***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 Panic disorder is a prevalent , often disabling condition among patients in the primary care setting . Although numerous studies have assessed the effectiveness of treatments for depression in primary care , few such studies have been conducted for panic disorder . OBJECTIVE To implement and test the effectiveness of a combined pharmacotherapy and cognitive-behavioral intervention for panic disorder tailored to the primary care setting . DESIGN R and omized , controlled study comparing intervention to treatment as usual . SETTING Six primary care clinics associated with 3 university medical schools , serving an ethnically and socioeconomically diverse patient population . PARTICIPANTS Two hundred thirty-two primary care patients meeting DSM-IV criteria for panic disorder . Comorbid mental and physical disorders were permitted , provided these did not contraindicate the treatment to be provided and were not acutely life threatening . INTERVENTION Patients were r and omized to receive either treatment as usual or an intervention consisting of a combination of up to 6 sessions ( across 12 weeks ) of cognitive-behavioral therapy ( CBT ) modified for the primary care setting , with up to 6 follow-up telephone contacts during the next 9 months , and algorithm-based pharmacotherapy provided by the primary care physician with guidance from a psychiatrist . Behavioral health specialists , the majority inexperienced in CBT for panic disorder , were trained to deliver the CBT and coordinated overall care , including pharmacotherapy . MAIN OUTCOMES MEASURES Proportion of subjects remitted ( no panic attacks in the past month , minimal anticipatory anxiety , and agoraphobia subscale score < 10 on Fear Question naire ) and responding ( Anxiety Sensitivity Index score < 20 ) and change over time in World Health Organization Disability Scale and short form 12 scores . RESULTS The combined cognitive-behavioral and pharmacotherapeutic intervention result ed in sustained and gradually increasing improvement relative to treatment as usual , with significantly higher rates at all points of both the proportion of subjects remitted ( 3 months , 20 % vs 12 % ; 12 months , 29 % vs 16 % ) and responding ( 3 months , 46 % vs 27 % ; 12 months , 63 % vs 38 % ) and significantly greater improvements in World Health Organization Disability Scale ( all points ) and short form 12 mental health functioning ( 3 and 6 months ) scores . These effects were obtained in spite of similar rates of delivery of guideline -concordant pharmacotherapy to the 2 groups . CONCLUSION Delivery of evidence -based CBT and medication using the collaborative care model and a CBT-naive , midlevel behavioral health specialist is feasible and significantly more effective than usual care for primary care panic disorder Objective The process of weaning from mechanical ventilation can be complex , requiring collaborative care planning by members of the healthcare team . Improved outcomes have been demonstrated to result from collaborative decision-making processes ( e.g. , when ventilator teams were utilized ) . The purpose of this study was to evaluate the effect of a collaborative weaning plan ( CWP ) on length of time on mechanical ventilation , length of stay in the intensive care unit ( ICU ) , and cost . Design A new , collaborative weaning plan in the form of a weaning board and flowsheet was introduced into a medical intensive care unit ( MICU ) setting . A pre- and post-quasi-experimental design using historical controls was used to test the hypotheses . Attempts to control for the effects of history were made by collecting data related to patient , staffing , and organizational variables that could independently effect outcome . Setting MICU in a west coast teaching hospital . Patients Critically ill patients receiving mechanical ventilation for 3 days or greater . InterventionImplementation of a collaborative weaning plan . Measurements Outcomes studied included length of stay in the MICU , length of time patients were mechanically ventilated in the MICU , cost per MICU stay , and the incidence of complications ( e.g. , reventilation , readmission to the ICU , and mortality rate . ) Main Results The CWP decreased length of stay in the MICU by 3.6 days ( p = .03 ) and length of ventilator time by 2.7 days ( p = .06 ) . There were no significant differences between groups related to cost or incidence of complications . Conclusions These results support the usefulness of collaborative structures ( such as weaning boards/flowsheets ) in decreasing ICU length of stay OBJECTIVE To determine the effect of a community hospital-wide program enabling nurses and prehospital personnel to mobilize institutional re sources for the treatment of patients with nontraumatic shock . DESIGN Historically controlled single-center study . SETTING A 180-bed community hospital . PATIENTS Patients in shock who were c and i date s for aggressive therapy . INTERVENTIONS From January 1998 to May 31 , 2000 , patients in shock received st and ard therapy ( control group ) . During the month of June 2000 , intensive education of all health-care providers ( ie , prehospital personnel , nurses , and physicians ) took place . From July 1 , 2000 , through June 30 , 2001 , patients in shock ( protocol group ) were managed with a hospital-wide shock program . The program included early recognition of shock and the initiation of therapy by nonphysicians . Frontline personnel mobilized a shock team , which used goal -directed resuscitation protocol s , early intensivist involvement , and rapid transfer to the ICU where protocol s specific to shock etiology were implemented . MEASUREMENTS AND MAIN RESULTS Eighty-six and 103 patients , respectively , were enrolled in the control and protocol groups . Baseline characteristics were similar . The protocol group had significant reductions in the median times to interventions , as follows : intensivist arrival , 2:00 h to 50 min ( p < 0.002 ) ; ICU/operating room admission , 2 h 47 min to 1 h 30 min ( p < 0.002 ) ; 2 L fluid infused , 3 h 52 min to 1 h 45 min ( p < 0.0001 ) ; and pulmonary artery catheter placement , 3 h 50 min to 2 h 10 min ( p 0.02 ) . Good outcomes ( ie , discharged to home or to a rehabilitation center ) were more likely in the protocol group than in the control group ( p = 0.02 ) . The hospital mortality rate was 40.7 % in the control group and 28.2 % in the protocol group ( p = 0.035 ) . CONCLUSION Similar to current practice in patients who have experienced trauma or cardiac arrest , the empowerment of nonphysician providers to mobilize hospital re sources for the care of patients with shock is effective . A community hospital program incorporating the education of providers , the activation of a coordinated team response , and early goal -directed therapy expedited appropriate treatment and was temporally associated with improved outcomes . R and omized multicenter trials are needed to further assess the impact of the shock program on outcomes OBJECTIVES To assess the feasibility of a multifaceted strategy to translate evidence -based guidelines for treating nursing home-acquired pneumonia ( NHAP ) into practice using a small intervention trial . DESIGN Pre-posttest with untreated control group . SETTING Two Colorado State Veterans Homes ( SVHs ) during two influenza seasons . PARTICIPANTS Eighty-six residents with two or more signs of lower respiratory tract infection . INTERVENTION Multifaceted , including a formative phase to modify the intervention , institutional-level change emphasizing immunization , and availability of appropriate antibiotics ; interactive educational sessions for nurses ; and academic detailing . MEASUREMENTS Subjects ' SVH medical records were review ed for guideline compliance retrospectively for the influenza season before the intervention and prospect ively during the intervention . Bivariate comparisons-of-care processes between the intervention and control facility before and after the intervention were made using the Fischer exact test . RESULTS At the intervention facility , compliance with five of the guidelines improved : influenza vaccination , timely physician response to illness onset , x-ray for patients not being hospitalized , use of appropriate antibiotics , and timely antibiotic initiation for unstable patients . Chest x-ray and appropriate and timely antibiotics were significantly better at the intervention than at the control facility during the intervention year but not during the control year . CONCLUSION Multifaceted , evidence -based , NHAP guideline implementation improved care processes in a SVH . Guideline implementation should be studied in a national sample of nursing homes to determine whether it improves quality of life and functional outcomes of this debilitating illness for long-term care residents Control of diabetes mellitus is a high priority for primary health care systems . One innovative method of diabetes care delivery is the use of structured diabetes care in primary care . This includes the use of chronic care diabetes clinics or mini-clinics operated by general practitioners in primary care . There is limited experience with this model in non-Western setting s. This study sought to evaluate a multi-component structured approach to diabetes care in primary care including chronic care diabetes clinics in a newly developed country in the Arabian Gulf . The study design used was a controlled before-after methodology . Three primary health centers were chosen for the intervention with six of the remaining clinics in a Health District being used as controls . A multifaceted intervention was initiated in the intervention clinics composed of chronic care diabetes clinics , a diabetic flow chart , and educational programs for clinic nurses and doctors and patients . The study intervention took place over a period of 18 months with three diabetic outcomes ( fasting blood glucose , blood pressure and cholesterol ) and adherence to seven diabetes guidelines being compared for the year prior to the intervention and during the last 12 months of the intervention period . Knowledge and satisfaction question naires were also administered to intervention and control subjects at the end of the study . In this study , 219 subjects were enrolled ( 130 males and 89 females ) . They had a mean age of 51.6 years and a mean of 3.1 years of formal education . Of these 109 were enrolled in one of three clinics that had a chronic care diabetes clinic and 110 were enrolled in one of the six control clinics . Subjects had diabetes for a mean of 7.8 ± 4.8 years and the majority was treated with pharmacological therapy . Baseline characteristics in the intervention and the control clinics were similar with the exception of younger age ( p = 0.01 ) and a trend for more males ( p = 0.06 ) in the intervention clinics . There was a statistically insignificant change noted with the intervention in the three clinical outcomes studied ( fasting blood glucose , blood pressure and cholesterol ) both in comparison to the control group before and after and within the intervention group . However most changes noted were in the expected direction of improvement ; six of the seven guidelines were statistically improved in the intervention group when compared with the control group . Within the intervention group , adherence with five of seven guidelines was also statistically significantly increased with the remaining guidelines showing a trend in favor of improvement ( fasting blood glucose measurements ( p = 0.07 ) and urine determinations for protein ( p = 0.07 ) ) . Knowledge question naire scores were similar between the intervention and control groups on completion of the study but 2 of 4 items on a satisfaction scale were statistically significantly higher in the intervention group . The intervention described in this setting was successful in improving adherence to diabetes guidelines and increased some aspects of satisfaction with diabetes care . The intervention did not result in a statistically significant improvement in clinical outcomes but changes noted were in the expected direction of improvement . The significant improvement in adherence to diabetes guidelines suggests that this intervention is a promising model for diabetes care for newly developed countries CONTEXT Most older adults with dementia will be cared for by primary care physicians , but the primary care practice environment presents important challenges to providing quality care . OBJECTIVE To test the effectiveness of a collaborative care model to improve the quality of care for patients with Alzheimer disease . DESIGN , SETTING , AND PATIENTS Controlled clinical trial of 153 older adults with Alzheimer disease and their caregivers who were r and omized by physician to receive collaborative care management ( n = 84 ) or augmented usual care ( n = 69 ) at primary care practice s within 2 US university-affiliated health care systems from January 2002 through August 2004 . Eligible patients ( identified via screening or medical record ) met diagnostic criteria for Alzheimer disease and had a self-identified caregiver . INTERVENTION Intervention patients received 1 year of care management by an interdisciplinary team led by an advanced practice nurse working with the patient 's family caregiver and integrated within primary care . The team used st and ard protocol s to initiate treatment and identify , monitor , and treat behavioral and psychological symptoms of dementia , stressing nonpharmacological management . MAIN OUTCOME MEASURES Neuropsychiatric Inventory ( NPI ) administered at baseline and at 6 , 12 , and 18 months . Secondary outcomes included the Cornell Scale for Depression in Dementia ( CSDD ) , cognition , activities of daily living , re source use , and caregiver 's depression severity . RESULTS Initiated by caregivers ' reports , 89 % of intervention patients triggered at least 1 protocol for behavioral and psychological symptoms of dementia with a mean of 4 per patient from a total of 8 possible protocol s. Intervention patients were more likely to receive  cholinesterase inhibitors  ( 79.8 % vs 55.1 % ; P = .002 ) and  antidepressants  ( 45.2 % vs 27.5 % ; P = .03 ) . Intervention patients had significantly fewer behavioral and psychological symptoms of dementia as measured by the total NPI score at 12 
    Output:
    
The review has provided evidence that a multi-pronged approach to dissemination and implementation of practice guidelines will assist in gaining significant improvements in change in knowledge , practice and patient outcomes