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Many studies investigated the barriers to the implementation of CPG in healthcare and the effective strategies for translating research into practice, however it is recognized that identification of local barriers to change is pivotal to changing practitioners' behavior towards adoption of guidelines [ 11].
Criticisms of the applicability of communication guidelines have been countered by suggestions for changing practitioners' attitudes or even the organisation of health care, but have rarely resulted in revisions of communication guidelines [ 41- 44].
In Germany, by contrast, patients are permitted to freely choose their general practitioner, but are prevented from changing practitioners for at least three months after the first visit, unless there is a special reason for doing so [ 36].
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Wensing et al. [ 9] report that multifaceted interventions are more effective than single interventions in changing practitioner behaviour.
14 Research evidence alters eventual clinical outcome through the intermediate steps of first changing clinician knowledge, then improving attitudes and lastly, changing practitioner behaviour.
The most comprehensive systematic reviews in the field [ 1, 2] established the benefits of CDSSs in changing practitioner performance and to a lesser extent, patient outcomes.
Given the methodological problems associated with cluster RCTs [ 74- 76], it is surprising that they dominate the scientific literature on changing practitioner behaviour with printed guidelines.
Is EBM a waste of time if we lack adequate understanding of practical methods of changing practitioner and patient actions [ 27]?
We cannot yet, from the results of the evaluation of this first year of activity, draw any conclusions about the approach's efficacy in changing practitioner and decision-maker behavior.
The CAMR practice-based mixed-methods research study currently underway in a larger sample of CAM Practitioners (N = 99) will evaluate the effectiveness of this intervention protocol in changing CAM practitioners' clinical practice behavior.
At the same time, medical care is also changing: General Practitioners (GPs), who are responsible for medical care in the residential homes in the Netherlands, have for instance halved the number of house visits since 1987 [ 20].
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