategy for the Dutch multidisciplinary guideline for non-specific back pain to improve outcomes on patient and professional level . The valuable information gained with this study may prove useful for policy-makers , health care providers , and research ers who are in the process of reducing the burden of back pain on individuals and society . Trial Registration Netherl and s Trial Register ( NTR ) : NTR4329 . Registered December 20th , 2013 Introduction This cluster r and omised trial evaluated an intervention to decrease x-ray referrals and increase giving advice to stay active for people with acute low back pain ( LBP ) in general practice . Methods General practice s were r and omised to either  access to a guideline for acute LBP ( control ) or facilitated interactive workshops ( intervention ) . We measured behavioural predictors ( e.g. knowledge , attitudes and intentions ) and fear avoidance beliefs . We were unable to recruit sufficient patients to measure our original primary outcomes so we introduced other outcomes measured at the general practitioner ( GP ) level : behavioural simulation ( clinical decision about vignettes ) and rates of x-ray and CT-scan ( medical administrative data ) . All those not involved in the delivery of the intervention were blinded to allocation . Results 47 practice s ( 53 GPs ) were r and omised to the control and 45 practice s ( 59 GPs ) to the intervention . The number of GPs available for analysis at 12 months varied by outcome due to missing confounder information ; a minimum of 38 GPs were available from the intervention group , and a minimum of 40 GPs from the control group . For the behavioural constructs , although effect estimates were small , the intervention group GPs had greater intention of practising consistent with the guideline for the clinical behaviour of x-ray referral . For behavioural simulation , intervention group GPs were more likely to adhere to guideline recommendations about x-ray ( OR 1.76 , 95%CI 1.01 , 3.05 ) and more likely to give advice to stay active ( OR 4.49 , 95%CI 1.90 to 10.60 ) . Imaging referral was not statistically significantly different between groups and the potential importance of effects was unclear ; rate ratio 0.87 ( 95%CI 0.68 , 1.10 ) for x-ray or CT-scan . Conclusions The intervention led to small changes in GP intention to practice in a manner that is consistent with an evidence -based guideline , but it did not result in statistically significant changes in actual behaviour . Trial Registration Australian New Zeal and Clinical Trials Registry Background The recent development and publication of evidence -based clinical practice guidelines ( CPGs ) for acute low back pain ( LBP ) has result ed in evidence -based recommendations that , if implemented , have the potential to improve the quality and safety of care for acute LBP . While a strategy has been specified for dissemination of the CPG for acute LBP in Australia , there is no accompanying plan for active implementation . Evidence regarding the cost-effectiveness of active implementation of CPGs for acute LBP is sparse . The IMPLEMENT study will consider the incremental benefits and costs of progressing beyond development and dissemination to implementation . Methods / design Cost-effectiveness and cost-utility analyses alongside the IMPLEMENT cluster r and omised controlled trial ( C RCT ) from a societal perspective to quantify the additional costs ( savings ) and health gains associated with a targeted implementation strategy as compared with access to the CPG via dissemination only . Discussion The protocol provided here registers our intent to conduct an economic evaluation alongside the IMPLEMENT study , facilitates peer- review of proposed methods and provides a transparent statement of planned analyses . Trial registration Australian New Zeal and Clinical Trials Registry Background In Denmark , guidelines on low back pain management are currently being implemented ; in association with this , a clinical trial is conducted . A health economic evaluation is carried out alongside the clinical trial to assess the cost-effectiveness of an extended implementation strategy to increase the general practitioners ' adherence to the guidelines . In addition to usual dissemination , the extended implementation strategy is composed of visits from a guid 
    Output:
    
agent
Meta-analyses did not reveal any differences in effect between multifaceted strategies and controls .
Conclusion This review showed that multifaceted strategies for the implementation of neck and /or back pain guidelines in health care do not significantly improve professional behaviour outcomes .
No effects on patient outcomes or cost of care could be found .
***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: OBJECTIVE To provide access to professional development opportunities for health care professionals , especially in rural Australian regions , consistent with recommendations in the Australian National Pain Strategy and state government policy . DESIGN AND SETTING A preliminary prospect i ve , single-cohort study design , which aligned health policy with evidence -informed clinical practice , evaluated the implementation and effectiveness of an interprofessional , health care provider pain education program ( hPEP ) for management of nonspecific low back pain ( nsLBP ) in rural Western Australia . INTERVENTION The 6.5-hour hPEP intervention was delivered to 60 care providers ( caseload nsLBP 19.8 % ± 22.5 ) at four rural WA regions . OUTCOME MEASURES Outcomes were recorded at baseline and 2 months post-intervention regarding attitudes , beliefs ( modified Health Care Providers Pain and Impairment Relationship Scale [ HC-PAIRS ] ) , Back Pain Beliefs Question naire [ BBQ ] ) , and self-reported evidence -based clinical practice ( knowledge and skills regarding nsLBP , rated on a 5-point Likert scale with 1 = nil and 5 = excellent ) . RESULTS hPEP was feasible to implement . At 2 months post-hPEP , responders ' ( response rate 53 % ) improved evidence -based beliefs were indicated by HC-PAIRS scores : baseline mean ( SD ) [ 43.2 ( 9.3 ) ] ; mean difference ( 95 % CI ) [ -5.9 ( -8.6 to -3.1 ) ] ; and BBQ baseline [ 34.3 ( 6.8 ) ] ; mean difference [ 2.1 ( 0.5 to 3.6 ) ] . Positive shifts were observed for all measures of clinical knowledge and skills ( P < 0.001 ) and increased assistance with planning lifestyle changes ( P < 0.001 ) , advice on self-management ( P = 0.010 ) , and for decreased referrals for spinal imaging ( P = 0.03 ) . CONCLUSIONS This policy-into- practice educational program is feasible to implement in rural Western Australia ( WA ) . While preliminary data are encouraging , a further r and omized controlled trial is recommended 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 AND PURPOSE An active strategy was developed for the implementation of the clinical guidelines on physical therapy for patients with low back pain . The effect of this strategy on patients ' physical functioning , coping strategy , and beliefs regarding their low back pain was studied . SUBJECTS One hundred thirteen primary care physical therapists treated a total of 500 patients . METHODS The physical therapists were r and omly assigned to 1 of 2 groups . The control group received the guidelines by mail ( st and ard passive method of dissemination ) . The intervention group , in contrast , received an additional active training strategy consisting of 2 sessions with education , group discussion , role playing , feedback , and reminders .  Patients with low back pain , treated by the participating therapists , completed question naires on physical functioning , pain , sick leave , coping , and beliefs . RESULTS Physical functioning and pain in the 2 groups improved substantially in the first 12 weeks . Multilevel longitudinal analysis showed no differences between the 2 groups on any outcome measure during follow-up . DISCUSSION AND CONCLUSION The authors found no additional benefit to applying an active strategy to implement the physical therapy guidelines for patients with low back pain . Active implementation strategies are not recommended if patient outcomes are to be improved Study Design . Cost-effectiveness analysis alongside a cluster r and omized controlled trial . Objective . To study the cost-effectiveness of 2 low back pain guideline implementation ( GI ) strategies . Summary of Background Data . Several evidence -based guidelines on management of low back pain have been published . However , there is still no consensus on the effective implementation strategy . Especially studies on the economic impact of different implementation strategies are lacking . Methods . This analysis was performed alongside a cluster r and omized controlled trial on the effectiveness of 2 GI strategies ( physician education alone [ GI ] or physician education in combination with motivational counseling [ MC ] by practice nurses)-–both compared with the postal dissemination of the guideline ( control group , C ) . Sociodemographic data , pain characteristics , and cost data were collected by interview at baseline and after 6 and 12 months . low back pain – related health care costs were valued for 2004 from the societal perspective . Results . For the cost analysis , 1322 patients from 126 general practice s were included . Both interventions showed lower direct and indirect costs as well as better patient outcomes during follow-up compared with controls . In addition , both intervention arms showed superiority of cost-effectiveness to C. The effects attenuated when adjusting for differences of health care utilization prior to patient recruitment and for clustering of data . Conclusion . Trends in cost-effectiveness are visible but need to be confirmed in future studies . Research ers performing cost-evaluation studies should test for baseline imbalances of health care utilization data instead of judging on the r and omization success by review ing non-cost parameters like clinical data alone Background Evidence -based clinical practice guidelines may improve treatment quality , but the uptake of guideline recommendations is often incomplete and slow . Recently new low back pain guidelines are being launched in Denmark . The guidelines are considered to reduce personal and public costs . The aim of this study is to evaluate whether a complex , multifaceted implementation strategy of the low back pain guidelines will reduce secondary care referral and improve patient outcomes compared to the usual simple implementation strategy . Methods / design In a two-armed cluster r and omised trial , 100 general practice s ( clusters ) and 2,700 patients aged 18 to 65 years from the North Denmark region will be included . Practice s are r and omly allocated 1:1 to a simple or a complex implementation strategy . Intervention practice s will receive a complex implementation strategy , including guideline facilitator visits , stratification tools , and quality reports on low back pain treatment . Primary outcome is referral to secondary care . Secondary outcomes are pain , physical function , health-related quality of life , patient satisfaction with care and treatment outcome , employment status , and sick leave . Primary and secondary outcomes pertain to the patient level . Assessment s of outcomes are blinded and follow the intention-to-treat principle . Additionally , a process assessment will evaluate the degree to which the intervention elements will be delivered as planned , as well as measure changes in beliefs and behaviours among general practitioners and patients . Discussion This study provides knowledge concerning the process and effect of an intervention to implement low back pain guidelines in general practice , and will provide insight on essential elements to include in future implementation strategies in general practice .Trial registration Registered as NCT01699256 on Clinical Trials.gov Background Low back pain ( LBP ) is one of the most prevalent and expensive health care problems in industrialised countries . LBP leads to high health care utility and productivity losses ; leaving the individual , the employer , and society with substantial costs . To improve the care for LBP patients and reduce the high societal and financial burden of LBP , in 2010 the ‘ Multidisciplinary care guideline for nonspecific low back pain ’ was developed in the Netherl and s. The current paper describes the design of a study aim ing to evaluate the ( cost- ) effectiveness of a multifaceted strategy to implement this guideline . Methods In a cluster-r and omised controlled trial , the ( cost- ) effectiveness of a multifaceted implementation strategy will be compared to passive guideline dissemination . Using a stepped-wedge approach , participating general practitioners , physiotherapists , and occupational physicians are allocated into clusters and will attend a multidisciplinary continuing medical education training session . The timing these clusters receive the training is the unit of r and omisation . LBP patients visiting the participating health care providers are invited to participate in the trial and will receive access to a multimedia intervention aim ed at improving beliefs , cognitions , and self-management . The primary outcome measure of this study is patient back beliefs . Secondary outcome measures on patient level include pain , functional status , quality of life , health care utility , and productivity losses . Outcome measures on professional level include knowledge and attitude towards the guideline , and guideline adherence . A process evaluation for the implementation strategy will be performed among the health care providers and the patients . Furthermore , a qualitative subgroup analysis among patients with various ethnic background s will be performed . Discussion This study will give insight into the ( cost- ) effectiveness of a multifaceted implementation strategy for the Dutch multidisciplinary guideline for non-specific back pain to improve outcomes on patient and professional level . The valuable information gained with this study may prove useful for policy-makers , health care providers , and research ers who are in the process of reducing the burden of back pain on individuals and society . Trial Registration Netherl and s Trial Register ( NTR ) : NTR4329 . Registered December 20th , 2013 Introduction This cluster r and omised trial evaluated an intervention to decrease x-ray referrals and increase giving advice to stay active for people with acute low back pain ( LBP ) in general practice . Methods General practice s were r and omised to either  access to a guideline for acute LBP ( control ) or facilitated interactive workshops ( intervention ) . We measured behavioural predictors ( e.g. knowledge , attitudes and intentions ) and fear avoidance beliefs . We were unable to recruit sufficient patients to measure our original primary outcomes so we introduced other outcomes measured at the general practitioner ( GP ) level : behavioural simulation ( clinical decision about vignettes ) and rates of x-ray and CT-scan ( medical administrative data ) . All those not involved in the delivery of the intervention were blinded to allocation . Results 47 practice s ( 53 GPs ) were r and omised to the control and 45 practice s ( 59 GPs ) to the intervention . The number of GPs available for analysis at 12 months varied by outcome due to missing confounder information ; a minimum of 38 GPs were available from the intervention group , and a minimum of 40 GPs from the control group . For the behavioural constructs , although effect estimates were small , the intervention group GPs had greater intention of practising consistent with the guideline for the clinical behaviour of x-ray referral . For behavioural simulation , intervention group GPs were more likely to adhere to guideline recommendations about x-ray ( OR 1.76 , 95%CI 1.01 , 3.05 ) and more likely to give advice to stay active ( OR 4.49 , 95%CI 1.90 to 10.60 ) . Imaging referral was not statistically significantly different between groups and the potential importance of effects was unclear ; rate ratio 0.87 ( 95%CI 0.68 , 1.10 ) for x-ray or CT-scan . Conclusions The intervention led to small changes in GP intention to practice in a manner that is consistent with an evidence -based guideline , but it did not result in statistically significant changes in actual behaviour . Trial Registration Australian New Zeal and Clinical Trials Registry Background The recent development and publication of evidence -based clinical practice guidelines ( CPGs ) for acute low back pain ( LBP ) has result ed in evidence -based recommendations that , if implemented , have the potential to improve the quality and safety of care for acute LBP . While a strategy has been specified for dissemination of the CPG for acute LBP in Australia , there is no accompanying plan for active implementation . Evidence regarding the cost-effectiveness of active implementation of CPGs for acute LBP is sparse . The IMPLEMENT study will consider the incremental benefits and costs of progressing beyond development and dissemination to implementation . Methods / design Cost-effectiveness and cost-utility analyses alongside the IMPLEMENT cluster r and omised controlled trial ( C RCT ) from a societal perspective to quantify the additional costs ( savings ) and health gains associated with a targeted implementation strategy as compared with access to the CPG via dissemination only . Discussion The protocol provided here registers our intent to conduct an economic evaluation alongside the IMPLEMENT study , facilitates peer- review of proposed methods and provides a transparent statement of planned analyses . Trial registration Australian New Zeal and Clinical Trials Registry Background In Denmark , guidelines on low back pain management are currently being implemented ; in association with this , a clinical trial is conducted . A health economic evaluation is carried out alongside the clinical trial to assess the cost-effectiveness of an extended implementation strategy to increase the general practitioners ' adherence to the guidelines . In addition to usual dissemination , the extended implementation strategy is composed of visits from a guid 
    Output:
    