***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: Summary Background Unnecessary antibiotic prescribing contributes to antimicrobial resistance . In this trial , we aim ed to reduce unnecessary prescriptions of antibiotics by general practitioners ( GPs ) in Engl and . Methods In this r and omised , 2 × 2 factorial trial , publicly available data bases were used to identify GP practice s whose prescribing rate for antibiotics was in the top 20 % for their National Health Service ( NHS ) Local Area Team . Eligible practice s were r and omly assigned ( 1:1 ) into two groups by computer-generated allocation sequence , stratified by NHS Local Area Team . Participants , but not investigators , were blinded to group assignment . On Sept 29 , 2014 , every GP in the  feedback intervention group was sent a letter from Engl and 's Chief Medical Officer and a leaflet on antibiotics for use with patients . The letter stated that the practice was prescribing antibiotics at a higher rate than 80 % of practice s in its NHS Local Area Team . GPs in the control group received no communication . The sample was re-r and omised into two groups , and in December , 2014 , GP practice s were either sent patient-focused information that promoted reduced use of antibiotics or received no communication . The primary outcome measure was the rate of antibiotic items dispensed per 1000 weighted population , controlling for past prescribing . Analysis was by intention to treat . This trial is registered with the IS RCT N registry , number IS RCT N32349954 , and has been completed . Findings Between Sept 8 and Sept 26 , 2014 , we recruited and assigned 1581 GP practice s to feedback intervention ( n=791 ) or control ( n=790 ) groups . Letters were sent to 3227 GPs in the intervention group . Between October , 2014 , and March , 2015 , the rate of antibiotic items dispensed per 1000 population was 126·98 ( 95 % CI 125·68–128·27 ) in the feedback intervention group and 131·25 ( 130·33–132·16 ) in the control group , a difference of 4·27 ( 3·3 % ; incidence rate ratio [ IRR ] 0·967 [ 95 % CI 0·957–0·977 ] ; p<0·0001 ) , representing an estimated 73 406 fewer antibiotic items dispensed . In December , 2014 , GP practice s were re-assigned to patient-focused intervention ( n=777 ) or control ( n=804 ) groups . The patient-focused intervention did not significantly affect the primary outcome measure between December , 2014 , and March , 2015 ( antibiotic items dispensed per 1000 population : 135·00 [ 95 % CI 133·77–136·22 ] in the patient-focused intervention group and 133·98 [ 133·06–134·90 ] in the control group ; IRR for difference between groups 1·01 , 95 % CI 1·00–1·02 ; p=0·105 ) . Interpretation Social norm feedback from a high-profile messenger can substantially reduce antibiotic prescribing at low cost and at national scale ; this outcome makes it a worthwhile addition to antimicrobial stewardship programmes . Funding Public Health Engl and Although self-enhancement is linked to psychological benefits , it is also associated with personal and interpersonal liabilities ( e.g. , excessive risk taking , social exclusion ) . Hence , structuring social situations that prompt people to keep their self-enhancing beliefs in check can confer personal and interpersonal advantages . The authors examined whether accountability can serve this purpose . Accountability was defined as the expectation to explain , justify , and defend one 's self-evaluations ( grade s on an essay ) to another person ( " audience " ) . Experiment 1 showed that accountability  curtails self-enhancement . Experiment 2 ruled out audience concreteness and status as explanations for this effect . Experiment 3 demonstrated that  accountability-induced self-enhancement reduction is due to identifiability . Experiment 4 documented that identifiability decreases self-enhancement because of evaluation expectancy and an accompanying focus on one 's weaknesses Abstract Objective To determine whether a behavioral intervention delivered through a video game can improve the appropriateness of trauma triage decisions in the emergency department of non-trauma centers . Design R and omized clinical trial . Setting Online intervention in national sample of emergency medicine physicians who make triage decisions at US hospitals . Participants 368 emergency medicine physicians primarily working at non-trauma centers . A r and om sample ( n=200 ) of those with primary outcome data was reassessed at six months . Interventions Physicians were r and omized in a 1:1 ratio to one hour of exposure to an adventure video game ( Night Shift ) or apps based on traditional didactic education ( myATLS and Trauma Life Support MCQ Review ) , both on iPads . Night Shift was developed to recalibrate the process of using pattern recognition to recognize moderate-severe injuries ( representativeness heuristics ) through the use of stories to promote behavior change ( narrative engagement ) . Physicians were r and omized with a 2 × 2 factorial design to intervention ( game v traditional education apps ) and then to the experimental condition under which they completed the outcome assessment tool ( low v high cognitive load ) . Blinding could not be maintained after allocation but group assignment was masked during the analysis phase . Main outcome measures Outcomes of a virtual simulation that included 10 cases ; in four of these the patients had severe injuries . Participants completed the simulation within four weeks of their intervention . Decisions to admit , discharge , or transfer were measured . The proportion of patients under-triaged ( patients with severe injuries not transferred to a trauma center ) was calculated then ( primary outcome ) and again six months later , with a different set of cases ( primary outcome of follow-up study ) . The secondary outcome was effect of cognitive load on under-triage . Results 149 ( 81 % ) physicians in the game arm and 148 ( 80 % ) in the traditional education arm completed the trial . Of these , 64/100 ( 64 % ) and 58/100 ( 58 % ) , respectively , completed re assessment at six months . The mean age was 40 ( SD 8.9 ) , 283 ( 96 % ) were trained in emergency medicine , and 207 ( 70 % ) were ATLS ( advanced trauma life support ) certified . Physicians exposed to the game  under-triaged fewer severely injured patients than those exposed to didactic education ( 316/596 ( 0.53 ) v 377/592 ( 0.64 ) , estimated difference 0.11 , 95 % confidence interval 0.05 to 0.16 ; P<0.001 ) . Cognitive load did not influence under-triage ( 161/308 ( 0.53 ) v 155/288 ( 0.54 ) in the game arm ; 197/300 ( 0.66 ) v 180/292 ( 0.62 ) in the traditional educational apps arm ; P=0.66 ) . At six months , physicians exposed to the game remained less likely to under-triage patients ( 146/256 ( 0.57 ) v 172/232 ( 0.74 ) , estimated difference 0.17 , 0.09 to 0.25 ; P<0.001 ) . No physician reported side effects . The sample might not reflect all emergency medicine physicians , and a small set of cases was used to assess performance . Conclusions Compared with apps based on traditional didactic education , exposure of physicians to a theoretically grounded video game improved triage decision making in a vali date d virtual simulation . Though the observed effect was large , the wide confidence intervals include the possibility of a small benefit , and the real world efficacy of this intervention remains uncertain . Trial registration clinical trials.gov ; NCT02857348 ( initial study ) /NCT03138304 ( follow-up ) Background The frequency of head computed tomography ( CT ) imaging for mild head trauma patients has raised safety and cost concerns . Vali date d clinical decision rules exist in the published literature and on-line sources to guide medical image ordering but are often not used by emergency department ( ED ) clinicians . Using simulation , we explored whether the presentation of a clinical decision rule ( i.e. Canadian CT Head Rule - CCHR ) , findings from mal practice cases related to clinicians not ordering CT imaging in mild head trauma cases , and estimated patient out-of-pocket cost might influence clinician brain CT ordering . Underst and ing what type and how information may influence clinical decision making in the ordering advanced medical imaging is important in shaping the optimal design and implementation of related clinical decision support systems . Methods Multi-center , double-blinded simulation-based r and omized controlled trial . Following st and ardized clinical vignette presentation , clinicians made an initial imaging decision for the patient . This was followed by additional information on decision support rules , mal practice outcome review , and patient cost ; each with opportunity to modify their initial order . The mal practice and cost information differed by assigned group to test the any temporal relationship . The simulation closed with a second vignette and an imaging decision . Results One hundred sixteen of the 167 participants ( 66.9 % ) initially ordered a brain CT scan . After CCHR presentation , the number of clinicians ordering a CT  dropped to 76 ( 45.8 % ) , representing a 21.1 % reduction in CT ordering ( P = 0.002 ) . This reduction in CT ordering was maintained , in comparison to initial imaging orders , when presented with mal practice review information ( p = 0.002 ) and patient cost information ( p = 0.002 ) . About 57 % of clinicians changed their order during study , while 43 % never modified their imaging order . Conclusion This study suggests that ED clinician brain CT imaging decisions may be influenced by clinical decision support rules , patient out-of-pocket cost information and findings from mal practice case review .Trial registration NCT03449862 , February 27 , 2018 , Retrospectively registered Background Inappropriate antibiotic prescribing for nonbacterial infections leads to increases in the costs of care , antibiotic resistance among bacteria , and adverse drug events . Acute respiratory infections ( ARIs ) are the most common reason for inappropriate antibiotic use . Most prior efforts to decrease inappropriate antibiotic prescribing for ARIs ( e.g. , educational or informational interventions ) have relied on the implicit assumption that clinicians inappropriately prescribe antibiotics because they are unaware of guideline recommendations for ARIs . If lack of guideline awareness is not the reason for inappropriate prescribing , educational interventions may have limited impact on prescribing rates . Instead , interventions that apply social psychological and behavioral economic principles may be more effective in deterring inappropriate antibiotic prescribing for ARIs by well-informed clinicians . Methods / design The Application of Behavioral Economics to Improve the Treatment of Acute Respiratory Infections ( BEARI ) Trial is a multisite , cluster-r and omized controlled trial with practice as the unit of r and omization . The primary aim is to test the ability of three interventions based on behavioral economic principles to reduce the rate of inappropriate antibiotic prescribing for ARIs . We r and omized practice s in a 2 × 2 × 2 factorial design to receive up to three interventions for non-antibiotic-appropriate diagnoses : 1 ) Accountable Justifications : When prescribing an antibiotic for an ARI , clinicians are prompted to record an explicit justification that appears in the patient electronic health record ; 2 ) Suggested Alternatives : Through computerized clinical decision support , clinicians prescribing an antibiotic for an ARI receive a list of non-antibiotic treatment choices ( including prescription options ) prior to completing the antibiotic prescription ; and 3 ) Peer Comparison : Each provider ’s rate of inappropriate antibiotic prescribing relative to top-performing peers is reported back to the provider periodically by email . We enrolled 269 clinicians ( practicing attending physicians or advanced practice nurses ) in 49 participating clinic sites and collected baseline data . The primary outcome is the antibiotic prescribing rate for office visits with non-antibiotic-appropriate ARI diagnoses . Secondary outcomes will examine antibiotic prescribing more broadly . The 18-month intervention period will be followed by a one year follow-up period to measure persistence of effects after interventions cease . Discussion The ongoing BEARI Trial will evaluate the effectiveness of behavioral economic strategies in reducing inappropriate prescribing of antibiotics . Trials registration Clinical Trials.gov : PURPOSE We wanted to evaluate novel decision aids design ed to help patients trust and accept the controversial , evidence -based , US Preventive Services Task Force recommendations about prostate cancer screening ( from 2012 ) and mammography screening for women aged 40 to 49 years ( from 2009 ) . METHODS We created recorded vignettes of physician-patient discussion s about prostate cancer screening and mammography , accompanied by illustrative slides , based on principles derived from preceding qualitative work and behavioral science literature . We conducted a r and omized crossover study with repeated measures with 27 men aged 50 to 74 years and 35 women aged 40 to 49 years . All participants saw a video intervention and a more traditional , paper-based decision aid intervention in r and om order . At entry and after seeing each intervention , they were surveyed about screening intentions , perceptions of benefits and harm , and decisional conflict . RESULTS Changes in screening 
    Output:
    
RESULTS We found that 10 behavioral economics concepts with nine cognitive biases were addressed and investigated for clinician decision-making , and that the following five concepts , which were actively explored , had an impact in CDS applications : social norms , framing effect , status-quo bias , heuristics , and overconfidence bias .
CONCLUSIONS Our review revealed that the use of behavioral economics techniques is increasing in areas such as antibiotics prescribing and preventive care , and that additional tests of the concepts and heuristics described would be useful in other areas of CDS .