***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: AIMS There are limited contemporary data on the presentation , management , and outcomes of acute coronary syndrome ( ACS ) admissions in India . We aim ed to develop a prospect i ve registry to address treatment and health systems gaps in the management of ACSs in Kerala , India . METHODS AND RESULTS We prospect ively collected data on 25 748 consecutive ACS admissions from 2007 to 2009 in 125 hospitals in Kerala . We evaluated data on presentation , management , and in-hospital mortality and major adverse cardiovascular events ( MACE ) . We created r and om-effects multivariate regression models to evaluate predictors of outcomes while accounting for confounders . Mean ( SD ) age at presentation was 60 ( 12 ) years and did not differ among ACS types [ ST-segment myocardial infa rct ion ( STEMI ) = 37 % ; non-STEMI = 31 % ; unstable angina = 32 % ] . In-hospital anti-platelet use was high ( > 90 % ) . Thrombolytics were used in 41 % of STEMI , 19 % of non-STEMI , and 11 % of unstable angina admissions .  Percutaneous coronary intervention rates were marginally higher in STEMI admissions . Discharge medication rates were variable and generally suboptimal ( < 80 % ) . In-hospital mortality and MACE rates were highest for STEMI ( 8.2 and 10.3 % , respectively ) . After adjustment , STEMI diagnosis ( vs. unstable angina ) [ odds ratio ( OR ) ( 95 % confidence interval = 4.06 ( 2.36 , 7.00 ) ] , symptom-to-door time > 6 h [ OR = 2.29 ( 1.73 , 3.02 ) ] , and inappropriate use of thrombolysis [ OR = 1.33 ( 0.92 , 1.91 ) ] were associated with higher risk of in-hospital mortality and door-to-needle time < 30 min [ OR = 0.44 ( 0.27 , 0.72 ) ] was associated with lower mortality . Similar trends were seen for risk of MACE . CONCLUSION These data represent the largest ACS registry in India and demonstrate opportunities for improving ACS care Background —Organizational and wider health system factors influence the implementation and success of interventions . Clinical Pathways in Acute Coronary Syndromes 2 is a cluster r and omized trial of a clinical pathway – based intervention to improve acute coronary syndrome care in hospitals in China . We performed a qualitative evaluation to examine the system-level barriers to implementing clinical pathways in the dynamic healthcare environment of China . Methods and Results —A qualitative descriptive analysis of 40 in-depth interviews with health professionals conducted in a sample of 10 hospitals purposively selected to explore barriers to implementation of the intervention . Qualitative data were analyzed using the Framework method . In-depth interviews identified 5 key system-level barriers to effective implementation : ( 1 ) leadership support for implementing quality improvement , ( 2 ) variation in the capacity of clinical services and quality improvement re sources , ( 3 ) fears of patient disputes and litigation , ( 4 ) healthcare funding constraints and high out-of-pocket expenses , and ( 5 ) patient-related factors . Conclusions —System-level barriers affect the ability of acute coronary syndrome clinical pathways to change practice . Addressing these barriers in the context of current and planned national health system reform will be critical for future improvements in the management of acute coronary syndromes , and potentially other hospitalized conditions , in China . Clinical Trial Registration —URL : http://www.anzctr.org.au/default.aspx . Register . Unique identifier : ACTRN12609000491268 BACKGROUND Acute coronary syndromes ( ACSs ) are a major cause of morbidity and mortality , yet effective ACS treatments are frequently underused in clinical practice . R and omized trials including the CPACS-2 study suggest that quality improvement initiatives can increase the use of effective treatments , but whether such programs can impact hard clinical outcomes has never been demonstrated in a well-powered r and omized controlled trial . DESIGN The CPACS-3 study is a stepped-wedge cluster-r and omized trial conducted in 104 remote level 2 hospitals without PCI facilities in China . All hospitalized ACS patients will be recruited consecutively over a 30-month period to an anticipated total study population of more than 25,000 patients . After a 6-month baseline period , hospitals will be r and omized to 1 of 4 groups , and a 6-component quality improvement intervention will be implemented sequentially in each group every 6months . These components include the following : establishment of a quality improvement team , implementation of a clinical pathway , training of physicians and nurses , hospital performance audit and feedback , online technical support , and patient education . All patients will be followed up for 6months postdischarge . The primary outcome will be the incidence of in-hospital major adverse cardiovascular events comprising all-cause mortality , myocardial infa rct ion or reinfa rct ion , and nonfatal stroke . CONCLUSIONS The CPACS-3 study will be the first large r and omized trial with sufficient power to assess the effects of a multifaceted quality of care improvement initiative on hard clinical outcomes , in patients with ACS Background —Substantial evidence - practice gaps exist in the management of acute coronary syndromes ( ACS ) in China . Clinical pathways are tools for improving ACS quality of care but have not been rigorously evaluated . Methods and Results —Between October 2007 and August 2010 , a quality improvement program was conducted in 75 hospitals throughout China with mixed methods evaluation in a cluster r and omized , controlled trial . Eligible hospitals were level 2 or level 3 centers routinely admitting > 100 patients with ACS per year . Hospitals were assigned immediate implementation of the American Heart Association/American College of Cardiology guideline based clinical pathways or commencement of the intervention 12 months later . Outcomes were several key performance indicators reflecting the management of ACS . The key performance indicators were measured 12 months after commencement in intervention hospitals and compared with baseline data in control hospitals , using data collected from 50 consecutive patients in each hospital . Pathway implementation was associated with an increased proportion of patients discharged on appropriate medical therapy , with nonsignificant improvements or absence of effects on other key performance indicators . Conclusions —Among hospitals in China , the use of a clinical pathway for the treatment of ACS compared with usual care improved secondary prevention treatments , but effectiveness was otherwise limited . An accompanying process evaluation identified several health system barriers to more successful implementation . Clinical Trial Registration —URL : http://www.anzctr.org.au/default.aspx . Unique identifier : ACTRN12609000491268 CONTEXT Studies have found that patients with acute coronary syndromes ( ACS ) often do not receive evidence -based therapies in community practice . This is particularly true in low- and middle-income countries . OBJECTIVE To evaluate whether a multifaceted quality improvement ( QI ) intervention can improve the use of evidence -based therapies and reduce the incidence of major cardiovascular events among patients with ACS in a middle-income country . DESIGN , SETTING , AND PARTICIPANTS The BRIDGE-ACS ( Brazilian Intervention to Increase Evidence Usage in Acute Coronary Syndromes ) trial , a cluster-r and omized ( concealed allocation ) trial conducted among 34 clusters ( public hospitals ) in Brazil and enrolling a total of 1150 patients with ACS from March 15 , 2011 , through November 2 , 2011 , with follow-up through January 27 , 2012 .  INTERVENTION Multifaceted QI intervention including educational material s for clinicians , reminders , algorithms , and case manager training , vs routine practice ( control ) . MAIN OUTCOME MEASURES Primary end point was the percentage of eligible patients who received all evidence -based therapies ( aspirin , clopidogrel , anticoagulants , and statins )  during the first 24 hours in patients without contraindications . RESULTS Mean age of the patients enrolled was 62 ( SD , 13 ) years ; 68.6 % were men , and 40 % presented with ST-segment elevation myocardial infa rct ion , 35.6 % with non-ST-segment elevation myocardial infa rct ion , and 23.6 % with unstable angina . The r and omized clusters included 79.5 % teaching hospitals , all from major urban areas and 41.2 % with 24-hour percutaneous coronary intervention capabilities . Among eligible patients ( 923/1150 [ 80.3 % ] ) , 67.9 % in the intervention vs 49.5 % in the control group received all eligible acute therapies ( population average odds ratio [ OR(PA ) ] , 2.64 [ 95 % CI , 1.28 - 5.45 ] ) . Similarly , among eligible patients ( 801/1150 [ 69.7 % ] ) , those in the intervention group were more likely to receive all eligible acute and discharge medications ( 50.9 % vs 31.9 % ; OR(PA ) , , 2.49 [ 95 % CI , 1.08 - 5.74 ] ) . Overall composite adherence scores were higher in the intervention clusters ( 89 % vs 81.4 % ; mean difference , 8.6 % [ 95 % CI , 2.2%-15.0 % ] ) . In-hospital cardiovascular event rates were 5.5 % in the intervention group vs 7.0 % in the control group ( OR(PA ) , 0.72 [ 95 % CI , 0.36 - 1.43 ] ) ; 30-day all-cause mortality was 7.0 % vs 8.4 % ( ORPA , 0.79 [ 95 % CI , 0.46 - 1.34 ] ) . CONCLUSION Among patients with ACS treated in Brazil , a multifaceted educational intervention result ed in significant improvement in the use of evidence -based therapies . TRIAL REGISTRATION clinical trials.gov Identifier : NCT00958958 & NA ; Ischemic heart disease is the leading cause of death in India , and there are likely more myocardial infa rct ions in India than in any other country in the world . We have previously reported heterogeneous care for patients with myocardial infa rct ion in Kerala , a state in southern India , including both gaps in optimal care and inappropriate care . Based on that prior work , limitations from previous nonr and omized quality improvement studies and promising gains in process of care measures demonstrated from previous r and omized trials , we and the Cardiological Society of India — Kerala chapter sought to develop , implement , and evaluate a quality improvement intervention to improve process of care measures and clinical outcomes for these patients . In this article , we report the rationale and study design for the ACS QUIK cluster‐r and omized stepped‐wedge clinical trial ( NCT02256657 ) in which we aim to enroll 15,750 participants with acute coronary syndromes across 63 hospitals . To date , most participants are men ( 76 % ) and have ST‐segment elevation myocardial infa rct ion ( 63 % ) . The primary outcome is 30‐day major adverse cardiovascular events defined as death , recurrent infa rct ion , stroke , or major bleeding . Our secondary outcomes include health‐related quality of life and individual‐ and household‐level costs . We also describe the principal features and limitations of the stepped‐wedge study design , which may be important for other investigators or sponsors considering cluster‐r and omized stepped‐wedge trials Background The burden of cardiovascular diseases ( CVDs ) remains unclear in many regions of the world . Objectives The GBD ( Global Burden of Disease ) 2015 study integrated data on disease incidence , prevalence , and mortality to produce consistent , up-to- date estimates for cardiovascular burden . Methods CVD mortality was estimated from vital registration and verbal autopsy data . CVD prevalence was estimated using modeling software and data from health surveys , prospect i ve cohorts , health system administrative data , and registries . Years lived with disability ( YLD ) were estimated by multiplying prevalence by disability weights . Years of life lost ( YLL ) were estimated by multiplying age-specific CVD deaths by a reference life expectancy . A sociodemographic index ( SDI ) was created for each location based on income per capita , educational attainment , and fertility . Results In 2015 , there were an estimated 422.7 million cases of CVD ( 95 % uncertainty interval : 415.53 to 427.87 million cases ) and 17.92 million CVD deaths ( 95 % uncertainty interval : 17.59 to 18.28 million CVD deaths ) . Declines in the age-st and ardized CVD death rate occurred between 1990 and 2015 in all high-income and some middle-income countries . Ischemic heart disease was the leading cause of CVD health lost globally , as well as in each world region , followed by stroke . As SDI increased beyond 0.25 , the highest CVD mortality shifted from women to men . CVD mortality decreased sharply for both sexes in countries with an SDI > 0.75 . Conclusions CVDs remain a major cause of health loss for all regions of the world . Sociodemographic change over the past 25 years has been associated with dramatic declines in CVD in regions with very high SDI , 
    Output:
    
Barriers that influenced the implementation or acceptability of the toolkit intervention for physicians included time and staff constraints , Internet access , patient volume , and inadequate underst and ing of the quality improvement toolkit intervention .