***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: OBJECTIVES A two-stage intervention comprising screening and a brief st and ardized nursing assessment and referral , for emergency department ( ED ) patients aged 65 years and over , reduced the rate of functional decline four months after the visit , without increasing societal costs . In this study , the authors investigated the effects of the intervention on the process of care at , and during the month after , the ED visit . METHODS Patients at four Montreal hospital EDs were r and omized by day of visit to the intervention or to usual care . Patients admitted to the hospital were excluded . Measures of process of care included : referrals and visits to the primary physician and to the local community health center , for home care or other services , and return ED visits . Data sources included hospital charts , patient question naires , and provincial administrative data bases . RESULTS The study sample included 166 intervention and 179 control group patients ready for discharge from the ED . Intervention group patients were more likely to have a chart-documented referral to their local community health center [ adjusted odds ratio ( OR ) 4.0 , 95 % confidence interval ( 95 % CI ) = 1.7 to 9.5 ] and their primary physician [ adjusted OR 1.9 , 95 % CI = 1.0 to 3.4 ] , and to have received home care services one month after the ED visit [ adjusted OR 2.3 , 95 % CI = 1.1 to 5.1 ] . Unexpectedly , they were also more likely to make a return visit to the ED [ adjusted OR 1.6 , 95 % CI = 1.0 to 2.6 ] . CONCLUSIONS The beneficial outcomes of the intervention appear to result primarily from the early provision of home care rather than early contact with the primary physician IN THE EARLY 1890S , DR WILLIAM HALSTED DEVELOPED radical mastectomy for breast cancer . Surgeons performed the Halsted procedure for more than 80 years even though there was little systematic evidence for its success . Then a new breed of scholars subjected the procedure to formal methods of evaluation unknown to Halsted . The methods —r and omized controlled trials ( RCTs ) principal among them — led to a surprise : radical mastectomy had no advantage over simpler forms of treatment . This is but 1 example of the hard-won victory of evidence over belief in medicine . The pioneers of the formal evaluation of medical practice s raised questions that traditional practitioners did not welcome . But in time , formal evaluation prevailed . The pioneers developed a hierarchy of evidentiary rigor relating the design of a study to the confidence that could be placed in the findings , from the lowly , nearly valueless anecdote to the royalty of evidence , the RCT . Concurrently , a similar story of hard-won learning unfolded in the so-called quality movement . Scholars illuminated the scale and types of defects in the processes of care and the outcomes , including high rates of unscientific care , inappropriate care , geographic variations in practice , latent disagreements among specialists , and oftenunrecognized medical injury to patients . Like the pioneers of evidence -based medicine , students of medical quality were at first largely ignored , but no longer . In 1999 and 2001 , the Institute of Medicine published 2 l and mark reports on the evidence for quality failures and called urgently for re design of care systems to achieve improvements . The story could end here happily with 2 great streams of endeavor merging into a framework for conjoint action : improving clinical evidence and improving the process of care . Instead , the 2 endeavors are often in unhappy tension . Neither disputes that progress toward health care ’s main goal , the relief of illness and pain , requires research of many kinds : basic , clinical , systems , epidemiologic . The disagreement centers on epistemology — ways to get at “ truth ” and how those ways should vary depending on the knowledge sought . Individuals most involved in day-to-day improvement work fear that if “ evidence ” is too narrowly defined and the approach to gathering evidence too severely constrained , progress may be the victim . For example , the RCT is a powerful , perhaps unequaled , research design to explore the efficacy of conceptually neat components of clinical practice —tests , drugs , and procedures . For other crucially important learning purpose s , however , it serves less well . Recent controversies about the evaluation of rapid response  teams  provide a case in point . These controversies show the importance of adjusting research methods to fit research questions . Although only 10 % to 15 % of in patients resuscitated outside intensive care units survive to hospital discharge , early warning signs are present in a large percentage of patients who ultimately experience cardiac arrest .  Rapid response team systems bring expert clinicians to the bedsides of deteriorating patients before arrest occurs . In the mid 1990s , based largely on reports from Australian investigators , the Institute for Healthcare Improvement and others began introducing the concept to willing hospitals . Local experience strongly suggested that these systems often , although not always , were associated with improved outcomes , including reduced anxiety among nursing staff ; increased interdisciplinary teamwork ; decreased cardiac arrests outside of intensive care units ; and , in some cases , declines in mortality . The evidence base took a turn in June 2005 with the publication of the Medical Early Response Intervention and Therapy ( MERIT ) Study , a cluster r and omized prospect i ve trial that cl aim ed to find no beneficial effect of these teams on several primary outcomes . Controversy has continued since then regarding the scientific evidence for rapid response systems . In fact , the MERIT trial was not negative ; it was inconclusive . The study team encountered an array of serious problems in execution , common in social science . For example , although the study ’s power calculation assumed a baseline rate of 30 events per 1000 admissions , the actual rate proved to be fewer than 7 events per 1000 admissions ; thus , the study was ef fect ively underpowered by 500 % . Crosscontamination abounded ; some control hospitals implemented rapid response protocol s , and several study The effect of home care on  patient outcomes and costs of care has been controversial . This information synthesis summarizes results from studies of home care using experimental or quasi-experimental design s , explicitly including judgments of method ologic soundness in weighing the results . In 12 studies of programs targeted at chronically ill population s , home care services appear to have no impact on mortality , patient functioning , or nursing home placements . Across studies , these services either have no effect on hospitalization or tend to increase the number of hospital days ; ambulatory care utilization may be increased by 40 percent . The cost of care either is not affected or is actually increased by 15 percent . The critical need at present is for better- design ed studies to test the effects of different types of home care , targeted at various types of patients , on the outcomes assessed in the existing studies , as well as on other important outcomes such as family finances , quality of life , and quality of care STUDY OBJECTIVES To evaluate the current status of clinical , educational , social , ethical , and re source issues related to the care of the elderly among practitioners of emergency medicine . DESIGN A mailed survey instrument . SETTING None . TYPE OF PARTICIPANTS Practicing emergency physicians r and omly drawn from the membership list of the American College of Emergency Physicians . INTERVENTIONS None . MEASUREMENTS AND MAIN RESULTS A total of 971 surveys were mailed , with 433 usable surveys among the 485 ( 50 % ) respondents . The surveyed emergency physicians anticipated a major impact on emergency department patient flow and bed availability in the hospital and ICU as the population ages . For each of seven clinical presentations ( abdominal pain , altered mental status , chest pain , dizziness/vertigo , fever without a source , headache , multisystem trauma ) , 45 % or more of the emergency physicians have more difficulty in the management of older compared with younger patients . Most respondents reported that each of these presentations required more time and re sources for older patients . The majority believed research , the availability of continuing medical education , and time spent during residency training regarding geriatric emergency medicine was inadequate . CONCLUSION Practicing emergency physicians are uncomfortable with elderly patients , and this may reflect the inadequacies of training , research , and continuing education in geriatric emergency medicine OBJECTIVES To compare the effects of nurse case management with usual care provided to community-dwelling frail older people in regard to quality of life , satisfaction with care , functional status , admission to hospital , length of hospital stay , and readmission to emergency department . DESIGN R and omized controlled trial . SETTING University hospital and two proximal community health centers . PARTICIPANTS 427 frail older people ( > or = 70 years of age and at risk for repeated hospital admissions ) discharged home from the emergency department . INTERVENTIONS EXPERIMENTAL Nurse case management , which consisted of coordination and provision of healthcare services by nurses , both in and out of hospital , for a 10-month period . CONTROL Usual care , which varied by healthcare provider and community health center . MEASUREMENTS Outcomes were assessed 10 months post-r and omization by telephone and /or home interview and by medical record review . Question naires included the SF-36 , CSQ-8 , and OARS . RESULTS No significant differences were found in quality of life , satisfaction with care , functional status , admission to hospital , or length of hospital stay . Nurse-case-managed older adults were readmitted to the emergency department significantly more often than their usual care counterparts . CONCLUSIONS Frail older people receiving nurse case management are more likely to use emergency health services without a concomitant increase in health benefits OBJECTIVES To determine the effectiveness of a two-stage ( screening and nursing assessment ) intervention for older patients in the emergency department ( ED ) who are at increased risk of functional decline and other adverse outcomes . DESIGN Controlled trial , r and omized by day of ED visit , with follow-up at 1 and 4 months . SETTING Four university-affiliated hospitals in Montreal . PARTICIPANTS Patients age 65 and older expected to be released from the ED to the community with a score of 2 or more on the Identification of Seniors At Risk ( ISAR ) screening tool and their primary family caregivers . One hundred seventy-eight were r and omized to the intervention , 210 to usual care . INTERVENTION The intervention consisted of disclosure of results of the ISAR screen , a brief st and ardized nursing assessment in the ED , notification of the primary care physician and home care providers , and other referrals as needed . The control group received usual care , without disclosure of the screening result . MEASUREMENTS Patient outcomes assessed at 4 months after enrollment included functional decline ( increased dependence on the Older American Re sources and Services activities of daily living scale or death ) and depressive symptoms ( as assessed by the short Geriatric Depression Scale ) . Caregiver outcomes , also assessed at baseline and 4 months , included the physical and mental summary scales of the Medical Outcomes Study Short Form-36 . Patient and caregiver satisfaction with care were assessed 1 month after enrollment . RESULTS The intervention increased the rate of referral to the primary care physician and to home care services . The intervention was associated with a significantly reduced rate of functional decline at 4 months , in both unadjusted ( odds ratio ( OR ) = 0.60 , 95 % confidence interval ( CI ) = 0.36 - 0.99 ) and adjusted ( OR = 0.53 , 95 % CI = 0.31 - 0.91 ) analyses . There was no intervention effect on patient depressive symptoms , caregiver outcomes , or satisfaction with care . CONCLUSION A two-stage ED intervention , consisting of screening with the ISAR tool followed by a brief , st and ardized nursing assessment and referral to primary and home care services , significantly reduced the rate of subsequent functional decline The aim of this r and omised controlled trial involving 224 elderly patients was to determine whether early geriatric assessment ( in the form of an aged care nurse intervention based in the emergency department ) reduced admission to the hospital , length of inpatient stay ( LOS ) , or functional decline during the hospitalisation . Baseline  geriatric assessment  s were recorded in the medical files of intervention patients ( n = 114 ) . The nurse also liaised with the patients ' carers and health care providers , organised referrals for out-of-hospital assessment and support services , and assisted in the care of those admitted as in patients by documenting suggestions for assessment and referral . Assessment data from  control patients ( n = 110 ) were withheld , and the nurse had no further involvement in their inpatient or outpatient care . One hundred and seventy-one patients ( 76 % ) were admitted to the hospital , for a median LOS of 10 days . The nurse successfully identified those needing admission ( odds ratio [ OR ] , 14.0 ; 95 % confidence interval [ CI ] , 2.6 - 75.1 ) . Thirty-nine of 160 in patients with available data ( 24 % ) had a functional deterioration during the hospitalisation . The intervention had no significant effect on admission to the hospital ( OR , 0.7 ; CI , 0.3 - 1.7 ) , LOS ( hazard ratio , 1.1 ; CI , 0.7 - 1.5 ) or functional decline during the hospitalisation ( OR , 1.3 ; CI , 0.5 - 3.3 ) Elderly people discharged directly home from an accident and emergency department are known to be a vulnerable group . The value of health visitor follow-up in patients aged 75 years and over was assessed in a r and om controlled trail ; 222 intervention patients were seen at home by a research health visitor shortly after discharge and screened for new dependency and support needs , appropriate community services then being offered . These patients , and 192 controls for whom no special arrangements were made , were followed up four weeks later by a research occupational therapist .  New dependency , most commonly trauma-related , was found in approximately 50 % , and in the majority proved transient . Advice and /or referral to 
    Output:
    
Successful models of ED-based case management models for older adults share certain key characteristics .
This study builds on the emerging literature in this area and leverages the differences in these models and their associated outcomes to support the development of an evidence -based normative and effective geriatric emergency management practice model design ed to address the special care needs and thereby improve the health and health service utilization outcomes of older patients