***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 and Purpose — Thrombolysis with intravenous recombinant tissue plasminogen activator is an effective treatment for acute ischemic stroke , but the number of treatable patients is limited . The PRomoting ACute Thrombolysis in Ischemic StrokE ( PRACTISE ) trial evaluated the effectiveness of a multidimensional implementation strategy for thrombolysis with intravenous recombinant tissue plasminogen activator in acute ischemic stroke . Methods — The PRACTISE trial was a national multicenter cluster-r and omized controlled trial with r and omization after pairwise matching . Twelve hospitals , both urban and community , academic and nonacademic , in the Netherl and s participated . All patients admitted with stroke within 24 hours from onset of symptoms were registered . The intervention included 5 implementation meetings based on the Breakthrough Series model . The primary outcome was treatment with thrombolysis . Secondary outcomes were admission within 4 hours after onset of symptoms , death or disability at 3 months , and quality of life . Results — Overall 5515 patients were included in the study ' 308 patients ( 12.2 % ) in the control centers and 393 patients ( 13.1 % ) in the intervention centers were treated with thrombolysis ( adjusted OR , 1.25 ; 95 % CI , 0.93 to 1.68 ) . Among the 1657 patients with ischemic stroke admitted within 4 hours from onset , 391 ( 44.5 % ) of 880 in the intervention centers were treated with thrombolysis and 305 ( 39.3 % ) of 777 in the control centers ; the adjusted OR for treatment with thrombolysis was 1.58 ( 95 % CI , 1.11 to 2.27 ) . Conclusions — An intensive implementation strategy increases the proportion of patients with acute stroke treated with thrombolysis in real-life setting s. An apparently pivotal factor in the improvement of the treatment rate is better application of contraindications for thrombolysis BACKGROUND The adherence to evidence -based treatment guidelines for acute myocardial infa rct ion ( AMI ) is still suboptimal . Therefore , we design ed a study to evaluate the effects of a collaborative quality improvement ( QI ) intervention on the adherence to AMI guidelines . The intervention used a national web-based quality registry to generate local and regular real-time performance feedback . METHODS A 12-month baseline measurement of the adherence rates was retrospectively collected , comprising the period July 1 , 2001 , through June 30 , 2002 . During the intervention period of November 1 , 2002 , through April 30 , 2003 , multidisciplinary teams from 19 nonr and omized intervention hospitals were subjected to a multifaceted QI-oriented intervention .  Another 19 hospitals , unaware of their status as controls , were matched to the intervention hospitals . During the postintervention measurement period of May 1 , 2003 , through April 30 , 2004 , a total of 6726 consecutive patients were included at the intervention ( n = 3786 ) and control ( n = 2940 ) hospitals . The outcome measures comprised 5 Swedish national guideline -derived quality indicators , compared between baseline and postintervention levels in the control and QUICC intervention hospitals . RESULTS In the control and QI intervention hospitals , the mean absolute increase of patients receiving angiotensin-converting enzyme inhibitors was 1.4 % vs 12.6 % ( P = .002 ) , lipid-lowering therapy 2.3 % vs 7.2 % ( P = .065 ) , clopidogrel 26.3 % vs 41.2 % ( P = .010 ) , heparin/low-molecular weight heparin 5.3 % vs 16.3 % ( P = .010 ) , and coronary angiography 6.2 % vs 16.8 % ( P = .027 ) , respectively . The number of QI intervention hospitals reaching a treatment level of at least 70 % in 4 or 5 of the 5 indicators was 15 and 5 , respectively . In the control group , no hospital reached 70 % or more in just 4 of the 5 indicators . CONCLUSIONS By combining a systematic and multidisciplinary QI collaborative with a web-based national quality registry with functionality allowing real-time performance feedback , major improvements in the adherence to national AMI guidelines can be achieved Objective Continuous quality improvement ( CQI ) methods are foundational approaches to improving healthcare delivery . Publications using the term CQI , however , are method ologically heterogeneous , and labels other than CQI are used to signify relevant approaches . St and ards for identifying the use of CQI based on its key method ological features could enable more effective learning across quality improvement ( QI ) efforts . The objective was to identify essential method ological features for recognizing CQI . Design Previous work with a 12-member international expert panel identified reliably abstract ed CQI method ological features . We tested which features met rigorous a priori st and ards as essential features of CQI using a three-phase online modified-Delphi process . Setting Primarily United States and Canada . Participants 119 QI experts r and omly assigned into four on-line panels . Intervention(s ) Participants rated  CQI features and discussed their answers using online , anonymous and asynchronous discussion boards . We analyzed ratings quantitatively and discussion threads qualitatively . Main outcome measure(s ) Panel consensus on definitional CQI features . Results Seventy-nine ( 66 % ) panelists completed the process . Thirty-three completers self-identified as QI research ers , 18 as QI practitioners and 28 as both equally . The features ‘ systematic data guided activities , ’ ‘ design ing with local conditions in mind ’ and ‘ iterative development and testing ’ met a priori st and ards as essential CQI features . Qualitative analyses showed cross-cutting themes focused on differences between QI and CQI . Conclusions We found consensus among a broad group of CQI research ers and practitioners on three features as essential for identifying QI work more specifically as ‘ CQI . ’ All three features are needed as a minimum st and ard for recognizing CQI methods Importance Wide heterogeneity exists in acute myocardial infa rct ion treatment and outcomes in India . Objective To evaluate the effect of a locally adapted quality improvement tool kit on clinical outcomes and process measures in Kerala , a southern Indian state . Design , Setting , and Participants Cluster r and omized , stepped-wedge clinical trial conducted between November 10 , 2014 , and November 9 , 2016 , in 63 hospitals in Kerala , India , with a last date of follow-up of December 31 , 2016 . During 5 predefined steps over the study period , hospitals were r and omly selected to move in a 1-way crossover from the control group to the intervention group . Consecutively presenting patients with acute myocardial infa rct ion were offered participation . Interventions Hospitals provided either usual care ( control group ; n = 10 066 participants [ step 0 : n = 2915 ; step 1 : n = 2649 ; step 2 : n = 2251 ; step 3 : n = 1422 ; step 4 ; n = 829 ; step 5 : n = 0 ] ) or care using a quality improvement tool kit ( intervention group ; n = 11 308 participants [ step 0 : n = 0 ; step 1 : n = 662 ; step 2 : n = 1265 ; step 3 : n = 2432 ; step 4 : n = 3214 ; step 5 : n = 3735 ] ) that consisted of audit and feedback , checklists , patient education material s , and linkage to emergency cardiovascular care and quality improvement training . Main Outcomes and Measures The primary outcome was the composite of all-cause death , reinfa rct ion , stroke , or major bleeding using st and ardized definitions at 30 days . Secondary outcomes included the primary outcome ’s individual components , 30-day cardiovascular death , medication use , and tobacco cessation counseling . Mixed-effects logistic regression models were used to account for clustering and temporal trends . Results Among 21 374 eligible r and omized participants ( mean age , 60.6 [ SD , 12.0 ] years ; n = 16 183 men [ 76 % ] ; n = 13 689 [ 64 % ] with ST-segment elevation myocardial infa rct ion ) , 21 079 ( 99 % ) completed the trial . The primary composite outcome was observed in 5.3 % of the intervention participants and 6.4 % of the control participants . The observed difference in 30-day major adverse cardiovascular event rates between the groups was not statistically significant after adjustment ( adjusted risk difference , −0.09 % [ 95 % CI , −1.32 % to 1.14 % ] ; adjusted odds ratio , 0.98 [ 95 % CI , 0.80 - 1.21 ] ) . The intervention group had a higher rate of medication use including reperfusion but no effect on tobacco cessation counseling . There were no unexpected adverse events reported . Conclusions and Relevance Among patients with acute myocardial infa rct ion in Kerala , India , use of a quality improvement intervention compared with usual care did not decrease a composite of 30-day major adverse cardiovascular events . Further research is needed to underst and the lack of efficacy . Trial Registration clinical trials.gov Identifier : Background : Retention in care is critical for improving HIV-infected maternal outcomes and reducing vertical transmission . Health systems ' interventions such as continuous quality improvement ( CQI ) may support health services to address factors that affect the delivery of HIV-related care and thereby influence rates of retention-in-care . Methodology : We evaluated the effect of a CQI intervention on retention-in-care at 6 months postpartum of pregnant women and mothers living with HIV who had been started on lifelong antiretroviral treatment . Thirty-two health care facilities were r and omized to either implement the intervention or not . We considered women fully retained in care when they attended the 6-month postpartum visit and did not miss any previous scheduled visit by more than 30 days . Results : Five hundred eleven women living with HIV attending antenatal clinics at 26 facilities were included in the analysis . Median age at enrolment was 27 years and gestational age was 20 weeks . Seventy-one percent of women were seen at 6-month postpartum irrespective of missing any scheduled visit . However , 43 % of women were fully retained at 6-month postpartum and did not miss any scheduled visit based on our stringent study definition of retention . There was no significant difference in retention at 6 months between the intervention and control arms [ 44 % vs. 41 % , relative risk : 1.08 ; 95 % confidence interval ( CI ) : 0.78 to 1.49 ] . Initiation of ARV prophylaxis among infants within 72 hours was not different by study arm ( 66.0 % vs. 74.7 % , relative risk = 0.95 ; 95 % CI : 0.84 to 1.07 ) but rates of early infant testing at 4–6 weeks were higher in intervention sites ( 48.8 % vs. 25.3 % , adjusted relative risk : 1.76 ; 95 % CI : 1.27 to 2.42 ) . Conclusions : CQI as implemented in this study did not differ across study arms in the rates of retention . Several intervention design or implementation issues or other context ual constraints may explain the absence of effect Continuous quality improvement ( CQI ) has grown in the U.S. since the 1970s , yet little is known about the costs to implement CQI in substance abuse treatment facilities . This paper is part of a larger group r and omized control trial in a large urban county evaluating the impact of Plan- Study -Do-Act (PDSA)-CQI design ed for community service organizations ( Hunter , Ober , Paddock , Hunt , & Levan , 2014 ) . Operated by one umbrella organization , each of the eight facilities of the study , four residential and four outpatient substance abuse treatment facilities , selected their own CQI Actions , including administrative- and clinical care-related Actions . Using an activity-based costing approach , we collected labor and supplies and equipment costs directly attributable to CQI Actions over a 12-month trial period . Our study finds implementation of CQI and meeting costs of this trial per facility were approximately $ 2000 to $ 10,500 per year ( $ 4500 on average ) , or $ 10 to $ 60 per admitted client . We provide a description of the sources of variation in these costs , including differing intensity of the CQI Actions selected , which should help decision makers plan use of PDSA-CQI OBJECTIVE To test a quality improvement intervention , a learning collaborative based on the Institute for Healthcare Improvement 's Breakthrough Series methodology , specifically intended to improve care and outcomes for patients with childhood asthma . DESIGN R and omized trial in primary care practice s. SETTING Practice s in greater Boston , Mass , and greater Detroit , Mich. PARTICIPANTS Forty-three practice s , with 13 878 pediatric patients with asthma , r and omized to intervention and control groups . Intervention Participation in a learning collaborative project based on the Breakthrough Series methodology of continuous quality improvement . MAIN OUTCOME MEASURES Change from baseline in the proportion of children with persistent asthma who 
    Output:
    
Findings suggested that the benefits of CQI compared to a non-CQI comparator on clinical process , patient , and other outcomes were limited , with less than half of RCTs showing any effect .
Where benefits were evident , it was usually on clinical process measures , with the model used ( i.e. , Plan-Do- Study -Act , Model of Improvement ) , the meeting type ( i.e. , involving leaders discussing implementation ) and their frequency ( i.e. , weekly ) having an effect .
None considered socio-economic health inequalities .