***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: CONTEXT A rigorous evaluation of continuous quality improvement ( CQI ) in medical practice has not been carried out on a national scale . OBJECTIVE To test whether low-intensity CQI interventions can be used to speed the national adoption of 2  coronary artery bypass graft (  CABG  )  surgery process-of-care measures : preoperative beta-blockade therapy and internal mammary artery ( IMA ) grafting in patients 75 years or older . DESIGN , SETTING , AND PARTICIPANTS Three hundred fifty-nine academic and nonacademic hospitals ( treating 267 917 patients using CABG surgery ) participating in the Society of Thoracic Surgeons National Cardiac Data base between January 2000 and July 2002 were r and omized to a control arm or to 1 of 2 groups that used CQI interventions design ed to increase use of the process-of-care measures . INTERVENTION Each intervention group received measure-specific information , including a call to action to a physician leader ; educational products ; and periodic longitudinal , nationally benchmarked , site-specific feedback . MAIN OUTCOME MEASURE Differential incorporation of the targeted care processes into practice at the intervention sites vs the control sites , assessed by measuring preintervention ( January-December 2000)/postintervention ( January 2001-July 2002 ) site differences and by using a hierarchical patient-level analysis . RESULTS From January 2000 to July 2002 , use of both process measures increased nationally ( beta-blockade , 60.0%-65.6 % ; IMA grafting , 76.2%-82.8 % ) . Use of beta-blockade increased significantly more at beta-blockade intervention sites ( 7.3 % [ SD , 12.8 % ] ) vs control sites ( 3.6 % [ SD , 11.5 % ] ) in the preintervention/postintervention ( P = .04 ) and hierarchical analyses ( P<.001 ) . Use of IMA grafting also tended to increase at IMA intervention sites ( 8.7 % [ SD , 17.5 % ] ) vs control sites ( 5.4 % [ SD,15.8 % ] ) ( P = .20 and P = .11 for preintervention/postintervention and hierarchical analyses , respectively ) . Both interventions tended to have more impact at lower-volume CABG sites ( for interaction : P = .04 for beta-blockade ; P = .02 for IMA grafting ) . CONCLUSIONS A multifaceted , physician-led , low-intensity CQI effort can improve the adoption of care processes into national practice within the context of a medical specialty society infrastructure 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 Background — Adherence to evidence -based guidelines for treatment of stroke or transient ischemic attack is suboptimal . We sought to establish whether participation in Get With the Guidelines –Stroke was associated with improvements in adherence . Methods and Results — This prospect i ve , nonr and omized , national quality improvement program measured adherence to guideline recommendations in 322 847 hospitalized patients discharged with a diagnosis of ischemic stroke or transient ischemic attack . A volunteer sample of 790 US academic and community hospitals participated from 2003 through 2007 . The main outcome measures were change in adherence over time to 7 prespecified performance measures and a composite measure ( total number of interventions provided in eligible patients divided by total number of care opportunities among eligible patients ) . Generalized estimating equations were used to identify factors associated with improvement . Participation in Get With the Guidelines –Stroke was associated with improvements in the 7 individual and 1 composite measures from baseline to the fifth year : intravenous thrombolytics ( 42.09 % versus 72.84 % ) , early antithrombotics ( 91.46 % versus 97.04 % ) , deep vein thrombosis prophylaxis ( 73.79 % versus 89.54 % ) , discharge antithrombotics ( 95.68 % versus 98.88 % ) , anticoagulation for atrial fibrillation ( 95.03 % versus 98.39 % ) , lipid treatment for low-density lipoprotein > 100 mg/dL ( 73.63 % versus 88.29 % ) , smoking cessation ( 65.21 % versus 93.61 % ) , and composite ( 83.52 % versus 93.97 % ) ( P<0.0001 for all comparisons ) . Multivariate analysis showed that time in Get With the Guidelines –Stroke was associated with a 1.18-fold yearly increase in the odds of fulfilling care opportunities that was independent of secular trends . Conclusions — Get With the Guidelines –Stroke participation was associated with increased adherence to all stroke performance measures . Markedly improved stroke care was seen in all hospitals regardless of size , geography , and teaching status Background and Purpose — Limited information is available on stroke management in developing countries . An accurate monitoring of quality of stroke care will become crucial , particularly with the emerging paradigm of pay-for-performance . Our aim was to explore the feasibility of measuring st and ardized indicators of quality of ischemic stroke care in acute care facilities in Argentina . Methods — ReNACer is a prospect i ve , multicenter , countrywide , stroke registry comprising 74 academic and nonacademic institutions in Argentina . The registry includes patient-level information on demography , clinical characteristics , diagnostic procedures , treatment , and the selected key performance indicators of quality of ischemic stroke care ( access to  thrombolysis or aspirin  use in the acute setting , admission to design ated stroke units , length of stay , risk-adjusted in-hospital pneumonia , risk-adjusted in-hospital mortality , discharge on  antithrombotics  , and antihypertensive agents )  . Results — We included 1991 patients with ischemic stroke from 74 institutions in Argentina between November 2004 and October 2006 . Seventy-nine per cent of the patients were prescribed antithrombotic therapy within 48 hours of admission , but only 1 % received thrombolytics . No more than 5.7 % were admitted to stroke units . In-hospital pneumonia was diagnosed in 14.3 % of the patients and was higher in nonacademic facilities ( 16.4 % versus 11.4 % , P<0.02 ) . The overall adjusted in-hospital mortality was 9.1 % , also higher in nonacademic hospitals ( 10.6 % versus 7.1 % , P<0.008 ) . At discharge ,  antithrombotics  were prescribed in 90.2 % and antihypertensive agents in 63.6 % of the patients . Conclusions — In ReNACer , there was a limited access to stroke units and thrombolytics , and a relatively high incidence of in-hospital pneumonia . Differences in stroke care were observed between academic and nonacademic institutions . There is an urgent need to develop national stroke programs in Argentina Cardiovascular disease remains the primary cause of mortality , and a major cause of disability in the developed world.1 This significant burden necessitates ongoing improvements in patient management , to minimize the impact of cardiovascular conditions on both patients and healthcare systems . These improvements in cardiovascular care are promoted by an evidence -based approach , shaped by comprehensive clinical guidelines . The scientific basis of recommendations is an important feature of clinical guidelines , and influences the degree to which they are followed in clinical practice .2 Recent studies have assigned the highest evidence grading to r and omized controlled trials ( RCTs ) that are clinical ly important , and representative of the clinical population covered by the guideline recommendation .3 For example , this highest grading was assigned to a recommendation based on a meta- analysis of RCTs showing low-dose diuretics to be the most effective first-line treatment for cardiovascular event prevention in hypertensive patients . This study review ed data from 42 RCTs which were , crucially , representative of the population that the recommendation was made for ( i.e. hypertensive patients ) .3,4 The importance of the applicability of evidence to recommendations highlights the need to consider evidence from clinical ly relevant situations , not all of which have been assessed by RCTs . This evidence can originate from expert consensus , as well as non-r and omized prospect i ve studies . Although generally providing a lower evidence -level than RCTs , 3,5 observational studies can make an important contribution to the evidence base when the study outcomes are clinical ly important , and the population s involved are representative . Indeed , information from several registries was considered in the recent American Heart Association Acute Coronary Care in the Elderly Scientific Statement.6 Non-r and omized prospect i ve registries document the treatment and outcomes for consecutive patients in clinical practice . Therefore , data are gained from a ‘ real-world ’ selection of patients , many of whom would be excluded from RCTs , OBJECTIVE To estimate the effect of multicentre surveillance for nosocomial infections on  patients ' risk of surgical site infection ( SSI ) .  DESIGN Prospect i ve multi-centre cohort study , from January 1996 to December 2000 . SETTING Acute care hospitals in The Netherl and s. STUDY PARTICIPANTS All 50 hospitals performing surveillance for one of seven selected procedures in the Dutch surveillance network for nosocomial infections PREZIES were invited . Thirty-seven hospitals participated ( 74 % ) and provided information on 21 920 operations , after which 885 ( 4 % ) SSI occurred . INTERVENTIONS The surveillance comprised the following : Development of surveillance methodology by multidisciplinary team ; use of a st and ardized registration protocol and software ; regular training of data collectors ; anonymous inter-hospital comparison of infection rates and feedback of results ; appointment of one contact person per hospital , responsible for data collection ; and dissemination of results to other health care professionals . Regular discussion of both successful and failing prevention strategies that had been instituted based on the surveillance results . OUTCOME MEASURE Risk of SSI . RESULTS The risk of infection was reduced for patients who had an operation during the fourth surveillance year ( RR = 0.69 ; 95 % confidence interval ( CI ) = 0.52 - 0.89 ) and decreased further for patients operated on during the fifth surveillance year ( RR = 0.43 ; CI = 0.24 - 0.76 ) as compared with patients who underwent surgery within one year of the start of surveillance in their hospital . No significant risk reduction was observed for patients operated on during the second and third surveillance years . CONCLUSION Surveillance , supported by participation in a surveillance network , reduced the risk of SSI in surgical patients registered in the Dutch surveillance network PREZIES . Our results suggest that infection control teams need to be perseverant and that surveillance programmes should be given time before evaluation Background — A treatment gap exists between heart failure ( HF ) guidelines and the clinical care of patients . The Registry to Improve the Use of Evidence -Based Heart Failure Therapies in the Outpatient Setting ( IMPROVE HF ) prospect ively tested a multidimensional practice -specific performance improvement intervention on the use of 
    Output:
    
The measures of impact of registries were multifarious and included change in processes of care , quality of care , treatment outcomes , adherence to guidelines and survival .
Despite the large number of published articles using data derived from CQRs , few have rigorously evaluated the impact of the registry as an intervention on improving health outcomes .
Those that have evaluated this impact have mostly found a positive impact on healthcare processes and outcomes .