***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: OBJECTIVE To quantify total diabetes care received ( generalist or specialist ) from diagnosis onward and its association with the incidence of diabetes complications in a representative cohort of patients with type 1 diabetes . RESEARCH DESIGN AND METHODS A total of 429 subjects from the Pittsburgh Epidemiology of Diabetes Complications Study , a prospect i ve follow-up study of childhood-onset type 1 diabetic subjects first seen between 1986 and 1988 ( mean age 28 years , mean duration 19 years ) , followed biennially for up to 10 years were studied . Specialist care was defined as care received from a board-certified endocrinologist , diabetologist , or diabetes clinic and quantified as the percent of diabetes duration spent in specialist care . RESULTS There was a significant trend for a higher incidence of neuropathy , overt nephropathy , and coronary artery disease with lower use of specialist care . Multivariate analyses controlling for diabetes duration , demographic characteristics , health care practice s , and physiological risk factors demonstrated that higher past use of specialist care was found to be significantly protective against the development of overt nephropathy ( risk ratio 0.43 , 95 % CI 0.21 - 0.88 ) and neuropathy ( 0.54 , 0.35 - 0.83 ) and weakly protective against coronary artery disease ( 0.65 , 0.37 - 1.1 ) . CONCLUSIONS A higher proportion of diabetes duration spent in specialist care may result in delayed development of certain diabetes complications independent of other risk factors . This study thus supports the concept that the benefits of specialist care should be available to all patients with type 1 diabetes CONTEXT Morbidity and mortality rates in intensive care units ( ICUs ) vary widely among institutions , but whether ICU structure and care processes affect these outcomes is unknown . OBJECTIVE To determine whether organizational characteristics of ICUs are related to clinical and economic outcomes for abdominal aortic surgery patients who typically receive care in an ICU . DESIGN Observational study , with patient data collected retrospectively and ICU data collected prospect ively . SETTING All Maryl and hospitals that performed abdominal aortic surgery from 1994 to 1996 . PATIENTS AND PARTICIPANTS We analyzed hospital discharge data for patients in non-federal acute care hospitals in Maryl and who had a principal procedure code for abdominal aortic surgery from January 1994 through December 1996 ( n = 2987 ) . We obtained information about ICU organizational characteristics by surveying ICU medical directors at the 46 Maryl and hospitals that performed abdominal aortic surgery . Thirty-nine ( 85 % ) of the ICU directors completed this survey . MAIN OUTCOME MEASURES In-hospital mortality and hospital and ICU length of stay . RESULTS For patients undergoing abdominal aortic surgery , in-hospital mortality varied among hospitals from 0 % to 66 % . In multivariate analysis adjusted for patient demographics , comorbid disease , severity of illness , hospital and surgeon volume , and hospital characteristics , not having daily rounds by an ICU physician was associated with a 3-fold increase in in-hospital mortality ( odds ratio [ OR ] , 3.0 ; 95 % confidence interval [ CI ] , 1.9 - 4.9 ) . Furthermore , not having daily rounds by an ICU physician was associated with an increased risk of cardiac arrest ( OR , 2.9 ; 95 % CI , 1.2 - 7.0 ) , acute renal failure ( OR , 2.2 ; 95 % CI , 1.3 - 3.9 ) , septicemia ( OR , 1.8 ; 95 % CI , 1.2 - 2.6 ) , platelet transfusion ( OR , 6.4 ; 95 % CI , 3.2 - 12.4 ) , and reintubation ( OR , 2.0 ; 95 % CI , 1.0 - 4.1 ) . Not having daily rounds by an ICU physician , having an ICU nurse-patient ratio of less than 1:2 , not having monthly review of morbidity and mortality , and extubating patients in the operating room were associated with increased re source use . CONCLUSIONS Organizational characteristics of ICUs are related to differences among hospitals in outcomes of abdominal aortic surgery . Clinicians and hospital leaders should consider the potential impact of ICU organizational characteristics on outcomes of patients having high-risk operations OBJECTIVE To determine whether an outpatient team management program for persons with early chronic inflammatory arthritis would produce improved clinical outcomes and lower costs than traditional , nonteam outpatient rheumatologic care in a clinic setting . METHODS One hundred eighteen patients with chronic inflammatory arthritis were r and omly assigned to a team managed outpatient care program ( TEAMCARE ) or to traditional , one on one , nonteam managed rheumatologic care ( TRADCARE ) . The TEAMCARE program consisted of a half day educational program , a needs assessment intake interview , and quarterly telephone calls , monthly team meetings , and routine rheumatologic care . TRADCARE patient received unconstrained , routine primary and specialty outpatient care as practised typically by rheumatologists at this large multi-specialty clinic . All patients had numerous physical and laboratory outcome assessment s by rheumatologists at office visit . Every 6 months , patients completed several self-report measures of functional status , pain , psychosocial status , and costs . RESULTS One hundred seven patients completed one year of study participation . No significant differences were found between groups in measures of physical status , physical functioning , psychosocial status , or pain . There were no differences between groups in economic or utilization measures . CONCLUSION This team managed outpatient program for persons with recent onset chronic inflammatory arthritis afforded no advantage to routine outpatient care , characterized mainly by one on one relationships between patients and primary care doctors and rheumatologists , in our active outpatient clinical environment CONTEXT Guidelines for managing cystic fibrosis ( CF ) patients have been widely circulated , but little is known about the variations in practice between sites and their association with outcomes . OBJECTIVE To determine whether differences in lung health existed between groups of patients attending different CF care sites and to determine whether these differences are associated with differences in monitoring and intervention . DESIGN The analysis was conducted using data from the Epidemiologic Study of Cystic Fibrosis from 1995 through 1996 . SETTING This was an observational data base collecting prospect i ve information from a large number of CF patients undergoing routine care in North America . PARTICIPANTS Participating sites that had at least 50 CF patients who had each made at least one visit to a center during the 2-year study period were ranked on the basis of median values for FEV(1 ) within each of three age groups ( 6 to 12 years , 13 to 17 years , and > or= 18 years ) . INTERVENTIONS There were no prespecified interventions in this observational study . MAIN OUTCOME MEASURES The frequency of patient monitoring and the use of therapeutic interventions were compared between sites in the upper and lower quartiles after stratification within the site for disease severity . RESULTS Within-site rankings tended to be consistent across the three age groups . Patients who were treated at higher ranking sites had more frequent monitoring of their clinical status , measurements of lung function , and cultures for respiratory pathogens . These patients also received more interventions , particularly IV  antibiotics  for pulmonary exacerbations . CONCLUSION We found substantial differences in lung health across different CF care sites . We found that frequent monitoring and increased use of appropriate medications in the management of CF are associated with improved outcomes OBJECTIVE Specialist care is reportedly associated with favorable therapeutic results , although detailed outcomes of recent large-scale prospect i ve surveys of specialist care have yet to be published . The goal of this study was to eluci date the effects of one year 's specialist care on the management of type 2 diabetes . PATIENTS AND METHODS A multi-centered , prospect i ve observational study was undertaken . 754 type 2 diabetes patients , who made their first visit to one of eleven participating outpatient clinics specializing in diabetes care , were enrolled .  Routine structured diabetes care according to established guideline , including diabetes self-management education , was provided to all patients at each clinic visit . Parameters relating to glycemic control , serum lipids , blood pressure , patient follow-up status and others were followed for twelve months . RESULTS The HbA(1C ) level had improved significantly from 8.4+/-2.2 % at baseline to 6.8+/-1.2 % after six months and was 7.0+/-1.3 % after twelve months ( mean+/-SD ) . The higher the baseline HbA(1C ) level , the greater the subsequent improvement . Moreover , the most dramatic improvements in HbA(1C ) levels were seen within the first three months . The proportion of patients satisfying all of the therapeutic goals was extremely low at baseline and remained at less than 10 % after twelve months of specialist care . CONCLUSIONS Diabetic patients under specialist care  experienced substantial improvement , especially in glycemic control , as early as a few months after the first visit . However , 35 percent of patients dropped out during the 12-month study period and this is one area that needs to be improved OBJECTIVE More than 100,000 people are hospitalized annually in the U.S. with diabetic ketoacidosis ( DKA ) . Outcome differences have not been examined for these patients based on whether their primary care provider is a generalist or a diabetes specialist . The objective of this study was to investigate hospital charges and hospital length of stay ( LOS ) for patients with DKA according to the specialty of their primary care provider . RESEARCH DESIGN AND METHODS We investigated all patients with a primary diagnosis of DKA during a 3.5-year period ( n = 260 ) in a large urban teaching hospital .  Hospital charges and LOS were studied regarding the specialty of the primary care provider . Demographic factors , severity of illness , laboratory data , and readmission rates were compared . RESULTS Patients cared for by generalists and endocrinologists had a similar case mix and severity of DKA . The age-adjusted mean LOS for patients of generalists was 4.9 days ( 95 % CI 4.5 - 5.4 ) , and the mean LOS for patients of endocrinologists was 3.3 days ( 2.6 - 4.2 ) ( P < 0.0043 ) . Mean hospital charges differed ( P < 0.0001 ) with an age- and sex-adjusted mean for patients of endocrinologists of $ 5,463 ( $ 4,179 - 7,141 ) and a mean for patients of generalists of $ 10,109 ( $ 9,151 - 11,166 ) . The additional charges incurred by generalists were due in part to patients undergoing more procedures . No differences in diabetes-related complications occurred during admission , but the endocrinologist-treated group had a lower readmission rate for DKA during the study period than the generalist-treated group ( 2 vs. 6 % , respectively ) ( P = 0.03 ) . CONCLUSIONS Endocrinologists provide more cost-effective care than generalists do when serving as primary care providers for patients hospitalized with DKA In a rheumatology department , 2 r and omized groups of female out patients with rheumatoid arthritis were studied prospect ively for 1 year . The outcome of multidisciplinary team care  ( T group , 31 patients ) was compared with that of regular outpatient clinic care  ( NT group , 28 patients ) . Pharmacologic treatment and orthopedic specialist consultations were similar in both groups , but use of paramedical care was higher in the T group . Outcome measures of disease activity , specific joint function , and self-rated physical discomfort disclosed no significant differences between the 2 groups . Mental well-being increased in the T group . Overall health , measured by the Sickness Impact Profile , improved significantly only in the T group . This improvement was also significant compared with the NT group This work presents results of a quasiexperimental prospect i ve cohort study of the medium-term course of chronic rheumatoid arthritis ( RA ) under two different conditions of care . During 1984 - 1986 a total of 262 patients was recruited . All were new referrals to a university outpatient department . 121 came from the city of Hannover , FRG , and were assigned to comprehensive team care ( cc )  provided by two rheumatologists , a nurse , physician 's assistant , occupational therapist , psychologist , and social worker ; 141 came from outside Hannover and received care from a physician in training for internal medicine/rheumatology and a nurse , supervised by a senior registrar (  TC ) . The patients in the first group were significantly older ( 57 vs 51 years ) , had more active disease ( ESR 44 vs 31 mm/h ) , were more disabled ( functional capacity 69 vs 78 % ) , more often lived alone ( 27 vs 10 % ) and were more depressed compared with patients in the second group . There were no significant differences in gender ( 80 % female ) , number of Rome criteria ( 5.2 ) , and disease duration ( 6 years ) between the two groups . 179 patients were followed for 2 years . There was no demonstrable difference between those who dropped out and those who continued in the study . Patients from both groups showed significant and clinical ly important improvements in ESR and number of swollen joints , whereas functional capacity and pain intensity did not change . Depression and patients ' global self-rating improved only in the CC-group . Analyses adjusting for differences between the 
    Output:
    
The available literature suggests that among patients with rheumatoid arthritis , diabetes mellitus or cystic fibrosis , outcomes are not superior in specialized centers or with subspecialists compared with other forms of chronic illness care