***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 : To evaluate the use of a computerised support system for decision making for implementing evidence based clinical guidelines for the management of asthma and angina in adults in primary care . Design : A before and after pragmatic cluster r and omised controlled trial utilising a two by two incomplete block design . Setting : 60 general practice s in north east Engl and . Participants : General practitioners and practice nurses in the study practice s and their patients aged 18 or over with angina or asthma . Main outcome measures : Adherence to the guidelines , based on review of case notes and patient reported generic and condition specific outcome measures . Results : The computerised decision support system had no significant effect on consultation rates , process of care measures ( including prescribing ) , or any patient reported outcomes for either condition . Levels of use of the software were low . Conclusions : No effect was found of computerised evidence based guidelines on the management of asthma or angina in adults in primary care . This was probably due to low levels of use of the software , despite the system being optimised as far as was technically possible . Even if the technical problems of producing a system that fully supports the management of chronic disease were solved , there remains the challenge of integrating the systems into clinical encounters where busy practitioners manage patients with complex , multiple conditions UNLABELLED Critics of the use of clinical practice guidelines ( CPGs ) in an emergency department ( ED ) setting believe that they are too cumbersome and time-consuming , but to the best of the authors ' knowledge , potential barriers to CPG adherence in the ED have not been prospect ively evaluated . OBJECTIVES To measure provider adherence to an ED CPG based on National Asthma Education and Prevention Program ( NAEPP ) recommendations , and to determine factors associated with provider nonadherence . METHODS Prospect i ve , cohort study of children aged 1 - 18 years with the diagnosis of an acute exacerbation of asthma who were seen in a pediatric ED and requiring admission , as well as a r and om selection of children discharged to home following pediatric ED care . The following adherence parameters were assessed : at least three nebulized albuterol treatments in the first hour ; early steroid administration ( after the first nebulizer treatment ) ; clinical assessment s using pulse oximetry and peak expiratory flow ( PEF ) ( for children > 6 years old ) ; and use of a clinical score to assess acute illness severity ( Asthma Severity Score ) . Nonadherence was defined as any deviation of the above parameters . RESULTS Between July 1 , 1998 , and June 30 , 1999 , 369 patients were studied . Of these , 38 % ( 139 ) were discharged to home , 38 % ( 140 ) were admitted to the observation unit , and 24 % ( 90 ) were admitted to the inpatient unit . Illness severities at initial presentation to the ED were : 24 % ( 86 ) had mild exacerbations , 59 % ( 212 ) had moderate exacerbations , and 17 % ( 62 ) had severe exacerbations . Sixty-eight percent ( 95 % CI = 63 % to 73 % ) of the patients were managed with complete adherence to the CPG . Of the 32 % with some form of nonadherence , most ( 63 % ) were children older than 6 years ; in this group 64 % ( 48/75 ) were nonadherent due to lack of PEF assessment . When PEF assessment was disregarded , an 83 % ( 95 % CI = 79 % to 87 % ) adherence to the CPG was achieved . Other nonadherence factors included : lack of at least three nebulized albuterol treatments provided timely within the first hour ( 5 % ) ; delay in steroid administration ( 6 % ) ; lack of pulse oximeter use ( 0.5 % ) ; and failure to record clinical score to assess severity ( 1.1 % ) . Patient age , illness severity ( acute and chronic ) , first episode of wheezing , and high ED volume periods ( evenings and weekends ) did not worsen adherence . CONCLUSIONS Clinical practice guidelines can be used successfully in the pediatric ED and provide a more efficient management and treatment approach to acute exacerbations of childhood asthma . With a systematic and concise CPG , barriers to adherence in a pediatric ED appear to be minimal , with the exception of using PEF in the routine ED assessment Background Internet-based self-management has shown to improve asthma control and asthma related quality of life , but the improvements were only marginally clinical ly relevant for the group as a whole . We hypothesized that self-management guided by weekly monitoring of asthma control tailors pharmacological therapy to individual needs and improves asthma control for patients with partly controlled or uncontrolled asthma . Methods In a 1-year r and omised controlled trial involving 200 adults ( 18 - 50 years ) with mild to moderate persistent asthma we evaluated the adherence with weekly monitoring and effect on asthma control and pharmacological treatment of a self-management algorithm based on the Asthma Control Question naire ( ACQ ) . Participants were assigned either to the Internet group ( n = 101 ) that monitored asthma control weekly with the ACQ on the Internet and adjusted treatment using a self-management algorithm supervised by an asthma nurse specialist or to the usual care group ( UC ) ( n = 99 ) . We analysed 3 subgroups : patients with well controlled ( ACQ ≤ 0.75 ) , partly controlled ( 0.75>ACQ ≤ 1.5 ) or uncontrolled ( ACQ>1.5 ) asthma at baseline .  Results Overall monitoring adherence was 67 % ( 95 % CI , 60 % to 74 % ) . Improvements in ACQ score after 12 months were -0.14 ( p = 0.23 ) , -0.52 ( p < 0.001 ) and -0.82 ( p < 0.001 ) in the Internet group compared to usual care for patients with well , partly and uncontrolled asthma at baseline , respectively . Daily inhaled corticosteroid dose significantly increased in the Internet group compared to usual care in the first 3 months in patients with uncontrolled asthma ( + 278 μg , p = 0.001 ) , but not in patients with well or partly controlled asthma . After one year there were no differences in daily inhaled corticosteroid use or long-acting β2-agonists between the Internet group and usual care . Conclusions Weekly self-monitoring and subsequent treatment adjustment leads to improved asthma control in patients with partly and uncontrolled asthma at baseline and tailors asthma medication to individual patients ' needs . Trial registration Current Controlled Trials IS RCT This prospect i ve study was design ed to determine whether incorporating formoterol into a st and ardized respiratory therapist-directed protocol for administering bronchodilators to hospitalized patients with obstructive airway disease would reduce health care re source use and provide a safety advantage . All patients admitted to Washington Hospital Center with asthma and chronic obstructive pulmonary disease ( CODP ) are administered bronchodilators under a st and ardized respiratory therapist-directed protocol . Formoterol was the primary bronchodilator for the intervention period from January through March 2002 , with levalbuterol , albuterol , and ipratropium available as needed . Results for the intervention period were compared against two historical control periods . From January through March 2000 , the bronchodilators in the protocol were albuterol and ipratropium , and from January through March 2001 levalbuterol , albuterol , and ipratropium were available . Health care re source use was determined by the number of bronchodilator treatments administered per admission . Costs ( adjusted to 2002 dollars ) for supplies , therapist time , and drugs were calculated for the three time periods . Adverse events related to bronchodilator administration were recorded in a st and ardized manner for all three time periods . Bronchodilator treatments per admission , respiratory therapist visits per admission , and time spent per admission , and cost per bronchodilator treatment significantly decreased in 2002 . Significantly fewer adverse events related to bronchodilator treatments were reported in 2002 than 2000 . The addition of formoterol to a respiratory therapist-directed protocol for administering bronchodilators reduced health care re source use and adverse events for patients with asthma and COPD OBJECTIVE : Asthma continues to be 1 of the most common chronic diseases of childhood and affects ∼6 million US children . Although National Asthma Education Prevention Program guidelines exist and are widely accepted , previous studies have demonstrated poor clinician adherence across a variety of population s. We sought to determine if clinical decision support ( CDS ) embedded in an electronic health record ( EHR ) would improve clinician adherence to national asthma guidelines in the primary care setting . METHODS : We conducted a prospect i ve cluster-r and omized trial in 12 primary care sites over a 1-year period . Practice s were stratified for analysis according to whether the site was urban or suburban . Children aged 0 to 18 years with persistent asthma were identified by International Classification of Diseases , Ninth Revision codes for asthma . The 6 intervention- practice sites had CDS alerts imbedded in the EHR . Outcomes of interest were the proportion of children with at least 1 prescription for controller medication , an up-to- date asthma care plan , and the performance of office-based spirometry . RESULTS : Increases in the number of prescriptions for controller medications , over time , was 6 % greater ( P = .006 ) and 3 % greater for spirometry ( P = .04 ) in the intervention urban practice s. Filing an up-to- date asthma care plan improved 14 % ( P = .03 ) and spirometry improved 6 % ( P = .003 ) in the suburban practice s with the intervention . CONCLUSION : In our study , using a cluster-r and omized trial design , CDS in the EHR , at the point of care , improved clinician compliance with National Asthma Education Prevention Program guidelines Background Little is known about the impact of implementing nursing-oriented best practice guidelines on the delivery of patient care in either hospital or community setting s. Methods A naturalistic study with a prospect i ve , before and after design documented the implementation of six newly developed nursing best practice guidelines ( asthma , breastfeeding , delirium-dementia-depression ( DDD ) , foot complications in diabetes , smoking cessation and venous leg ulcers ) . Eleven health care organisations were selected for a one-year project . At each site , clinical re source nurses ( CRNs ) worked with managers and a multidisciplinary steering committee to conduct an environmental scan and develop an action plan of activities ( i.e. education sessions , policy review ) . Process and patient outcomes were assessed by chart audit ( n = 681 pre-implementation , 592 post-implementation ) . Outcomes were also assessed for four of six topics by in-hospital/home interviews ( n = 261 pre-implementation , 232 post-implementation ) and follow-up telephone interviews ( n = 152 pre , 121 post ) . Interviews were conducted with 83/95 ( 87 % ) CRN 's , nurses and administrators to describe recommendations selected , strategies used and participants ' perceived facilitators and barriers to guideline implementation . Results While statistically significant improvements in 5 % to 83 % of indicators were observed in each organization , more than 80 % of indicators for breastfeeding , DDD and smoking cessation did not change . Statistically significant improvements were found in > 50 % of indicators for asthma ( 52 % ) , diabetes foot care ( 83 % ) and venous leg ulcers ( 60 % ) . Organizations with > 50 % improvements reported two unique implementation strategies which included h and s-on skill practice sessions for nurses and the development of new patient education material s. Key facilitators for all organizations included education sessions as well as support from champions and managers while key barriers were lack of time , workload pressure and staff resistance . Conclusion Implementation of nursing best practice guidelines can result in improved practice and patient outcomes across diverse setting s yet many indicators remained unchanged . Mobilization of the nursing workforce to actively implement guidelines and to monitor the delivery of their care is important so that patients may learn about and receive recommended healthcare Objective . To evaluate effects on the process and outcomes of care brought about by use of a h and held , computer-based system that implements the American Academy of Pediatrics guideline on office management of asthma exacerbations . Design . A before – after trial with r and omly selected , office-based Connecticut pediatricians . In both the control and intervention phases , physicians collected data from 10 patient encounters for acute asthma exacerbations . During the intervention phase , the computer provided for structured encounter documentation and offered recommendations based on the guideline of the American Academy of Pediatrics . Patients were contacted by telephone 7 to 14 days after the visit to assess outcomes . Results . Nine study -physicians enrolled 91 patients in the control phase and 74 in the intervention phase . Follow-up information was available for 93 % of encounters . Use of the intervention was associated with increased mean frequency/visit of : 1 ) measurements of peak expiratory flow rate ( 2.18 vs 1.57 ) and oxygen saturation ( 1.12 vs .42 ) , and 2 ) administration of nebulized β2-agonists ( 1.25 vs .71 ) . Visits in the intervention phase lasted longer and fees were higher ( $ 145.61 vs $ 103.11 ) . There were no significant differences in immediate disposition or subsequent emergency department visits , hospitalizations , missed school , or caretaker 
    Output:
    
Paper-based reminders were the most frequent with fully computerized , then computer generated , and other modalities .
No study reported a decrease in health care practitioner performance or declining patient outcomes .
The most common primary outcome measure was compliance with provided or prescribing guidelines , key clinical indicators such as patient outcomes or quality of life , and length of stay .
Conclusions Paper-based implementations are by far the most popular approach to implement a guideline or protocol .
Asthma guidelines generally improved patient care and practitioner performance regardless of the implementation method