***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 Chronic diseases represent a major challenge for health care and social services . A number of people with chronic diseases require more services due to characteristics that increase their vulnerability . Given the burden of increasingly vulnerable patients on primary care , a pragmatic intervention in four Family Medicine Groups ( primary care practice s in Quebec , Canada ) has been proposed for individuals with chronic diseases ( diabetes , cardiovascular diseases , respiratory diseases , musculoskeletal diseases and /or chronic pain ) who are frequent users of hospital services . The intervention combines case management by a nurse with group support meetings encouraging self-management based on the Stanford Chronic Disease Self-Management Program . The goals of this study are to : ( 1 ) analyze the implementation of the intervention in the participating practice s in order to determine how the various context s have influenced the implementation and the observed effects ; ( 2 ) evaluate the proximal ( self-efficacy , self-management , health habits , activation and psychological distress ) and intermediate ( empowerment , quality of life and health care use ) effects of the intervention on patients ; ( 3 ) conduct an economic analysis of the efficiency and cost-effectiveness of the intervention . Methods / Design The analysis of the implementation will be conducted using realistic evaluation and participatory approaches within four categories of stakeholders ( Family Medicine Group and health centre management , Family Medicine Group practitioners , patients and their families , health centre or community partners ) . The data will be obtained through individual and group interviews , project documentation review s and by documenting the intervention . Evaluation of the effects on patients will be based on a pragmatic r and omized before-after experimental design with a delayed intervention control group ( six months ) . Economic analysis will include cost-effectiveness and cost-benefit analysis . Discussion The integration of a case management intervention delivered by nurses and self-management group support into primary care practice s has the potential to positively impact patient empowerment and quality of life and hopefully reduce the burden on health care . Decision-makers , managers and health care professionals will be aware of the factors to consider in promoting the implementation of this intervention into other primary care practice s in the region and elsewhere . Trial Registration Background Care management programmes are an effective approach to care for high risk patients with complex care needs result ing from multiple co-occurring medical and non-medical conditions . These patients are likely to be hospitalized for a potentially " avoidable " cause . Nurse-led care management programmes for high risk elderly patients showed promising results . Care management programmes based on health care assistants ( HCAs ) targeting adult patients with a high risk of hospitalisation may be an innovative approach to deliver cost-efficient intensified care to patients most in need . Methods / Design PraCMan is a cluster r and omized controlled trial with primary care practice s as unit of r and omisation . The study evaluates a complex primary care practice -based care management of patients at high risk for future hospitalizations . Eligible patients either suffer from type 2 diabetes mellitus , chronic obstructive pulmonary disease , chronic heart failure or any combination . Patients with a high likelihood of hospitalization within the following 12 months ( based on insurance data ) will be included in the trial . During 12 months of intervention patients of the care management group receive comprehensive assessment of medical and non-medical needs and re sources as well as regular structured monitoring of symptoms . Assessment and monitoring will be performed by trained HCAs from the participating practice s. Additionally , patients will receive written information , symptom diaries , action plans and a medication plan to improve self-management capabilities . This intervention is addition to usual care . Patients from the  control group  receive usual care . Primary outcome is the number of all-cause hospitalizations at 12 months follow-up , assessed by insurance cl aims data . Secondary outcomes are health-related quality of life ( SF12 , EQ5D ) , quality of chronic illness care ( PACIC ) , health care utilisation and costs , medication adherence ( MARS ) , depression status and severity ( PHQ-9 ) , self-management capabilities and clinical parameters . Data collection will be performed at baseline , 12 and 24 months ( 12 months post-intervention ) . Discussion Practice -based care management for high risk individuals involving trained HCAs appears to be a promising approach to face the needs of an aging population with increasing care dem and s . Trial registration Current Controlled Trials IS RCT OBJECTIVE To examine to what extent general practitioners in consultations after a geriatric assessment set shared health priorities with older patients experiencing multimorbidity and to what extent this was facilitated through patient-centered behavior . METHODS Observation of consultations embedded in a cluster r and omized controlled trial,(1 ) in which 317 patients from 41 general practice s received the  STEP assessment followed by a care planning consultation with their GPs . GPs in the intervention group used a structured procedure for setting health ( care ) priorities in contrast to control GPs . A sample of 43 consultations ( 24 intervention ; 19 control ) were recorded , transcribed and analyzed with regard to priority setting and patient-centeredness . RESULTS Patient-centeredness was only moderately apparent in consultations dealing with complex care plans for older patients with multimorbidity . The shared determination of health priorities seemed unusual for both doctors and patients and was rarely practice d , albeit more frequently in intervention consultations . CONCLUSION Setting health care priorities with patients experiencing multimorbidity is ethically desirable and medically appropriate . Yet a short structured guide for doctors can not easily achieve this . PRACTICE IMPLICATION S More research is needed in regard to h and ling complex health needs of older patients . It requires a professional approach and training in patient-centered holistic care planning Background Care management interventions in the German health-care system have been evaluated with promising results , but further research is necessary to explore their full potential in the context of multi-morbidity . Our aim in this trial is to assess the efficacy of a primary care practice network – based care management intervention in improving self-care behaviour among patients with type 2 diabetes mellitus and multiple co-occurring chronic conditions . Methods / Design The study is design ed as a prospect i ve , 18-month , multicentre , investigator-blinded , two-arm , open-label , individual-level , r and omized parallel-group superiority trial . We will enrol 582 patients with type 2 diabetes mellitus and at least two severe chronic conditions and one informal caregiver per patient . Data will be collected at baseline ( T0 ) , at the primary endpoint after 9 months ( T1 ) and at follow-up after 18 months ( T2 ) . The primary outcome will be the differences between the  intervention and control groups  in changes of diabetes-related self-care behaviours from baseline to T1 using a German version of the revised Summary of Diabetes Self-Care Activities ( SDSCA-G ) . The secondary outcomes will be the differences between the intervention and control groups in : changes in scores on the SDSCA-G subscales , glycosylated haemoglobin A level , health-related quality of life , self-efficacy , differences in ( severe ) symptomatic hypoglycaemia , cost-effectiveness and financial family burden . The intervention will be delivered by trained health-care assistants as an add-on to usual care and will consist of three main elements : ( 1 ) three home visits , including structured assessment of medical and social needs ; ( 2 ) 24 structured telephone monitoring contacts ; and ( 3 ) self-monitoring of blood glucose levels after T1 in 3-month intervals . The control group will receive usual care . The confirmatory primary analysis will be performed following the intention-to-treat ( ITT ) principle . The efficacy of the intervention will be quantified using two-level linear regression stratified by type of medical treatment adjusted for baseline values on the SDSCA-G. Secondary analyses will be performed according to the ITT principle . In health economic evaluations , we will estimate the incremental cost-effectiveness ratios . Discussion We hope that the results of this study will provide insights into the efficacy of practice network – based care management among patients with complex health-care needs . Trial registration Current Controlled Trials IS RCT N83908315 ( IS RCT N assigned 25 February 2014 ) Background Frail elderly people need an integrated and coordinated care . The two-armed study " Continuum of care for frail elderly people " is a multi-professional and multidimensional intervention for frail community-dwelling elderly people . It was design ed to evaluate whether the intervention programme for frail elderly people  can reduce the number of visits to hospital , increase satisfaction with health and social care and maintain functional abilities . The implementation process is explored and analysed along with the intervention . In this paper we present the study design , the intervention and the outcome measures as well as the baseline characteristics of the study participants . Methods / design The study is a r and omised two-armed controlled trial with follow ups at 3 , 6 and 12 months . The study group includes elderly people who sought care at the emergency ward and discharged to their own homes in the community . Inclusion criteria were 80 years and older or 65 to 79 years with at least one chronic disease and dependent in at least one activity of daily living . Exclusion criteria were acute severely illness with an immediate need of the assessment and treatment by a physician , severe cognitive impairment and palliative care . The intention was that the study group should comprise a representative sample of frail elderly people at a high risk of future health care consumption . The intervention includes an early geriatric assessment , early family support , a case manager in the community with a multi-professional team and the involvement of the elderly people and their relatives in the planning process . Discussion The design of the study , the r and omisation procedure and the protocol meetings were intended to ensure the quality of the study . The implementation of the intervention programme is followed and analysed throughout the whole study , which enables us to generate knowledge on the process of implementing complex interventions . The intervention contributes to early recognition of both the elderly peoples ' needs of information , care and rehabilitation and of informal caregivers ' need of support and information . This study is expected to show positive effects on frail elderly peoples ' health care consumption , functional abilities and satisfaction with health and social care . Trial registration Clinical Trials.gov : OBJECTIVE Sub clinical depression is one of the most frequent mental comorbidities in patients with diabetes and is associated with a poorer long-term prognosis . Since there is a lack of specific intervention concepts for this patient group , a self-management – oriented group program ( DIAMOS [ Diabetes Motivation Strengthening ] ) was newly developed and evaluated in a r and omized trial . RESEARCH DESIGN AND METHODS DIAMOS is composed of cognitive behavioral interventions aim ing at the reduction of  diabetes distress . The active control group ( CG ) received diabetes education . The primary outcome was depressive symptoms . Secondary outcomes were diabetes distress , well-being , self-care behavior , diabetes acceptance , diabetes treatment satisfaction , HbA1c , and sub clinical inflammation . RESULTS Two hundred fourteen participants ( mean age 43.3 ± 13.3 years , female sex 56.5 % , type 2 diabetes 34.1 % , mean diabetes duration 14.2 ± 10.5 years , HbA1c 8.9 ± 1.8 % , BMI 28.7 ± 71 kg/m2 ) were r and omized . The 12-month follow-up revealed a significantly stronger reduction of depressive symptoms ( Center for Epidemiologic Studies Depression Scale score ) in the DIAMOS group compared with the CG ( Δ3.9 [ 95 % CI 0.6–7.3 ] , P = 0.021 ) . Of the secondary variables , the Patient Health Question naire-9 ( Δ1.7 [ 95 % CI 0.2–3.2 ] , P = 0.023 ) , Problem Areas in Diabetes scale ( Δ8.2 [ 95 % CI 3.1–13.3 ] , P = 0.002 ) , and Diabetes Distress Scale scores ( Δ0.3 [ 95 % CI 0.1–0.5 ] , P = 0.012 ) displayed significant treatment effects . Moreover , the risk of incident major depression in the DIAMOS group was significantly reduced ( odds ratio 0.63 [ 95 % CI 0.42–0.96 ] , P = 0.028 ) . Inflammatory variables were not substantially affected . CONCLUSIONS DIAMOS is more effective in lowering depressive symptoms and diabetes-related distress in diabetic patients with sub clinical depression . DIAMOS also has a preventive effect with respect to the incidence of major depression BACKGROUND In the Medicare Modernization Act of 2003 , Congress required the Centers for Medicare and Medicaid Services to test the commercial disease-management model in the Medicare fee-for-service program . METHODS The Medicare Health Support Pilot Program was a large , r and omized study of eight commercial programs for disease management that used nurse-based call centers . We r and omly assigned patients with heart failure , diabetes , or both to the intervention or to usual care ( control )  and compared them with the use of a difference-in-differences method to evaluate the effects of the commercial programs on the quality of clinical care , acute care utilization , and Medicare expenditures for Medicare fee-for-service beneficiaries . RESULTS The study included 242,417 patients ( 163,107 in the intervention group and 79,310 in the control group ) . The eight commercial disease-management programs did not reduce hospital admissions or emergency room visits , as compared with usual care . We observed only 14 significant improvements in process-of-care measures out of 40 comparisons . These modest improvements came at substantial cost to the Medicare program in fees paid to the disease-management companies ( $ 400 million ) , with no demonstrable savings in Medicare expenditures . CONCLUSIONS In this large study , commercial disease-management programs using nurse-based call centers achieved only modest improvements in quality -of-care measures , with 
    Output:
    
There was little or no difference in clinical outcomes ( based on moderate certainty evidence ) .
It is possible that the findings may change with the inclusion of large ongoing well-organised trials in future up date s. The results suggest an improvement in health outcomes if interventions can be targeted at risk factors such as depression , or specific functional difficulties in people with multimorbidity