***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: 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 CONTEXT The emergence and spread of antibiotic-resistant Streptococcus pneumoniae in US communities is due , in part , to the excessive use of antibiotics for acute respiratory tract infections . OBJECTIVE To decrease total antibiotic use for uncomplicated acute bronchitis in adults . DESIGN Prospect i ve , nonr and omized controlled trial , including baseline ( November 1996-February 1997 ) and study ( November 1997-February 1998 ) periods . SETTING Four selected primary care practice s belonging to a group-model health maintenance organization in the Denver , Colo , metropolitan area . PARTICIPANTS Consecutive adults diagnosed as having uncomplicated acute bronchitis . A total of 2462 adults were included at baseline and 2027 adults were included in the study . Clinicians included 56 physicians , 28 physician assistants or nurse practitioners , and 9 registered nurses . INTERVENTION The full intervention site received household and office-based patient educational material s , as well as a clinician intervention consisting of education , practice -profiling , and academic detailing . A limited intervention site received only office-based educational material s , and control sites provided usual care . MAIN OUTCOME MEASURE Antibiotic prescriptions for uncomplicated acute bronchitis during baseline and study periods . RESULTS Antibiotic prescription rates for uncomplicated acute bronchitis were similar at all 4 sites during the baseline period . During the study period , there was a substantial decline in antibiotic prescription rates at the full intervention site ( from 74 % to 48 % [ P = .003 ] ) , but not at the control and limited intervention sites ( 78 % to 76 % [ P = .81 ] and 82 % to 77 % [ P = .68 ] , respectively ) . Compared with control sites , changes in nonantibiotic prescriptions ( inhaled bronchodilators , cough suppressants , and analgesics ) were not significantly different for intervention sites . Return office visits ( within 30 days of the incident visit ) for bronchitis or pneumonia did not change significantly for any of the sites . CONCLUSIONS Antibiotic treatment of adults diagnosed as having uncomplicated acute bronchitis can be safely reduced using a combination of patient and clinician interventions From 1998 to 2000 , 13 rural Alaskan villages ( population , 3326 ) were surveyed annually by nasopharyngeal cultures for Streptococcus pneumoniae carriage . Data regarding antibiotic use for the entire population was abstract ed from clinic records . In 1999 , education of medical providers and the community about appropriate antibiotic use began in 4 villages ; this program was exp and ed to include all villages in 2000 .  Antibiotic courses per person decreased by 31 % in the initial intervention villages and by 35 % in the remaining villages after education ( P<.01 for each ) . Sample s were obtained for culture from a mean of 31 % of the population each year ; 31 % carried pneumococcus . No sustained decrease in carriage of penicillin-nonsusceptible strains was observed . When linear regression was used , serotype accounted for 81 % of the variance in pneumococcal minimum inhibitory concentrations after the intervention , compared with 7 % for antibiotic use . This suggests that reducing the carriage of serotypes associated with antibiotic resistance by use of pneumococcal conjugate vaccines may have a greater short-term impact than does decreasing antibiotic use Objectives To test the hypothesis that a multifaceted , local public campaign could be feasible and influence antibiotic prescribing for out patients . Design Community level , controlled , non-r and omised trial . Setting Provinces of Modena and Parma in Emilia-Romagna , northern Italy , November 2011 to February 2012 . Population 1 150 000 residents of Modena and Parma ( intervention group ) and 3 250 000 residents in provinces in the same region but where no campaign had been implemented ( control group ) . Interventions Campaign material s ( mainly posters , brochures , and advertisements on local media , plus a newsletter on local antibiotic resistance targeted at doctors and pharmacists ) . General practitioners and paediatricians in the intervention area participated in design ing the campaign messages . Main outcomes measures Primary outcome was the average change in prescribing rates of antibiotics for outpatient in five months , measured as defined daily doses per 1000 inhabitants/day , using health districts as the unit of analysis . Results Antibiotic prescribing was reduced in the intervention area compared with control area ( −4.3 % , 95 % confidence interval −7.1 % to −1.5 % ) . This result was robust to “ sensitivity analysis ” modifying the baseline period from two months ( main analysis ) to one month . A higher decrease was observed for penicillins resistant to β lactamase and a lower decrease for penicillins susceptible to β lactamase , consistent with the content of the newsletter on antibiotic resistance directed at health professionals . The decrease in expenditure on antibiotics was not statistically significant in a district level analysis with a two month baseline period ( main analysis ) , but was statistically significant in sensitivity analyses using either a one month baseline period or a more powered doctor level analysis . Knowledge and attitudes of the target population about the correct use of antibiotics did not differ between the intervention and control areas . Conclusions A local low cost information campaign targeted at citizens , combined with a newsletter on local antibiotic resistance targeted at doctors and pharmacists , was associated with significantly decreased total rates of antibiotic prescribing but did not affect the population ’s knowledge and attitudes about antibiotic resistance . Trial registration Clinical Trials.gov NCT01604096 OBJECTIVE To assess the marginal impact of patient education on antibiotic prescribing to children with pharyngitis and adults with acute bronchitis in private office practice s. DATA SOURCES / STUDY SETTING Antibiotic prescription rates based on cl aims data from four managed care organizations in Colorado during baseline ( winter 2000 ) and study ( winter 2001 ) periods . STUDY DESIGN A nonr and omized controlled trial of a household and office-based patient educational intervention was performed . During both periods , Colorado physicians were mailed antibiotic prescribing profiles and practice s guidelines as part of an ongoing quality improvement program .  Intervention practice s ( n=7 ) were compared with local and distant control practice s. DATA COLLECTION / EXTRACTION METHODS Office visits were extracted by managed care organizations using International Classification of Diseases-9- Clinical Modification codes for acute respiratory tract infections , and merged with pharmacy cl aims data based on visit and dispensing date s coinciding within 2 days . PRINCIPAL FINDINGS Adjusted antibiotic prescription rates during baseline and study periods increased from 38 to 39 percent for pediatric pharyngitis at the distant control practice s , and decreased from 39 to 37 percent at the local control practice s , and from 34 to 30 percent at the intervention practice s ( p=.18 compared with distant control practice s ) . Adjusted antibiotic prescription rates decreased from 50 to 44 percent for adult bronchitis at the distant control practice s , from 55 to 45 percent at the local control practice s , and from 60 to 36 percent at the intervention practice s ( p<.002 and p=.006 compared with distant and local control practice s , respectively ) . CONCLUSIONS In office practice s , there appears to be little room for improvement in antibiotic prescription rates for children with pharyngitis . In contrast , patient education helps reduce antibiotic use for adults with acute bronchitis beyond that achieved by physician-directed efforts Context : Large-scale strategies are needed to reduce overuse of antibiotics in US communities . Objectives : To evaluate the impact of a mass media campaign—“Get Smart Colorado”—on public exposure to campaign , antibiotic use , and office visit rates . Design : Nonr and omized controlled trial . Setting : Two metropolitan communities in Colorado , United States . Subjects : The general public , managed care enrollees , and physicians residing in the mass media ( 2.2 million persons ) and comparison ( 0.53 million persons ) communities . Intervention : The campaign consisting of paid outdoor advertising , earned media and physician advocacy ran between November 2002 and February 2003 . Principal Measures : Antibiotics dispensed per 1000 persons or managed care enrollees , and the proportion of office visits receiving antibiotics measured during 10 to 12 months before and after the campaign . Results : After the mass media campaign , there was a 3.8 % net decrease in retail pharmacy antibiotic dispenses per 1000 persons ( P = 0.30 ) and an 8.8 % net decrease in managed care-associated antibiotic dispenses per 1000 members ( P = 0.03 ) in the mass media community . Most of the decline occurred among pediatric members , and corresponded with a decline in pediatric office visit rates . There was no change in the office visit prescription rates among pediatric or adult managed care members , nor in visit rates for complications of acute respiratory tract infections . Conclusions : A low-cost mass media campaign was associated with a reduction in antibiotic use in the community , and seems to be mediated through decreases in office visits rates among children . The campaign seems to be cost-saving BACKGROUND GPs decide whether or not to prescribe antibiotics for acute cough . Apart from clinical signs and symptoms , non-medical reasons influence this decision as well . AIM To obtain a valid estimate of the effect of perceived patient dem and . DESIGN OF STUDY Secondary analysis of cluster r and omised controlled trial data . SETTING Eighty-five Flemish GPs . METHOD GPs completed a preprinted form with medical as well as non-medical information and their prescription for 20 consecutive adult patients consulting with acute cough in the periods February to April 2000 and 2001 . The effect of perceived patient dem and on antibiotic prescribing was estimated by performing alternating logistic regression analysis . A hierarchical backwards elimination procedure , described by Kleinbaum , was used . RESULTS Seventy-two GPs participated , including 1448 patients eligible for analysis ; 500 ( 34.5 % ) were prescribed an antibiotic and , according to the GP , 218 ( 15.1 % ) asked for an antibiotic . In cases of perceived patient dem and antibiotics were prescribed significantly more often ( odds ratio [ OR ] = 4.64 , 95 % confidence interval [ CI ] = 2.96 to 7.26 ) . In the final model ( n = 819 ; OR = 4.60 , 2.59 to 8.17 ) ; Hosmer-Lemeshow goodness-of-fit P = 0.72 ) , the effect of perceived patient dem and for an antibiotic depended on the outcome of the lung auscultation . When patient dem and was perceived , antibiotics were prescribed significantly more often only in the case of a normal lung auscultation or in the case of only one abnormal auscultatory finding ( adjusted OR = 20.83 , 95 % CI = 8.86 to 48.99 ; adjusted OR = 4.79 ; 95 % CI = 2.16 to 10.60 , respectively ) . CONCLUSIONS Perceived patient dem and has a significant , independent and clinical ly relevant effect on antibiotic prescribing for acute cough with negative findings on the lung auscultation . Practice guidelines and interventions to optimise antibiotic prescribing have to take this effect into account AIMS To assess changes in public knowledge , attitudes , and reported behaviour of antibiotic use in the management of the common cold and to compare with results of a 1998 study . The context is a nationwide project to reduce the consumption of antibiotics . METHOD Cross-section survey : telephone interviews of r and om sample of consenting Auckl and telephone subscribers aged over 15 years comparing 1998 and 2003 responses . RESULTS A 55 % response rate of eligible participants was recorded . No change was noted between 1998 and 2003 in public awareness that antibiotics are not helpful in treating viral infections ( 38 % ) . However there was a significant reduction in those attending doctor for the common cold ( 24 % to 15 % ) . In 2003 , patients were less likely to receive antibiotic prescription and more likely to receive a delayed prescription . CONCLUSIONS The majority of general public still do not underst and that the common cold does not need antibiotic treatment . The advertising campaign may have reduced doctor prescribing hence the reduction in antibiotic use from 1998 to 2003 BACKGROUND Antibiotic prescribing for upper 
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Conclusion Multi-faceted communication interventions that target both the general public and clinicians can reduce antibiotic prescribing in high-income countries but the sustainability of reductions in antibiotic prescribing is unclear