***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: Summary Background Unnecessary antibiotic prescribing contributes to antimicrobial resistance . In this trial , we aim ed to reduce unnecessary prescriptions of antibiotics by general practitioners ( GPs ) in Engl and . Methods In this r and omised , 2 × 2 factorial trial , publicly available data bases were used to identify GP practice s whose prescribing rate for antibiotics was in the top 20 % for their National Health Service ( NHS ) Local Area Team . Eligible practice s were r and omly assigned ( 1:1 ) into two groups by computer-generated allocation sequence , stratified by NHS Local Area Team . Participants , but not investigators , were blinded to group assignment . On Sept 29 , 2014 , every GP in the  feedback intervention group was sent a letter from Engl and 's Chief Medical Officer and a leaflet on antibiotics for use with patients . The letter stated that the practice was prescribing antibiotics at a higher rate than 80 % of practice s in its NHS Local Area Team . GPs in the control group received no communication . The sample was re-r and omised into two groups , and in December , 2014 , GP practice s were either sent patient-focused information that promoted reduced use of antibiotics or received no communication . The primary outcome measure was the rate of antibiotic items dispensed per 1000 weighted population , controlling for past prescribing . Analysis was by intention to treat . This trial is registered with the IS RCT N registry , number IS RCT N32349954 , and has been completed . Findings Between Sept 8 and Sept 26 , 2014 , we recruited and assigned 1581 GP practice s to feedback intervention ( n=791 ) or control ( n=790 ) groups . Letters were sent to 3227 GPs in the intervention group . Between October , 2014 , and March , 2015 , the rate of antibiotic items dispensed per 1000 population was 126·98 ( 95 % CI 125·68–128·27 ) in the feedback intervention group and 131·25 ( 130·33–132·16 ) in the control group , a difference of 4·27 ( 3·3 % ; incidence rate ratio [ IRR ] 0·967 [ 95 % CI 0·957–0·977 ] ; p<0·0001 ) , representing an estimated 73 406 fewer antibiotic items dispensed . In December , 2014 , GP practice s were re-assigned to patient-focused intervention ( n=777 ) or control ( n=804 ) groups . The patient-focused intervention did not significantly affect the primary outcome measure between December , 2014 , and March , 2015 ( antibiotic items dispensed per 1000 population : 135·00 [ 95 % CI 133·77–136·22 ] in the patient-focused intervention group and 133·98 [ 133·06–134·90 ] in the control group ; IRR for difference between groups 1·01 , 95 % CI 1·00–1·02 ; p=0·105 ) . Interpretation Social norm feedback from a high-profile messenger can substantially reduce antibiotic prescribing at low cost and at national scale ; this outcome makes it a worthwhile addition to antimicrobial stewardship programmes . Funding Public Health Engl and Objective To investigate recruitment and retention , data collection methods and the acceptability of a ‘ within-consultation ’ complex intervention design ed to reduce antibiotic prescribing . Design Primary care feasibility cluster r and omised controlled trial . Setting 32 general practice s in South West Engl and recruiting children from October 2014 to April 2015 . Participants Children ( aged 3 months to < 12 years ) with acute cough and respiratory tract infection ( RTI ) . Intervention A web-based clinician-focussed clinical rule to predict risk of future hospitalisation and a printed leaflet with individualised child health information for carers , safety-netting advice and a treatment decision record . Controls Usual practice , with clinicians recording data on symptoms , signs and treatment decisions . Results Of 542 children invited , 501 ( 92.4 % ) consented to participate , a month ahead of schedule . Antibiotic prescribing data were collected for all children , follow-up data for 495 ( 98.8 % ) and the National Health Service re source use data for 494 ( 98.6 % ) . The overall antibiotic prescribing rates for children ’s RTIs were 25 % and 15.8 % ( p=0.018 ) in intervention and control groups , respectively . We found evidence of postr and omisation differential recruitment : the number of children recruited to the intervention arm was higher ( 292 vs 209 ) ; over half were recruited by prescribing nurses compared with less than a third in the control arm ; children in the intervention arm were younger ( median age 2 vs 3 years controls , p=0.03 ) and appeared to be more unwell than those in the control arm with higher respiratory rates ( p<0.0001 ) , wheeze prevalence ( p=0.007 ) and global illness severity scores assessed by carers ( p=0.045 ) and clinicians ( p=0.01 ) . Interviews with clinicians confirmed preferential recruitment of less unwell children to the trial , more so in the control arm . Conclusion Differential recruitment may explain the paradoxical antibiotic prescribing rates . Future cluster level studies should consider design s which remove the need for individual consent postr and omisation and embed the intervention within electronic primary care records . Trial registration number IS RCT N 23547970 UKCRN study ID Background There is a strong link between antibiotic consumption and the rate of antibiotic resistance . In Australia , the vast majority of antibiotics are prescribed by general practitioners , and the most common indication is for acute respiratory infections . The aim of this study is to assess if implementing a package of integrated , multifaceted interventions reduces antibiotic prescribing for acute respiratory infections in general practice . Methods / design This is a cluster r and omised trial comparing two parallel groups of general practitioners in 28 urban general practice s in Queensl and , Australia : 14 intervention and 14 control practice s. The protocol was peer- review ed by content experts who were nominated by the funding organization . This study evaluates an integrated , multifaceted evidence -based package of interventions implemented over a six month period . The included interventions , which have previously been demonstrated to be effective at reducing antibiotic prescribing for acute respiratory infections , are : delayed prescribing ; patient decision aids ; communication training ; commitment to a practice prescribing policy for antibiotics ; patient information leaflet ; and near patient testing with C-reactive protein . In addition , two sub- studies are nested in the main study : ( 1 ) point prevalence estimation carriage of bacterial upper respiratory pathogens in practice staff and asymptomatic patients ; ( 2 ) feasibility of direct measures of antibiotic resistance by nose/throat swabbing . The main outcome data are from Australia ’s national health insurance scheme , Medicare , which will be accessed after the completion of the intervention phase . They include the number of antibiotic prescriptions and the number of patient visits per general practitioner for periods before and during the intervention . The incidence of antibiotic prescriptions will be modelled using the numbers of patients as the denominator and seasonal and other factors as explanatory variables . Results will compare the change in prescription rates before and during the intervention in the two groups of practice s . Semi-structured interviews will be conducted with the general practitioners and practice staff ( practice nurse and /or practice manager ) from the intervention practice s on conclusion of the intervention phase to assess the feasibility and uptake of the interventions .An economic evaluation will be conducted to estimate the costs of implementing the package , and its cost-effectiveness in terms of cost per unit reduction in prescribing . Discussion The results on the effectiveness , cost-effectiveness , acceptability and feasibility of this package of interventions will inform the policy for any national implementation . Trial registration The GAPS trial is registered under the Australian New Zeal and Clinical Trials Register , reference number : ACTRN12615001128583 ( registered 26/10/2015 ) Objective To develop a conceptual model for effective use of telehealth in the management of chronic health conditions , and to use this to develop and evaluate an intervention for people with two exemplar conditions : raised cardiovascular disease risk and depression . Design The model was based on several str and s of evidence : a meta review and realist synthesis of quantitative and qualitative evidence on telehealth for chronic conditions ; a qualitative study of patients ’ and health professionals ’ experience of telehealth ; a quantitative survey of patients ’ interest in using telehealth ; and review of existing models of chronic condition management and evidence -based treatment guidelines . Based on these evidence str and s , a model was developed and then refined at a stakeholder workshop . Then a telehealth intervention ( ‘ Healthlines ’ ) was design ed by incorporating strategies to address each of the model components . The model also provided a framework for evaluation of this intervention within parallel r and omised controlled trials in the two exemplar conditions , and the accompanying process evaluations and economic evaluations . Setting Primary care . Results The TElehealth in CHronic Disease ( TECH ) model proposes that attention to four components will offer interventions the best chance of success : ( 1 ) engagement of patients and health professionals , ( 2 ) effective chronic disease management ( including subcomponents of self-management , optimisation of treatment , care coordination ) , ( 3 ) partnership between providers and ( 4 ) patient , social and health system context . Key intended outcomes are improved health , access to care , patient experience and cost-effective care . Conclusions A conceptual model has been developed based on multiple sources of evidence which articulates how telehealth may best provide benefits for patients with chronic health conditions . It can be used to structure the design and evaluation of telehealth programmes which aim to be acceptable to patients and providers , and cost-effective OBJECTIVES To assess the effectiveness of implementing guidelines , coupled with individual feedback , on antibiotic prescribing behaviour of primary care physicians in Switzerl and . METHODS One hundred and forty general practice s from a representative Swiss sentinel network of primary care physicians participated in this cluster-r and omized prospect i ve intervention study . The intervention consisted of providing guidelines on treatment of respiratory tract infections ( RTIs ) and uncomplicated lower urinary tract infections ( UTIs ) , coupled with sustained , regular feedback on individual antibiotic prescription behaviour during 2 years . The main aims were : ( i ) to increase the percentage of prescriptions of penicillins  for all RTIs treated with antibiotics ; ( ii ) to increase the percentage of  trimethoprim/sulfamethoxazole prescriptions for all uncomplicated lower UTIs treated with antibiotics ; ( iii ) to decrease the percentage of quinolone prescriptions for all cases of exacerbated COPD ( e COPD ) treated with antibiotics ; and ( iv ) to decrease the proportion of sinusitis and other upper RTIs treated with antibiotics . The study was registered at Clinical Trials.gov ( NCT01358916 ) . RESULTS While the percentage of antibiotics prescribed for sinusitis or other upper RTIs and the percentage of quinolones prescribed for e COPD did not differ between the intervention group and the control group , there was a significant increase in the percentage of prescriptions of penicillins for all RTIs treated with antibiotics [ 57 % versus 49 % , OR=1.42 ( 95 % CI 1.08 - 1.89 ) , P=0.01 ] and in the percentage of trimethoprim/sulfamethoxazole prescriptions for all uncomplicated lower UTIs treated with antibiotics [ 35 % versus 19 % , OR=2.16 ( 95 % CI 1.19 - 3.91 ) , P=0.01 ] in the intervention group . CONCLUSIONS In our setting , implementing guidelines , coupled with sustained individual feedback , was not able to reduce the proportion of sinusitis and other upper RTIs treated with antibiotics , but increased the use of recommended antibiotics for RTIs and UTIs , as defined by the guidelines Background The Medical Research Councils ’ framework for complex interventions has been criticized for not including theory-driven approaches to evaluation . Although the framework does include broad guidance on the use of theory , it contains little practical guidance for implementers and there have been calls to develop a more comprehensive approach . A prospect i ve , theory-driven process of intervention design and evaluation is required to develop complex healthcare interventions which are more likely to be effective , sustainable and scalable . Methods We propose a theory-driven approach to the design and evaluation of complex interventions by adapting and integrating a programmatic design and evaluation tool , Theory of Change ( ToC ) , into the MRC framework for complex interventions . We provide a guide to what ToC is , how to construct one , and how to integrate its use into research projects seeking to design , implement and evaluate complex interventions using the MRC framework . We test this approach by using ToC within two r and omized controlled trials and one non-r and omized evaluation of complex interventions . Results Our application of ToC in three research projects has shown that ToC can strengthen key stages of the MRC framework . It can aid the development of interventions by providing a framework for enhanced stakeholder engagement and by explicitly design ing an intervention that is embedded in the local context . For the feasibility and piloting stage , ToC enables the systematic identification of knowledge gaps to generate research questions that strengthen intervention design . ToC may improve the evaluation of interventions by providing a comprehensive set of indicators to evaluate all 
    Output:
    
Results The synthesis produced a series of evidence -based statements summarizing the quantitative and qualitative evidence for intervention elements most likely to result in changes in clinician behaviour .
We design ed a web-based within-consultation intervention to reduce clinician uncertainty and pressure to prescribe , design ed to be used when children with RTI present to a prescribing clinician in primary care .
Our synthesis provided intervention guidance , recommendations for practice , and highlighted evidence gaps , but questions remain about how best to implement these recommendations .