***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: Presentation  Quality Improvement ( QI ) research may be defined as “ the design , development and evaluation of complex interventions aim ed at the re- design of health care systems to produce improved outcomes ” . The challenge of QI lies in bridging the gap between knowing what needs to happen at an individual patient level and implementing this at a systems level . The inherent complexity of systems poses challenges in terms of implementation , but also presents the research er with circumstances for which conventional research methods may not prove useful . Explanatory trials are design ed to answer the question “ does this intervention work under ideal circumstances ? ” Patient and system variability are typically rigorously controlled . Pragmatic trials seek to answer how well an intervention works in usual practice [ 1 ] . It is important to contend with variation ( e.g. , in patient volume or complexity ) and not control for it . Consider the analogy of water sample d from a pond versus a river [ 2 ] . If one takes r and om sample s of water from a still pool of water one can draw inference about the pond as aw hole , as it is relatively static and unchanging . This is the principle we are using in attempting to extrapolate the findings of a r and omized controlled trial to a population . The real world however , behaves far more like a river where the water changes from second to second , influenced by innumerable complex interacting factors such as the season , rain , construction . In QI research it is important to underst and the changing nature of the river ( i.e. causes of system variation ) in order to be able to predict how to make an intervention work under all the conditions in which it will be expected to perform . QI research should focus therefore on robust , sequential experimentation . Too often , quality improvement investigators seek to proceed to clinical trials before sufficient exploration , investigation , and underst and ing of the complex system and its interactions have been achieved . Campbell et al present a trajectory for QI research required to build requisite knowledge [ 3 ] . The design and testing of complex interventions in care delivery proceeds through a series of planned stages . One begins by developing a concept or theory and then progresses to design ing a prototype . Next , an intervention is piloted on a small scale before performing a detailed test and finally disseminating the ideas generated . A variety of study design s may be used as learning proceeds across this trajectory of underst and ing . Research methods that address issues of internal validity without r and omization of individuals are referred to as “ quasi-experimental ” design s and include time-series , equivalent time series , multiple baseline and factorial design BACKGROUND We assessed patient outcomes 90 days after hospital admission for stroke following a multidisciplinary intervention targeting evidence -based management of fever , hyperglycaemia , and swallowing dysfunction in acute stroke units ( ASUs ) . METHODS In the Quality in Acute Stroke Care ( QASC ) study , a single-blind cluster r and omised controlled trial , we r and omised ASUs ( clusters ) in New South Wales , Australia , with immediate access to CT and on-site high dependency units , to intervention or control group . Patients were eligible if they spoke English , were aged 18 years or older , had had an ischaemic stroke or intracerebral haemorrhage , and presented within 48 h of onset of symptoms . Intervention ASUs received treatment protocol s to manage fever , hyperglycaemia , and swallowing dysfunction with multidisciplinary team building workshops to address implementation barriers . Control ASUs received only an abridged version of existing guidelines . We recruited pre-intervention and post-intervention patient cohorts to compare 90-day death or dependency ( modified Rankin scale [ mRS ] ≥2 ) , functional dependency ( Barthel index ) , and SF-36 physical and mental component summary scores . Research assistants , the statistician , and patients were masked to trial groups . All analyses were done by intention to treat . This trial is registered at the Australia New Zeal and Clinical Trial Registry ( ANZCTR ) , number ACTRN12608000563369 . FINDINGS 19 ASUs were r and omly assigned to intervention ( n=10 ) or control ( n=9 ) . Of 6564 assessed for eligibility , 1696 patients ' data were obtained ( 687 pre-intervention ; 1009 post-intervention ) . Results showed that , irrespective of stroke severity , intervention ASU patients were significantly less likely to be dead or dependent ( mRS ≥2 ) at 90 days than control ASU patients ( 236 [ 42 % ] of 558 patients in the intervention group vs 259 [ 58 % ] of 449 in the control group , p=0·002 ; number needed to treat 6·4 ; adjusted absolute difference 15·7 % [ 95 % CI 5·8 - 25·4 ] ) . They also had a better SF-36 mean physical component summary score ( 45·6 [ SD 10·2 ] in the intervention group vs 42·5 [ 10·5 ] in the control group , p=0·002 ; adjusted absolute difference 3·4 [ 95 % CI 1·2 - 5·5 ] ) but no improvement was recorded in mortality ( 21 [ 4 % ] of 558 in intervention group and 24 [ 5 % ] of 451 in the control group , p=0·36 ) , SF-36 mean mental component summary score ( 49·5 [ 10·9 ] in the intervention group vs 49·4 [ 10·6 ] in the control group , p=0·69 ) or functional dependency ( Barthel Index ≥60 : 487 [ 92 % ] of 532 patients vs 380 [ 90 % ] of 423 patients ; p=0·44 ) . INTERPRETATION Implementation of multidisciplinary supported evidence -based protocol s initiated by nurses for the management of fever , hyperglycaemia , and swallowing dysfunction delivers better patient outcomes after discharge from stroke units . Our findings show the possibility to augment stroke unit care . FUNDING National Health & Medical Research Council ID 353803 , St Vincent 's Clinic Foundation , the Curran Foundation , Australian Diabetes Society-Servier , the College of Nursing , and Australian Catholic University The methods of evaluating change and improvement strategies are not well described . The design and conduct of a range of experimental and non-experimental quantitative design s are considered . Such study design s should usually be used in a context where they build on appropriate theoretical , qualitative and modelling work , particularly in the development of appropriate interventions . A range of experimental design s are discussed including single and multiple arm r and omised controlled trials and the use of more complex factorial and block design s. The impact of r and omisation at both group and individual levels and three non-experimental design s ( uncontrolled before and after , controlled before and after , and time series analysis ) are also considered . The design chosen will reflect both the needs ( and re sources ) in any particular circumstances and also the purpose of the evaluation . The general principle underlying the choice of evaluative design is , however , simple — those conducting such evaluations should use the most robust design possible to minimise bias and maximise generalisability Background : Recent clinical trials indicate that treatment with lipid modifying therapy improves outcomes in patients with ischemic heart disease ( IHD ) and low levels of high density lipoprotein ( HDL ) cholesterol . The results of these trials , however , have not been widely implemented in clinical practice . Objectives : To develop and test an intervention design ed to increase the rate of prescription of lipid modifying therapy  and to determine the relative effectiveness of three different prompts ( progress notes , patient letters , or computer chart reminders ) . Methods : The study was conducted in 11 US Department of Veterans Affairs Medical Centers . The effect of the intervention on the proportion of eligible patients receiving lipid modifying therapy  was compared between five intervention sites and six matched control sites using a controlled before and after study design . Additionally , 92 providers within the intervention clinics were r and omized to receive one of the three prompts . Data were analyzed using logistic regression modeling which incorporated terms to account for the clustered nature of the data . Results : At the intervention sites the prescription rate increased from 8.3 % during the pre-intervention period to 39.1 % during the intervention ( OR = 6.5 , 95 % CI 5.2 to 8.2 , p<0.0001 ) but remained unchanged at the control sites . The interaction between group ( control v intervention ) and time period was highly significant ( p<0.0001 ) . The adjusted odds of receiving a prescription during the intervention period was 3.1 times higher at the intervention sites than at the control sites ( 95 % CI 2.1 to 4.7 ) . Overall , there was no significant difference in prescription rates among the three prompt groups . However , there was a significant interaction between prompt group and site , indicating that the efficacy of the prompts differed by site . Conclusion : An intervention for primary care providers consisting of an educational workshop , opinion leader influence , and prompts substantially increased the prescription rate of lipid modifying therapy Background Anxiety is a common mental health problem seen in primary care . However , its management in clinical practice varies greatly . Clinical practice guidelines ( CPGs ) have the potential to reduce variations and improve the care received by patients by promoting interventions of proven benefit . However , uptake and adherence to their recommendations can be low . Method / design This study involves a community based on cluster r and omized trial in primary healthcare centres in the Madrid Region ( Spain ) . The project aims to determine whether the use of implementation strategy ( including training session , information , opinion leader , reminders , audit , and feed-back ) of CPG for patients with anxiety disorders in primary care is more effective than usual diffusion . The number of patients required is 296 ( 148 in each arm ) , all older than 18 years and diagnosed with generalized anxiety disorder , panic disorder , and panic attacks by the Diagnostic and Statistical Manual of Mental Disorders-IV ( DSM-IV ) . They are chosen by consecutive sampling . The main outcome variable is the change in two or more points into Goldberg anxiety scale at six and twelve months . Secondary outcome variables include quality of life ( EuroQol 5D ) , and degree of compliance with the CPG recommendations on treatment , information , and referrals to mental health services . Main effectiveness will be analyzed by comparing the patients percentage improvement on the Goldberg scale between the intervention group and the control group . Logistic regression with r and om effects will be used to adjust for prognostic factors . Confounding factors or factors that might alter the effect recorded will be taken into account in this analysis . Discussion There is a need to identify effective implementation strategies for CPG for the management of anxiety disorders present in primary care . Ensuring the appropriate uptake of guideline recommendations can reduce clinical variation and improve the care patients receive . Trial registration IS RCT N : IS RCT Background . The influence of an opinion leader intervention on adherence to Unstable Angina ( UA ) guidelines compared with a traditional quality improvement model was investigated . Research Design . A group-r and omized controlled trial with 2210 patients from 21 hospitals was design ed . There were three intervention arms : ( 1 ) no intervention ( NI ) ; ( 2 ) a traditional Health Care Quality Improvement Program ( HCQIP ) ; and ( 3 ) a physician opinion leader in addition to the HCQIP model ( OL ) . Quality indicators included :  electrocardiogram within 20 minutes , antiplatelet therapy within 24 hours and at discharge , and heparin and & bgr;-blockers  during hospitalization . Hospitals could determine the specific indicators they wished to target . Potential cases of UA were identified from Medicare cl aims data . UA confirmation was determined by a clinical algorithm based on data abstract ed from medical records . Data analyses included both hospital level analysis ( analysis of variance ) and patient level analysis ( generalized linear models ) . Results . The only statistically significant postintervention difference in percentage compliant was greater improvement for the OL group in the use of antiplatelet therapy at 24 hours in both hospital level ( P = 0.01 ) and patient level analyses ( P < 0.05 ) compared with the HCQIP and NI groups . When analyses were confined to hospitals that targeted specific indicators , compared with the HCQIP hospitals , the OL hospitals showed significantly greater change in percentage compliant postintervention in both antiplatelet therapy during the first 24 hours ( 20.2 % vs. −3.9 % , P = 0.02 ) and heparin ( 31.0 % vs.9.1 % , P = 0.05 ) . Conclusions . The influence of physician opinion leaders was unequivocally positive for only one of five quality indicators . To maximize adherence to best practice s through physician opinion leaders , more research on how these physicians influence health care delivery in their organizations will be required Abstract Objective : To develop a working model with which prescribing behaviour among general practitioners might be influenced . Design : Intervention based on feedback on prescribing rates and problem-oriented educational outreach visits , using educational material and local opinion leaders . R and omised study with three parallel intervention groups of general practitioners , which also served as controls for each other . The pharmacotherapeutic fields chosen were hypertension , peptic ulcer/dyspepsia and depression . Prescription data were retrieved from the electronic patient records for periods of 1 year before and after the intervention . Setting : Six health care centres and three continuing medical education groups in Stockholm . Subjects : Forty general practitioners . Main outcome measures : Drug prescribing rates and patterns before and after the intervention . Results : In the hypertension field , desired trends in fractional prescribing ( favouring diuretics and beta blocking agents ) were recorded , with a significant ( P<0.05 ) effect on prescriptions for agents acting on the renin – angiotensin system , despite a pre-existing prescribing behaviour already much in line with the goals . In the peptic ulcer/dyspepsia field , desired trends were recorded for both types of therapies addressed . The fractional prescribing rates for proton-pump inhibitors decreased from 61.0 % to 52.6 % in the intervention arm and increased from 68.1 % to 
    Output:
    
Opinion leaders alone or in combination with other interventions may successfully promote evidence -based practice , but effectiveness varies both within and between studies .
In most of the studies the role of the opinion leader was not clearly described , and it is therefore not possible to say what the best way is to optimise the effectiveness of opinion leaders