***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 Our objective was to underst and family practice s from the ground up through intensive direct observation of the practice environment and patient care . METHODS Eighteen practice s were purpose fully drawn from a r and om sample of Nebraska family practice s that had earlier participated in a study of preventive service delivery . Each practice was studied intensely over a 4- to 12-week period using a comparative case study design that included extended direct observation of the practice environment and clinical encounters , formal and informal interviews of clinicians and staff , and medical record review . DESIGN This multi method assessment process ( MAP ) provided insights into a wide range of practice activities ranging from descriptions of the organization and patient care activities to quantitative documentation of physician- and practice -level delivery of a wide range of evidence -based preventive services . Initial insights guided subsequent data collection and analysis and led to the integration of complexity science concepts into the design . In response to the needs and wishes of the participants , practice meetings were initiated to provide feedback , result ing in a more collaborative model of practice -based research . CONCLUSIONS Our multi method assessment process provided rich data for describing multiple aspects of primary care practice , testing a priori hypotheses , discovering new insights grounded in the actual experience of practice participants , and fostering collaborative practice change OBJECTIVE To evaluate the effectiveness of a managed care approach to health care delivery , group visits , in the management of uninsured or inadequately insured patients with type 2 diabetes . RESEARCH DESIGN AND METHODS A total of 120 patients with uncontrolled type 2 diabetes were r and omly assigned to receive their care in group visits or usual care for 6 months . After 6 months , concordance with 10 process-of-care indicators recommended by the American Diabetes Association ( ADA ) st and ards of care was evaluated through chart abstract ion . The 10 items evaluated were up-to- date HbA(1c ) levels and lipid profiles , urine for microalbumin , appropriate use of ACE inhibitor or angiotensin receptor blockers , use of lipid-lowering agents where indicated , daily aspirin use , annual foot examinations , annual referrals for retinal examinations , and immunizations against streptococcal pneumonia and influenza . RESULTS Patients who received care in group visits showed statistically significant improvement in concordance with these 10 process-of-care indicators ( P < 0.001 ) . Of the patients , 76 % who received care in group visits had at least 9 of these 10 items up to date , as compared with 23 % of control patients ; 86 % of patients in group visits had at least 8 of the 10 indicators compared with 47 % of control patients . CONCLUSIONS Group visits proved more effective in promoting concordance with ADA st and ards of care than usual care in the treatment of uninsured or inadequately insured patients with type 2 diabetes OBJECTIVE To evaluate the impact of primary care group visits ( chronic care clinics ) on the process and outcome of care for diabetic patients . RESEARCH DESIGN AND METHODS We evaluated the intervention in primary care practice s r and omized to intervention and control groups in a large-staff model health maintenance organization ( HMO ) . Patients included diabetic patients > or = 30 years of age in each participating primary care practice , selected at r and om from an automated diabetes registry . Primary care practice s were r and omized within clinics to either a chronic care clinic ( intervention ) group or a  usual care ( control ) group . The intervention group conducted periodic one-half day chronic care clinics for groups of approximately 8 diabetic patients in their respective doctor 's practice .  Chronic care clinics consisted of st and ardized assessment s ; visits with the primary care physician , nurse , and clinical pharmacist ; and a group education/peer support meeting . We collected  self-report question  naires from patients and data from administrative systems . The question naires were mailed , and telephoned interviews were conducted for nonrespondents , at baseline and at 12 and 24 months ; we queried the process of care received , the satisfaction with care , and the health status of each patient . Serum cholesterol and HbA1c levels and health care use and cost data was collected from HMO administrative systems . RESULTS In an intention-to-treat analysis at 24 months , the intervention group had received significantly more recommended preventive procedures  and helpful patient education .  Of five primary health status indicators examined , two ( SF-36 general health and bed disability days ) were significantly better in the intervention group . Compared with control patients , intervention patients had slightly more primary care visits , but significantly fewer specialty and emergency room visits . Among intervention participants , we found consistently positive associations between the number of chronic care clinics attended and a number of outcomes , including patient satisfaction and HbA1c levels . CONCLUSIONS Periodic primary care sessions organized to meet the complex needs of diabetic patients imrproved the process of diabetes care and were associated with better outcomes BACKGROUND The potential of primary care practice setting s to prevent disease and morbidity through health habit counseling , screening for asymptomatic disease , and immunizations has been incompletely met . This study was design ed to test a practice -tailored approach to increasing preventive service delivery with particular emphasis on health habit counseling . DESIGN Group r and omized clinical trial and multi method process assessment . SETTING / PARTICIPANTS Seventy-seven community family practice s in northeast Ohio . INTERVENTION After a 1-day practice assessment , a nurse facilitator met with practice clinicians and staff and assisted them with choosing and implementing individualized tools and approaches aim ed at increasing preventive service delivery . MAIN OUTCOME MEASURE Summary scores of the health habit counseling , screening and immunization services recommended by the U.S. Preventive Services Task Force up to date for consecutive patients during r and omly selected chart review days . RESULTS A significant increase ( p=0.015 ) in global preventive service delivery rates at the 1-year follow-up was found in the intervention group ( 31 % to 42 % ) compared to the control group ( 35 % to 37 % ) . Rates specifically for health habit counseling ( p=0.007 ) and screening services ( p=0.048 ) were increased , but not for immunizations . CONCLUSIONS An approach to increasing preventive service delivery that is individualized to meet particular practice needs can increase global preventive service delivery rates An intervention was developed to increase patient involvement in care . Using a treatment algorithm as a guide , patients were helped to read their medical record and coached to ask questions and negotiate medical decisions with their physicians during a 20-minute session before their regularly scheduled visit . In a r and omized controlled trial we compared this intervention with a st and ard educational session of equal length in a clinic for patients with ulcer disease . Six to eight weeks after the trial , patients in the experimental group reported fewer limitations in physical and role-related activities ( p less than 0.05 ) , preferred a more active role in medical decision-making , and were as satisfied with their care as the control group . Analysis of audiotapes of physician-patient interactions showed that patients in the experimental group were twice as effective as control patients in obtaining information from physicians ( p less than 0.05 ) . Results of the intervention included increased involvement in the interaction with the physician , fewer limitations imposed by the disease on patients ' functional ability , and increased preference for active involvement in medical decision-making Background : In 1998 , the Health Re sources and Services Administration ’s Bureau of Primary Health Care began the Health Disparities Collaboratives ( HDC ) to improve chronic disease management in community health centers ( HCs ) nationwide . The HDC incorporates rapid quality improvement , a chronic care model , and best practice learning sessions . Objectives : To determine whether the HDC improves diabetes care in HCs over 4 years and whether more intensive interventions enhance care further . Subjects : Chart review of 2364 , 2417 , and 2212 r and omly selected patients with diabetes from 34 HCs in 17 states in 1998 , 2000 , and 2002 , respectively . Measures : American Diabetes Association st and ards . Research Design : We performed a r and omized controlled trial with an embedded prospect i ve longitudinal study . We r and omized 34 HCs that had undergone 1–2 years of the HDC . The st and ard-intensity arm continued the baseline HDC intervention . High-intensity arm centers received 4 additional learning sessions , provider training in behavioral change , and patient empowerment material s. To assess the impact of the HDC , we analyzed changes in clinical processes and outcomes in the st and ard-intensity centers . To determine the effect of more intensive interventions , we compared the st and ard- and high-intensity centers . Results : Between 1998 and 2002 , HCs undertaking the st and ard HDC improved 11 diabetes processes and lowered hemoglobin A1c [ −0.45 % ; 95 % confidence interval ( CI ) , −0.72 to −0.17 ] and low-density lipoprotein cholesterol ( −19.7 mg/dL ; 95 % CI , −25.8 to −13.6 ) . High-intensity intervention centers had greater use of angiotensin converting enzyme inhibitors [ adjusted odds ratio ( OR ) , 1.47 ; 95 % CI , 1.07–2.01 ] and aspirin ( OR , 2.20 ; 95 % CI , 1.28–3.76 ) , but lower use of dietary ( OR , 0.24 ; 95 % CI , 0.08–0.68 ) and exercise counseling ( OR , 0.34 ; 95 % CI , 0.15–0.75 ) . Conclusions : Diabetes care and outcomes improved in HCs during the first 4 years of the HDC quality improvement collaborative . More intensive interventions helped marginally To maximize disease control , patients must participate effectively in their medical care . The authors developed an intervention design ed to increase the involvement of  patients  in medical decision making . In a 20-minute session just before the regular visit to a physician , a clinic assistant review ed the medical record of each experimental patient with him/her , guided by a diabetes algorithm . Using systematic prompts , the assistant encouraged patients to use the information gained to negotiate medical decisions with the doctor . A r and omized trial was conducted in two university hospital clinics to compare this intervention with st and ard educational material s in sessions of equal length . The mean pre-intervention glycosylated hemoglobin ( HbA1 ) values were 10.6 + /- 2.1 % for 33 experimental patients and 10.3 + /- 2.0 % for 26 controls . After the intervention the mean levels were 9.1 + /- 1.9 % in the experimental group ( p less than 0.01 ) and 10.6 + /- 2.22 % for controls . Analysis of audiotapes of the visits to the physician showed the experimental patients were twice as effective as controls in eliciting information from the physician . Experimental patients reported significantly fewer function limitations . The authors conclude that the intervention is feasible and that it changes patient behavior , improves blood sugar control , and decreases functional limitations OBJECTIVE To study differences in diabetes-related parameters in type 2 diabetic patients treated with the support of a Diabetes Service compared to conventional general practice care . DESIGN Parallel clinical trial with r and omisation at practice level . SETTING Fifteen general practice s. PATIENTS Type 2 diabetic patients , aged < 76 years , treated by a GP . MAIN OUTCOME MEASURES Level of glycated haemoglobin ( HbA1c ) . RESULTS 246 patients entered the study .  Final mean HbA1c of all evaluable patients allocated to the intervention ( n = 84 ) was 7.1+/-1.2 % , vs 7.5+/-1.8 % in the controls ( n = 140 ) ( p = 0.06 ) . Patients who were initially poorly controlled ( Fasting Blood Glucose > 10 mmol/l ) had a significantly lower final HbA1c if they were in an intervention practice ( p=0.001 ) . Fewer patients in intervention practice s were referred to hospital specialists ( 1 vs 14 ) . CONCLUSIONS Support by the Dutch Diabetes Service did not significantly influence glycated haemoglobin . The subgroup of initially poorly controlled patients developed a significantly lower HbA1c in intervention practice s ( supported by a Diabetes Service ) than in control practice BACKGROUND The design of delivery systems that can truly conduct continuous quality improvement ( CQI ) as a routine part of clinical care provision remains a vexing problem . The effectiveness of the " computerized firm system " approach to chronic disease CQI was examined , with diabetes as the focus of a 5-year case study . METHODS A large family medical center had been divided into two parallel group practice s for reasons of efficiency . These frontline structures ( also known as primary care " firms " ) were supported to serially adapt and evaluate selected CQI interventions by first introducing process changes on one firm but not the other and comparing the groups . Because all the required longitudinal data were contained in a computerized repository , it was possible to conduct these controlled " firm trials " in a matter of months at low cost . RESULTS During a 3-year period , implementation of point-of-service reminders and a pharmacist out-reach program increased recommended glycohemoglobin ( HbA1c ) testing by 50 % ( p = 0.02 ) and reduced the number of diabetic patients inadequately controlled by 43 % ( p < 0.01 ) . Following this outcome improvement , patients exhibited a 16 % reduction in ambulatory visit rates ( p = 0.04 ) . The observed outcome improvement , however , was reversed during the subsequent 2 years , when staffing austerities forced by unrelated declines in clinic revenue caused the withdrawal of trial interventions . CONCL 
    Output:
    
The number of sustained activities was associated with the number of PF visits , but not with practice characteristics .
In spite of the PF intervention , it was difficult for these small practice s to implement comprehensive CCM changes .
Although practice s implemented and sustained a remarkable number and variety of key activities , the majority of these focused on patient self-management support , as opposed to other components of the CCM , such as clinical information systems , decision support , delivery system re design , and community linkages