***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 Maternal and perinatal mortality are major problems for which progress in sub-Saharan Africa has been inadequate , even though childbirth services are available , even in the poorest countries . Reducing them is the aim of two of the main Millennium Development Goals . Many initiatives have been undertaken to remedy this situation , such as the Advances in Labour and Risk Management ( ALARM ) International Program , whose purpose is to improve the quality of obstetric services in low-income countries . However , few interventions have been evaluated , in this context , using rigorous methods for analyzing effectiveness in terms of health outcomes . The objective of this trial is to evaluate the effectiveness of the ALARM International Program ( AIP ) in reducing maternal mortality in referral hospitals in Senegal and Mali . Secondary goals include evaluation of the relationships between effectiveness and re source availability , service organization , medical practice s , and satisfaction among health personnel . Methods / Design This is an international , multi-centre , controlled cluster-r and omized trial of a complex intervention . The intervention is based on the concept of evidence -based practice and on a combination of two approaches aim ed at improving the performance of health personnel : 1 ) Educational outreach visits ; and 2 ) the implementation of facility-based maternal death review s . The unit of intervention is the public health facility equipped with a functional operating room . On the basis of consent provided by hospital authorities , 46 centres out of 49 eligible were selected in Mali and Senegal . Using r and omization stratified by country and by level of care , 23 centres will be allocated to the intervention group and 23 to the  control  group . The intervention will last two years . It will be preceded by a pre-intervention one-year period for baseline data collection . A continuous clinical data collection system has been set up in all participating centres . This , along with the inventory of re sources and the satisfaction surveys administered to the health personnel , will allow us to measure results before , during , and after the intervention . The overall rate of maternal mortality measured in hospitals during the post-intervention period ( Year 4 ) is the primary outcome . The evaluation will also include cost-effectiveness . Trial Registration The QUARITE trial is registered on the Current Controlled Trials website under the number IS RCT N46950658 Accurate , affordable , and valid measurements of clinical practice are the basis for quality -of-care assessment s ( 1 ) . However , to date , most measurement tools have relied on incomplete data sources , such as medical records or administrative data ; require highly trained and expensive personnel to implement ; and are difficult to vali date ( 2 - 5 ) . Comparisons of clinical practice across different sites and health care systems are also difficult because they require relatively complex instrument design s or statistical techniques to adjust for variations in case mix among the underlying patient population s ( 6 , 7 ) . We have developed a measurement tool , computerized clinical vignettes , that overcomes these limitations and measures physicians ' clinical practice against a predefined set of explicit quality criteria . These vignettes simulate patient visits and can be given to physicians to measure their ability to evaluate , diagnose , and treat specific medical conditions . Each vignette-simulated case contains realistic clinical detail , allowing an identical clinical scenario to be presented to many physicians . Each physician can be asked to complete several vignettes to simulate diverse clinical conditions . This instrument design obviates the need to adjust quality scores for the variation in disease severity and comorbid conditions found in actual patient population s. Our vignettes are also distinct from other quality measurements of clinical practice because they do not focus on a single task , or even a limited set of tasks , but instead comprehensively evaluate the range of skills needed to care for a patient . Vignettes are particularly well-suited for quality assessment s of clinical practice that are used for large-scale ( 8 , 9 ) , cross-system comparisons ( 10 , 11 ) or for cases in which ethical issues preclude involving patients or their records ( 7 , 12 , 13 ) . They are also ideal for evaluations that require holding patient variation constant ( 14 , 15 ) or manipulating patient-level variables ( 15 - 17 ) . The appeal of vignettes has result ed in their extensive use in medical school education ( 18 , 19 ) , as well as various studies that explicitly evaluate the quality of clinical practice in real-life setting s and comparative analysis among national health care systems ( 10 , 20 - 23 ) . Before vignette-measured quality can be used confidently in these setting s , however , 2 important questions must be answered : How valid are vignettes as a measure of actual clinical practice ? Can vignettes discriminate among variations in the quality of clinical practice ? This has led to a search to define a gold st and ard for validation ( 24 - 26 ) . We and others have used st and ardized patients as this st and ard . St and ardized patients are trained actors who present unannounced to outpatient clinics as patients with a given clinical condition . Immediately after meeting with a physician , the st and ardized patient records on a checklist what the physician did during the visit ( 26 - 28 ) . Rigorous methods , which we have described in detail elsewhere ( 29 ) , ensure that st and ardized patients can be considered a gold st and ard . In addition , we have demonstrated the validity of st and ardized patients as a gold st and ard by concealing audio recorders on st and ardized patients during visits . The overall rate of agreement between the st and ardized patients ' checklists and the independent assessment of the audio transcripts was 91 % ( 26 ) . We previously used paper- and -pen vignettes in a study limited to only 1 health care system , the Veterans Administration , and found that they seemed to be a valid measure of the quality of clinical practice according to their rate of agreement with st and ardized patient checklists ( 26 ) . For this study , we wanted to confirm the validity of vignettes by using a more complex study design that introduced many more r and omly assigned physicians , a broader range of clinical cases , and several sites representing different health care systems . We also wanted to test a refined , computerized version of vignettes , which we believe are more realistic and streamline data collection and scoring . We were particularly interested in determining whether the vignettes accurately capture variation in the quality of clinical practice , which has become increasingly prominent in the national debate on quality of care ( 30 , 31 ) . We hoped that vignettes could contribute to this debate by providing a low-cost measure of variation across different health care systems . Methods Sites The study was conducted in 4 general internal medicine clinics : 2 Veterans Affairs ( VA ) medical centers and 2 large , private medical centers . One private site is a closed group model , and the other , primarily staffed by employed physicians , contracts with managed care plans . All sites are located in California , and each has an internal medicine residency training program . One VA medical center and 1 private site are located in 1 of 2 cities . The 2 VA medical centers are large , academically affiliated hospitals with large primary care general internal medicine practice s. We chose the 2 private sites that were generally similar to the VA medical centers and to each other ; each had large primary care practice s and capitated reimbursement systems that provide primary care general internists with a broad scope of clinical decision-making authority . Study Design At each site , all attending physicians and second- and third-year residents who were actively engaged in the care of general internal medicine out patients were eligible to participate in the study . We excluded only interns . Of 163 eligible physicians , 144 agreed to participate . We informed consenting physicians that 6 to 10 st and ardized patients might be introduced unannounced into their clinics over the course of a year and that they might be asked to complete an equal number of vignettes . Sixty physicians were r and omly selected to see st and ardized patients : 5 physicians from each of the 3 training levels at each of the 4 sites ( Figure 1 ) . We assigned st and ardized patients to each selected physician for 8 clinical casessimple and complex cases of chronic obstructive pulmonary disease , diabetes , vascular disease , and depression . We abstract ed the medical records from the 480 st and ardized patient visits . Each selected physician also completed a computerized clinical vignette for each of the 8 cases . For st and ardized patient visits that a selected physician did not complete , a replacement physician , who was r and omly selected from the same training level at the same site , completed the visit . Eleven physicians required replacements . The 11 replacement physicians completed 24 st and ardized patient visits . Each replacement physician completed vignettes for all 8 cases . Finally , we r and omly selected 45 additional physicians to serve as controls and complete vignettes ( only ) for all 8 cases . A total of 116 physicians participated in the study by seeing st and ardized patients , completing vignettes , or both . St and ardized patients presented to the clinics between March and July 2000 , and physicians completed vignettes between May and August 2000 . Figure 1 . Planned study design showing sites and physician sample by level of training and clinical case for the 3 quality measurement methods . Vignette Data Collection We developed the vignettes by using a st and ardized protocol . We first selected relatively common medical conditions frequently seen by internists . All selected conditions had explicit , evidence -based quality criteria and accepted st and ards of practice that could be used to score the vignettes , as well as be measured by st and ardized patients and chart abstract ion . We developed written scenarios that described a typical patient with 1 of the same 4 diseases ( chronic obstructive pulmonary disease , diabetes , vascular disease , or depression ) . For each disease , we developed a simple ( uncomplicated ) case and a more complex case with a comorbid condition of either hypertension or hypercholesterolemia . This yielded a total of 8 clinical cases . ( A sample vignette and scoring sheet are available online . ) Supplement . Appendix Figure : Vignette scoring sheet . Published online with permission from John W. Peabody , MD , PhD The physician completing the vignette sees the patient on a computer .  Each vignette is organized into 5 sections , or domains , which , when completed in sequential order , recreate the normal sequence of events in an actual patient visit : taking the patient 's history , performing the physical examination , ordering radiologic or laboratory tests , making a diagnosis , and administering a treatment plan . For example , the computerized vignette first states the presenting problem to the physician and prompts the physician to take the patient 's history ( that is , ask questions that would determine the history of the present illness ; past medical history , including prevention ; and social history ) . Physicians can record components of the history in any order without penalty . The entire format is open-ended : The physician enters the history questions directly into the computer and , in the most recent computerized versions , receives realtime responses . When the history is completed , the computer confirms that the physician has finished and then provides key responses typical of a patient with the specific case . The same process is repeated for the 4 remaining domains . In addition to the open-ended format , we have taken 3 steps to avoid potential inflation of vignette scores . First , physicians are not allowed to return to a previous domain and change their queries after they have seen the computerized response . Second , the number of queries is limited in the history and physical examination domains . For example , in the physical examination domain , physicians are asked to list only the 6 to 10 essential elements of the examination that they would perform . Third , they are given limited time to complete the vignette ( just as time is limited during an actual patient visit OBJECTIVE To determine whether clinical vignettes can measure variations in the quality of clinical care in two economically divergent countries . DATA SOURCE / STUDY SETTING Primary data collected between February 1997 and February 1998 at two Veterans Affairs facilities in the United States and four government-run outpatient facilities in Macedonia . STUDY DESIGN R and omly selected , eligible Macedonian and U.S. physicians ( > 97 percent participation rate ) completed vignettes for four common outpatient conditions .  Responses were judged against a master list of explicit quality criteria and scored as percent correct . DATA COLLECTION / EXTRACTION : An ANOVA model and two-tailed t-tests were used to compare overall scores by case , study site , and country . Principal Findings . The mean score for U.S. physicians was 67 percent ( + /-11 percent ) compared to 48 percent ( + /-11 percent ) for Macedonian physicians . The quality of clinical practice , which emphasizes basic skills , varied greatly in both sites , but more so in Macedonia . However , the top Macedonian physicians in all sites approached or-in one case-exceeded the median score in the U.S. sites . CONCLUSIONS Vignettes are a useful method for making cross-national comparisons of the quality of care provided in very different setting s. The vignette measurements revealed that some physicians in Macedonia performed at a st and ard comparable to that of their counterparts in the United States , despite the disparity of the two health systems . We infer that in poorer countries , policy that promotes improvements in the quality of clinical practice -not just structural inputs-could lead to rapid improvements in health 
    Output:
    
Re source availability positively correlated with mean hospital CBCA scores and maternal and perinatal mortality were inversely correlated with hospital CBCA scores .
Conclusion Our CBCA has substantial inter-rater reliability and there is compelling evidence of its validity as the tool performs according to theory .