Improving glycaemic control of patients with Type 2 diabetes in a primary care setting: a French application of the Staged Diabetes Management programme. Physician management of hypercholesterolemia. A randomized trial of continuing medical education. A randomized controlled trial of two strategies to implement active sick leave for patients with low back pain. Improving management of obesity in primary care: cluster randomised trial. A cluster randomised trial to evaluate a nutrition training programme. Effect of a medication management training package for nurses on clinical outcomes for patients with schizophrenia: cluster randomised controlled trial. Interactional group discussion: results of a controlled trial using a behavioral intervention to reduce the use of injections in public health facilities. Education program for general practitioners on breast and cervical cancer screening: a randomized trial. PRE.SA.GF Collaborative Group. Positioning of stroke patients: evaluation of a teaching intervention with nurses. Effectiveness of a skin cancer control educational intervention for internal medicine housestaff and attending physicians. Randomised controlled trial of a theoretically grounded tailored intervention to diffuse evidence-based public health practice [ISRCTN23257060]. The effectiveness of continuing medical education in changing the behavior of physicians caring for patients with acute myocardial infarction. A controlled randomized trial. An educational programme for peer review groups to improve treatment of chronic heart failure and diabetes mellitus type 2 in general practice. Experimental evaluation of the effects of drug information on antibiotic prescribing: a study in outpatient care in an area of Sri lanka. The effect of educational intervention on intercultural communication: results of a randomised controlled trial. The effects of continuing medical education on family doctor performance in office practice: a randomized control study. Training obstetricians and midwives to present screening tests: evaluation of two brief interventions. Can evidence change the rate of back surgery? A randomized trial of community-based education. The impact of an educational program on improving diabetes knowledge and changing behaviors of nurses in long-term care facilities. Cancer: improving early detection and prevention. A community practice randomised trial. An intervention to increase patients' trust in their physicians. Stanford Trust Study Physician Group. Family Physicians and Exercise Counseling: Can they be influenced to provide more? Can small group education and peer review improve care for patients with asthma/chronic obstructive pulmonary disease? Effects of an education program for community pharmacists on detecting drug-related problems in elderly patients. Continuing medical education using clinical algorithms. A controlled-trial assessment of effect on neonatal care. The effects of two continuing medical education programs on communication skills of practicing primary care physicians. Identification and management of domestic violence: a randomized trial. Improving drug use through continuing education: a randomized controlled trial in Zambia. Spirometry in primary care practice: the importance of quality assurance and the impact of spirometry workshops. Cluster randomised controlled trial of tailored interventions to improve the management of urinary tract infections in women and sore throat. Effects of a clinical-practice guideline and practice-based education on detection and outcome of depression in primary care: Hampshire Depression Project randomised controlled trial. Does a 3-day workshop for family medicine trainees improve preventive care? A randomized control trial. A randomized controlled trial assessing the impact of problem-based versus didactic teaching methods in CME. Diabetes care from diagnosis: effects of training in patient-centred care on beliefs, attitudes and behaviour of primary care professionals. Small group intervention vs formal seminar for improving appropriate drug use. Randomized controlled trial of education and feedback for implementation of guidelines for acute low back pain. Breast-feeding training for health professionals and resultant institutional changes. A pragmatic cluster randomized controlled trial of an educational intervention for GPs in the assessment and management of depression. Cluster randomised trial of an active, multifaceted educational intervention based on the WHO Reproductive Health Library to improve obstetric practices. Implementation strategies for a Scottish national epilepsy guideline in primary care: results of the Tayside Implementation of Guidelines in Epilepsy Randomized (TIGER) trial. Effectiveness of an educational strategy to improve family physicians' detection and management of depression: a randomized controlled trial. Pragmatic randomised controlled trial to evaluate guidelines for the management of infertility across the primary care-secondary care interface. Methods to encourage the use of antenatal corticosteroid therapy for fetal maturation: a randomized controlled trial. Improving the recognition and management of depression: is there a role for physician education? Efficacy of a Cancer Research UK communication skills training model for oncologists: a randomised controlled trial. One-to-one versus group sessions to improve prescription in primary care: a pragmatic randomized controlled trial. A multimethod quality improvement intervention to improve preventive cardiovascular care: a cluster randomized trial. Strategies to promote the use of advance directives in a residency outpatient practice. Effect of clinician communication skills training on patient satisfaction. A randomized, controlled trial. Can residents be trained to counsel patients about quitting smoking? Results from a randomized trial. Evaluating an educational intervention to improve the treatment of asthma in four European countries. Drug Education Project Group. Impact of IMCI training and language used by provider on quality of counseling provided to parents of sick children in Bougouni District, Mali. Staff training and ambulatory tuberculosis treatment outcomes: a cluster randomized controlled trial in South Africa. Randomized, controlled trial of prescribing training in a South African province. Effects of brief therapy training on practicing psychotherapists and their clients. A randomized intervention to improve heart failure outcomes in community-based home health care. Effectiveness of a multiple intervention to reduce antibiotic prescribing for respiratory tract symptoms in primary care: randomised controlled trial. Improving the health behaviours of elderly people: randomised controlled trial of a general practice education programme. Randomised controlled trial of training health visitors to identify and help couples with relationship problems following a birth. Multifaceted intervention to improve rheumatologists' management of glucocorticoid-induced osteoporosis: a randomized controlled trial. Effect of a practice-based strategy on test ordering performance of primary care physicians: a randomized trial. Effectiveness of teaching general practitioners skills in brief cognitive behaviour therapy to treat patients with depression: randomised controlled trial. Randomised controlled trial to change the hospital management of unstable angina. Physicians' communication with a cancer patient and a relative: a randomized study assessing the efficacy of consolidation workshops. A randomized trial to increase smoking intervention by physicians. Doctors Helping Smokers, Round I. Intervention among frequent attenders of the out-of-hours service: a stratified cluster randomized controlled trial. Feasibility of a national cholesterol guideline in daily practice. A randomized controlled trial in 20 general practices. Training pharmacy workers in recognition, management, and prevention of STDs: district-randomized controlled trial. Arthritis care in older-adult centers. A controlled study of an education program for public health nurses. Improving physicians' interviewing skills and reducing patients' emotional distress. A randomized clinical trial. Improving test ordering in primary care: the added value of a small-group quality improvement strategy compared with classic feedback only. Improving pediatricians' compliance-enhancing practices. A randomized trial. Teaching sigmoidoscopy to primary care physicians: a controlled study of continuing medical education. Efficacy of case method learning in general practice for secondary prevention in patients with coronary artery disease: randomised controlled study. Effect of training and a structured office practice on physician-delivered nutrition counseling: the Worcester-Area Trial for Counseling in Hyperlipidemia (WATCH).
To assess the impact of a French adaptation of the Staged Diabetes Management (SDM) programme on glycaemic control of people with Type 2 diabetes in primary care. Secondary endpoints were blood pressure, blood lipids, healthcare costs and quality of life.
                Prospective, randomized controlled study, of 1 years' duration. General practitioners (GPs) were recruited in four separate districts of a French region. They enrolled consecutive patients with Type 2 diabetes. GPs in the intervention group were educated in the SDM programme. GPs in the control group were asked to provide usual care. Healthcare costs were collected by medical departments of the Health Insurance systems. Quality of life was assessed with the Duke Health Profile.
                Three hundred and forty patients enrolled by 57 GPs completed the study, 192 in the intervention group and 148 in the control group. Patients in the intervention group were managed more adequately in accordance with the guidelines (P < 0.05 for nine out of 10 items). HbA(1c) decreased by 0.31% in the intervention group and increased by 0.56% in the control group, resulting in a difference of 0.87% by the end of the study (P = 0.001). Blood pressure and blood lipids did not differ between groups. Occurrence of major complications was low and identical in both groups. Incremental costs during the study in the intervention group were 35 euros per patient per month, and this was not significantly different in comparison with the control group. Quality of life was not affected by the intervention.
                Educating GPs in the French adaptation of the SDM programme improves glycaemic control in a primary care setting, without significantly increasing healthcare costs. To determine the effect of continuing medical education (CME) on compliance with the recommendations of the National Cholesterol Education Program Expert Panel on high serum cholesterol levels in adults, we randomly assigned primary physicians in 174 practices to 3 groups, 2 that underwent either standard or intensive CME and a control group. The standard CME group was offered a free 3-hour seminar on high serum cholesterol levels; the intensive CME group was offered in addition follow-up seminars and free office materials. After 18 months, we audited 13,099 medical records from the 140 practices that remained in the study. There were no significant differences (P > .15) in screening for high serum cholesterol or compliance with guidelines between the groups receiving continuing medical education (51% screening; 33% compliance) and the control group (57% screening; 37% compliance). In the prespecified subgroup of patients with hypercholesterolemia, there was a trend toward a modest benefit from the continuing medical education interventions: compliance was 21% in the control group, 23% in the standard CME group, and 27% in the intensive CME group (P = .07 overall). These results emphasize the need for better ways to change behavior in practicing physicians and the importance of studying the implementation of preventive health recommendations. Cluster randomized controlled trial.
                To evaluate the effectiveness of two strategies to improve the use of active sick leave (ASL) for patients with low back pain.
                ASL is a public sickness benefit scheme offered to promote early return to modified work for temporarily disabled workers. It was poorly used, and the authors designed two community interventions to strengthen the implementation of ASL based on the results of a study of barriers to use among back pain patients, employers, general practitioners (GPs), and local National Insurance Administration staff.
                Sixty-five municipalities in three counties in Norway, randomly assigned to a passive intervention, a proactive intervention, or a control group. The interventions were targeted at patients on sick leave for low back pain for more than 16 days (n = 6176), their GPs, employers, and local insurance officers. The passive intervention included reminders about ASL on the sick leave form that GPs must complete, a standard agreement to facilitate ASL, targeted information, and a desktop summary for GPs of clinical practice guidelines for low back pain, emphasizing the importance of advice to stay active. The proactive intervention included these elements plus a resource person to facilitate the use of ASL and a continuing education workshop for GPs. The main outcome measure reported here is the proportion of eligible patients that used ASL.
                ASL was used significantly more in the proactive intervention municipalities (17.7%) compared with the passive intervention and control municipalities (11.5%, P = 0.018).
                A passive intervention that addressed identified barriers to the use of ASL did not increase its use. Although modest, a proactive intervention did increase its use. The main impact of the intervention was through direct contact and motivating telephone calls to patients. To the extent that GPs' practice was changed, it was either patient mediated or by patients bypassing their GP. To evaluate a training programme intended to improve the management of obesity, delivered to general practice teams.
                Cluster randomised trial.
                Northern and Yorkshire region of England.
                44 general practices invited consecutively attending obese adults to participate; 843 patients attended for collection of baseline data and were subsequently randomised.
                4.5 hour training programme promoting an obesity management model.
                Difference in weight between patients in intervention and control groups at 12 months (main outcome measure) and at 3 months and 18 months; change in practitioners' knowledge and behaviour in obesity management consultations.
                Twelve months after training the patients in the intervention group were 1 (95% confidence interval--1.9 to 3.9) kg heavier than controls (P = 0.5). Some evidence indicated that practitioners' knowledge had improved. Some aspects of the management model, including recording weight, target weight, and dietary targets, occurred more frequently in intervention practices after the training, but in absolute terms levels of implementation were low.
                A training package promoting a brief, prescriptive approach to the treatment of obesity through lifestyle modification, intended to be incorporated into routine clinical practice, did not ultimately affect the weight of this motivated and at risk cohort of patients. The need for training to equip primary care staff with the knowledge and skills to provide dietary advice to the public has been acknowledged. Little is known about the effectiveness of such training at improving the dietary counselling skills of multidisciplinary practice teams.
                To evaluate the effectiveness of a nutrition training programme, delivered to primary care teams by a dietitian.
                A paired-cluster randomised trial.
                Twelve general practices in Sunderland, in the United Kingdom.
                A nutrition training programme, aimed at improving the quality of dietary consultations, was developed and delivered to six primary care teams by a dietitian. Main outcome measures were patients' recall of seven key consulting behaviours. Data were collected from patients in intervention and control practices, pre- and post-intervention. Change in knowledge and attitude of practitioners was also measured.
                All 12 practices completed the trial. Data were collected from 251 patients pre-intervention and 228 patients post-intervention. Of the seven consulting behaviours targeted in the training, only the proportion of consultations where written information (diet sheets) was provided to patients was significantly higher (13% higher, 95% confidence interval [CI = 4 to 21, P = 0.004) in the intervention practices post-training. Some evidence of improved practitioner knowledge and attitude was detected.
                This evaluation of a nutrition training intervention detected only a limited impact on the behaviour, knowledge, and attitudes of primary care practitioners in dietary consultations. Non-compliance attenuates the efficacy of treatments for physical and mental disorders.
                To assess the effectiveness of a medication management training package for community mental health nurses (CMHNs) in improving compliance and clinical outcomes in patients with schizophrenia.
                Pragmatic randomised controlled trial. Sixty CMHNs in geographical clusters were assigned randomly to medication management training or treatment as usual. Each CMHN identified two patients on their case-load who were assessed at baseline and again after 6 months by a research worker. The primary efficacy outcome of interest was psychopathology, measured using the Positive and Negative Syndrome Scale (PANSS).
                Nurses who had received medication management training produced a significantly greater reduction in patients'overall psychopathology compared with treatment as usual at the end of the 6-month study period (change in PANSS total scores: medication management -16.62, treatment as usual 1.17; difference -17.79; 95% CI -24.12 to -11.45; P<0.001).
                Medication management training for CMHNs is effective in improving clinical outcomes in patients with schizophrenia. Injections are commonly overused in Indonesia. More than 60% of patients attending public health facilities receive at least one injection, which increases clinical risk and has adverse economic impact. This study assesses the efficacy of an innovative behavioral intervention, the Interactional Group Discussion (IGD), for reducing the overuse of injections. This study was a controlled trial in a single district with 24 public health centers randomized to intervention and control groups. Prescribers in the intervention group were invited to one IGD, each of which consisted of 6 prescribers and 6 patients; a total of 24 IGDs were held in a 4-week period, and all invited prescribers participated. The groups, which lasted 90-120 minutes, were facilitated by a behavioral scientist and a clinician, who also served as a scientific resource person. The hypothesized mechanism of behavior change involved reality testing prescribers' assumptions about patient beliefs, imparting scientific information about injection efficacy, and establishing peer norms about correct behavior. Outcomes were measured by a retrospective prescribing survey covering the periods 3 months before and 3 months after the intervention, with samples of 100 prescriptions per center per month. Rates of injection and average number of drugs per prescription were computed separately for each center, and t-tests were used to compare pre-post changes in outcomes in both groups. Results showed a significant decrease in injection use from 69.5 to 42.3% in the intervention group, compared to a decrease from 75.6 to 67.1% among controls [-18.7.0% intervention vs control, 95% CI = (-31.1%, -6.4%), P < 0.025]. There was also a significant reduction in average number of drugs per prescription [-0.37 drugs prescribed per patient, 95% CI = (-0.04, -0.52), P < 0.05], indicating that injections were not substituted with other drugs. We conclude that the IGD significantly reduces the overuse of injections. It is suggested to try out other behavioral interventions to improve the rational use of drugs. This study was aimed at evaluating the effects of an education program for general practitioners on their prescribing behaviour for cervical and breast cancer screening tests, and assessing the feasibility of general practitioners participation in screening programs. All three cytology laboratories and 19 of the 20 radiologists in one administrative region ("Haute-Savoie") in France agreed to participate. The 278 general practices in this region were randomly assigned to either the intervention group (a one-day seminar on screening for breast cancer and cervical cancer) or the control group (n for both = 139). The prescriptions of tests for the following year were noted from the laboratories' and radiologists' records. No significant differences were observed between the intervention group and the control group for the number of mammographies prescribed with a mean of 19.3 and 15.2 per practice, respectively. However, significantly more mammographies were prescribed in women aged over 50 by the intervention group (p = 0.038). Inversely, fewer smear tests were prescribed in the intervention group (mean per practice: 40.5 and 46.1, respectively). A significantly higher number of practices in the intervention group did not prescribe any smear tests (p = 0.007). This study suggests that it is possible to influence general practitioners' participation in screening programs, but that the messages should be carefully presented, since negative effects are possible. There is agreement, although little evidence, that consistently positioning stroke patients in allegedly reflex-inhibiting positions is therapeutic and will enhance functional recovery. The nursing staff, therefore, needs to know and implement these postures and understand their potential underlying value. We examined nurses' knowledge of and practice in positioning stroke patients before and after a formal teaching intervention.
                In a quasi-experimental study, 38 stroke patients and 59 nursing staff members (44 trained nurses and 15 healthcare assistants) from 6 wards were studied. The wards were randomly allocated to experimental or control status. Patients were assessed on entry into the study by use of a range of measures to establish group equivalence. Nineteen aspects of their position were documented at intervals throughout their stay with a previously developed observational tool. One thousand sets of observations of patient position were made. Using 2 questionnaires, the nurses' knowledge of the terminology used to denote posture and of issues relating to the moving and positioning of stroke patients was assessed before, immediately after, and 3 months after a package of formal teaching was implemented on the experimental wards. Nurse knowledge and patient position were used as the main outcome measures.
                Immediately after teaching, nurses in the experimental group scored significantly higher than those in the control group on the terminology questionnaire (P < 0.05) and the moving and positioning questionnaire (P < 0.001). Three months later, the experimental group scored higher on the latter questionnaire only (P < 0.005). The positioning of patients in the experimental group was improved overall after the teaching (P < 0.0005), and improvements to specific parts of the body were noted.
                It was possible to effect a degree of change in the nurses' knowledge of and practice in the positioning of stroke patients. However, the quality of patient positioning remained variable. More effective ways of improving positioning need to be developed. Only then can the effects of recommended positioning be evaluated. To evaluate the effects of a brief educational program on beliefs, knowledge, and behaviors related to skin cancer control among internal medicine housestaff and attending physicians.
                Randomised controlled trial.
                Urban academic general medicine practice.
                Internal medicine housestaff and attending physicians with continuity clinics at the practice site.
                Two 1-hour educational seminars on skin cancer control conducted jointly by a general internist and a dermatologist.
                Self-reported attitudes and beliefs about skin cancer control, ability to identify and make treatment decisions on 18 skin lesions, and knowledge of skin cancer risk factors were measured by a questionnaire before and after the teaching intervention. Exit surveys of patients at moderate to high risk of skin cancer were conducted 1 month before and 1 month after the intervention to measure physician skin cancer control practices reported by patients. Eighty-two physicians completed baseline questionnaires and were enrolled in the study, 46 in the intervention group and 36 in the control group. Twenty-five physicians attended both sessions, 11 attended one, and 10 attended neither. Postintervention, the percentage of physicians feeling adequately trained increased from 35% to 47% in the control group (p = .34) and from 37% to 57% in the intervention group (p = .06). Intervention physicians had an absolute mean improvement in their risk factor identification score of 6.7%, while control physicians' mean score was unchanged (p = .06). Intervention and control physicians had similar increases in their postintervention lesion identification and management scores. Postintervention, the mean proportion of patients per physician stating they were advised to watch their moles increased more among intervention physicians than control physicians (absolute difference of 19% vs -8%, p = .04). Other changes in behavior were not significant.
                Although we observed a few modest intervention effects, overall this brief skin cancer education intervention did not significantly affect primary care physicians' skin cancer control attitudes, beliefs, knowledge, or behaviors. A more intensive intervention with greater participation may be necessary to show a stronger impact on attitudes and knowledge about skin cancer control among primary care physicians. Previous studies have shown that Norwegian public health physicians do not systematically and explicitly use scientific evidence in their practice. They work in an environment that does not encourage the integration of this information in decision-making. In this study we investigate whether a theoretically grounded tailored intervention to diffuse evidence-based public health practice increases the physicians' use of research information.
                148 self-selected public health physicians were randomised to an intervention group (n = 73) and a control group (n = 75). The intervention group received a multifaceted intervention while the control group received a letter declaring that they had access to library services. Baseline assessments before the intervention and post-testing immediately at the end of a 1.5-year intervention period were conducted. The intervention was theoretically based and consisted of a workshop in evidence-based public health, a newsletter, access to a specially designed information service, to relevant databases, and to an electronic discussion list. The main outcome measure was behaviour as measured by the use of research in different documents.
                The intervention did not demonstrate any evidence of effects on the objective behaviour outcomes. We found, however, a statistical significant difference between the two groups for both knowledge scores: Mean difference of 0.4 (95% CI: 0.2-0.6) in the score for knowledge about EBM-resources and mean difference of 0.2 (95% CI: 0.0-0.3) in the score for conceptual knowledge of importance for critical appraisal. There were no statistical significant differences in attitude-, self-efficacy-, decision-to-adopt- or job-satisfaction scales. There were no significant differences in Cochrane library searching after controlling for baseline values and characteristics.
                Though demonstrating effect on knowledge the study failed to provide support for the hypothesis that a theory-based multifaceted intervention targeted at identified barriers will change professional behaviour. A randomized controlled trial was done to assess the ability of continuing medical education to change physicians' knowledge and behavior in the care of patients with acute myocardial infarction. Patient care practices on eight objectives were audited 6 months before and after physicians completed a 2-hour educational program. Sixty-three physicians from eight randomly selected communities constituted the experimental group and 40 physicians from four similar communities served as controls. The average score for desired care practices over all objectives increased from 48.5% to 60% (p less than 0.001). Three objectives showed significantly greater gains for physicians in the experimental group. The generalizability of these effects was also studied in two additional educational contexts: a multitopic and a unitopic university-based continuing medical education program. Similar significant changes in behavior resulted in both contexts. Significant overall increases in knowledge occurred and persisted for all groups. Continuing medical education can effect changes in physicians' knowledge and care practices that can persist for at least 6 months. Peer review groups are considered helpful for quality improvement in primary care. An interactive educational programme for small peer groups was developed, focusing on the implementation of newly developed treatment guidelines. The aim is to evaluate the effect of the programme on adherence to treatment guidelines in general practice.
                A cluster randomized trial using a balanced incomplete block design was used; one arm received a programme on treatment of chronic heart failure (CHF), the other on hypertension treatment in diabetes mellitus type 2 (T2DM). A random sample of 10 CHF and 10 T2DM patients per GP was drawn, for whom data were extracted from electronic patient records 1 years before and 6 months after the intervention. The outcomes were prescribing of ACE inhibitors, and antihypertensive treatment in T2DM. The effect was analysed separately for both programmes using multilevel regression models.
                All 27 peer review groups in one region in the Netherlands were randomized, of which 16 participated. No significant effects were observed in the CHF group or in the T2DM group. The opportunity for change was limited, as only 53% of the CHF patients and 60% of the T2DM patients had a contact with their GP between the intervention and follow-up measurement.
                The peer review programme was not successful for changing the treatment of chronic patients, although the programme focused on dealing with barriers perceived by the participants. Not all problems perceived can be solved in a peer group discussion. The intervention level of epidemiology is useful for studying effects in health systems research. Due to practical and ethical reasons, it is often difficult to apply experimental methods such as classical randomized clinical trials in the field. However with alternative approaches such as 'randomization by group' some of these problems can be overcome. Drug information has since long been considered as an instrument to influence physicians, however evaluation of its effects is a new field of research. In the present study the impact of drug information on prescribing behaviour was evaluated in an outpatient setting in Sri Lanka. The study included 15 state health institutions (45 prescribers) with a common drug formulary. Groups of prescribers were randomized into two interventions; newsletters and newsletters reinforced by a group seminar, and one control group. The target topic was 'rational prescribing of antibiotics'. Some 18,766 randomly selected outpatient drug prescriptions were studied. Antibiotics (and sulphonamides) were prescribed to 33.2% of the patients. An overall trend towards a decrease in proportion of patients prescribed antibiotics in the two intervention groups was seen, although the difference was not significant (p greater than 0.05) compared to the control group. This is similar to the effect of written information on prescribing in other studies. A mean difference of -7.4% in written, -7.3% in written + seminar and -0.4% in the control group was shown. The general antibiotic prescribing pattern did not change in any of the three groups. Penicillin was the most commonly prescribed antibiotic and tetracycline was only rarely prescribed to children. This experiment indicates the feasibility of drug information intervention studies in developing countries.(ABSTRACT TRUNCATED AT 250 WORDS) Due to worldwide migration to Western countries, physicians are increasingly encountering patients with different ethnic backgrounds. Communication problems can arise as a result of differences in cultural backgrounds and poor language proficiency.
                To assess the effectiveness of an educational intervention on intercultural communication aimed to decrease inequalities in care provided between Western and non-Western patients.
                A randomised controlled trial with randomisation at the GP level and outcome measurements at the patient level.
                General practice in Rotterdam.
                Thirty-eight Dutch GPs in the Rotterdam region, with at least 25% of inhabitants of non-Western origin, and 2407 visiting patients were invited to participate in the study. A total of 986 consultations were finally included. The GPs were educated about cultural differences and trained in intercultural communication. Patients received a videotaped instruction focusing on how to communicate with their GP in a direct way. The primary outcome measure was mutual understanding and the secondary outcomes were patient's satisfaction and perceived quality of care. The intervention effect was assessed for all patients together, for the 'Western' and 'non-Western' patients, and for patients with different cultural backgrounds separately.
                An intervention effect was seen 6 months after the intervention, as improvement in mutual understanding (and some improvement in perceived quality of care) in consultations with 'non-Western' patients.
                A double intervention on intercultural communication given to both physician and patient decreases the gap in quality of care between 'Western' and 'non-Western' patients. A randomized controlled study was conducted to determine if specifically designed continuing medical education in the fields of cardiovascular and cancer medicine could change doctor office behaviour significantly. Thirty-one volunteer family doctors from 25 offices participated. Six (three cardiovascular and three cancer) learning objectives were defined. Two educational formats were selected as the independent variables: (1) group interaction opportunities (face-to-face and teleconference); and (2) concisely written newsletters. Chart measures of doctor performance prior to and 6 and 12 months following education served as the dependent variables. The family doctors receiving education were found to perform the recommended behaviours significantly more than those who did not receive the education (P less than 0.05) at 6 months post-education. This difference was maintained at the 12-month post-educational period for one of the educational programmes offered. A carefully planned programme of continuing medical education will result in favourable changes in the office practice of volunteer doctors. These changes can persist for as long as 12 months. Adherence to several essential learning principles is required. The objective of this study was to assess the effects of two brief training interventions to improve obstetricians' and midwives' explanations to patients of a routine prenatal screening test. Health professionals were randomly allocated to one of two intervention groups or a control group. Information-giving about the test and communication skills were assessed at baseline, post-training and 3-month follow-up from audiotaped consultations. Both intervention groups received a 1-h training session involving small group discussions focused around a video. In addition, one group received individual feedback on their baseline and post-training consultations. Twenty-six midwives and nine obstetricians completed the study according to the protocol. Changes between baseline and post-training, and between baseline and follow-up, were computed. Information-giving and communication skills improved significantly in subjects receiving training and feedback on their performance, with the greatest improvements occurring before feedback was given. Those receiving training without feedback significantly improved their communication skills and showed some improvement in information-giving. These results show that modest improvements in communication can be made with relatively brief training. Greater and more sustained improvements may be found if all staff were trained, and trained on a regular basis. Timely adoption of clinical practice guidelines is more likely to happen when the guidelines are used in combination with adjuvant educational strategies that address social as well as rational influences.
                To implement the conservative, evidence-based approach to low-back pain recommended in national guidelines, with the anticipated effect of reducing population-based rates of surgery.
                A randomized, controlled trial.
                Ten communities in western Washington State with annual rates of back surgery above the 1990 national average (158 operations per 100,000 adults).
                Spine surgeons, primary care physicians, patients who were surgical candidates, and hospital administrators.
                The five communities randomized to the intervention group received a package of six educational activities tailored to local needs by community planning groups. Surgeon study groups, primary care continuing medical education conferences, administrative consensus processes, videodisc-aided patient decision making, surgical outcomes management, and generalist academic detailing were serially implemented over a 30-month intervention period.
                Quarterly observations of surgical rates.
                After implementation of the intervention, surgery rates declined in the intervention communities but increased slightly in the control communities. The net effect of the intervention is estimated to be a decline of 20.9 operations per 100,000, a relative reduction of 8.9% (P = 0.01).
                We were able to use scientific evidence to engender voluntary change in back pain practice patterns across entire communities. Nursing staffs from two long-term care facilities attended a multisession educational program about the care of residents with diabetes (treatment group). A control group consisted of the nursing staffs from two other similar facilities who did not participate in the educational program. Both groups were given a knowledge pretest and posttest. A chart review also was conducted following the educational intervention to determine any changes in the diabetes care provided by the treatment group. Following the educational program, the treatment group had a significant increase in their mean score on the knowledge test compared with the control group. However, a review of the residents' charts revealed no significant increases in specific behaviors related to diabetes care. The findings suggest that, in addition to educational programs, more focused training concerning diabetes care is needed to improve the care of residents with diabetes in long-term care facilities. Implications for diabetes educators are discussed. To test the impact of physician education and facilitator assisted office system interventions on cancer early detection and preventive services.
                A randomised trial of two interventions alone and in combination.
                Physicians in 98 ambulatory care practices in the United States.
                The education intervention consisted of a day long physician meeting directed at improving knowledge, attitudes, and skills relevant to cancer prevention and early detection. The office system intervention consisted of assistance from a project facilitator in establishing routines for providing needed services. These routines included division of responsibilities for providing services among physicians and their staff and the use of medical record flow sheets.
                The proportions of patients provided the cancer prevention and early detection services indicated annually according to the US National Cancer Institute.
                Based on cross sectional patient surveys, the office system intervention was associated with an increase in mammography, the recommendation to do breast self examination, clinical breast examination, faecal occult blood testing, advice to quit smoking, and the recommendation to decrease dietary fat. Education was associated only with an increase in mammography. Record review for a patient cohort confirmed cross sectional survey findings regarding the office system for mammography and faecal occult blood testing.
                Community practices assisted by a facilitator in the development and implementation of an office system can substantially improve provision of cancer early detection and preventive services. To investigate the effect of a one-day workshop in which physicians were taught trust-building behaviors on their patients' levels of trust and on outcomes of care.
                In 1994, the study recruited 20 community-based family physicians and enrolled 412 consecutive adult patients from those physicians' practices. Ten of the physicians (the intervention group) were randomly assigned to receive a one-day training course in building and maintaining patients' trust. Outcomes were patients' trust in their physicians, patients' and physicians' satisfaction with the office visit, continuity in the patient-physician relationship, patients' adherence to their treatment plans, and the numbers of diagnostic tests and referrals.
                Physicians and patients in the intervention and control groups were similar in demographic and other data. There was no significant difference in any outcome. Although their overall ratings were not statistically significantly different, the patients of physicians in the intervention group reported more positive physician behaviors than did the patients of physicians in the control group.
                The trust-building workshop had no measurable effect on patients' trust or on outcomes hypothesized to be related to trust. This trial took 22 volunteer family physicians and randomly exposed some to training intervention and some to no training to study the effect on frequency and quality of exercise prescription to ambulatory adults. During the 6 weeks after training, the trained physicians addressed the issue of exercise with 35.3% of patients. The untrained physicians discussed exercise with only 8.6% of their patients. To study the effectiveness of an intensive small group education and peer review programme aimed at implementing national guidelines on asthma/chronic obstructive pulmonary disease (COPD) on care provision by general practitioners (GPs) and on patient outcomes.
                A randomised experimental study with pre-measurement and post-measurement (after one year) in an experimental group and a control group in Dutch general practice.
                Two groups of GPs were formed and randomised. The education and peer review group (17 GPs with 210 patients) had an intervention consisting of an interactive group education and peer review programme (four sessions each lasting two hours). The control group consisted of 17 GPs with 223 patients (no intervention).
                Knowledge, skills, opinion about asthma and COPD care, presence of equipment in practice; actual performance about peakflow measurement, non-pharmacological and pharmacological treatment; asthma symptoms (Dutch Medical Research Council), smoking habits, exacerbation ratio, and disease specific quality of life (QOL-RIQ). Data were collected by a written questionnaire for GPs, by self recording of consultations by GPs, and by a written self administered questionnaire for adult patients with asthma/COPD.
                Data from 34 GP questionnaires, 433 patient questionnaires, and recordings from 934 consultations/visits and 350 repeat prescriptions were available. Compared with the control group there were only significant changes for self estimated skills (+16%, 95% confidence interval 4% to 26%) and presence of peakflow meters in practice (+18%, p < 0.05). No significant changes were found for provided care and patient outcomes compared with the control group. In the subgroup of more severe patients, the group of older patients, and in the group of patients not using anti-inflammatory medication at baseline, no significant changes compared with the control group were seen in patient outcomes.
                Except for two aspects, intensive small group education and peer review in asthma and COPD care do not seem to be effective in changing relevant aspects of the provided care by GPs in accordance with guidelines, nor in changing patients' health status. Community pharmacists are in a position to assume increased responsibility for preventing and resolving drug-related problems in ambulatory patients. Such an expanded role is mandated under provisions of the Omnibus Budget Reconciliation Act of 1990. The need for pharmacist oversight of drug therapy may be most acute in elderly patients. This study reports on a program to teach community pharmacists a process of assessing drug therapy of elderly patients and intervening to correct problems. Community pharmacists (N = 102) were assigned to treatment and control conditions. Both groups targeted patients meeting criteria and enrolled them into the study. Treatment group pharmacists, who participated in a training program, also assessed the medication use of enrolled patients to identify and resolve medication-related problems. Patients (N = 762) were telephoned by researchers 1 month after enrollment for an interview. Comparisons between treatment and control group patients were made on reports of pharmacist activities, knowledge of regimens, compliance, and potential drug therapy problems, such as interactions and side effects. Treatment patients were more likely to report that pharmacists provided information and assessed for problems than were control patients. These differences were maintained on 3-month follow-up questionnaires. No differences were found on the odds that patients indicated misunderstanding of regimens, non-compliance, or potential therapeutic problems. nan To evaluate and compare the effects of two types of continuing medical education (CME) programs on the communication skills of practicing primary care physicians.
                Fifty-three community-based general internists and family practitioners practicing in the Portland, Oregon, metropolitan area and 473 of their patients.
                For the short program (a 4 1/2-hour workshop), 31 physicians were randomized to either the intervention or the control group. In the long program (a 2 1/2-day course), 20 physicians participated with no randomization. A research assistant visited all physicians' offices both one month before and one month after the CME program and audiotaped five sequential visits each time. Data were based on analysis of the content and the affect of the interviews, using the Roter Interactional Analysis Scheme.
                Based on both t-test analysis and analysis of covariance, no effect on communication was evident from the short program. The physicians enrolled in the long program asked more open-ended questions, more frequently asked patients' opinions, and gave more biomedical information than did the physicians in the short program. Patients of the physicians who attended the long program tended to disclose more biomedical and psychosocial information to their physicians. In addition, there was a decrease in negative affect for both patient and physician, and patients tended to demonstrate fewer signs of outward distress during the visit.
                This study demonstrates some potentially important changes in physicians' and patients' communication after a 2 1/2-day CME program. The changes demonstrated in both content and affect may have important influences on both biologic outcome and physician and patient satisfaction. Diagnosis of domestic violence (DV) in primary care is low compared to its prevalence. Care for patients is deficient. Over a 1-year period, we tested the effectiveness of an intensive intervention to improve asking about DV, case finding, and management in primary care. The intervention included skill training for providers, environmental orchestration (posters in clinical areas, DV questions on health questionnaires), and measurement and feedback.
                We conducted a group-randomized controlled trial in five primary care clinics of a large health maintenance organization (HMO). Outcomes were assessed at baseline and follow-up by survey, medical record review, and qualitative means.
                Improved provider self-efficacy, decreased fear of offense and safety concerns, and increased perceived asking about DV were documented at 9 months, and also at 21 months (except for perceived asking) after intervention initiation. Documented asking about DV was increased by 14.3% with a 3.9-fold relative increase at 9 months in intervention clinics compared to controls. Case finding increased 1.3-fold (95%, confidence interval 0.67-2.7).
                The intervention improved documented asking about DV in practice up to 9 months later. This was mainly because of the routine use of health questionnaires containing DV questions at physical examination visits and the placement of DV posters in clinical areas. A small increase in case finding also resulted. System changes appear to be a cost-effective method to increase DV asking and identification. The objective of this study was to evaluate the impact of three continuing education seminars (within a period of 4 months) on the quality of patient management and rational drug use. The study was designed as a randomized controlled trial. Prescribers in 16 general health centers were allocated to an intervention (eight health centers) or a control (eight health centers) group. A total of 5,685 patient cards was analyzed for quality of case management and rational drug use. In the intervention health centers the average number of drugs per patient decreased from 2.3 to 1.9 (p = 0.005) and the proportion of patients managed with nonpharmacological treatment increased from 1 to 13.2%. Recorded history taking, examination, and diagnosis improved in the intervention health centers. More drugs were correctly chosen in the intervention health centers compared to control health centers (p = 0.03). The proportion of patients prescribed antibiotics decreased and the proportion of patients adequately managed increased in the intervention health centers. Our conclusion is that continuing education in the form of repeated seminars is effective in influencing prescribers and in promoting rational drug use in primary care. To determine the quality of spirometry performed in primary care practice and to assess the impact of formal training.
                Randomized, controlled prospective interventional study.
                Primary care practice, Auckland City, New Zealand.
                Thirty randomly selected primary care practices randomized to "trained" or "usual" groups. One doctor and one practice nurse were nominated to participate from each practice.
                "Trained" was defined as participation in an "initial" spirometry workshop at week 0 and a "maintenance of standards" workshop at week 12. "Usual" was defined as no formal training until week 12, when participants they attended the same "initial" workshop provided for the trained group. The study duration was 16 weeks. Each practice was provided with a spirometer to be used at their clinical discretion.
                Spirometry data were uploaded weekly and analyzed using American Thoracic Society (ATS) criteria for acceptability and reproducibility. The workshops were assessed objectively with practical and written assessments, confirming a significant training effect. However, analysis of spirometry performed in clinical practice by the trained practitioners revealed three acceptable blows in only 18.9% of patient tests. In comparison, 5.1% of patient tests performed by the usual practitioners had three acceptable blows (p<0.0001). Only 13.5% of patient tests in the trained group and 3.4% in the usual group (p<0.0001) satisfied full acceptability and reproducibility criteria. However, 33.1% and 12.5% of patient tests in the trained and usual groups, respectively (p<0.0001), achieved at least two acceptable blows, the minimum requirement. Nonacceptability was largely ascribable to failure to satisfy end-of-test criteria; a blow of at least 6 s. Visual inspection of the results of these blows as registered on the spirometer for the presence of a plateau on the volume-time curve suggests that < 15% were acceptable.
                Although a significant training effect was demonstrated, the quality of the spirometry performed in clinical practice did not generally satisfy full ATS criteria for acceptability and reproducibility. Further study would be required to determine the clinical impact. However, the ATS guidelines allow for the use of data from unacceptable or nonreproducible maneuvers at the discretion of the interpreter. Since most of the failures were end-of-test related, the FEV1 levels are likely to be valid. Our results serve to emphasize the importance of effective training and quality assurance programs to the provision of successful spirometry in primary care practice. To assess the effectiveness of tailored interventions to implement guidelines for urinary tract infections in women and sore throat.
                Unblinded, cluster randomised pretest-post-test trial.
                142 general practices in Norway.
                72 practices received interventions to implement guidelines for urinary tract infection and 70 practices received interventions to implement guidelines for sore throat, serving as controls for each other. 59 practices in the urinary tract infection group and 61 practices in the sore throat group completed the study. Outcomes were measured in 16 939 consultations for sore throat and 9887 consultations for urinary tract infection.
                Interventions were developed to overcome identified barriers to implementing the guidelines. The main components of the tailored interventions were patient educational material, computer based decision support and reminders, an increase in the fee for telephone consultations, and interactive courses for general practitioners and practice assistants.
                Changes in rates of use of antibiotics, laboratory tests, and telephone consultations. Results: Patients in the sore throat group were 3% less likely to receive antibiotics after the intervention. Women with symptoms of urinary tract infection in the intervention group were 5.1% less likely to have a laboratory test ordered. No significant differences were found between the groups for the other outcomes. Large variation was found across the included practices in the rates of antibiotic prescription, use of laboratory tests and telephone consultations, and in the extent of change for all three outcome measures.
                Passively delivered, complex interventions targeted at identified barriers to change had little effect in changing practice. Depression is a major individual and public-health burden throughout the world and is managed mainly in primary care. The most effective strategy to reduce this burden has been believed to be education of primary-care practitioners. We tested this assumption by assessing the effectiveness of an educational programme based on a clinical-practice guideline in improving the recognition and outcome of primary-care depression.
                We carried out a randomised controlled trial in a representative sample of 60 primary-care practices (26% of the total) in an English health district. Education was delivered to practice teams and quality tested by feedback from participants and expert raters. The primary endpoints were recognition of depression, defined by the hospital anxiety and depression (HAD) scale, and clinical improvement. Analysis was by intention to treat.
                The education was well received by participants, 80% of whom thought it would change their management of patients with depression. 21409 patients were screened, of whom 4192 were classified as depressed by the HAD scale. The sensitivity of physicians to depressive symptoms was 39% in the intervention group and 36% in the control group after education (odds ratio 1.2 [95% CI 0.88-1.61]). The outcome of depressed patients as a whole at 6 weeks or 6 months after the assessment did not significantly improve.
                Although well received, this in-practice programme, which was designed to convey the current consensus on best practice for the care of depression, did not deliver improvements in recognition of or recovery from depression. To evaluate the impact on clinical behavior of a 3-day workshop designed to increase trainees' rates of smoking cessation counseling and reminders about Pap smears in routine consultations.
                Randomized control trial.
                Accredited teaching practices of the Royal Australian College of General Practitioners' Training Program.
                Thirty-four trainees and 1,500 consecutive adult patients ages 16-65 years.
                Trainees randomly allocated to the experimental group participated in a 3-day interactive workshop on disease prevention during their 13-week family medicine term. Audiotapes of consultations with adults conducted by trainees at the beginning and end of the rotation were analyzed blind to compare assessment of patients' smoking status and, for women, date of last Pap smear. A questionnaire mailed to each patient after the consultation also allowed identification of smokers and women overdue for a smear. Consultations with these patients at risk were analyzed for preventive counseling. Inter- and intrarater reliability was calculated for audiotape analysis.
                Preworkshop rates of questions about smoking were low, occurring in 22% of consultations. While trainees allocated to the experimental workshop were more likely to ask a routine question about smoking at the end of the term than those in the control group (P = 0.01), two-thirds of smokers remained undetected irrespective of trainee group and fewer than one in five were advised to stop smoking. Reminders about Pap smears did not change as a result of training and remained low in fewer than 20% of consultations. kappa values demonstrated high reliability of audiotape analysis.
                This direct measurement of clinical behavior revealed that low levels of preventive care provided by trainees are resistant to skills training without reinforcement in clinical practice. In view of the importance of prevention in routine consultations, we recommend continued evaluation of more intensive educational programs. Those withstanding rigorous evaluation could be considered for implementation in similar training contexts seeking to improve the frequency and quality of disease prevention in primary medical care. A Continuing Medical Education short course was designed to examine the effect of presenting topics in three learning formats - traditional lectures, large-group, case discussions or small-group, problem-solving sessions, on knowledge and performance of family physicians. The physicians in the small group session rated the CME short course higher and performed better on one aspect of patient management than the lecture or large group physicians but there were no other differences between groups on knowledge or physician performance. In a randomised trial, general practitioners and nurses in 21 practices were trained in patient-centred consulting and use of materials for people with Type 2 diabetes (GPs 0.5 days; nurses 1.5 days; two optional follow-up half-days). Twenty practices formed the comparison group. Professional beliefs, attitudes and behaviour were measured (pre-trial, close-of-course and end-of-trial), supported by patient reports of nurse behaviour (141 trained: 108 comparison patients, 1 year after diagnosis). A total of 49 practice nurses responded (29 trained; 20 comparison). Trained nurses rated relative importance of patient-centred to professional-centred care as greater than comparison nurses. Trained nurses became less keen on the approach during the trial, and perceived time constraints persisted. Patients diagnosed later in the study were less likely to recognise intervention materials. Trained nurses rated delivery of important aspects of care and satisfaction with style of care as lower than comparison nurses, but patients were more positive about delivery of care from trained than comparison nurses. Although nurses rated patient-centred care as important, whether or not they had been trained as part of the trial, the short, generalizable training programme significantly reduced nurse perceptions of their ability to deliver it. Nonetheless, patients reported that important aspects of diabetes care were delivered more if their nurses had been trained in patient-centred consulting. This raises issues concerning measurement scales completed by trained professionals. In an attempt to evaluate the efficacy of different methods of interventions to improve the appropriate use of drugs for acute diarrhoea, a controlled study has been carried out in 6 districts in Yogyakarta and Central Java provinces, Indonesia. This study was designed to investigate the impacts of two different methods of educational intervention, i.e. a small group face-to-face intervention and a formal seminar for prescribers, on prescribing practice in acute diarrhoea. The districts were randomly assigned into 3 groups and 15 health centers were selected from each district. Prescribers in Group 1 underwent a small group face-to-face intervention conducted in the respective health center. Those in Group 2 attended a formal seminar conducted at the district level. Prescribers in Group 3 served as the control group. Both interventions were given on a single occasion without follow-up supervision or monitoring. Written information materials on the appropriate management of acute diarrhoea were developed and were provided to all prescribers in the intervention groups. Focus group discussions (FGDs) involving prescribers and consumers in the 6 districts were carried out to identify various underlying motivations of drug use in acute diarrhoea. The findings of the FGDs were used as part of the intervention materials. To evaluate the impacts of these interventions on prescribing practice, a prescribing survey for patients under five years old with acute diarrhoea was carried out in health centers covering 3-month periods before and after the intervention. The results showed that both interventions were equally effective in improving the levels of knowledge of prescribers about the appropriate management of acute diarrhoea. They were also partially effective in improving the appropriate use of drugs, reducing the use of non-rehydration medications. There was a highly significant reduction of antimicrobial usage either after small-group face-to-face intervention (77.4 +/- 2.7% to 60.4 +/- 2.9%; P < 0.001) or formal seminar (82.3 +/- 3.0% to 72.3 +/- 3.6%; P < 0.001), and the former caused significantly (P < 0.001) greater reduction than the latter. There was also a significant (P < 0.01) reduction in the usage of antidiarrhoeals after both interventions, i.e. from 20.3 +/- 3.7% to 12.5 +/- 3.3% (P < 0.01) after face-to-face intervention and from 48.5 +/- 4.1% to 27.0 +/- 4.3% (P < 0.01) after seminar. However, the formal seminar had a significantly (P < 0.01) greater impact than the small group face-to-face intervention. There was also a trend toward increased oral rehydration solution (ORS) usage after both interventions, but this did not achieve the level of statistical significance (P > 0.05). No changes were observed in the control group. Although the small group face-to-face intervention did not appear to offer greater impacts over large seminars in improving the appropriate use of drugs in acute diarrhoea, since the unit cost of training is far less costly than the seminar, it might be feasibly implemented in the existing supervisory structure of the health system. The effect of clinical guidelines on resource 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.
                Physician groups were randomized to receive guideline education and individual feedback, supporting patient education materials, both, or neither. The impact on guideline adherence and resource utilization was evaluated during the 12-month period before and after implementation.
                Fourteen physician groups with 120 primary care physician and associate practitioners from 2 group model HMO practices.
                Guideline implementation utilized an education/audit/feedback model with local peer opinion leaders. The patient education component included written and videotaped materials on the care of low back pain.
                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.
                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 materials did not enhance guideline effectiveness. Implementation barriers could limit the utility of this approach in usual care settings. Assessed is a breast-feeding training course that was attended by health professionals at the Santos Lactation Center (SLC), Santos, São Paulo, Brazil, as well as its impact on the implementation of breast-feeding programmes in maternity hospitals. Eight maternity hospitals were studied--four were randomly allocated to the experimental group and sent three health professionals to attend an 18-day course at SLC; the remaining four institutions constituted the control group. The compliance of all eight hospitals with WHO/UNICEF's "Ten steps for successful breast-feeding" was determined using scores obtained before and 6 months after the training course. Institutions in the experimental group had an improved score, but those in the control group did not. The SLC training course was efficient since it enabled the participants to promote breast-feeding practices. However, in order to succeed in implementing breast-feeding programmes, health professionals require also to develop skills to apply the knowledge they acquire in the course, as well as to involve the whole maternity unit team in the activities. General practitioners (GPs) can be provided with effective training in the skills to manage depression. However, it remains uncertain whether such training achieves health gain for their patients.
                The study aimed to measure the health gain from training GPs in skills for the assessment and management of depression. The study design was a cluster randomized controlled trial. GP participants were assessed for recognition of psychological disorders, attitudes to depression, prescribing patterns and experience of psychiatry and communication skills training. They were then randomized to receive training at baseline or the end of the study. Patients selected by GPs were assessed at baseline, 3 and 12 months. The primary outcome was depression status, measured by HAM-D. Secondary outcomes were psychiatric symptoms (GHQ-12) quality of life (SF-36), satisfaction with consultations, and health service use and costs.
                Thirty-eight GPs were recruited and 36 (95%) completed the study. They selected 318 patients, of whom 189 (59%) were successfully recruited. At 3 months there were no significant differences between intervention and control patients on HAM-D, GHQ-12 or SF-36. At 12 months there was a positive training effect in two domains of the SF-36, but no differences in HAM-D, GHQ-12 or health care costs. Patients reported trained GPs as somewhat better at listening and understanding but not in the other aspects of satisfaction.
                Although training programmes may improve GPs' skills in managing depression, this does not appear to translate into health gain for depressed patients or the health service. We conducted a trial to evaluate the effect of an active, multifaceted educational strategy to promote the use of the WHO Reproductive Health Library (RHL) on obstetric practices.
                Cluster randomised trial. The trial was assigned the International Standardised Randomised Controlled Trial Number ISRCTN14055385.
                Twenty-two hospitals in Mexico City and 18 in the Northeast region of Thailand.
                The intervention consisted primarily of three interactive workshops using RHL over a period of 6 months. The focus of the workshops was to provide access to knowledge and enable its use. A computer and support for using both the computer and RHL were provided at each hospital. The control hospitals did not receive any intervention.
                The main outcome measures were changes in ten selected clinical practices as recommended in RHL starting approximately four to six months after the third workshop. Clinical practice data were collected at each hospital from 1000 consecutively delivered women or for a 6-month period whichever was reached sooner.
                The active, multifaceted educational intervention we employed did not affect the ten targeted practices in a consistent and substantive way. Iron/folate supplementation, uterotonic use after birth and breastfeeding on demand were already frequently practiced, and we were unable to measure external cephalic version. Of the remaining six practices, selective, as opposed to routine episiotomy policy increased in the intervention group (difference in adjusted mean rate = 5.3%; 95% CI -0.1 to 10.7%) in Thailand, and there was a trend towards an increased use of antibiotics at caesarean section in Mexico (difference in adjusted mean rate = 19.0%; 95% CI: -8.0 to 46.0%). There were no differences in the use of labour companionship, magnesium sulphate use for eclampsia, corticosteroids for women delivering before 34 weeks and vacuum extraction. RHL awareness (24.8-65.5% in Mexico and 33.9-83.3% in Thailand) and use (4.8-34.9% in Mexico and 15.5-76.4% in Thailand) increased substantially after the intervention in both countries.
                The multifaceted, active strategy to provide health workers with the knowledge and skills to use RHL to improve their practice led to increased access to and use of RHL, however, no consistent or substantive changes in clinical practices were detected within 4-6 months after the third workshop. To determine the effectiveness of two dissemination and implementation strategies to implement a national guideline for epilepsy management in primary care settings.
                Three-arm cluster-randomized controlled trial. The participants were general practitioners from 68 practices in Tayside, Scotland, and 1,133 of their patients with self-reported epilepsy treated with antiepileptic medications (AEDs). Practices were randomized blind to a control, intermediate, or intensive intervention. Control: Postal dissemination of a nationally developed clinical guideline. Intermediate intervention: Postal dissemination of the guideline supported by interactive, accredited workshops, and dedicated, structured protocol documents. Intensive intervention: Intermediate intervention plus a nurse specialist who supported and educated practices in the establishment of epilepsy review clinics. The primary outcome was the SF-36 health-related quality-of-life instrument. Secondary measures were a battery of prevalidated epilepsy-specific quality-of-life instruments. These were administered at baseline and after the intervention phase. Process of care was assessed by case-note review on number of review meetings and counseling sessions for epilepsy before and after the interventions.
                None of the intervention groups showed any change in the primary or secondary outcome measures or process-of-care measures.
                None of the intervention strategies led to improvements in patient quality of life or quality of epilepsy care. Further research is needed to discover why the interventions failed, to identify barriers to adoption of guidelines, and to develop strategies that might improve implementation and uptake in the future. Depression, a common disorder often treated by family physicians, may be both underdiagnosed and undertreated. The objective of this study was to determine whether the diagnosis and treatment of depression by family physicians could be improved through an educational strategy.
                In this study, conducted between July and December 1997, 42 family physicians in Newfoundland were randomly assigned to an intervention group (3-hour case-based educational session on clinical practice guidelines [CPGs] for depression and access to a psychiatrist for consultation) or to a control group (receipt of CPGs without educational session or access to the psychiatrist). Physicians were asked to keep a log of patients with newly diagnosed depression and to record information on severity of depression, medications and referrals to mental health professionals. Patients were asked to complete the Centre for Epidemiologic Studies Depression (CES-D) scale before treatment and after 6 months of follow-up. The primary outcome measure was the "gain" score (difference between first and last CES-D scores).
                During the study period physicians in the intervention group diagnosed 91 new cases of depression (mean 4.1 per physician) and those in the control group diagnosed 56 (mean 2.8 per physician); the difference was not significant. Most patients (91.2% in the intervention group and 89.3% in the control group received a prescription for an antidepressant on their first visit. Similar proportions (46.2% in the intervention group and 37.5% in the control group) took their medication for the full 6 months; however, significantly more patients in the intervention group were taking an antidepressant at the 6-month follow-up (56% v. 39.3%, p = 0.02). The mean number of visits per patient was similar in the 2 groups (7.7 in the intervention group and 7.6 in the control group). Physicians in the intervention group consulted the psychiatrist 9 times. The overall rate of referrals to psychiatrists and other mental health professionals was 10.9%; however, referrals were significantly higher in the intervention group (15.4% v. 3.5%, p = 0.05). After 6 months of follow-up, a significant difference in gain scores was detected between the intervention and control groups for both the patient's self-rated CES-D scores (mean gain score 19.3 v. 15.5 respectively, p = 0.04) and the physicians' ratings of depression severity before treatment and at 6 months (mean gain 1.1 v. 0.7 respectively, p = 0.02).
                The educational strategy had a modest beneficial effect on the outcomes of patients with depression, but there are still concerns regarding the low rates of drug treatment and referral to mental health professionals by family physicians. To investigate the effect of clinical guidelines on the management of infertility across the primary care-secondary care interface.
                Cluster randomised controlled trial.
                General practices and NHS hospitals accepting referrals for infertility in the Greater Glasgow Health Board area. Participants: All 221 general practices in Glasgow; 214 completed the trial.
                General practices in the intervention arm received clinical guidelines developed locally. Control practices received them one year later. Dissemination of the guidelines included educational meetings.
                The time from presentation to referral, investigations completed in general practice, the number and content of visits as a hospital outpatient, the time to reach a management plan, and costs for referrals from the two groups.
                Data on 689 referrals were collected. No significant difference was found in referral rates for infertility. Fewer than 1% of couples were referred inappropriately early. Referrals from intervention practices were significantly more likely to have all relevant investigations carried out (odds ratio 1.32, 95% confidence interval 1.00 to 1.75, P=0.025). 70% of measurements of serum progesterone concentrations during the midluteal phase and 34% of semen analyses were repeated at least once in hospital, despite having been recorded as normal when checked in general practice. No difference was found in the proportion of referrals in which a management plan was reached within one year or in the mean duration between first appointment and date of management plan. NHS costs were not significantly affected.
                Dissemination of infertility guidelines by commonly used methods results in a modest increase in referrals having recommended investigations completed in general practice, but there are no detectable differences in outcome for patients or reduction in costs. Clinicians in secondary care tended to fail to respond to changes in referral practice by doctors. Guidelines that aim to improve the referral process need to be disseminated and implemented so as to lead to changes in both primary care and secondary care. Antenatal corticosteroids for fetal maturation have been underused, despite evidence for their benefits in cases of preterm birth.
                To evaluate dissemination strategies aimed at increasing appropriate use of this therapy.
                Twenty-seven tertiary care institutions were randomly assigned to either usual dissemination of practice recommendations (n = 14) or usual dissemination plus an active, focused dissemination effort (n = 13).
                Obstetricians and their preterm delivery cases at participating hospitals.
                Recommendations by a National Institutes of Health (NIH) Consensus Conference held in late February-early March 1994 were disseminated in early May 1994. Usual dissemination was publication of the recommendations and endorsement by the American College of Obstetricians and Gynecologists. Active dissemination was a year-long educational effort led by an influential physician and a nurse coordinator at each facility, consisting of grand rounds, a chart reminder system, group discussion of case scenarios, monitoring, and feedback.
                Use or nonuse of antenatal corticosteroids was abstracted from medical records of eligible women delivering at the participating hospitals in the 12 months immediately prior to release of the NIH recommendations (average number of records abstracted, 130) and in the 12 months following their release (average number of records abstracted, 122).
                Active dissemination significantly increased the odds of corticosteroid use after the conference. Use increased from 33.0% of eligible patients receiving corticosteroids to 57.6%, or by 75% over baseline, in usual dissemination hospitals. Use increased from 32.9% to 68.3%, oran 108% increase, in active dissemination hospitals. Gestational age and maternal diagnosis affected use of the therapy in complex ways.
                An active, focused dissemination effort increased the effectiveness of usual dissemination methods when combined with key principles to change physician practices. Many patients who visit primary care physicians suffer from depression, but physicians may miss the diagnosis or undertreat these patients. Improving physicians' communication skills pertaining to diagnosing and managing depression may lead to better outcomes.
                We performed a randomized controlled trial involving 49 primary care physicians to determine the effect of the Depression Education Program on their knowledge of depression and their behavior toward depressed patients. After randomization, physicians in the intervention group completed the Depression Education Program, which consists of 2 4-hour interactive workshops that combine lectures, discussion, audiotape review, and role-playing. Between sessions, physicians audiotaped an interview with one of their patients. Two to 6 weeks following the intervention program, physicians completed a knowledge test and received office visits from 2 unannounced people acting as standardized patients with major depression. These "patients" completed a checklist and scales. Logistic and linear regression were used to control for sex, specialty, and suspicion that the patient was a standardized patient.
                For both standardized patients, more intervention physicians than control physicians asked about stresses at home, and they also scored higher on the Participatory Decision-Making scale. During the office visits of one of the standardized patients, more intervention physicians asked about at least 5 criteria for major depression (82% and 38%, P = .006), discussed the possibility of depression (96% and 65%, P = .049), scheduled a return visit within 2 weeks (67% and 33%, P = .004), and scored higher than control physicians on the Patient Satisfaction scale (40.3 and 35.5, P = .014).
                The Depression Education Program changed physicians' behavior and may be an important component in the efforts to improve the care of depressed patients. Doctors' communication with patients is commonly hampered by lack of training in this core skill. This study aimed to assess the efficacy of an intensive 3-day training course on communication skills in a randomised controlled trial with a two-by-two factorial design and several outcomes.
                160 oncologists from 34 UK cancer centres were randomly allocated to four groups: written feedback followed by course; course alone; written feedback alone; and control. At each of two assessment periods, consultations with six to ten consecutive, consenting patients per doctor were videotaped. 2407 patients participated. Outcome measures included objective and subjective ratings made by researchers, doctors, and patients. The primary outcomes were objective improvements after the intervention in key communication skills. Course content included structured feedback, videotape review of consultations, role-play with simulated patients, interactive group demonstrations, and discussion led by a trained facilitator.
                In Poisson regression analysis of counts of communication behaviours, course attendance significantly improved key outcomes. The estimated effect sizes corresponded to higher rates of use of focused questions (difference between course attenders [n=80] and non-attenders [n=80] 34%, p=0.003), focused and open questions (27%, p=0.005), expressions of empathy (69%, p=0.003), and appropriate responses to patients' cues (38%, p=0.026), and a 24% lower rate of use of leading questions (p=0.11). There was little evidence for the effectiveness of written feedback.
                The communication problems of senior doctors working in cancer medicine are not resolved by time and clinical experience. This trial shows that training courses significantly improve key communication skills. More resources should be allocated to address doctors' training needs in this vital area. The objective of the study was to evaluate the effectiveness of 2 educational strategies aimed at improving prescribing standards in primary care.
                A pragmatic controlled trial was designed; the study population included general and family practitioners in Galicia (northwestern Spain) divided into 3 study groups: a one-to-one education group (n = 98), a by-group education group (n = 92), and a control group (n = 405). The educational intervention included explicit recommendations for selecting nonsteroidal anti-inflammatory drugs (NSAIDs) for inflammation signs. Some of the subjects were given reminders. Mixed-effect linear models were applied to data analysis. Analyses were done by intention-to-treat. The dependent variable is a rate with a numerator that is the number of prescribed units of the NSAIDs recommended during intervention; the denominator is the total number of prescribed units of the NSAID total.
                One-to-one education obtained an average prescribing behavior improvement of 6.5% (P < 0.001) in the 9 months after intervention. In the education group, the average improvement was 2.4% (P < 0.05) for the same period. Statistically significant differences were observed between the group intervention and one-to-one groups. The reminder increased significantly the effectiveness of the one-to-one intervention.
                A single, short educational session to primary care doctors can improve their prescribing standards during long periods of > or = 9 months. Of the 2 strategies followed in the trial, one-to-one education has shown to be the most effective. Results also show that the effectiveness of these interventions increases when presented together with written material. Research is needed to validate effective and practical strategies for improving the provision of evidence-based medicine in primary care.
                To determine whether a multimethod quality improvement intervention was more effective than a less intensive intervention for improving adherence to 21 quality indicators for primary and secondary prevention of cardiovascular disease and stroke.
                2-year randomized, controlled clinical trial with the practice as the unit of randomization.
                20 community-based family or general internal medicine practices in 14 states. All used the same electronic medical record.
                44 physicians, 17 midlevel providers, and approximately 200 staff members; data from the electronic medical records of 87,291 patients.
                All practices received copies of practice guidelines and quarterly performance reports. Intervention practices also hosted quarterly site visits to help them adopt quality improvement approaches and participated in 2 network meetings to share "best practice" approaches.
                The percentage of indicators at or above predefined targets and the percentage of patients who had achieved each clinical indicator.
                Intervention practices improved 22.4 percentage points (from 11.3% to 33.7%) in the percentage of indicators at or above the target; control practices improved 16.4 percentage points (from 6.3% to 22.7%). The 6.0-percentage point absolute difference between the intervention and control group was not statistically significant (P > 0.2). Patients in intervention practices had greater improvements than those in control practices for diagnoses of hypertension (improvement difference, 15.7 percentage points [95% CI, 5.2 to 26.3 percentage points]) and blood pressure control in patients with hypertension (improvement difference, 8.0 percentage points [CI, 0.0 to 16.0 percentage points]).
                The study involved a small number of practices and lacked a pure control group.
                Primary care practices that use electronic medical records and receive regular performance reports can improve their adherence to clinical practice guidelines for cardiovascular disease and stroke prevention. To evaluate patient education and resident education strategies to promote advance directives in the outpatient setting, and to assess barriers to implementation.
                Controlled clinical trial.
                The internal medicine residents' practice of an urban, university medical center.
                Medical residents and 250 patients seen at least twice in the 3 months prior to the study.
                We randomized practice days: one to patient education, one to resident education, and three controls. Resident education consisted of a lecture, a videotape of a model advance directives discussion, and videotaping of an actual discussion by each resident, followed by individual review. Patient education consisted of distributing pamphlets in the waiting room and offering all patients an opportunity to discuss advance directives.
                We interviewed 187 of these patients (response rate 75%) and surveyed 62 residents (response rate 70%). After 18 months, there were no significant differences in the number of advance directives in charts among the three groups. Documented advance directives discussions with patients in the resident education group increased from 3% to 17% (p < .001), more than those in the patient education (5%) or control group (10%, p = .04). Residents in the resident education group were more likely to report discussing advance directives than those in the patient education or control groups (p = .05). Lack of time (95%) and lack of continuity (76%) were the most frequently cited barriers. In multivariate logistic regression, nonwhite race and non-U.S. birth were negatively associated with patient interest in advance directives. Patient race and birthplace were not associated with actual discussions of advance directives.
                Even with intensive efforts to educate outpatients and residents about advance directives, important barriers remain, raising questions about how best to promote advance directives among outpatients. Although substantial resources have been invested in communication skills training for clinicians, little research has been done to test the actual effect of such training on patient satisfaction.
                To determine whether clinicians' exposure to a widely used communication skills training program increased patient satisfaction with ambulatory medical care visits.
                Randomized, controlled trial.
                A not-for-profit group-model health maintenance organization in Portland, Oregon.
                69 primary care physicians, surgeons, medical subspecialists, physician assistants, and nurse practitioners from the Permanente Medical Group of the Northwest.
                "Thriving in a Busy Practice: Physician-Patient Communication," a communication skills training program consisting of two 4-hour interactive workshops. Between workshops, participants audiotaped office visits and studied the audiotapes.
                Change in mean overall score on the Art of Medicine survey (HealthCare Research, Inc., Denver, Colorado), which measures patients' satisfaction with clinicians' communication behaviors, and global visit satisfaction.
                Although participating clinicians' self-reported ratings of their communication skills moderately improved, communication skills training did not improve patient satisfaction scores. The mean score on the Art of Medicine survey improved more in the control group (0.072 [95% CI, -0.010 to 0.154]) than in the intervention group (0.030 [CI, -0.060 to 0.1201).
                "Thriving in a Busy Practice: Physician-Patient Communication," a typical continuing medical education program geared toward developing clinicians' communication skills, is not effective in improving general patient satisfaction. To improve global visit satisfaction, communication skills training programs may need to be longer and more intensive, teach a broader range of skills, and provide ongoing performance feedback. To evaluate the effectiveness of two teaching interventions to increase residents' performance of smoking cessation counseling.
                Randomized controlled factorial trial.
                Eleven residency programs, in internal medicine (six), family medicine (three), and pediatrics (two). Programs were located in three university medical centers and four university-affiliated community hospitals.
                261 residents who saw ambulatory care patients at least one half-day per week, and 937 returning patients aged 17 to 75 years who reported having smoked five or more cigarettes in the preceding seven days. Of the 937, 843 were eligible for follow-up, and 659 (78%) were interviewed by phone at six months.
                Two interventions (tutorial and prompt) and four groups. The tutorial was a two-hour educational program in minimal-contact smoking cessation counseling for residents. The prompt was a chart-based reminder to assist physician counseling. One group of residents received the tutorial; one, the prompt; and one, both. A fourth group received no intervention.
                Six months after the intervention, physician self-reports showed that residents in the tutorial + prompt and tutorial-only groups had used more counseling techniques (1.5-1.9) than had prompt-only or control residents (0.9). Residents in all three intervention groups advised more patients to quit smoking (76-79%) than did control group residents (69%). The tutorial had more effect on counseling practices than did the prompt. Physician confidence, perceived preparedness, and perceived success followed similar patterns. Exit interviews with 937 patients corroborated physician self-reports of counseling practices. Six months later, self-reported and biochemically verified patient quitting rates for residents in the three intervention groups (self-reported: 5.3-8.2%; biochemically verified: 3.4-5.7%) were higher than those for residents in the control group (self-reported: 5.2%; biochemically verified: 1.7%), though the differences were not statistically significant.
                A simple and feasible educational intervention can increase residents' smoking cessation counseling. In the international Drug Education Project, a new educational program for peer groups of doctors was developed and tested to improve the treatment of asthma patients in The Netherlands, Norway, Sweden, and Slovakia. Individualized feedback on prescribing and the underlying decision strategy was presented and discussed within the group of doctors, in relation to existing guidelines. In a parallel, randomized controlled design the effect on competence and actual prescribing was tested. Results were related to national guidelines. In general, the program improved the doctors' attitudes as well as some of their prescribing behavior. The proportion of patients treated with inhaled corticosteroids significantly improved in The Netherlands (effect size 1.27), and the proportion of oral corticosteroid use for exacerbation treatment increased both in The Netherlands and in Norway (effect sizes 1.99 and 0.87, respectively). Overall attitudes of Dutch and Norwegian doctors also improved significantly (effect sizes 1.06 and 0.87, respectively), as did both knowledge (effect size 1.06) and attitudes (effect size 1.49) concerning exacerbation treatment in Slovakia. In Sweden no significant improvements could be measured. Conclusively, improvements in asthma treatment are possible with an educational program based on self-learning in small peer groups, although effects in one health care setting may not occur in another health care setting. Possible explaining factors may be different attitudes to and experiences with guidelines as well as with continuing medical education programs, and differences in the opportunities for change, including prevailing trends in prescribing behavior. This study evaluates the impact of the Integrated Management Of Childhood Illness (IMCI) training on quality of counseling provided to caregivers about administration of antimalarials to their children. Ten community health centers in southern Mali were randomized to either training or comparison arms of the study, and health providers' consultations with caregivers were observed. Out of a 10-point counseling scale (Cronbach's alpha=0.77), IMCI-trained providers completed an average of 1.47 (95% CI, -0.25, 3.2) more tasks than did providers who had not received IMCI training in a linear regression analysis that accounted for intra-provider correlations. Drug consultations done in both French and the local language, Bambara, had higher scores than those conducted exclusively in Bambara. The effect of providers receiving IMCI training was more pronounced in bilingual consultations, with an average increase of 2.49 (95% CI, 0.76, 4.22) in IMCI, bilingual consultations, and average increase of 0.87 (95% CI, -0.95, 2.69) in IMCI monolingual (Bambara) consultations as compared to non-IMCI-trained providers in monolingual consultations. IMCI training showed a non-significant trend overall in improving drug counseling provided to caregivers, with significant improvements in bilingual consultations. The IMCI program in Mali should consider strategies such as role-playing of counseling in Bambara or other local languages during training to improve patient-provider communication. Similar problems related to counseling by health workers in local languages are likely to be present throughout Africa, and warrant further study. To assess whether adding a training intervention for clinic staff to the usual DOTS strategy (the internationally recommended control strategy for tuberculosis (TB)) would affect the outcomes of TB treatment in primary care clinics with treatment success rates below 70%.
                A cluster randomized controlled trial was conducted from July 1996 to July 2000 in nurse-managed ambulatory primary care clinics in Cape Town, South Africa. Clinics with successful TB treatment completion rates of less than 70% and annual adult pulmonary TB loads of more than 40 patients per year were randomly assigned to either the intervention (n = 12) or control (n = 12) groups. All clinics completed follow-up. Treatment outcomes were measured in cohorts of adult, pulmonary TB patients before the intervention (n = 1200) and 9 months following the training (n = 1177). The intervention comprised an 18-hour experiential, participatory in-service training programme for clinic staff delivered by nurse facilitators and focusing on patient centredness, critical reflection on practice, and quality improvement. The main outcome measure was successful treatment, defined as patients who were cured and those who had completed tuberculosis treatment.
                The estimated effect of the intervention was an increase in successful treatment rates of 4.8% (95% confidence interval (CI): -5.5% to 15.2%) and in bacteriological cure rates of 10.4% (CI: -1.2% to 22%). A treatment effect of 10% was envisaged, based on the views of policy-makers on the minimum effect size for large-scale implementation.
                This is the first evidence from a randomized controlled trial on the effects of experiential, participatory training on TB outcomes in primary care facilities in a developing country. Such training did not appear to improve TB outcomes. However, the results were inconclusive and further studies are required. Prescribing practices impact greatly on drug use and expenditure. The situation in developing countries is often compounded by a limited health budget. Furthermore, because of role substitution in these countries, prescribers are often not formally trained in rational prescribing. The study described in this paper assesses the effect of a prescribing training intervention for primary health care nurses.
                A generic training-of-trainers course and a 4-day effective prescribing course were presented to 24 provincial trainers. These trainers then conducted effective prescribing workshops for 20 primary health care nurses per workshop. In 1997, 457 prescribers were trained by this method in South Africa's Northern Province. The study investigated the impact of the training on prescribing practices for two target conditions, in a control and a study group of 11 clinics each, 1 month after and 3 months after the intervention.
                Primary health care clinics in the Lowveld Region of the Northern Province of South Africa.
                Prescribing practices for the two conditions examined were significantly improved by the training. Changed behaviour was not only seen in prescribing for upper respiratory tract infections, used as an example condition, but also for diarrhoea and/or vomiting, a common condition in the region, which was not included in the training programme. These results show that prescribers not only retained the knowledge gained, but were also able to apply their new skills to other conditions (transfer effect). The change in the study group was maintained for 3 months after training, while there were no significant improvements in prescribing in the control group.
                The training intervention had a beneficial effect on prescribing practices. A ten hour brief therapy training program with format representative of postgraduate training workshops was delivered to practicing psychotherapists at three public clinics. Training procedures and content were specified and provided to program participants in a manual. Clinician volunteers (n = 22) were randomly assigned to Training (n = 12) and Control (n = 10) conditions. Pretraining assessments found no differences between Training and Control group therapists or their clients (n = 176). Relative to clients of Control therapists, Trained therapists' clients received more brief therapy, reported greater treatment satisfaction, had lower client-reported dropout rates, and obtained better therapist ratings of outcome. Possible causes of the training impact and its limitations were discussed. This study examines the effects of a home health intervention designed to standardize nursing care, strengthen nurses' support for patient self-management and yield better CHF patient outcomes. Participants were 371 Medicare CHF patients served by 205 nurses randomized to intervention and control groups in a large urban home healthcare agency (HHA). The intervention consisted of an evidence-based nursing protocol, patient self-care guide, and training to improve nurses'teaching and support skills. Outcome measures included home care,physician and emergency department (ED) use, hospital admission, condition-specific quality of life (QoL), satisfaction with home care services and survival at 90 days. The intervention was associated with a marginally significant reduction in the volume of skilled nursing visits (p = .074), and a reduction variation in the typical number of visits provided (p < .05), without a significant increase in physician or ED use or patient mortality. Hypothesized improvement in other outcomes did not occur. To assess the effectiveness of a multiple intervention aimed at reducing antibiotic prescription rates for symptoms of the respiratory tract in primary care.
                Randomised controlled trial.
                Twelve peer review groups including 100 general practitioners with their collaborating pharmacists in the region of Utrecht, Netherlands.
                The intervention consisted of group education meetings, with a consensus procedure on indication for and type of antibiotics and with training in communication skills; monitoring and feedback on prescribing behaviour; group education for assistants of general practitioners and pharmacists; and education material for patients. The control group did not receive any of these elements.
                Antibiotic prescription rates for acute symptoms of the respiratory tract and patients' satisfaction.
                89 general practitioners completed the study (89%). At baseline, prescription rates for antibiotics for respiratory tract symptoms did not differ between intervention and control group (27% v 29%, respectively). After nine months, the prescription rates in the intervention group fell to 23%, whereas the control group's rose to 37% (mean difference in change -12%, 95% confidence interval -18.9% to -4.0%). Multilevel analysis confirmed the results of the unadjusted analysis (intervention effect -10.7%, -20.3% to -1.0%). Patients' satisfaction was high and did not differ in the two groups at baseline or after the intervention.
                A multiple intervention reduced prescribing rates of antibiotics for respiratory tract symptoms while maintaining a high degree of satisfaction among patients. Further research should focus on the sustainability and cost effectiveness of this intervention. To establish the effect of an educational intervention for general practitioners on the health behaviours and wellbeing of elderly patients.
                Randomised controlled trial with 1 year follow up.
                Metropolitan general practices in Melbourne, Australia.
                42 general practitioners and 267 of their patients aged over 65 years.
                Educational and clinical practice audit programme for general practitioners on health promotion for elderly people.
                Patients' physical activity, functional status, self rated health, immunisation status, social contacts, psychological wellbeing, drug usage, and rate of influenza vaccination. Primary efficacy variables were changes in outcome measures over 1 year period.
                Patients in the intervention group had increased (a) walking by an average of 88 minutes per fortnight, (b) frequency of pleasurable activities, and (c) self rated health compared with the control group. No change was seen in drug usage, rate of influenza vaccination, functional status, or psychological wellbeing as a result of the intervention. Extrapolations of the known effect of these changes in behaviour suggest mortality could be reduced by 22% if activity was sustained for 5 years.
                Education of the general practitioners had a positive effect on health outcomes of their elderly patients. General practitioners may have considerable public health impact in promotion of health for elderly patients. Stresses imposed by parenthood can provoke or intensify relationship problems between parents. These problems, which are often associated with postnatal depression, can have serious consequences for family well-being but are often not revealed to primary health care personnel.
                To evaluate a means of extending the primary health care team's ability to identify and respond to relationship problems of mothers and their partners in the postnatal period.
                Cluster randomised controlled trial.
                Specially trained health visitors in nine 'intervention' clinics--each matched with a 'control' clinic' in an outer London borough.
                Health visitors in intervention clinics invited mothers attending for the six-to-eight-week developmental check to complete a screening scale for relationship problems, and offered help (supportive listening, advice, or referral) if needed. When visiting the clinic for the 12-week immunizations, mothers from all clinics were asked to complete a follow-up self-report questionnaire. After the completion of the trial, 25 women who had attended the intervention clinics and had been offered support with a relationship problem were interviewed to elicit their views on the acceptability and value of the intervention. All 25 of the health visitors engaged in the intervention were asked to complete a questionnaire on their experience.
                Screening led to striking differences between intervention and control clinics in the percentage of women identified at the six-to-eight-week check as potentially in need of help with a relationship problem (21% versus 5%, P = 0.007) and in the percentage actually offered help (18% versus 3%, P = 0.014). About one-half of the mothers so identified were also identified as having postnatal depression. At the 12-week visit for immunizations, the intervention group was twice as likely (P = 0.006) as the control group to report having discussed relationship problems with the health visitor and 75% more likely (P = 0.046) to report having received help with a problem.
                The intervention offers a useful way of extending the primary health care team's ability to respond to problems that often have serious consequences for family well-being. To assess the effectiveness of a multifaceted intervention to improve the management of glucocorticoid-induced osteoporosis (GIOP).
                Of 21 rheumatologists, 11 were randomly assigned to a 3-part intervention consisting of a lecture and discussion regarding optimal management of GIOP, a confidential doctor-specific audit regarding management of GIOP, and a reminder mailing including concise pharmacologic recommendations. The remaining 10 rheumatologists received no special education. Patients with rheumatoid arthritis (RA) taking oral glucocorticoids seen in the 2 months after the intervention were followed for 6 months. Medical records were assessed to determine the proportion undergoing bone mineral density testing or receiving pharmacologic interventions for GIOP during the 6 months before and 6 months after the intervention.
                There were 373 patients with RA taking oral glucocorticoids whose records were assessed. Patients in both arms of the trial were similar with respect to age, sex, menopausal status, glucocorticoid dosage and duration, duration of RA, disease-modifying antirheumatic drug use, and the proportion with comorbid conditions. At baseline, there was no significant difference between the patients with respect to osteoporosis medication use (intervention 32% versus control 34%) or bone densitometry use (intervention 9% versus control 5%). After the intervention and a 6-month followup period, there were no differences in treatment (intervention 33% versus control 38%) or bone densitometry use (intervention 8% versus control 8%). Adjusting for patient and physician characteristics did not significantly change these results.
                A multifaceted intervention for GIOP, including doctor education, practice audit, and treatment suggestions, had no significant benefit on testing or treatment by rheumatologists over a 6-month followup period. Other intervention approaches need to be tested. Numbers of diagnostic tests ordered by primary care physicians are growing and many of these tests seem to be unnecessary according to established, evidence-based guidelines. An innovative strategy that focused on clinical problems and associated tests was developed.
                To determine the effects of a multifaceted strategy aimed at improving the performance of primary care physicians' test ordering.
                Multicenter, randomized controlled trial with a balanced, incomplete block design and randomization at group level. Thirteen groups of primary care physicians underwent the strategy for 3 clinical problems (arm A; cardiovascular topics, upper and lower abdominal complaints), while 13 other groups underwent the strategy for 3 other clinical problems (arm B; chronic obstructive pulmonary disease and asthma, general complaints, degenerative joint complaints). Each arm acted as a control for the other.
                Primary care physician groups in 5 regions in the Netherlands with diagnostic centers recruited from May to September 1998.
                Twenty-six primary care physician groups, including 174 primary care physicians.
                During the 6 months of intervention, physicians discussed 3 consecutive, personal feedback reports in 3 small group meetings, related them to 3 evidence-based clinical guidelines, and made plans for change.
                According to existing national, evidence-based guidelines, a decrease in the total numbers of tests ordered per clinical problem, and of some defined inappropriate tests, is considered a quality improvement.
                For clinical problems allocated to arm A, the mean total number of requested tests per 6 months per physician was reduced from baseline to follow-up by 12% among physicians in the arm A intervention, but was unchanged in the arm B control, with a mean reduction of 67 more tests per physician per 6 months in arm A than in arm B (P =.01). For clinical problems allocated to arm B, the mean total number of requested tests per 6 months per physician was reduced from baseline to follow-up by 8% among physicians in the arm B intervention, and by 3% in the arm A control, with a mean reduction of 28 more tests per physician per 6 months in arm B than in arm A (P =.22). Physicians in arm A had a significant reduction in mean total number of inappropriate tests ordered for problems allocated to arm A, whereas the reduction in inappropriate test ordered physicians in arm B for problems allocated to arm B was not statistically significant.
                In this study, a practice-based, multifaceted strategy using guidelines, feedback, and social interaction resulted in modest improvements in test ordering by primary care physicians. To assess the effectiveness of teaching general practitioners skills in brief cognitive behaviour therapy.
                Parallel group, cluster randomised, controlled trial of an educational package on cognitive behaviour therapy.
                General practices in north London.
                84 general practitioner principals and 272 patients attending their practices who scored above the threshold for psychological distress on the hospital anxiety and depression scale. Intervention: A training package of four half days on brief cognitive behaviour therapy. Main outcome measures: Scores on the depression attitude questionnaire (general practitioners) and the Beck depression inventory (patients).
                Doctors' knowledge of depression and attitudes towards its treatment showed no major difference between intervention and control groups after 6 months. The training had no discernible impact on patients' outcomes.
                General practitioners may require more training and support than a basic educational package on brief cognitive behaviour therapy to acquire skills to help patients with depression. To examine the benefits of a guideline-based educational program to improve management of unstable angina pectoris (UAP) in hospital patients.
                Randomised controlled trial.
                37 public hospitals across New South Wales.
                1,872 patients admitted with a diagnosis of UAP between 1 February and 30 June 1996 (baseline survey), and 1,368 patients with the same diagnosis admitted between 1 July and 31 December 1998 (follow-up survey).
                Educational sessions run by local opinion leaders, presenting guidelines on management of UAP from the National Health and Medical Research Council and feedback on local practice using data from the baseline survey. Sessions were run between March and June 1998.
                Use of evidence-based practice, identified by review of medical records.
                Use of beta-blockers increased in intervention and control hospitals, although the increase was significant only in the former. Use of calcium-channel blockers decreased significantly in both intervention and control hospitals. However, the change in drug use between baseline and follow-up did not differ significantly between intervention and control hospitals.
                Despite some appropriate changes in drug use for UAP management between 1996 and 1998, there was no evidence that a guideline-based educational program was of benefit in changing management. This reaffirms the difficulty of changing doctors' behaviour through practice guidelines. Alternative methods of encouraging evidence-based practice should be considered. Although patients with cancer are often accompanied by a relative during medical interviews, to the authors' knowledge little is known regarding the efficacy of communication skills training programs on physicians' communication skills in this context. The objective of the current study was to assess the efficacy of 6 consolidation workshops, 3 hours in length, that were conducted after a 2.5-day basic training program.
                After attending the basic training program, physicians were assigned randomly to consolidation workshops or to a waiting list. Training efficacy was assessed through simulated and actual interviews that were recorded on an audio tape at baseline, after consolidation workshops for the consolidation-workshops group, and 5 months after the end of basic training for the waiting-list group. Communication skills were assessed according to the Cancer Research Campaign Workshop Evaluation Manual. Patients' and relatives' perceptions of and satisfaction with physicians' communication performance were assessed using a 15-item questionnaire.
                Sixty-two physicians completed the training program. Compared with physicians who participated to the basic training program, when addressing the patient, physicians who were randomized to the consolidation workshops used more open, open directive, and screening questions (P = 0.011 in simulated patient interviews and P = 0.005 in actual patient interviews) and elicited and clarified psychologic concerns more often (P = 0.006 in simulated patient interviews and P < 0.001 in actual patient interviews). When they addressed the relative, physicians who were randomized to the consolidation workshops gave less premature information (P = 0.032 in simulated patient interviews and P < 0.001 in actual patient interviews). When they addressed the patient and the relative simultaneously, physicians who were randomized to the consolidation workshops used more empathy, educated guesses, alerting to reality, confronting, negotiating, and summarizing (P = 0.003 in simulated patient interviews and P = 0.024 in actual patient interviews). Patients, but not relatives, who interacted with physicians in the consolidation-workshops group were more satisfied globally with the interviews (P = 0.022).
                Six 3-hour consolidation workshops resulted in improved communication skills addressed to patients and to relatives. The current results showed that the transfer of skills addressing relatives' concerns remained limited and that consolidation workshops should focus even more systematically on the practice of three-person interviews. Sixty-six physicians were randomized to three groups to conduct a 1-month campaign to help their patients stop smoking. The workshop group received free patient education materials and a 6-hour training workshop. The materials group received free patient education materials, and the no-assistance group received nothing. A telephone interview was completed with 89% of the 6767 eligible adult patients seen during the month of the campaign. The brief training program and patient education materials marginally increased the smoking intervention activities of volunteer physicians in private practice. Both workshop and materials physicians asked 54% of their smoking patients to stop; no-assistance physicians asked 40%. One year later, 36% of patients who had not even been asked by their doctors if they smoked reported that they had tried to stop smoking. If the physician had asked the patient if he or she smoked, the probability of a quit attempt was 47%. Patients who had been asked if they smoked were more likely to claim to have stopped (13%) than patients who had not been asked (9%). However, the proportion of patients claiming continued abstinence (range, 12% to 14%) was not related to the group of the physician. To investigate whether the number of frequent attenders (FA) contacts with the out-of-hours service can be reduced by deploying a combination of intervention strategies.
                A stratified cluster randomized controlled trial, each cluster containing a general practice and all its listed patients.
                The out-of-hours service in the county of Northern Jutland (490,000 inhabitants), Denmark.
                The following intervention strategies were deployed: predisposition, individual instruction, economic incitement, continuing medical education meetings, feedback/reminder, and patient-mediated intervention.
                An intervention group of 3500 patients and a control group of 4635 patients.
                Absolute and relative fall in the number of contacts with the out-of-hours service per patient after 6 and 12 months.
                Analysed by group, intervention patients saw a more pronounced decline in the number of contacts than controls, except for two outcomes. However, this difference was only significant after 12 months. For women aged 17-66 years with 5-9 contacts during the previous 12 months, the decrease was significantly more pronounced in the intervention group for all outcomes (p=0.004-0.042). However, for the rest of the subgroups the effect varied more, and in several cases it was more distinct in the control group.
                The data collected point towards an effect of intervention on the use of out-of-hours services even if the responses obtained were not uniform and unequivocal. However, one has to consider the problems of multiple comparisons and in conclusion no convincing effect of the intervention was found. To evaluate the feasibility and implementation needs of a cholesterol guideline by assessing the effectiveness of simple dissemination as well as extensive implementation of this guideline on actual performance of general practitioners (GPs).
                Randomized controlled trial.
                Thirty-two Dutch GPs in 20 general practices, 3950 patient records.
                Guideline dissemination to all 32 GPs, and a 5-month programme for improvement in the intervention group. This programme was developed after barriers to working according to the guideline had been investigated, and consisted of group education, desktop supportive materials, feedback on performance, and face-to-face instruction on location.
                The outcome parameters were defined as quality of selective case finding and quality of diagnostic procedures, and were measured by chart audit.
                The quality of selective case finding, especially the targeting of cholesterol testing to those with positive cardiovascular risk profiles, did not improve following intervention. Performance of the procedure necessary to diagnose hypercholesterolaemia even deteriorated. The quantity of cholesterol testing increased in both groups, but this was probably explained by the increased availability of desktop cholesterol analysers.
                Neither simple dissemination nor an intensive programme for improvement had measurable impact on actual performance on working according to the cholesterol guideline. Both the validity and the opinion about feasibility of the guideline in daily practice deserve more attention during guideline development. To determine the effectiveness of an intervention for pharmacy workers in improving their recognition and management of sexually transmitted disease (STD) syndromes.
                We randomly selected 14 districts (total population nearly 4 million) from the 24 districts of low socioeconomic status in Lima, Peru. We randomly assigned paired districts to receive training and support for management and prevention of STDs or a control intervention about management of diarrhoea. The STD intervention included interactive luncheon seminars on recognition and management of four STD syndromes (urethral discharge, vaginal discharge, genital ulcers, and pelvic inflammatory disease) and STD/HIV prevention counselling; monthly pharmacy visits by "prevention salespersons" who distributed materials that included "STD/HIV prevention packets" containing information, condoms, and cards given to patients for referral of their sex partners; and workshops for physicians on managing patients with STD syndromes referred from pharmacies. Standardized simulated patients visited pharmacies in intervention and control districts at one, three, and six months after training to assess outcomes.
                Standardized simulated patients reported significantly better recognition and management (appropriate antimicrobial regimens provided for discharge syndromes and referral to specially trained physicians for genital ulcers or pelvic inflammatory disease) by pharmacy workers of all four STD syndromes. They also reported significantly more frequent recommendations for use of condoms and treatment of partners at pharmacies in intervention districts than in control districts (by "intention-to-train" analyses, P<0.05 for 47/48 primary outcome comparisons).
                Training was feasible and effectively improved pharmacy workers' practices. In this study, we evaluated an inservice training program for public health nurses. The training program concerned arthritis screening and management of the disease in elderly subjects. Twenty-nine nurses were assigned randomly to experimental (training) or control conditions. Evaluation data from 158 interviews with patients showed that screening for arthritis was done twice as frequently by nurses in the experimental group, compared with that done by nurses who were not in the experimental group (P less than 0.01). Recommended management of arthritis was not correspondingly improved. Stronger inservice programs are discussed in light of the need to anticipate seasonal conflicts between arthritis care and preventive care for the elderly, to change habitual practice patterns, and to increase access to arthritis health professionals. Despite high prevalence, emotional distress among primary care patients often goes unrecognized during routine medical encounters.
                To explore the effect of communication-skills training on the process and outcome of care associated with patients' emotional distress.
                A randomized, controlled field trial was conducted with 69 primary care physicians and 648 of their patients. Physicians were randomized to a no-training control group or one of two communication-skills training courses designed to help physicians address patients' emotional distress. The two training courses addressed communication through problem-defining skills or emotion-handling skills. All office visits of study physicians were audiotaped until five emotionally distressed and five nondistressed patients were enrolled based on patient response to the General Health Questionnaire. Physicians were also audiotaped interviewing a simulated patient to evaluate clinical proficiency. Telephone monitoring of distressed patients for utilization of medical services and General Health Questionnaire scores was conducted 2 weeks, 3 months, and 6 months after their audiotaped office visits.
                Audiotape analysis of actual and simulated patients showed that trained physicians used significantly more problem-defining and emotion-handling skills than did untrained physicians, without increasing the length of the visit. Trained physicians also reported more psychosocial problems, engaged in more strategies for managing emotional problems with actual patients, and scored higher in clinical proficiency with simulated patients. Patients of trained physicians reported reduction in emotional distress for as long as 6 months.
                Important changes in physicians' communication skills were evident after an 8-hour program. The training improved the process and outcome of care without lengthening the visits. We wanted to evaluate the added value of small peer-group quality improvement meetings compared with simple feedback as a strategy to improve test-ordering behavior. Numbers of tests ordered by primary care physicians are increasing, and many of these tests seem to be unnecessary according to established, evidence-based guidelines.
                We enrolled 194 primary care physicians from 27 local primary care practice groups in 5 health care regions (5 diagnostic centers). The study was a cluster randomized trial with randomization at the local physician group level. We evaluated an innovative, multifaceted strategy, combining written comparative feedback, group education on national guidelines, and social influence by peers in quality improvement sessions in small groups. The strategy was aimed at 3 specific clinical topics: cardiovascular issues, upper abdominal complaints, and lower abdominal complaints. The mean number of tests per physician per 6 months at baseline and the physicians' region were used as independent variables, and the mean number of tests per physician per 6 months was the dependent variable.
                The new strategy was executed in 13 primary care groups, whereas 14 groups received feedback only. For all 3 clinical topics, the decrease in mean total number of tests ordered by physicians in the intervention arm was far more substantial (on average 51 fewer tests per physician per half-year) than the decrease in mean number of tests ordered by physicians in the feedback arm (P = .005). Five tests considered to be inappropriate for the clinical problem of upper abdominal complaints decreased in the intervention arm, with physicians in the feedback arm ordering 13 more tests per 6 months (P = .002). Interdoctor variation in test ordering decreased more in the intervention arm.
                Compared with only disseminating comparative feedback reports to primary care physicians, the new strategy of involving peer interaction and social influence improved the physicians' test-ordering behavior. To be effective, feedback needs to be integrated in an interactive, educational environment. Previous evaluations of continuing medical education (CME) have yielded conflicting results regarding its effects on physician knowledge, performance, and subsequent patient outcomes. Poor adherence by mothers to prescribed pediatric regimens is a separate, but well-documented, problem. In the present study we assessed the ability of CME to: (1) increase the knowledge of pediatricians about compliance-enhancing strategies; (2) increase the performance of these practices by pediatricians; and (3) improve mothers' compliance with antibiotic regimens for their children's otitis media. Ninety pediatricians were randomly assigned to either a control group or one of two CME interventions: tutorial plus printed materials or mailed printed materials only. Following the interventions, data on compliance and on reported behaviors of pediatricians were gathered from a random sample of mothers (N = 771) whose children were being treated for otitis media. Findings indicated that CME increased physician knowledge and compliance-enhancing practices and resulted in improvement in mothers' adherence to therapy. A sigmoidoscopy skills preceptorship was developed for physicians to increase the rate of sigmoidoscopy by physicians in a health maintenance organization. The preceptorship was designed as a randomized, controlled study of continuing medical education. Baseline sigmoidoscopy rates of participating physicians were similar to those of nonparticipants, as were selected demographic and professional characteristics. Physicians randomized to receive sigmoidoscopy training significantly increased their rate of sigmoidoscopy when compared with controls. The proportion of barium enemas accompanied by sigmoidoscopy likewise increased. All physicians who participated improved when compared with nonparticipants. The sigmoidoscopy skills preceptorship appears to be a worthwhile endeavor in continuing medical education. To study the efficacy of case method learning, for general practitioners, on patients' lipid concentrations in the secondary prevention of coronary artery disease.
                Prospective controlled trial.
                Södertälje, Stockholm County, Sweden.
                255 consecutive patients with coronary artery disease.
                Guidelines were mailed to all general practitioners (n=54) and presented at a common lecture. General practitioners who were randomised to the intervention group participated in recurrent case method learning dialogues at their primary healthcare centres during a two year period. A locally well known cardiologist served as a facilitator.
                Concentration of low density lipoprotein cholesterol at baseline and after two years. Analysis according to intention to treat (intervention and control groups (n=88)) was based on group affiliation at baseline.
                Low density lipoprotein cholesterol was reduced by 0.5 mmol/l (95% confidence interval 0.2 to 0.8 mmol/l) (9.3% (2.9% to 15.8%)) from baseline in patients in the intervention group and by 0.5 (0.1 to 0.9) mmol/l compared with controls (P<0.05). No change occurred in the control group (0.0 (-0.2 to 0.2) mmol/l). Low density lipoprotein cholesterol decreased by 0.6 (0.4 to 0.8) mmol/l in a group of patients who received specialist care.
                Case method learning resulted in a lowering of low density lipoprotein cholesterol in the primary care patients with coronary artery disease comparable to that achieved at a specialist clinic. Conventional presentation of practice guidelines had no effect. We examined the effectiveness of a training program for physician-delivered nutrition counseling, alone and in combination with a structured office practice environment for nutrition management, on physicians' counseling practices. Forty-five primary care internists and 1,278 of their patients in the top quarter of the cholesterol distribution at a central Massachusetts health maintenance organization (the Fallon Clinic) were enrolled into a randomized controlled trial. Physicians were randomized by site into three conditions: (1) usual care, (2) physician nutrition counseling training, and (3) physician nutrition counseling training plus a structured office practice environment for nutrition management (prompts and the provision of lipid results and counseling algorithms). A randomly selected 325 patients were given a 10-item patient exit interview (PEI) assessing whether the physician provided advice; assessed past changes, barriers, and resources; negotiated specific plans and goals; provided patient materials; referred the patient to a dietitian; and developed plans for follow-up. Condition 3 physicians demonstrated significantly greater implementation of the nutrition counseling sequence than did physicians in either of the other two conditions (P < .0001). Referrals to nutrition services were markedly reduced in condition 2, despite PEI scores no different than those in condition 1. Higher PEI scores for patients seen by physicians in condition 3 were stable for as long as two years beyond training. Primary care internists, when provided with both training in counseling techniques and a supportive office environment, will carry out patient counseling appropriately. Training alone, however, is not sufficient and may be counterproductive. Medical Subject Headings (MeSH): hypercholesterolemia, diet therapy, coronary disease, health behavior, primary health care, medical education, managed care programs.
Educational meetings alone or combined with other interventions, can improve professional practice and healthcare outcomes for the patients. The effect is most likely to be small and similar to other types of continuing medical education, such as audit and feedback, and educational outreach visits. Strategies to increase attendance at educational meetings, using mixed interactive and didactic formats, and focusing on outcomes that are likely to be perceived as serious may increase the effectiveness of educational meetings. Educational meetings alone are not likely to be effective for changing complex behaviours.