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: We used a  resident continuity clinic  to compare prospect ively the impact of salary v fee-for-service reimbursement on physician practice behavior . This model allowed r and omization of physicians into salary and fee-for-service groups and separation of the effects of reimbursement from patient behavior . Physicians reimbursed by fee-for-services scheduled more visits per patient than did salaried physicians ( 3.69 visits v 2.83 visits , P less than .01 ) and saw their patients more often ( 2.70 visits v 2.21 visits , P less than .05 ) during the 9-month study . Almost all of this difference was because fee-for-service physicians saw more well patients than salaried physicians ( 1.42 visits and .99 visits per enrolled patient , respectively , P less than .01 ) . Evaluating visits by American Academy of Pediatrics ' guidelines indicated that fee-for-service physicians saw more patients for well-childcare than salaried physicians because they missed fewer recommended visits and scheduled visits in excess of those recommendations . Fee-for-service physicians also provided better continuity of care than salaried physicians by attending a larger percentage of all visits made by their patients ( 86.6 % of visits v 78.3 % of visits , P less than .05 ) , and by encouraging fewer emergency visits per enrolled patient ( 0.12 visits v 0.22 visits , P less than .01 ) . Physicians ' interest in private practice , as determined by their career plans , correlated significantly with total number of patients enrolled ( r = .48 , P less than .05 ) and total clinic patients seen by each resident during the study ( r = .40 , P less than .05 ) . ( ABSTRACT TRUNCATED AT 250 WORDS Background The implementation of new medical knowledge into general practice is a complex process . Blended learning may offer an effective and efficient educational intervention to reduce the knowledge-to- practice gap . The aim of this study was to compare knowledge acquisition about dementia management between a blended learning approach using online modules in addition to quality circles ( QCs ) and QCs alone . Methods In this cluster-r and omised trial with QCs as clusters and general practitioners ( GPs ) as participants , 389 GPs from 26 QCs in the western part of Germany were invited to participate . Data on the GPs ' knowledge were obtained at three points in time by means of a question naire survey . Primary outcome was the knowledge gain before and after the interventions . A subgroup analysis of the users of the online modules was performed . Results 166 GPs were available for analysis and filled out a knowledge test at least two times . A significant increase of knowledge was found in both groups that indicated positive learning effects of both approaches . However , there was no significant difference between the groups . A subgroup analysis of the GPs who self-reported that they had actually used the online modules showed that they had a significant increase in their knowledge scores . Conclusion A blended learning approach was not superior to a QCs approach for improving knowledge about dementia management . However , a subgroup of GPs who were motivated to actually use the online modules had a gain in knowledge . Trial registration Current Controlled Trials IS RCT N36550981 Objective . Immunizations and other cost-effective preventive services remain underused by many children , especially those living in poverty . Given the effectiveness of provider-based tracking systems and the widespread use by managed care organizations of financial incentives to influence physician practice patterns , we design ed and tested an intervention combining these strategies . We studied whether a system of semiannual assessment and feedback , coupled with financial incentives , could improve pediatric preventive care in a Medicaid health maintenance organization ( HMO ) . Methodology . We r and omly assigned primary care sites serving children in a Medicaid HMO to one of three groups : a feedback group ( where physicians received written feedback about compliance scores ) , a feedback and incentive group ( where physicians received feedback and a financial bonus when compliance criteria were met ) , and a control group . We evaluated compliance with pediatric preventive care guidelines  through semiannual chart audits during the years 1993 to 1995 . Results . Compliance with pediatric preventive care improved dramatically in the study period . Repeated measures ANOVA demonstrated a significant increase in all three study groups throughout the time in total compliance scores ( from 56%–73 % ) , as well as scores for immunizations ( from 62%–79 % ) and other preventive care ( from 54%–71 % ) . However , no significant differences were observed between either intervention group and the control group , nor were there any interaction ( group-by-time ) effects . Conclusions . Feedback to physicians , with or without financial incentives , did not improve pediatric preventive care in this Medicaid HMO during a time of rapid , secular improvements in care . Possible explanations include the context and timing of the intervention , the magnitude of the financial incentives , and lack of physician awareness of the intervention OBJECTIVE To determine the effects of a financial incentive on the number and types of  cognitive services ( CS )  provided by community pharmacies to Medicaid recipients in the State of Washington . DESIGN Prospect i ve r and omized trial . CS were reported using a problem-intervention- result coding system over a 20-month period . SETTING AND SUBJECTS Pharmacists practicing in 110 study ( financial incentive ) and 90 control community pharmacies . RESULTS Study pharmacists documented an average of 1.59 CS interventions per 100 prescriptions over a 20-month period , significantly more than controls , who documented an average of 0.67 interventions ( P < .05 ) per 100 prescriptions . One-half ( 48.4 % ) of all CS were for patient-related problems , 32.6 % were for drug-related problems , 17.6 % were for prescription-related problems , and 1.4 % were for other problems that did not involve drug therapy . A change in drug therapy occurred as a result of 28 % of all CS documented in this demonstration . Changes were rarely ( 2.4 % ) due to generic or therapeutic substitution and almost always ( 90 % ) followed communication with the prescriber . The average self-reported time to perform CS was 7.5 minutes ; 75 % of interventions were < or = 6 minutes . Considerable differences existed between study and control groups in the types of problems identified , intervention activities performed , and results of interventions . CONCLUSION A financial incentive was associated with significantly more , and different types of , CS performed by pharmacists Background Health risk appraisal is a promising method for health promotion and prevention in older persons . The Health Risk Appraisal for the Elderly ( HRA-E ) developed in the U.S. has unique features but has not been tested outside the United States . Methods Based on the original HRA-E , we developed a scientifically up date d and regionally adapted multilingual Health Risk Appraisal for Older Persons ( HRA-O ) instrument consisting of a self-administered question naire and software-generated feed-back reports . We evaluated the practicability and performance of the question naire in non-disabled community-dwelling older persons in London ( U.K. ) ( N = 1090 ) , Hamburg ( Germany ) ( N = 804 ) , and Solothurn ( Switzerl and ) ( N = 748 ) in a sub- sample of an international r and omised controlled study . Results Over eighty percent of invited older persons returned the self-administered HRA-O question  naire . Fair or poor self-perceived health status and older age were correlated with higher rates of non-return of the question naire . Older participants and those with lower educational levels reported more difficulty in completing the HRA-O question naire as compared to younger and higher educated persons . However , even among older participants and those with low educational level , more than 80 % rated the question naire as easy to complete . Prevalence rates of risks for functional decline or problems were between 2 % and 91 % for the 19 HRA-O domains . Participants ' intention to change health behaviour suggested that for some risk factors participants were in a pre-contemplation phase , having no short- or medium-term plans for change . Many participants perceived their health behaviour or preventative care uptake as optimal , despite indications of deficits according to the HRA-O based evaluation . Conclusion The HRA-O question naire was highly accepted by a broad range of community-dwelling non-disabled persons . It identified a high number of risks and problems , and provided information on participants ' intention to change health behaviour OBJECTIVE --To investigate the effects on general practitioners ' activities of a change in their remuneration from a capitation based system to a mixed fee per item and capitation based system . DESIGN --Follow up study with data collected from contact sheets completed by general practitioners in one period before ( March 1987 ) a change in their remuneration system and two periods after ( March 1988 , November 1988 ) , with a control group of general practitioners with a  mixed fee per item and capitation based system  throughout . SETTING --General practice s in Copenhagen city ( index group ) and Copenhagen county ( control group ) . SUBJECTS--265 General practitioners in Copenhagen city , of whom 100 were selected r and omly from the 130 who agreed to participate ( 10 exclusions ) and 326 general practitioners in Copenhagen county . MAIN OUTCOME MEASURES --Number of consultations ( face to face and by telephone ) and renewals of prescriptions , diagnostic and curative services , and specialist and hospital referrals per 1000 enlisted patients in one week . RESULTS --Of the 75 general practitioners who completed all three sheets , four were excluded for incomplete data . Total contact rates per 1000 patients listed rose significantly compared with the rates before the change index in the city ( 100.0 before the change v 111.7 ( 95 % confidence interval 106.4 to 117.4 after the change ) and over the same time in the control group ( 100.0 v 106.0 ) , but within a year these rates fell ( to 104.2(99.1 to 109.6 ) and 104.0 respectively ) . There was an increase in consultations by telephone initially but not thereafter . Rates of examinations and treatments that attracted specific additional remuneration after the change rose significantly compared with those before ( diagnostic services , 138.1 ( 118.7 to 160.5 ) and 159.5 ( 137.8 to 184.7 ) and curative services 194.6 ( 152.2 to 248.9 ) and 194.8(152.3 to 249.2 ) for second and third data collection s respectively ) and with the control group ( diagnostic services 105.3 , 107.6 and curative services 106.0 , 115.0 ) whereas referral rates to secondary care fell ( specialist referrals 90.1 ( 80.7 to 100.6 ) and 77.0 ( 68.6 to 86.4 ) and hospital referrals 87.4 ( 71.1 to 107.5 ) and 68.4 ( 54.7 to 85.4 ] in doctors in the city . CONCLUSIONS --Introducing a partial fee for service system seemed to stimulate the provision of services by general practitioners , result ing in reduced referral rates . The concept of a " target income " which doctors aim at , rather than maximising their income seemed to play a part in adjustment to changing the system of remuneration OBJECTIVE This study determined the effect of 2 financial incentives --- bonus and enhanced fee-for-service --- on documented immunization rates during a second period of observation . METHODS Incentives were given to 57 r and omly selected inner-city physicians 4 times at 4-month intervals based on the performance of 50 r and omly selected children . Coverage from linked records from all sources was determined for a sub sample of children within physician offices . RESULTS Up-to- date coverage rates documented in the charts increased significantly for children in the bonus group ( 49.7 % to 55.6 % ; P < .05 ) and the enhanced fee-for-service group ( 50.8 % to 58.2 % ; P < .01 ) compared with the control group . The number of immunizations given by these physicians did not change significantly , although the number of immunizations given by others and documented by physicians in the bonus group did increase ( P < .05 ) . Up-to- date coverage for all groups increased from 20 to 40 percentage points when immunizations from physician charts were combined with other sources . CONCLUSIONS Both financial incentives produced a significant increase in coverage levels . Increases were primarily due to better documentation not to better immunizing practice s. The financial incentives appeared to provide motivation to physicians but were not sufficient to overcome entrenched behavior patterns . However , true immunization coverage was substantially higher than that documented in the charts BACKGROUND This study tested the effects of two organizational support processes , the provision of financial incentives for superior clinical performance and the availability of a  patient ( smoker ) registry and proactive telephone support system for smoking cessation , on provider adherence to accepted practice guidelines and associated patient outcomes . METHODS Forty clinics of a large multispecialty medical group practice providing primary care services were r and omly allocated to study conditions . Fifteen clinics each were assigned to the experimental conditions " control " ( distribution of printed versions of smoking cessation guidelines ) and " incentive " ( financial incentive pay-out for reaching preset clinical performance targets ) .  Ten clinics were r and omized to receive financial incentives combined with access to a central ized patient registry and intervention system ( " registry " ) . Main outcome measures were adherence to smoking cessation clinical practice guidelines and patients ' smoking cessation behaviors . RESULTS  Patients ' tobacco use status  was statistically significant ( P < 0.01 ) more frequently 
    Output:
    
agent
Financial incentives may be effective in changing healthcare professional practice .
We found no evidence from review s that examined the effect of financial incentives on patient 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: We used a  resident continuity clinic  to compare prospect ively the impact of salary v fee-for-service reimbursement on physician practice behavior . This model allowed r and omization of physicians into salary and fee-for-service groups and separation of the effects of reimbursement from patient behavior . Physicians reimbursed by fee-for-services scheduled more visits per patient than did salaried physicians ( 3.69 visits v 2.83 visits , P less than .01 ) and saw their patients more often ( 2.70 visits v 2.21 visits , P less than .05 ) during the 9-month study . Almost all of this difference was because fee-for-service physicians saw more well patients than salaried physicians ( 1.42 visits and .99 visits per enrolled patient , respectively , P less than .01 ) . Evaluating visits by American Academy of Pediatrics ' guidelines indicated that fee-for-service physicians saw more patients for well-childcare than salaried physicians because they missed fewer recommended visits and scheduled visits in excess of those recommendations . Fee-for-service physicians also provided better continuity of care than salaried physicians by attending a larger percentage of all visits made by their patients ( 86.6 % of visits v 78.3 % of visits , P less than .05 ) , and by encouraging fewer emergency visits per enrolled patient ( 0.12 visits v 0.22 visits , P less than .01 ) . Physicians ' interest in private practice , as determined by their career plans , correlated significantly with total number of patients enrolled ( r = .48 , P less than .05 ) and total clinic patients seen by each resident during the study ( r = .40 , P less than .05 ) . ( ABSTRACT TRUNCATED AT 250 WORDS Background The implementation of new medical knowledge into general practice is a complex process . Blended learning may offer an effective and efficient educational intervention to reduce the knowledge-to- practice gap . The aim of this study was to compare knowledge acquisition about dementia management between a blended learning approach using online modules in addition to quality circles ( QCs ) and QCs alone . Methods In this cluster-r and omised trial with QCs as clusters and general practitioners ( GPs ) as participants , 389 GPs from 26 QCs in the western part of Germany were invited to participate . Data on the GPs ' knowledge were obtained at three points in time by means of a question naire survey . Primary outcome was the knowledge gain before and after the interventions . A subgroup analysis of the users of the online modules was performed . Results 166 GPs were available for analysis and filled out a knowledge test at least two times . A significant increase of knowledge was found in both groups that indicated positive learning effects of both approaches . However , there was no significant difference between the groups . A subgroup analysis of the GPs who self-reported that they had actually used the online modules showed that they had a significant increase in their knowledge scores . Conclusion A blended learning approach was not superior to a QCs approach for improving knowledge about dementia management . However , a subgroup of GPs who were motivated to actually use the online modules had a gain in knowledge . Trial registration Current Controlled Trials IS RCT N36550981 Objective . Immunizations and other cost-effective preventive services remain underused by many children , especially those living in poverty . Given the effectiveness of provider-based tracking systems and the widespread use by managed care organizations of financial incentives to influence physician practice patterns , we design ed and tested an intervention combining these strategies . We studied whether a system of semiannual assessment and feedback , coupled with financial incentives , could improve pediatric preventive care in a Medicaid health maintenance organization ( HMO ) . Methodology . We r and omly assigned primary care sites serving children in a Medicaid HMO to one of three groups : a feedback group ( where physicians received written feedback about compliance scores ) , a feedback and incentive group ( where physicians received feedback and a financial bonus when compliance criteria were met ) , and a control group . We evaluated compliance with pediatric preventive care guidelines  through semiannual chart audits during the years 1993 to 1995 . Results . Compliance with pediatric preventive care improved dramatically in the study period . Repeated measures ANOVA demonstrated a significant increase in all three study groups throughout the time in total compliance scores ( from 56%–73 % ) , as well as scores for immunizations ( from 62%–79 % ) and other preventive care ( from 54%–71 % ) . However , no significant differences were observed between either intervention group and the control group , nor were there any interaction ( group-by-time ) effects . Conclusions . Feedback to physicians , with or without financial incentives , did not improve pediatric preventive care in this Medicaid HMO during a time of rapid , secular improvements in care . Possible explanations include the context and timing of the intervention , the magnitude of the financial incentives , and lack of physician awareness of the intervention OBJECTIVE To determine the effects of a financial incentive on the number and types of  cognitive services ( CS )  provided by community pharmacies to Medicaid recipients in the State of Washington . DESIGN Prospect i ve r and omized trial . CS were reported using a problem-intervention- result coding system over a 20-month period . SETTING AND SUBJECTS Pharmacists practicing in 110 study ( financial incentive ) and 90 control community pharmacies . RESULTS Study pharmacists documented an average of 1.59 CS interventions per 100 prescriptions over a 20-month period , significantly more than controls , who documented an average of 0.67 interventions ( P < .05 ) per 100 prescriptions . One-half ( 48.4 % ) of all CS were for patient-related problems , 32.6 % were for drug-related problems , 17.6 % were for prescription-related problems , and 1.4 % were for other problems that did not involve drug therapy . A change in drug therapy occurred as a result of 28 % of all CS documented in this demonstration . Changes were rarely ( 2.4 % ) due to generic or therapeutic substitution and almost always ( 90 % ) followed communication with the prescriber . The average self-reported time to perform CS was 7.5 minutes ; 75 % of interventions were < or = 6 minutes . Considerable differences existed between study and control groups in the types of problems identified , intervention activities performed , and results of interventions . CONCLUSION A financial incentive was associated with significantly more , and different types of , CS performed by pharmacists Background Health risk appraisal is a promising method for health promotion and prevention in older persons . The Health Risk Appraisal for the Elderly ( HRA-E ) developed in the U.S. has unique features but has not been tested outside the United States . Methods Based on the original HRA-E , we developed a scientifically up date d and regionally adapted multilingual Health Risk Appraisal for Older Persons ( HRA-O ) instrument consisting of a self-administered question naire and software-generated feed-back reports . We evaluated the practicability and performance of the question naire in non-disabled community-dwelling older persons in London ( U.K. ) ( N = 1090 ) , Hamburg ( Germany ) ( N = 804 ) , and Solothurn ( Switzerl and ) ( N = 748 ) in a sub- sample of an international r and omised controlled study . Results Over eighty percent of invited older persons returned the self-administered HRA-O question  naire . Fair or poor self-perceived health status and older age were correlated with higher rates of non-return of the question naire . Older participants and those with lower educational levels reported more difficulty in completing the HRA-O question naire as compared to younger and higher educated persons . However , even among older participants and those with low educational level , more than 80 % rated the question naire as easy to complete . Prevalence rates of risks for functional decline or problems were between 2 % and 91 % for the 19 HRA-O domains . Participants ' intention to change health behaviour suggested that for some risk factors participants were in a pre-contemplation phase , having no short- or medium-term plans for change . Many participants perceived their health behaviour or preventative care uptake as optimal , despite indications of deficits according to the HRA-O based evaluation . Conclusion The HRA-O question naire was highly accepted by a broad range of community-dwelling non-disabled persons . It identified a high number of risks and problems , and provided information on participants ' intention to change health behaviour OBJECTIVE --To investigate the effects on general practitioners ' activities of a change in their remuneration from a capitation based system to a mixed fee per item and capitation based system . DESIGN --Follow up study with data collected from contact sheets completed by general practitioners in one period before ( March 1987 ) a change in their remuneration system and two periods after ( March 1988 , November 1988 ) , with a control group of general practitioners with a  mixed fee per item and capitation based system  throughout . SETTING --General practice s in Copenhagen city ( index group ) and Copenhagen county ( control group ) . SUBJECTS--265 General practitioners in Copenhagen city , of whom 100 were selected r and omly from the 130 who agreed to participate ( 10 exclusions ) and 326 general practitioners in Copenhagen county . MAIN OUTCOME MEASURES --Number of consultations ( face to face and by telephone ) and renewals of prescriptions , diagnostic and curative services , and specialist and hospital referrals per 1000 enlisted patients in one week . RESULTS --Of the 75 general practitioners who completed all three sheets , four were excluded for incomplete data . Total contact rates per 1000 patients listed rose significantly compared with the rates before the change index in the city ( 100.0 before the change v 111.7 ( 95 % confidence interval 106.4 to 117.4 after the change ) and over the same time in the control group ( 100.0 v 106.0 ) , but within a year these rates fell ( to 104.2(99.1 to 109.6 ) and 104.0 respectively ) . There was an increase in consultations by telephone initially but not thereafter . Rates of examinations and treatments that attracted specific additional remuneration after the change rose significantly compared with those before ( diagnostic services , 138.1 ( 118.7 to 160.5 ) and 159.5 ( 137.8 to 184.7 ) and curative services 194.6 ( 152.2 to 248.9 ) and 194.8(152.3 to 249.2 ) for second and third data collection s respectively ) and with the control group ( diagnostic services 105.3 , 107.6 and curative services 106.0 , 115.0 ) whereas referral rates to secondary care fell ( specialist referrals 90.1 ( 80.7 to 100.6 ) and 77.0 ( 68.6 to 86.4 ) and hospital referrals 87.4 ( 71.1 to 107.5 ) and 68.4 ( 54.7 to 85.4 ] in doctors in the city . CONCLUSIONS --Introducing a partial fee for service system seemed to stimulate the provision of services by general practitioners , result ing in reduced referral rates . The concept of a " target income " which doctors aim at , rather than maximising their income seemed to play a part in adjustment to changing the system of remuneration OBJECTIVE This study determined the effect of 2 financial incentives --- bonus and enhanced fee-for-service --- on documented immunization rates during a second period of observation . METHODS Incentives were given to 57 r and omly selected inner-city physicians 4 times at 4-month intervals based on the performance of 50 r and omly selected children . Coverage from linked records from all sources was determined for a sub sample of children within physician offices . RESULTS Up-to- date coverage rates documented in the charts increased significantly for children in the bonus group ( 49.7 % to 55.6 % ; P < .05 ) and the enhanced fee-for-service group ( 50.8 % to 58.2 % ; P < .01 ) compared with the control group . The number of immunizations given by these physicians did not change significantly , although the number of immunizations given by others and documented by physicians in the bonus group did increase ( P < .05 ) . Up-to- date coverage for all groups increased from 20 to 40 percentage points when immunizations from physician charts were combined with other sources . CONCLUSIONS Both financial incentives produced a significant increase in coverage levels . Increases were primarily due to better documentation not to better immunizing practice s. The financial incentives appeared to provide motivation to physicians but were not sufficient to overcome entrenched behavior patterns . However , true immunization coverage was substantially higher than that documented in the charts BACKGROUND This study tested the effects of two organizational support processes , the provision of financial incentives for superior clinical performance and the availability of a  patient ( smoker ) registry and proactive telephone support system for smoking cessation , on provider adherence to accepted practice guidelines and associated patient outcomes . METHODS Forty clinics of a large multispecialty medical group practice providing primary care services were r and omly allocated to study conditions . Fifteen clinics each were assigned to the experimental conditions " control " ( distribution of printed versions of smoking cessation guidelines ) and " incentive " ( financial incentive pay-out for reaching preset clinical performance targets ) .  Ten clinics were r and omized to receive financial incentives combined with access to a central ized patient registry and intervention system ( " registry " ) . Main outcome measures were adherence to smoking cessation clinical practice guidelines and patients ' smoking cessation behaviors . RESULTS  Patients ' tobacco use status  was statistically significant ( P < 0.01 ) more frequently 
    Output:
    