***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: PURPOSE The Women to Women Diabetes Project tested the use of telecommunication technology to deliver diabetes education and social support to rural women with diabetes . The aims were to ( 1 ) test the effects of the computer intervention in providing support , information , and education on selected outcomes , and ( 2 ) evaluate the women 's attitudes toward and satisfaction with the intervention and the support provided . METHODS Thirty women were r and omized into computer and noncomputer groups and participated for 10 months . For 5 months , one group participated in a self-help support and educational group via the computer ; the other group continued to use their usual modes of support and communication .  Psychosocial well-being scales were administered and attitudes were surveyed . RESULTS Improving health and higher educational levels positively influenced measures of social support and quality of life .  Women who were married or who reported greater support had higher scores on the Personal Re source Question naire . The women expressed positive effects of the computer-based support group on their lives . CONCLUSIONS The intervention was enthusiastically accepted , and could be conducted effectively in isolated rural areas OBJECTIVE To conduct a 1-year r and omized clinical trial to evaluate a remote comprehensive diabetes self-management education ( DSME ) intervention , Diabetes TeleCare , administered by a dietitian and nurse/certified diabetes educator ( CDE ) in the setting of a federally qualified health center ( FQHC ) in rural South Carolina . RESEARCH DESIGN AND METHODS Participants were recruited from three member health centers of an FQHC and were r and omized to either Diabetes TeleCare , a 12-month , 13-session curriculum delivered using telehealth strategies , or usual care .  RESULTS Mixed linear regression model results for repeated measures showed a significant reduction in glycated hemoglobin ( GHb ) in the Diabetes TeleCare group from baseline to 6 and 12 months ( 9.4 ± 0.3 , 8.3 ± 0.3 , and 8.2 ± 0.4 , respectively ) compared with usual care ( 8.8 ± 0.3 , 8.6 ± 0.3 , and 8.6 ± 0.3 , respectively ) . LDL cholesterol was reduced at 12 months in the Diabetes TeleCare group compared with usual care . Although not part of the original study design , GHb was reduced from baseline to 12 and 24 months in the Diabetes TeleCare group ( 9.2 ± 0.4 , 7.4 ± 0.5 , and 7.6 ± 0.5 , respectively ) compared with usual care ( 8.7 ± 0.4 , 8.1 ± 0.4 , and 8.1 ± 0.5 , respectively ) in a post hoc analysis of a subset of the r and omized sample who completed a 24-month follow-up visit . CONCLUSIONS Telehealth effectively created access to successfully conduct a 1-year remote DSME by a nurse CDE and dietitian that improved metabolic control and reduced cardiovascular risk in an ethnically diverse and rural population BACKGROUND We examine the changes in waist circumference ( WC ) and body mass index ( BMI ) in older adults enrolled in a diabetes telemedicine program . The subjects were elderly Medicare beneficiaries participating in the rural ( upstate New York ) cohort of Informatics and Diabetes Education and Telemedicine , a r and omized , controlled trial using telemedicine to improve diabetes care in which the primary outcome was glycemic control . METHODS Ninety-two percent of the subjects had BMI > 25 kg/m(2 ) , and 65.8 % had a BMI > or = 30 kg/m(2 ) . Intervention subjects received home televisits with a dietitian or nurse educator every 4 - 6 weeks .  Blood glucose and blood pressure values  were review ed , and lifestyle and medication changes were recommended . Non-intervention subjects received usual care through their primary care physicians . Change in WC , BMI , diet , and exercise behaviors and knowledge were examined at baseline and 12 and 24 months . A mixed-effects path analysis was performed to examine direct and indirect effects . RESULTS The telemedicine participants increased diet and exercise knowledge over time ( P < 0.001 ) . It was estimated that women in the  telemedicine  group reduced their WC over the 2 years by 1.2 cm , whereas women in the usual care group increased their WC by almost 1 cm ( P = 0.02 ) . Path analysis demonstrated that the intervention , through improved diet and exercise knowledge , was related to the decrease in WC ( P = 0.006 ) and BMI ( P = 0.004 ) . CONCLUSIONS Diabetes case management using telemedicine improved self-reported diet and exercise knowledge , practice s , and behaviors , which in turn was associated with reductions in WC and BMI at 2 years OBJECTIVE The aim of this study was to examine patient-reported outcomes in a controlled trial of a multifaceted provider-level intervention to improve quality of care for rural patients with type 2 diabetes . RESEARCH DESIGN AND METHODS We conducted a before/after intervention study with concurrent controls in two rural regions in Alberta , Canada . The intervention consisted of six monthly visits by a multidisciplinary health care team and was primarily directed at primary care providers .  Clinical and patient-reported outcomes were assessed after 6 months . Patient-reported outcomes included changes in health-related quality of life ( Health Utilities Index Mark 3 [ HUI3 ] ) , satisfaction with care , lifestyle ( Diabetes Lifestyle Form ) , and adherence to self-care activities . Analysis of covariance was used to assess differences over time between the control and intervention regions . RESULTS A total of 200 intervention and 172 control subjects were included in this analysis . After adjusting for important clinical and demographic differences , a statistically significant and clinical ly important improvement in the overall HUI3 score was seen at the 6-month follow-up in the intervention region ( 0.06 [ 95 % CI 0.02 - 0.10 ] ) compared with the control region ( 0.01 [ -0.04 to 0.04 ] ) ( P = 0.03 for the difference between groups ) . Satisfaction with general medical care ( P < 0.001 between groups ) and diabetes care ( P < 0.001 between groups ) increased among patients in the intervention region compared with the control region . Self-efficacy , attitudes , and beliefs about diabetes control all increased in the intervention region when compared with the control region , but adherence to self-care activities did not . CONCLUSIONS A provider-level intervention directed at improving quality of clinical care for patients with type 2 diabetes also had a favorable impact on overall health-related quality of life , satisfaction with care , and other humanistic outcomes OBJECTIVE To determine the effects of a culturally competent diabetes self-management intervention in Mexican Americans with type 2 diabetes . RESEARCH DESIGN AND METHODS A prospect i ve , r and omized , repeated measures study was conducted on the Texas-Mexico border in Starr County . A total of 256 r and omly selected individuals with type 2 diabetes between 35 and 70 years of age , diagnosed with type 2 diabetes after 35 years of age , and accompanied by a family member or friend were included . The intervention consisted of 52 contact hours over 12 months and was provided by bilingual Mexican American nurses , dietitians , and community workers . The intervention involved 3 months of weekly instructional sessions on nutrition , self-monitoring of blood glucose , exercise , and other self-care topics and 6 months of biweekly support group sessions to promote behavior changes . The approach was culturally competent in terms of language , diet , social emphasis , family participation , and incorporation of cultural health beliefs . Outcomes included indicators of metabolic control ( HbA(1c ) and fasting blood glucose ) , diabetes knowledge , and diabetes-related health beliefs . RESULTS Experimental groups showed significantly lower levels of HbA(1c ) and fasting blood glucose at 6 and 12 months and higher diabetes knowledge scores . At 6 months , the mean HbA(1c ) of the experimental subjects was 1.4 % below the mean of the control group ; however , the mean level of the experimental subjects was still high ( > 10 % ) . CONCLUSIONS This study confirms the effectiveness of culturally competent diabetes self-management education on improving health outcomes of Mexican Americans , particularly for those individuals with HbA(1c ) levels > 10 % OBJECTIVE to examine the effects of the Informatics for Diabetes Education and Telemedicine ( IDEATel ) telemedicine intervention and pedometer use on physical activity ( PA ) and impairment in older adults with diabetes . DESIGN r and omised clinical trial . Subjects ethnically diverse medically underserved Medicare beneficiaries with diabetes ( n= 1,650 ) . METHODS participants received home videovisits with a diabetes educator every 4 - 6 weeks or usual care . All received a pedometer . Annual measurements included hemoglobin A1c , Comprehensive Assessment and Referral Evaluation Activities of Daily Living , Diabetes Self-Care Activities , Charlson Comorbidity Index , Luben Social Support and pedometer use . Mixed model analyses were performed using r and om effects to adjust for clustering within primary care physicians . RESULTS in the telemedicine group compared with the usual care group , the rate of decline in PA ( P= 0.0128 ) and physical impairment ( PI ) ( P= 0.0370 ) was significantly less over time . Significant mean endpoint differences were observed for PA ( P= 0.003 ) . Pedometer use was significantly associated with PA ( P= 0.0006 ) and PI ( P < 0.0001 ) . Baseline characteristics associated with greater PA included having fewer comorbid conditions ( P= 0.0054 ) , less depression ( P < 0.0001 ) , more social networking ( P < 0.0001 ) , lower BMI ( P < 0.0001 ) , male gender ( P < 0.0001 ) and lower hemoglobin A1c level ( P= 0.0045 ) . Similar predictors were observed for PI , except duration of diabetes also predicted increased impairment ( P < 0.0001 ) . Significant indirect effects were observed through use of the pedometer on reduced decline in PA ( P= 0.0024 , 0.0013 ) and PI ( P= 0.0024 , P < 0.0001 ) . CONCLUSIONS this telemedicine intervention reduced rates of decline in PA and impairment in older adults with diabetes . Pedometers may be a helpful inexpensive adjunct to diabetes initiatives delivered remotely with emerging technologies . Clinical Trials.gov identifier NCT 00271739 CONTEXT Telemedicine is a promising but largely unproven technology for providing case management services to patients with chronic conditions and lower access to care . OBJECTIVES To examine the effectiveness of a telemedicine intervention to achieve clinical management goals in older , ethnically diverse , medically underserved patients with diabetes . DESIGN , Setting , and Patients A r and omized controlled trial was conducted , comparing telemedicine case management to usual care , with blinded outcome evaluation , in 1,665 Medicare recipients with diabetes , aged > /= 55 years , residing in federally design ated medically underserved areas of New York State . Interventions Home telemedicine unit with nurse case management versus usual care . Main Outcome Measures The primary endpoints assessed over 5 years of follow-up were hemoglobin A1c ( HgbA1c ) , low density lipoprotein ( LDL ) cholesterol , and blood pressure levels . RESULTS Intention-to-treat mixed models showed that telemedicine achieved net overall reductions over five years of follow-up in the primary endpoints ( HgbA1c , p = 0.001 ; LDL , p < 0.001 ; systolic and diastolic blood pressure , p = 0.024 ; p < 0.001 ) . Estimated differences ( 95 % CI ) in year 5 were 0.29 ( 0.12 , 0.46)% for HgbA1c , 3.84 ( -0.08 , 7.77 ) mg/dL for LDL cholesterol , and 4.32 ( 1.93 , 6.72 ) mm Hg for systolic and 2.64 ( 1.53 , 3.74 ) mm Hg for diastolic blood pressure . There were 176 deaths in the intervention group and 169 in the usual care group ( hazard ratio 1.01 [ 0.82 , 1.24 ] ) . CONCLUSIONS Telemedicine case management result ed in net improvements in HgbA1c , LDL-cholesterol and blood pressure levels over 5 years in medically underserved Medicare beneficiaries . Mortality was not different between the groups , although power was limited . Trial Registration http:// clinical trials.gov Identifier : NCT00271739 OBJECTIVE Despite good evidence and clinical practice guidelines , studies document that treatment of type 2 diabetes is less than optimal . Lack of re sources or limited access may put patients in rural communities at particular risk for suboptimal care . RESEARCH DESIGN AND METHODS We conducted a prospect i ve , before/after study with concurrent controls to assess the effectiveness of a multidisciplinary diabetes outreach service ( intervention ) for improving the quality of care for rural patients with type 2 diabetes . Our intervention consisted of six monthly visits by a traveling team 
    Output:
    
Most of the interventions produced a positive impact on processes of care or diabetes self-management , but a lower effect on health outcomes was observed .
Interventions with multiple strategies and targeting the health system and /or clinicians were more likely to be effective .
This work identified several characteristics associated with successful interventions to improve the quality of diabetes care in rural areas .