***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: BACKGROUND A multiple intervention targeted to reduce antibiotic prescribing with an educational outreach programme had proven to be effective in a r and omized controlled trial in 12 peer review groups , demonstrating 12 % less prescriptions for respiratory tract infections . OBJECTIVE To assess the effectiveness of a multiple intervention in primary care at a large scale . METHODS A controlled before and after study in 2006 and 2007 was design ed . Participants were from general practice s within a geographically defined area in the middle region of The Netherl and s. Participants were GPs in 141 practice s in 25 peer review groups . A control group of GP practice s from the same region , matched for type of practice and mean volume of antibiotic prescribing . The multiple intervention consisted of the following elements : ( i ) group education meeting and communication training ; ( ii ) monitoring and feedback on prescribing behaviour ; ( iii ) group education for GPs and pharmacists assistants and ( iv ) patient education material . The main outcome measures are as follows : ( i ) number of antibiotic prescriptions per 1000 patients per GP and ( ii ) number of second-choice antibiotics , obtained from cl aims data from the regional health insurance company . The associations between predictors and outcome measurements were assessed by means of a multiple regression analyses . RESULTS At baseline , the number of antibiotic prescriptions per 1000 patients was slightly higher in the intervention group than in the control group ( 184 versus 176 ) . In 2007 , the number of prescriptions had increased to 232 and 227 , respectively , and not differed between intervention and control group . CONCLUSIONS The implementation of an already proven effective multiple intervention strategy at a larger scale showed no reduction of antibiotic prescription rates . The failure might be attributed to a less tight monitoring of intervention and audit . Inserting practical tools in the intervention might be more successful and should be studied 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 establish whether an interactive booklet on  respiratory tract infections in children reduces reconsultation for the same illness episode , reduces antibiotic use , and affects future consulting intentions , while maintaining parental satisfaction with care . Design Pragmatic cluster r and omised controlled trial . Setting 61 general practice s in Wales and Engl and . Participants 558 children ( 6 months to 14 years ) presenting to primary care with an acute respiratory tract infection ( 7 days or less ) . Children with suspected pneumonia , asthma or a serious concomitant illness , or needing immediate hospital admission were excluded . Three withdrew and 27 were lost to follow-up , leaving 528 ( 94.6 % ) with main outcome data . Interventions Clinicians in the intervention group were trained in the use of an interactive booklet on respiratory tract infections and asked to use the booklet during consultations with recruited patients ( and provide it as a take home re source ) . Clinicians in the control group conducted their consultations as usual . Main outcome measures The proportion of children who attended a face-to-face consultation about the same illness during the two week follow-up period . Secondary outcomes included antibiotic prescribing , antibiotic consumption , future consulting intentions , and parental satisfaction , reassurance , and enablement . Results Reconsultation occurred in 12.9 % of children in the intervention group and 16.2 % in the control group ( absolute risk reduction 3.3 % , 95 % confidence interval −2.7 % to 9.3 % , P=0.29 ) . Using multilevel modelling ( at the practice and individual level ) to account for clustering , no significant difference in reconsulting was noted ( odds ratio 0.75 ; 0.41 to 1.38 ) . Antibiotics were prescribed at the index consultation to 19.5 % of children in the intervention group and 40.8 % of children in the control group ( absolute risk reduction 21.3 % , 95 % confidence interval 13.7 to 28.9 ) , P<0.001 ) . A significant difference was still present after adjusting for clustering ( odds ratio 0.29 ; 0.14 to 0.60 ) . There was also a significant difference in the proportion of parents who said they would consult in the future if their child developed a similar illness ( odds ratio 0.34 ; 0.20 to 0.57 ) . Satisfaction , reassurance , and parental enablement scores were not significantly different between the two groups . Conclusions Use of a booklet on respiratory tract infections in children within primary care consultations led to important reductions in antibiotic prescribing and reduced intention to consult without reducing satisfaction with care . Trial registration Current Controlled Trials IS RCT Background To explore ways to reduce the overuse of antibiotics for acute respiratory infections ( ARIs ) , we conducted a pilot clustered r and omized controlled trial ( RCT ) to evaluate DECISION+ , a training program in shared decision making ( SDM ) for family physicians ( FPs ) . This pilot project demonstrated the feasibility of conducting a large clustered RCT and showed that DECISION+ reduced the proportion of patients who decided to use antibiotics immediately after consulting their physician . Consequently , the objective of this study is to evaluate , in patients consulting for ARIs , if exposure of physicians to a modified version of DECISION+ , DECISION+2 , would reduce the proportion of patients who decide to use antibiotics immediately after consulting their physician . Methods / design The study is a multi-center , two-arm , parallel clustered RCT . The 12 family practice teaching units ( FPTUs ) in the network of the Department of Family Medicine and Emergency Medicine of Université Laval will be r and omized to a DECISION+2 intervention group ( experimental group ) or to a no-intervention control group . These FPTUs will recruit patients consulting family physicians and residents in family medicine enrolled in the study . There will be two data collection periods : pre-intervention ( baseline ) including 175 patients with ARIs in each study arm , and post-intervention including 175 patients with ARIs in each study arm ( total n = 700 ) . The primary outcome will be the proportion of patients reporting a decision to use antibiotics immediately after consulting their physician . Secondary outcome measures include : 1 ) physicians and patients ' decisional conflict ; 2 ) the agreement between the parties ' decisional conflict scores ; and 3 ) perception of patients and physicians that SDM occurred . Also in patients , at 2 weeks follow-up , adherence to the decision , consultation for the same reason , decisional regret , and quality of life will be assessed . Finally , in both patients and physicians , intention to engage in SDM in future clinical encounters will be assessed . Intention-to-treat analyses will be applied and account for the nested design of the trial will be taken into consideration . Discussion DECISION+2 has the potential to reduce antibiotics use for ARIs by priming physicians and patients to share decisional process and empowering patients to make informed , value-based decisions . Trial Registration Clinical Trials.gov : CONTEXT The emergence and spread of antibiotic-resistant Streptococcus pneumoniae in US communities is due , in part , to the excessive use of antibiotics for acute respiratory tract infections . OBJECTIVE To decrease total antibiotic use for uncomplicated acute bronchitis in adults . DESIGN Prospect i ve , nonr and omized controlled trial , including baseline ( November 1996-February 1997 ) and study ( November 1997-February 1998 ) periods . SETTING Four selected primary care practice s belonging to a group-model health maintenance organization in the Denver , Colo , metropolitan area . PARTICIPANTS Consecutive adults diagnosed as having uncomplicated acute bronchitis . A total of 2462 adults were included at baseline and 2027 adults were included in the study . Clinicians included 56 physicians , 28 physician assistants or nurse practitioners , and 9 registered nurses . INTERVENTION The full intervention site received household and office-based patient educational material s , as well as a clinician intervention consisting of education , practice -profiling , and academic detailing . A limited intervention site received only office-based educational material s , and control sites provided usual care . MAIN OUTCOME MEASURE Antibiotic prescriptions for uncomplicated acute bronchitis during baseline and study periods . RESULTS Antibiotic prescription rates for uncomplicated acute bronchitis were similar at all 4 sites during the baseline period . During the study period , there was a substantial decline in antibiotic prescription rates at the full intervention site ( from 74 % to 48 % [ P = .003 ] ) , but not at the control and limited intervention sites ( 78 % to 76 % [ P = .81 ] and 82 % to 77 % [ P = .68 ] , respectively ) . Compared with control sites , changes in nonantibiotic prescriptions ( inhaled bronchodilators , cough suppressants , and analgesics ) were not significantly different for intervention sites . Return office visits ( within 30 days of the incident visit ) for bronchitis or pneumonia did not change significantly for any of the sites . CONCLUSIONS Antibiotic treatment of adults diagnosed as having uncomplicated acute bronchitis can be safely reduced using a combination of patient and clinician interventions BACKGROUND Overuse of antibiotics for children 's upper respiratory infections is widespread and contributes to the emergence of antibiotic-resistant bacteria . OBJECTIVE To assess changes in knowledge and awareness regarding antibiotic resistance and appropriate antibiotic use after community-wide educational interventions to reduce inappropriate antibiotic use . DESIGN Baseline survey conducted during June through July 1997 and postintervention survey of baseline participants during June through August 1998 . SETTING Communities in northern Wisconsin . PARTICIPANTS Parents of 729 r and omly selected children < 4 years of age were called until 215 in each of the intervention and control areas were reached . Of the 430 baseline participants , 365 ( 85 % ) participated in the postintervention survey . INTERVENTION Parent-oriented activities included distribution of material s and presentations . Physician-oriented activities included formal presentations and small group meetings . OUTCOME MEASURE Change in awareness about antibiotic resistance and knowledge about antibiotic indications . RESULTS A 
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There was no evidence addressing resolution of patients ' symptoms , patient knowledge about antibiotics for acute URTIs , or frequency of complications .