human
***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: Aims To assess the association of social determinants on the performance of health systems around the world . Methods A transnational ecological study was conducted with an observation level focused on the country . In order to research on the strength of the association between the annual maternal and child mortality in 154 countries and social determinants :  corruption , democratization , income ine quality and cultural fragmentation , we used a mixed linear regression model for repeated measures with r and om intercepts and a conglomerate-based geographical analysis , between 2000 and 2010 . Results Health determinants with a significant association on child mortality(<1year ) : higher access to water ( βa Quartile 4(Q4 ) vs Quartile 1(Q1 ) = -6,14 ; 95%CI : -11,63 to -0,73 ) , sanitation systems , ( Q4 vs Q1 = -25,58 ; 95%CI : -31,91 to -19,25 ) , % measles vaccination coverage ( Q4 vs Q1 = -7.35 ; 95%CI : -10,18 to -4,52 ) , % of births attended by a healthcare professional ( Q4 vs Q1 = -7,91 ; 95%CI : -11,36 to -4,52 ) and a % of the total health expenditure ( Q3 vs Q1 = -2,85 ; 95%CI : -4,93 to -0,7 ) . Ethnic fragmentation ( Q4 vs Q1 = 9,93 ; 95%CI : -0.03 to 19.89 ) had a marginal effect . For child mortality<5 years , an association was found for these variables and democratization ( not free vs free = 11,23 ; 95%CI : -0,82 to 23,29 ) , out-of-pocket expenditure ( Q1 vs Q4 = 17,71 ; 95%CI : 5,86 to 29,56 ) . For MMR ( Maternal mortality ratio ) , % of access to water for all the quartiles , % of access to sanitation systems , ( Q3 vs Q1 = -171,15 ; 95%CI : -281,29 to -61 ) , birth attention by a healthcare professional ( Q4 vs Q1 = -231,23 ; 95%CI : -349,32 to -113,15 ) , and having corrupt government ( Q3 vs Q1 = 83,05 ; 95%CI : 33,10 to 133 ) . Conclusions Improving access to water and sanitation systems , decreasing corruption in the health sector must become priorities in health systems . The ethno-linguistic cultural fragmentation and the detriment of democracy turn out to be two factors related to health results OBJECTIVES There is often substantial uncertainty about the impacts of health system and policy interventions . Despite that , r and omized controlled trials ( RCTs ) are uncommon in this field , partly because experiments can be difficult to carry out . An alternative method for impact evaluation is the interrupted time-series ( ITS ) design . Little is known , however , about how results from the two methods compare . Our aim was to explore whether ITS studies yield results that differ from those of r and omized trials . STUDY DESIGN AND SETTING We conducted single-arm ITS analyses ( segmented regression ) based on data from the intervention arm of cluster r and omized trials ( C- RCTs ) , that is , discarding control arm data . Secondarily , we included the control group data in the analyses , by subtracting control group data points from intervention group data points , thereby constructing a time series representing the difference between the intervention and control groups . We compared the results from the single-arm and controlled ITS analyses with results based on conventional aggregated analyses of trial data . RESULTS The findings were largely concordant , yielding effect estimates with overlapping 95 % confidence intervals ( CI ) across different analytical methods . However , our analyses revealed the importance of a concurrent control group and of taking baseline and follow-up trends into account in the analysis of C- RCTs . CONCLUSION The ITS design is valuable for evaluation of health systems interventions , both when RCTs are not feasible and in the analysis and interpretation of data from C- RCTs BACKGROUND Artificially influencing the case mix of hospitals may have several deleterious consequences for the hospital care system . One distinguishes over-evaluation ( up-coding ) and under-evaluation ( under-coding ) of the case mix . Apart from its financial consequences , miscoding may cause a fracture in epidemiological time series and , by increasing artificially the severity of illness , may affect the assessment of the quality of hospital care , based on administrative data . METHODS Fixed effects models were used to assess deviant coding behavior  at the hospital level . To do so , we examined the linear evolution over time of characteristics such as length of stay and of 21 " triggering " conditions susceptible to increase the case mix of a stay . In case of deviant coding , these triggering conditions were checked to direct the audit towards fraud-suspected discharge abstract s. Hereto , a method consisting in comparing a single hospital 's linear evolution over time with the national linear evolution over time was developed , using an interaction term between linear evolution over time and hospitals . To test this methodology , fraud-directed audits were carried out in addition to the usual , at r and om audits . RESULTS Important inter-hospital differences in the linear evolution over time of several characteristics of Belgian hospitals were identified , as well as evidence not only of improving coding practice s , but also of up-coding , fraudulent under-coding and of numerous coding errors without financial impact . The coding errors , ascertained in the at r and om audit , result ed in a wrongful gain for the faulty hospitals of 28.23 days in 258 stays , whereas in case of fraud-directed audits these figures amounted up to 642.68 days in 334 stays . CONCLUSION Fraud-directed audit may constitute a valuable tool in the quality assurance of administrative data bases , improving their use in epidemiology and assessment of the quality of care Objective : The authors sought to determine the effect of an educational seminar on interactions with pharmaceutical representatives on residents ’ attitudes and behavior . Method : A controlled trial of an educational intervention was conducted . Residents at a university-affiliated residency program ( N=32 ) were divided into two groups : one group ( N=18 ) received a 1-hour educational intervention , while the other group ( N= 14 ) served as a control . Both groups completed a 33-item survey before the intervention and 2 months after the intervention . Results : Residents interacted substantially with pharmaceutical representatives . The majority of residents found the interactions and gifts useful and believed their prescribing practice s were not influenced . Compared to the comparison group , the intervention group significantly decreased the reported number of office supplies and noneducational gifts , but showed no change in attitude toward pharmaceutical representatives and their gifts . Conclusion : One-time educational interventions may have significant impact on psychiatric residents ’ targeted gift-accepting behavior but little effect on attitudes BACKGROUND Inappropriate use of hospital services , in the form of unjustified hospital stay days ( HSD ) , constitutes a major burden on a health budget . Reduction of unjustified HSD was achieved in a medical ward in a previous intervention study . METHODS A controlled intervention aim ed at reducing unjustified hospital stay was performed on 155 paediatric in patients and 248 controls , by applying pre-set criteria for hospitalization and comparing to results in previous studies . RESULTS Unjustified stay was decreased from 32.6 % to 14.8 % on the study ward , and from 25.7 % to 19.3 % on the control ward . The children on both wards did not differ significantly in rates of subsequent out of hospital mortality , re-admission , and the subjective evaluation of health by their parents one month following discharge . CONCLUSIONS This study demonstrates that despite the fact that the per cent of unjustified HSD on a paediatric wars is much lower than on medicine or surgery , a significant reduction in unjustified stay can be achieved by intervention programme Background : Authentication processes based on mass serialization technology may help to make the drug supply more secure for patients . Objective : To analyze the AegateProtect service , a new drug authentication service implemented in Belgian and Greek community pharmacies . Methods : A prospect i ve analysis conducted via a mystery shopper audit assessed the reliability of the authentication service in a sample of Belgian community pharmacies . A retrospective analysis evaluated the effectiveness of the authentication service in Belgian and Greek community pharmacies in terms of the number of scans relating to authentic , recalled , expired , and suspicious products . Also , the costs of providing an authentication service in a hypothetical country were weighed against the benefits in terms of preventing the dispensing of subst and ard drugs . Results : The authentication service attained a sample reliability of 100 % ( 95 % CI 99.8 to 100 ) in Belgium . The 220,751 scans tested in Belgium during June – August 2008 consisted of authentic products ( 96.13 % of scans ) , recalled products ( 0.74 % ) , products that may be recalled ( 3.00 % ) , and expired products ( 0.13 % ) . No suspicious products were identified . Similar results were observed in Greece . For a hypothetical country , a modeling exercise showed that an authentication service  would become cost-neutral in a scenario in which 0.47 % of products per year are identified as recalled or expired . Conclusions : A drug authentication process such as the AegateProtect service is reliable and effective in identifying recalled , expired , and suspicious drugs in community pharmacies at the point of dispensing . The proportion of products identified as recalled , expired , or suspicious in a given country determines the level of cost benefits of an authentication service This paper identifies which types of patients and hospitals have abusive Medicare billings  that are responsive to law enforcement . For a 20 % r and om sample of elderly Medicare beneficiaries hospitalized from 1994 to 1998 with one or more of six illnesses that are prone to abuse , we obtain longitudinal cl aims data linked with social security death records , hospital characteristics , and state/year-level anti-fraud enforcement efforts . We show that increased enforcement leads certain types of types of patients and hospitals to have lower billings , without adverse consequences for patients ' health outcomes Medicare ’s Physician Quality Reporting System ( PQRS ) is the largest quality -reporting system in the U.S. health care system and a basis for the new value-based modifier system for physician payment . The PQRS allows health care providers to report measures of quality of care that include both the process of care and physiological outcomes . Using a multivariate difference-in-differences model , we examine the relationship of PQRS participation to three cl aims -computable measures of inappropriate utilization of health care services and risk-adjusted per capita Medicare expenditures . The data are a national r and om sample of PQRS-participating providers matched to nonparticipating providers by zip code and caseload . We found few significant relationships in the overall analysis . However , the magnitude and statistical significance of the desirable associations increased in subgroups of providers and beneficiaries more prone to overutilization ( e.g. , males , older beneficiaries , beneficiaries treated in larger medical practice s or by nonphysicians , and practice s in rural areas ) , and among beneficiaries with heart conditions , diabetes , and eye problems 
    Output:
    
agent
Authors ' conclusions There is a paucity of evidence regarding how best to reduce corruption .
Promising interventions include improvements in the  detection and punishment of corruption  , especially efforts that are coordinated by an independent agency .
Other promising interventions include guidelines that prohibit doctors from accepting benefits from the pharmaceutical industry , internal control practice s in community health centres , and increased transparency and accountability for co-payments combined with reduced incentives for informal payments .
Key messages The review suggests that some strategies to fight corruption in the health sector can have an effect on corruption .
This study shows that these strategies may have led to fewer patients giving their doctors informal payments ( low certainty evidence ) . •
The study suggests that this may have changed doctors ' attitudes about the influence of pharmaceutical companies on their choice of medicines ( low certainty evidence ) . •
We do n't know what the effects of these strategies have on healthcare or people 's health , or if these strategies had any harmful effects .
***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: Aims To assess the association of social determinants on the performance of health systems around the world . Methods A transnational ecological study was conducted with an observation level focused on the country . In order to research on the strength of the association between the annual maternal and child mortality in 154 countries and social determinants :  corruption , democratization , income ine quality and cultural fragmentation , we used a mixed linear regression model for repeated measures with r and om intercepts and a conglomerate-based geographical analysis , between 2000 and 2010 . Results Health determinants with a significant association on child mortality(<1year ) : higher access to water ( βa Quartile 4(Q4 ) vs Quartile 1(Q1 ) = -6,14 ; 95%CI : -11,63 to -0,73 ) , sanitation systems , ( Q4 vs Q1 = -25,58 ; 95%CI : -31,91 to -19,25 ) , % measles vaccination coverage ( Q4 vs Q1 = -7.35 ; 95%CI : -10,18 to -4,52 ) , % of births attended by a healthcare professional ( Q4 vs Q1 = -7,91 ; 95%CI : -11,36 to -4,52 ) and a % of the total health expenditure ( Q3 vs Q1 = -2,85 ; 95%CI : -4,93 to -0,7 ) . Ethnic fragmentation ( Q4 vs Q1 = 9,93 ; 95%CI : -0.03 to 19.89 ) had a marginal effect . For child mortality<5 years , an association was found for these variables and democratization ( not free vs free = 11,23 ; 95%CI : -0,82 to 23,29 ) , out-of-pocket expenditure ( Q1 vs Q4 = 17,71 ; 95%CI : 5,86 to 29,56 ) . For MMR ( Maternal mortality ratio ) , % of access to water for all the quartiles , % of access to sanitation systems , ( Q3 vs Q1 = -171,15 ; 95%CI : -281,29 to -61 ) , birth attention by a healthcare professional ( Q4 vs Q1 = -231,23 ; 95%CI : -349,32 to -113,15 ) , and having corrupt government ( Q3 vs Q1 = 83,05 ; 95%CI : 33,10 to 133 ) . Conclusions Improving access to water and sanitation systems , decreasing corruption in the health sector must become priorities in health systems . The ethno-linguistic cultural fragmentation and the detriment of democracy turn out to be two factors related to health results OBJECTIVES There is often substantial uncertainty about the impacts of health system and policy interventions . Despite that , r and omized controlled trials ( RCTs ) are uncommon in this field , partly because experiments can be difficult to carry out . An alternative method for impact evaluation is the interrupted time-series ( ITS ) design . Little is known , however , about how results from the two methods compare . Our aim was to explore whether ITS studies yield results that differ from those of r and omized trials . STUDY DESIGN AND SETTING We conducted single-arm ITS analyses ( segmented regression ) based on data from the intervention arm of cluster r and omized trials ( C- RCTs ) , that is , discarding control arm data . Secondarily , we included the control group data in the analyses , by subtracting control group data points from intervention group data points , thereby constructing a time series representing the difference between the intervention and control groups . We compared the results from the single-arm and controlled ITS analyses with results based on conventional aggregated analyses of trial data . RESULTS The findings were largely concordant , yielding effect estimates with overlapping 95 % confidence intervals ( CI ) across different analytical methods . However , our analyses revealed the importance of a concurrent control group and of taking baseline and follow-up trends into account in the analysis of C- RCTs . CONCLUSION The ITS design is valuable for evaluation of health systems interventions , both when RCTs are not feasible and in the analysis and interpretation of data from C- RCTs BACKGROUND Artificially influencing the case mix of hospitals may have several deleterious consequences for the hospital care system . One distinguishes over-evaluation ( up-coding ) and under-evaluation ( under-coding ) of the case mix . Apart from its financial consequences , miscoding may cause a fracture in epidemiological time series and , by increasing artificially the severity of illness , may affect the assessment of the quality of hospital care , based on administrative data . METHODS Fixed effects models were used to assess deviant coding behavior  at the hospital level . To do so , we examined the linear evolution over time of characteristics such as length of stay and of 21 " triggering " conditions susceptible to increase the case mix of a stay . In case of deviant coding , these triggering conditions were checked to direct the audit towards fraud-suspected discharge abstract s. Hereto , a method consisting in comparing a single hospital 's linear evolution over time with the national linear evolution over time was developed , using an interaction term between linear evolution over time and hospitals . To test this methodology , fraud-directed audits were carried out in addition to the usual , at r and om audits . RESULTS Important inter-hospital differences in the linear evolution over time of several characteristics of Belgian hospitals were identified , as well as evidence not only of improving coding practice s , but also of up-coding , fraudulent under-coding and of numerous coding errors without financial impact . The coding errors , ascertained in the at r and om audit , result ed in a wrongful gain for the faulty hospitals of 28.23 days in 258 stays , whereas in case of fraud-directed audits these figures amounted up to 642.68 days in 334 stays . CONCLUSION Fraud-directed audit may constitute a valuable tool in the quality assurance of administrative data bases , improving their use in epidemiology and assessment of the quality of care Objective : The authors sought to determine the effect of an educational seminar on interactions with pharmaceutical representatives on residents ’ attitudes and behavior . Method : A controlled trial of an educational intervention was conducted . Residents at a university-affiliated residency program ( N=32 ) were divided into two groups : one group ( N=18 ) received a 1-hour educational intervention , while the other group ( N= 14 ) served as a control . Both groups completed a 33-item survey before the intervention and 2 months after the intervention . Results : Residents interacted substantially with pharmaceutical representatives . The majority of residents found the interactions and gifts useful and believed their prescribing practice s were not influenced . Compared to the comparison group , the intervention group significantly decreased the reported number of office supplies and noneducational gifts , but showed no change in attitude toward pharmaceutical representatives and their gifts . Conclusion : One-time educational interventions may have significant impact on psychiatric residents ’ targeted gift-accepting behavior but little effect on attitudes BACKGROUND Inappropriate use of hospital services , in the form of unjustified hospital stay days ( HSD ) , constitutes a major burden on a health budget . Reduction of unjustified HSD was achieved in a medical ward in a previous intervention study . METHODS A controlled intervention aim ed at reducing unjustified hospital stay was performed on 155 paediatric in patients and 248 controls , by applying pre-set criteria for hospitalization and comparing to results in previous studies . RESULTS Unjustified stay was decreased from 32.6 % to 14.8 % on the study ward , and from 25.7 % to 19.3 % on the control ward . The children on both wards did not differ significantly in rates of subsequent out of hospital mortality , re-admission , and the subjective evaluation of health by their parents one month following discharge . CONCLUSIONS This study demonstrates that despite the fact that the per cent of unjustified HSD on a paediatric wars is much lower than on medicine or surgery , a significant reduction in unjustified stay can be achieved by intervention programme Background : Authentication processes based on mass serialization technology may help to make the drug supply more secure for patients . Objective : To analyze the AegateProtect service , a new drug authentication service implemented in Belgian and Greek community pharmacies . Methods : A prospect i ve analysis conducted via a mystery shopper audit assessed the reliability of the authentication service in a sample of Belgian community pharmacies . A retrospective analysis evaluated the effectiveness of the authentication service in Belgian and Greek community pharmacies in terms of the number of scans relating to authentic , recalled , expired , and suspicious products . Also , the costs of providing an authentication service in a hypothetical country were weighed against the benefits in terms of preventing the dispensing of subst and ard drugs . Results : The authentication service attained a sample reliability of 100 % ( 95 % CI 99.8 to 100 ) in Belgium . The 220,751 scans tested in Belgium during June – August 2008 consisted of authentic products ( 96.13 % of scans ) , recalled products ( 0.74 % ) , products that may be recalled ( 3.00 % ) , and expired products ( 0.13 % ) . No suspicious products were identified . Similar results were observed in Greece . For a hypothetical country , a modeling exercise showed that an authentication service  would become cost-neutral in a scenario in which 0.47 % of products per year are identified as recalled or expired . Conclusions : A drug authentication process such as the AegateProtect service is reliable and effective in identifying recalled , expired , and suspicious drugs in community pharmacies at the point of dispensing . The proportion of products identified as recalled , expired , or suspicious in a given country determines the level of cost benefits of an authentication service This paper identifies which types of patients and hospitals have abusive Medicare billings  that are responsive to law enforcement . For a 20 % r and om sample of elderly Medicare beneficiaries hospitalized from 1994 to 1998 with one or more of six illnesses that are prone to abuse , we obtain longitudinal cl aims data linked with social security death records , hospital characteristics , and state/year-level anti-fraud enforcement efforts . We show that increased enforcement leads certain types of types of patients and hospitals to have lower billings , without adverse consequences for patients ' health outcomes Medicare ’s Physician Quality Reporting System ( PQRS ) is the largest quality -reporting system in the U.S. health care system and a basis for the new value-based modifier system for physician payment . The PQRS allows health care providers to report measures of quality of care that include both the process of care and physiological outcomes . Using a multivariate difference-in-differences model , we examine the relationship of PQRS participation to three cl aims -computable measures of inappropriate utilization of health care services and risk-adjusted per capita Medicare expenditures . The data are a national r and om sample of PQRS-participating providers matched to nonparticipating providers by zip code and caseload . We found few significant relationships in the overall analysis . However , the magnitude and statistical significance of the desirable associations increased in subgroups of providers and beneficiaries more prone to overutilization ( e.g. , males , older beneficiaries , beneficiaries treated in larger medical practice s or by nonphysicians , and practice s in rural areas ) , and among beneficiaries with heart conditions , diabetes , and eye problems 
    Output:
    