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: Objectives : The aim of the study was twofold ; 1 ) to develop a clinical pharmacist-led 12 month lasting follow-up program for patients with established coronary heart disease ( CHD ) discharged from the University Hospital of North Norway , and 2 ) to explore the impact of the program with regards to adherence to a medication assessment tool for secondary prevention of CHD and change in biomedical risk factors . Methods : A total of 102 patients aged 18 - 82 years were enrolled in a non-blinded r and omized controlled trial with an intervention group and a control group . The intervention comprised medication reconciliation , medication review and patient education during three meetings ; at discharge , after three months and after twelve months . The control group received st and ard care from their general practitioner . Primary outcomes were adherence to clinical guideline recommendations concerning prescription , therapy goal achievement and lifestyle education  defined in the medication assessment tool for secondary prevention of CHD ( MAT-CHDSP ) . Secondary outcomes included changes in the biomedical risk factors cholesterol , blood pressure and blood glucose . Results : Ninety-four patients completed the trial , 48 intervention group patients and 46 controls . Appropriate prescribing was high , but therapy goal achievement was low in both groups . Overall adherence to MAT-CHDSP criteria increased in both groups and was significantly higher in the intervention group at study end , 78.4 % vs. 62.0 % , p<0.001 . The difference was statistically significant for the documented lifestyle advices in intervention group patients . No significant improvements in biomedical risk factors were observed in favor of the intervention group . Conclusions : The study showed an increased guideline adherence in both study groups . This indicates that attention to clinical practice guideline recommendations in itself increases adherence – which may be a clinical pharmacist task . A larger adequately powered study is needed to show a significant difference in biomedical risk factor improvements in favor of the intervention . Amendments to the follow-up program are suggested before implementation in st and ard patient care can be recommended CONTEXT Coronary heart disease ( CHD ) mortality has declined substantially in Canada since 1994 . OBJECTIVE To determine what proportion of this decline was associated with temporal trends in CHD risk factors and advancements in medical treatments . DESIGN , SETTING , AND PATIENTS Prospect i ve analytic study of the Ontario , Canada , population aged 25 to 84 years between 1994 and 2005 , using an up date d version of the vali date d IMPACT model , which integrates data on population size , CHD mortality , risk factors , and treatment uptake changes . Relative risks and regression coefficients from the published literature quantified the relationship between CHD mortality and ( 1 ) evidence -based therapies in 8 distinct CHD sub population s ( acute myocardial infa rct ion [ AMI ] , acute coronary syndromes , secondary prevention post-AMI , chronic coronary artery disease , heart failure in the hospital vs in the community , and primary prevention for hyperlipidemia or hypertension ) and ( 2 ) population trends in 6 risk factors ( smoking , diabetes mellitus ,  systolic blood pressure ,  plasma cholesterol level , exercise , and obesity  ) . MAIN OUTCOME MEASURES The number of deaths prevented or delayed in 2005 ; secondary outcome measures were improvements in medical treatments and trends in risk factors . RESULTS Between 1994 and 2005 , the  age-adjusted CHD mortality rate  in Ontario decreased by 35 % from 191 to 125 deaths per 100,000 inhabitants , translating to an estimated 7585 fewer CHD deaths in 2005 . Improvements in medical and surgical treatments were associated with 43 % ( range , 11 % to 124 % ) of the total mortality decrease , most notably in AMI ( 8 % ; range , -5 % to 40 % ) , chronic stable coronary artery disease ( 17 % ; range , 7 % to 35 % ) , and heart failure occurring while in the community ( 10 % ; range , 6 % to 31 % ) . Trends in risk factors accounted for 3660 fewer CHD deaths prevented or delayed ( 48 % of total ; range , 28 % to 64 % ) , specifically , reductions in total cholesterol ( 23 % ; range , 10 % to 33 % ) and systolic blood pressure ( 20 % ; range , 13 % to 26 % ) . Increasing diabetes prevalence and body mass index had an inverse relationship associated with higher CHD mortality of 6 % ( range , 4 % to 8 % ) and 2 % ( range , 1 % to 4 % ) , respectively . CONCLUSION Between 1994 and 2005 , there was a decrease in CHD mortality rates in Ontario that was associated primarily with trends in risk factors and improvements in medical treatments , each explaining about half of the decrease BACKGROUND Quality improvement is central to improving the care of patients with cardiovascular disease ; however , the optimum type of data feedback to support such efforts is unknown . METHODS Over 26 months , 149 eligible Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines hospitals were r and omized to receive either st and ard ( n = 76 control ) or targeted ( n = 73 intervention ) performance feedback reports for acute myocardial infa rct ion patient care . Each report summarized performance on identified metrics ( providing hospitals with detailed data on their 3 lowest-performing quality metrics , relative to their peers ) . Intervention sites received 5 targeted feedback reports .  Overall composite performance was compared between cohorts at end of study and as a change from baseline . RESULTS Intervention ( n = 60 ) and control ( n = 64 ) hospitals that completed the study had similar baseline performance ( median score 83.7 % vs 84.2 % ) . Over 26 months of follow-up , the change in overall composite score across hospitals was neutral ( median 0.1 % [ interquartile range { IQR } -2.4 % to 3.3 % ] ) . There was no difference in observed improvement in either the intervention ( median -0.2 % [ IQR-2.6 % to 3.3 % ] ) or control ( median 0.1 % [ IQR -2.2 % to 3.4 % ] ) hospitals . CONCLUSIONS We were unable to demonstrate that targeted performance feedback reports lead to more rapid care improvements than st and ard reports . Future directions should explore the relationship between hospital self- selection of targeted metrics and the identification and promulgation of less common metrics -- particularly those that reflect processes of care Background Although numerous therapies have been shown to be beneficial in the prevention of myocardial infa rct ion and /or death in patients with coronary disease , these therapies are under-used and this gap contributes to sub-optimal patient outcomes . To increase the uptake of proven efficacious therapies in patients with coronary disease , we design ed a multifaceted quality improvement intervention employing patient-specific reminders delivered at the point-of-care , with one-page treatment guidelines endorsed by local opinion leaders ( " Local Opinion Leader Statement " ) . This trial is design ed to evaluate the impact of these Local Opinion Leader Statements on the practice s of primary care physicians caring for patients with coronary disease . In order to isolate the effects of the messenger ( the local opinion leader ) from the message , we will also test an identical quality improvement intervention that is not signed by a local opinion leader ( " Unsigned Evidence Statement " ) in this trial . Methods R and omized trial testing three different interventions in patients with coronary disease : ( 1 ) usual care versus ( 2 ) Local Opinion Leader Statement versus ( 3 ) Unsigned Evidence Statement .  Patients diagnosed with coronary artery disease after cardiac catheterization ( but without acute coronary syndromes ) will be r and omly allocated to one of the three interventions by cluster r and omization ( at the level of their primary care physician ) , if they are not on optimal statin therapy at baseline . The primary outcome is the proportion of patients demonstrating improvement in their statin management in the first six months post-catheterization . Secondary outcomes include examinations of the use of ACE inhibitors , anti-platelet agents , beta-blockers , non-statin lipid lowering drugs , and provision of smoking cessation advice in the first six months post-catheterization in the three treatment arms . Although r and omization will be clustered at the level of the primary care physician , the design effect is anticipated to be negligible and the unit of analysis will be the patient . Discussion If either the Local Opinion Leader Statement or the Unsigned Evidence Statement improves secondary prevention in patients with coronary disease , they can be easily modified and applied in other communities and for other target conditions Background Acute coronary syndromes , including myocardial infa rct ion and unstable angina , are important causes of premature mortality , morbidity and hospital admissions . Acute coronary syndromes consume large amounts of health care re sources , and have a major negative economic and social impact through days lost at work , support for disability , and coping with the psychological consequences of illness . Several registries have shown that evidence based treatments are under-utilised in this patient population , particularly in high-risk patients . There is evidence that systematic educational programmes can lead to improvement in the management of these patients . Since application of the results of important clinical trials and expert clinical guidelines into clinical practice leads to improved patient care and outcomes , we propose to test a quality improvement programme in a general group of hospitals in Europe . Methods / Design This will be a multi-centre cluster-r and omised study in 5 European countries : France , Spain , Pol and , Italy and the UK . Thirty eight hospitals will be r and omised to receive a quality improvement programme or no quality improvement programme . Centres will enter data for all eligible non-ST segment elevation acute coronary syndrome patients admitted to their hospital for a period of approximately 10 months onto the study data base and the sample size is estimated at 2,000 - 4,000 patients . The primary outcome is a composite of eight measures to assess aggregate potential for improvement in the management and treatment of this patient population ( risk stratification , early coronary angiography , anticoagulation , beta-blockers , statins , ACE-inhibitors , clopidogrel as a loading dose and at discharge ) . After the quality improvement programme , each of the eight measures will be compared between the two groups , correcting for cluster effect . Discussion If we can demonstrate important improvements in the quality of patient care as a result of a quality improvement programme , this could lead to a greater acceptance that such programmes should be incorporated into routine health training for health professionals and hospital managers . Trial registration Clinical trials.gov Background The Veterans Health Administration ( VHA ) oversees the largest integrated healthcare system in the United States . The feasibility of a large-scale , nationwide , group-r and omized implementation trial of VHA outpatient practice s has not been reported . We describe the recruitment and enrollment of such a trial testing a clinician-directed , Internet-delivered intervention for improving the care of postmyocardial infa rct ion patients with multiple comorbidities . Methods With a recruitment goal of 200 eligible community-based outpatient clinics , parent VHA facilities ( medical centers ) were recruited because they oversee their affiliated clinics and the research conducted there . Eligible facilities had at least four VHA-owned and -operated primary care clinics , an affiliated Institutional Review Board ( IRB ) , and no ongoing , potentially overlapping , quality -improvement study . Between December 2003 and December 2005 , in two consecutive phases , we used initial and then intensified recruitment strategies . Results Overall , 48 of 66 ( 73 % ) eligible facilities were recruited . Of the 219 clinics and 957 clinicians associated with the 48 facilities , 168 ( 78 % ) clinics and 401 ( 42 % ) clinicians participated . The median time from initial facility contact to clinic enrollment was 222 days , which decreased by over one-third from the first to the second recruitment phase ( medians : 323 and 195 days , respectively ; p < .001 ) , when more structured recruitment with physician recruiters was implemented and a dedicated IRB manager was added to the coordinating center staff . Conclusions Large group-r and omized trials benefit from having dedicated physician investigators and IRB personnel involved in recruitment . A large-scale , nationally representative , group-r and omized trial of community-based clinics is feasible within the VHA or a similar national healthcare system BACKGROUND No single quality improvement instrument has proved consistently effective , but multifaceted interventions are believed to have the greatest impact . However , only little is known regarding what combinations are likely to be successful . OBJECTIVE To evaluate the impact of a multifaceted intervention strategy combining GP registration s , outreach visits and feedback , targeting secondary prevention of ischemic heart disease in general practice . METHODS A r and omised controlled trial including 28 GPs in Ringkjøbing County , Denmark . Half of the GPs received outreach visits and feedback on their prescribing of heart disease drugs . Evaluation was based on registration of consultations with patients suffering from ischemic heart disease . RESULTS The intervention had a statistically significant impact on prescribing of lipid lowering drugs [ odds ratio 1.59 ; 95 % confidence interval ( CI ) 1.00 to 2.53 ] and acetylsalicylic acid ( odds ratio 2.54 ; 95 % CI 1.21 to 5.31 ) . CONCLUSION An intervention strategy combining outreach visits , feedback and GP registration s is a promising way of improving the quality of preventive treatment in general practice Abstract Objective : To assess the effectiveness 
    Output:
    
agent
Conclusions Organisational and professional interventions improved prescribing of statins/lipid-lowering agents and target blood pressure in patients with IHDs but there was little evidence of change in other outcomes .
***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: Objectives : The aim of the study was twofold ; 1 ) to develop a clinical pharmacist-led 12 month lasting follow-up program for patients with established coronary heart disease ( CHD ) discharged from the University Hospital of North Norway , and 2 ) to explore the impact of the program with regards to adherence to a medication assessment tool for secondary prevention of CHD and change in biomedical risk factors . Methods : A total of 102 patients aged 18 - 82 years were enrolled in a non-blinded r and omized controlled trial with an intervention group and a control group . The intervention comprised medication reconciliation , medication review and patient education during three meetings ; at discharge , after three months and after twelve months . The control group received st and ard care from their general practitioner . Primary outcomes were adherence to clinical guideline recommendations concerning prescription , therapy goal achievement and lifestyle education  defined in the medication assessment tool for secondary prevention of CHD ( MAT-CHDSP ) . Secondary outcomes included changes in the biomedical risk factors cholesterol , blood pressure and blood glucose . Results : Ninety-four patients completed the trial , 48 intervention group patients and 46 controls . Appropriate prescribing was high , but therapy goal achievement was low in both groups . Overall adherence to MAT-CHDSP criteria increased in both groups and was significantly higher in the intervention group at study end , 78.4 % vs. 62.0 % , p<0.001 . The difference was statistically significant for the documented lifestyle advices in intervention group patients . No significant improvements in biomedical risk factors were observed in favor of the intervention group . Conclusions : The study showed an increased guideline adherence in both study groups . This indicates that attention to clinical practice guideline recommendations in itself increases adherence – which may be a clinical pharmacist task . A larger adequately powered study is needed to show a significant difference in biomedical risk factor improvements in favor of the intervention . Amendments to the follow-up program are suggested before implementation in st and ard patient care can be recommended CONTEXT Coronary heart disease ( CHD ) mortality has declined substantially in Canada since 1994 . OBJECTIVE To determine what proportion of this decline was associated with temporal trends in CHD risk factors and advancements in medical treatments . DESIGN , SETTING , AND PATIENTS Prospect i ve analytic study of the Ontario , Canada , population aged 25 to 84 years between 1994 and 2005 , using an up date d version of the vali date d IMPACT model , which integrates data on population size , CHD mortality , risk factors , and treatment uptake changes . Relative risks and regression coefficients from the published literature quantified the relationship between CHD mortality and ( 1 ) evidence -based therapies in 8 distinct CHD sub population s ( acute myocardial infa rct ion [ AMI ] , acute coronary syndromes , secondary prevention post-AMI , chronic coronary artery disease , heart failure in the hospital vs in the community , and primary prevention for hyperlipidemia or hypertension ) and ( 2 ) population trends in 6 risk factors ( smoking , diabetes mellitus ,  systolic blood pressure ,  plasma cholesterol level , exercise , and obesity  ) . MAIN OUTCOME MEASURES The number of deaths prevented or delayed in 2005 ; secondary outcome measures were improvements in medical treatments and trends in risk factors . RESULTS Between 1994 and 2005 , the  age-adjusted CHD mortality rate  in Ontario decreased by 35 % from 191 to 125 deaths per 100,000 inhabitants , translating to an estimated 7585 fewer CHD deaths in 2005 . Improvements in medical and surgical treatments were associated with 43 % ( range , 11 % to 124 % ) of the total mortality decrease , most notably in AMI ( 8 % ; range , -5 % to 40 % ) , chronic stable coronary artery disease ( 17 % ; range , 7 % to 35 % ) , and heart failure occurring while in the community ( 10 % ; range , 6 % to 31 % ) . Trends in risk factors accounted for 3660 fewer CHD deaths prevented or delayed ( 48 % of total ; range , 28 % to 64 % ) , specifically , reductions in total cholesterol ( 23 % ; range , 10 % to 33 % ) and systolic blood pressure ( 20 % ; range , 13 % to 26 % ) . Increasing diabetes prevalence and body mass index had an inverse relationship associated with higher CHD mortality of 6 % ( range , 4 % to 8 % ) and 2 % ( range , 1 % to 4 % ) , respectively . CONCLUSION Between 1994 and 2005 , there was a decrease in CHD mortality rates in Ontario that was associated primarily with trends in risk factors and improvements in medical treatments , each explaining about half of the decrease BACKGROUND Quality improvement is central to improving the care of patients with cardiovascular disease ; however , the optimum type of data feedback to support such efforts is unknown . METHODS Over 26 months , 149 eligible Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines hospitals were r and omized to receive either st and ard ( n = 76 control ) or targeted ( n = 73 intervention ) performance feedback reports for acute myocardial infa rct ion patient care . Each report summarized performance on identified metrics ( providing hospitals with detailed data on their 3 lowest-performing quality metrics , relative to their peers ) . Intervention sites received 5 targeted feedback reports .  Overall composite performance was compared between cohorts at end of study and as a change from baseline . RESULTS Intervention ( n = 60 ) and control ( n = 64 ) hospitals that completed the study had similar baseline performance ( median score 83.7 % vs 84.2 % ) . Over 26 months of follow-up , the change in overall composite score across hospitals was neutral ( median 0.1 % [ interquartile range { IQR } -2.4 % to 3.3 % ] ) . There was no difference in observed improvement in either the intervention ( median -0.2 % [ IQR-2.6 % to 3.3 % ] ) or control ( median 0.1 % [ IQR -2.2 % to 3.4 % ] ) hospitals . CONCLUSIONS We were unable to demonstrate that targeted performance feedback reports lead to more rapid care improvements than st and ard reports . Future directions should explore the relationship between hospital self- selection of targeted metrics and the identification and promulgation of less common metrics -- particularly those that reflect processes of care Background Although numerous therapies have been shown to be beneficial in the prevention of myocardial infa rct ion and /or death in patients with coronary disease , these therapies are under-used and this gap contributes to sub-optimal patient outcomes . To increase the uptake of proven efficacious therapies in patients with coronary disease , we design ed a multifaceted quality improvement intervention employing patient-specific reminders delivered at the point-of-care , with one-page treatment guidelines endorsed by local opinion leaders ( " Local Opinion Leader Statement " ) . This trial is design ed to evaluate the impact of these Local Opinion Leader Statements on the practice s of primary care physicians caring for patients with coronary disease . In order to isolate the effects of the messenger ( the local opinion leader ) from the message , we will also test an identical quality improvement intervention that is not signed by a local opinion leader ( " Unsigned Evidence Statement " ) in this trial . Methods R and omized trial testing three different interventions in patients with coronary disease : ( 1 ) usual care versus ( 2 ) Local Opinion Leader Statement versus ( 3 ) Unsigned Evidence Statement .  Patients diagnosed with coronary artery disease after cardiac catheterization ( but without acute coronary syndromes ) will be r and omly allocated to one of the three interventions by cluster r and omization ( at the level of their primary care physician ) , if they are not on optimal statin therapy at baseline . The primary outcome is the proportion of patients demonstrating improvement in their statin management in the first six months post-catheterization . Secondary outcomes include examinations of the use of ACE inhibitors , anti-platelet agents , beta-blockers , non-statin lipid lowering drugs , and provision of smoking cessation advice in the first six months post-catheterization in the three treatment arms . Although r and omization will be clustered at the level of the primary care physician , the design effect is anticipated to be negligible and the unit of analysis will be the patient . Discussion If either the Local Opinion Leader Statement or the Unsigned Evidence Statement improves secondary prevention in patients with coronary disease , they can be easily modified and applied in other communities and for other target conditions Background Acute coronary syndromes , including myocardial infa rct ion and unstable angina , are important causes of premature mortality , morbidity and hospital admissions . Acute coronary syndromes consume large amounts of health care re sources , and have a major negative economic and social impact through days lost at work , support for disability , and coping with the psychological consequences of illness . Several registries have shown that evidence based treatments are under-utilised in this patient population , particularly in high-risk patients . There is evidence that systematic educational programmes can lead to improvement in the management of these patients . Since application of the results of important clinical trials and expert clinical guidelines into clinical practice leads to improved patient care and outcomes , we propose to test a quality improvement programme in a general group of hospitals in Europe . Methods / Design This will be a multi-centre cluster-r and omised study in 5 European countries : France , Spain , Pol and , Italy and the UK . Thirty eight hospitals will be r and omised to receive a quality improvement programme or no quality improvement programme . Centres will enter data for all eligible non-ST segment elevation acute coronary syndrome patients admitted to their hospital for a period of approximately 10 months onto the study data base and the sample size is estimated at 2,000 - 4,000 patients . The primary outcome is a composite of eight measures to assess aggregate potential for improvement in the management and treatment of this patient population ( risk stratification , early coronary angiography , anticoagulation , beta-blockers , statins , ACE-inhibitors , clopidogrel as a loading dose and at discharge ) . After the quality improvement programme , each of the eight measures will be compared between the two groups , correcting for cluster effect . Discussion If we can demonstrate important improvements in the quality of patient care as a result of a quality improvement programme , this could lead to a greater acceptance that such programmes should be incorporated into routine health training for health professionals and hospital managers . Trial registration Clinical trials.gov Background The Veterans Health Administration ( VHA ) oversees the largest integrated healthcare system in the United States . The feasibility of a large-scale , nationwide , group-r and omized implementation trial of VHA outpatient practice s has not been reported . We describe the recruitment and enrollment of such a trial testing a clinician-directed , Internet-delivered intervention for improving the care of postmyocardial infa rct ion patients with multiple comorbidities . Methods With a recruitment goal of 200 eligible community-based outpatient clinics , parent VHA facilities ( medical centers ) were recruited because they oversee their affiliated clinics and the research conducted there . Eligible facilities had at least four VHA-owned and -operated primary care clinics , an affiliated Institutional Review Board ( IRB ) , and no ongoing , potentially overlapping , quality -improvement study . Between December 2003 and December 2005 , in two consecutive phases , we used initial and then intensified recruitment strategies . Results Overall , 48 of 66 ( 73 % ) eligible facilities were recruited . Of the 219 clinics and 957 clinicians associated with the 48 facilities , 168 ( 78 % ) clinics and 401 ( 42 % ) clinicians participated . The median time from initial facility contact to clinic enrollment was 222 days , which decreased by over one-third from the first to the second recruitment phase ( medians : 323 and 195 days , respectively ; p < .001 ) , when more structured recruitment with physician recruiters was implemented and a dedicated IRB manager was added to the coordinating center staff . Conclusions Large group-r and omized trials benefit from having dedicated physician investigators and IRB personnel involved in recruitment . A large-scale , nationally representative , group-r and omized trial of community-based clinics is feasible within the VHA or a similar national healthcare system BACKGROUND No single quality improvement instrument has proved consistently effective , but multifaceted interventions are believed to have the greatest impact . However , only little is known regarding what combinations are likely to be successful . OBJECTIVE To evaluate the impact of a multifaceted intervention strategy combining GP registration s , outreach visits and feedback , targeting secondary prevention of ischemic heart disease in general practice . METHODS A r and omised controlled trial including 28 GPs in Ringkjøbing County , Denmark . Half of the GPs received outreach visits and feedback on their prescribing of heart disease drugs . Evaluation was based on registration of consultations with patients suffering from ischemic heart disease . RESULTS The intervention had a statistically significant impact on prescribing of lipid lowering drugs [ odds ratio 1.59 ; 95 % confidence interval ( CI ) 1.00 to 2.53 ] and acetylsalicylic acid ( odds ratio 2.54 ; 95 % CI 1.21 to 5.31 ) . CONCLUSION An intervention strategy combining outreach visits , feedback and GP registration s is a promising way of improving the quality of preventive treatment in general practice Abstract Objective : To assess the effectiveness 
    Output:
    