***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: Abstract OBJECTIVE : There is a well-documented gap between diabetes care guidelines and the services received by patients in almost all health care setting s. This project reports initial results from a computer-assisted , patient-centered intervention to improve the level of recommended services received by patients from a wide variety of primary care providers . DESIGN AND SETTING S : Eight hundred eighty-six patients with type 2 diabetes under the care of 52 primary care physicians participated in the Diabetes Priority Program . Physicians were stratified and r and omized to intervention or control conditions and evaluated on 2 primary outcomes : number of recommended laboratory screenings and recommended patient-centered care activities completed . Secondary outcomes were evaluated using the Problem Areas in Diabetes scale and the Patient Health Question naire (PHQ)-9 depression scale , and the RE- AIM framework was used to evaluate potential for dissemination . RESULTS : The program was well-implemented and significantly improved both number of recommended laboratory assays ( 3.4 vs 3.1 ; P<.001 ) and patient-centered aspects of diabetes care patients received ( 3.6 vs 3.2 ; P<.001 ) compared to those in r and omized control practice s. Activities that were increased most were foot exams ( follow-up rates of 80 % vs 52 % ; P<.003 ) and nutrition counseling ( 76 % vs 52 % ; P<.001 ) . CONCLUSIONS : Patients are very willing to participate in a brief computer-assisted intervention that is effective in enhancing quality of diabetes care . Staff in primary care offices can consistently deliver an intervention of this nature , but most physicians were unwilling to participate in this translation research study Background Research and practice partnerships have the potential to enhance the translation of research findings into practice . Purpose This paper describes such a partnership in the development of Walk Kansas ( WK ) and highlights individual and organizational level outcomes . Method Phase 1 examined : ( a ) the reach of WK , ( b ) physical activity changes , and ( c ) maintenance of physical activity changes 6 months after the program was completed . Phase 2 explored WK adoption and sustainability over 5 years . Results WK attracted a large number of participants who were more likely to be female , more active , and older than the adult population within the counties where they resided . Inactive or insufficiently active participants at baseline experienced significant increases in both moderate ( p < 0.001 ) and vigorous ( p < 0.001 ) physical activity . A r and om selection of participants who were assessed 6 months post-program did not demonstrate a significant decrease in moderate or vigorous activity between program completion and 6-month follow-up . The number of counties adopting the program increased across years , peaking at 97 in 2006 and demonstrated the sustainability of the WK over 5 years . Conclusions WK is effective , has a broad reach , and enables participants to maintain increased activity . It also shows promise for broad adoption and sustainability PURPOSE The purpose of this study was to evaluate costs associated with the primary intervention of the Mediterranean Lifestyle Program ( MLP ) , which targeted postmenopausal women with type 2 diabetes at risk for coronary heart disease . METHODS Using retrospective data collected during MLP development and implementation , the authors estimated costs for the first 6 months relative to the usual care condition and incremental costs per behavioral , biologic , and quality -of-life change . Sensitivity analyses were conducted using variations in inflation rates , implementation setting s , labor and nonlabor inputs , and market wage rates . RESULTS Of the sample of 279 study participants , 163 were r and omized into the MLP condition .  Total intervention costs were estimated at $ 211 061 ( $ 148 022 direct costs ) or $ 1295 per MLP participant relative to usual care ( $ 908 direct costs ) . This translates to $ 3808 per average change in coronary heart disease risk as measured by an average 1-point reduction in hemoglobin A1C . Relative to other measured improvements , this corresponds to $ 2345 per unit reduction in body mass index and $ 644 per unit improvement in Problem Areas in Diabetes Quality -of-Life Self-care Summary score , and a $ 196 per-gram reduction in intake of saturated fatty acids as noted by the Food Frequency Question naire . A significant portion of the direct costs were related to the re sources used during the recruitment phase . CONCLUSIONS Providing a relatively intensive lifestyle self-management program for this high-risk group is associated with modest incremental costs compared with usual care , making the program potentially appealing to policy makers Purpose Large-scale effectiveness trials design ed to translate evidence -based diabetes care to community setting s are few . Studies describing these methods among high-risk minority population s are particularly limited . Methods The authors describe Project Sugar , a r and omized controlled trial conducted in 2 phases : Project Sugar 1 ( 1994 - 1999 ) , which piloted a 4-arm clinic and homebased intervention using nurse case management and community health workers in 186 urban African Americans with type 2 diabetes , and Project Sugar 2 ( 2000 - 2005 ) , which examined effectiveness of this intervention among 542 diabetic , urban African Americans . Results and Conclusions Project Sugar had success with regard to recruitment and retention , both in phase 1 ( 80 % rate at 24 months ) and phase 2 ( > 90 % at 24 months ) . Using the RE- AIM framework , planning and research design for Project Sugar 2 is described in detail for elements that contributed to the reach , effectiveness , adoption , implementation , and maintenance of this study within a minority community setting . In addition to successful strategies , challenges to conducting effectiveness trials in an inner-city African American community are identified Background Increased access to the Internet and the availability of efficacious eHealth interventions offer great promise for assisting adults with diabetes to change and maintain health behaviors . A key concern is whether levels of engagement in Internet programs are sufficient to promote and sustain behavior change . Objective This paper used automated data from an ongoing Internet-based diabetes self-management intervention study to calculate various indices of website engagement . The multimedia website involved goal setting , action planning , and self-monitoring as well as offering features such as “ Ask an Expert ” to enhance healthy eating , physical activity , and medication adherence . We also investigated participant characteristics associated with website engagement and the relationship between website use and 4-month behavioral and health outcomes . Methods We report on participants in a r and omized controlled trial ( RCT ) who were r and omized to receive ( 1 ) the  website alone ( n = 137 ) or ( 2 ) the website plus human support ( n = 133 ) that included additional phone calls and group meetings . The website was available in English and Spanish and included features to enhance engagement and user experience . A number of engagement variables were calculated for each participant including number of log-ins , number of website components visited at least twice , number of days entering self-monitoring data , number of visits to the “ Action Plan ” section , and time on the website . Key outcomes included exercise , healthy eating , and medication adherence as well as body mass index ( BMI ) and biological variables related to cardiovascular disease risk . Results Of the 270 intervention participants , the average age was 60 , the average BMI was 34.9 kg/m2 , 130 ( 48 % ) were female , and 62 ( 23 % ) self-reported Latino ethnicity . The number of participant visits to the website over 4 months ranged from 1 to 119 ( mean 28 visits , median 18 ) . Usage decreased from 70 % of participants visiting at least weekly during the first 6 weeks to 47 % during weeks 7 to 16 . There were no significant differences between website only and website plus support conditions on most of the engagement variables . In total , 75 % of participants entered self-monitoring data at least once per week . Exercise action plan pages were visited more often than medication taking and healthy eating pages ( mean of 4.3 visits vs 2.8 and 2.0 respectively , P < .001 ) . Spearman nonparametric correlations indicated few significant associations between patient characteristics and summary website engagement variables , and key factors such as ethnicity , baseline computer use , age , health literacy , and education were not related to use . Partial correlations indicated that engagement , especially in self-monitoring , was most consistently related to improvement in healthy eating ( r = .20 , P = .04 ) and reduction of dietary fat ( r = -.31 , P = .001 ) . There was also a significant correlation between self-monitoring and improvement in exercise ( r = .20 , P = .033 ) but not with medication taking . Conclusions Participants visited the website fairly often and used all of the theoretically important sections , but engagement decreased over 4 months . Usage rates and patterns were similar for a wide range of participants , which has encouraging implication s for the potential reach of online interventions . Trial Registration NCT00987285 ; http:// clinical trials.gov/show/NCT00987285 ( Archived by WebCite at http://www.webcitation.org/5vpe4RHTV Background Multiple-risk-factor interventions offer a promising means for addressing the complex interactions between lifestyle behaviors , psychosocial factors , and the social environment . This report examines the long-term effects of a multiple-risk-factor intervention . Methods Postmenopausal women ( N = 279 ) with type 2 diabetes participated in the  Mediterranean Lifestyle Program ( MLP ) , a r and omized , comprehensive lifestyle intervention study . The intervention targeted healthful eating , physical activity , stress management , smoking cessation , and social support . Outcomes included lifestyle behaviors ( i.e. , dietary intake , physical activity , stress management , smoking cessation ) , psychosocial variables ( e.g. , social support , problem solving , self-efficacy , depression , quality of life ) , and cost analyses at baseline , and 6 , 12 , and 24 months . Results MLP participants showed significant 12- and 24-month improvements in all targeted lifestyle behaviors with one exception ( there were too few smokers to analyze tobacco use effects ) , and in psychosocial measures of use of supportive re sources , problem solving , self-efficacy , and quality of life . Conclusion The MLP was more effective than usual care over 24 months in producing improvements on behavioral and psychosocial outcomes . Directions for future research include replication with other population OBJECTIVE Internet-based programs offer potential for practical , cost-effective chronic illness self-management programs . METHODS We report 12-month results of an Internet-based diabetes self-management program , with and without additional support , compared to enhanced usual care in a 3-arm practical r and omized trial . Patients ( n=463 ) were r and omized : 77.3 % completed 12-month follow-up . Primary outcomes were changes in health behaviors of healthy eating , physical activity , and medication taking . Secondary outcomes were hemoglobin A1c , body mass index , lipids , blood pressure , and psychosocial factors . RESULTS Internet conditions  improved health behaviors significantly vs. usual care over the 12-month period ( d for effect size=.09-.16 ) . All conditions improved moderately on biological and psychosocial outcomes .  Latinos , lower literacy , and higher cardiovascular disease risk patients improved as much as other participants . CONCLUSIONS The Internet intervention meets the reach and feasibility criteria for a potentially broad public health impact . However , 12-month magnitude of effects was small , suggesting that different or more intensive approaches are necessary to support long-term outcomes . Research is needed to underst and the linkages between intervention and maintenance processes and downstream outcomes . PRACTICE IMPLICATION S Automated self-management interventions should be tailored and integrated into primary care ; maintenance of patient self-management can be enhanced through links to community re sources Background A number of single case reports have suggested that the context within which intervention studies take place may challenge the assumptions that underpin r and omised controlled trials ( RCTs ) . However , the diverse ways in which context may challenge the central tenets of the RCT , and the degree to which this information is known to research ers or subsequently reported , has received much less attention . In this paper , we explore these issues by focusing on seven RCTs of interventions varying in type and degree of complexity , and across diverse context s. Methods This in-depth multiple case study using interviews , focus groups and documentary analysis was conducted in two phases . In phase one , a RCT of a nurse-led intervention  provided a single exploratory case and informed the design , sampling and data collection within the main study . Phase two consisted of a multiple explanatory case study covering a spectrum of trials of different types of complex intervention . A total of eighty-four data sources across the seven trials were accessed . Results We present consistent empirical evidence across all trials to indicate that four key elements of context ( personal , organisational , trial and problem context ) are crucial to underst and ing how a complex intervention works and to enable both assessment s of internal validity and likely generalisability to other setting s. The ways in which context challenged trial operation was often complex , idiosyncratic , and subtle ; often falling outside of current trial reporting formats . However , information on such issues appeared to be available via first h and ‘ insider accounts ’ of each trial suggesting that improved reporting on the role of context is possible . Conclusions Sufficient detail about context needs to be understood and reported in RCTs of complex interventions , in order for the transferability of complex interventions to be assessed . Improved reporting formats that require and encourage the clarification of both general and project-specific threats to the likely internal and external validity need to be developed . In addition , a cultural change is required in which the open and honest reporting of such issues is seen as an indicator of study strength and research er integrity , rather than a symbol of a poor quality study or investigator ability BACKGROUND Smoking is the leading preventable cause of premature death in the 
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Further , there are few interventions that aim to improve outcomes related to reach , adoption , implementation , and maintenance