***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 and Purpose — High rates of ischemic stroke and poor adherence to secondary prevention measures are observed in the Chinese population . Methods — We used a national , multicenter , cluster-r and omized controlled trial in which 47 hospitals were r and omized to either a  structured care program group ( n=23 ) or a usual care group ( n=24 ) . The structured care program consisted of a specialist-administered , guideline -recommended pharmaceutical treatment and a lifestyle modification algorithm associated with written and Internet-accessed educational material for patients for the secondary prevention of ischemic stroke . The primary efficacy outcome was the proportion of patients who adhered to the recommended measures at 12-month postdischarge . This trial is registered with Clinical Trial.gov ( NCT00664846 ) . Results — At 12 months , 1287 ( 72.1 % ) patients in the St and ard Medical Management in Secondary Prevention of Ischemic Stroke in China ( SMART ) group and 1430 ( 72 % ) patients in the usual care group had completed the 12-month follow-up ( P=0.342 ) . Compared with the usual care group , those in the SMART group showed higher adherence to statins ( 56 % versus 33 % ; P=0.006 ) but no difference in adherence to antiplatelet ( 81 % versus 75 % ; P=0.088 ) , antihypertensive ( 67 % versus 69 % ; P=0.661 ) , or diabetes mellitus drugs ( 73 % versus 67 % ; P=0.297 ) . No significant difference in the composite end point ( new-onset ischemic stroke , hemorrhagic stroke , acute coronary syndrome , and all-cause death ) was observed ( 3.56 % versus 3.59 % ; P=0.921 ) . Conclusions — The implementation of a program to improve adherence to secondary ischemic stroke prevention efforts in China is feasible , but these programs had only a limited impact on adherence and no impact on 1-year outcomes . Further development of a structured program to reduce vascular events after stroke is needed . Clinical Trial Registration — URL : http://www . clinical trials.gov . Unique identifier : NCT00664846 Background Managing oral anticoagulant treatment ( OAT ) is a challenge for patients and primary care providers . It requires a high level of patient knowledge and adherence . Studies have shown that insufficient adherence and a low level of patient knowledge about OAT are primary causes for complications . This trial is the first to evaluate the long-term effects of a complex practice nurse-based patient education program in comparison to a patient brochure only . Methods and design This trial will be a cluster-r and omized controlled trial in 22 general practice s ( GPs ) recruiting 360 patients with OAT . GPs will be r and omized into an intervention group or a control group . A baseline question naire will assess pre-existing knowledge about OAT . The patients in the intervention group will be educated by a complex education program which consists of a video , a brochure and individual training by a practice nurse . The video gives information about OAT , nutrition , and instructions about how to manage critical situations . The brochure repeats the content of the video . After 4 to 6 weeks , the intervention will be recapitulated . The control group will receive the brochure only . After 6 months , question naires will be used in both groups to assess patient knowledge about OAT as well as patients ' subjective feelings of safety . Separately , we will evaluate patient records , looking for documented complications and the time spent in the therapeutic range . Discussion This trial will start in January 2011 . This trial will evaluate the long-term effectiveness of a video-assisted education program on patients with OAT  in comparison to a patient information brochure . Most previous studies have evaluated knowledge directly after an educational intervention . Our trial will look for long-term differences in basic knowledge of OAT . We expect that our complex patient education program effectively increases long-term basic knowledge about OAT . Although the population of our study is too small to observe differences in adverse effects , we expect to discover differences in secondary outcomes , such as the time spent in the therapeutic range . Trial registration Deutsches Register Klinischer Studien ( German Clinical Trials Register ) : DRKS00000586Universal Trial Number ( UTN U1111 - 1118 - 3464 Background — Oral anticoagulation ( OAC ) therapy is effective in atrial fibrillation but requires vigilance to maintain the international normalized ratio in the therapeutic range . This report examines how differences in time in therapeutic range ( TTR ) between centers and between countries affect the outcomes of OAC therapy . Methods and Results — In a posthoc analysis , the TTRs of patients on OAC in a r and omized trial of OAC versus clopidogrel plus aspirin  ( Atrial Fibrillation Clopidogrel Trial With Irbesartan for Prevention of Vascular Events [ ACTIVE W ] ) were used to calculate the mean TTR  for each of 526 centers and 15 countries . Proportional-hazards analysis , with and without adjustment for baseline variables , was performed , with patients stratified by TTR quartile and country . A wide variation in TTRs was found between centers , with mean TTRs for centers in the 4 quartiles of 44 % , 60 % , 69 % , and 78 % . For patients at centers below the median TTR ( 65 % ) , no treatment benefit was demonstrated as measured by relative risk for vascular events of clopidogrel plus aspirin versus OAC ( relative risk , 0.93 ; 95 % confidence interval , 0.70 to 1.24 ; P=0.61 ) . However , for patients at centers with a TTR above the study median , OAC had a marked benefit , reducing vascular events by > 2-fold ( relative risk , 2.14 ; 95 % confidence interval , 1.61 to 2.85 ; P<0.0001 ) . Mean TTR also varied between countries from 46 % to 78 % ; relative risk ( clopidogrel plus aspirin versus OAC ) varied from 0.6 to 3.6 ( a 5-fold difference ) . A population -average model predicted that a TTR of 58 % would be needed to be confident that patients would benefit from being on OAC . Conclusions — A wide variation exists in international normalized ratio control , as measured by TTR , between clinical centers and between countries , which has a major impact on the treatment benefit of OAC therapy . For centers and countries , a target threshold TTR exists ( estimated between 58 % and 65 % ) below which there appears to be little benefit of OAC over antiplatelet therapy Background Comparison of self-management of oral anticoagulant therapy versus conventional management has been hindered by use of different methods . We tested the hypothesis that there is no difference in the International Normalized Ratio ( INR ) variability , INR level , and coumarin dose among patients r and omized to conventional management versus self-management .  Methods The study design included uniform analysis of blinded control blood sample s in both treatment arms . Ninety-two patients were r and omly assigned to either self-management of oral anticoagulant therapy ( including a teaching program for self-management followed by 6 months of independent self-management ) or 6 months of conventional management . The endpoints were the variance ( median square of the st and ard deviation ) of the INR value , the median INR-value ( using a blinded control sample analyzed monthly by a reference laboratory ) , and the coumarin dose . Results Self-management was associated with a statistically significant smaller variance in INR values , a higher median INR value , and a higher dose of warfarin compared with conventional management . No difference was found in the group of patients using phenprocoumon . Conclusion Training and implementation of patient self-management leads to a smaller variance in INR values , a higher median INR value and a higher dose of coumarin compared with results obtained for conventionally managed patients BACKGROUND There is increased pressure on primary care physicians to monitor oral anticoagulation . OBJECTIVE To test the null hypothesis that oral anticoagulation care can be provided at least as well in primary care through a nurse-led clinic , involving near-patient testing and computerized decision support software , compared with routine hospital management based on a variety of clinical outcome measures . METHODS A r and omized , controlled trial in 12 primary care practice s in Birmingham , Engl and ( 9 intervention and 3 control ) . Two control population s were used :  patients individually r and omly allocated as controls in the intervention practice s ( intra practice controls ) and all patients in control practice s ( inter practice controls ) . Intervention practice s ' patients were r and omized to the intervention ( practice -based anticoagulation clinic ) or control ( hospital clinic ) group . The main outcome measure was therapeutic control of the international normalized ratio . RESULTS Three hundred sixty-seven patients were recruited ( 122 intervention patients , 102 intra practice control patients , and 143 inter practice control patients ) . St and ard measures of control of the international normalized ratio ( point prevalence ) showed no significant difference between the intervention and control groups . Data on proportion of time spent in the international normalized ratio range showed significant improvement for patients in the intervention group ( paired t test , P = .008 ) . CONCLUSIONS Nurse-led anticoagulation clinics can be implemented in novice primary care setting s by means of computerized decision support software and near-patient testing . Care given by this model is at least as good as routine hospital follow-up . The model is generalizable to primary health care centers operating in developed health care systems Self-management is safe and reliable in patients with long-term oral anticoagulation ( OAC ) . However , no study has yet assessed the safety and efficacy of OAC self-management in elderly patients with major thromboembolic and haemorrhagic complications as primary outcomes . In this multi-centre , open , r and omised controlled trial , patients aged 60 years or more were r and omised into the self-management group ( SMG ) ( N = 99 ) or routine care group ( RCG ) ( N = 96 ) . We describe the rationale , design , baseline characteristics and interim analyses of oral anticoagulation control quality within the first year of follow-up . The medians of the squared international normalised ratio ( INR ) value deviations after six and 12 months were significantly lower in the SMG with medians of 0.16 and 0.16 compared to the RCG with medians of 0.25 and 0.25 . The percentage of time within target range and the percentage of INR measurements within target range were significantly higher in the SMG versus the RCG within the first six months ( medians 71 % vs. 58 % and 69 % vs. 57 % ) , and during the second six months of the study ( 75 % vs. 67 % and 72 % vs. 57 % ) . The numbers of all thromboembolic events requiring hospitalisation , major bleeding events , and deaths were similar in both groups . These preliminary results suggest that  self-management of oral anticoagulation is safe and feasible for elderly patients willing to participate in a structured training programme CONTEXT Control of oral anticoagulation therapy has been reported to often be inadequate . Previous retrospective investigations suggest that patients ' self-adjustment of oral anticoagulants may lead to improved control . OBJECTIVE To investigate the effects of patients ' self-management of oral anticoagulation therapy on accuracy of control and measures of treatment-related quality of life . DESIGN R and omized , single-blind , multicenter trial . SETTING AND PARTICIPANTS A total of 179 patients receiving long-term oral anticoagulation treatment were enrolled at 5 referral centers in Germany . INTERVENTION Patients were r and omized to an oral anticoagulation self-management group based on a structured treatment and teaching program and international normalized ratio ( INR ) self-monitoring . The control group received conventional care as provided by family physicians , including referral to specialists if necessary . MAIN OUTCOME MEASURES Deviation of INR values from the individual INR target range ( squared ) and the 5 categories of treatment-related quality of life . RESULTS Deviation of INR value from the mean of the INR target range was significantly lower in the intervention group at 3-month ( squared INR deviation , 0.59 vs 0.95 ; P<.001 ) and 6-month follow-up ( 0.65 vs 0.83 ; P=.03 ) compared with the control group . Also , the intervention group had INR values within the target range more often ( repeated measurement analysis for categorical data , P=.006 ) . The results were mainly due to less frequent suboptimal INR values in the intervention group ( 32.8 % vs 50.0 % [ P=.03 ] at 3-month , and 33.7 % vs 48.2 % [ P=.08 ] at 6-month follow-up ) . Treatment-related quality -of-life measures , especially treatment satisfaction scores , were significantly higher in the intervention group compared with controls . CONCLUSIONS An anticoagulation education program that includes self-management of anticoagulation therapy results in improved accuracy of anticoagulation control and in treatment-related quality -of-life measures . Further studies are needed to describe whether the program will reduce risk of bleeding or thromboembolism AIMS The management of patients with atrial fibrillation ( AF ) is often inadequate due to deficient adherence to the guidelines . A nurse-led AF clinic providing integrated chronic care to improve guideline adherence and activate patients in their role , may effectively reduce morbidity and mortality but such care has not been tested in a large r and omized trial . Therefore , we performed a r and omized clinical trial to compare the AF clinic with routine clinical care in patients with AF . METHODS AND RESULTS We r and omly assigned 712 patients with AF to nurse 
    Output:
    
This review demonstrates that there is insufficient evidence to draw definitive conclusions regarding the impact of educational or behavioural interventions on TTR in AF patients receiving OAT .
It is also important to explore the psychological implication s for patients suffering from this long-term chronic condition