***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 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 The methods of evaluating change and improvement strategies are not well described . The design and conduct of a range of experimental and non-experimental quantitative design s are considered . Such study design s should usually be used in a context where they build on appropriate theoretical , qualitative and modelling work , particularly in the development of appropriate interventions . A range of experimental design s are discussed including single and multiple arm r and omised controlled trials and the use of more complex factorial and block design s. The impact of r and omisation at both group and individual levels and three non-experimental design s ( uncontrolled before and after , controlled before and after , and time series analysis ) are also considered . The design chosen will reflect both the needs ( and re sources ) in any particular circumstances and also the purpose of the evaluation . The general principle underlying the choice of evaluative design is , however , simple — those conducting such evaluations should use the most robust design possible to minimise bias and maximise generalisability OBJECTIVES To evaluate the effect of pharmaceutical care provided in addition to acute Geriatric Evaluation and Management ( GEM ) care on the appropriateness of prescribing . DESIGN R and omized , controlled trial , with the patient as unit of r and omization . SETTING Acute GEM unit . PARTICIPANTS Two hundred three patients aged 70 and older . INTERVENTION Pharmaceutical care provided from admission to discharge by a specialist clinical pharmacist who had direct contacts with the GEM team and patients . MEASUREMENTS Appropriateness of prescribing on admission , at discharge , and 3 months after discharge , using the Medication Appropriateness Index ( MAI ) , Beers criteria , and Assessing Care of Vulnerable Elders ( ACOVE ) underuse criteria and mortality , readmission , and emergency visits up to 12 months after discharge . RESULTS Intervention patients were significantly more likely than control patients to have an improvement in the MAI and in the ACOVE underuse criteria from admission to discharge ( odds ratio (OR)=9.1 , 95 % confidence interval (CI)=4.2 - 21.6 and OR=6.1 , 95 % CI=2.2 - 17.0 , respectively ) . The control and intervention groups had comparable improvements in the Beers criteria . CONCLUSION Pharmaceutical care provided in the context of acute GEM care improved the appropriate use of medicines during the hospital stay and after discharge . This is an important finding , because only limited data exist on the effect of various strategies to improve medication use in elderly in patients . The present approach has the potential to minimize risk and improve patient outcomes Abstract Objective To test a multifaceted collaborative quality improvement intervention design ed to promote evidence based surfactant treatment for preterm infants of 23 - 29 weeks ' gestation . Design Cluster r and omised controlled trial Setting and participants 114 neonatal intensive care units ( which treated 6039 infants of 23 - 29 weeks gestation born in 2001 ) . Main outcome measures Process of care measures : proportion of infants receiving first surfactant in the delivery room  , proportion receiving first surfactant more than two hours after birth  , and median time from birth to first dose of surfactant . Clinical outcomes : death before discharge home , and pneumothorax . Intervention Multifaceted collaborative quality improvement advice including audit and feedback , evidence review s , an interactive training workshop , and ongoing faculty support via conference calls and email . Results Compared with those in control hospitals , infants in intervention hospitals were more likely to receive surfactant in the delivery room ( adjusted odds ratio 5.38 ( 95 % confidence interval 2.84 to 10.20 ) ) , were less likely to receive the first dose more than two hours after birth ( adjusted odds ratio 0.35 ( 0.24 to 0.53 ) ) , and received the first dose of surfactant sooner after birth ( median of 21 minutes v 78 minutes , P < 0.001 ) . The intervention effect on timing of surfactant was larger for infants born in the participating hospitals than for infants transferred to a participating hospital after birth . There were no significant differences in mortality or pneumothorax . Conclusion A multifaceted intervention including audit and feedback , evidence review s , quality improvement training , and follow up support changed the behaviour of health professionals and promoted evidence based practice OBJECTIVE To assess the impact of an automated intraoperative alert to redose prophylactic antibiotics in prolonged cardiac operations . DESIGN R and omized , controlled , evaluator-blinded trial . SETTING University-affiliated hospital . PATIENTS Patients undergoing cardiac surgery that lasted more than 4 hours after the preoperative administration of cefazolin , unless they were receiving therapeutic antibiotics at the time of surgery . INTERVENTION R and omization to an audible and visual reminder on the operating room computer console at 225 minutes after the administration of preoperative antibiotics ( reminder group , n = 137 ) or control ( n = 136 ) . After another 30 minutes , the circulating nurse was required to indicate whether a follow-up dose of antibiotics had been administered . RESULTS Intraoperative redosing was significantly more frequent in the reminder group ( 93 of 137 ; 68 % ) than in the control group ( 55 of 136 ; 40 % ) ( adjusted odds ratio , 3.31 ; 95 % confidence interval , 1.97 to 5.56 ; P < .0001 ) . The impact of the reminder was even greater when compared with the 6 months preceding the study period ( 129 of 480 ; 27 % ; P < .001 ) , suggesting some spillover effect on the control group . Redosing was formally declined for 19 of the 44 patients in the reminder group without redosing . The rate of surgical-site infection in the reminder group ( 5 of 137 ; 4 % ) was similar to that in the control group ( 8 of 136 ; 6 % ; P = .42 ) , but significantly lower than that in the pre- study period ( 48 of 480 ; 10 % ; P = .02 ) . CONCLUSION The use of an automatic reminder system in the operating room improved compliance with guidelines on perioperative antibiotic prophylaxis Low bone mineral density is a major risk factor for future fragility fracture [ 1 - 4 ] . This led the World Health Organization to include bone mineral density measurement in the definition of osteoporosis [ 5 ] . Quantitation of axial bone mineral density is most often done with dual x-ray absorptiometry , although radiography and ultrasonography of appendicular bone mass are being actively studies as alternative techniques [ 6 , 7 ] . Despite the high prevalence of osteoporosis and osteopenia [ 8 ] and the availability of therapy to prevent and treat these conditions , it has been estimated that few patients at risk are referred for bone mineral density measurements [ 9 ] . This low testing rate may result from the cost and lack of widespread availability of diagnostic equipment . However , it may also result from underuse of existing diagnostic facilities that occurs because physicians have difficulty comprehending the often brief technical reports . We hypothesized that giving primary care physicians more detailed clinical reporting ( compared with brief technical reporting ) of bone mineral density results would increase the use , underst and ing , and acceptance of bone densitometry and would affect subsequent management of osteoporosis . Methods All primary care physicians ( general internists , family practitioners , and gynecologists ) ordering dual x-ray absorptiometry ( Hologic 1000W , Waltham , Massachusetts ) for bone mineral density measurements between 2 October 1995 and 23 April 1996 at the osteoporosis center of a community teaching hospital were enrolled . When their patients underwent their first procedure , physicians were r and omly assigned by a computer-generated allocation sequence to receive either short technical reports or long narrative clinical reports ( Appendix ) and a printout generated by the bone densitometer software that contained morphometry , bone density data , and statistical comparisons with control groups in tabular format . Specialists with expertise in bone metabolism received the short reports and were not included in the study . Reports were written by two endocrinologists trained in bone metabolism . Clinical information was obtained from a data base compiled by the bone density technologist during the procedure . The study was approved by the Human Studies Review Committee of UMass Memorial Health Care ( Worcester , Massachusetts ) . One of the authors interviewed the physicians by telephone by using an intake form after the physicians had received at least two reports in a given format . Physicians were asked whether they understood various concepts of bone densitometry ; if they answered yes , they were asked to explain the concept . Specific questions about individual patients ( Appendix ) were then posed to each physician with the data base available to the investigator and the office record available to the primary care physician . A minimum of two and a maximum of six reports were included in the analysis for each physician . After the interview , physicians who had received the short technical reports began to receive the long clinical reports and were reinterviewed after having received at least two long reports . Numerical data were analyzed by using the t-test , the Mann-Whitney rank-sum test , one-way analysis of variance , or Kruskal-Wallis analysis of variance on ranks ; Bonferroni correction was used where appropriate . Nominal data were analyzed with the Fisher exact test or the z-test , the McNem 
    Output:
    
Results of the review indicate that most QI effectiveness research is conducted in hospital setting s , is focused on multiple QI interventions , and utilizes process measures as outcomes .