***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 
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    Input: Background There is a need for assistance from primary care mental health workers in general practice in the Netherl and s. General practitioners ( GPs ) experience an overload of frequent attenders suffering from psychological problems . Problem Solving Treatment ( PST ) is a brief psychological treatment tailored for use in a primary care setting . PST is provided by nurses , and earlier research has shown that it is a treatment at least as effective as usual care . However , research outcomes are not totally satisfying . This protocol describes a r and omized clinical trial on the effectiveness of PST provided by nurses for patients in general practice . The results of this study , which currently being carried out , will be presented as soon as they are available . Methods / design This study protocol describes the design of a r and omized controlled trial to investigate the effectiveness and cost-effectiveness of PST and usual care compared to usual care only .  Patients , 18 years and older , who present psychological problems and are frequent attenders in general practice are recruited by the research assistant . The participants receive question naires at baseline , after the intervention , and again after 3 months and 9 months . Primary outcome is the reduction of symptoms , and other outcomes measured are improvement in problem solving skills , psychological and physical well being , daily functioning , social support , coping styles , problem evaluation and health care utilization . Discussion Our results may either confirm that PST in primary care is an effective way of dealing with emotional disorders and a promising addition to the primary care in the UK and USA , or may question this assumption . This trial will allow an evaluation of the effects of PST in practical circumstances and in a rather heterogeneous group of primary care patients . This study delivers scientific support for this use and therefore indications for optimal treatment and referral The only r and omised controlled trial to test high-fidelity  assertive community treatment ( ACT ) in the UK ( the R and omised Evaluation of Assertive Community Treatment ( REACT ) study ) found no advantage over usual care from community mental health teams in reducing the need for in-patient care and in other clinical outcomes , but participants found ACT  more acceptable and engaged better with it . One possible reason for the lack of efficacy of ACT might be the short period of follow-up ( 18 months in the REACT study ) . This paper reports on participants ' service contact , in-patient service use and adverse events 36 months after r and omisation OBJECTIVE To determine whether a new model of primary care , Chronic Care Clinics , can improve outcomes of common geriatric syndromes ( urinary incontinence , falls , depressive symptoms ,  high risk medications  ,  functional impairment ) in frail older adults . DESIGN R and omized controlled trial with 24 months of follow-up . Physician practice s were r and omized either to the Chronic Care Clinics intervention or to usual care . SETTING Nine primary care physician practice s that comprise an ambulatory clinic in a large staff-model HMO in western Washington State . PARTICIPANTS Those patients aged 65 and older in each practice with the highest risk for being hospitalized or experiencing functional decline . INTERVENTION Intervention practice s ( 5 physicians , 96 patients ) held half-day Chronic Care Clinics every 3 to 4 months . These clinics included an extended visit with the physician and nurse dedicated to planning chronic disease management ; a pharmacist visit that emphasized reduction of polypharmacy and high-risk medications ; and a patient self-management/support group . Control practice s ( 4 physicians , 73 patients ) received usual care . MEASUREMENTS Changes in self-reported urinary incontinence , frequency of falls , depressive symptoms , physical function , and satisfaction were analyzed using an intention-to-treat analysis adjusted for baseline differences , covariates , and practice -level variation . Prescriptions for high-risk medications and cost/utilization data obtained from administrative data were similarly analyzed . RESULTS After 24 months , no significant improvements in frequency of incontinence , proportion with falls , depression scores , physical function scores , or prescriptions for high risk medications were demonstrated . Costs of medical care including frequency of hospitalization , hospital days , emergency and ambulatory visits , and total costs of care were not significantly different between intervention and control groups . A higher proportion of intervention patients rated the overall quality of their medical care as excellent compared with control patients ( 40.0 % vs 25.3 % , P = .10 ) . CONCLUSIONS Although intervention patients expressed high levels of satisfaction with Chronic Care Clinics , improved outcomes for selected geriatric syndromes were not demonstrated . These findings suggest the need for developing greater system-wide support for managing geriatric syndromes in primary care and illustrate the challenges of conducting practice improvement research in a rapidly changing delivery system OBJECTIVE To determine the effect of the Program for Assertive Community Treatment ( PACT ) model on psychiatric inpatient service use in a population of non-emergency psychiatric patients with severe chronic mental illness , and to test for variations in this effect with program staffing levels and patient characteristics such as race and age . DATA SOURCES / STUDY SETTING Data are taken from a r and omized trial of PACT in Charleston , South Carolina for 144 patients recruited from August 1989 through July 1991 . STUDY DESIGN Subjects were r and omly assigned either to one of two PACT programs or to usual care at a local mental health center . Effects on hospital use were measured over an 18-month follow-up period via multiple regression analysis . DATA COLLECTION METHODS Data were obtained from Medicaid cl aims , chart review s , subject , case manager , and family interviews ; search es of the computerized patient and financial data bases of the South Carolina Department of Mental Health and relevant hospitals ; and search es of the hard copy and computerized financial data bases of the two major local hospitals providing inpatient psychiatric care . PRINCIPAL FINDINGS PACT participants were about 40 percent less likely to be hospitalized during the follow-up period . The effect was stronger for older patients . Lower  PACT client/staff ratios also reduced the risk of hospitalization . No evidence of differential race effects was found . Given some hospital use , PACT did not influence the number of days of use . CONCLUSIONS Controlling for other covariates , PACT significantly reduces hospitalizations but the size of this effect varies with patient and program characteristics . This study shows that previous results on PACT can be applied to non-emergency patients even when the control condition is an up-to- date CMHC office-based case management program BACKGROUND Trials in community psychiatry must balance rigour with generalisability . The UK700 trial failed to find a significant effect on hospitalisation , but its sample population contained significant heterogeneity of exposure to case management in the two groups . AIMS To test whether patients successfully exposed to a minimum of 12 months ' intensive case management over the 2-year follow-up period achieved reduced hospitalisation . METHOD Of 679 participants with hospitalisation data , 84 were identified as having < 12 months ' exposure owing to prolonged hospitalisation , imprisonment or a combination of the two . These patients were excluded and outcomes tested for the remaining 595 patients . RESULTS Overall reduced case-load size did not reduce hospitalisation or treatment costs over 2 years despite elimination of outliers . Age , previous hospitalisation and source of recruitment to the study all correlated with outcome . CONCLUSIONS Case-load reduction is not in itself enough to reduce the need for hospital care in psychosis . Baseline patient characteristics ( in particular length of previous hospitalisation and recruitment from in-patient care ) have a significant influence and should be allowed for in power calculations . Identifying the optimal clinical profile for patients likely to benefit from intensive case management remains a pressing need for further studies Background A number of recently published r and omized controlled trials conducted in developed countries have reported no advantage for assertive interventions over st and ard care models . One possible explanation could be that so-called " st and ard care " has become more comprehensive in recent years , incorporating some of the salient aspects of assertive models in its modus oper and i. Our study represents the first r and omised controlled trial assessing the effect of a modified assertive treatment service on readmission rates and other measures of outcome in a developing country . Methods High frequency service users were r and omized into an intervention ( n = 34 ) and a control ( n = 26 ) group . The control group received st and ard community care and the active group an assertive intervention based on a modified version of the international model of assertive community treatment . Study visits were conducted at baseline and 12 months with demographic and illness information collected at visit 1 and readmission rates documented at study end . Symptomatology and functioning were measured at both visits using the PANSS , CDSS , ESRS , WHO-QOL and SOFAS . Results At 12 month follow-up subjects receiving the assertive intervention had significantly lower total PANSS ( p = 0.02 ) as well as positive ( p < 0.01 ) and general psychopathology ( p = 0.01 ) subscales ' scores . The mean SOFAS score was also significantly higher ( p = 0.02 ) and the mean number of psychiatric admissions significantly lower ( p < 0.01 ) in the intervention group . Conclusions Our results indicate that assertive interventions in a developing setting where st and ard community mental services are often under re source d can produce significant outcomes . Furthermore , these interventions need not be as expensive and comprehensive as international , first-world models in order to reduce inpatient days , improve psychopathology and overall levels of functioning in patients with severe mental illness BACKGROUND Heavy users of psychiatric services , often defined as the population that uses the most beds , consume a large part of the re sources used by the whole service , despite being relatively small in number . Any intervention that reduces heavy use is therefore likely to lead to significant savings , and enhancement of st and ard care using a form of intensive case management akin to assertive community treatment was thought to be a pragmatic strategy for testing in this group . METHODS The effectiveness of  enhanced community management ( ECM ) was compared with st and ard care alone in heavy users , who represented the 10 % of patients with the highest number of hospital admissions and occupied bed days over the previous 6.5 years in an outer London borough . One hundred and ninety-three patients were r and omly assigned to ECM or st and ard care and their use of services was determined after 1 and 2 years , with assessment s of costs , clinical symptoms , needs , and social function made before entry into the study and after 1 and 2 years . RESULTS Despite a 24 fold increase in community contacts in the study group , there were no significant differences between the two groups in any of the main outcome measures . Small savings on in-patient and day-hospital service costs were counterbalanced by the increased costs of outpatient and community care for the subjects assigned to ECM . Clinical outcome data derived from interviews in two-thirds of the subjects were similar in both groups . CONCLUSIONS Providing additional intensive community focused care to a group of heavy users of psychiatric in-patient services in an outer London borough does not lead to any important clinical gains or reduced costs of psychiatric care At three community mental health centers ( CMHCs ) in Indiana , 167 clients at risk for rehospitalization were r and omly assigned to experimental groups receiving assertive case management ( ACM ) or to control groups eligible to receive all other aftercare services at the centers . During a six-month follow-up period , experimental clients received an average of one visit a week from the ACM team , usually in the client 's home or in community setting s. Overall , ACM clients were rehospitalized an average of 9.2 days , significantly less than the 30.8 days for controls . In two of the three centers , significant rehospitalization differences were also found between ACM and control groups . No differences were found between groups in quality of life , medication compliance , involvement in CMHC programs , or contacts with the legal system in any of the centers . The most cost-effective center had savings of about + 5,500 for each ACM client CONTEXT Emergency department utilization by chronically ill older adults may be an important sentinel event signifying a breakdown in care coordination . A primary care group visit ( i.e. , several patients meeting together with the provider at the same time ) may reduce fragmentation of care and subsequent emergency department utilization . OBJECTIVE To determine whether primary care group visits reduce emergency department utilization in chronically ill older adults . DESIGN R and omized trial conducted over a 2-year period . SETTING Group-model HMO in Denver , Colorado . PATIENTS 295 older adults ( > or = 60 years of age ) with frequent utilization of outpatient services and one or more chronic illnesses . INTERVENTION Monthly group visits ( generally 8 to 12 patients ) with a primary care physician , nurse , and pharmacist held in 19 physician practice s. Visits emphasized self-management of chronic illness , peer support , and regular contact with the primary care team . MEASURES Emergency department visits , hospitalizations , and primary care visits . RESULTS On average , patients in the intervention group attended 10.6 group visits during the 2-year study period . These patients averaged fewer emergency department visits ( 0.65 vs. 1.08 visits ; P = 0.005 ) and were less likely to have any emergency department visits ( 34.9 % vs. 52.4 % ; P = 0.003 ) than controls . These differences remained statistically significant after controlling for demographic factors , comorbid conditions , functional status , and prior utilization . Adjusted mean difference in visits was -0.42 visits ( 95 % CI , -0.13 to -0.72 ) , and adjusted RR for any emergency department visit was 0.64 ( CI , 0.44 to 0.86 ) . CONCLUSION Monthly group visits reduce emergency department utilization for chronically ill older adults OBJECTIVES We sought to determine whether a multidisciplinary outpatient management program decreases  chronic heart failure ( CHF )  hospital readmissions and mortality over a six-month period . BACKGROUND Hospital admission for CHF is an important problem amenable to improved outpatient management . METHODS Two hundred patients hospitalized with CHF at increased risk of hospital readmission were r and omized to a multidisciplinary 
    Output:
    
INTERPRETATION We found that quality improvement strategies for coordination of care reduced hospital admissions among patients with chronic conditions other than mental illness and reduced emergency department visits among older patients .