***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: In an academic general medicine clinic , we performed a r and omized , controlled trial to compare ( 1 ) the effects of supplying monthly feedback reports of compliance with preventive care protocol s by 135 internal medicine house staff with ( 2 ) the effects of specific reminders given to them at the time of patient visits . The protocol s were r and omly divided into two groups , A and B , and half the house staff were given feedback for Group A and half for Group B. Thus , each group served as a control for the other . Each feedback group was also r and omly assigned to receive reminders for either Group A or B protocol s. House staff receiving feedback more often complied with fecal occult blood testing , mammography , pneumococcal vaccination , use of metronidazole , and combined Group A and B protocol s than did controls ( P < 0.01 ) . There was also significantly more compliance with the same protocol s by house staff receiving reminders , but the increase for fecal occult blood testing , pneumococcal vaccination , and combined Group A protocol s was twice that seen in physicians given feedback alone . In addition , reminders alone increased compliance with oral calcium supplementation . Overall compliance with the preventive care protocol s was low : 10 - 15 % in physicians receiving neither feedback nor reminders , increasing to 15 - 30 % in those receiving reminders . Physician compliance with suggested preventive care protocol s can be increased by both delayed feedback and immediate reminders , but reminders have a greater effect To determine effective methods of promoting routine cancer screening , we r and omly assigned 62 internal medicine residents to receive cancer screening reminders ( computer-generated lists of overdue tests at patients ' visits ) , audit with feedback ( monthly seminars about screening , with feedback about their performance rates ) , or no intervention ( controls ) .  Half of the residents in each group also were r and omized to receive patient education ( patients received literature and notices of overdue tests ) . We review ed a sample of each physician 's medical records to assess performance of seven tests during 9-month periods before and after initiating the interventions . Cancer screening reminders increased performance of six of seven tests ; audit with feedback , four of seven tests ; and patient education , one of two targeted breast cancer screening tests . The results indicate that the cancer screening reminders strategy was the most effective in promoting the performance of routine cancer screening tests BACKGROUND Simple distribution of clinical practice guidelines to physicians does not change practice behavior . A low-cost , continuous peer review feedback method was used to promote resident physicians ' compliance with nine preventive care guidelines at the ambulatory care clinic at the Marshall University School of Medicine ( Huntington , West Virginia ) . METHODS Preventive care guidelines were distributed and a peer review feedback program was instituted in the resident physician primary care practice . The frequency of resident physician use of nine preventive care services was assessed and compared during three periods : pre guideline ( September 1 , 1993 , to March 1 , 1994 ; 148 patients ) , guideline ( September 1 , 1994 , to March 1 , 1995 ; 148 patients ) , and one-year follow-up ( September 1 , 1995 , to March 1 , 1996 ; 150 patients ) . The patients in the three periods were similar in age , gender , and risk for influenza and pneumococcal infection . RESULTS During the guideline period , resident physicians offered patients four preventive care services-tetanus toxoid immunization , clinical breast examination , Papanicolaou smear testing , and hemoccult testing significantly more often than during the pre guideline period . All services were offered significantly more often during the one-year follow-up period compared with the pre guideline period and as often as in the guideline period . CONCLUSION A low-cost , continuous peer review feedback program significantly and durably improves  resident physician compliance with clinical practice guidelines on preventive care services . However , the effectiveness of the poor review feedback method may not generalize to private practice or other setting s. Research on other methods to promote compliance with clinical practice guidelines and to influence physician behavior in general should continue Many studies have tested the efficacy of intervention strategies for improving  physicians ' performance of cancer screening tests . Less attention has been paid to the feasibility of strategy implementation . Three important dimensions of feasibility are acceptability to the targeted audience , logistical difficulties , and cost and cost-effectiveness . We assessed the relative feasibility along these dimensions of three intervention strategies shown previously to be efficacious among 62 internal medicine resident physicians . Two strategies , medical record audit with feedback and computerized cancer screening reminders were aim ed at physicians directly , and one , patient education , indirectly through their patients . While all three interventions were acceptable to the physicians , implementation of the audit with feedback intervention was logistically more difficult and more costly than either the cancer screening reminders or patient education interventions . The average cost per additional screening test ( beyond the number that would have been performed without intervention ) was $ 50.40 for audit with feedback , $ 18.19 for cancer screening reminders , and $ 51.20 for patient education . Overall , the cancer screening reminder intervention was the most feasible of the three strategies OBJECTIVES A r and omized controlled trial evaluated the impact of feedback and financial incentives on physician compliance with cancer screening guidelines for women 50 years of age and older in a Medicaid health maintenance organization ( HMO ) . METHODS Half of 52 primary care sites received the intervention , which included written feedback and a financial bonus .  Mammography , breast exam , colorectal screening , and Pap testing compliance rates were evaluated . RESULTS From 1993 to 1995 , screening rates doubled overall ( from 24 % to 50 % ) , with no significant differences between intervention and control group sites . CONCLUSIONS Financial incentives and feedback did not improve physician compliance with cancer screening guidelines in a Medicaid HMO Screening mammography is underutilized in many primary care practice s. We design ed a prospect i ve , controlled trial to evaluate two strategies for improving the utilization of mammography in an academic general medicine clinic . We assigned teams of house officers to ( 1 ) physician audit with periodic feedback , ( 2 ) a visit-based strategy directed at both patient and physician , or ( 3 ) a no intervention concurrent control arm . After 6 months , the percentage of 50- to 74-year-old women meeting the st and ard of an annual mammogram  was 36 % for patients in the control arm , 62 % for patients of feedback residents , and 54 % for patients of the arm receiving the visit-based strategy . Patients of female providers were slightly more likely to meet the st and ard , but no effects were detected for patient race , new as opposed to follow-up patient , or higher frequency of clinic visits . We conclude that audit with feedback and a new visit-based strategy of a patient cue associated with a simplification of the ordering process each greatly improved the rate of utilization of screening mammography . Practitioners could reasonably choose the strategy most suited to their own situation Abstract OBJECTIVE : To evaluate an innovative approach to continuing medical education , an outreach intervention design ed to improve performance rates of breast cancer screening through implementation of office systems in community primary care practice s. DESIGN : R and omized , controlled trial with primary care practice s assigned to either the intervention group or control group , with the practice as the unit of analysis . SETTING : Twenty mostly rural counties in North Carolina . PARTICIPANTS : Physicians and staff of 62 r and omly selected family medicine and general internal medicine practice s , primarily fee-for-service , half group practice s and half solo practitioners . INTERVENTION : Physician investigators and facilitators met with practice physicians and staff over a period of 12 to 18 months to provide feedback on breast cancer screening performance , and to assist these primary care practice s in developing office systems tailored to increase breast cancer screening . MEASUREMENTS AND MAIN RESULTS : Physician question naires were obtained at baseline and follow-up to assess the presence of five indicators of an office system . Three of the five indicators of office systems increased significantly more in intervention practice s than in control practice s , but the mean number of indicators in intervention practice s at follow-up was only 2.8 out of 5 . Cross-sectional review s of r and omly chosen medical records of eligible women patients aged 50 years and over were done at baseline ( n=2,887 ) and follow-up ( n=2,874 ) to determine whether clinical breast examinations and mammography , were performed . Results for mammography were recorded in two ways , mention of the test in the visit note and actual report of the test in the medical record . These review s showed an increase from 39 % to 51 % in mention of mammography in intervention practice s , compared with an increase from 41 % to 44 % in control practice s ( p=.01 ) . There was no significant difference , however , between the two groups in change in mammograms reported ( intervention group increased from 28 % to 32.7 % ; control group increased from 30.6 % to 34.0 % , p=.56 ) . There was a nonsignificant trend ( p=.06 ) toward a greater increase in performance of clinical breast examination in intervention versus control practice s. CONCLUSIONS : A moderately intensive outreach intervention to increase rates of breast cancer screening through the development of office systems was modestly successful in increasing indicators of office systems and in documenting mention of mammography , but had little impact on actual performance of breast cancer screening . At follow-up , few practice s had a complete office system for breast cancer screening . Outreach approaches to assist primary care practice s implement office systems are promising but need further development Quality assurance is required of all hospital outpatient clinics although there is little evidence documenting its value . The purpose s of this study were to assess the impact of quality assurance audits on physicians ’ ordering behavior and to learn whether doctors who actually performed audits behaved differently from physicians who passively received audit results . Baseline influenza vaccination and screening mammography ordering rates were established for the authors ’ residents ’ clinic in 1985 . In 1986 , residents were assigned r and omly to three groups . Residents in one group audited their own charts for 1985 influenza vaccination ordering ; the second group audited its own charts for 1985 screening mammography ordering ; and the third group performed no audit but received the other groups ’ results . Passive receipt of results improved ordering of vaccination from 40 % to 59 % and ordering of mammography from 8 % to 16 % . Actual performance of audits improved ordering of mammography from 16 % to 26 % but did not improve vaccination ordering . These quality assurance audits were effective in improving the performance of selected preventive health measures in a residents ’ clinic Similar general medical outpatient clinics with r and omly assigned patients were used to evaluate the effectiveness of a program that was to increase house staff compliance with preventive medicine guidelines . Two clinics were design ated experimental and two served as controls . In the experimental clinics , age-specific checklists of all recommended preventive procedures ( drawn from the Canadian Task Force report on The Periodic Health Examination and American Cancer Society guidelines ) were appended to each patient 's chart . In addition , house officers were presented with a series of weekly seminars dealing with issues in screening , as well as the specific recommendations included in the checklist . House officers in all four clinics were tested for their knowledge and attitudes toward the preventive program before and after the intervention . Counts of immunizations and mammograms performed and the total population s eligible for these procedures were determined for all four clinics . As predicted , test scores as well as mammography and immunization rates increased significantly ( from 2 - 40 per cent ) in the intervention clinics as compared with controls . We conclude that this intervention was clearly effective in the short run . However , follow-up studies will be necessary to determine whether the desired long-term effect has been achieved BACKGROUND This 1-year r and omized trial tested the efficacy of behavioral techniques for increasing mammography referrals by primary care physicians in small , community practice s. METHODS Sixty-one practice s were r and omly assigned to one of three conditions : ( 1 ) education-only control , ( 2 ) education plus cue enhancement using mammography chart stickers , and ( 3 ) education plus cue enhancement plus feedback and token rewards . Quarterly chart audits of a defined sample ( N = 11,716 ) of women patients 50 years of age or older were conducted to document mammography referrals , completions , and compliance . RESULTS Referral and completion rates increased from baseline to first quarter and gradually declined thereafter . Overall , these rates were higher in the cuing conditions than in the control condition . In contrast , compliance rates in both experimental conditions increased over the year while remaining static in the control condition , demonstrating a strong and continuing effect for cue enhancement . Compliance increases were greatest for physicians who were older , nonwhite , with a second speciality , in solo practice , not members of the AMA , not residency trained , and not board certified . CONCLUSIONS Chart stickers can significantly increase mammography utilization in small , community practice s. These practice s are an efficient route to reaching large numbers of older women in need of mammography screening 
    Output:
    
Evidence in these review s indicates that provider assessment and feedback interventions can effectively increase screening by mammography , Pap test , and fecal occult blood test .
Evidence was insufficient to determine the effectiveness of provider incentives  in increasing use of any of these tests .
Specific areas for further research are suggested in this report , including the need for additional research to determine whether  provider incentives are effective in increasing use of any of these screening tests , and whether assessment and feedback interventions  are effective in increasing other tests for colorectal cancer ( i.e. , flexible sigmoidoscopy , colonoscopy , or double-contrast barium enema )