***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 To determine whether a medication review by a specialized team would promote regimen changes in elders taking multiple medications and to measure the effect of regimen changes on monthly cost and functioning . DESIGN A r and omized-controlled trial . SETTING Health center ambulatory clinic . PARTICIPANTS Community-dwelling older adults taking five or more medications were assessed at baseline and 6 weeks . A  medication-change intervention group of 57 elders was compared with a control group of 76 elder adults . INTERVENTION The primary intervention was a comprehensive review and recommended modification of a patient 's medication regimen . Changes were endorsed by each patient 's primary physician and discussed with each patient . MEASUREMENTS Measures were the Timed Manual Performance Test , Physical Performance Test , Functional Reach Assessment , subtests from the Wechsler Adult Intelligence Scale , a modified R and t Memory Test , the Center for Epidemiological Studies -Depression Scale , the Self-Rating Anxiety Scale , and the R and 36-item Health Survey 1.0 . Comorbidity was determined using the International Classification of Diseases , Ninth Revision , Clinical Modification . Medication usage was determined using brown bag review . RESULTS Intervention subjects decreased their medications by an average of 1.5 drugs . No differences in functioning were observed between groups . Intervention subjects saved an average $ 26.92 per month in wholesale medication costs ; control subjects saved $ 6.75 per month ( P<.006 ) . CONCLUSION Although the intervention significantly reduced the medications taken and monthly cost , most patients were resistant to reducing medications to the recommended level . Further study is needed to underst and patient resistance to reducing adverse polypharmacy and to devise better strategies for addressing this important problem in geriatric health . Greater focus on prescriber behavior is recommended Background : There is no single generally accepted clinical definition of frailty . Previously developed tools to assess frailty that have been shown to be predictive of death or need for entry into an institutional facility have not gained acceptance among practising clinicians . We aim ed to develop a tool that would be both predictive and easy to use . Methods : We developed the 7-point Clinical Frailty Scale and applied it and other established tools that measure frailty to 2305 elderly patients who participated in the second stage of the Canadian Study of Health and Aging ( CSHA ) . We followed this cohort prospect ively ; after 5 years , we determined the ability of the Clinical Frailty Scale to predict death or need for institutional care , and correlated the results with those obtained from other established tools . Results : The CSHA Clinical Frailty Scale was highly correlated ( r = 0.80 ) with the Frailty Index . Each 1-category increment of our scale significantly increased the medium-term risks of death ( 21.2 % within about 70 mo , 95 % confidence interval [ CI ] 12.5%–30.6 % ) and entry into an institution ( 23.9 % , 95 % CI 8.8%–41.2 % ) in multivariable models that adjusted for age , sex and education . Analyses of receiver operating characteristic curves showed that our Clinical Frailty Scale performed better than measures of cognition , function or comorbidity in assessing risk for death ( area under the curve 0.77 for 18-month and 0.70 for 70-month mortality ) . Interpretation : Frailty is a valid and clinical ly important construct that is recognizable by physicians . Clinical judgments about frailty can yield useful predictive information Background Computer-based decision support systems are a promising method for incorporating research evidence into clinical practice . However , evidence is still scant on how such information technology solutions work in primary healthcare when support is provided across many health problems . In Finl and , we design ed a trial where a set of evidence -based , patient-specific reminders was introduced into the local Electronic Patient Record ( EPR ) system . The aim was to measure the effects of such reminders on patient care . The hypothesis was that the total number of triggered reminders would decrease in the intervention group compared with the control group , indicating an improvement in patient care . Methods From July 2009 to October 2010 all the patients of one health center were r and omized to an intervention or a control group . The intervention consisted of patient-specific reminders concerning 59 different health conditions triggered when the healthcare professional ( HCP ) opened and used the EPR . In the intervention group , the triggered reminders were shown to the HCP ; in the control group , the triggered reminders were not shown . The primary outcome measure was the change in the number of reminders triggered over 12 months . We developed a unique data gathering method , the Repeated Study Virtual Health Check ( RSVHC ) , and used Generalized Estimation Equations ( GEE ) for analysing the incidence rate ratio , which is a measure of the relative difference in percentage change in the numbers of reminders triggered in the intervention group and the control group . Results In total , 13,588 participants were r and omized and included . Contrary to our expectation , the total number of reminders triggered increased in both the intervention and the control groups . The primary outcome measure did not show a significant difference between the groups . However , with the inclusion of patients followed up over only six months , the total number of reminders increased significantly less in the intervention group than in the control group when the confounding factors ( age , gender , number of diagnoses and medications ) were controlled for . Conclusions Computerized , tailored reminders in primary care did not decrease during the 12 months of follow-up time after the introduction of a patient-specific decision support system . Trial registration Clinical Trial.gov OBJECTIVES To describe patterns of comorbidity and multimorbidity in elderly people . DESIGN A community-based survey . SETTING Data were gathered from the Kungsholmen Project , a urban , community-based prospect i ve cohort in Sweden . PARTICIPANTS Adults aged 77 and older living in the community and in institutions of the geographically defined Kungsholmen area of Stockholm ( N=1,099 ) . MEASUREMENTS Diagnoses based on physicians '  examinations  and supported by hospital records , drug use , and blood sample s. Patterns of comorbidity and multimorbidity were evaluated using four analytical approaches : prevalence figures , conditional count , logistic regression models , and cluster analysis . RESULTS Visual impairments and heart failure were the diseases with the highest comorbidity ( mean 2.9 and 2.6 co-occurring conditions , respectively ) , whereas dementia had the lowest ( mean 1.4 comorbidities ) . Heart failure occurred rarely without any comorbidity ( 0.4 % ) . The observed prevalence of comorbid pairs of conditions exceeded the expected prevalence for several circulatory diseases and for dementia and depression . Logistic regression analyses detected similar comorbid pairs . The cluster analysis revealed five clusters . Two clusters included vascular conditions ( circulatory and cardiopulmonary clusters ) , and another included mental diseases along with musculoskeletal disorders . The last two clusters included only one major disease each ( diabetes mellitus and malignancy ) together with their most common consequences ( visual impairment and anemia , respectively ) . CONCLUSION In persons with multimorbidity , there exists co-occurrence of diseases beyond chance , which clinicians need to take into account in their daily practice . Some pathological mechanisms behind the identified clusters are well known ; others need further clarification to identify possible preventative strategies BACKGROUND Older people consume an increasing amount of medication . Polypharmacy is associated with an elevated risk of adverse health outcomes result ing in hospitalizations and sometimes death . OBJECTIVES To describe the prevalence of prescribed and over-the-counter ( OTC ) medications among older general practice patients living in the community . To determine predictors of polypharmacy ( five or more prescribed drugs ) from a variety of patient- and doctor-related factors . METHODS Sixty-seven r and omly selected practice s in two areas of Germany and 466 of their older patients ( 70 + years ) were recruited for a geriatric assessment study . A cross-sectional analysis of health problems , GPs ' awareness and their interventions was conducted . In this post hoc analysis , we assessed the  medication  use as reported by older patients and compared it with doctors ' perceived medication regimens for their respective patients . The detailed assessment of patients ' health and well-being enabled us to explore a variety of predictors of polypharmacy using logistic regression analysis with forward selection . RESULTS Study participants consumed an average of 3.7 prescribed medicines and an additional 1.4 OTC drugs . In all , 26.7 % of patients used five and more chronically prescribed drugs . A set of five determinants predicted polypharmacy best : breathlessness , hypertension , dependency on instrumental activities of daily living , low subjective health and medication disagreement between doctors and patients . CONCLUSION This older general practice population in Germany is among the top pharmaceutical user group of European study sample s. Apart from disease-specific determinants , GPs should be aware that low subjective health and medication disagreement are independent predictors of polypharmacy Abstract Objective To ascertain the current burden of adverse drug reactions ( ADRs ) through a prospect i ve analysis of all admissions to hospital . Design Prospect i ve observational study . Setting Two large general hospitals in Merseyside , Engl and . Participants 18 820 patients aged > 16 years admitted over six months and assessed for cause of admission . Main outcome measures Prevalence of admissions due to an ADR , length of stay , avoidability , and outcome . Results There were 1225 admissions related to an ADR , giving a prevalence of 6.5 % , with the ADR directly leading to the admission in 80 % of cases . The median bed stay was eight days , accounting for 4 % of the hospital bed capacity . The projected annual cost of such admissions to the NHS is £ 466 m ( € 706 m , $ 847 m ) . The overall fatality was 0.15 % . Most reactions were either definitely or possibly avoidable . Drugs most commonly implicated in causing these admissions included low dose aspirin , diuretics , warfarin , and non-steroidal anti-inflammatory drugs other than aspirin , the most common reaction being gastrointestinal bleeding . Conclusion The burden of ADRs on the NHS is high , accounting for considerable morbidity , mortality , and extra costs . Although many of the implicated drugs have proved benefit , measures need to be put into place to reduce the burden of ADRs and thereby further improve the benefit : harm ratio of the drugs Background Disease management programmes ( DMPs ) are costly and impose additional work load on general practitioners ( GPs ) . Data on their effectiveness are inconclusive . We therefore conducted a cluster-r and omised controlled trial to evaluate the effectiveness of the Austrian DMP for diabetes mellitus type 2 on HbA1c and quality of care for adult patients in primary care . Methods All GPs of Salzburg-province were invited to participate . After cluster-r and omisation by district , all patients with diabetes type 2 were recruited consecutively from 7 - 11/2007 . The DMP , consisting mainly of physician and patient education , st and ardised documentation and agreement on therapeutic goals , was implemented in the intervention group while the control group received usual care . We aim ed to show superiority of the intervention regarding metabolic control and process quality . The primary outcome measure was a change in HbA1c after one year . Secondary outcomes were days in the hospital , blood pressure , lipids , body mass index ( BMI ) , enrolment in patient education and regular guideline -adherent examination . Blinding was not possible . Results 92 physicians recruited 1489 patients ( 649 intervention , 840 control ) . After 401 ± 47 days , 590 intervention- patients and 754 controls had complete data . In the intention to treat analysis ( ITT ) of all 1489 patients , HbA1c decreased 0.41 % in the intervention group and 0.28 % in controls . The difference of -0.13 % ( 95 % CI -0.24 ; -0.02 ) was significant at p = 0.026 . Significance was lost in mixed models adjusted for baseline value and cluster-effects ( adjusted mean difference -0.03 ( 95 % CI -0.15 ; 0.09 , p = 0.607 ) . Of the secondary outcome measures , BMI and cholesterol were significantly reduced in the intervention group compared to controls in ITT after adjustments ( -0.53 kg/m² ; 95 % CI -1.03;-0.02 ; p = 0.014 and -0.10 mmol/l ; 95 % CI -0.21 ; -0.003 ; p = 0.043 ) . Additionally , more patients received patient education ( 49.5 % vs. 20.1 % , p < 0.0001 ) , eye- ( 71.0 % vs. 51.2 % , p < 0.0001 ) , foot examinations ( 73.8 % vs. 45.1 % , p < 0.0001 ) , and regular HbA1c checks ( 44.1 % vs. 36.0 % , p < 0.01 ) in the intervention group . Conclusion The Austrian  DMP implemented by statutory health insurance improves process quality and enhances weight reduction , but does not significantly improve metabolic control for patients with type 2 diabetes mellitus . Whether the small benefit seen in secondary outcome measures leads to better patient outcomes , remains unclear . Trial Registration Current Controlled trials Ltd. , IS RCT N27414162 INTRODUCTION STOPP ( Screening Tool of Older Persons '  potentially inappropriate Prescriptions ) is a new , systems-defined medicine review tool . We compared the performance of STOPP to that of established Beers ' criteria in detecting potentially inappropriate medicines ( PIMs ) 
    Output:
    
Discussion The principal hypothesis is that reduction of polypharmacy and inappropriate prescribing can improve the clinical composite outcome of hospitalization or death .
A positive result of the trial will contribute substantially to the improvement of care in multimorbidity .