***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 Primary care physicians are well placed to identify patients in need of advance care planning ( ACP )  and initiate ACP in advance of an acute situation . OBJECTIVES This study aim ed to underst and Australian general practitioner ( GP ) clinical decision making relating to a patient 's " need for ACP " and the likelihood of initiating ACP . METHODS An experimental vignette study pseudor and omly manipulated factors thought to influence decision making regarding ACP . Patient-level factors included gender , age , type of disease , medical severity , openness to  ACP , doctor-patient relationship , and family support . An accompanying demographic survey assessed health professional-level factors , including gender , years of experience , place of training , place of practice , caseload of patients with ACP , direct personal experience in ACP , and self-reported attitudes toward ACP . Seventy GPs were recruited , and each completed six unique vignettes , providing ratings of patient need for ACP , importance of initiating ACP in the coming months , and likelihood of initiating ACP at the next consultation . RESULTS Older patients , with malignant or cardiovascular disease , severe clinical presentations , good doctor-patient relationship , female gender , and poor family support were more likely to receive prompt ACP . Positive GP attitudes toward ACP were associated with greater likelihood of initiating ACP promptly . CONCLUSION Patients with presentations suggesting higher mortality risk were identified as being in need of ACP ; however , the likelihood of initiating ACP was sensitive to GP attitudes and psychosocial aspects of the doctor-patient interaction . Training material s aim ed at encouraging GP involvement in ACP should target attitudes toward ACP and communication skills , rather than focusing solely on prognostic risk This summary reflects on this monograph regarding  multilevel intervention ( MLI ) research to 1 ) assess its added value ; 2 ) discuss what has been learned to date about its challenges in cancer care delivery ; and 3 ) identify specific ways to improve its scientific soundness , feasibility , policy relevance , and research agenda . The 12 su bmi tted chapters , and discussion of them at the March 2011 multilevel meeting , were review ed and discussed among the authors to elicit key findings and results addressing the questions raised at the outset of this effort . MLI research is underrepresented as an explicit focus in the cancer literature but may improve implementation of studies of cancer care delivery if they assess context ual , organizational , and environmental factors important to underst and ing behavioral and /or system-level interventions . The field lacks a single unifying theory , although several psychological or biological theories are useful , and an ecological model helps conceptualize and communicate interventions . MLI research design s are often complex , involving nonlinear and nonhierarchical relationships that may not be optimally studied in r and omized design s. Simulation modeling and pilot studies may be necessary to evaluate MLI interventions . Measurement and evaluation of team and organizational interventions are especially needed in cancer care , as are attention to the context of health-care reform , eHealth technology , and genomics-based medicine . Future progress in MLI research requires greater attention to developing and supporting relevant metrics of level effects and interactions and evaluating  MLI interventions .  MLI research holds an unrealized promise for underst and ing how to improve cancer care delivery Advance directives name a surrogate decision maker or provide written instructions with the intent of extending patient autonomy with respect to end-of-life decisions [ 1 - 3 ] . Supported on various grounds by the public [ 1 ] , physicians [ 4 ] , ethicists [ 5 ] , and legislators [ 6 ] , advance directives have also been promoted as a way to control the high costs of health care at the end of life [ 7 , 8 ] . Most patients are interested in establishing advance directives , but few actually complete them [ 1 , 9 , 10 ] . In 1990 , the U.S. Congress passed the Patient Self-Determination Act , which requires hospitals to inform admitted patients about their right to record advance directives [ 6 , 11 ] . The Act does not dictate who should initiate these discussion s ( patients , physicians , or an admissions officer , for example ) [ 12 , 13 ] . It is therefore not surprising that the Act has had little effect on the rate of completion of advance directives [ 11 , 13 - 15 ] . Because hospitalized patients are often acutely ill and lose their ability to make decisions [ 3 ] , it may be more appropriate to discuss such issues before hospitalization [ 12 , 16 , 17 ] . Other interventions aim ed at increasing the establishment of advance directives have met with mixed success [ 18 ] . With one exception [ 19 ] , patient education has had little or no effect [ 20 - 24 ] . More effective interventions have trained physicians , social workers , or counselors to discuss advance directives [ 18 , 22 , 25 - 27 ] ; this has led to the conclusion that counseling by a clinician is the best catalyst for the completion of advance directives [ 28 ] . However , little is known about how to educate and motivate clinicians to solicit advance directives [ 28 ] . We [ 29 - 31 ] and others [ 32 ] have previously shown that computer reminders increase physician compliance with practice guidelines . In this study , we tested the hypothesis that reminding primary care physicians to discuss advance directives would stimulate such discussion s and lead to the establishment of more advance directives . Methods Setting and Patients This study was approved by the institutional review board of Indiana University as expedited research with waiver of informed consent from both patients and physicians . It was conducted in the General Medicine Practice [ 31 ] , an academic primary care practice affiliated with an urban public teaching hospital . This practice is staffed by general internal medicine faculty , fellows , and residents . Each resident and fellow attends the General Medicine Practice one half-day per week ; faculty attend one to four half-days per week . Residents always practice with the same attending faculty physicians . All physicians , except for study investigators , were eligible to participate . At the time of this study , the General Medicine Practice comprised four separate practice s with separate waiting areas , clerks , and nurses . Each practice held eight half-day sessions per week . Each session was attended by two faculty members and two or three residents , each of whom provided primary care to assigned panels of patients . Residents were required to briefly discuss each patient with the attending faculty . Fellows served as faculty and were treated as such . Since 1981 , a computerized program has r and omly assigned new physicians to the practice sessions [ 31 ] . New patients have been sequentially assigned to open appointment slots ; this result ed in no important differences in patients or clinical practice among the sessions [ 29 , 33 ] . We included patients who were at risk for acute deterioration ( and therefore might benefit from advance directives ) because of advanced age ( 75 years , the typical threshold for the oldest old ) or because they were 50 years of age or older and had one of the following chronic conditions : cardiac ischemia , heart failure , chronic lung disease , cancer other than nonmelanomatous skin cancer , cerebrovascular disease , renal insufficiency , or cirrhosis . We chose 50 years of age as a cut-off to yield sufficient numbers of patients . A computer program identified eligible patients among those with scheduled appointments at the General Medicine Practice by using problem lists and test results stored in the Regenstrief Medical Record System [ 34 ] . Eligible patients who kept appointments at the General Medicine Practice were approached by research assistants in the waiting room . The research assistants , who were blinded at all times to the patients ' study groups , explained the study to the patients , invited them to participate , and interviewed those who agreed to participate ; patients from nursing homes and prisons and patients who were deaf or did not speak English were excluded . The assistants then administered the Pfeiffer Mental Status Question naire [ 35 ] ; patients whose scores indicated cognitive dysfunction were excluded . The remaining patients provided sociodemographic information and stated whether they had previously discussed or completed advance directives ; patients who had completed advance directives were excluded . Patients also stated their preferences with regard to six treatments in the event of a terminal illness [ 36 ] . Advance Directives Before the study , we created two separate forms for instruction directives and proxy directives ; these forms became the official advance directive documents of the hospital and its outpatient services . The instruction directive allowed patients to indicate whether , in the event of terminal illness and mental incapacity , they wanted or did not want eight types of care : cardiopulmonary resuscitation , mechanical ventilation , surgery , invasive procedures , nutrition and hydration , transfusion of blood or blood products , antibiotics , or noninvasive diagnostic tests . The primary care physician had to sign each completed instruction directive form to indicate that he or she was aware of its contents . The proxy directive design ated both primary and secondary health care representatives . We placed both advance directive forms in a drawer of the desk of each physician in the General Medicine Practice . We also placed the forms in a bin near the door of the staff room along with other forms and requisitions and business reply envelopes for patients who wanted to complete the forms at home . Research assistants entered the data from completed forms into the Regenstrief Medical Record System , where the forms were available for viewing through computer terminals and workstations in all inpatient and outpatient venues [ 34 ] . Before the study , the three physician-investigators presented the basic concepts of advance directives at gr and rounds . They also had face-to-face meetings with each physician in the General Medicine Practice and explained how to complete and process the forms . We encouraged physicians to discuss advance directives with their elderly and debilitated patients and posted flyers in each practice staffing room suggesting that physicians discuss advance directives with patients who had the target study conditions . Study Methods The intent of the r and omization scheme was to expose physicians to the same type of reminder or reminders , or no reminders , during all of their scheduled primary care visits with enrolled patients . At the time of this study , 32 weekly half-day sessions took place on the four General Medicine Practice practice s. Two sessions attended by study investigators were excluded . We r and omly assigned all of the physicians who worked in a particular half-day session to the same reminder category . At the time of r and omization , 16 physicians ( all of whom were faculty members ) practice d in more than 1 session per week ( 14 practice d in 2 sessions and 2 practice d in 3 sessions ) . Therefore , we r and omly assigned the sessions in a stepped manner by first allocating the 16 physicians and all of their associated sessions to four categories : control ( no reminders ) , computer-generated reminders for instruction directives , computer-generated reminders for proxy directives , and computer-generated reminders for both types of directives . We then r and omly assigned the remaining 8 sessions and their physicians to the four categories ( Table 1 ) . Each practice contained sessions in all four categories , which were equally distributed between mornings and afternoons . Table 1 . Results of R and omization All physicians routinely received computer-generated reminders for patients with scheduled visits . They were reminded to give preventive care , note abnormal test results , and avoid drug interactions [ 29 , 34 ] . These reminders appeared at the bottom of computer-generated printed encounter forms [ 34 ] ( Figure 1 ) . Physicians routinely review ed the encounter forms and the practice chart immediately before visiting the patient . As recommended by Litzelman and coworkers [ 37 ] , the advance directive reminders were followed by a choice list ( discussed today , next visit , not applicable , patient too ill , patient refuses to discuss , I disagree with advance directives ) . Instruction directives were called advance directives , and proxies were called health care representatives ( Figure 1 ) . Figure 1 . General Medicine Practice encounter form showing reminders for both types of advance directive . After patients were enrolled , research assistants attempted to interview them in the waiting room after each scheduled appointment to assess whether they had discussed advance directives with their physicians that day . Patients who answered yes were defined as having had an advance directive discussion . During the first scheduled General Medicine Practice visit in the 5-month period between 11 and 16 months after enrollment , a close-out interview was attempted . If no scheduled visit had occurred by 15 months after enrollment , the close-out interview was attempted by telephone . Form completion was defined as having occurred if either completed form was received between study enrollment and 30 days after the final interview ( this made it possible to receive by mail forms that were completed after the close-out OBJECTIVE : To determine efficient ways of promoting advance directives among heterogeneous population s of elderly ambulatory patients . DESIGN : One-year quasi-experimental trial . SETTING : Five suburban and urban health centers in one region of a large managed care organization . One additional suburban center served as a control site . PARTICIPANTS : Individuals ages 65 and older ( N=2,120 ) who were continuously enrolled and had a health maintenance visit with their primary care provider during the study year . INTERVENTION : Physician education ( oral and written ) and physician and patient prompts to discuss advance directives . MAIN RESULTS : Sixty-six ( 7.8 % ) of patients at the intervention centers completed new advance directives  , versus 9 of 1,277 ( < 1 % ) at the comparison center ( P<.001 ) . Patients 75 and older were twice as likely ( odds ratio [ OR ] , 2.0 ; 95 % confidence limits [ CL ] , 1.2 to 3.3 ) as those 65 to 74 to file a new advance directive , and the odds were twice as great ( OR , 2.6 ; 95 % CL , 1.4 to 4.6 ) at centers serving communities with median household income over the state median .  Gender , recent hospitalization , emergency room visits , and number of chronic conditions were not related to making new directives nor was predominant ethnicity of the center community ( African-American versus white ) . Adjusted for these factors , the intervention result ed in a 20-fold increase ( 95 % CL , 10.4 to 47.8 ) in the odds of creating a new advance directive . Doctors reported barriers of time and unwillingness to press discussion s with patients . CONCLUSIONS : A replicable intervention largely targeting doctors 
    Output:
    
Review findings identified a diverse and disaggregated body of ACP literature describing barriers and enablers to ACP in general practice , and interventions testing single or multiple mechanisms to improve ACP generally without explicit consideration for level of influence .