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 Osteoporosis is a serious but treatable condition . However , appropriate therapy utilization of the disease remains suboptimal . Thus , the objective of the study was to change physicians ' therapy administration behavior in accordance with the Osteoporosis Canada 2002 guidelines . Methods The Project was a two year cohort study that consisted of five Quality Circle ( QC ) phases that included : 1 ) Training & Baseline Data Collection , 2 ) First Educational Intervention & First Follow-Up Data Collection 3 ) First Strategy Implementation Session , 4 ) Final Educational Intervention & Final Follow-up Data Collection , and 5 ) Final Strategy Implementation Session . A total of 340 family physicians formed 34 QCs and participated in the study . Physicians evaluated a total of 8376 , 7354 and 3673 r and omly selected patient charts at baseline , follow-up # 1 and the final follow-up , respectively . Patients were divided into three groups ; the high-risk , low-risk , and low-risk without fracture groups . The generalized estimating equations technique was utilized to model the change over time of whether physicians Results The odds of appropriate therapy was 1.29 ( 95 % CI : 1.13 , 1.46 ) , and 1.41 ( 95 % CI : 1.20 , 1.66 ) in the high risk group , 1.15 ( 95 % CI : 0.97 , 1.36 ) , and 1.16 ( 95 % CI : 0.93 , 1.44 ) in the low risk group , and 1.20 ( 95 % CI : 1.01 , 1.43 ) , and 1.23 ( 95 % CI : 0.97 , 1.55 ) in the low risk group without fractures at follow-up # 1 and the final follow-up , respectively . Conclusion QCs methodology was successful in increasing physicians ' appropriate use of osteoporosis medications in accordance with Osteoporosis Canada guidelines Background : Postfracture care is suboptimal , and strategies to address this major gap in care are necessary . We investigated whether notifications sent by mail to physicians and patients would lead to improved postfracture care . Methods : We conducted a r and omized controlled trial ( Clinical Trials.gov identifier NCT00594789 ) in the province of Manitoba , Canada , from June 2008 to May 2010 . Using medical cl aims data , we identified 4264 men and women age 50 years or older who recently reported major fractures , and who had not undergone recent bone mineral density testing or treatment for osteoporosis . Participants were r and omized to three groups : group 1 received usual care ( n = 1480 ) , patients in group 2 had mailed notification of the fracture sent to their primary care physicians ( n = 1363 ) , and group 3 had notifications sent to both physicians and patients ( n = 1421 ) . Bone mineral density testing and the start of pharmacologic treatment for osteoporosis within the following 12 months were documented . Results : Among participants in group 1 ( usual care ) , 15.8 % of women and 7.6 % of men underwent testing for bone mineral density or started pharmacologic treatment for osteoporosis . Outcome measures improved among participants in group 2 ( 30.3 % of women and 19.0 % of men , both p < 0.001 ) and group 3 ( 34.0 % of women and 19.8 % of men , both p < 0.001 ) . No additional benefit was seen with patient notification in addition to physician notification . Combining groups 2 and 3 , the absolute increase for the combined end point of bone mineral density testing or pharmacologic treatment was 14.9 % ( 16.4 % among women , 11.8 % among men ) . The number needed to notify to change patient care was 7 ( 6 for women , 6 for men ) . The adjusted odds ratio ( OR ) to change patient care in group 2 was 2.45 ( 95 % confidence interval [ CI ] 2.01–2.98 ) ; for group 3 the OR was 2.82 ( 95 % CI 2.33–3.43 ) . Interpretation : This notification system provides a relatively simple way to enhance post-fracture care AIM To investigate whether the effect of educational reminder messages for knee and lumbar spine radiographs varied over a 12 month period . MATERIAL S AND METHODS In a previous r and omized , controlled trial , educational reminder messages attached to x-ray reports were shown to be effective in reducing the number of radiograph requests by general practitioners for knee and lumbar spine radiographs . In this study , all radiology departments from the previous trial were asked for monthly referral records for the 12 month intervention period for knee and lumbar spine radiographs for each general practice . Poisson regression was used to test for a change over time in the number of referrals between control and intervention practice s. RESULTS Data were obtained for 66 % of the general practice s in the main trial . The number of referrals for both knee and lumbar spine radiographs remained consistently and statistically significantly lower in the educational reminder messages group compared with the control group ( relative risk=0.65 and 0.64 , respectively ) . There was no evidence that this difference increased or decreased throughout the 12 month period . CONCLUSIONS The effect of educational reminder messages was produced as soon as the intervention was delivered and maintained throughout the intervention period . There was no evidence of the effect of the intervention wearing off OBJECTIVE To assess whether providing information on arthritis self-management through general practitioners ( GPs ) increases the quality of life in patients with osteoarthritis and whether additional case management provided by practice nurses shows better results . METHODS We conducted a pragmatic , cluster-r and omized , controlled , 3-arm trial that included 1,021 patients from 75 primary care practice s in Germany . GPs were r and omized to intervention group I , group II , or a control group . GPs of both intervention groups participated in 2 peer group meetings . In intervention group II , additional case management was conducted via telephone by a practice nurse . The primary outcome was change in quality of life , assessed by the German version of the Arthritis Impact Measurement Scales Short Form ( AIMS 2-SF ) . Secondary outcomes were health service utilization , prescriptions , and physical activity . Data were controlled for depression using the Patient Health Question naire 9 as a potential confounder . RESULTS Of 1,125 administered question naires , 1,021 were analyzed . Compared with the control group , no significant changes occurred in intervention group I with respect to the primary outcome . Performed radiographs decreased significantly ( P = 0.050 ) , whereas prescriptions of  acetaminophen  increased significantly ( P < 0.001 ) . In intervention group II , significant changes in the AIMS 2-SF dimensions social ( P < 0.001 ) , symptom ( P = 0.048 ) , and lower body ( P = 0.049 ) were identified . Radiographs ( P = 0.031 ) and orthopedic referrals ( P = 0.044 ) decreased whereas prescriptions of pain relievers increased significantly . CONCLUSION Improving the quality of life in patients with arthritis using arthritis self-management seems challenging . Simply providing this information through GPs is not sufficient but combining it with case management seems to be a promising approach Background Osteoporosis-related fractures are a significant public health concern . Interventions that increase detection and treatment of osteoporosis are underutilized . This pragmatic r and omised study was done to evaluate the impact of a multifaceted community-based care program aim ed at optimizing evidence -based management in patients at risk for osteoporosis and fractures . Methods This was a 12-month r and omized trial performed in Ontario , Canada . Eligible patients were community-dwelling , aged ≥55 years , and identified to be at risk for osteoporosis-related fractures . Two hundred and one patients were allocated to the intervention group or to usual care . Components of the intervention were directed towards primary care physicians and patients and included facilitated bone mineral density testing , patient education and patient-specific recommendations for osteoporosis treatment . The primary outcome was the implementation of appropriate osteoporosis management . Results 101 patients were allocated to intervention and 100 to control . Mean age of participants was 71.9 ± 7.2 years and 94 % were women . Pharmacological treatment ( alendronate , risedronate , or raloxifene ) for osteoporosis was increased by 29 % compared to usual care ( 56 % [ 29/52 ] vs. 27 % [ 16/60 ] ; relative risk [ RR ] 2.09 , 95 % confidence interval [ CI ] 1.29 to 3.40 ) . More individuals in the intervention group were taking calcium ( 54 % [ 54/101 ] vs. 20 % [ 20/100 ] ; RR 2.67 , 95 % CI 1.74 to 4.12 ) and vitamin D ( 33 % [ 33/101 ] vs. 20 % [ 20/100 ] ; RR 1.63 , 95 % CI 1.01 to 2.65 ) . Conclusions A multi-faceted community-based intervention improved management of osteoporosis in high risk patients compared with usual care . Trial Registration This trial has been registered with clinical trials.gov ( ID : NCT00465387 OBJECTIVE To address the question whether general practitioners ( GPs ) should receive practical training in shoulder problems and to test whether cortisone injections are better than anaesthetic injections for rotator cuff problems . METHODS A pragmatic split-plot , r and omized trial with a cluster factorial design , conducted in general practice s across five centres across the United Kingdom . Ninety-one practice s were r and omized to receive additional training in diagnosing and injecting rotator cuff problems or no additional training .  Two hundred patients consulting their general practice s with shoulder pain were then r and omized to receive either a corticosteroid or lignocaine injection . The main outcome was score on the British Shoulder Disability Question naire ( BSDQ ) . The Short-Form 36-item Health Survey and EuroQol at 12 months from entry to the trial were also scored . RESULTS Over the course of the trial there was a mean difference of 0.94 ( s.e . = 1.01 ) on the BSDQ score between the groups , with patients treated by the untrained group having a mean of 9.46 ( s.e . = 0.82 ) and those by the trained group having a mean of 8.51 ( s.e . = 0.60 ) . There were no statistically significant differences between the groups . Analysing by substance injected , there was a mean difference of 0.15 ( s.e . = 0.48 ) throughout the trial between the groups , with patients given the cortisone having a mean BSDQ of 9.67 ( s.e . = 0.39 ) and those given lignocaine , 9.82 ( s.e . = 0.39 ) . This was not statistically significantly different . CONCLUSIONS Training GPs in the diagnosis and treatment of shoulder disorders does not make any difference to the outcome , in terms of pain and disability , 1 yr later . Further , there is no advantage to injecting steroid in a group with predominant rotator cuff disorder . Trial registration . International St and ard R and omized Controlled Trial Number 58537244 . Trial steering committee comprised Prof. Paul Dieppe , Prof. Elaine Hay , Dr Brian Hazleman and Dr Kerenza Hood Background Osteoarthritis ( OA ) has a high prevalence in primary care . Conservative , guideline orientated approaches aim ing at improving pain treatment and increasing physical activity , have been proven to be effective in several context s outside the primary care setting , as for instance the Arthritis Self management Programs ( ASMPs ) . But it remains unclear if these comprehensive evidence based approaches can improve patients ' quality of life if they are provided in a primary care setting . Methods / Design PraxArt is a cluster r and omised controlled trial with GPs as the unit of r and omisation . The aim of the study is to evaluate the impact of a comprehensive evidence based medical education of GPs on individual care and patients ' quality of life . 75 GPs were r and omised either to intervention group I or II or to a control group . Each GP will include 15 patients suffering from osteoarthritis according to the criteria of ACR.In intervention group I GPs will receive medical education and patient education leaflets including a physical exercise program . In intervention group II the same is provided , but in addition a practice nurse will be trained to monitor via monthly telephone calls adherence to GPs prescriptions and advices and ask about increasing pain and possible side effects of medication . In the control group no intervention will be applied at all . Main outcome measurement for patients ' QoL is the GERMAN- AIMS 2-SF question naire . In addition data about patients ' satisfaction ( using a modified EUROPEP-tool ) , medication , health care utilization , comorbidity , physical activity and depression ( using PHQ-9 ) will be retrieved . Measurements ( pre data collection ) will take place in months I-III , starting in June 2005 . Post data collection will be performed after 6 months . Discussion Despite the high prevalence and increasing incidence , comprehensive and evidence based treatment approaches for OA in a primary care setting are neither established nor evaluated in Germany . If the evaluation of the presented approach reveals a clear benefit it is planned to provide this GP-centred interventions on a much larger scale Introduction This cluster r and omised trial evaluated an intervention to decrease x-ray referr 
    Output:
    
agent
The 12 remaining studies across all musculoskeletal conditions showed little or no improvement in GP behaviour and patient outcomes .The direction of the targeted behaviour ( i.e. increasing or decreasing a behaviour ) does not seem to affect the effectiveness of an intervention .
There is good- quality evidence that a GP alerting system with or without patient-directed education on osteoporosis improves guideline -consistent GP behaviour , result ing in better diagnosis and treatment rates .
Interventions such as GP reminder messages and GP feedback on performance combined with guideline dissemination may lead to small improvements in guideline -consistent GP behaviour with regard to low back pain , while GP education on osteoarthritis pain and the use of educationally influential physicians may lead to slight improvement in patient outcomes and guideline -consistent behaviour respectively .
***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 Osteoporosis is a serious but treatable condition . However , appropriate therapy utilization of the disease remains suboptimal . Thus , the objective of the study was to change physicians ' therapy administration behavior in accordance with the Osteoporosis Canada 2002 guidelines . Methods The Project was a two year cohort study that consisted of five Quality Circle ( QC ) phases that included : 1 ) Training & Baseline Data Collection , 2 ) First Educational Intervention & First Follow-Up Data Collection 3 ) First Strategy Implementation Session , 4 ) Final Educational Intervention & Final Follow-up Data Collection , and 5 ) Final Strategy Implementation Session . A total of 340 family physicians formed 34 QCs and participated in the study . Physicians evaluated a total of 8376 , 7354 and 3673 r and omly selected patient charts at baseline , follow-up # 1 and the final follow-up , respectively . Patients were divided into three groups ; the high-risk , low-risk , and low-risk without fracture groups . The generalized estimating equations technique was utilized to model the change over time of whether physicians Results The odds of appropriate therapy was 1.29 ( 95 % CI : 1.13 , 1.46 ) , and 1.41 ( 95 % CI : 1.20 , 1.66 ) in the high risk group , 1.15 ( 95 % CI : 0.97 , 1.36 ) , and 1.16 ( 95 % CI : 0.93 , 1.44 ) in the low risk group , and 1.20 ( 95 % CI : 1.01 , 1.43 ) , and 1.23 ( 95 % CI : 0.97 , 1.55 ) in the low risk group without fractures at follow-up # 1 and the final follow-up , respectively . Conclusion QCs methodology was successful in increasing physicians ' appropriate use of osteoporosis medications in accordance with Osteoporosis Canada guidelines Background : Postfracture care is suboptimal , and strategies to address this major gap in care are necessary . We investigated whether notifications sent by mail to physicians and patients would lead to improved postfracture care . Methods : We conducted a r and omized controlled trial ( Clinical Trials.gov identifier NCT00594789 ) in the province of Manitoba , Canada , from June 2008 to May 2010 . Using medical cl aims data , we identified 4264 men and women age 50 years or older who recently reported major fractures , and who had not undergone recent bone mineral density testing or treatment for osteoporosis . Participants were r and omized to three groups : group 1 received usual care ( n = 1480 ) , patients in group 2 had mailed notification of the fracture sent to their primary care physicians ( n = 1363 ) , and group 3 had notifications sent to both physicians and patients ( n = 1421 ) . Bone mineral density testing and the start of pharmacologic treatment for osteoporosis within the following 12 months were documented . Results : Among participants in group 1 ( usual care ) , 15.8 % of women and 7.6 % of men underwent testing for bone mineral density or started pharmacologic treatment for osteoporosis . Outcome measures improved among participants in group 2 ( 30.3 % of women and 19.0 % of men , both p < 0.001 ) and group 3 ( 34.0 % of women and 19.8 % of men , both p < 0.001 ) . No additional benefit was seen with patient notification in addition to physician notification . Combining groups 2 and 3 , the absolute increase for the combined end point of bone mineral density testing or pharmacologic treatment was 14.9 % ( 16.4 % among women , 11.8 % among men ) . The number needed to notify to change patient care was 7 ( 6 for women , 6 for men ) . The adjusted odds ratio ( OR ) to change patient care in group 2 was 2.45 ( 95 % confidence interval [ CI ] 2.01–2.98 ) ; for group 3 the OR was 2.82 ( 95 % CI 2.33–3.43 ) . Interpretation : This notification system provides a relatively simple way to enhance post-fracture care AIM To investigate whether the effect of educational reminder messages for knee and lumbar spine radiographs varied over a 12 month period . MATERIAL S AND METHODS In a previous r and omized , controlled trial , educational reminder messages attached to x-ray reports were shown to be effective in reducing the number of radiograph requests by general practitioners for knee and lumbar spine radiographs . In this study , all radiology departments from the previous trial were asked for monthly referral records for the 12 month intervention period for knee and lumbar spine radiographs for each general practice . Poisson regression was used to test for a change over time in the number of referrals between control and intervention practice s. RESULTS Data were obtained for 66 % of the general practice s in the main trial . The number of referrals for both knee and lumbar spine radiographs remained consistently and statistically significantly lower in the educational reminder messages group compared with the control group ( relative risk=0.65 and 0.64 , respectively ) . There was no evidence that this difference increased or decreased throughout the 12 month period . CONCLUSIONS The effect of educational reminder messages was produced as soon as the intervention was delivered and maintained throughout the intervention period . There was no evidence of the effect of the intervention wearing off OBJECTIVE To assess whether providing information on arthritis self-management through general practitioners ( GPs ) increases the quality of life in patients with osteoarthritis and whether additional case management provided by practice nurses shows better results . METHODS We conducted a pragmatic , cluster-r and omized , controlled , 3-arm trial that included 1,021 patients from 75 primary care practice s in Germany . GPs were r and omized to intervention group I , group II , or a control group . GPs of both intervention groups participated in 2 peer group meetings . In intervention group II , additional case management was conducted via telephone by a practice nurse . The primary outcome was change in quality of life , assessed by the German version of the Arthritis Impact Measurement Scales Short Form ( AIMS 2-SF ) . Secondary outcomes were health service utilization , prescriptions , and physical activity . Data were controlled for depression using the Patient Health Question naire 9 as a potential confounder . RESULTS Of 1,125 administered question naires , 1,021 were analyzed . Compared with the control group , no significant changes occurred in intervention group I with respect to the primary outcome . Performed radiographs decreased significantly ( P = 0.050 ) , whereas prescriptions of  acetaminophen  increased significantly ( P < 0.001 ) . In intervention group II , significant changes in the AIMS 2-SF dimensions social ( P < 0.001 ) , symptom ( P = 0.048 ) , and lower body ( P = 0.049 ) were identified . Radiographs ( P = 0.031 ) and orthopedic referrals ( P = 0.044 ) decreased whereas prescriptions of pain relievers increased significantly . CONCLUSION Improving the quality of life in patients with arthritis using arthritis self-management seems challenging . Simply providing this information through GPs is not sufficient but combining it with case management seems to be a promising approach Background Osteoporosis-related fractures are a significant public health concern . Interventions that increase detection and treatment of osteoporosis are underutilized . This pragmatic r and omised study was done to evaluate the impact of a multifaceted community-based care program aim ed at optimizing evidence -based management in patients at risk for osteoporosis and fractures . Methods This was a 12-month r and omized trial performed in Ontario , Canada . Eligible patients were community-dwelling , aged ≥55 years , and identified to be at risk for osteoporosis-related fractures . Two hundred and one patients were allocated to the intervention group or to usual care . Components of the intervention were directed towards primary care physicians and patients and included facilitated bone mineral density testing , patient education and patient-specific recommendations for osteoporosis treatment . The primary outcome was the implementation of appropriate osteoporosis management . Results 101 patients were allocated to intervention and 100 to control . Mean age of participants was 71.9 ± 7.2 years and 94 % were women . Pharmacological treatment ( alendronate , risedronate , or raloxifene ) for osteoporosis was increased by 29 % compared to usual care ( 56 % [ 29/52 ] vs. 27 % [ 16/60 ] ; relative risk [ RR ] 2.09 , 95 % confidence interval [ CI ] 1.29 to 3.40 ) . More individuals in the intervention group were taking calcium ( 54 % [ 54/101 ] vs. 20 % [ 20/100 ] ; RR 2.67 , 95 % CI 1.74 to 4.12 ) and vitamin D ( 33 % [ 33/101 ] vs. 20 % [ 20/100 ] ; RR 1.63 , 95 % CI 1.01 to 2.65 ) . Conclusions A multi-faceted community-based intervention improved management of osteoporosis in high risk patients compared with usual care . Trial Registration This trial has been registered with clinical trials.gov ( ID : NCT00465387 OBJECTIVE To address the question whether general practitioners ( GPs ) should receive practical training in shoulder problems and to test whether cortisone injections are better than anaesthetic injections for rotator cuff problems . METHODS A pragmatic split-plot , r and omized trial with a cluster factorial design , conducted in general practice s across five centres across the United Kingdom . Ninety-one practice s were r and omized to receive additional training in diagnosing and injecting rotator cuff problems or no additional training .  Two hundred patients consulting their general practice s with shoulder pain were then r and omized to receive either a corticosteroid or lignocaine injection . The main outcome was score on the British Shoulder Disability Question naire ( BSDQ ) . The Short-Form 36-item Health Survey and EuroQol at 12 months from entry to the trial were also scored . RESULTS Over the course of the trial there was a mean difference of 0.94 ( s.e . = 1.01 ) on the BSDQ score between the groups , with patients treated by the untrained group having a mean of 9.46 ( s.e . = 0.82 ) and those by the trained group having a mean of 8.51 ( s.e . = 0.60 ) . There were no statistically significant differences between the groups . Analysing by substance injected , there was a mean difference of 0.15 ( s.e . = 0.48 ) throughout the trial between the groups , with patients given the cortisone having a mean BSDQ of 9.67 ( s.e . = 0.39 ) and those given lignocaine , 9.82 ( s.e . = 0.39 ) . This was not statistically significantly different . CONCLUSIONS Training GPs in the diagnosis and treatment of shoulder disorders does not make any difference to the outcome , in terms of pain and disability , 1 yr later . Further , there is no advantage to injecting steroid in a group with predominant rotator cuff disorder . Trial registration . International St and ard R and omized Controlled Trial Number 58537244 . Trial steering committee comprised Prof. Paul Dieppe , Prof. Elaine Hay , Dr Brian Hazleman and Dr Kerenza Hood Background Osteoarthritis ( OA ) has a high prevalence in primary care . Conservative , guideline orientated approaches aim ing at improving pain treatment and increasing physical activity , have been proven to be effective in several context s outside the primary care setting , as for instance the Arthritis Self management Programs ( ASMPs ) . But it remains unclear if these comprehensive evidence based approaches can improve patients ' quality of life if they are provided in a primary care setting . Methods / Design PraxArt is a cluster r and omised controlled trial with GPs as the unit of r and omisation . The aim of the study is to evaluate the impact of a comprehensive evidence based medical education of GPs on individual care and patients ' quality of life . 75 GPs were r and omised either to intervention group I or II or to a control group . Each GP will include 15 patients suffering from osteoarthritis according to the criteria of ACR.In intervention group I GPs will receive medical education and patient education leaflets including a physical exercise program . In intervention group II the same is provided , but in addition a practice nurse will be trained to monitor via monthly telephone calls adherence to GPs prescriptions and advices and ask about increasing pain and possible side effects of medication . In the control group no intervention will be applied at all . Main outcome measurement for patients ' QoL is the GERMAN- AIMS 2-SF question naire . In addition data about patients ' satisfaction ( using a modified EUROPEP-tool ) , medication , health care utilization , comorbidity , physical activity and depression ( using PHQ-9 ) will be retrieved . Measurements ( pre data collection ) will take place in months I-III , starting in June 2005 . Post data collection will be performed after 6 months . Discussion Despite the high prevalence and increasing incidence , comprehensive and evidence based treatment approaches for OA in a primary care setting are neither established nor evaluated in Germany . If the evaluation of the presented approach reveals a clear benefit it is planned to provide this GP-centred interventions on a much larger scale Introduction This cluster r and omised trial evaluated an intervention to decrease x-ray referr 
    Output:
    