***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: Abstract OBJECTIVE : We evaluated the effect of implementing quality improvement ( QI ) programs for depression , relative to usual care , on primary care clinicians ’ knowledge about treatment . DESIGN AND METHODS : Matched primary care clinics ( 46 ) from seven managed care organizations were r and omized to usual care  ( mailed written guidelines only ) versus  one of two QI interventions . Self-report surveys assessed clinicians ’ knowledge of depression treatments prior to full implementation ( June 1996 to March 1997 ) and 18 months later . We used an intent-to-treat analysis to examine intervention effects on change in knowledge , controlling for clinician and practice characteristics , and the nested design . PARTICIPANTS : One hundred eighty-one primary care clinicians . INTERVENTIONS : The interventions included institutional commitment to QI , training local experts , clinician education , and training nurses for patient assessment and education . One intervention had re sources for nurse follow-up on medication use ( QI-meds ) and the other had reduced copayment for therapy from trained , local therapists ( QI-therapy ) . RESULTS : Clinicians in the intervention group had greater increases compared with clinicians in the usual care group over 18 months in knowledge of psychotherapy ( by 20 % for QI-meds , P=.04 and by 33 % for QI-therapy , P=.004 ) , but there were no significant increases in medication knowledge . Significant increases in knowledge scores ( P=.01 ) were demonstrated by QI-therapy clinicians but not clinicians in the QI-meds group . Clinicians were exposed to multiple intervention components . CONCLUSIONS : Dissemination of QI programs for depression in managed , primary care practice s improved clinicians ’ treatment knowledge over 18 months , but breadth of learning was somewhat greater for a program that also included active collaboration with local therapists Objective : To test whether an intervention to improve primary care depression management significantly improves productivity at work and absenteeism over 2 years . Setting and Subjects : Twelve community primary care practice s recruiting depressed primary care patients identified in a previsit screening . Research Design : Practice s were stratified by depression treatment patterns before r and omization to enhanced or usual care . After delivering brief training , enhanced care clinicians provided improved depression management over 24 months . The research team evaluated productivity and absenteeism at baseline , 6 , 12 , 18 , and 24 months in 326 patients who reported full-or part-time work at one or more completed waves . Results : Employed patients in the enhanced care condition reported 6.1 % greater productivity and 22.8 % less absenteeism over 2 years . Consistent with its impact on depression severity and emotional role functioning , intervention effects were more observable in consistently employed subjects where the intervention improved productivity by 8.2 % over 2 years at an estimated annual value of $ 1982 per depressed full-time equivalent and reduced absenteeism by 28.4 % or 12.3 days over 2 years at an estimated annual value of $ 619 per depressed full-time equivalent . Conclusions : This trial , which is the first to our knowledge to demonstrate that improving the quality of care for any chronic disease has positive consequences for productivity and absenteeism , encourages formal cost-benefit research to assess the potential return-on-investment employers of stable workforces can realize from using their purchasing power to encourage better depression treatment for their employees OBJECTIVE Depression research and practice focus increasingly on diverse patient population s with varying probabilities of response to clinical care . Prognostic indices use preexisting patient characteristics to estimate the probability of subsequent negative clinical outcomes and are useful tools for improving the study and care of diverse population s. Few such measures , however , have been developed for mental health conditions . This study developed and vali date d a depression prognosis measure for primary care patients with major depression . METHODS Consecutive patients in 108 primary care practice s were screened for depression , and 1,471 with major depression were enrolled . A  Depression Prognosis Index ( DPI )  predicting persistent depression six months after baseline was developed for a r and om one-third sub sample and vali date d with the remaining two-thirds . Models included prior treatment , demographic characteristics , comorbidities , and other physical , psychological , and social predictors . RESULTS Sixty-four percent to 65 % of patients classified by baseline DPI score as being in the sample quartile with the worst prognosis had probable major depression six months later , compared with 14 % to 15 % in the best-prognosis quartile . The DPI had an R2 of .40 in the development sample and .27 in the validation sample . Important predictors included severity of depression symptoms at baseline , social support , common physical symptoms , and having completed three months of antidepressants at sample entry . CONCLUSIONS The ability of the DPI to predict six-month outcomes compares favorably to that of prognostic indices for general medical problems . These results vali date the DPI and provide conceptual guidance for further development of depression risk stratification instruments for clinical and research use CONTEXT Most older adults with dementia will be cared for by primary care physicians , but the primary care practice environment presents important challenges to providing quality care . OBJECTIVE To test the effectiveness of a collaborative care model to improve the quality of care for patients with Alzheimer disease . DESIGN , SETTING , AND PATIENTS Controlled clinical trial of 153 older adults with Alzheimer disease and their caregivers who were r and omized by physician to receive collaborative care management ( n = 84 ) or augmented usual care ( n = 69 ) at primary care practice s within 2 US university-affiliated health care systems from January 2002 through August 2004 . Eligible patients ( identified via screening or medical record ) met diagnostic criteria for Alzheimer disease and had a self-identified caregiver . INTERVENTION Intervention patients received 1 year of care management by an interdisciplinary team led by an advanced practice nurse working with the patient 's family caregiver and integrated within primary care . The team used st and ard protocol s to initiate treatment and identify , monitor , and treat behavioral and psychological symptoms of dementia , stressing nonpharmacological management . MAIN OUTCOME MEASURES Neuropsychiatric Inventory ( NPI ) administered at baseline and at 6 , 12 , and 18 months . Secondary outcomes included the Cornell Scale for Depression in Dementia ( CSDD ) , cognition , activities of daily living , re source use , and caregiver 's depression severity . RESULTS Initiated by caregivers ' reports , 89 % of intervention patients triggered at least 1 protocol for behavioral and psychological symptoms of dementia with a mean of 4 per patient from a total of 8 possible protocol s. Intervention patients were more likely to receive  cholinesterase inhibitors  ( 79.8 % vs 55.1 % ; P = .002 ) and  antidepressants  ( 45.2 % vs 27.5 % ; P = .03 ) . Intervention patients had significantly fewer behavioral and psychological symptoms of dementia as measured by the total NPI score at 12 months ( mean difference , -5.6 ; P = .01 ) and at 18 months ( mean difference , -5.4 ; P = .01 ) . Intervention caregivers also reported significant improvements in distress as measured by the caregiver NPI at 12 months ; at 18 months , caregivers showed improvement in depression as measured by the Patient Health Question naire-9 . No group differences were found on the CSDD , cognition , activities of daily living , or on rates of hospitalization , nursing home placement , or death . CONCLUSIONS Collaborative care for the treatment of Alzheimer disease result ed in significant improvement in the quality of care and in behavioral and psychological symptoms of dementia among primary care patients and their caregivers . These improvements were achieved without significantly increasing the use of antipsychotics or sedative-hypnotics . TRIAL REGISTRATION clinical trials.gov Identifier : NCT00246896 CONTEXT Few depressed older adults receive effective treatment in primary care setting s. OBJECTIVE To determine the effectiveness of the Improving Mood-Promoting Access to Collaborative Treatment ( IMPACT ) collaborative care management program for late-life depression .  DESIGN R and omized controlled trial with recruitment from July 1999 to August 2001 . SETTING Eighteen primary care clinics from 8 health care organizations in 5 states . PARTICIPANTS A total of 1801 patients aged 60 years or older with major depression ( 17 % ) , dysthymic disorder ( 30 % ) , or both ( 53 % ) . INTERVENTION Patients were r and omly assigned to the IMPACT intervention ( n = 906 ) or to usual care ( n = 895 ) . Intervention patients had access for up to 12 months to a depression care manager who was supervised by a psychiatrist and a primary care expert and who offered education , care management , and support of antidepressant management by the patient 's primary care physician or a brief psychotherapy for depression , Problem Solving Treatment in Primary Care . MAIN OUTCOME MEASURES Assessment s at baseline and at 3 , 6 , and 12 months for depression , depression treatments , satisfaction with care , functional impairment , and quality of life . RESULTS At 12 months , 45 % of intervention patients had a 50 % or greater reduction in depressive symptoms from baseline compared with 19 % of usual care participants ( odds ratio [ OR ] , 3.45 ; 95 % confidence interval [ CI ] , 2.71 - 4.38 ; P<.001 ) . Intervention patients also experienced greater rates of depression treatment ( OR , 2.98 ; 95 % CI , 2.34 - 3.79 ; P<.001 ) , more satisfaction with depression care ( OR , 3.38 ; 95 % CI , 2.66 - 4.30 ; P<.001 ) , lower depression severity ( range , 0 - 4 ; between-group difference , -0.4 ; 95 % CI , -0.46 to -0.33 ; P<.001 ) , less functional impairment ( range , 0 - 10 ; between-group difference , -0.91 ; 95 % CI , -1.19 to -0.64 ; P<.001 ) , and greater quality of life ( range , 0 - 10 ; between-group difference , 0.56 ; 95 % CI , 0.32 - 0.79 ; P<.001 ) than participants assigned to the usual care group . CONCLUSION The IMPACT collaborative care model appears to be feasible and significantly more effective than usual care for depression in a wide range of primary care practice CONTEXT : Previous studies testing continuous quality improvement ( CQI ) for depression showed no effects . Methods for practice s to self-improve depression care performance are needed . We assessed the impacts of evidence -based quality improvement ( EBQI ) , a modification of CQI , as carried out by 2 different health care systems , and collected qualitative data on the design and implementation process . OBJECTIVE : Evaluate impacts of EBQI on practice -wide depression care and outcomes . DESIGN : Practice -level r and omized experiment comparing EBQI with usual care . SETTING : Six Kaiser Permanente of Northern California and 3 Veterans Administration primary care practice s r and omly assigned to EBQI teams ( 6 practice s ) or usual care ( 3 practice s ) . Practice s included 245 primary care clinicians and 250,000 patients .INTERVENTION : Research ers assisted system senior leaders to identify priorities for EBQI teams ; initiated the manual-based EBQI process ; and provided references and tools . EVALUATION PARTICIPANTS : Five hundred and sixty-seven representative patients with major depression . MAIN OUTCOME MEASURES : Appropriate treatment , depression , functional status , and satisfaction . RESULTS : Depressed patients in EBQI practice s showed a trend toward more appropriate treatment compared with those in usual care ( 46.0 % vs 39.9 % at 6 months , P=.07 ) , but no significant improvement in 12-month depression symptom outcomes ( 27.0 % vs 36.1 % poor depression outcome , P=.18 ) . Social functioning improved significantly ( mean score 65.0 vs 56.8 at 12 months , P=.02 ) ; physical functioning did not . CONCLUSION : Evidence -based quality improvement had perceptible , but modest , effects on practice performance for patients with depression . The modest improvements , along with qualitative data , identify potential future directions for improving CQI research and practice It is difficult to evaluate the promise of primary care quality -improvement interventions for depression because published studies have evaluated diverse interventions by using different research design s in dissimilar population s. Preplanned meta- analysis provides an alternative to derive more precise and generalizable estimates of intervention effects ; however , this approach requires the resolution of analytic challenges result ing from design differences that threaten internal and external validity . This paper describes the  four-project Quality Improvement for Depression ( QID ) collaboration specifically design ed for preplanned meta- analysis of intervention effects on outcomes . This paper summarizes the interventions the four projects tested , characterizes commonalities and heterogeneity in the research design s used to evaluate these interventions , and discusses the implication s of this heterogeneity for preplanned meta- analysis Abstract Objective : To assess the validity of  st and ardised patients to measure the quality of physicians ' practice . Design : Validation study of st and ardised patients ' assessment s. Physicians saw unannounced st and ardised patients presenting with common outpatient conditions . The st and ardised patients covertly tape recorded their visit and completed a checklist of quality criteria immediately afterwards . Their assessment s were compared against 
    Output:
    
Contribution This observational study from 45 primary care practice s found that clinicians adhered well to only one third of the guideline recommendations for depression .
Most clinicians initially recognized and treated depression ; however , they often did not address suicide risk , assess alcohol use , adjust treatment appropriately , or follow through on long-term treatment plans .
Better clinician adherence to recommendations was associated with a lower probability of persistent depressive symptoms among patients .
Caution Data on depression-related care were based on patients ' self-report .
Higher DPI scores indicate worse prognosis .
Because patients must score in the depressed range on all 3 measures according to st and ard depression cutoffs ( the measures map closely to diagnostic criteria from the Diagnostic and Statistical Manual of Mental Disorders , Fourth Edition ) and major symptoms must be current , the patients identified by the composite measure for persistent depression are substantially and currently impaired .
In st and ard care , a care process would be likely to ensure good to excellent outcomes for most patients , whereas below-st and ard care would lead to poor outcomes among some patients and above-st and ard care would have a high likelihood of leading to optimal outcomes .