***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 Type 2 diabetes is rapidly growing as a proportion of the disease burden in Australia as elsewhere . This study addresses the cost effectiveness of an integrated approach to assisting general practitioners ( GPs ) with diabetes management . This approach uses a central ized data base of clinical data of an Australian Division of General Practice ( a network of GPs ) to co-ordinate care according to national guidelines . Methods Long term outcomes for patients in the program were derived using clinical parameters after 5 years of program participation , and the United Kingdom Prospect i ve Diabetes Study ( UKPDS ) Outcomes Model , to project outcomes for 40 years from the time of diagnosis and from 5 years post-diagnosis . Cost information was obtained from a range of sources . While program costs are directly available , and costs of complications can be estimated from the UKPDS model , other costs are estimated by comparing costs in the Division with average costs across the state or the nation . The outcome and cost measures are used derive incremental cost-effectiveness ratios . Results The clinical data show that the program is effective in the short term , with improvement or no statistical difference in most clinical measures over 5 years . Average HbA1c levels increased by less than expected over the 5 year period . While the program is estimated to generate treatment cost savings , overall net costs are positive . However , the program led to projected improvements in expected life years and Quality Adjusted Life Expectancy ( QALE ) , with incremental cost effectiveness ratios of $ A8,106 per life-year saved and $ A9,730 per year of QALE gained . Conclusions The combination of an established model of diabetes progression and generally available data has provided an opportunity to establish robust methods of testing the cost effectiveness of a program for which a formal control group was not available . Based on this methodology , integrated health care delivery provided by a network of GPs improved health outcomes of type 2 diabetics with acceptable cost effectiveness , which suggests that similar outcomes may be obtained elsewhere Objectives : To determine the effects of a nurse led intermediate care programme in patients who have been hospitalised with an acute exacerbation of chronic obstructive pulmonary disease ( AE COPD ) . Design : R and omised controlled trial . Setting : Community and hospital care in west London . Participants : 122 patients with COPD . Intervention : A care package incorporating initial pulmonary rehabilitation and self-management education , provision of a written , personalised COPD action plan , monthly telephone calls and 3 monthly home visits by a specialist nurse for a period of 2 years . Main outcome measure : Hospital readmission rate . Secondary outcomes : Unscheduled primary care consultations and quality of life . Results : There were no differences in hospital admission rates or in exacerbation rates between the two groups . Self-management of exacerbations was significantly different and the intervention group were more likely to be treated with oral steroids alone or oral steroids and antibiotics , and the initiators of treatment for exacerbations were statistically more likely to be the patients themselves . 12 patients in the control group died during the 2 year period , eight as a result of COPD , compared with six patients in the intervention group , of whom one died from COPD . This is a significant difference . When the numbers were adjusted to reflect the numbers still alive at 2 years , in the intervention group patients reported a total of 171 unscheduled contacts with their general practitioner ( GP ) and in the control group , 280 contacts . The number needed to treat was 0.558—ie , for every one COPD patient receiving the intervention and self-management advice , there were 1.79 fewer unscheduled contacts with the GP . Conclusions : An intermediate care package incorporating pulmonary rehabilitation , self-management education and the receipt of a written COPD action plan , together with regular nurse contact , is associated with a reduced need for unscheduled primary care consultations and a reduction in deaths due to COPD but did not affect the hospital readmission rate OBJECTIVE To determine the long-term effects on total healthcare costs of the Improving Mood : Promoting Access to Collaborative Treatment ( IMPACT ) program for late-life depression compared with usual care . STUDY DESIGN R and omized controlled trial with enrollment from July 1999 through August 2001 . The IMPACT trial , conducted in primary care practice s in 8 delivery organizations across the United States , enrolled 1801 depressed primary care patients 60 years or older . Data are from the 2 IMPACT sites for which 4-year cost data were available . Trial enrollment across these 2 health maintenance organizations was 551 patients . METHODS Participants were r and omly assigned to the  IMPACT intervention  ( n = 279 ) or to  usual primary care ( n = 272 ) . Intervention patients had access to a depression care manager who provided education , behavioral activation , support of antidepressant medication management prescribed by their regular primary care provider , and problem-solving treatment in primary care for up to 12 months . Care managers were supervised by a psychiatrist and a primary care provider . The main outcome measures were healthcare costs during 4 years . RESULTS  IMPACT participants had lower mean total healthcare costs ( $ 29 422 ; 95 % confidence interval , $ 26 479-$32 365 ) than usual care patients ( $ 32 785 ; 95 % confidence interval , $ 27 648-$37 921 ) during 4 years . Results of a bootstrap analysis suggested an 87 % probability that the IMPACT program was associated with lower healthcare costs than usual care . CONCLUSION Compared with usual primary care , the IMPACT program is associated with a high probability of lower total healthcare costs during a 4-year period OBJECTIVE This study explored the cost-effectiveness of quality -improvement interventions  for depression in primary care , relative to usual care , among patients with subthreshold depression or depressive disorder . METHODS A total of 746 primary care patients in managed care organizations with 12-month depressive disorder and 502 with current depressive symptoms but no disorder ( subthreshold depression ) participated in a group-level r and omized controlled trial initiated between June 1996 and March 1997 . Matched clinics were r and omly assigned to enhanced usual care or one of two quality improvement interventions that provided education to manage depression over time and re sources to facilitate access to medication management or psychotherapy for six to 12 months . RESULTS The cost-effectiveness ratio for the pooled intervention groups versus usual care was $ 2,028 for patients with subthreshold depression ( 95 % confidence interval [CI]=-$17,225 to $ 21,282 ) and $ 53,716 for those with depressive disorder ( CI=$14,194 to $ 93,238 ) , by using a measure of quality -adjusted life years ( QALY ) based on the 12-Item Short Form Health Survey . Similar results were obtained when alternative QALY measures were used . CONCLUSIONS Although precision was limited , even the upper limit of the 95 % CIs suggests that such interventions are as cost-effective for patients with subthreshold depression as are many widely used medical therapies . Despite lack of evidence for efficacy of treatments for subthreshold depression , disease management programs that support clinical care decisions over time for patients with subthreshold depression or depressive disorder can yield cost-effectiveness ratios comparable to those of widely adopted medical therapies . Achieving greater certainty about average cost-effectiveness would require a much larger study Chronic respiratory patients requiring oxygen or home mechanical ventilation experience frequent exacerbations and hospitalisations with related costs . Strict monitoring and care have been recommended . The aim of the present study was to primarily evaluate reduction in hospitalisations and , secondly , exacerbations , general practitioner ( GP ) calls and related cost-effectiveness of  tele-assistance ( TA ) for these patients . A total of 240 patients ( 101 with chronic obstructive pulmonary disease ( COPD ) ) were r and omised to two groups : an intervention group entered a 1-yr TA programme  while  controls received traditional care . No anthropometric and clinical differences were found between groups both in baseline and in mortality ( 18 % for TA , 23 % for controls ) . Compared with controls , the TA group experienced significantly fewer hospitalisations ( -36 % ) , urgent GP calls ( -65 % ) and acute exacerbations ( -71 % ) . Only COPD patients , as a separate group , had fewer hospitalisations , emergency room admissions , urgent GP calls or exacerbations . Each patient referred to staff a mean±sd 36±25 times . After deduction of TA costs , the average overall cost for each patient was 33 % less than that for usual care . In chronic respiratory failure patients on oxygen or home mechanical ventilation , a nurse-centred tele-assistance prevents hospitalisations while it is cost-effective . The chronic obstructive pulmonary disease group seems to have a greater advantage from tele-assistance Introduction The efficacy of antidepressants in the treatment of depression has been convincingly demonstrated in r and omised trials . However , non-adherence to antidepressant treatment is common . Objective To evaluate , from a societal perspective , the cost effectiveness of a pharmacy-based intervention to improve adherence to antidepressant therapy in adult patients receiving treatment in primary care . Methods An economic evaluation was performed alongside a 6-month r and omised controlled trial in The Netherl and s. Patients who came to 19 pharmacies with a new prescription for a non-tricyclic antidepressant , i.e. those who had not received any prescription for an antidepressant in the past 6 months , were invited to participate . They were then r and omly allocated to education and coaching by the pharmacist or to usual care . The coaching programme consisted of three contacts with the pharmacist , with a mean duration of between 13 and 20 minutes , and a take-home video review ing important facts on depression and antidepressant treatment . The clinical outcome measures were adherence to antidepressant treatment measured using an electronic pill container ( eDEM ) and improvement in depressive symptoms measured using the Hopkins Symptom Checklist ( SCL ) . Re source use was measured by means of question naires . The uncertainty around differences in costs and cost effectiveness between the treatment groups was evaluated using bootstrapping . Results Seventy patients were r and omised to the intervention group and 81 to the usual care group ; of these , 40 in the intervention group and 48 in the control group completed all of the follow-up question naires . There were no significant differences in adherence , improvements in the SCL depression mean item score and costs over 6 months between the two treatment groups . Mean total costs ( 2002 values ) were € 3275 in the intervention group and € 2961 in the control group ( mean difference € 315 ; 95 % CI —1922 , 2416 ) . The incremental cost-effectiveness ratio associated with the pharmacist intervention was € 149 per 1 % improvement in adherence and € 2550 per point improvement in the SCL depression mean item score . Cost-effectiveness planes and acceptability curves indicated that the pharmacist intervention was not likely to be cost effective compared with usual care . Conclusion In patients starting treatment with antidepressants , there were no significant differences in adherence , severity of depression , costs and cost effectiveness between patients receiving coaching by a pharmacist and patients receiving usual care after 6 months . Considering the re sources needed to implement an intervention like this in clinical practice , based on these results , the continuation of usual care is recommended The LifeMasters Supported SelfCare demonstration program provides disease management ( DM ) services to Florida Medicare beneficiaries who are also enrolled in Medicaid and have congestive heart failure ( CHF ) , diabetes , or coronary artery disease ( CAD ) . The population -based program provides primarily telephonic patient education and monitoring services . Findings from the r and omized , intent-to-treat design over the first 18 months of operations show virtually no overall impacts on hospital or emergency room ( ER ) use , Medicare expenditures , quality of care , or prescription drug use for the 33,000 enrollees . However , for beneficiaries with CHF who resided in high-cost South Florida counties , the program reduced Medicare expenditures by 9.6 percent OBJECTIVE To assess the effect of a specialist telemedicine intervention for improving diabetes care using the chronic care model ( CCM ) . PARTICIPANTS AND METHODS As part of the CCM , 97 primary care physicians at 6 primary care practice s in Rochester , MN , referred 639 patients to an on-site diabetes educator between July 1 , 2001 , and December 31 , 2003 . On first referral , physicians were central ly r and omized to receive a telemedicine intervention ( specialty advice and evidence -based messages regarding medication management for cardiovascular risk ) or no intervention , keeping outcome assessors and data analysts blinded to group assignment . After each subsequent clinical encounter , endocrinologists review ed an abstract from the patient 's electronic medical record and provided management recommendations and supporting evidence to intervention physicians via e-mail . Control physicians received e-mail with periodic generic information about cardiovascular risk reduction in diabetes . Outcome measures included diabetes care processes ( diabetes test completion ) , outcomes ( metabolic and cardiovascular risk factors , estimated coronary artery disease risk ) , and patient costs ( payer perspective ) . RESULTS During the intervention , 951 ( 70 % ) of the 1361 endocrinology review s detected performance gaps and result ed in a message ; primary care physicians reported using 49 % of messages in patient care . With a mean of 21 months ' follow-up , the intervention , compared with control , did not significantly enhance metabolic outcomes or reduce estimated risk of coronary artery disease ( adjusted mean difference , -1 % ; 95 % confidence interval , -19 % to 17 % ) . The intervention group incurred lower costs ( P=.02 ) but not in di 
    Output:
    
Although it is widely believed that disease management programs reduce healthcare expenditures , the present study shows that evidence for this cl aim is still inconclusive .