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: Background Lifestyle risk factors like smoking , nutrition , alcohol consumption , and physical inactivity ( SNAP ) are the main behavioural risk factors for chronic disease . Primary health care is an appropriate setting to address these risk factors in individuals . Generalist community health nurses ( GCHNs ) are uniquely placed to provide lifestyle interventions as they see clients in their homes over a period of time . The aim of the paper is to examine the impact of a service-level intervention on the risk factor management practice s of GCHNs . Methods The trial used a quasi-experimental design involving four generalist community nursing services in NSW , Australia . The services were r and omly allocated to either an intervention group or control group . Nurses in the intervention group were provided with training and support in the provision of brief lifestyle assessment s and interventions . The control group provided usual care .  A sample of 129 GCHNs completed surveys at baseline , 6 and 12 months to examine changes in their practice s and levels of confidence related to the management of SNAP risk factors . Six semi-structured interviews and four focus groups were conducted among the intervention group to explore the feasibility of incorporating the intervention into everyday practice . Results Nurses in the intervention group became more confident in assessment and intervention over the three time points compared to their control group peers . Nurses in the intervention group reported assessing physical activity , weight and nutrition more frequently , as well as providing more brief interventions for physical activity , weight management and smoking cessation . There was little change in referral rates except for an improvement in weight management related referrals . Nurses ’ perception of the importance of ‘ client and system-related ’ barriers to risk factor management diminished over time . Conclusions This study shows that the intervention was associated with positive changes in self-reported lifestyle risk factor management practice s of GCHNs . Barriers to referral remained . The service model needs to be adapted to sustain these changes and enhance referral . Trial registration Background The risk factors for chronic disease , smoking , poor nutrition , hazardous alcohol consumption , physical inactivity and weight ( SNAPW ) are common in primary health care ( PHC ) affording opportunity for preventive interventions . Community nurses are an important component of PHC in Australia . However there has been little research evaluating the effectiveness of lifestyle interventions in routine community nursing practice . This study aim ed to address this gap in our knowledge . Methods The study was a quasi-experimental trial involving four generalist community nursing ( CN ) services in New South Wales , Australia . Two services were r and omly allocated to an ‘ early intervention ’ and two to a ‘ late intervention ’ group . Nurses in the early intervention group received training and support in identifying risk factors and offering brief lifestyle intervention for clients . Those in the late intervention group provided usual care for the first 6 months and then received training .  Clients aged 30–80 years who were referred to the services between September 2009 and September 2010 were recruited prior to being seen by the nurse and baseline self-reported data collected . Data on their SNAPW risk factors , readiness to change these behaviours and advice and referral received about their risk factors in the previous 3 months were collected at baseline , 3 and 6 months . Analysis compared changes using univariate and multilevel regression techniques . Results 804 participants were recruited from 2361 ( 34.1 % ) eligible clients . The proportion of clients who recalled receiving dietary or physical activity advice increased between baseline and 3 months in the early intervention group ( from 12.9 to 23.3 % and 12.3 to 19.1 % respectively ) as did the proportion who recalled being referred for dietary or physical activity interventions ( from 9.5 to 15.6 % and 5.8 to 21.0 % respectively ) . There was no change in the late intervention group . There a shift towards greater readiness to change in those who were physically inactive in the early but not the comparison group . Clients in both groups reported being more physically active and eating more fruit and vegetables but there were no significant differences between groups at 6 months . Conclusion The study demonstrated that although the intervention was associated with increases in advice and referral for diet or physical activity and readiness for change in physical activity , this did not translate into significant changes in lifestyle behaviours or weight . This suggests a need to facilitate referral to more intensive long-term interventions for clients with risk factors identified by primary health care nurses . Trial registration Objective Continuous quality improvement ( CQI ) methods are foundational approaches to improving healthcare delivery . Publications using the term CQI , however , are method ologically heterogeneous , and labels other than CQI are used to signify relevant approaches . St and ards for identifying the use of CQI based on its key method ological features could enable more effective learning across quality improvement ( QI ) efforts . The objective was to identify essential method ological features for recognizing CQI . Design Previous work with a 12-member international expert panel identified reliably abstract ed CQI method ological features . We tested which features met rigorous a priori st and ards as essential features of CQI using a three-phase online modified-Delphi process . Setting Primarily United States and Canada . Participants 119 QI experts r and omly assigned into four on-line panels . Intervention(s ) Participants rated  CQI features and discussed their answers using online , anonymous and asynchronous discussion boards . We analyzed ratings quantitatively and discussion threads qualitatively . Main outcome measure(s ) Panel consensus on definitional CQI features . Results Seventy-nine ( 66 % ) panelists completed the process . Thirty-three completers self-identified as QI research ers , 18 as QI practitioners and 28 as both equally . The features ‘ systematic data guided activities , ’ ‘ design ing with local conditions in mind ’ and ‘ iterative development and testing ’ met a priori st and ards as essential CQI features . Qualitative analyses showed cross-cutting themes focused on differences between QI and CQI . Conclusions We found consensus among a broad group of CQI research ers and practitioners on three features as essential for identifying QI work more specifically as ‘ CQI . ’ All three features are needed as a minimum st and ard for recognizing CQI methods Objective To evaluate an intervention to improve implementation of guidelines for the prevention of chronic vascular disease . Setting 32 urban general practice s in 4 Australian states . R and omisation Stratified r and omisation of practice s. Participants 122 general practitioners ( GPs ) and practice nurses ( PNs ) were recruited at baseline and 97 continued to 12 months . 21 848 patient records were audited for those aged 40–69 years who attended the practice in the previous 12 months without heart disease , stroke , diabetes , chronic renal disease , cognitive impairment or severe mental illness . Intervention The practice level intervention over 6 months included small group training of practice staff , feedback on audited performance , practice facilitation visits and provision of patient education and referral information . Outcome measures Primary : 1 . Change in proportion of  patients aged 40–69 years  with smoking status , alcohol intake , body mass index ( BMI ) , waist circumference ( WC ) , blood pressure ( BP ) recorded and for those aged 45–69 years with lipids , fasting blood glucose and cardiovascular risk in the medical record . 2 . Change in the level of risk for each factor . Secondary change in self-reported frequency and confidence of GPs and PNs in assessment . Results Risk recording improved in the intervention but not the control group for WC ( OR 2.52 ( 95 % CI 1.30 to 4.91 ) ) , alcohol consumption ( OR 2.19 ( CI 1.04 to 4.64 ) ) , smoking status ( OR 2.24 ( 1.17 to 4.29 ) ) and cardiovascular risk ( OR 1.50 ( 1.04 to 2.18 ) ) . There was no change in recording of BP , lipids , glucose or BMI and no significant change in the level of risk factors based on audit data . The confidence but not reported practice s of GPs and PNs in the intervention group improved in the assessment of some risk factors . Conclusions This intervention was associated with improved recording of some risk factors but no change in the level of risk at the follow-up audit . Trial registration number Australian and New Zeal and Clinical Trials Register ( ANZCTR ) : ACTRN12612000578808 , results Background To determine the effectiveness of a single checklist reminder form to improve the delivery of preventive health services at adult health check-ups in a family practice setting . Methods A prospect i ve cluster r and omized controlled trial was conducted at four urban family practice clinics among 38 primary care physicians affiliated with the University of Toronto .  Preventive Care Checklist Forms © were created to be used by family physicians at adult health check-ups over a five-month period . The sex-specific forms incorporate evidence -based recommendations on preventive health services and documentation space for routine procedures such as physical examination . The forms were used in two intervention clinics and two control clinics . Rates and relative risks ( RR ) of the performance of 13 preventive health maneuvers at baseline and post-intervention and the percentage of up-to- date preventive health services delivered per patient were compared between the two groups . Results R and omly-selected charts were review ed at baseline ( n = 509 ) and post-intervention ( n = 608 ) . Baseline rates for provision of preventive health services ranged from 3 % ( fecal occult blood testing ) to 93 % ( blood pressure measurement ) , similar to other setting s. The percentage of up-to- date preventive health services delivered per patient at the end of the intervention was 48.9 % in the control group and 71.7 % in the intervention group . This is an overall 22.8 % absolute increase ( p = 0.0001 ) , and 46.6 % relative increase in the delivery of preventive health services per patient in the intervention group compared to controls . Eight of thirteen preventive health services showed a statistically significant change ( p < 0.05 ) in favor of the intervention ( adjusted RR ( 95 % C.I. ) ) :  counseling on brushing/flossing teeth  ( 9.2 ( 4.3–19.6 ) ) ,  folic acid counseling  ( 7.5 ( 2.7–20.8 ) ) , fecal occult blood testing ( 6.7 ( 1.9–24.1 ) ) , smoking cessation counseling ( 3.9 ( 2.2–7.2 ) ) , tetanus immunization ( 3.0 ( 1.7–5.2 ) ) , history of alcohol intake ( 1.33 ( 1.2–1.5 ) ) , history of smoking habits ( 1.28 ( 1.2–1.4 ) ) and blood pressure measurement ( 1.05 ( 1.00–1.10 ) ) . Conclusion This simple , low cost , clinical ly relevant intervention improves the delivery of preventive health services by prompting physicians of evidence -based recommendations in a checklist format that incorporates existing practice patterns . Periodic up date s of the Preventive Care Checklist Forms © will allow a feasible and easy-to-use tool for primary care physicians to provide evidence -based preventive health services to adults at routine health check-ups . The forms can also be incorporated into an electronic health record . The Preventive Care Checklist Forms © are accessible in English and French at the College of Family Physicians of Canada web site OBJECTIVE To assess the effects of a communication skills training program for physicians and patients . DESIGN A r and omized experiment to improve physician communication skills was assessed 1 and 6 months after a training intervention ; patient training to be active participants was assessed after 1 month . Across three primary medical care setting s , 156 physicians treating 2,196 patients were r and omly assigned to control group or one of three conditions ( physician , patient , or both trained ) . MAIN OUTCOME MEASURES Patient satisfaction and perceptions of choice , decision-making , information , and lifestyle counseling ; physicians ' satisfaction and stress ; and global ratings of the communication process . RESULTS The following significant ( p < .05 ) effects emerged : physician training improved patients ' satisfaction with information and overall care ; increased willingness to recommend the physician ; increased physicians ' counseling ( as reported by patients ) about weight loss , exercise , and quitting smoking and alcohol ; increased physician satisfaction with physical exam detail ; increased independent ratings of physicians ' sensitive , connected communication with their patients , and decreased physician satisfaction with interpersonal aspects of professional life . Patient training improved physicians ' satisfaction with data collection ; if only physician or patient was trained , physician stress increased and physician satisfaction decreased . CONCLUSION Implication s for improving physician-patient relationship outcomes through communication skills training are discussed Background Unhealthy alcohol use is a major contributor to the global burden of disease and injury . The US Preventive Services Task Force has recommended alcohol screening and intervention in general medical setting s since 2004 . Yet less than one in six US adults report health care professionals discussing alcohol with them . Little is known about methods for increasing implementation ; different staffing models may be related to implementation effectiveness . This implementation trial compared delivery of alcohol screening , brief intervention and referral to specialty treatment ( SBIRT ) by physicians versus non-physician providers receiving training , technical assistance , and feedback reports . Methods The study was a cluster r and omized implementation trial ( ADVISe [ Alcohol Drinking as a Vital Sign ] ) . Within a private , integrated health care system , 54 adult primary care clinics were stratified by medical center and r and omly assigned in blocked groups of three to SBIRT by physicians ( PCP arm ) versus non-physician providers and medical assistants ( NPP and MA arm ) , versus usual care ( Control arm ) . NIH-recommended screening questions were added to the electronic health record ( EHR ) to facilitate SBIRT . We examined  screening  and brief intervention and referral rates by arm 
    Output:
    
agent
***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 Lifestyle risk factors like smoking , nutrition , alcohol consumption , and physical inactivity ( SNAP ) are the main behavioural risk factors for chronic disease . Primary health care is an appropriate setting to address these risk factors in individuals . Generalist community health nurses ( GCHNs ) are uniquely placed to provide lifestyle interventions as they see clients in their homes over a period of time . The aim of the paper is to examine the impact of a service-level intervention on the risk factor management practice s of GCHNs . Methods The trial used a quasi-experimental design involving four generalist community nursing services in NSW , Australia . The services were r and omly allocated to either an intervention group or control group . Nurses in the intervention group were provided with training and support in the provision of brief lifestyle assessment s and interventions . The control group provided usual care .  A sample of 129 GCHNs completed surveys at baseline , 6 and 12 months to examine changes in their practice s and levels of confidence related to the management of SNAP risk factors . Six semi-structured interviews and four focus groups were conducted among the intervention group to explore the feasibility of incorporating the intervention into everyday practice . Results Nurses in the intervention group became more confident in assessment and intervention over the three time points compared to their control group peers . Nurses in the intervention group reported assessing physical activity , weight and nutrition more frequently , as well as providing more brief interventions for physical activity , weight management and smoking cessation . There was little change in referral rates except for an improvement in weight management related referrals . Nurses ’ perception of the importance of ‘ client and system-related ’ barriers to risk factor management diminished over time . Conclusions This study shows that the intervention was associated with positive changes in self-reported lifestyle risk factor management practice s of GCHNs . Barriers to referral remained . The service model needs to be adapted to sustain these changes and enhance referral . Trial registration Background The risk factors for chronic disease , smoking , poor nutrition , hazardous alcohol consumption , physical inactivity and weight ( SNAPW ) are common in primary health care ( PHC ) affording opportunity for preventive interventions . Community nurses are an important component of PHC in Australia . However there has been little research evaluating the effectiveness of lifestyle interventions in routine community nursing practice . This study aim ed to address this gap in our knowledge . Methods The study was a quasi-experimental trial involving four generalist community nursing ( CN ) services in New South Wales , Australia . Two services were r and omly allocated to an ‘ early intervention ’ and two to a ‘ late intervention ’ group . Nurses in the early intervention group received training and support in identifying risk factors and offering brief lifestyle intervention for clients . Those in the late intervention group provided usual care for the first 6 months and then received training .  Clients aged 30–80 years who were referred to the services between September 2009 and September 2010 were recruited prior to being seen by the nurse and baseline self-reported data collected . Data on their SNAPW risk factors , readiness to change these behaviours and advice and referral received about their risk factors in the previous 3 months were collected at baseline , 3 and 6 months . Analysis compared changes using univariate and multilevel regression techniques . Results 804 participants were recruited from 2361 ( 34.1 % ) eligible clients . The proportion of clients who recalled receiving dietary or physical activity advice increased between baseline and 3 months in the early intervention group ( from 12.9 to 23.3 % and 12.3 to 19.1 % respectively ) as did the proportion who recalled being referred for dietary or physical activity interventions ( from 9.5 to 15.6 % and 5.8 to 21.0 % respectively ) . There was no change in the late intervention group . There a shift towards greater readiness to change in those who were physically inactive in the early but not the comparison group . Clients in both groups reported being more physically active and eating more fruit and vegetables but there were no significant differences between groups at 6 months . Conclusion The study demonstrated that although the intervention was associated with increases in advice and referral for diet or physical activity and readiness for change in physical activity , this did not translate into significant changes in lifestyle behaviours or weight . This suggests a need to facilitate referral to more intensive long-term interventions for clients with risk factors identified by primary health care nurses . Trial registration Objective Continuous quality improvement ( CQI ) methods are foundational approaches to improving healthcare delivery . Publications using the term CQI , however , are method ologically heterogeneous , and labels other than CQI are used to signify relevant approaches . St and ards for identifying the use of CQI based on its key method ological features could enable more effective learning across quality improvement ( QI ) efforts . The objective was to identify essential method ological features for recognizing CQI . Design Previous work with a 12-member international expert panel identified reliably abstract ed CQI method ological features . We tested which features met rigorous a priori st and ards as essential features of CQI using a three-phase online modified-Delphi process . Setting Primarily United States and Canada . Participants 119 QI experts r and omly assigned into four on-line panels . Intervention(s ) Participants rated  CQI features and discussed their answers using online , anonymous and asynchronous discussion boards . We analyzed ratings quantitatively and discussion threads qualitatively . Main outcome measure(s ) Panel consensus on definitional CQI features . Results Seventy-nine ( 66 % ) panelists completed the process . Thirty-three completers self-identified as QI research ers , 18 as QI practitioners and 28 as both equally . The features ‘ systematic data guided activities , ’ ‘ design ing with local conditions in mind ’ and ‘ iterative development and testing ’ met a priori st and ards as essential CQI features . Qualitative analyses showed cross-cutting themes focused on differences between QI and CQI . Conclusions We found consensus among a broad group of CQI research ers and practitioners on three features as essential for identifying QI work more specifically as ‘ CQI . ’ All three features are needed as a minimum st and ard for recognizing CQI methods Objective To evaluate an intervention to improve implementation of guidelines for the prevention of chronic vascular disease . Setting 32 urban general practice s in 4 Australian states . R and omisation Stratified r and omisation of practice s. Participants 122 general practitioners ( GPs ) and practice nurses ( PNs ) were recruited at baseline and 97 continued to 12 months . 21 848 patient records were audited for those aged 40–69 years who attended the practice in the previous 12 months without heart disease , stroke , diabetes , chronic renal disease , cognitive impairment or severe mental illness . Intervention The practice level intervention over 6 months included small group training of practice staff , feedback on audited performance , practice facilitation visits and provision of patient education and referral information . Outcome measures Primary : 1 . Change in proportion of  patients aged 40–69 years  with smoking status , alcohol intake , body mass index ( BMI ) , waist circumference ( WC ) , blood pressure ( BP ) recorded and for those aged 45–69 years with lipids , fasting blood glucose and cardiovascular risk in the medical record . 2 . Change in the level of risk for each factor . Secondary change in self-reported frequency and confidence of GPs and PNs in assessment . Results Risk recording improved in the intervention but not the control group for WC ( OR 2.52 ( 95 % CI 1.30 to 4.91 ) ) , alcohol consumption ( OR 2.19 ( CI 1.04 to 4.64 ) ) , smoking status ( OR 2.24 ( 1.17 to 4.29 ) ) and cardiovascular risk ( OR 1.50 ( 1.04 to 2.18 ) ) . There was no change in recording of BP , lipids , glucose or BMI and no significant change in the level of risk factors based on audit data . The confidence but not reported practice s of GPs and PNs in the intervention group improved in the assessment of some risk factors . Conclusions This intervention was associated with improved recording of some risk factors but no change in the level of risk at the follow-up audit . Trial registration number Australian and New Zeal and Clinical Trials Register ( ANZCTR ) : ACTRN12612000578808 , results Background To determine the effectiveness of a single checklist reminder form to improve the delivery of preventive health services at adult health check-ups in a family practice setting . Methods A prospect i ve cluster r and omized controlled trial was conducted at four urban family practice clinics among 38 primary care physicians affiliated with the University of Toronto .  Preventive Care Checklist Forms © were created to be used by family physicians at adult health check-ups over a five-month period . The sex-specific forms incorporate evidence -based recommendations on preventive health services and documentation space for routine procedures such as physical examination . The forms were used in two intervention clinics and two control clinics . Rates and relative risks ( RR ) of the performance of 13 preventive health maneuvers at baseline and post-intervention and the percentage of up-to- date preventive health services delivered per patient were compared between the two groups . Results R and omly-selected charts were review ed at baseline ( n = 509 ) and post-intervention ( n = 608 ) . Baseline rates for provision of preventive health services ranged from 3 % ( fecal occult blood testing ) to 93 % ( blood pressure measurement ) , similar to other setting s. The percentage of up-to- date preventive health services delivered per patient at the end of the intervention was 48.9 % in the control group and 71.7 % in the intervention group . This is an overall 22.8 % absolute increase ( p = 0.0001 ) , and 46.6 % relative increase in the delivery of preventive health services per patient in the intervention group compared to controls . Eight of thirteen preventive health services showed a statistically significant change ( p < 0.05 ) in favor of the intervention ( adjusted RR ( 95 % C.I. ) ) :  counseling on brushing/flossing teeth  ( 9.2 ( 4.3–19.6 ) ) ,  folic acid counseling  ( 7.5 ( 2.7–20.8 ) ) , fecal occult blood testing ( 6.7 ( 1.9–24.1 ) ) , smoking cessation counseling ( 3.9 ( 2.2–7.2 ) ) , tetanus immunization ( 3.0 ( 1.7–5.2 ) ) , history of alcohol intake ( 1.33 ( 1.2–1.5 ) ) , history of smoking habits ( 1.28 ( 1.2–1.4 ) ) and blood pressure measurement ( 1.05 ( 1.00–1.10 ) ) . Conclusion This simple , low cost , clinical ly relevant intervention improves the delivery of preventive health services by prompting physicians of evidence -based recommendations in a checklist format that incorporates existing practice patterns . Periodic up date s of the Preventive Care Checklist Forms © will allow a feasible and easy-to-use tool for primary care physicians to provide evidence -based preventive health services to adults at routine health check-ups . The forms can also be incorporated into an electronic health record . The Preventive Care Checklist Forms © are accessible in English and French at the College of Family Physicians of Canada web site OBJECTIVE To assess the effects of a communication skills training program for physicians and patients . DESIGN A r and omized experiment to improve physician communication skills was assessed 1 and 6 months after a training intervention ; patient training to be active participants was assessed after 1 month . Across three primary medical care setting s , 156 physicians treating 2,196 patients were r and omly assigned to control group or one of three conditions ( physician , patient , or both trained ) . MAIN OUTCOME MEASURES Patient satisfaction and perceptions of choice , decision-making , information , and lifestyle counseling ; physicians ' satisfaction and stress ; and global ratings of the communication process . RESULTS The following significant ( p < .05 ) effects emerged : physician training improved patients ' satisfaction with information and overall care ; increased willingness to recommend the physician ; increased physicians ' counseling ( as reported by patients ) about weight loss , exercise , and quitting smoking and alcohol ; increased physician satisfaction with physical exam detail ; increased independent ratings of physicians ' sensitive , connected communication with their patients , and decreased physician satisfaction with interpersonal aspects of professional life . Patient training improved physicians ' satisfaction with data collection ; if only physician or patient was trained , physician stress increased and physician satisfaction decreased . CONCLUSION Implication s for improving physician-patient relationship outcomes through communication skills training are discussed Background Unhealthy alcohol use is a major contributor to the global burden of disease and injury . The US Preventive Services Task Force has recommended alcohol screening and intervention in general medical setting s since 2004 . Yet less than one in six US adults report health care professionals discussing alcohol with them . Little is known about methods for increasing implementation ; different staffing models may be related to implementation effectiveness . This implementation trial compared delivery of alcohol screening , brief intervention and referral to specialty treatment ( SBIRT ) by physicians versus non-physician providers receiving training , technical assistance , and feedback reports . Methods The study was a cluster r and omized implementation trial ( ADVISe [ Alcohol Drinking as a Vital Sign ] ) . Within a private , integrated health care system , 54 adult primary care clinics were stratified by medical center and r and omly assigned in blocked groups of three to SBIRT by physicians ( PCP arm ) versus non-physician providers and medical assistants ( NPP and MA arm ) , versus usual care ( Control arm ) . NIH-recommended screening questions were added to the electronic health record ( EHR ) to facilitate SBIRT . We examined  screening  and brief intervention and referral rates by arm 
    Output:
    