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: 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 OBJECTIVE : The effect of clinical guidelines on re source utilization for complex conditions with substantial barriers to clinician behavior change has not been well studied . We report the impact of a multifaceted guideline implementation intervention on primary care clinician utilization of radiologic and specialty services for the care of acute low back pain . DESIGN : Physician groups were r and omized to receive guideline education and individual feedback , supporting patient education material s , both , or neither . The impact on guideline adherence and re source utilization was evaluated during the 12-month period before and after implementation . PARTICIPANTS : Fourteen physician groups with 120 primary care physician and associate practitioners from 2 group model HMO practice s. INTERVENTIONS : Guideline implementation utilized an education/audit/feedback model with local peer opinion leaders . The patient education component included written and videotaped material s on the care of low back pain . MAIN RESULTS : The clinician intervention was associated with an absolute increase in guideline -consistent behavior of 5.4 % in the intervention group versus a decline of 2.7 % in the control group ( P=.04 ) . The patient education intervention produced no significant change in guideline -consistent behavior , but was poorly adopted . Patient characteristics including duration of pain , prior history of low back pain , and number of visits during the illness episode were strong predictors of service utilization and guideline -consistent behavior . CONCLUSIONS : Implementation of an education and feedback-supported acute low back pain care guideline for primary care clinicians was associated with an increase in guideline -consistent behavior . Patient education material s did not enhance guideline effectiveness . Implementation barriers could limit the utility of this approach in usual care setting BACKGROUND The Royal College of General Practitioners ( RCGP ) has produced guidelines for the management of acute low back pain in primary care . AIM To investigate the impact on patient management of an educational strategy to promote these guidelines among general practitioners ( GPs ) . DESIGN OF STUDY Group r and omised controlled trial , using the health centre as the unit of r and omisation . SETTING Primary care teams in north-west Engl and . METHOD Twenty-four health centres were r and omly allocated to an intervention or control arm . Practice s in the intervention arm were offered outreach visits to promote national guidelines on acute low back pain , as well as access to fast-track physiotherapy and to a triage service for patients with persistent symptoms . RESULTS Twenty-four centres were r and omised . Two thous and , one hundred and eighty-seven eligible patients presented with acute low back pain during the study period : 1049 in the intervention group and 1138 in the control group . There were no significant differences between study groups in the proportion of patients who were referred for X-ray , issued with a sickness certificate , prescribed opioids or muscle relaxants , or who were referred to secondary care , but significantly more patients in the intervention group were referred to physiotherapy or the back pain unit ( difference in proportion = 12.2 % , 95 % confidence interval [ CI ] = 2.8 % to 21.6 % ) . CONCLUSION The management of patients presenting with low back pain to primary care was mostly unchanged by an outreach educational strategy to promote greater adherence to RCGP guidelines among GPs . An increase in referral to physiotherapy or educational programmes followed the provision of a triage service BACKGROUND AND PURPOSE : We conducted a prospect i ve r and omized study of patients with acute low back pain and /or radiculopathy to assess the effect of knowledge of diagnostic findings on clinical outcome . The practice of ordering spinal imaging , perhaps unintentionally , includes a large number of patients for whom the imaging test is performed for purpose s of reassurance or because of patient expectations . If this rationale is valid , one would expect to see a measurable effect from diagnostic information , per se . MATERIAL S AND METHODS : A total of 246 patients with acute ( <3 weeks ) low back pain ( LBP ) and /or radiculopathy ( 150 LBP and 96 radiculopathy patients ) were recruited . Patients were r and omized using a stratified block design with equal allocation to either the unblinded group ( MR imaging results provided within 48 hours ) or the blinded group ( both patient and physician blinded to MR imaging results . ) After the initial MR imaging , patients followed 6 weeks of conservative management .  Rol and function , visual pain analog , absenteeism , Short Form (SF)-36 Health Status Survey , self-efficacy scores , and Fear Avoidance Question naire were completed at presentation ; 2 , 4 , 6 , and 8 weeks ; and 6 , 12 , and 24 months . Improvement of Rol and score by 50 % or more and patient satisfaction assessed by Cherkin symptom satisfaction measure were considered a positive outcome . RESULTS : Clinical outcome at 6 weeks was similar for unblinded and blinded patients . Self-efficacy , fear avoidance beliefs , and the SF-36 subscales were similar over time for blinded and unblinded patients , except for the general health subscale on the SF-36 . General health of the blinded group improved more than for the unblinded group ( P = .008 ) . CONCLUSIONS : Patient knowledge of imaging findings do not alter outcome and are associated with a lesser sense of well-being PURPOSE To prospect ively determine in patients with acute low back pain ( LBP ) or radiculopathy , the magnetic resonance ( MR ) imaging findings , prognostic role of these findings , and effect of diagnostic information on outcome . MATERIAL S AND METHODS Institutional review board approval and informed consent were obtained . This study was HIPAA compliant . A total of 246 patients with acute-onset LBP or radiculopathy were r and omized to either the early information arm of the study , with MR results provided within 48 hours , or the second arm of the study , where both patients and physicians were blinded to MR results , unless this information was critical to patient care . Patients underwent 6 weeks of conservative care . Rol and function scoring , visual pain analog , Short Form 36 health status survey , self-efficacy scoring , and a fear avoidance question naire were completed at presentation ; at 2- , 4- , 6- , and 8-week follow-up ; and at 6- , 12- , and 24-month follow-up . A second MR imaging examination was performed at 6-week follow-up . Multivariate logistic regression analysis was used to determine which imaging and nonimaging variables can be used to predict improvement in Rol and function and patient satisfaction . The chi(2 ) test and repeated- measures analysis of variance were used to compare outcome of blinded and unblinded patients . RESULTS Herniation was identified in 60 % ( n = 147 ) of patients at the initial examination . The prevalence of herniations in patients with LBP ( 57 % ) ( n = 85 ) and those with radiculopathy ( 65 % ) ( n = 62 ) were similar ( P = .217 ) , although patients with radiculopathy were more likely to have stenosis and nerve root compression ( P < .006 ) . There was no relationship between herniation type , size , and behavior over time with outcome . An improvement of 50 % or more in Rol and function score at 6-week follow-up occurred 2.7 times as often among patients with a herniation at baseline ( P = .003 ) . Improvement at 6-week follow-up was similar in unblinded ( 60 % ) ( n = 55 ) and blinded ( 67 % ) ( n = 57 ) patients ( P = .397 ) . Self-efficacy , fear avoidance beliefs , and the Short Form 36 subscales were similar for blinded and unblinded patients . CONCLUSION In typical patients with LBP or radiculopathy , MR imaging does not appear to have measurable value in terms of planning conservative care . Patient knowledge of imaging findings does not alter outcome and is associated with a lesser sense of well-being OBJECTIVE To reduce variability in primary care physicians ' use of procedures for imaging the lumbar spine . DESIGN Controlled intervention using clinical practice guideline and practice pattern feedback . STUDY SAMPLE Sixty-seven internists and 28 family practitioners in a large , group-model HMO . MEASUREMENTS AND MAIN RESULTS Intervention group physicians received the clinical practice guideline for low back pain , followed after 4 months by three bimonthly feedback reports on their current use rates for lumber spine x-rays and computed tomography and magnetic resonance imaging scans of the lumbar spine . Control group physicians received neither the guideline nor the feedback reports . Automated radiology utilization data were used to compare intervention and control group physicians ' changes in use rates and variability in use rates over the course of the study period . Neither the guideline alone nor the guideline plus feedback was associated with a significant decrease in use rates or in the variability in use rates for the lumbar spine imaging procedures under study . CONCLUSIONS Clinical practice guidelines and practice pattern feedback fail to achieve their goals when features of the practice setting and patient expectations and behavior are not identified and addressed BACKGROUND Radiological tests are often used by general practitioners ( GPs ) . These tests can be overused and contribute little to clinical management . We aim ed to assess two methods of reducing GP requests for radiological tests in accordance with the UK Royal College of Radiologists ' guidelines on lumbar spine and knee radiographs . METHODS We assessed audit and feedback , and educational reminder messages in six radiology departments and 244 general practice s that they served . The study was a before- and -after , pragmatic , cluster r and omised controlled trial with a 232 factorial design . A r and om subset of GP patients ' records were examined for concordance with the guidelines . The main outcome measure was number of radiograph requests per 1000 patients per year . Analysis was by intention to treat . FINDINGS The effect of  educational reminder messages  ( ie , the change in request rate after intervention ) was an absolute change of -1.53 ( 95 % CI -2.5 to -0.57 ) for lumbar spine and of -1.61 ( -2.6 to -0.62 ) for knee radiographs , both relative reductions of about 20 % . The effect of audit and feedback  was an absolute change of -0.07 ( -1.3 to 0.9 ) for lumbar spine of 0.04 ( -0.95 to 1.03 ) for knee radiograph requests , both relative reductions of about 1 % . Concordance between groups did not differ significantly . INTERPRETATION 6-monthly feedback of audit data is ineffective but the routine attachment of educational reminder messages to radiographs is effective and does not affect quality of referrals . Any department of radiology that h and les referrals from primary care could deliver this intervention to good effect BACKGROUND The purpose of this study was to examine the impact of a multifaceted , clinical decision support (CDS)-enabled intervention on magnetic resonance imaging ( MRI ) use in adult primary care patients with low back pain . METHODS After a baseline observation period , we implemented a CDS targeting lumbar-spine MRI use in primary care patients with low back pain through our computerized physician order entry , as well as 2 accountability tools : m and atory peer-to-peer consultation when test utility was uncertain and quarterly practice pattern variation reports to providers . Our primary outcome measure was rate of lumbar-spine MRI use . Secondary measures included utilization of MRI of any body part , comparing it with that of a concurrent national comparison , as well as proportion of lumbar-spine MRI performed in the study cohort that was adherent to evidence -based guideline . Chi-squared , t-tests , and logistic regression were used to assess pre- and postintervention differences . RESULTS In the study cohort preintervention , 5.3 % of low back 
    Output:
    
agent
***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: 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 OBJECTIVE : The effect of clinical guidelines on re source utilization for complex conditions with substantial barriers to clinician behavior change has not been well studied . We report the impact of a multifaceted guideline implementation intervention on primary care clinician utilization of radiologic and specialty services for the care of acute low back pain . DESIGN : Physician groups were r and omized to receive guideline education and individual feedback , supporting patient education material s , both , or neither . The impact on guideline adherence and re source utilization was evaluated during the 12-month period before and after implementation . PARTICIPANTS : Fourteen physician groups with 120 primary care physician and associate practitioners from 2 group model HMO practice s. INTERVENTIONS : Guideline implementation utilized an education/audit/feedback model with local peer opinion leaders . The patient education component included written and videotaped material s on the care of low back pain . MAIN RESULTS : The clinician intervention was associated with an absolute increase in guideline -consistent behavior of 5.4 % in the intervention group versus a decline of 2.7 % in the control group ( P=.04 ) . The patient education intervention produced no significant change in guideline -consistent behavior , but was poorly adopted . Patient characteristics including duration of pain , prior history of low back pain , and number of visits during the illness episode were strong predictors of service utilization and guideline -consistent behavior . CONCLUSIONS : Implementation of an education and feedback-supported acute low back pain care guideline for primary care clinicians was associated with an increase in guideline -consistent behavior . Patient education material s did not enhance guideline effectiveness . Implementation barriers could limit the utility of this approach in usual care setting BACKGROUND The Royal College of General Practitioners ( RCGP ) has produced guidelines for the management of acute low back pain in primary care . AIM To investigate the impact on patient management of an educational strategy to promote these guidelines among general practitioners ( GPs ) . DESIGN OF STUDY Group r and omised controlled trial , using the health centre as the unit of r and omisation . SETTING Primary care teams in north-west Engl and . METHOD Twenty-four health centres were r and omly allocated to an intervention or control arm . Practice s in the intervention arm were offered outreach visits to promote national guidelines on acute low back pain , as well as access to fast-track physiotherapy and to a triage service for patients with persistent symptoms . RESULTS Twenty-four centres were r and omised . Two thous and , one hundred and eighty-seven eligible patients presented with acute low back pain during the study period : 1049 in the intervention group and 1138 in the control group . There were no significant differences between study groups in the proportion of patients who were referred for X-ray , issued with a sickness certificate , prescribed opioids or muscle relaxants , or who were referred to secondary care , but significantly more patients in the intervention group were referred to physiotherapy or the back pain unit ( difference in proportion = 12.2 % , 95 % confidence interval [ CI ] = 2.8 % to 21.6 % ) . CONCLUSION The management of patients presenting with low back pain to primary care was mostly unchanged by an outreach educational strategy to promote greater adherence to RCGP guidelines among GPs . An increase in referral to physiotherapy or educational programmes followed the provision of a triage service BACKGROUND AND PURPOSE : We conducted a prospect i ve r and omized study of patients with acute low back pain and /or radiculopathy to assess the effect of knowledge of diagnostic findings on clinical outcome . The practice of ordering spinal imaging , perhaps unintentionally , includes a large number of patients for whom the imaging test is performed for purpose s of reassurance or because of patient expectations . If this rationale is valid , one would expect to see a measurable effect from diagnostic information , per se . MATERIAL S AND METHODS : A total of 246 patients with acute ( <3 weeks ) low back pain ( LBP ) and /or radiculopathy ( 150 LBP and 96 radiculopathy patients ) were recruited . Patients were r and omized using a stratified block design with equal allocation to either the unblinded group ( MR imaging results provided within 48 hours ) or the blinded group ( both patient and physician blinded to MR imaging results . ) After the initial MR imaging , patients followed 6 weeks of conservative management .  Rol and function , visual pain analog , absenteeism , Short Form (SF)-36 Health Status Survey , self-efficacy scores , and Fear Avoidance Question naire were completed at presentation ; 2 , 4 , 6 , and 8 weeks ; and 6 , 12 , and 24 months . Improvement of Rol and score by 50 % or more and patient satisfaction assessed by Cherkin symptom satisfaction measure were considered a positive outcome . RESULTS : Clinical outcome at 6 weeks was similar for unblinded and blinded patients . Self-efficacy , fear avoidance beliefs , and the SF-36 subscales were similar over time for blinded and unblinded patients , except for the general health subscale on the SF-36 . General health of the blinded group improved more than for the unblinded group ( P = .008 ) . CONCLUSIONS : Patient knowledge of imaging findings do not alter outcome and are associated with a lesser sense of well-being PURPOSE To prospect ively determine in patients with acute low back pain ( LBP ) or radiculopathy , the magnetic resonance ( MR ) imaging findings , prognostic role of these findings , and effect of diagnostic information on outcome . MATERIAL S AND METHODS Institutional review board approval and informed consent were obtained . This study was HIPAA compliant . A total of 246 patients with acute-onset LBP or radiculopathy were r and omized to either the early information arm of the study , with MR results provided within 48 hours , or the second arm of the study , where both patients and physicians were blinded to MR results , unless this information was critical to patient care . Patients underwent 6 weeks of conservative care . Rol and function scoring , visual pain analog , Short Form 36 health status survey , self-efficacy scoring , and a fear avoidance question naire were completed at presentation ; at 2- , 4- , 6- , and 8-week follow-up ; and at 6- , 12- , and 24-month follow-up . A second MR imaging examination was performed at 6-week follow-up . Multivariate logistic regression analysis was used to determine which imaging and nonimaging variables can be used to predict improvement in Rol and function and patient satisfaction . The chi(2 ) test and repeated- measures analysis of variance were used to compare outcome of blinded and unblinded patients . RESULTS Herniation was identified in 60 % ( n = 147 ) of patients at the initial examination . The prevalence of herniations in patients with LBP ( 57 % ) ( n = 85 ) and those with radiculopathy ( 65 % ) ( n = 62 ) were similar ( P = .217 ) , although patients with radiculopathy were more likely to have stenosis and nerve root compression ( P < .006 ) . There was no relationship between herniation type , size , and behavior over time with outcome . An improvement of 50 % or more in Rol and function score at 6-week follow-up occurred 2.7 times as often among patients with a herniation at baseline ( P = .003 ) . Improvement at 6-week follow-up was similar in unblinded ( 60 % ) ( n = 55 ) and blinded ( 67 % ) ( n = 57 ) patients ( P = .397 ) . Self-efficacy , fear avoidance beliefs , and the Short Form 36 subscales were similar for blinded and unblinded patients . CONCLUSION In typical patients with LBP or radiculopathy , MR imaging does not appear to have measurable value in terms of planning conservative care . Patient knowledge of imaging findings does not alter outcome and is associated with a lesser sense of well-being OBJECTIVE To reduce variability in primary care physicians ' use of procedures for imaging the lumbar spine . DESIGN Controlled intervention using clinical practice guideline and practice pattern feedback . STUDY SAMPLE Sixty-seven internists and 28 family practitioners in a large , group-model HMO . MEASUREMENTS AND MAIN RESULTS Intervention group physicians received the clinical practice guideline for low back pain , followed after 4 months by three bimonthly feedback reports on their current use rates for lumber spine x-rays and computed tomography and magnetic resonance imaging scans of the lumbar spine . Control group physicians received neither the guideline nor the feedback reports . Automated radiology utilization data were used to compare intervention and control group physicians ' changes in use rates and variability in use rates over the course of the study period . Neither the guideline alone nor the guideline plus feedback was associated with a significant decrease in use rates or in the variability in use rates for the lumbar spine imaging procedures under study . CONCLUSIONS Clinical practice guidelines and practice pattern feedback fail to achieve their goals when features of the practice setting and patient expectations and behavior are not identified and addressed BACKGROUND Radiological tests are often used by general practitioners ( GPs ) . These tests can be overused and contribute little to clinical management . We aim ed to assess two methods of reducing GP requests for radiological tests in accordance with the UK Royal College of Radiologists ' guidelines on lumbar spine and knee radiographs . METHODS We assessed audit and feedback , and educational reminder messages in six radiology departments and 244 general practice s that they served . The study was a before- and -after , pragmatic , cluster r and omised controlled trial with a 232 factorial design . A r and om subset of GP patients ' records were examined for concordance with the guidelines . The main outcome measure was number of radiograph requests per 1000 patients per year . Analysis was by intention to treat . FINDINGS The effect of  educational reminder messages  ( ie , the change in request rate after intervention ) was an absolute change of -1.53 ( 95 % CI -2.5 to -0.57 ) for lumbar spine and of -1.61 ( -2.6 to -0.62 ) for knee radiographs , both relative reductions of about 20 % . The effect of audit and feedback  was an absolute change of -0.07 ( -1.3 to 0.9 ) for lumbar spine of 0.04 ( -0.95 to 1.03 ) for knee radiograph requests , both relative reductions of about 1 % . Concordance between groups did not differ significantly . INTERPRETATION 6-monthly feedback of audit data is ineffective but the routine attachment of educational reminder messages to radiographs is effective and does not affect quality of referrals . Any department of radiology that h and les referrals from primary care could deliver this intervention to good effect BACKGROUND The purpose of this study was to examine the impact of a multifaceted , clinical decision support (CDS)-enabled intervention on magnetic resonance imaging ( MRI ) use in adult primary care patients with low back pain . METHODS After a baseline observation period , we implemented a CDS targeting lumbar-spine MRI use in primary care patients with low back pain through our computerized physician order entry , as well as 2 accountability tools : m and atory peer-to-peer consultation when test utility was uncertain and quarterly practice pattern variation reports to providers . Our primary outcome measure was rate of lumbar-spine MRI use . Secondary measures included utilization of MRI of any body part , comparing it with that of a concurrent national comparison , as well as proportion of lumbar-spine MRI performed in the study cohort that was adherent to evidence -based guideline . Chi-squared , t-tests , and logistic regression were used to assess pre- and postintervention differences . RESULTS In the study cohort preintervention , 5.3 % of low back 
    Output:
    