***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 — Cardiac stress testing in patients at low risk for acute coronary syndrome is associated with increased false-positive test results , unnecessary downstream procedures , and increased cost . We judged it unlikely that patient preferences were driving the decision to obtain stress testing . Methods and Results — The Chest Pain Choice trial was a prospect i ve r and omized evaluation involving 204 patients who were r and omized to a decision aid or usual care and were followed for 30 days . The decision aid included a 100-person pictograph depicting the pretest probability of acute coronary syndrome and available management options ( observation unit admission and stress testing or 24–72 hours outpatient follow-up ) . The primary outcome was patient knowledge measured by an immediate postvisit survey . Additional outcomes included patient engagement in decision making and the proportion of patients who decided to undergo observation unit admission and cardiac stress testing . Compared with usual care patients ( n=103 ) , decision aid patients ( n=101 ) had significantly greater knowledge ( 3.6 versus 3.0 questions correct ; mean difference , 0.67 ; 95 % CI , 0.34–1.0 ) , were more engaged in decision making as indicated by higher OPTION ( observing patient involvement ) scores ( 26.6 versus 7.0 ; mean difference , 19.6 ; 95 % CI , 1.6–21.6 ) , and decided less frequently to be admitted to the observation unit for stress testing ( 58 % versus 77 % ; absolute difference , 19 % ; 95 % CI , 6%–31 % ) . There were no major adverse cardiac events after discharge in either group . Conclusions — Use of a  decision aid  in patients with chest pain increased knowledge and engagement in decision making and decreased the rate of observation unit admission for stress testing . Clinical Trial Registration — URL : http://www . clinical trials.gov . Unique identifier : NCT01077037 Background While some research has examined general attitudes about efforts to reduce overutilization of services , such as the Choosing Wisely ® ( CW ) initiative , little data exists regarding primary care providers ’ attitudes regarding individual recommendations . Objective We sought to identify whether particular CW recommendations were perceived by primary care providers as difficult to follow , difficult for patients to accept , or both . Design Two national surveys , one by mail to a r and om sample of 2000 U.S. primary care physicians in November 2013 , and the second electronically to a r and om sample of 2500 VA primary care providers ( PCPs ) in October – December 2014 . Participants A total of 603 U.S. primary care physicians and 1173 VA primary care providers . Response rates were 34 and 48 % , respectively . Main Measures PCP ratings of whether 12 CW recommendations  for screening , testing and treatments applicable to adult primary care were difficult to follow and difficult for patients to accept ; and ratings of potential barriers to reducing overutilization . Key Results For four recommendations regarding not screening or testing in asymptomatic patients , less than 20 % of PCPs found the  CW recommendations difficult to accept ( range 7.2–16.6 % ) or difficult for patients to follow ( 12.2–19.3 % ) . For five recommendations regarding testing or treatment for symptomatic conditions , however , there was both variation in reported difficulty to follow ( 9.8–32 % ) and a high level of reported difficulty for patients to accept ( 35.7–87.1 % ) . The most frequently reported barriers to reducing overuse included mal practice concern , patient requests for services , lack of time for shared decision making , and the number of tests recommended by specialists . Conclusions While PCPs found many CW recommendations easy to follow , they felt that some , especially those for symptomatic conditions , would be difficult for patients to accept . Overcoming PCPs ’ perceptions of patient acceptability will require approaches beyond routine physician education , feedback and financial incentives Objective To establish whether an interactive booklet on  respiratory tract infections in children reduces reconsultation for the same illness episode , reduces antibiotic use , and affects future consulting intentions , while maintaining parental satisfaction with care . Design Pragmatic cluster r and omised controlled trial . Setting 61 general practice s in Wales and Engl and . Participants 558 children ( 6 months to 14 years ) presenting to primary care with an acute respiratory tract infection ( 7 days or less ) . Children with suspected pneumonia , asthma or a serious concomitant illness , or needing immediate hospital admission were excluded . Three withdrew and 27 were lost to follow-up , leaving 528 ( 94.6 % ) with main outcome data . Interventions Clinicians in the intervention group were trained in the use of an interactive booklet on respiratory tract infections and asked to use the booklet during consultations with recruited patients ( and provide it as a take home re source ) . Clinicians in the control group conducted their consultations as usual . Main outcome measures The proportion of children who attended a face-to-face consultation about the same illness during the two week follow-up period . Secondary outcomes included antibiotic prescribing , antibiotic consumption , future consulting intentions , and parental satisfaction , reassurance , and enablement . Results Reconsultation occurred in 12.9 % of children in the intervention group and 16.2 % in the control group ( absolute risk reduction 3.3 % , 95 % confidence interval −2.7 % to 9.3 % , P=0.29 ) . Using multilevel modelling ( at the practice and individual level ) to account for clustering , no significant difference in reconsulting was noted ( odds ratio 0.75 ; 0.41 to 1.38 ) . Antibiotics were prescribed at the index consultation to 19.5 % of children in the intervention group and 40.8 % of children in the control group ( absolute risk reduction 21.3 % , 95 % confidence interval 13.7 to 28.9 ) , P<0.001 ) . A significant difference was still present after adjusting for clustering ( odds ratio 0.29 ; 0.14 to 0.60 ) . There was also a significant difference in the proportion of parents who said they would consult in the future if their child developed a similar illness ( odds ratio 0.34 ; 0.20 to 0.57 ) . Satisfaction , reassurance , and parental enablement scores were not significantly different between the two groups . Conclusions Use of a booklet on respiratory tract infections in children within primary care consultations led to important reductions in antibiotic prescribing and reduced intention to consult without reducing satisfaction with care . Trial registration Current Controlled Trials IS RCT Background : Few interventions have proven effective in reducing the overuse of antibiotics for acute respiratory infections . We evaluated the effect of DECISION+2 , a shared decision-making training program , on the percentage of patients who decided to take  antibiotics  after consultation with a physician or resident . Methods : We performed a r and omized trial , clustered at the level of family practice teaching unit , with 2 study arms : DECISION+2 and control . The DECISION+2 training program included a 2-hour online tutorial followed by a 2-hour interactive seminar about shared decision-making . The primary outcome was the proportion of patients who decided to use antibiotics immediately after consultation . We also recorded patients ’ perception that shared decision-making had occurred . Two weeks after the initial consultation , we assessed patients ’ adherence to the decision , repeat consultation , decisional regret and quality of life . Results : We compared outcomes among 181 patients who consulted 77 physicians in 5 family practice teaching units in the DECISION+2 group , and 178 patients who consulted 72 physicians in 4 family practice teaching units in the control group . The percentage of patients who decided to use antibiotics after consultation was 52.2 % in the control group and 27.2 % in the DECISION+2 group ( absolute difference 25.0 % , adjusted relative risk 0.48 , 95 % confidence interval 0.34–0.68 ) . DECISION+2 was associated with patients taking a more active role in decision-making ( Z = 3.9 , p < 0.001 ) . Patient outcomes 2 weeks after consultation were similar in both groups . Interpretation : The shared decision-making program DECISION+2 enhanced patient participation in decision-making and led to fewer patients deciding to use antibiotics for acute respiratory infections . This reduction did not have a negative effect on patient outcomes 2 weeks after consultation . Clinical Trials.gov trial register no. NCT01116076 Objective To compare the effectiveness of shared decision making with usual care in choice of admission for observation and further cardiac testing or for referral for outpatient evaluation in patients with possible acute coronary syndrome . Design Multicenter pragmatic parallel r and omized controlled trial . Setting Six emergency departments in the United States . Participants 898 adults ( aged > 17 years ) with a primary complaint of chest pain who were being considered for admission to an observation unit for cardiac testing ( 451 were allocated to the decision aid  and 447 to  usual care ) , and 361 emergency clinicians ( emergency physicians , nurse practitioners , and physician assistants ) caring for patients with chest pain . Interventions Patients were r and omly assigned ( 1:1 ) by an electronic , web based system to shared decision making facilitated by a decision aid or to usual care . The primary outcome , selected by patient and caregiver advisers , was patient knowledge of their risk for acute coronary syndrome and options for care ; secondary outcomes were involvement in the decision to be admitted , proportion of patients admitted for cardiac testing , and the 30 day rate of major adverse cardiac events . Results Compared with the usual care arm , patients in the decision aid arm had greater knowledge of their risk for acute coronary syndrome and options for care ( questions correct : decision aid , 4.2 v usual care , 3.6 ; mean difference 0.66 , 95 % confidence interval 0.46 to 0.86 ) , were more involved in the decision ( observing patient involvement scores : decision aid , 18.3 v usual care , 7.9 ; 10.3 , 9.1 to 11.5 ) , and less frequently decided with their clinician to be admitted for cardiac testing ( decision aid , 37 % v usual care , 52 % ; absolute difference 15 % ; P<0.001 ) . There were no major adverse cardiac events due to the intervention . Conclusions Use of a decision aid in patients at low risk for acute coronary syndrome increased patient knowledge about their risk , increased engagement , and safely decreased the rate of admission to an observation unit for cardiac testing . Trial registration Clinical Trials.gov NCT01969240 Flaws in the design , conduct , analysis , and reporting of r and omised trials can cause the effect of an intervention to be underestimated or overestimated . The Cochrane Collaboration ’s tool for assessing risk of bias aims to make the process clearer and more INTRODUCTION Antibiotic overuse promotes resistant strains of bacteria and puts patients at risk for adverse reactions . Given the use of educational posters in government-sponsored public health campaigns , this study examined the effectiveness of a waiting room poster in reducing excessive antibiotic use in clinical practice . METHODS Investigators conducted a 1-month trial of an educational poster with historical controls using three private pediatric group practice s in Westchester County , New York . Children between the ages of 6 months and 10 years at the time of a visit to diagnose and treat symptoms of respiratory illness were enrolled as subjects .  Antibiotic prescriptions for children with respiratory illnesses seen during the poster month were compared with prescriptions written during three 1-month historical control periods . The proportion of visits that result ed in a prescription for an antibiotic served as the outcome measure . RESULTS Overall , 326 of the 720 patients ( 45.2 % ) enrolled in the study were treated with an antibiotic . Multiple logistic regression analysis revealed no statistically significant difference in the proportion of visits result ing in an antibiotic prescription among the 4 study months ( P = .79 ) , indicating that the educational poster had no effect on antibiotic use . DISCUSSION Public education in the form of a waiting room poster was not sufficient to decrease antibiotic prescriptions . This finding has implication s for current large-scale programs and for health care providers as they continue to attempt to educate patients on the appropriate use of antibiotics Decision aids are evidence -based sources of health information that can help patients make informed treatment decisions . However , little is known about how decision aids affect health care use when they are implemented outside of r and omized controlled clinical trials . We conducted an observational study to examine the associations between introducing decision aids for hip and knee osteoarthritis and rates of joint replacement surgery and costs in a large health system in Washington State . Consistent with prior r and omized trials , our introduction of decision aids was associated with 26 percent fewer hip replacement surgeries , 38 percent fewer knee replacements , and 12 - 21 percent lower costs over six months . These findings support the concept that patient decision aids for some health conditions , for which treatment decisions are highly sensitive to both patients ' and physicians ' preferences , may reduce rates of elective surgery and lower costs OBJECTIVES To determine the effects of two computer based decision aids on decisional conflict and mode of delivery among pregnant women with a previous caesarean section . DESIGN R and omised trial , conducted from May 2004 to August 2006 . SETTING Four maternity units in south west Engl and , and Scotl and . PARTICIPANTS 742 pregnant women with one previous lower segment caesarean section and delivery expected at > or=37 weeks . Non-English speakers were excluded . INTERVENTIONS Usual care : st and ard care given by obstetric and midwifery staff . Information programme : women navigated through descriptions and probabilities of clin 
    Output:
    
De-implementation interventions that engage patients within the patient-clinician interaction through patient-targeted educational material s or shared decision-making tools are effective in decreasing the use of low-value care .