***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: We developed a computer-stored medical record system containing a limited set of the total clinical data base -- primarily diagnostic studies and treatments . This system responds to its own content according to physician-authored reminder rules . To determine the effect of the reminder messages generated by 1490 rules on physician behavior , we r and omly assigned practitioners in a general medicine clinic to study or control groups . The computer found indications for six different actions per patient in 12 467 patients during a 2-year study : 61 study group residents who received computer  reminders responded to 49 % of these indications ; 54 control group residents , to only 29 % ( p less than 0.0001 ) . Preventive care ( occult blood testing , mammographic screening , weight reduction diets , influenza and pneumococcal vaccines ) was affected . The intentions of the study group to use a given action for an indication predicted their response to the indications ( p less than 0.03 , r2 = 0.33 ) . The intentions of the control residents did not A computerized medical record system was design ed to detect and remind the responsible clinician about clinical events that might need corrective action . These reminders significantly increased the clinician response rate ( in terms of test orders and treatment changes ) to the events in question . The addition of relevant medical literature citations to the reminders did not significantly change the clinician response rate as compared with that with reminders alone , nor did it stimulate the physicians to read any of the cited articles kept in an immediately available " library " of reprints OBJECTIVE This study explores : ( 1 ) the feasibility of involvement of  nursing staff  in routine bedside testing of activated clotting time and ( 2 ) joint implementation with resident medical staff of a preformulated plan for management of mediastinal bleeding after cardiac surgery . DESIGN Patients were divided r and omly into two groups , an experimental group  ( n = 108 ) subjected to ACT testing and management by protocol , and a control group  ( n = 146 )  treated by independent medical decisions . RESULTS Bleeding , volume of blood replaced , abnormal coagulation profiles and reoperations to control bleeding and its consequences were all reduced in the study group . CONCLUSION We concluded that bedside measurement of activated clotting time by nursing staff , associated with therapy based on a flow diagram , enhanced the overall management of early mediastinal bleeding after cardiac surgery as compared with independent management decisions by resident medical staff . In addition , the method provided a sensitive and reliable means of detecting and correcting rebound heparinization in the early postoperative period OBJECTIVE To study the effects of a comprehensive discharge planning protocol , design ed specifically for the elderly and implemented by nurse specialists , on  patient and caregiver outcomes and cost of care . DESIGN R and omized clinical trial . SETTING Hospital of the University of Pennsylvania . PATIENTS 276 patients and 125 caregivers . Patients were 70 years and older and were placed in selected medical and surgical cardiac diagnostic-related groups . MEASUREMENTS Group differences in patient outcomes ( length of initial hospital stay , length of time between initial hospital discharge and readmission , and rehospitalization rates ) and charges for care ( charges for initial hospitalization , rehospitalizations , health services after discharge , and nurse specialist services ) were measured 2 , 6 , and 12 weeks after discharge . RESULTS From the initial hospital discharge to 6 weeks after discharge , patients in the medical intervention group had fewer readmissions , fewer total days rehospitalized , lower readmission charges , and lower charges for health care services after discharge . No differences in these outcomes were found between the surgical intervention and control groups during this period . CONCLUSIONS Study findings support the need for comprehensive discharge planning design ed for the elderly and implemented by nurse specialists to improve their outcomes after hospital discharge and to achieve cost savings . The findings also suggest that this intervention had its greatest effect in delaying or preventing rehospitalization of patients in the medical intervention group during the first 6 weeks after discharge 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 vaccinate independent of MD initiative . MEASUREMENTS AND MAIN RESULTS Medical records were review ed for the 1202 patients seen , including 756 patients seen during both the 1988 - 89 and 1989 - 90 influenza seasons , to determine documented offering and receipt of vaccinations . During the intervention period ( 1989 - 90 ) ,  influenza vaccinations  were offered significantly more frequently to prevention team patients ( 68.3 % ) than to patients in either the patient education ( 50.4 % ) or control ( 47.6 % ) groups ( P = 0.006 ) , even after adjusting for the patients ' prior vaccination status , age , gender , race , and high-risk co-morbidity and for physicians ' level of training . Likewise , pneumococcal vaccinations  were offered more frequently to previously unvaccinated prevention team patients ( 28.3 % ) than to patient education ( 6.5 % ) or control ( 5.4 % ) group patients ( P = 0.001 ) , even after adjusting for the factors using multivariate analysis . Compliance rates did not differ between patient education and control subjects for either vaccine . Pre-intervention physician surveys documented higher perceived than actual compliance for both vaccines , with 89.0 % and 52.8 % of physicians believing that they complied with influenza and pneumococcal vaccination guidelines , respectively . CONCLUSIONS The results of this trial provide strong support for organizational changes that involve non-physician personnel to enhance vaccination rates among older adults OBJECTIVE To assess the effect of medical nutrition therapy ( MNT ) provided by dietitians on medical and clinical outcomes for adults with non-insulin-dependent diabetes mellitus ( NIDDM ) , and to compare MNT administered according to practice guidelines nutrition care ( PGC ) to MNT administered with basic nutrition care ( BC ) . DESIGN A prospect i ve , r and omized , controlled clinical trial of two levels of MNT on metabolic control in persons newly diagnosed with or currently under treatment for NIDDM was conducted at diabetes centers in three states ( Minnesota , Florida , and Colorado ) .  BC consisted of a single visit with a dietitian ; PGC involved an initial visit with a dietitian followed by two visits during the first 6 weeks of the study period . Data were collected at entry to the study and at 3 and 6 months . SUBJECTS Results are reported for 179 men and women aged 38 to 76 years : 85 assigned r and omly to BC and 94 to PGC . This represents 72 % of the 247 subjects enrolled . An additional 62 adults with NIDDM at one site who had no contact with a dietitian were identified as a nonr and om comparison group . OUTCOMES Medical outcome measures included fasting plasma glucose ( FPG ) , glycated hemoglobin ( HbA1c ) , and serum lipid levels . Clinical outcomes included weight , body mass index , waist-to-hip ratio , and changes in medical therapy . STATISTICAL ANALYSES Initial analysis of the discrete variables was done using the chi 2 statistic with Yates ' correction . Initial analysis of continuous variables was done by analysis of variance . The changes in variables between time periods were analyzed by paired t test , and comparisons between groups were analyzed using a t test for independent groups . RESULTS At 6 months , PGC result ed in significant improvements in blood glucose control as indicated by FPG and HbA1c levels and BC result ed in significant improvements in HbA1c level . Participants assigned to the PGC group had a mean FPG level at 6 months that was 10.5 % lower than the level at entry , and those in the BC group had a 5.3 % lower value . Among subjects who had diabetes for longer than 6 months , those who received PGC had a significantly better HbA1c level at 3 months compared with those receiving BC . The comparison group showed no improvement in glycemic control over a comparable 6 months . PGC subjects had significant improvements in cholesterol values at 6 months , and subjects in both the PGC and the BC groups had significant weight loss . CONCLUSIONS MNT provided by dietitians result ed in significant improvements in medical and clinical outcomes in both the BC and PGC groups and is beneficial to persons with NIDDM . Persons with a duration of diabetes longer than 6 months tended to do better with PGC than with BC . Because of the upward trend in glucose levels after 3 months , ongoing MNT by dietitians is important for long-term metabolic control To test the validity of a nurse-administered protocol for  low back pain  , a prospect i ve trial of 419 patients was undertaken in a walk-in clinic . In all , 222 patients were r and omly allocated to a " nurse- protocol group "  in which they were evaluated by one of five nurses using the protocol ;  the nurses independently managed 53 percent of the patients and referred to a physician patients with potentially complex conditions . In addition , 197 patients in a r and omly allocated control group were managed by one of 32 physicians . Care in the experimental and control groups was compared by follow-up telephone contact and by a four-month chart review . There was no significant difference in symptomatic relief or the development of serious disease in the two groups . Nurse- protocol patients expressed greater satisfaction with the care they had received ; patient satisfaction correlated positively with symptom relief . In over 95 percent of the patients , there were noncomplex , nonserious , nonchronic conditions as the cause of back pain . We conclude that nurse- protocol management of this generally benign condition in a primary care setting is both effective and efficient BACKGROUND Active management of labor is a multifaceted program that , as implemented at the National Maternity Hospital in Dublin , is associated with a lower rate of cesarean delivery than the rate usually found in the United States . We conducted a r and omized trial to evaluate the efficacy of this approach in lowering the rate of cesarean section among women delivering their first babies . METHODS We r and omly assigned 1934 nulliparous women at low risk of complications of pregnancy , before 30 weeks ' gestation , to active management of labor or to a usual-care group .  The components of active management were customized childbirth classes ; strict criteria for the diagnosis of labor ; st and ardized management of labor , including early amniotomy and treatment with high-dose oxytocin ; and one-to-one nursing .  A low-risk subgroup was defined as including women with full-term , uncomplicated pregnancies who spontaneously went into labor ( the protocol -eligible subgroup ) . Women meeting these criteria who had been r and omly assigned to the active-management group were admitted to a separate unit where their labor was managed by trained , certified nurse-midwives . RESULTS There was no difference between groups in the rate of cesarean section either among all women ( active management , 19.5 percent ; usual care , 19.4 percent ) or in the protocol -eligible subgroup ( active management , 10.9 percent ; usual care , 11.5 percent ) . In the protocol -eligible subgroup , the median duration of labor was shortened by 2.7 hours by active management ( from 8.9 to 6.2 hours ) , and the rate of maternal fever was lower ( 7 percent vs. 11 percent , P = 0.007 ) . The percentage of women in whom labor lasted longer than 12 hours was three times higher in the usual-care group than in the active-management group ( 26 percent vs. 9 percent , P < 0.001 ) . CONCLUSIONS Active management of labor did not reduce the rate of cesarean section in nulliparous women but was associated with a somewhat shorter duration of labor and less maternal fever Opinion leaders are members within a social group with significant social influence over others . A guideline on urinary catheter care was introduced in three groups ( A , B , and C ) of two r and omly allocated wards . Two opinion leaders per ward were identified by nurses in groups A and B with the use of a sociometric method . For education , in-service lectures for 30 % of nurses and opinion leaders ' tutorials for all nurses were used in group A ; opinion leaders ' tutorials alone in B , and lectures alone in C. Before and after the education program , the guideline 's frequency of practice was assessed by surveying 30 % of r and omly selected nurses and by direct observation . Results of the survey were comparable for groups A and B and both groups were significantly higher ( p less than 0.05 ) than C , suggesting that informational transmission by opinion leaders was superior to that by the lecture . However , practice s by direct observation in group A were significantly better ( p less than 0.05 ) than those in B , indicating that staff compliance is best achieved by using both opinion leaders and lectures . The lecture probably endorsed the opinion leaders ' leadership , enhancing their ability to influence the staff A prospect i ve experiment was conducted in a university-affiliated hospital to evaluate the effectiveness of a core of specially trained staff nurses in the maintenance of IV therapy .  Five staff nurses for each of two experimental units were trained for 1 month by an IV nurse educator and were expected to perform venipuncture and monitor peripheral IV care on their units . On three control units , IV 
    Output:
    
Skill substitution studies generally supported the hypothesis of no difference between protocol driven by nurses and care by a physician .
: Findings from the review provide some evidence that care driven by a guideline can be effective in changing the process and outcome of care .