***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: A prospect i ve analysis of patients hospitalized with pneumococcal infection at two Rochester ( NY ) hospitals was performed during an 18-month period to assess the feasibility of a pneumococcal vaccination program directed at in patients . Of the 113 patients hospitalized with pneumococcal infection , only nine patients ( 8 % ) had previously received pneumococcal vaccine  and 76 patients ( 67 % ) had been hospitalized at least once in the previous three years . Of the 104 patients who had a source of regular medical care , 100 % had made at least one outpatient visit in the previous three years . The association between the acquisition of a serious pneumococcal infection and hospitalization within the previous three years suggests that a vaccination strategy directed at hospitalized high-risk patients would be potentially effective . Also , vaccination of high-risk ambulatory patients remains a viable strategy to prevent serious pneumococcal infection Pneumococcal vaccine effectiveness was assessed in a r and omized trial among 1,686 old people ( mean age : 74 , st and ard deviation : 4 years ) living in 24 geriatric hospitals and 26 homes for the aged in our district ; 937 were vaccinated with  Merck-Sharp and Dohme pneumococcal vaccine ( 14 serotypes ) . The 749 others composed the reference group . This study was performed during 2 years , since December 1980 . Both groups were r and omized after a two- criteria stratification : by clinical risk assessed before the study , and by type of homes for the aged . Forty pneumonias were diagnosed , with 13 proved pneumococcal etiology . The incidence of pneumonia was significantly reduced in the vaccinated group ( p less than 10(-4 ) but the mortality rate was not modified . We concluded in favor of the effectiveness of pneumococcal  vaccine :  etiological fraction 77.1 % ( 51.2%-89.3 % confidence limits , 95 % risk ) in the population we studied . The incidence of pneumococcal-proved pneumonia was not significantly reduced CONTEXT Many groups have developed guidelines to shorten hospital length of stay in pneumonia in order to decrease costs , but the length of time until a patient hospitalized with pneumonia becomes clinical ly stable has not been established . OBJECTIVE To describe the time to resolution of abnormalities in vital signs , ability to eat , and mental status in patients with community-acquired pneumonia and assess clinical outcomes after achieving stability . DESIGN Prospect i ve , multicenter , observational cohort study . SETTING Three university and 1 community teaching hospital in Boston , Mass , Pittsburgh , Pa , and Halifax , Nova Scotia . PATIENTS Six hundred eighty-six adults hospitalized with community-acquired pneumonia . MAIN OUTCOME MEASURES Time to resolution of vital signs , ability to eat , mental status , hospital length of stay , and admission to an intensive care , coronary care , or telemetry unit . RESULTS The median time to stability was 2 days for heart rate ( < or = 100 beats/min ) and systolic blood pressure ( > or = 90 mm Hg ) , and 3 days for respiratory rate ( < or = 24 breaths/min ) , oxygen saturation ( > or = 90 % ) , and temperature ( < or = 37.2 degrees C [ 99 degrees F ] ) . The median time to overall clinical stability was 3 days for the most lenient definition of stability and 7 days for the most conservative definition . Patients with more severe cases of pneumonia at presentation took longer to reach stability . Once stability was achieved , clinical deterioration requiring intensive care , coronary care , or telemetry monitoring occurred in 1 % of cases or fewer . Between 65 % to 86 % of patients stayed in the hospital more than 1 day after reaching stability , and fewer than 29 % to 46 % were converted to oral antibiotics within 1 day of stability , depending on the definition of stability . CONCLUSIONS Our estimates of time to stability in pneumonia and explicit criteria for defining stability can provide an evidence -based estimate of optimal length of stay , and outline a clinical ly sensible approach to improving the efficiency of inpatient management OBJECTIVE To study the effect of a length of stay practice guideline on patient outcomes . DESIGN A prospect i ve , nonr and omized , interventional trial . SETTING Six geographically distributed hospitals . PATIENTS Two hundred forty-two consecutively hospitalized " low-risk " patients with pneumonia . MEASUREMENTS AND RESULTS One hundred fifty-two patients ( 63 % ) completed the mailed postdischarge survey  and were included in the analysis . Data were prospect ively collected for 85 patients from the baseline observation period ( B ) and 67 patients from the intervention period ( I ) . During the I , case managers provided physicians with patient risk information based on guideline recommendations . There was no significant change in guideline compliance ( B vs I : 76.5 % vs 83.6 % ; p=0.32 ) or length of stay ( B vs I : 3.5 days [ 95 % confidence interval , 3.2 to 3.8 ] vs 3.6 days [ 95 % confidence interval , 3.3 to 4.0 ] ) . Also , there were no statistically significant effects of the intervention on patient outcomes , care following hospital discharge , and patient satisfaction scores . CONCLUSION Patients in this study often had shorter lengths of stay than recommended by the practice guideline . This suggests that the external environment may have had a greater effect on physician behavior and length of stay than the practice guideline itself . Moreover , it demonstrates the importance of continuous assessment of physician practice s immediately prior to , during , and after application of the clinical practice guideline This study compared three interventions design ed to increase acceptance of influenza and pneumococcal vaccines among elderly hospitalized patients . All individuals 65 and older able to give informed consent ( 73 patients ) who were admitted to one medical floor of an acute care hospital were r and omized to one of three groups . All groups received informational pamphlets explaining influenza and pneumococcal disease , their respective vaccines , and indications for their use . The first group received pamphlets only , the second received nursing follow-up , and the third received trained volunteer follow-up .  Patients on another medical floor served as controls . The results showed a significant improvement in vaccine acceptance in all three study groups compared to controls for both influenza ( 78 % vs 0 % ) and pneumococcal ( 75 % vs 0 % ) vaccines . The differences among the three groups were not significant . No significant differences were found among patients accepting or refusing vaccination with regard to diagnosis , age , length of stay , sex , or having a private physician . We conclude that a simple educational program followed by offering vaccination before hospital discharge can be easily implemented , and dramatically increase immunization rates in this high risk group CONTEXT Large variations exist among hospitals in the use of treatment re sources for community-acquired pneumonia ( CAP ) . Lack of a common approach to the diagnosis and treatment of CAP has been cited as an explanation for these variations . OBJECTIVE To determine if use of a critical pathway improves the efficiency of treatment for CAP without compromising the well-being of patients . DESIGN Multicenter controlled clinical trial with cluster r and omization and up to 6 weeks of follow-up . SETTING Nineteen teaching and community hospitals in Canada . PATIENTS A total of 1743 patients with CAP presenting to the emergency department at 1 of the participating institutions between January 1 and July 31 , 1998 . INTERVENTION Hospitals were assigned to continue conventional management ( n = 10 ) or implement the critical pathway ( n = 9 ) , which consisted of a clinical prediction rule to guide the admission decision , levofloxacin therapy , and practice guidelines . MAIN OUTCOME MEASURES Effectiveness of the critical pathway , as measured by health-related quality of life on the Short-Form 36 Physical Component Summary ( SF-36 PCS ) scale at 6 weeks ; and re source utilization , as measured by the number of bed days per patient managed ( BDPM ) . RESULTS Quality of life and the occurrence of complications , readmission , and mortality were not different for the 2 strategies ; the 1-sided 95 % confidence limit of the between-group difference in the SF-36 PCS change score was 2.4 points , which was within a predefined 3-point boundary for equivalence . Pathway use was associated with a 1.7-day reduction in BDPM ( 4.4 vs 6.1 days ; P = .04 ) and an 18 % decrease in the admission of low-risk patients ( 31 % vs 49 % ; P = .01 ) . Although in patients at critical pathway hospitals had more severe disease , they required 1.7 fewer days of intravenous therapy ( 4.6 vs 6.3 days ; P = .01 ) and were more likely to receive treatment with a single class of antibiotic ( 64 % vs 27 % ; P<.001 ) . CONCLUSION In this study , implementation of a critical pathway reduced the use of institutional re sources without causing adverse effects on the well-being of patients BACKGROUND Vaccination rates for healthy senior citizens are lower than those for senior citizens with underlying medical conditions such as chronic heart or lung disease . Uncertainty about the benefits of influenza vaccination for healthy senior citizens may contribute to lower rates of utilization in this group . OBJECTIVE To clarify the benefits of influenza vaccination among low-risk senior citizens while concurrently assessing the benefits for intermediate- and high-risk senior citizens . METHODS All elderly members of a large health maintenance organization were included in each of 6 consecutive study cohorts . Subjects were grouped according to risk status : high risk ( having heart or lung disease ) , intermediate risk ( having diabetes , renal disease , stroke and /or dementia , or rheumatologic disease ) , and low risk . Outcomes were compared between vaccinated and unvaccinated subjects after controlling for baseline demographic and health characteristics . RESULTS There were more than 20000 subjects in each of the 6 cohorts who provided 147551 person-periods of observation . The pooled vaccination rate was 60 % . There were 101 619 person-periods of observation for low-risk subjects , 15 482 for intermediate-risk , and 30 450 for high-risk subjects . Vaccination over the 6 seasons was associated with an overall reduction of 39 % for pneumonia hospitalizations ( P<.001 ) , a 32 % decrease in hospitalizations for all respiratory conditions ( P<.001 ) , and a 27 % decrease in hospitalizations for congestive heart failure ( P<.001 ) . Immunization was also associated with a 50 % reduction in all-cause mortality ( P<.001 ) . Within the risk subgroups , vaccine effectiveness was 29 % , 32 % , and 49 % for high- , intermediate- , and low-risk senior citizens for reducing hospitalizations for pneumonia and influenza ( for high and low risk , P < or = .002 ; for intermediate risk , P = .11 ) . Effectiveness was 19 % , 39 % , and 33 % ( for each , P < or = .008 ) , respectively , for reducing hospitalizations for all respiratory conditions and 49 % , 64 % , and 55 % for reducing deaths from all causes ( for each , P<.001 ) . Vaccination was also associated with direct medical care cost savings of $ 73 per individual vaccinated for all subjects combined ( P = .002 ) . Estimates of cost savings within each risk group suggest that vaccination would be cost saving for each subgroup ( range of cost savings of $ 171 per individual vaccinated for high risk to $ 7 for low risk ) , although within the subgroups these findings did not reach statistical significance ( for each , P > or = .05 ) . CONCLUSIONS This study confirms that healthy senior citizens as well as senior citizens with underlying medical conditions are at risk for the serious complications of influenza and benefit from vaccination . All individuals 65 years or older should be immunized with this vaccine Since the introduction of the prospect i ve payment system ( PPS ) , anecdotal evidence has accumulated that patients are leaving the hospital " quicker and sicker . " We developed valid measures of discharge impairment and measured these levels in a nationally representative sample of patients with one of five conditions prior to and following the PPS implementation .  Instability at discharge ( important clinical problems usually first occurring prior to discharge ) predicted the likelihood of postdischarge deaths . At 90 days postdischarge , 16 % of patients discharged unstable were dead vs 10 % of patients discharged stable . After the PPS introduction , instability increased primarily among patients discharged home . Prior to the PPS , 10 % of patients discharged home were unstable ; after the PPS was implemented , 15 % were discharged unstable , a 43 % relative change . Efforts to monitor the effect of this increase in discharge instability on health should be implemented OBJECTIVE To compare three approaches for improving compliance with influenza and pneumococcal vaccination of elderly patients . DESIGN R and omized controlled trial using three parallel group practice s at a public urban teaching hospital . SETTING Public teaching hospital . SUBJECTS All patients 65 years of age and older ( n = 1202 ) seen by resident physicians ( n = 66 ) attending three ambulatory medical practice s from October 1 , 1989 to March 31 , 1990 . INTERVENTIONS All three provider groups received intensive education in immunization st and ards . The control group received no further intervention . Staff in the second group offered education to patients at their visits . In the third group , the prevention team , a flowsheet was used , patient education offered , and staff had their tasks redefined to facilitate compliance ; for vaccinations , eg , nurses could vacc 
    Output:
    
The systematic review ( 22 ) found that interventions aim ed at hospitalized patients may have the greatest effect on increasing influenza vaccinations .
The Advisory Committee on Immunization Practice s recommendation , which is based on an informal review of the literature , identifies st and ing orders as the most effective method to increase pneumococcal vaccination rates .
Quality Indicator 5 Influenza Vaccination of Health Care Workers IF a health care organization cares for vulnerable elders , THEN it should have a formal plan to offer and encourage influenza vaccination among its employees BECAUSE vaccination of health care workers is associated with reductions in total patient mortality and in the incidence of influenza-like illness .
Results of this study support recommendations for influenza vaccination of health care workers employed in long-term geriatric care .
Quality Indicator 6 Smoking Cessation IF a vulnerable elder smoker develops pneumonia , THEN the smoker should be advised to quit smoking BECAUSE interventions tailored for such acutely ill patients may increase the rate of long-term cessation of smoking .
This , in turn , may ultimately reduce the risk for developing recurrent pneumonia or other long-term complications of cigarette smoking .
A meta- analysis ( 36 ) and a large observational study , the Pneumonia Patient Outcomes Research Team ( PORT ) cohort study ( 37 ) , support the finding that interventions to advise smokers with pneumonia to quit smoking may increase the rate of long-term cessation of smoking .