Evaluating two implementation strategies for whiplash guidelines in physiotherapy: a cluster randomised trial. Effect on the process of care of an active strategy to implement clinical guidelines on physiotherapy for low back pain: a cluster randomised controlled trial Implementation of RCGP guidelines for acute low back pain: a cluster randomised controlled trial. European Respiratory Society guidelines for the management of adult bronchiectasis A multi-faceted strategy to improve the use of national fertility guidelines; a cluster-randomized controlled trial. Testing the effectiveness of an innovative information package on practitioner reported behaviour and beliefs: The UK Chiropractors, Osteopaths and Musculoskeletal Physiotherapists Low back pain ManagemENT (COMPLeMENT) trial [ISRCTN77245761] Implementation of a clinical dementia guideline Management of headache disorders: design of a randomised clinical trial screening for prognostic patient characteristics Adherence to physiotherapy clinical guideline acute ankle injury and determinants of adherence: a cohort study Study protocol of an economic evaluation of an extended implementation strategy for the treatment of low back pain in general practice: a cluster randomised controlled trial A national framework for supporting improvements in the physiotherapy assessment and management of low back pain: the Scottish experience. Implementation of clinical guidelines on physical therapy for patients with low back pain: randomized trial comparing patient outcomes after a standard and active implementation strategy. Development and delivery of a physiotherapy intervention for the early management of whiplash injuries: the Managing Injuries of Neck Trial (MINT) Intervention. Evaluation of a tailored, multi-component intervention for implementation of evidence-based clinical practice guidelines in primary care physical therapy: a non-randomized controlled trial Monitoring the change: current trends in outcome measure usage in physiotherapy. Development and evaluation of an implementation strategy for the German guideline on community-acquired pneumonia The Effectiveness of Guideline Implementation Strategies on Improving Antipsychotic Medication Management for Schizophrenia Implementation of the Swedish Guideline for Prevention of Mental ill-health at the Workplace: study protocol of a cluster randomized controlled trial, using multifaceted implementation strategies in schools An economic analysis of implementing the SIGN third molar guideline: implications for the design and analysis of implementation studies Enhanced implementation of low back pain guidelines in general practice: study protocol of a cluster randomised controlled trial Direct mail improves knowledge of basic life support guidelines in general practice: a randomised study Implementation of the Dutch Low Back Pain Guideline for General Practitioners: A Cluster Randomized Controlled Trial Randomised controlled trial of tailored strategies to implement guidelines for the management of patients with depression in general practice.
QUESTION Are implementation strategies involving education any more effective than mere dissemination of clinical practice guidelines in changing physiotherapy practice and reducing patient disability after acute whiplash ? DESIGN Cluster-r and omised trial . PARTICIPANTS Twenty-seven physiotherapists from different private physiotherapy clinics and the 103 patients ( 4 dropouts ) who presented to them with acute whiplash . INTERVENTION The implementation group of physiotherapists underwent education by opinion leaders about whiplash guidelines and the dissemination group had the guidelines mailed to them . OUTCOME MEASURES The primary outcome was patient disability , measured using the Functional Rating Index , collected on admission to the trial and at 1.5 , 3 , 6 and 12 months . Physiotherapist knowledge about the guidelines was measured using a custom-made question naire . Physiotherapist practice and cost of care were measured by audit of patient notes . RESULTS There were no significant differences between groups for any of the patient outcomes at any time . The implementation patients had 0.6 points ( 95 % CI -7.8 to 6.6 ) less disability than the dissemination patients at 12 months ; 44 % more physiotherapists in the implementation group reported that they prescribed two out of the five guideline -recommended treatments ; and 32 % more physiotherapists actually prescribed them . The cost of care for patients in the implementation group was $ 255 ( 95 % CI -1505 to 996 ) less than for patients in the dissemination group . CONCLUSION Although the active implementation program increased guideline -consistent practice , patient outcomes and cost of care were not affected 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 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 Bronchiectasis in adults is a chronic disorder associated with poor quality of life and frequent exacerbations in many patients . There have been no previous international guidelines . The European Respiratory Society guidelines for the management of adult bronchiectasis describe the appropriate investigation and treatment strategies determined by a systematic review of the literature . A multidisciplinary group representing respiratory medicine , microbiology , physiotherapy , thoracic surgery , primary care , methodology and patients considered the most relevant clinical questions ( for both clinicians and patients ) related to management of bronchiectasis . Nine key clinical questions were generated and a systematic review was conducted to identify published systematic review s , r and omised clinical trials and observational studies that answered these questions . We used the GRADE approach to define the quality of the evidence and the level of recommendations . The result ing guideline addresses the investigation of underlying causes of bronchiectasis , treatment of exacerbations , pathogen eradication , long term antibiotic treatment , anti-inflammatories , mucoactive drugs , bronchodilators , surgical treatment and respiratory physiotherapy . These recommendations can be used to benchmark quality of care for people with bronchiectasis across Europe and to improve outcomes . The publication of the first ERS guidelines for bronchiectasis BACKGROUND Proper use of clinical practice guidelines can decrease variation in care between setting s. However , actual use of fertility guidelines is suboptimal and in need of improvement . Hence , a cluster-r and omized controlled trial was design ed to study the effects of two strategies to implement national Dutch guidelines on comprehensive fertility care . METHODS Sixteen fertility clinics participated in the trial . A minimal , professional-oriented implementation strategy of audit and feedback was tested versus a maximal multi-faceted strategy that was both professional and patient oriented . The extent of adherence to guideline recommendations , reflected in quality indicator scores , was the primary outcome measure . To gain an insight into unwanted side effects , patient anxiety and depression scores were gathered as secondary outcomes . Data collection encompassed medical record search , patient and professional question naires . RESULTS A total of 1499 couples were included at baseline and 1396 at the after-measurement . No overall significant improvement in indicator scores was found for either strategy [ odds ratios ranging from 0.23 ( 95 % confidence interval ( CI ) : 0.06 - 0.95 ) to 6.66 ( 95 % CI : 0.33 - 132.8 ] . Secondary outcomes did not differ significantly for both groups , although selected anxiety scores appeared lower in the maximal intervention group . Process evaluation of the trial revealed positive patient experiences with the intervention material [ e.g. an increased underst and ing of their doctor 's treatment policy ( 61 % ) , an increased ability to ask questions about the treatment ( 61 % ) ] . Professionals ' appreciation of intervention elements varied , and execution of the multi-faceted strategy appeared incomplete . DISCUSSION Absence of an intervention effect may be due to the nature of the strategies , incomplete execution or flaws in study design . Process evaluation data raise the question of whether professionals should be the only stakeholder responsible for guideline implementation . This study therefore contributes to an increased underst and ing of fertility guideline implementation in general , and the role of patients in particular Background Low back pain ( LBP ) is a common and costly problem . Initiatives design ed to assist practitioner and patient decisions about appropriate healthcare for LBP include printed evidence -based clinical guidelines . The three professional groups of chiropractic , osteopathy and musculoskeletal physiotherapy in the UK share common ground with their approaches to managing LBP and are amongst those targeted by LBP guidelines . Even so , many seem unaware that such guidelines exist . Furthermore , the behaviour of at least some of these practitioners differs from that recommended in these guidelines .Few r and omised controlled trials evaluating printed information as an intervention to change practitioner behaviour have utilised a no-intervention control . All these trials have used a cluster design and most have method ological flaws . None specifically focus upon practitioner behaviour towards LBP patients . Studies that have investigated other strategies to change practitioner behaviour with LBP patients have produced conflicting results . Although numerous LBP guidelines have been developed worldwide , there is a paucity of data on whether their dissemination actually changes practitioner behaviour . Primarily because of its low unit cost , sending printed information to large numbers of practitioners is an attractive dissemination and implementation strategy . The effect size of such a strategy , at an individual practitioner level , is likely to be small . However , if large numbers of practitioners are targeted , this strategy might achieve meaningful changes at a population level . Methods The primary aim of this prospect i ve , pragmatic r and omised controlled trial is to test the short-term effectiveness ( six-months following intervention ) of a directly-posted information package on the reported clinical behaviour ( primary outcome ) , attitudes and beliefs of UK chiropractors , osteopaths and musculoskeletal physiotherapists . We sought to r and omly allocate a combined sample of 1,800 consenting practitioners to receive either the information package ( intervention arm ) or no information above that gained during normal practice ( control arm ) . We collected question naire data at baseline and six-months post-intervention . The analysis of the primary outcome will assess between-arm differences of proportions of responses to questions on recommendations about activity , work and bed-rest , that fall within categories previously defined by an expert consensus exercise as either ' guideline -consistent ' and ' guideline -inconsistent ' Implementation of clinical practice guidelines has been proposed to improve quality in health care . Multifaceted implementation did not increase guideline acceptance . GPs ' self-reports may overestimate performance . Objective - To assess the impact of a multifaceted implementation strategy aim ing to improve GP adherence to a clinical guideline on dementia . Design - Controlled before and after study using data records from regional laboratories . The guideline was mailed to all GPs . The multifaceted implementation strategy was planned with local GPs , and consisted of seminars , outreach visits , reminders and continuing medical education ( CME ) small group training . Setting - Primary health care . Subjects - 535 GP practice s with 727 physicians in Denmark . Main outcome measures - The diffusion and use of the guideline was measured by a mailed survey . Adherence to guideline recommendations was monitored by data on laboratory tests from general practice in patient 's S 65 years : thyroid stimulating hormone requested with vitamin B 12 or methylmalonate . The use of these tests as part of a diagnostic evaluation of dementia was subsequently verified by a question naire to the practice s. Results - Of the GPs who read the guideline , 88 % found it applicable in primary care . No increase in the adherence to guideline recommendations was observed regarding the use of laboratory tests or cognitive tests in the diagnostic evaluation of dementia in general practice . Conclusion - Although GPs regarded the guideline applicable in primary care , no change in practice adherence to guideline recommendations was detected after a multifaceted implementation Background Treatment of headache disorders is not always optimal . Patients are treated in multiple ways , and the lack of scientific arguments for referral and the insufficient implementation of guidelines result in unclear treatment strategies . The coexistence of headache and neck pain can lead to the referral to a musculoskeletal physiotherapist . This treatment can only be successful if an underlying cervical segmental dysfunction is present . In such cases a physical treatment can be a valuable option that should be considered . The aim of this study is to identify prognostic therapeutic patient characteristics and to increase the number of correct physiotherapy referrals . Methods / design This trial is design ed to identify patient characteristics which can influence the prognosis of the patient . Patients with recurrent headache and co-existent neck pain are recruited via a multicenter setup . After screening for eligibility , subjects are tested at baseline and r and omly allocated to one of two treatment groups . Testing includes the administering of question naires ( a  Headache Diagnosis Question naire ,  Headache Inventory List  and the Headache Impact Test ( HIT-6 ) ) and physical tests ( Thermal Stimuli , Manual Cervical Spine Examination and Pressure Algometry ) . Treatment groups are a usual care group ( UC ) administered by the General Practitioner ( GP ) and a usual care plus musculoskeletal physiotherapy treatment group ( UCMT ) . UC is based on the Dutch GP Guideline for Headache . UCMT consists of the UC plus a combination of exercises and spinal cervical mobilisations . Follow-up measurements consist of the completion of the Headache Inventory List , the HIT-6 and scoring of the global perceived effect ( GPE ) . The latter allowing the distinction between responders ( positive effect ) and non-responders ( no effect or worse ) . Logistic regression analysis will be used to identify the specific patient characteristics of the responders and the non-responders . The additional value of the musculoskeletal physiotherapy will be examined . Follow-up measurements up to 52 weeks are scheduled . Discussion This trial aims to identify prognostic patient characteristics , in order to supply a useful diagnostic tool for all health care workers , dealing with headache sufferers Background Clinical guidelines are considered important instruments to improve quality in health care . In physiotherapy , insight in adherence to guidelines is limited . Knowledge of adherence is important to identify barriers and to enhance implementation . Purpose of this study is to investigate the ability to adherence to recommendations of the guideline Acute ankle injury , and to identify patient characteristics that determine adherence to the guideline . Methods Twenty-two physiotherapists collected data of 174 patients in a prospect i ve cohort study , in which the course of treatment was systematic ally registered . Indicators were used to investigate adherence to recommendations . Patient characteristics were used to identify prognostic factors that may determine adherence to the guideline . Correlation between patient characteristics and adherence to outcome -indicators ( treatment sessions , functioning of patient , accomplished goals ) was calculated using univariate logistic regression . To calculate explained variance of combined patient characteristics , multivariate analysis was performed . Results Adherence to individual recommendations varied from 71 % to 100 % . In 99 patients ( 57 % ) the physiotherapists showed adherence to all indicators . Adherence to preset maximum of six treatment sessions for patients with severe ankle injury was 81 % ( 132 patients ) .The odds to receive more than six sessions were statistically significant for three patient characteristics : females ( OR:3.89 ; 95%CI : 1.41–10.72 ) , recurrent sprain ( OR : 6.90 ; 95%CI : 2.34 – 20.37 ) , co-morbidity ( OR : 25.92 ; 95 % CI : 6.79 – 98.93 ) . All factors together explained 40 % of the variance . Inclusion of physiotherapist characteristics in the regression model showed that work-experience reduced the odds to receive more than six sessions ( OR : 0.2 ; 95%CI : 0.06 – 0.77 ) , and increased explained variance to 45 % . Conclusion Adherence to the clinical guideline Acute ankle sprain showed that the guideline is applicable in daily practice . Adherence to the guideline , even in a group of physiotherapists familiar with the guideline , showed possibilities for improvement . The necessity to exceed the expected number of treatment sessions may be explained by co-morbidity and recurrent sprains . It is not clear why female patients were treated with more sessions . Experience of the physiotherapist reduced the number of treatment sessions . Quality indicators may be used for audit and feedback as part of the implementation strategy 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 guideline facilitator , stratification tools , and feedback on guideline adherence . The aim of this paper is to provide the considerations on the design of the health economic evaluation . Methods / design The economic evaluation is carried out alongside a cluster r and omised controlled trial consisting of 60 general practice s in the North Denmark Region . An expected 1,200 patients between the age of 18 and 65 years with a low back pain diagnosis will be enrolled . The economic evaluation comprises both a cost-effectiveness analyses and a cost-utility analysis . Effectiveness measures include referral to secondary care , health-related quality of life measured by EQ-5D-5L , and disability measured by the Rol and Morris disability question naire . Cost measures include all relevant additional costs of the extended implementation strategy compared to usual implementation . The economic evaluation will be performed from both a societal perspective and a health sector perspective with a 12-month time horizon . Discussion It is expected that the extended implementation strategy will reduce the number of patients referred to secondary care . It is hypothesised that the additional upfront cost of extended implementation will be counterbalanced by improvements in clinical practice and patient-related outcomes , thereby rendering the extended implementation strategy cost-effective . Trial registration Clinical Trials.gov : BACKGROUND Similar to other countries worldwide , Scotl and lacked a national view of whether the quality of the physiotherapy management of low back pain was compliant with national guidelines . Anecdotal evidence suggested that st and ards of care varied considerably despite the wide availability of clinical guidelines to clinicians . AIM To develop a framework that supports National Health Service ( NHS ) Scotl and in providing consistently applied high- quality physiotherapy assessment and management of low back pain in line with guideline recommendations . DESIGN Prospect i ve , multicentred national study , data collection and improvement phase . SETTING All NHS boards in Scotl and ( n=14 ) plus two private provider sites . PARTICIPANTS One hundred and eighty-six individual NHS sites and two private providers of services to patients with low back pain . METHOD A national data set was developed from evidence - and consensus-based guideline sources . All sites collected data ( two 5-week periods ) over 1 year ( 2008 - 2009 ) using a web-based data base . This was interspersed by an improvement phase during which required improvements were considered and implemented . Issues were shared through a national network and national meeting . RESULTS Data from 2147 patients showed improvements in the documented physiotherapy management of low back pain over the two cycles . All participants developed and implemented remedial action plans based on the results of the first cycle . CONCLUSION It is possible to implement a framework , which is led nationally but driven and owned locally , supporting physiotherapists in an active programme of locally determined improvement . However , although process and outcome are linked , the direct impact of this initiative on patient outcome is not known 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 This paper describes the development and implementation of a physiotherapy intervention for a large multicentred r and omised controlled trial of the early management of whiplash injuries in a National Health Service setting . Participants were eligible if they were classified as having whiplash-associated disorder grade s I to III and self-referred for treatment within 6 weeks of injury . The intervention development was informed through a variety of methods including the current evidence base , published guidelines , clinician opinion , a pilot study and expert opinion . The intervention was targeted at known , potentially modifiable risk factors for poor recovery , and utilised manual therapy , exercises and psychological strategies . The treatment was individually tailored , with a maximum of six treatments allowed within the trial protocol over an 8-week period . The intervention was delivered to 300 participants . The amount and types of treatments delivered are described Background Clinical practice guidelines are important for transmitting research findings into practice and facilitating the application of evidence -based practice ( EBP ) . There is a paucity of knowledge about the impact of guideline implementation strategies in primary care physical therapy . The aim of this study was to evaluate the effect of a guideline implementation intervention in primary care physical therapy in western Sweden . Methods An implementation strategy based on theory and current evidence was developed . A tailored , multi-component implementation intervention , addressing earlier identified determinants , was carried out in three areas comprising 28 physical therapy practice s including 277 physical therapists ( PTs ) ( intervention group ) . In two adjacent areas , 171 PTs at 32 practice s received no intervention ( control group ) . The core component of the intervention was an implementation seminar with group discussion s. Among other components were a website and email reminders . Data were collected at baseline and follow-up with a web-based question naire . Primary outcomes were the self-reported awareness of , knowledge of , access to , and use of guidelines . Secondary outcomes were self-reported attitudes toward EBP and guidelines . Analyses were performed using Pearson ’s χ2 test and approximative z-test . Results 168 PTs ( 60.6 % ) in the intervention group and 88 PTs ( 51.5 % ) in the control group responded to the follow-up question naire . 186/277 PTs ( 67.1 % ) participated in the implementation seminars , of which 97 ( 52.2 % ) responded . The proportions of PTs reporting awareness of ( absolute difference in change 20.6 % , p = 0.023 ) , knowledge where to find ( 20.4 % , p = 0.007 ) , access to ( 21.7 % , p < 0.001 ) , and frequent use of ( 9.5 % , NS ) guidelines increased more in the intervention group than in the control group . The proportion of PTs reporting frequent guideline use after participation in the implementation seminar was 15.2 % ( p = 0.043 ) higher than the proportion in the control group . A higher proportion considered EBP helpful in decision making ( p = 0.018 ) . There were no other significant differences in secondary outcomes . Conclusions A tailored , theory- and evidence -informed , multi-component intervention for the implementation of clinical practice guidelines had a modest , positive effect on awareness of , knowledge of , access to , and use of guidelines , among PTs in primary care in western Sweden . In general , attitudes to EBP and guidelines were not affected Physiotherapists have traditionally relied on impairment measures such as range of motion and muscle strength to monitor patient progress . The impact of treatment on patients ' daily activities can be assessed with valid and reliable question naires , but the use of st and ardized question naires by physiotherapists appeared to be limited . A range of strategies were implemented that aim ed to increase physiotherapists ' use of st and ardized measures of functional activities . A simple r and om sample of 300 was drawn from a data base of physiotherapy providers to a transport accident scheme , and was surveyed in March and September 2003 , with response rates of 51 % and 55 % , respectively . There was a statistically significant ( P<.05 ) increase in reported use of seven question naires and a significant reduction in the perception of barriers that were targeted by the interventions The most frequently utilized tests were a pain rating scale and question naires for lumbar and cervical problems . Physiotherapists ' attitudes to outcome measurement were generally positive although there was a small but statistically significant ( P=.02 ) reduction in mean attitude score over the re-test period . Physiotherapists in the population sample d significantly increased their reported use of a range of st and ardized outcome measures over the re-test period . The trend towards greater objectivity in measuring the progress of rehabilitation can enable physiotherapists to develop improved treatment plans with the patients ' needs at the centre of the equation Background Data of the German Competence Network for Community-Acquired Pneumonia showed a gap between the recommendations of the national guideline for management of community-acquired pneumonia ( CAP ) and the routine care . We developed and evaluated an implementation strategy to improve the quality of care of patients with CAP . Method A prospect i ve , r and omised , controlled trail was conducted within CAPNETZ . In four local clinical centres ( LCC ) , the guideline was implemented by different strategies . The other four LCC served as control group . Indicators for guideline adherence comprised initial site of treatment , initial antibiotic treatment and duration of antibiotic treatment . As patient-related factors , we assessed the effect of guideline implementation on 30-day mortality and length of hospital stay . Results Active guideline implementation yielded an increased proportion of guideline adherence to the length of antibiotic treatment in out patients ( + 9.2 % ) , the recommended antibiotic treatment ( + 5.6 % ) and duration of antibiotic treatment in in patients ( + 5.0 % ) compared with baseline . In contrast , the proportion of patients in the control group , treated according to the guideline , decreased in the same period by 7.9 % , 2.9 % and 4.7 % , respectively . None of these results was statistically significant . Decrease of CAP-related mortality was higher in the intervention group compared with the control group ( 2.9 % vs 0.5 % , ns ) . Conclusion This study showed improvements in the process of care after implementation of a guideline for treating CAP . Further strategies , such as quality improvement cycles and medical practice audits , may enhance this effect Objectives : To compare the effectiveness of a conceptually-based , multicomponent “ enhanced ” strategy with a “ basic ” strategy for implementing antipsychotic management recommendations of VA schizophrenia guidelines . Methods : Two VA medical centers in each of 3 Veterans Integrated Service Networks were r and omized to either a basic educational implementation strategy or the enhanced strategy , in which a trained nurse promoted provider guideline adherence and patient compliance . Patients with acute exacerbation of schizophrenia were enrolled and assessed at baseline and 6 months and their medical records were abstract ed ; 291 participants were included in analyses . Logistic regression models were developed for rates of : ( 1 ) switching patients from first-generation antipsychotics ( FGA ) to second-generation antipsychotics ( SGA ) , and ( 2 ) guideline -concordant antipsychotic dose . Results : Of participants prescribed FGAs at baseline , those at enhanced sites were significantly more likely than participants at basic sites to have an SGA added to the FGA during the study ( 29 % vs. 8 % ; adjusted OR = 7.7 ; 95 % CI : 2.0–30.1 ) , but were not significantly more likely to be switched to monotherapy with an SGA ( 29 % vs. 23 % ) . Guideline -concordant antipsychotic dosing was not significantly affected by the intervention . Conclusions : The enhanced guideline implementation strategy increased addition of SGAs to FGA therapy , but did not significantly increase guideline -recommended switching from FGA to SGA monotherapy . Antipsychotic dosing was not significantly altered . The study illustrates the challenges of changing clinical behavior . Strategies to improve medication management for schizophrenia are needed , and must incorporate recommendations likely to emerge from recent research suggesting comparable effectiveness of SGAs and FGAs Given today ’s high prevalence of common mental disorders and related sick leave among teachers , an urgent need exists for a more systematic approach to the management of social and organizational risk factors within schools . In 2015 , we launched the first Swedish occupational health guideline to support a structured prevention of these risks at the workplace . The existence of guidelines does however not guarantee their usage , as studies show that guidelines are often underused . Knowledge is therefore needed on effective implementation strategies that can facilitate the translation of guidelines into practice . The primary aim of the r and omized waiting list-controlled trial described in this study protocol is to compare the effectiveness of a multifaceted implementation strategy versus a single implementation strategy for implementing the Guideline for the prevention of mental ill-health at the workplace within schools . The effectiveness will be compared regarding the extent to which the recommendations are implemented ( implementation effectiveness ) and with regard to social and organisational risk factors for mental ill-health , absenteeism and presenteeism ( intervention effectiveness ) . The trial is conducted among primary schools of two municipalities in Sweden . The single implementation strategy is an educational strategy ( an educational meeting ) . The multifaceted strategy consists of the educational meeting , an implementation team and a series of workshops . The outcome measure of implementation effectiveness is  guideline adherence . The primary outcome of intervention effectiveness is exhaustion . Secondary outcomes include dem and s at work , work organization and job contents , interpersonal relations and leadership , presenteeism , work performance , recovery , work-life balance , work-engagement , self-reported stress , self-perceived health , sickness absence and psychosocial safety climate . Process outcomes as well as barriers and facilitators influencing the implementation process are assessed . Data will be collected at baseline , 6 , 12 , 18 and 24 months by mixed methods ( i.e. survey , focus-group interviews , observation ) . The study described in this protocol will provide valuable knowledge on the effectiveness of implementation strategies for implementing a guideline for the prevention of common mental disorders within schools . We hypothesize that successful implementation will result in reductions in school personnel ’s  perceived social and organizational risk factors , mental ill-health and sick-leave . Clinical Trials.gov ID : NCT03322839 ( trial registration : 09/19/2017 ) Objectives : To compare the cost-effectiveness of four  third molar guideline implementation strategies . Methods : Fifty-one dental practice s in Scotl and were r and omized to one of four implementation strategies .  The effectiveness of the strategies was measured by general dental practitioners ' compliance with the guideline . Results : The effectiveness of the guideline depended crucially upon the type of patient treated . In particular , for a minority of patients ( 14 % ) with no clinical signals of their ' type ' , the implementation strategies generate potentially large gains in evidence -based practice . However , the cost per patient of achieving these gains is large given that the costs are incurred for all patients , but benefits accrue only to a minority . Discussion : The results show that the type of patient presenting for treatment can influence the effectiveness , cost-effectiveness and therefore policy conclusions . Consequently , the design and analysis of studies need to be sufficiently sensitive to detect subtle interaction effects . This may explain the dearth of guideline implementation trials with significant findings . The results also suggest that a more cost-effective implementation method in primary care dentistry may be to subsidize treatment conditional upon patient type 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 Implementation of new guidelines into clinical practice is often incomplete . Direct mail is a simple way of providing information to physicians and may improve implementation of new guidelines on basic life support ( BLS ) . The aim of this study was to describe knowledge of the most recent European Resuscitation Council ( ERC ) Guidelines for BLS among general practitioners ( GPs ) and investigate whether direct mail improves theoretical knowledge of these guidelines . Methods All general practice clinics ( n=351 ) in Central Denmark Region were r and omised to receive either direct mail  ( intervention ) or no direct mail ( control ) . The direct mail consisted of the official ERC BLS/AED poster and a cover letter outlining changes in compression depth and frequency in the new guidelines . In general practice clinics r and omised to intervention , every GP received a direct mail addressed personally to him/her . Two weeks later , a multiple-choice question naire on demographics and BLS guidelines were mailed to GPs in both groups . Results In total , 830 GPs were included in this study ( direct mail , n=408 ; control , n=422 ) . The response rate was 58 % . The majority ( 91 % ) of GPs receiving direct mail were familiar with BLS Guidelines 2010 compared to 72 % in the control group ( P<0.001 ) . Direct mail improved knowledge of the new recommended chest compression depth ( 67 % vs. 40 % , P<0.001 ) and chest compression frequency ( 62 % vs. 40 % , P<0.001 ) . Conclusion Direct mail improved knowledge of changes in BLS guidelines and thus facilitated the implementation of this knowledge into clinical practice . Resuscitation councils and medical societies may consider using direct mail as a simple strategy to facilitate implementation of changes in clinical guidelines Study Design . Cluster r and omized controlled trial for a multifaceted implementation strategy . Objectives . To assess the effectiveness of tailored  interventions ( multifaceted implementation strategy ) to implement the  Dutch low back pain guideline for general practitioners with regard to adherence to guideline recommendations . Summary of Background Data . Guidelines for the management of low back pain in primary care have been developed in various countries , but little is known about the optimal implementation strategy . A multifaceted implementation strategy was developed to overcome identified barriers to the implementation of the Dutch low back pain guideline for general practitioners . Methods . General practitioners were r and omized to an intervention or a control group . The general practitioners in the intervention group ( n = 21 ) received tailored interventions consisting of the Dutch low back pain guideline for general practitioners , a 2-hour educational and clinical practice workshop ; two scientific articles on low back pain management ; the guideline for occupational physicians ; a tool for patient education ; and a tool for reaching agreement on low back care with physical , exercise , and manual therapists . The control group ( n = 20 ) received no intervention . The participating general practitioners were asked to recruit consecutive patients with a new episode of low back pain as the main reason for consultation . General practitioners completed registration forms of each individual consultation with regard to the main outcome measures : advice and information , referral to other health-care providers , and prescription of medication . Results . Forty-one of the 67 r and omized general practitioners reported on a total of 616 consultations for 531 patients with nonspecific low back pain . The advice and explanation provided by the general practitioners , the prescription of paracetamol or nonsteroidal anti-inflammatory drugs , and prescription of pain medication on atime contingent or a pain contingent basis showed no statistically significant differences between the intervention and control groups . There were also no differences in overall referral rate . However , in follow-up consultations fewer patients were referred to a physical or exercise therapist by the general practitioners in the intervention group than in the control group . Conclusions . The multifaceted intervention strategy modestly improved implementation ( for parts of the recommendations in ) the Dutch low back pain guideline by general practitioners and produced small concomitant changes in patient management . The implementation strategy produced fewer referrals to therapists during follow-up consultations BACKGROUND Various methods are available for implementing change in the clinical behaviour of general practitioners ( GPs ) . Although passive dissemination of information is generally ineffective , other methods can be variably effective . Few studies have investigated the impact of tailored methods . AIM To determine whether methods tailored to overcome obstacles to change using psychological theories are more effective than dissemination alone in the implementation of guidelines for depression among GPs . DESIGN OF STUDY R and omised controlled trial . SETTING Sixty general practice s in Engl and ; 30 GPs in the control group , 34 in the intervention group . METHOD Practitioners identified patients presenting with depression before and after the implementation of guidelines ( control group n = 192 in the first data collection , n = 181 in the second ; intervention group n = 210 in the first data collection and n = 197 in the second ) . The main outcome measures were : record of adherence to guideline recommendations in clinical records ; proportion of patients with Beck Depression Inventory ( BDI ) score less than 11 at 16 weeks after diagnosis . RESULTS In comparison with the control group , in the group of GPs receiving tailored implementation , there were increases in the proportions of patients assessed for suicide risk . In the intervention group , the proportion of patients with BDI scores of less than 11 at 16 weeks increased . CONCLUSION Obstacles to implementation can be identified and strategies tailored to address them . The findings indicate a new approach for research to underst and and develop methods of implementation
There was no evidence that patient health was improved or that the cost of care was reduced .
This review shows that multifaceted interventions based on educational meetings to increase implementation of clinical guidelines may improve some outcomes of professional practice but do not improve patient health or reduce cost of care .
These findings are comparable with results among other health professions
QUESTION What is the effectiveness of strategies to increase the implementation of physiotherapy clinical guidelines ?