***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 The aim of the SPHERE study is to design , implement and evaluate tailored practice and personal care plans to improve the process of care and objective clinical outcomes for patients with established coronary heart disease ( CHD ) in general practice across two different health systems on the isl and of Irel and .CHD is a common cause of death and a significant cause of morbidity in Irel and . Secondary prevention has been recommended as a key strategy for reducing levels of CHD mortality and general practice has been highlighted as an ideal setting for secondary prevention initiatives . Current indications suggest that there is considerable room for improvement in the provision of secondary prevention for patients with established heart disease on the isl and of Irel and . The review literature recommends structured programmes with continued support and follow-up of patients ; the provision of training , tailored to practice needs of access to evidence of effectiveness of secondary prevention ; structured recall programmes that also take account of individual practice needs ; and patient-centred consultations accompanied by attention to disease management guidelines . Methods SPHERE is a cluster r and omised controlled trial , with practice -level r and omisation to intervention and control groups , recruiting 960 patients from 48 practice s in three study centres ( Belfast , Dublin and Galway ) . Primary outcomes are blood pressure , total cholesterol , physical and mental health status ( SF-12 ) and hospital re-admissions . The intervention takes place over two years and data is collected at baseline , one-year and two-year follow-up . Data is obtained from medical charts , consultations with practitioners , and patient postal question naires . The SPHERE intervention involves the implementation of a structured systematic programme of care for patients with CHD attending general practice . It is a multi-faceted intervention that has been developed to respond to barriers and solutions to optimal secondary prevention identified in preliminary qualitative research with practitioners and patients . General practitioners and practice nurses attend training sessions in facilitating behaviour change and medication prescribing guidelines for secondary prevention of CHD . Patients are invited to attend regular four-monthly consultations over two years , during which targets and goals for secondary prevention are set and review ed . The analysis will be strengthened by economic , policy and qualitative components Abstract Objective : To compare the effect of individual educational visits versus group visits using academic detailing to discuss prescribing of highly anticholinergic antidepressants in elderly people . Design : R and omised controlled trial with three arms ( individual visits , group visits , and a control arm ) . Setting : Southwest Netherl and s. Participants : 190 general practitioners and 37 pharmacists organised in 21 peer review groups were studied using a data base covering all prescriptions to people covered by national health insurance in the area ( about 240 000 ) . Intervention : All general practitioners and pharmacists in both intervention arms were offered two educational visits . For physicians in groups r and omised to the individual visit arm , 43 of 70 general practitioners participated ; in the group visit intervention arm , five of seven groups ( 41 of 52 general practitioners ) participated . Main outcome measures : Numbers of elderly people ( 60 years ) with new prescriptions of highly anticholinergic antidepressants and less anticholinergic antidepressants . Results : An intention to treat analysis found a 26 % reduction in the rate of starting highly anticholinergic antidepressants in elderly people ( 95 % confidence interval —4 % to 48 % ) in the individual intervention arm and 45 % ( 8 % to 67 % ) in the group intervention arm . The use of less anticholinergic antidepressants increased by 40 % ( 6 % to 83 % ) in the individual intervention arm and 29 % ( —7 % to 79 % ) in the group intervention arm . Conclusions : Both the individual and the group visits decreased the use of highly anticholinergic antidepressants and increased the use of less anticholinergic antidepressant in elderly people . These approaches are practical means to improve prescribing by continuing medical education BACKGROUND Antibiotic misuse is common and costly and may promote antibiotic resistance . We tested the efficacy of a targeted one-on-one educational program ( " academic detailing " ) design ed to improve the appropriateness of broad-spectrum antibiotic use . METHODS A r and omized controlled trial was conducted in a large US teaching hospital . During an 18-week study period , 17 general medical , oncology , and cardiology services either received academic detailing or did not . The intervention was prompted by an order for either levofloxacin or ceftazidime that led to a computer-based review of data for that patient . Orders for the 2 target antibiotics deemed unnecessary by a priori criteria were included in the study . The primary outcome examined was the number of days that unnecessary levofloxacin or ceftazidime was administered in intervention and control groups . RESULTS Before the trial , intervention and control services had similar prescribing patterns for the target antibiotics ; the drugs were used for similar indications throughout the study period . During the intervention , there was a reduction of 37 % in days of unnecessary levofloxacin or ceftazidime use per 2-week interval on services r and omized to the educational intervention vs control services ( P < .001 ) . In multivariable analyses controlling for baseline prescribing and study interval , the rate of unnecessary use of the 2 target antibiotics was reduced by 41 % on the intervention services compared with controls ( 95 % confidence interval , 44%-78 % ; P < .001 ) . Length of stay , intensive care unit transfers , readmission rates , and in-hospital death rates were similar in both groups ( P > or = .10 for all ) . CONCLUSION Targeted one-on-one education is a practical , effective , and safe method for reducing excessive broad-spectrum antibiotic use Background Patients in hospitals and nursing homes are at risk of the development of , often preventable , adverse events ( AEs ) , which threaten patient safety . Guidelines for prevention of many types of AEs are available , however , compliance with these guidelines appears to be lacking . Besides general barriers that inhibit implementation , this non-compliance is associated with the large number of guidelines competing for attention . As implementation of a guideline is time-consuming , it is difficult for organisations to implement all available guidelines . Another problem is lack of feedback about performance using quality indicators of guideline based care and lack of a recognisable , unambiguous system for implementation . A program that allows organisations to implement multiple guidelines simultaneously may facilitate guideline use and thus improve patient safety . The aim of this study is to develop and test such an integral patient safety program that addresses several AEs simultaneously in hospitals and nursing homes . This paper reports the design of this study . Methods and design The patient safety program addresses three AEs : pressure ulcers , falls and urinary tract infections . It consists of bundles and outcome and process indicators based on the existing evidence based guidelines . In addition it includes a multifaceted tailored implementation strategy : education , patient involvement , and a computerized registration and feedback system . The patient safety program was tested in a cluster r and omised trial on ten hospital wards and ten nursing home wards . The baseline period was three months followed by the implementation of the patient safety program for fourteen months . Subsequently the follow-up period was nine months . Primary outcome measure was the incidence of AEs on every ward . Secondary outcome measures were the utilization of preventive interventions and the knowledge of nurses regarding the three topics . R and omisation took place on ward level . The results will be analysed separately for hospitals and nursing homes . Discussion Major challenges were the development of the patient safety program including a digital registration and feedback system and the implementation of the patient safety program . Trial registration Trial registration : Clinical Trials.gov ID [ NCT00365430 BACKGROUND A cluster r and omized trial of tailored interventions to support the implementation of guidelines for  sore throat and urinary tract infection  found little or no change in the main outcomes , which were antibiotic prescriptions , use of laboratory tests and use of telephone consultations . There was great variation between the practice s in the change in these outcomes . OBJECTIVES Our aim was to evaluate how the interventions were received and to underst and why practice s did or did not change . METHODS The trial was conducted in general practice s in Norway . Data for this process evaluation were collected from the 120 practice s that completed the trial . Multiple methods were used : observations , semi-structured telephone interviews , a postal survey and data extracted from electronic medical records . We investigated factors that might explain a lack of change , including : agreement with the guidelines ; communication within each practice ; degree of participation in the project ; taking time to discuss the guidelines and their implementation ; use of the  components of the interventions ; and routines for telephone consultations .  Possible explanatory factors were explored in relation to variation in change and the overall extent of change in rates of use of antibiotics , laboratory tests and telephone consultations . RESULTS Sixty-three per cent of practice s agreed with the guidelines . Only 35 % reported having regular meetings , and 33 % discussed the project before its start , although 75 % reported agreement about participating within the practice . Only 33 % reported meeting to discuss the guidelines . Use of the components of the interventions ranged from 11 % for the increased fee for telephone consultations to 48 % for the computerized decision support . Forty-four per cent reported problems with telephone routines . No single factor explained the observed variation in the extent of change across practice s. CONCLUSIONS Inadequate time , re sources and support were the most salient factors that might explain a lack of change . Problems with internal communication and telephone routines were important contributing factors in many practice Objective : To compare baseline cardiovascular risk management between people from two different healthcare systems recruited to a research trial of an intervention to optimise secondary prevention . Design : Cross-sectional study . Setting : 16 r and omly selected general practice s in Northern Irel and ( NI ) ( UK NHS , strong infrastructure , pay-for-performance ) and 32 in the Republic of Irel and ( RoI ) ( mixed healthcare economy , less infrastructure , no pay-for-performance ) . Patients : 903 ( mean age 67.5 years ; 69.9 % male ) r and omly selected patients with known coronary heart disease . Main outcome measures : Blood pressure ( BP ) , cholesterol , medications ; vali date d question naires for diet ( DINE ) , exercise ( Godin ) and quality of life ( SF-12 ) ; healthcare usage . Results : More RoI than NI participants had systolic BP > 140 mm Hg ( 37 % vs 28 % , p = 0.01 ) and cholesterol > 5 mmol/l ( 24 % vs 17 % , p = 0.02 ) . RoI mean systolic BP was higher ( 139 vs 132 mm Hg ) . More RoI participants reported a high fibre intake ( 35 % vs 23 % ) , higher levels of physical activity ( 62 % vs 44 % ) and better physical and mental health ( SF-12 ) ; they also had more GP ( 5.6 vs 4.4 ) and fewer nurse visits ( 1.6 vs 2.1 ) in the previous year . Fewer participants in the RoI ( 55 % vs 70 % ) were prescribed β blockers . ACE inhibitor prescribing was similar for both groups ( 41 % ; 48 % ) ; high proportions were prescribed statins ( 84 % ; 85 % ) and aspirin ( 83 % ; 77 % ) . Conclusions : BP and cholesterol are better controlled among patients in a primary healthcare system with a strong infrastructure supporting computerisation and rewarding measured performance , but this is not associated with healthier lifestyle or better quality of life . Further exploration of differences in professionals ’ and patients ’ engagement in secondary prevention in different healthcare systems is needed Abstract Objective To test the effectiveness of educational interventions in improving detection rates and management of dementia in primary care . Design Unblinded , cluster r and omised , before and after controlled study . Setting General practice s in the United Kingdom ( central Scotl and and London ) between 1999 and 2002 . Interventions Three educational interventions : an electronic tutorial carried on a CD Rom ; decision support software built into the electronic medical record ; and practice based workshops . Participants 36 practice s participated in the study . Eight practice s were r and omly assigned to the electronic tutorial ; eight to decision support software ; 10 to practice based workshops ; and 10 to control . Electronic and manual search es yielded 450 valid and usable medical records . Main outcome measures Rates of detection of dementia and the extent to which medical records showed evidence of improved concordance with guidelines regarding diagnosis and management . Results Decision support software ( P = 0.01 ) and practice based workshops ( P = 0.01 ) both significantly improved rates of detection compared with control . There were no significant differences by intervention in the measures of concordance with guidelines . Conclusions Decision support systems and practice based workshops are effective educational approaches in improving detection rates in dementia Community clinics provide inadequate breast cancer screening services to low-income , racially- and ethnically-diverse communities . This study develops and evaluates the effectiveness of multifaceted organizational system interventions —operational assessment s , tracking systems , reminder calls , tailored education , physician prompts and a tailored counseling call — on mammography rescreening rates  within three community clinics . We used the Chronic Care Model and Put Prevention Into Practice framework to re design breast screening delivery services within the California Cancer Detection Programs : Every Woman Counts(CDP : EWC ) , community clinic setting s. We used a quasi-experimental design with a r and om selection of 400 patients at pre-intervention . To establish a post-intervention clinic ’s rescreening rate a new comparable cross-sectional r and om sample of 347 women was drawn . Measures A chart abstract ion instrument was used to establish clinics 
    Output:
    
AUTHORS ' CONCLUSIONS Interventions tailored to prospect ively identified barriers are more likely to improve professional practice than no intervention or dissemination of guidelines .