***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: 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 To explore ways to reduce the overuse of antibiotics for acute respiratory infections ( ARIs ) , we conducted a pilot clustered r and omized controlled trial ( RCT ) to evaluate DECISION+ , a training program in shared decision making ( SDM ) for family physicians ( FPs ) . This pilot project demonstrated the feasibility of conducting a large clustered RCT and showed that DECISION+ reduced the proportion of patients who decided to use antibiotics immediately after consulting their physician . Consequently , the objective of this study is to evaluate , in patients consulting for ARIs , if exposure of physicians to a modified version of DECISION+ , DECISION+2 , would reduce the proportion of patients who decide to use antibiotics immediately after consulting their physician . Methods / design The study is a multi-center , two-arm , parallel clustered RCT . The 12 family practice teaching units ( FPTUs ) in the network of the Department of Family Medicine and Emergency Medicine of Université Laval will be r and omized to a DECISION+2 intervention group ( experimental group ) or to a no-intervention control group . These FPTUs will recruit patients consulting family physicians and residents in family medicine enrolled in the study . There will be two data collection periods : pre-intervention ( baseline ) including 175 patients with ARIs in each study arm , and post-intervention including 175 patients with ARIs in each study arm ( total n = 700 ) . The primary outcome will be the proportion of patients reporting a decision to use antibiotics immediately after consulting their physician . Secondary outcome measures include : 1 ) physicians and patients ' decisional conflict ; 2 ) the agreement between the parties ' decisional conflict scores ; and 3 ) perception of patients and physicians that SDM occurred . Also in patients , at 2 weeks follow-up , adherence to the decision , consultation for the same reason , decisional regret , and quality of life will be assessed . Finally , in both patients and physicians , intention to engage in SDM in future clinical encounters will be assessed . Intention-to-treat analyses will be applied and account for the nested design of the trial will be taken into consideration . Discussion DECISION+2 has the potential to reduce antibiotics use for ARIs by priming physicians and patients to share decisional process and empowering patients to make informed , value-based decisions . Trial Registration Clinical Trials.gov : OBJECTIVES . To determine whether we could increase adherence to the Centers for Disease Control and Prevention ( CDC ) recommendations with well-accepted approaches to improving quality of care and adherence to the CDC recommendations result ed in improved outcomes for acute otitis media ( AOM ) . METHODS . A cluster r and omization study was conducted in 12 pediatric practice s ( 6 intervention and 6 control sites ) . The main outcome measures were adherence to the CDC recommendations  ( modified to include 2 additional antimicrobial agents ) and a subsequent antibiotic prescription for AOM within 30 days after diagnosis . RESULTS . Of 3152 patients referred to research assistants , 2584 ( 82 % ) were eligible . Of those eligible , 1368 ( 99 % ) of 1382 at the intervention sites and 1138 ( 99 % ) of 1146 at the control sites consented to participate . Rates of adherence to the CDC recommendations were not significantly higher at the intervention sites than at the control sites , for initial enrollment episodes ( 78.2 % vs 70.6 % ) or second episodes ( 62.6 % vs 59.9 % ) . After controlling for clustering according to site and covariates , children who were not treated in adherence to the CDC recommendations for both episodes had 1.60 times the odds of a subsequent prescription within 12 days , compared with those treated in adherence at both episodes . CONCLUSIONS . Despite using evidence -based approaches that are known to influence physician behavior , we were unable to increase adherence to the CDC recommendations for treatment of AOM . However , we did establish that prescription of antimicrobial therapy consistent with the CDC recommendations for a second episode of AOM was associated with improved outcomes , measured as the need for subsequent antibiotic prescription . Because of the selection of resistant otopathogens , adherence to the CDC recommendations is likely more important in subsequent episodes of AOM than in the initial episode Abstract Objective : To assess the medicalising effect of prescribing antibiotics for sore throat . Setting : 11 general practice s in Engl and . Design : R and omised trial of three approaches to sore throat : a 10 day prescription of antibiotics , no antibiotics , or a delayed prescription if the sore throat had not started to settle after three days . Patients : 716 patients aged 4 and over with sore throat and an abnormal physical sign : 84 % had tonsillitis or pharyngitis . Outcome measures : Number and rate of patients making a first return with sore throat , pharyngitis , or tonsillitis . Early returns ( within two weeks ) and complications ( otitis media , sinusitis , quinsy ) . Outcomes were documented in 675 subjects ( 94 % ) . Results : Mean follow up time was similar ( antibiotic group 1.07 years , other two groups 1.03 years ) . More of those initially prescribed antibiotics initially returned to the surgery with sore throat ( 38 % v 27 % , adjusted hazard ratio for return 1.39 , 95 % confidence interval 1.03 to 1.89 ) . Antibiotics prescribed for sore throat during the previous year had an additional effect ( hazard ratio 1.69 , 1.20 to 2.37 ) . Longer duration of illness ( > 5 days ) was associated with increased return within six weeks ( hazard ratio 2.90 , 1.70 to 4.92 ) . Prior attendance with upper respiratory conditions was also associated with increased reattendance . There was no difference between groups in early return ( 13/238 ( 5.5 % ) v 27/437 ( 6 % ) ) , or complications ( 2/236 ( 0.8 % ) v3/434 ( 0.7 % ) ) . Conclusions : Complications and early return result ing from no or delayed prescribing of antibiotics for sore throat are rare . Both current and previous prescribing for sore throat increase reattendance . To avoid medicalising a self limiting illness doctors should avoid antibiotics or offer a delayed prescription for most patients with sore throat . Key messages Sore throat is one of the commonest presentations of upper respiratory illness in primary care and attendence is increasing Complications are rare with no , or delayed , antibiotic prescription Prescribing antibiotics increases reattendance for future episodes Unless patients are very ill general practitioners should consider exploring concerns , explain the natural history , and avoid or delay prescribing CONTEXT Prescribing practice s for otitis media are not consistent with current evidence -based recommendations . OBJECTIVE To determine whether point-of-care evidence delivery regarding the use and duration of antibiotics for otitis media decreases the duration of therapy from 10 days and decreases the frequency of prescriptions written . DESIGN R and omized , controlled trial . SETTING Primary care pediatric clinic affiliated with university training program . Intervention . A point-of-care evidence -based message system presenting real time evidence to providers based on their prescribing practice for otitis media . MAIN OUTCOME MEASURES Proportion of prescriptions for otitis media that were for < 10 days and frequency with which antibiotics were prescribed . RESULTS Intervention providers had a 34 % greater reduction in the proportion of time they prescribed antibiotics for < 10 days . Intervention providers were less likely to prescribe antibiotics than were control providers . CONCLUSIONS A point-of-care information system integrated into outpatient pediatric care can significantly influence provider behavior for a common condition A r and omised controlled trial involving 54 general practitioners ( GPs ) was conducted in Canberra , Australian Capital Territory from September 1997 to November 1999 . In the first year of the study , 24 GPs , who constituted the active arm of the intervention group , were involved in the consideration of evidence and the development and implementation of a set of clinical guidelines for the treatment of  acute respiratory infections . These guidelines were then endorsed in a meeting together with specialist colleagues . In the second year of the study the group of GPs who had been acting as controls , received a moderate intervention consisting of a brief educational event and distribution of the locally developed guidelines . We obtained data from January 1997 to December 1999 from the Health Insurance Commission on prescribing rates for 40 of the doctors in the study . The rate of prescribing was calculated as the number of antibiotic prescriptions per 100 Medicare services . The average yearly prescribing decreased significantly in the intensive intervention group and increased in the moderate intervention group , ( p=0.026 ) . A mixed effects longitudinal time series model was fitted to the data to account for seasonal variation of antibiotic prescribing and trends over time . The intensive intervention group significantly reduced their antibiotic prescribing over time compared to the moderate intervention group , ( p<0.001 ) . This study has shown that an intensive intervention in which general practitioners were actively engaged in development and consideration of the evidence base for the guidelines result ed in a significant fall in general antibiotic prescribing Objective To assess the effect of general practitioner testing for C reactive protein ( disease approach ) and receiving training in enhanced communication skills ( illness approach ) on antibiotic prescribing for lower respiratory tract infection . Design Pragmatic , 2 × 2 factorial , cluster r and omised controlled trial . Setting 20 general practice s in the Netherl and s. Participants 40 general practitioners from 20 practice s recruited 431 patients with lower respiratory tract infection . Main outcome measures The primary outcome was antibiotic prescribing at the index consultation . Secondary outcomes were antibiotic prescribing during 28 days ’ follow-up , reconsultation , clinical recovery , and patients ’ satisfaction and enablement . Interventions General practitioners ’ use of C reactive protein point of care testing and training in enhanced communication skills separately and combined , and usual care . Results General practitioners in the C reactive protein test group prescribed antibiotics to 31 % of patients compared with 53 % in the no test group ( P=0.02 ) . General practitioners trained in enhanced communication skills prescribed antibiotics to 27 % of patients compared with 54 % in the no training group ( P<0.01 ) . Both interventions showed a statistically significant effect on antibiotic prescribing at any point during the 28 days ’ follow-up . Clinicians in the combined intervention group prescribed antibiotics to 23 % of patients ( interaction term was non-significant ) . Patients ’ recovery and satisfaction were similar in all study groups . Conclusion Both general practitioners ’ use of point of care testing for C reactive protein and training in enhanced communication skills significantly reduced antibiotic prescribing for lower respiratory tract infection without compromising patients ’ recovery and satisfaction with 
    Output:
    
Interventions that combined parent education with clinician behaviour change  decreased antibiotic prescribing rates by between 6 - 21 % ; structuring the parent-clinician interaction during the consultation may further increase the effectiveness of these interventions .
Automatic computerised prescribing prompts increased prescribing appropriateness , while passive information , in the form of waiting room educational material s , yielded no benefit .
Conflicting evidence from the included studies found that interventions directed towards parents and /or clinicians can reduce rates of antibiotic prescribing .
The most effective interventions target both parents and clinicians during consultations , provide automatic prescribing prompts , and promote clinician leadership in the intervention design