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: Background Since a higher level of self-efficacy in common mental disorders is associated with earlier return-to-work ( RTW ) , it is important to know if work related self-efficacy can be increased by occupational health care . The primary aim of this study was to evaluate whether an intervention to enhance guideline adherence of occupational physicians lead to an increase in RTW self-efficacy in workers three months later . The secondary aim was to evaluate whether the intervention modified the association between RTW self-efficacy and return-to-work three months later . Methods A total of 66 occupational physicians participated in the study . They were r and omized into two groups ; the intervention group received a training , the control group did not . The training aim ed to enhance adherence to a mental health guideline that contained strategies that are supposed to enhance RTW self-efficacy . In 128 sick-listed workers guided by these occupational physicians , RTW self-efficacy , RTW , and personal , health-related and work-related variables were measured at baseline and three months later . Generalized linear mixed models analysis and linear mixed models analysis were used for the evaluations . Results In workers whose occupational physicians had received the training RTW self-efficacy increased significantly more than in workers whose occupational physicians had participated in the control group ( t = −2.626 , p ≤ .05 ) . Higher baseline RTW self-efficacy scores were significantly more often associated with full RTW than with no RTW three months later ( OR 2.20 , 95 % CI 1.18–4.07 ) , but the intervention did not affect this association . Conclusions This study showed that a training to enhance guideline adherence of occupational physicians leads to increased RTW self-efficacy in workers sick-listed with common mental disorders during the first months of sickness absence in a real-life occupational health care setting . This insight is helpful for optimizing the recovery and RTW process , and for underst and ing the role of RTW self-efficacy in this process . Trial registration IS RCT OBJECTIVE To assess physiotherapists ' adherence to the  Dutch guidelines  for nonspecific low back pain , the motivational determinants related to guideline adherence , and the role of physiotherapists ' awareness of their performance in this respect . STUDY DESIGN & SETTING This was a cross-sectional survey among a r and om sample of 1,500 private practice physiotherapists in the Netherl and s. The actual  guideline adherence  was measured by means of vali date d clinical vignettes and self-reported adherence by asking the physiotherapists to report their own level of adherence . The assessment of motivational determinants was based on a theoretical framework . RESULTS The  response rate was 31.5 % ( N=472 ) . The average guideline adherence rate was 50.4 % ( SD=16.8 ) . Only 38.5 % of the physiotherapists had realistic perceptions of their personal performance . Awareness levels seriously interfered with the relationship between motivational determinants and actual guideline adherence . Actual adherence was mainly related to the perceived relative advantages and awareness of adherence to the perceived social norm . CONCLUSION The moderating role of awareness in this study confirms the view that motivational determinants of a particular behavior can only be accurately assessed if people hold realistic perceptions of that behavior . Our approach illustrates the added value of a theory-based approach in guideline implementation studies 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 & NA ; Guidelines for the management of low back pain ( LBP ) have existed for many years , but adherence to these by health care practitioners ( HCPs ) remains suboptimal . The aim of this study was to measure the attitudes , beliefs and reported clinical behaviour of UK physiotherapists ( PTs ) and general practitioners ( GPs ) about LBP and to explore the associations between these . A cross‐sectional postal survey of GPs ( n = 2000 ) and PTs ( n = 2000 ) was conducted that included the  Pain Attitudes and Beliefs Scale ( PABT.PT )  , and a vignette of a  patient with non‐specific LBP ( NSLBP )  with questions asking about recommendations for work , activity and bedrest . Data from 1022 respondents ( 442 GPs and 580 PTs ) who had recently treated patients with LBP were analysed . Although the majority of HCPs reported providing advice for the vignette patient that was broadly in line with guideline recommendations , 28 % reported they would advise this patient to remain off work . Work advice was significantly related to the PABS.PT scores with higher biomedical ( F1,986 = 77.5 , p < 0.0001 ) and lower behavioural ( F1,981 = 31.9 , p < 0.001 ) scores associated with advice to remain off work . We have demonstrated that the attitudes and reported practice behaviour of UK GPs and PTs for patients with NSLBP are diverse . Many HCPs held the belief that LBP necessitates some avoidance of activities and work . The attitudes and beliefs of these HCPs were associated with their self‐reported clinical behaviour regarding advice about work . Future studies need to investigate whether approaches aim ed at modifying these HCP factors can lead to improved patient outcomes OBJECTIVE Identify barriers and facilitators related to the use of low-back pain guidelines as perceived by occupational therapists ( OTs ) . METHODS AND PARTICIPANTS A qualitative approach was used . Nine OTs with varied characteristics were r and omly selected . Participants were asked to use the guidelines with at least two clients .  Semi-structured interviews were done to identify barriers and facilitators related to use . Transcripts of the interviews were analyzed . RESULTS Participants agreed with the guidelines , found them compatible with their current practice , and believed using them would help in preventing persistent disability . Some question ed if their work organization , based on group therapy , would limit their use of the guidelines . Because of the guidelines ' biopsychosocial perspective , they anticipated problems regarding client expectations and collaboration with other health professionals . CONCLUSIONS Participating OTs raised few barriers related to them . Barriers were mostly related to client expectations , work organization and peers . It appears the guidelines would be easily implemented by OTs , but environmental elements could limit this One of the major challenges for general practitioners is to manage individuals with acute low back pain appropriately to reduce the risk of chronicity . A prospect i ve study was design ed to assess the actual management of acute low back pain in one primary care setting and to determine whether existing practice patterns conform to published guidelines . Twenty-four family physicians from public primary care centers of the Basque Health Service in Bizkaia , Basque Country ( Spain ) , participated in the study . A total of 105 patients aged 18–65 years presenting with acute low back pain over a 6-month period were included . Immediately after consultation , a research assistant performed a structured clinical interview . The patients ’ care provided by the general practitioner was compared with the Agency for Health Care Policy and Research ( AHCPR ) guidelines and guidelines issued by the Royal College of General Practitioners . The diagnostic process showed a low rate of appropriate use of history ( 27 % ) , physical examination ( 32 % ) , lumbar radiographs ( 31 % ) , and referral to specialized care ( 33 % ) . Although the therapeutic process showed a relatively high rate of appropriateness in earlier mobilization ( 77 % ) and educational advice ( 65 % ) , only 23 % of patients were taught about the benign course of back pain . The study revealed that management of acute low back pain in the primary care setting is far from being in conformance with published clinical guidelines Context Do clinicians who follow  depression practice guidelines have better patient outcomes ? Contribution This observational study from 45 primary care practice s found that clinicians adhered well to only one third of the guideline recommendations for depression . Most clinicians initially recognized and treated depression ; however , they often did not address suicide risk , assess alcohol use , adjust treatment appropriately , or follow through on long-term treatment plans . Better clinician adherence to recommendations was associated with a lower probability of persistent depressive symptoms among patients . Caution Data on depression-related care were based on patients ' self-report . Implication Clinicians should try harder to deliver guideline -concordant depression care . The Editors Depression practice guidelines for primary care represent expert consensus , based on systematic review of several r and omized clinical trials and other relevant literature , on how depression should be diagnosed and treated . Guidelines provide guidance for depression assessment , referral to mental health specialists , and follow-up in primary care ( 13 ) . Numerous studies document low rates of adherence to guideline recommendations on antidepressant use or psychotherapy ( 46 ) and less-than-optimal outcomes in usual care ( 7 ) . Far fewer studies have assessed adherence to the broader set of recommendations on additional aspects of care ranging from detection of depression symptoms to treatment discontinuation . National efforts to improve care ( 8) rely substantially on 1 or 2 guideline recommendations ( for example , completion of a short-term care course of antidepressant medication ) . Knowing the strengths and gaps in care for primary care patients with depression could provide a stronger basis for quality improvement . We sought to determine whether adherence to the broader set of depression guideline recommendations improves depression outcomes and , if so , to identify which guideline recommendations are most and least likely to be followed . To achieve these aims , we used expert panel methods to develop 20 guideline -based quality indicators for depression care ( 9 , 10 ) . We applied the indicators to secondary data from surveys of 1131 representative depressed patients from 45 diverse and geographically dispersed primary care practice s. We analyzed the link between performance on our measure and depression outcomes at 12 , 18 , and 24 months and assessed the level of performance on each of our indicators to identify which aspects of depression care were most and least in need of improvement . Methods We performed secondary analysis of data collected through the Quality Improvement for Depression ( QID ) collaboration ( 11 ) between 1996 and 1998 . The 4 studies in this collaboration used cluster r and omized design s to evaluate encouragement strategies for implementing Agency for Healthcare Research and Quality guidelines for depression ( 13 ) in primary care . One QID study used self-administered surveys ( 12 ) , which had some questions that were worded differently from questions in the other 3 studies . We included only the 3 QID studies that used virtually identical telephone-administered surveys . Among these 3 studies , only 1 showed statistically significant improvement in depression-specific outcomes ( 13 , 14 ) . In the QID studies , experimental-group clinician leaders were given training , material s , and protocol s to encourage them to provide collaborative care for depression-based quality improvement ( Figure ) . Additional details on the encouragement approach used by each study are published elsewhere ( 1114 ) . For our observational analyses , we combined the usual care and experimental groups . The study was approved by the institutional review board at each study site . Figure . Quasi-experimental design of studies in the Quality Improvement for Depression collaboration . Setting Patients and clinicians were recruited from 45 primary care practice s within 4 health care organizations in 13 states . Organizations included a multistate family practice network ( 11 ) , 2 staff-model managed care organizations ( Kaiser Permanente and Veterans Affairs [ 14 ] ) , and a network model managed care organization whose patients were cared for in private practice s throughout Maryl and ( 11 , 15 ) . Sample Research ers consecutively approached patients visiting participating practice s to identify those with symptoms of depression on a brief self-report depression screening instrument derived from the World Health Organization Composite International Diagnostic Interview ( CIDI ) ( 16 ) . Telephone interviewers used the full CIDI for Affective Disorders to assess consenting patients who tested positive on the CIDI screen 
    Output:
    
agent
Clinicians believed that guidelines were categorical , prescriptive , and constrained professional practice ; however , popular clinical practice s superseded the guidelines .
Imaging referrals were used to manage consultations and to obtain definitive diagnoses .
Clinicians ' perceptions reflected a lack of content knowledge and underst and ing of how guidelines are developed .
DISCUSSION Addressing misconceptions and other barriers to uptake of evidence -based guidelines for managing LBP is needed to improve knowledge transfer and close the evidence - practice gap in the treatment of this common condition
***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 Since a higher level of self-efficacy in common mental disorders is associated with earlier return-to-work ( RTW ) , it is important to know if work related self-efficacy can be increased by occupational health care . The primary aim of this study was to evaluate whether an intervention to enhance guideline adherence of occupational physicians lead to an increase in RTW self-efficacy in workers three months later . The secondary aim was to evaluate whether the intervention modified the association between RTW self-efficacy and return-to-work three months later . Methods A total of 66 occupational physicians participated in the study . They were r and omized into two groups ; the intervention group received a training , the control group did not . The training aim ed to enhance adherence to a mental health guideline that contained strategies that are supposed to enhance RTW self-efficacy . In 128 sick-listed workers guided by these occupational physicians , RTW self-efficacy , RTW , and personal , health-related and work-related variables were measured at baseline and three months later . Generalized linear mixed models analysis and linear mixed models analysis were used for the evaluations . Results In workers whose occupational physicians had received the training RTW self-efficacy increased significantly more than in workers whose occupational physicians had participated in the control group ( t = −2.626 , p ≤ .05 ) . Higher baseline RTW self-efficacy scores were significantly more often associated with full RTW than with no RTW three months later ( OR 2.20 , 95 % CI 1.18–4.07 ) , but the intervention did not affect this association . Conclusions This study showed that a training to enhance guideline adherence of occupational physicians leads to increased RTW self-efficacy in workers sick-listed with common mental disorders during the first months of sickness absence in a real-life occupational health care setting . This insight is helpful for optimizing the recovery and RTW process , and for underst and ing the role of RTW self-efficacy in this process . Trial registration IS RCT OBJECTIVE To assess physiotherapists ' adherence to the  Dutch guidelines  for nonspecific low back pain , the motivational determinants related to guideline adherence , and the role of physiotherapists ' awareness of their performance in this respect . STUDY DESIGN & SETTING This was a cross-sectional survey among a r and om sample of 1,500 private practice physiotherapists in the Netherl and s. The actual  guideline adherence  was measured by means of vali date d clinical vignettes and self-reported adherence by asking the physiotherapists to report their own level of adherence . The assessment of motivational determinants was based on a theoretical framework . RESULTS The  response rate was 31.5 % ( N=472 ) . The average guideline adherence rate was 50.4 % ( SD=16.8 ) . Only 38.5 % of the physiotherapists had realistic perceptions of their personal performance . Awareness levels seriously interfered with the relationship between motivational determinants and actual guideline adherence . Actual adherence was mainly related to the perceived relative advantages and awareness of adherence to the perceived social norm . CONCLUSION The moderating role of awareness in this study confirms the view that motivational determinants of a particular behavior can only be accurately assessed if people hold realistic perceptions of that behavior . Our approach illustrates the added value of a theory-based approach in guideline implementation studies 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 & NA ; Guidelines for the management of low back pain ( LBP ) have existed for many years , but adherence to these by health care practitioners ( HCPs ) remains suboptimal . The aim of this study was to measure the attitudes , beliefs and reported clinical behaviour of UK physiotherapists ( PTs ) and general practitioners ( GPs ) about LBP and to explore the associations between these . A cross‐sectional postal survey of GPs ( n = 2000 ) and PTs ( n = 2000 ) was conducted that included the  Pain Attitudes and Beliefs Scale ( PABT.PT )  , and a vignette of a  patient with non‐specific LBP ( NSLBP )  with questions asking about recommendations for work , activity and bedrest . Data from 1022 respondents ( 442 GPs and 580 PTs ) who had recently treated patients with LBP were analysed . Although the majority of HCPs reported providing advice for the vignette patient that was broadly in line with guideline recommendations , 28 % reported they would advise this patient to remain off work . Work advice was significantly related to the PABS.PT scores with higher biomedical ( F1,986 = 77.5 , p < 0.0001 ) and lower behavioural ( F1,981 = 31.9 , p < 0.001 ) scores associated with advice to remain off work . We have demonstrated that the attitudes and reported practice behaviour of UK GPs and PTs for patients with NSLBP are diverse . Many HCPs held the belief that LBP necessitates some avoidance of activities and work . The attitudes and beliefs of these HCPs were associated with their self‐reported clinical behaviour regarding advice about work . Future studies need to investigate whether approaches aim ed at modifying these HCP factors can lead to improved patient outcomes OBJECTIVE Identify barriers and facilitators related to the use of low-back pain guidelines as perceived by occupational therapists ( OTs ) . METHODS AND PARTICIPANTS A qualitative approach was used . Nine OTs with varied characteristics were r and omly selected . Participants were asked to use the guidelines with at least two clients .  Semi-structured interviews were done to identify barriers and facilitators related to use . Transcripts of the interviews were analyzed . RESULTS Participants agreed with the guidelines , found them compatible with their current practice , and believed using them would help in preventing persistent disability . Some question ed if their work organization , based on group therapy , would limit their use of the guidelines . Because of the guidelines ' biopsychosocial perspective , they anticipated problems regarding client expectations and collaboration with other health professionals . CONCLUSIONS Participating OTs raised few barriers related to them . Barriers were mostly related to client expectations , work organization and peers . It appears the guidelines would be easily implemented by OTs , but environmental elements could limit this One of the major challenges for general practitioners is to manage individuals with acute low back pain appropriately to reduce the risk of chronicity . A prospect i ve study was design ed to assess the actual management of acute low back pain in one primary care setting and to determine whether existing practice patterns conform to published guidelines . Twenty-four family physicians from public primary care centers of the Basque Health Service in Bizkaia , Basque Country ( Spain ) , participated in the study . A total of 105 patients aged 18–65 years presenting with acute low back pain over a 6-month period were included . Immediately after consultation , a research assistant performed a structured clinical interview . The patients ’ care provided by the general practitioner was compared with the Agency for Health Care Policy and Research ( AHCPR ) guidelines and guidelines issued by the Royal College of General Practitioners . The diagnostic process showed a low rate of appropriate use of history ( 27 % ) , physical examination ( 32 % ) , lumbar radiographs ( 31 % ) , and referral to specialized care ( 33 % ) . Although the therapeutic process showed a relatively high rate of appropriateness in earlier mobilization ( 77 % ) and educational advice ( 65 % ) , only 23 % of patients were taught about the benign course of back pain . The study revealed that management of acute low back pain in the primary care setting is far from being in conformance with published clinical guidelines Context Do clinicians who follow  depression practice guidelines have better patient outcomes ? Contribution This observational study from 45 primary care practice s found that clinicians adhered well to only one third of the guideline recommendations for depression . Most clinicians initially recognized and treated depression ; however , they often did not address suicide risk , assess alcohol use , adjust treatment appropriately , or follow through on long-term treatment plans . Better clinician adherence to recommendations was associated with a lower probability of persistent depressive symptoms among patients . Caution Data on depression-related care were based on patients ' self-report . Implication Clinicians should try harder to deliver guideline -concordant depression care . The Editors Depression practice guidelines for primary care represent expert consensus , based on systematic review of several r and omized clinical trials and other relevant literature , on how depression should be diagnosed and treated . Guidelines provide guidance for depression assessment , referral to mental health specialists , and follow-up in primary care ( 13 ) . Numerous studies document low rates of adherence to guideline recommendations on antidepressant use or psychotherapy ( 46 ) and less-than-optimal outcomes in usual care ( 7 ) . Far fewer studies have assessed adherence to the broader set of recommendations on additional aspects of care ranging from detection of depression symptoms to treatment discontinuation . National efforts to improve care ( 8) rely substantially on 1 or 2 guideline recommendations ( for example , completion of a short-term care course of antidepressant medication ) . Knowing the strengths and gaps in care for primary care patients with depression could provide a stronger basis for quality improvement . We sought to determine whether adherence to the broader set of depression guideline recommendations improves depression outcomes and , if so , to identify which guideline recommendations are most and least likely to be followed . To achieve these aims , we used expert panel methods to develop 20 guideline -based quality indicators for depression care ( 9 , 10 ) . We applied the indicators to secondary data from surveys of 1131 representative depressed patients from 45 diverse and geographically dispersed primary care practice s. We analyzed the link between performance on our measure and depression outcomes at 12 , 18 , and 24 months and assessed the level of performance on each of our indicators to identify which aspects of depression care were most and least in need of improvement . Methods We performed secondary analysis of data collected through the Quality Improvement for Depression ( QID ) collaboration ( 11 ) between 1996 and 1998 . The 4 studies in this collaboration used cluster r and omized design s to evaluate encouragement strategies for implementing Agency for Healthcare Research and Quality guidelines for depression ( 13 ) in primary care . One QID study used self-administered surveys ( 12 ) , which had some questions that were worded differently from questions in the other 3 studies . We included only the 3 QID studies that used virtually identical telephone-administered surveys . Among these 3 studies , only 1 showed statistically significant improvement in depression-specific outcomes ( 13 , 14 ) . In the QID studies , experimental-group clinician leaders were given training , material s , and protocol s to encourage them to provide collaborative care for depression-based quality improvement ( Figure ) . Additional details on the encouragement approach used by each study are published elsewhere ( 1114 ) . For our observational analyses , we combined the usual care and experimental groups . The study was approved by the institutional review board at each study site . Figure . Quasi-experimental design of studies in the Quality Improvement for Depression collaboration . Setting Patients and clinicians were recruited from 45 primary care practice s within 4 health care organizations in 13 states . Organizations included a multistate family practice network ( 11 ) , 2 staff-model managed care organizations ( Kaiser Permanente and Veterans Affairs [ 14 ] ) , and a network model managed care organization whose patients were cared for in private practice s throughout Maryl and ( 11 , 15 ) . Sample Research ers consecutively approached patients visiting participating practice s to identify those with symptoms of depression on a brief self-report depression screening instrument derived from the World Health Organization Composite International Diagnostic Interview ( CIDI ) ( 16 ) . Telephone interviewers used the full CIDI for Affective Disorders to assess consenting patients who tested positive on the CIDI screen 
    Output:
    