***TASK*** the task is to summarize an input biomedical literature in six sentences 
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    Input: OBJECTIVE To assess the quality of antibiotic prescribing by Victorian general practitioners , and the effectiveness of educational intervention techniques in improving prescribing . DESIGN A r and omised , controlled , parallel group trial . SETTING AND PARTICIPANTS In rural and metropolitan Victoria , 182 general practitioners ( 78 control , 104 intervention ) began and 103 ( 41 control , 62 intervention ) completed the study . INTERVENTION Participants recorded their  antibiotic prescribing for tonsillitis .  The intervention group received an educational mailing campaign . A project pharmacist visited each doctor to discuss campaign messages . MAIN OUTCOME MEASURE The percentages of prescriptions of antibiotics for tonsillitis complying with those recommended in Antibiotic guidelines . RESULTS In the intervention group , prescriptions consistent with recommendations in the guidelines increased from 60.5 % before the campaign to 87.7 % afterwards . Improvement also occurred in the control group , from 52.9 % to 71.7 % of prescriptions . The improvement within the intervention group was significantly greater than that within the control group . CONCLUSIONS The educational campaign significantly improved the prescribing of appropriate antibiotics for tonsillitis by general practitioners Since the dawn of therapeutics , the prescribing of medications and their use by patients has been marked by substantial variability in both rationality and effectiveness . Drug use historically has reflected the highest principles of science as well as strikingly irrational behavior . This heterogeneity has been particularly vivid in the case of antibiotics . Antibiotics are among the most commonly used therapeutic agents , accounting for 12 % of ambulatory care prescriptions ( 1 ) . Their use ranges from treatment of minor self-limited outpatient symptoms to potentially fatal conditions in critically ill patients .  Antibiotics loom large economically as well , accounting for approximately 15 % of the nearly $ 100 billion in annual medication expenditures in the United States ( 2 ) . Because of their role in treating infections , antibiotics tap into some of our most deeply held beliefs about bodily integrity and invasion . Furthermore , other than certain vaccines , antibiotics are the only drug class whose use influences not just the patient being treated but the entire ecosystem in which he or she lives , with potentially profound consequences . The determinants of antibiotic use and misuse are thus of particular importance . They include factors as diverse as the physicianpatient relationship , clinical microbiology , health economics , and the most basic definitions of illness and therapy ( 3 ) . Factors Leading to Antibiotic Misuse In their psychosocial dimension , medications can have properties that transcend pharmacology and may take center stage in some clinical situations . Social scientists and wise clinicians have long been aware that providing a patient with a drug is an interpersonal as well as a biochemical intervention ( 4 ) ; this is particularly true of antibiotics . The writing of a prescription signifies that the physician has made a diagnosis and that treatment is possible . A prescription officially ( and tangibly ) assigns the patient to the sick role , with all of its benefits and responsibilities ( 5 ) . It can also act as a termination strategy for an office visit , a sign that the visit has been consummated , the encounter is complete , and it is time for the patient to move on . This strategy creates a paradoxical outcome in the current environment , which is so preoccupied with throughput . A prescription for an  antibiotic  is often seen as the quickest way to end the visit of a patient with possible infectious symptoms . The number of patients seen per hour is increasing , and such increased productivity is frequently commended in the same management memor and um that criticizes out-of-control drug expenditures . Ironically , managers ' desire to reduce the use of diagnostic tests ( cultures ) and prevent return visits also creates pressures that favor heavy antibiotic use . Through the alchemy of the pharmacy , the paper prescription and its inscrutable ritualistic writings are transformed into a container of tablets or capsules . In a real sense , the drug prescription prolongs the physicianpatient encounter by enabling the patient to ingest a dose of the doctor several times a day . As Sir William Osler noted , The desire to ingest medicines is one of the principal features which distinguish man from the animals ( 6 ) . This perspective helps to explain the drug hunger that many symptomatic patients bring to the physician visit , in which they feel satisfied only by receiving a prescription ( 7 ) . Such dem and s are not based on clinical data as we know it ( 8 - 10 ) . Patient expectations have been further intensified by the advent of direct-to-consumer advertising of antibiotics by pharmaceutical manufacturers . Unlike the situation of depression , incontinence , or impotence , for which undertreatment is common , no logic exists for increasing the public 's dem and for antibiotics . These advertisements serve primarily to persuade patients to dem and newer , more costly antibiotics in clinical situations in which older , generic products , or no drug at all , would often work just as well . They are skillfully constructed to promote the ease or effectiveness of the target product and , of course , do not mention cost or note the similar effects of older therapies ( 11 ) . Two trends have intensified the effect of direct-to-consumer promotion of antibiotics . First , the credibility of many once-respected sources of authority is waning , taking a toll on physicians ' professional sovereignty ( 12 , 13 ) . Related to this trend is the parallel rise of consumer activism ; worried that their health maintenance organization will deny them needed therapy to reduce expenditures , patients dem and treatments that they fear might otherwise be withheld . Taken together , these trends turn therapeutic decision making into more of a dialogue ( at best ) or a tug-of-war ( at worst ) between patient and physician , a phenomenon that would have been unthinkable a generation ago . Add to this a growing if belated concern over patient satisfaction , the drive to shorten outpatient encounters as much as possible , and aggressive marketing directed at physicians , and the stage is set for the dem and and receipt of astoundingly large quantities of unnecessary antibiotics . Viewed in this context , it is not surprising that the small voice of therapeutic restraint and concern about microbial resistance is so difficult to hear above the din . The movement favoring adoption of clinical guidelines for rational antibiotic use often runs headlong into the pressures on the primary care physician as the proprietor of a small business , just trying to get through the day and satisfy his or her customers . For example , in focus groups design ed to reveal physicians ' knowledge about , attitudes toward , and motivations for prescribing , some clinicians presented with clinical vignettes that were constructed to sound compellingly viral in cause still favored use of antibiotics to improve symptoms and reduce the likelihood of superinfection ( 14 ) . However , a larger group argued that even if antibiotics were not indicated , they often felt obliged to prescribe them because of patient dem and . This problem is still more acute in the developing world , although a full discussion is beyond the scope of this paper . In the inpatient setting , a different set of forces conspires to encourage excessive antibiotic use . In teaching hospitals , prescribing decisions frequently are made by those with the least clinical experience ( interns and residents ) ; at the same time , each year hospitalized patients become more acutely ill and their cases increasingly complex . These factors , combined with the ubiquitous pressure to keep length of stays short ( the inpatient equivalent of the shrinking office visit ) , make it difficult to pursue a course of watchful waiting in managing a fever of unknown origin . Such temperance is particularly difficult if the prescribing physician has been in practice for only a few months . The first priority becomes the prevention of disaster within the next 24 hours , a goal often thought to be met best by broad-spectrum antibiotics or a cacophony of narrower-spectrum agents used in combination . Evidence for Antibiotic Misuse The perspective outlined above helps explain why analyses of antibiotic use patterns have consistently documented that prescribing is suboptimal ( 15 ) . Many r and omized , placebo-controlled trials of acute bronchitis , cough , and upper respiratory illnesses have found that outcomes are no better in typical patients taking antibiotics than in those given placebo ( 8 - 10 ) . However , of the 51 million visits for colds , upper respiratory tract infections , and bronchitis in the United States in one recent year , 50 % to 66 % culminated in an antibiotic prescription ( 16 , 17 ) . Clinical factors often seem to play a minor role in antibiotic decision making in these illnesses . Diagnostic uncertainty also plays a role ; a recent study of patients with sore throats found that two thirds of antibiotic prescriptions were written for patients whose cultures came back negative ( 18 ) . A large current survey of antibiotic use in treating infectious symptoms in children revealed widespread disregard of commonly recommended diagnostic strategies and therapeutic guidelines and frequent overuse of antibiotics in upper respiratory tract infections ( 65 % ) ( 19 ) . Several patient demographic factors have been found to increase the likelihood that antibiotics will be prescribed . These include being female , young , and white and living in a rural area ( 15 ) . In the developing world , social and economic factors as well as suboptimal drug use have driven the emergence and spread of multidrug-resistant tuberculosis ( 20 ) . In hospitalized patients , incorrect dosing or poor choice of drug occurs often . In a study performed at one teaching hospital ( 21 ) , we found that physicians usually ordered inappropriate doses or intervals for clindamycin , metronidazole , and cefazolin . At another large hospital , antibiotic prophylaxis before surgery was found to be correctly timed in only 40 % of cases ( 22 ) . At the same institution , physicians did not respond correctly to 25 % of instances in which culture and sensitivity data were available ( 23 ) . Overuse of such antibiotics as vancomycin raises concern about the emergence of resistant organisms as well as cost . One recent study found that only 40 % of orders at several hospitals were compatible with Centers for Disease Control and Prevention ( CDC ) guidelines ( 24 ) . Overuse of vancomycin  is probably an important factor in the spread of resistance ( 25 ) ; during a period when vancomycin use was rapidly increasing , resistance rates increased from 0.8 % to 4.0 % ( 26 ) . Antibiotic Resistance and Costs The total costs associated with antibiotics come from multiple sources : medication , adverse events , and the often hidden cost of antimicrobial resistance ( 2 ) . Adverse events occur in a small proportion of antibiotic courses , but because of the frequency of antibiotic use , they accounted for 23 % of all adverse events recorded at one Our aim was to evaluate effects on prescribing for urinary tract infection ( UTI ) and asthma , of an education with messages based on national guidelines , aim ed at improving prescribing in primary care in Sweden . The study is part of the European Drug Education Project . A r and omized controlled trial , with groups of general practitioners ( GPs ) allocated to education on UTI ( 18 groups , 104 GPs ) or asthma ( 18 groups , 100 GPs ) , the two parallel intervention arms being controls for each other . Feedback was provided on the GP 's judgments of simulated cases and prescribing . Prescribing indicators were developed and measured before and after the intervention . Analysis was performed by multi-level technique . Prescribing of first choice UTI drugs increased in the intervention arm from 52 % to 70 % and remained constant in the control arm ( P < 0.001 ) . The proportion of patients receiving an inhaled corticosteroid increased insignificantly in both study arms . The educational model can be used to improve prescribing . Further studies are needed to define when the model is effective Systematic review s provide the best evidence on the effectiveness of healthcare interventions including quality improvement strategies . The methods of systematic review of individual patient r and omised trials of healthcare interventions are well developed . We discuss method ological and practice issues that need to be considered when undertaking systematic review s of quality improvement strategies including developing a review protocol , identifying and screening evidence sources , quality assessment and data abstract ion , analytical methods , reporting systematic review s , and appraising systematic review s. This paper builds on our experiences within the Cochrane Effective Practice and Organisation of Care ( EPOC ) review group Background —It is difficult to put research findings into clinical practice by either guidelines or prescription feedback . Aim —To study the effect on the quality of prescribing by a combined intervention of providing individual feedback and deriving quality criteria using guideline recommendations in peer review groups . Methods —199 general practitioners in 32 groups were r and omised to participate in peer review meetings related to either asthma or urinary tract infections . The dispensing by the participating doctors of antiasthmatic drugs and antibiotics during the year before the intervention period provided the basis for prescription feedback . The intervention feedback was design ed to describe the treatment given in relation to recommendations in the national guidelines . In each group the doctors agreed on quality criteria for their own treatment of the corresponding diseases based on these recommendations . Comparison of their prescription feedback with their own quality criteria gave each doctor the proportion of acceptable and unacceptable treatments . Main outcome measure — Difference in the prescribing behaviour between the year before and the year after the intervention . Results —Before intervention the mean proportions of acceptably treated asthma patients in the asthma group and urinary tract infection ( control ) group were 28 % and 27 % , respectively . The mean proportion of acceptably treated patients in the asthma group was increased by 6 % relative to the control group ; this difference was statistically significant . The mean proportions of acceptable treatments of urinary tract infection before intervention in the urinary tract infection group and asthma ( control ) group were 12 % for both groups which increased by 1 
    Output:
    
Active forms of education , sustained interventions , and other features traditionally associated with successful quality improvement interventions were not associated with effect size and showed no evidence of confounding the association between clinician education-only strategies and outcome .
Conclusions : Multidimensional interventions using audit and feedback to improve antibiotic selection were less effective than interventions using clinician education alone .
Although confounding may partially account for this finding , our results suggest that enhancing the intensity of a focused intervention may be preferable to a less intense , multidimensional approach