***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: In the GRADE approach , r and omized trials start as high- quality evidence and observational studies as low- quality evidence , but both can be rated down if most of the relevant evidence comes from studies that suffer from a high risk of bias . Well-established limitations of r and omized trials include failure to conceal allocation , failure to blind , loss to follow-up , and failure to appropriately consider the intention-to-treat principle . More recently recognized limitations include stopping early for apparent benefit and selective reporting of outcomes according to the results . Key limitations of observational studies include use of inappropriate controls and failure to adequately adjust for prognostic imbalance . Risk of bias may vary across outcomes ( e.g. , loss to follow-up may be far less for all-cause mortality than for quality of life ) , a consideration that many systematic review s ignore . In deciding whether to rate down for risk of bias -- whether for r and omized trials or observational studies -- authors should not take an approach that averages across studies . Rather , for any individual outcome , when there are some studies with a high risk , and some with a low risk of bias , they should consider including only the studies with a lower risk of bias BACKGROUND Use of the emergency department for nonemergency care is frequent and costly . We studied the effect of a copayment on emergency department use in a group-model health maintenance organization ( HMO ) . METHODS We examined the use of the emergency department in 1992 and 1993 by 30,276 subjects who ranged in age from 1 to 63 years at the start of the study and belonged to the Kaiser Permanente HMO in northern California . We assessed their use of various HMO services and their clinical outcomes before and after the introduction of a copayment of $ 25 to $ 35 for using the emergency department . This copayment group was compared with two r and omly selected control groups not affected by the copayment . One control group , with 60,408 members , was matched for age , sex , and area of residence to the copayment group .  The second , with 37,539 members , was matched for these factors and also for the type of employer . RESULTS After adjustment for age , sex , socioeconomic status , and use of the emergency department in 1992 , the decline in the number of visits in 1993 was 14.6 percentage points greater in the copayment group than in either control group ( P<0.001 for each comparison ) . Visits for urgent care did not increase among subjects in any stratum defined by age and sex , and neither did the number of outpatient visits by adults and children . The decline in emergency visits for presenting conditions classified as " always an emergency " was small and not significant . For conditions classified as " often an emergency " . " sometimes not an emergency " , or " often not an emergency " , the declines in the use of the emergency department were larger and statistically significant , and they increased with decreasing severity of the presenting condition . Although our ability to detect any adverse effects of the copayment was limited , there was no suggestion of excess adverse events in the copayment group , such as increases in mortality or in the number of potentially avoidable hospitalizations . CONCLUSIONS Among members of an HMO , the introduction of a small copayment for the use of the emergency department was associated with a decline of about 15 percent in the use of that department , mostly among patients with conditions considered likely not to present an emergency Cl aims -based utilization data collected in four Medicaid demonstration programs are used to examine the impact of primary care case management on patterns of reliance on the emergency room as a source of services . The experience of stratified r and om sample s of AFDC ( Aid to Families with Dependent Children ) adults and children in the demonstration programs is compared with that of equivalent sample s from comparison  groups in traditional Medicaid programs .  Data were analyzed in multivariate models controlling for person characteristics in a pre/post , demonstration/comparison design . Results indicated large reductions in the proportion of persons with at least one emergency room visit ranging from 27 to 37 per cent for children and 30 to 45 per cent for adults . Use levels for persons with at least one ER visit are less substantially affected . The findings suggest that gatekeeping design s can alter patterns of enrollee use with respect to the emergency room and some discussion of these implication s is presented OBJECTIVE : To evaluate the effect of primary care coordination on utilization rates and satisfaction with care among public hospital patients . DESIGN : Prospect i ve r and omized gatekeeper intervention , with 1-year follow-up . SETTING : The Adult General Medical Clinic at San Francisco General Hospital , a university-affiliated public hospital . PATIENTS : We studied 2,293 established patients of 28 primary care physicians . INTERVENTION : Patients were r and omized based on their primary care physician ’s main clinic day . The 1,121 patients in the intervention group ( Ambulatory Patient-Physician Relationship Organized to Achieve Coordinated Healthcare [ APPROACH ] group ) required primary care physician approval to receive specialty and emergency department ( ED ) services ; 1,172 patients in the control group did not .  MEASUREMENTS AND MAIN RESULTS : Changes in outpatient , ED , and inpatient utilization were measured for APPROACH and control groups over the 1-year observation period , and the differences in the changes between groups were calculated to estimate the effect of the intervention . Acceptability of the gatekeeping model was determined via patient satisfaction surveys . RESULTS : Over the 1-year observation period , APPROACH patients decreased their specialty use by 0.57 visits per year more than control patients did ( P=.04 ; 95 % confidence interval [ CI ] −1.05 to −0.01 ) . While APPROACH patients increased their primary care use by 0.27 visits per year more than control patients , this difference was not statistically significant ( P=.14 ; 95 % CI , −0.11 to 0.66 ) . Changes in lowacuity ED care were similar between the two groups ( 0.06 visits per year more in APPROACH group than control group , P=.42 ; 95 % CI , −0.09 to 0.22 ) . APPROACH patients decreased yearly hospitalizations by 0.14 visits per year more than control patients ( P=.02 ; 95 % CI , −0.26 to −0.03 ) . Changes in patient satisfaction with care , perceived access to specialists , and use of out-of-network services between the 2 groups were similar . CONCLUSIONS : A primary care model of health delivery in a public hospital that utilized a gatekeeping strategy decreased outpatient specialty and hospitalization rates and was acceptable to patients Background Out-of-hours care in the primary care setting is rapidly changing and evolving towards general practitioner ' cooperatives ' ( GPC ) . GPCs already exist in the Netherl and s , the United Kingdom and Sc and inavia , all countries with strong general practice , including gatekeepers ' role . This intervention study reports the use and caseload of out-of-hours care before and after implementation of a  GPC in a well subscribed region in a country with an open access health care system and no gatekeepers ' role for general practice . Methods We used a prospect i ve before/after interventional study design . The intervention was the implementation of a GPC . Results One year after the implementation of a GPC , the number of patient contacts in the intervention region significantly increased at the GPC ( OR : 1.645 ; 95 % CI : 1.439 - 1.880 ) , while there were no significant changes in patient contacts at the Emergency Department ( ED ) or in other regions where a simultaneous registration was performed . Although home visits decreased in all general practitioner registration s , the difference was more pronounced in the intervention region ( intervention region : OR : 0.515 ; 95 % CI : 0.411 - 0.646 , other regions : OR : 0.743 ; 95 % CI : 0.608 - 0.908 ) . At the ED we observed a decrease in the number of trauma cases ( OR : 0.789 ; 95 % CI : 0.648 - 0.960 ) and of patients who came to hospital by ambulance ( OR : 0.687 ; 95 % CI : 0.565 - 0.836 ) . Conclusions One year after its implementation more people seek help at the GPC , while the number of contacts at the ED remains the same . The most prominent changes in caseload are found in the trauma cases . Establishing a GPC in an open health care system , might redirect some patients with particular medical problems to primary care . This could lead to a lowering of costs or a more cost-effective out of hours care , but further research should focus on effective usage to divert patient flows and on quality and outcome of care OBJECTIVE To evaluate the effect of emergency department ( ED ) copayment levels on ED use and unfavorable clinical events . Data Source / Study Setting . Kaiser Permanente-Northern California ( KPNC ) , a prepaid integrated delivery system . STUDY DESIGN In a quasi-experimental longitudinal study with concurrent controls , we estimated rates of ED visits , hospitalizations , ICU admissions , and deaths associated with higher ED copayments relative to no copayment , using Poisson r and om effects and proportional hazard models , controlling for patient characteristics . The study period began in January 1999 ; more than half of the population experienced an employer-chosen increase in their  ED copayment in January 2000 . DATA COLLECTION / EXTRACTION METHODS Using KPNC automated data bases , the 2000 U.S. Census , and California state death certificates , we collected data on ED visits and unfavorable clinical events over a 36-month period ( January 1999 through December 2001 ) among 2,257,445 commercially insured and 261,091 Medicare insured health system members . PRINCIPAL FINDINGS Among commercially insured subjects , ED visits decreased 12 percent with the $ 20 - 35 copayment ( 95 percent confidence interval [ CI ] : 11 - 13 percent ) , and 23 percent with the $ 50 - 100 copayment ( 95 percent CI : 23 - 24 percent ) compared with no copayment . Hospitalizations , ICU admissions , and deaths did not increase with copayments . Hospitalizations decreased 4 percent ( 95 percent CI : 2 - 6 percent ) and 10 percent ( 95 percent CI : 7 - 13 percent ) with ED copayments of $ 20 - 35 and $ 50 - 100 , respectively , compared with no copayment . Among Medicare subjects , ED visits decreased by 4 percent ( 95 percent CI : 3 - 6 percent ) with the $ 20 - 50 copayments compared with no copayment ; unfavorable clinical events did not increase with copayments , e.g. , hospitalizations were unchanged ( 95 percent CI : -3 percent to + 2 percent ) with $ 20 - 50 ED copayments compared with no copayment . CONCLUSIONS Relatively modest levels of patient cost-sharing for ED care decreased ED visit rates without increasing the rate of unfavorable clinical events Home health nurses provided individualized instruction in diabetes self-care within the home environment of 393 diabetic individuals . Each subject was r and omly assigned to either the intervention ( those receiving home teaching ) or control ( those not receiving home teaching ) group . At 6 mo postenrollment , intervention subjects showed significantly greater self-care knowledge and skills than control subjects , although the actual differences between the two groups in terms of self-care skills were probably too small to have any practical meaning . The primary objective of the study , which was the reduction of the number of preventable diabetes-related hospitalizations ( ketoacidosis , ketotic coma , nonketotic coma , insulin reaction , and diabetes out of control ) , was not achieved ; no differences between the groups were noted after 12 mo of follow-up . Similarly , length of hospital stay , foot problems , emergency room and physician visits , and sick days were roughly equivalent in both groups during the follow-up year . These results suggest that , in the absence of concurrent changes in the health-care delivery system and strategies for influencing attitudes toward self-care , education alone is ineffective Objective : To evaluate triage and transportation  to a minor injury unit ( MIU ) by emergency ambulance crews . Methods : Ambulance crews in two services were asked to transport appropriate patients to MIU during r and omly selected weeks of one year . During all other weeks they were to treat such patients according to normal practice . Patients were followed up through ambulance service , hospital and /or MIU records , and by postal question naire . Semi-structured interviews were undertaken with crews ( n = 15 ) . Cases transferred from MIU to accident and emergency ( A&E ) were review ed . Results : 41 intervention cluster patients attended MIU , 303 attended A&E , 65 were not conveyed . Thirty seven control cluster patients attended MIU  , 327 attended A&E , 61 stayed at scene . Because of low study design compliance , outcomes of patients taken to MIU were compared with those taken to A&E , adjusted for case mix . MIU patients were 7.2 times as likely to rate their care as excellent ( 95 % CI 1.99 to 25.8 ) . Ambulance service job-cycle time and time in unit were shorter for MIU patients ( −7.8 , 95 % CI −11.5 to −4.1 ) ; ( −222.7 , 95%CI −331.9 to −123.5 ) . Crews cited patient and operational factors as inhibiting MIU use ; and location , service , patient choice , job-cycle time , and h and over as encouraging their use . Of seven patients transferred by ambulance from MIU to A&E , medical review ers judged that three had not met the protocol for conveyance to MIU . No patients were judged to have suffered adverse consequences 
    Output:
    
The interventions with the greatest number of studies showing reductions in ED use include patient financial incentives and managed care , while the greatest magnitude of reductions were found in patient education .