***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: BACKGROUND Increasing clinician awareness of racial disparities and improving communication may enhance diabetes care among black patients . OBJECTIVE To evaluate the effect of cultural competency training and performance feedback for primary care clinicians on diabetes care for black patients . DESIGN Cluster r and omized , controlled trial conducted between June 2007 and May 2008 . ( Clinical Trials.gov registration number : NCT00436176 ) SETTING : 8 ambulatory health centers in eastern Massachusetts . PARTICIPANTS 124 primary care clinicians caring for 2699 ( 36 % ) black and 4858 ( 64 % ) white diabetic patients . INTERVENTION INTERVENTION clinicians received cultural competency training and monthly race-stratified performance reports that highlighted racial differences in control of hemoglobin A(1c ) ( HbA(1c ) ) and low-density lipoprotein ( LDL ) cholesterol levels and blood pressure . MEASUREMENTS Clinician awareness of racial differences in diabetes care and rates of achieving clinical control targets among black patients at 12 months . RESULTS White and black patients differed significantly in baseline rates of achieving an HbA(1c ) level less than 7 % ( 46 % vs. 40 % ) , an LDL cholesterol level less than 2.59 mmol/L ( < 100 mg/dL ) ( 55 % vs. 43 % ) , and blood pressure less than 130/80 mm Hg ( 32 % vs. 24 % ) ( all P < 0.050 ) . At study completion , intervention clinicians were significantly more likely than control clinicians to acknowledge the presence of racial disparities in the 8 health centers as a whole ( 82 % vs. 59 % ; P = 0.003 ) , within their local health center ( 70 % vs. 51 % ; P = 0.020 ) , and among their own patients ( 63 % vs. 43 % ; P = 0.037 ) . Black patients of clinicians in the intervention and control groups did not differ at 12 months in rates of controlling HbA(1c ) level ( 48 % vs. 45 % ; P = 0.24 ) , LDL cholesterol level ( 48 % vs. 49 % ; P = 0.40 ) , or blood pressure ( 23 % vs. 25 % ; P = 0.47 ) . LIMITATION 11 % of primary care teams did not attend cultural competency training sessions . CONCLUSION The combination of cultural competency training and race-stratified performance reports increased clinician awareness of racial disparities in diabetes care but did not improve clinical outcomes among black patients BACKGROUND Complete diagnostic evaluation or CDE ( i.e. , colonoscopy or combined flexible sigmoidoscopy plus barium enema X-ray ) is often not performed for persons with an abnormal screening fecal occult blood test ( FOBT+ ) result . METHOD This study evaluated the impact of a reminder-feedback and educational outreach intervention on primary care practice CDE recommendation and performance rates . Four hundred seventy primary care physicians ( PCPs ) in 318 practice s participated in the study . Patients were mailed an FOBT kit annually as part of a screening program . Practice s were r and omly assigned to a Control Group ( N = 198 ) or an Intervention Group ( N = 120 ) . During an 18-month pre-r and omization period and a 9-month post-r and omization period , 2992 screening FOBT+ patients were identified . Intervention practice s received the screening program and the intervention . Control practice s received only the screening program . Study outcomes were baseline-adjusted CDE recommendation and performance rates . RESULTS At baseline , about two-thirds of FOBT+ patients received a CDE recommendation , and about half had a CDE performed . At endpoint , CDE recommendation and performance rates were both significantly higher for the Intervention as compared to the Control practice s ( OR = 2.28 ; 95 % CI : 1.37 , 3.78 , and OR = 1.63 ; 95 % CI : 1.06 , 2.50 , respectively ) . CONCLUSIONS The reminder-feedback plus educational outreach intervention significantly increased CDE recommendation and performance We performed a r and omized , prospect i ve study to evaluate the use of a written feedback system in reducing the intraoperative costs of drugs and supplies used by anesthesiologists . Over 6 mo , 27 anesthesiology residents were r and omized to feedback and control groups for their rotations in neurosurgical anesthesia . We recorded the cost of drugs and supplies for three procedures : carotid endarterectomy , lumbar decompression , and cervical decompression . For each study case , members of the feedback group received a written cost analysis showing their performance relative to the departmental average . Members of the feedback group had significantly lower costs for carotid endarterectomies ( $ 79.98 + /- $ 15.20 vs $ 97.59 + /- $ 21.53 ) and for lumbar decompressions ( $ 56.72 + /- $ 16.49 vs $ 76.05 + /- $ 20.11 ) . The source of savings included lower use rates for propofol and etomi date and for patient warming devices . Analysis of data from recovery areas revealed a trend toward lower patient temperature in lumbar procedures performed by the feedback group . Three months after the feedback period , we collected a follow-up data set in the absence of feedback . This revealed a significant rebound in overall cost by the feedback group for both carotid endarterectomies and lumbar surgery . Implication s : This is the first r and omized , prospect i ve evaluation of a cost management system in anesthesia . Using resident anesthesiologists , we showed that the written feedback of individualized performance data can be used to lower the overall cost of intraoperative drugs and supplies used for an anesthetic in the absence of m and ated clinical guidelines . ( Anesth Analg 1998;86:510 - 5 Although numerous utilization review s of serum digoxin assays have demonstrated the positive impact of therapeutic drug monitoring , to our knowledge , the question of whether the withdrawal of such a program would reverse the effect has not been addressed . The current study employed a prospect i ve , r and omized , crossover design to evaluate this question and document the cost savings . There were 196 serum digoxin assays performed in the 207 patients . It was found that a continuous therapeutic drug-monitoring program was warranted since , after its withdrawal , there was a deterioration in audit criteria performance . Reimplementation of the therapeutic drug-monitoring program result ed in a significant decrease in the average number of assays requested per patient ( from 1.41 to 0.73 ) and an improvement in audit criteria performance OBJECTIVE : To determine whether residents perceived oral , face-to-face feedback about their continuity clinic performance as better than a similar , written version . DESIGN : Single-blind , r and omized controlled trial . SETTING : Two university-based , internal medicine residency clinics . PARTICIPANTS : All 68 internal medicine and combined program ( medicine-pediatrics , medicine-psychiatry , medicine-neurology , and preliminary year ) residents and their clinic preceptors . MEASUREMENTS AND MAIN RESULTS : Residents at each program were separately r and omized to oral or written feedback sessions with their clinic preceptors . The oral and written sessions followed similar , structured formats . Both groups were later sent question naires about aspects of the clinic . Sixty-five ( 96 % ) of the residents completed the question naire . Eight of the 19 questions dealt with aspects of feedback . A feedback scale was developed from the survey responses to those eight questions ( α=.86 ) . There were no significant differences in the responses to individual questions or in scale means ( p>.20 ) between the two feedback groups . When each university was analyzed separately , one had a higher scale mean ( 3.10 vs 3.57 , p=.047 ) , but within each university , there were no differences between the oral and written feedback groups ( p>.20 ) . CONCLUSIONS : No differences were observed between the oral and written feedback groups . In attempting to provide better feedback to their residents , medical educators may better apply their efforts to other aspects , such as the frequency of their feedback , rather than the form of its delivery Due to possible method ological and practical problems , many research ers refrain from using a r and omized controlled trial design to evaluate procedures already embedded in routine health care . We performed a r and omized controlled trial on the effects of routine individual feedback on test ordering behavior of family physicians . The trial started after 4 years of feedback and lasted for 2.5 years . With some adaptations a r and omized trial proved to be possible . In evaluating health-care procedures that can not be blinded in a traditional way , asking full and study -specific informed consent may conflict with the validity of the design . In such studies , an alternative procedure is to be considered . Our trial , with doctors as study subjects , was held on an already accepted routine procedure ( feedback ) . This made it possible to refrain from obtaining study -specific informed consent . Consequently , a Hawthorne effect and contamination of the trial arms through information leakage could be avoided . Justification and general criteria for not obtaining full and study -specific informed consent are worked out . In health-care research on the performance of doctors or on interventions into the quality of care , obtaining a general informed consent in advance is an acceptable alternative approach OBJECTIVE To evaluate the impact of systematic patient evaluation and patient and provider feedback on the processes and intermediate outcomes of diabetes care in Independent Practice Association model internal medicine practice s. RESEARCH DESIGN AND METHODS Nine practice s providing care to managed care patients were r and omly assigned as intervention or comparison sites . Intervention-site subjects had Annual Diabetes Assessment Program ( ADAP ) assessment s ( HbA(1c  ) , blood pressure , lipids , smoking , retinal photos , urine microalbumin , and foot examination ) at years 1 and 2 . Comparison-site subjects had ADAP assessment s at year 2 . At Intervention sites , year 1 ADAP results were review ed with subjects , mailed to providers , and incorporated into electronic medical records with guideline -generated suggestions for treatment and follow-up . Medical records were evaluated for both groups for the year before both the year 1 and year 2 ADAP assessment s. Processes and intermediate outcomes were compared using linear and logistic mixed hierarchical models . RESULTS Of 284 eligible subjects , 103 of 173 ( 60 % ) at the Intervention sites and 71 of 111 ( 64 % ) at the comparison sites participated ; 83 of 103 ( 81 % ) of the intervention-site subjects returned for follow-up at year 2 . Performance of the six recommended assessment s improved in intervention-site subjects at year 2 compared with year 1 ( 5.8 vs. 4.3 , P = 0.0001 ) and compared with comparison-site subjects at year 2 ( 4.2 , P = 0.014 ) . No significant changes were noted in intermediate outcomes . CONCLUSIONS The ADAP significantly improved processes of care but not intermediate outcomes . Additional interventions are needed to improve intermediate outcomes OBJECTIVE To assess the effects of a facilitator enhanced multifaceted intervention to implement a locally adapted guideline on the shared care for people with type 2 diabetes . METHODS During 1 year a cluster-r and omized trial was performed in 30 general practice s. In the intervention group , nurse facilitators enhanced guideline implementation by analysing barriers to change , introducing structured care , training practice staff and giving performance feedback . Targets for HbA1c% , systolic blood pressure as well as indications for angiotensin converting enzyme/angiotensin receptor blocking agent prescription differed from the national guidelines . In the control group , GPs were asked to continue the care for people with diabetes as usually . Generalized estimating equations were used to control for the clustered design of the study . RESULTS In the intervention group , more people were seen on a 3-monthly basis ( 88 % versus 69 % , P < 0.001 ) and more blood pressure and bodyweight measurements were performed every 3 months ( blood pressure 83 % versus 66 % , P < 0.001 and bodyweight 78.9 % versus 48.5 % , P < 0.001 ) . Apart from a marginal difference in mean cholesterol , differences in HbA1c% , blood pressure , body mass index and treatment satisfaction were not significant . CONCLUSION Multifaceted implementation of locally adapted shared care guidelines did improve the process of diabetes care but hardly changed intermediate outcomes . In the short term , local adaptation of shared care guidelines does not improve the cardiovascular risks of people with type 2 diabetes Improved pneumococcal vaccine ( PPV ) immunization for seniors is a national goal of the Medicare program . This study examined whether adding a simple telephone follow-up to an existing mailed physician performance feedback under the Medicare program would increase the impact on billed pneumococcal immunizations . Medicare fee-for-service cl aims data were used to select New York primary care physicians with high volume ( n = 732 ) or African-American serving ( n = 329 ) practice s. All practice s received mailed feedback on their 1999 Medicare practice specific PPV coverage rates , along with educational material s and offers of assistance . Practice s were also r and omized to receive telephone calls directing attention to the mailing and further promoting improvements in PPV coverage or no active follow-up . Physicians r and omized to telephone follow-up showed significantly higher rates of practice specific PPV coverage in 2000 than those receiving the routine mailing only , and 27 % vs. 17 % ( p = 0.01 ) of high volume physicians and 34 % vs. 
    Output:
    
Multivariable meta-regression indicated that feedback may be more effective when baseline performance is low , the source is a supervisor or colleague , it is provided more than once , it is delivered in both verbal and written formats , and when it includes both explicit targets and an action plan .
In addition , the effect size varied based on the clinical behaviour targeted by the intervention .
Audit and feedback generally leads to small but potentially important improvements in professional practice .
The effectiveness of  audit and feedback seems to depend on baseline performance and how the feedback is provided .