***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 Because smoking has a profound impact on socioeconomic disparities in illness and death , it is crucial that vulnerable population s of smokers be targeted with treatment . The U.S. Public Health Service recommends that all patients be asked about their smoking at every visit and that smokers be given brief advice to quit and referred to treatment . PURPOSE Initiatives to facilitate these practice s include the 5A 's ( ask , advise , assess , assist , arrange ) and Ask-Advise-Refer ( AAR ) . Unfortunately , primary care referrals are low , and most smokers referred fail to enroll . This study evaluated the efficacy of the Ask-Advise-Connect ( AAC ) approach to linking smokers with treatment in a large , safety net public healthcare system . DESIGN The study design was a pair-matched group-r and omized trial with two treatment arms . SETTING / PARTICIPANTS Ten safety net clinics in Houston TX . INTERVENTION Clinics were r and omized to AAC ( n=5 ; intervention ) or AAR ( n=5 ; control ) . Licensed vocational nurses ( LVNs ) were trained to assess and record the smoking status of all patients at all visits in the electronic health record . Smokers were given brief advice to quit . In AAC , the names and phone numbers of smokers who agreed to be connected were sent electronically to the Texas quitline daily , and patients were proactively called by the quitline within 48 hours . In AAR , smokers were offered a quitline referral card and encouraged to call on their own . Data were collected between June 2010 and March 2012 and analyzed in 2012 . MAIN OUTCOME MEASURES The primary outcome was impact , defined here as the proportion of identified smokers that enrolled in treatment . RESULTS The impact ( proportion of identified smokers who enrolled in treatment ) of AAC ( 14.7 % ) was significantly greater than the impact of AAR ( 0.5 % ) , t(4)=14.61 , p=0.0001 , OR=32.10 ( 95 % CI=16.60 , 62.06 ) . CONCLUSIONS The AAC approach to aiding smoking cessation has tremendous potential to reduce tobacco-related health disparities Background To determine the effectiveness of a single checklist reminder form to improve the delivery of preventive health services at adult health check-ups in a family practice setting . Methods A prospect i ve cluster r and omized controlled trial was conducted at four urban family practice clinics among 38 primary care physicians affiliated with the University of Toronto .  Preventive Care Checklist Forms © were created to be used by family physicians at adult health check-ups over a five-month period . The sex-specific forms incorporate evidence -based recommendations on preventive health services and documentation space for routine procedures such as physical examination . The forms were used in two intervention clinics and two control clinics . Rates and relative risks ( RR ) of the performance of 13 preventive health maneuvers at baseline and post-intervention and the percentage of up-to- date preventive health services delivered per patient were compared between the two groups . Results R and omly-selected charts were review ed at baseline ( n = 509 ) and post-intervention ( n = 608 ) . Baseline rates for provision of preventive health services ranged from 3 % ( fecal occult blood testing ) to 93 % ( blood pressure measurement ) , similar to other setting s. The percentage of up-to- date preventive health services delivered per patient at the end of the intervention was 48.9 % in the control group and 71.7 % in the intervention group . This is an overall 22.8 % absolute increase ( p = 0.0001 ) , and 46.6 % relative increase in the delivery of preventive health services per patient in the intervention group compared to controls . Eight of thirteen preventive health services showed a statistically significant change ( p < 0.05 ) in favor of the intervention ( adjusted RR ( 95 % C.I. ) ) :  counseling on brushing/flossing teeth  ( 9.2 ( 4.3–19.6 ) ) ,  folic acid counseling  ( 7.5 ( 2.7–20.8 ) ) , fecal occult blood testing ( 6.7 ( 1.9–24.1 ) ) , smoking cessation counseling ( 3.9 ( 2.2–7.2 ) ) , tetanus immunization ( 3.0 ( 1.7–5.2 ) ) , history of alcohol intake ( 1.33 ( 1.2–1.5 ) ) , history of smoking habits ( 1.28 ( 1.2–1.4 ) ) and blood pressure measurement ( 1.05 ( 1.00–1.10 ) ) . Conclusion This simple , low cost , clinical ly relevant intervention improves the delivery of preventive health services by prompting physicians of evidence -based recommendations in a checklist format that incorporates existing practice patterns . Periodic up date s of the Preventive Care Checklist Forms © will allow a feasible and easy-to-use tool for primary care physicians to provide evidence -based preventive health services to adults at routine health check-ups . The forms can also be incorporated into an electronic health record . The Preventive Care Checklist Forms © are accessible in English and French at the College of Family Physicians of Canada web site OBJECTIVE To test the effectiveness of a care coordination program for telephone counseling in raising referral and treatment rates for  smoking cessation . STUDY DESIGN A demonstration project implementing a smoking cessation care coordination program offering telephone counseling and medication management to patients referred from primary care . METHODS The study was performed at 18 Veterans Health Administration ( VA ) sites in California . Participants were VA patients receiving primary care . We r and omly allocated 10 of 18 sites to receive the Telephone Care Coordination Program , which included simple 2-click referral , proactive care coordination , medication management , and 5 follow-up telephone calls . Each patient received a 30- to 45-minute counseling session from the California Smokers ' Helpline . Patients at control sites received usual care . RESULTS During 10 months , we received 2965 referrals . We were unable to reach 1156 patients ( 39 % ) , despite at least 3 attempts . We excluded 73 patients ( 3 % ) , and 391 patients ( 13 % ) were not interested . We connected the remaining 1345 patients ( 45 % ) to the Helpline . At 6-month followup , 335 patients ( 11 % of all referrals and 25 % of participating patients ) were abstinent . Providers at intervention sites reported referring many more patients to telephone counseling than providers at control sites ( 15.6 vs 0.7 in the prior month ) . CONCLUSIONS The program generated a large number of referrals ; almost half of the patients referred were connected with the Helpline . Long-term abstinence was excellent . These results suggest that managed care organizations may be able to improve tobacco control by implementing a similar system of care coordination Background : Strategies to improve smoking cessation counseling in clinical setting s are critical to supporting smokers ’ attempts to quit . This study evaluates the impact of adding 2 smoking-related vital sign questions in an electronic medical records system on identification , assessment , and counseling for patients who smoke : “ Current smoker ? ” and “ Plan to quit ? ” Methods : Baseline data and data after intervention were collected through record review of 899 r and omly selected patient visits across 3 outpatient clinics . Results : From before to after intervention , identification of smokers increased 18 % ( from 71 % to 84 % ; P < .001 ) , and assessment for a plan to quit increased 100 % ( from 25.5 % to 51 % ; P < .005 ) . Among all smokers , cessation counseling increased 26 % ( from 23.6 % to 29.8 % ; P = .41 ) . Significantly more smokers who received the  assessment for a plan to quit received cessation counseling ( 46 % vs. 14 % , P < .001 ) . Regression analysis showed that patients receiving an  assessment for plan to quit were 80 % more likely to receive cessation counseling ( OR 0.209 ; 95 % CI , 0.095–0.456 ) . Conclusions : Physician-documented counseling rates are significantly higher when patients are asked about smoking and assessed for a plan to quit . Two questions that ask about smoking status and assess plans to quit may provide prompts to increase the likelihood that patients who smoke receive cessation counseling OBJECTIVE To evaluate the impact of a locally adapted evidence -based quality improvement ( EBQI ) approach to implementation of smoking cessation guidelines into routine practice . DATA SOURCES / STUDY SETTING We used patient question naires , practice surveys , and administrative data in Veterans Health Administration ( VA ) primary care practice s across five southwestern states . STUDY DESIGN In a group-r and omized trial of 18 VA facilities , matched on size and academic affiliation , we evaluated intervention practice s ' abilities to implement evidence -based smoking cessation care following structured evidence review , local priority setting , quality improvement plan development , practice facilitation , expert feedback , and monitoring . Control practice s received mailed guidelines and VA audit-feedback reports as usual care . DATA COLLECTION To represent the population of primary care-based smokers , we r and omly sample d and screened 36,445 patients to identify and enroll eligible smokers at baseline ( n=1,941 ) and follow-up at 12 months ( n=1,080 ) . We used computer-assisted telephone interviewing to collect smoking behavior , nicotine dependence , readiness to change , health status , and patient sociodemographics . We used practice surveys to measure structure and process changes , and administrative data to assess population utilization patterns . PRINCIPAL FINDINGS Intervention practice s adopted multifaceted EBQI plans , but had difficulty implementing them , ultimately focusing on smoking cessation clinic referral strategies . While attendance rates increased ( p<.0001 ) , we found no intervention effect on smoking cessation . CONCLUSIONS EBQI stimulated practice s to increase smoking cessation clinic referrals and try other less evidence -based interventions that did not translate into improved quit rates at a population level Cluster r and omized trials are increasingly common in general practice ( family medicine ) . This paper will consider the design and analysis of such trials and emphasize the similarities and differences with trials in education , heath promotion and public health . Issues discussed are the estimation and range of values of the intra-cluster correlation coefficient found in general practice , and the associated sample size problems . There are problems with widely varying numbers of subjects per cluster , which leads to planning and analysis difficulties . Ethical issues in these trials , and considerations such as the principle of intention to treat are also considered . An example of the type of analysis available for a continuous outcome variable is given , and the available software is summarized briefly IMPORTANCE Several national health care-based smoking cessation initiatives have been recommended to facilitate the delivery of evidence -based treatments , such as quitline ( telephone-based tobacco cessation services ) assistance . The most notable examples are the 5 As ( Ask , Advise , Assess , Assist , Arrange ) and Ask . Advise . Refer . ( AAR ) programs . Unfortunately , rates of primary care referrals to quitlines are low , and most referred smokers fail to call for assistance . OBJECTIVE To evaluate a new approach -- Ask-Advise-Connect (AAC)-- design ed to address barriers to linking smokers with treatment . DESIGN A pair-matched , 2-treatment-arm , group-r and omized design in 10 family practice clinics in a single metropolitan area . Five clinics were r and omized to the AAC ( intervention ) and 5 to the AAR ( control ) conditions . In both conditions , clinic staff were trained to assess and record the smoking status of all patients at all visits in the electronic health record , and smokers were given brief advice to quit . In the AAC clinics , the names and telephone numbers of smokers who agreed to be connected were sent electronically to the quitline daily , and patients were called proactively by the quitline within 48 hours . In the AAR clinics , smokers were offered a quitline referral card and encouraged to call on their own . All data were collected from February 8 through December 27 , 2011 . SETTING Ten clinics in Houston , Texas . PARTICIPANTS Smoking status assessment s were completed for 42,277 patients ; 2052 unique smokers were identified at AAC clinics , and 1611 smokers were identified at AAR clinics . INTERVENTIONS Linking smokers with quitline-delivered treatment . MAIN OUTCOME MEASURE Impact was based on the RE- AIM ( Reach , Efficacy , Adoption , Implementation , and Maintenance ) conceptual framework and defined as the proportion of all identified smokers who enrolled in treatment . RESULTS In the AAC clinics , 7.8 % of all identified smokers enrolled in treatment vs 0.6 % in the AAR clinics ( t4 = 9.19 [ P < .001 ] ; odds ratio , 11.60 [ 95 % CI , 5.53 - 24.32 ] ) , a 13-fold increase in the proportion of smokers enrolling in treatment . CONCLUSIONS AND RELEVANCE The system changes implemented in the AAC approach could be adopted broadly by other health care systems and have tremendous potential to reduce tobacco-related morbidity and mortality BACKGROUND Preventive care is an important role for general practitioners , yet opportunities for prevention are often missed . METHOD We provided an automatic electronic record preventive care reminder system for  12 preventive care activities for one 10 doctor practice . All patients who attended were r and omised by 
    Output:
    
Overall , these studies found only modest improvements in some of the recommended clinician actions on tobacco use .
AUTHORS ' CONCLUSIONS Documentation of tobacco status and referral to cessation counselling appears to increase following EHR modifications design ed to prompt the recording and treating of tobacco use at healthcare visits .