***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: To determine whether adding telehealth technology to traditional home care services increases health-related quality of life ( HRQOL ) and home care satisfaction , and decreases re source utilization among home care patients . This trial included 37 home care patients receiving services in a Veterans Affairs medical center , r and omized into intervention and control groups . Outcome measures included patient satisfaction and HRQOL at baseline and 6-month follow- up , and the use of inpatient and outpatient services before and during the 6-month study period . Intervention group patients reported greater improvement in the mental health component of HRQOL , ( t = 2.27 ; df = 15 ; p = 0.04 ) . Satisfaction with the telehealth equipment was high ( means exceeded 4.0 on six measures ranging from 1 - 5 ) . However , no statistically significant differences were observed between intervention and control groups in terms of changes in physical health , inpatient admissions , bed days of care , emergency department visits , or general satisfaction with home care services . Intervention group members did show a trend ( p = 0.10 ) toward fewer overall outpatient visits ( mean = 29.1 ; st and ard deviation [ SD ] + /- 30.1 ) compared to those receiving traditional home care services ( mean = 38.9 ; SD + /- 28.9 ) The use of telehealth services as an adjunct to traditional home care is associated with greater improvements in mental health status and a trend toward lower use of inpatient and outpatient healthcare services . Further work , utilizing larger sample sizes , is needed to investigate the relationship between telehealth services , the use of healthcare re sources , and other outcomes Pulmonary rehabilitation is beneficial for patients with chronic lung disease . However , long-term maintenance has been difficult to achieve after short-term treatment . We evaluated a telephone-based maintenance program after pulmonary rehabilitation in 172 patients with chronic lung disease recruited from pulmonary rehabilitation graduates . Subjects were r and omly assigned to a 12-month maintenance intervention with weekly telephone contacts and monthly supervised reinforcement sessions ( n = 87 ) or st and ard care ( n = 85 ) and followed for 24 months . Except for a slight imbalance between sexes , experimental and control groups were equivalent at baseline and showed similar improvements after rehabilitation . During the 12-month intervention , exercise tolerance ( maximum treadmill workload and 6-minute walk distance ) and overall health status ratings were better maintained in the experimental group together with a reduction in hospital days . There were no group differences for other measures of pulmonary function , dyspnea , self-efficacy , generic and disease-specific quality of life , and health care use . By 24 months , there were no significant group differences . Patients returned to levels close to but above prerehabilitation measures . We conclude that a maintenance program of weekly telephone calls and monthly supervised sessions produced only modest improvements in the maintenance of benefits after pulmonary rehabilitation It was postulated that home hospitalisation ( HH ) of selected chronic obstructive pulmonary disease ( COPD ) exacerbations admitted at the emergency room ( ER ) could facilitate a better outcome than conventional hospitalisation . To this end , 222 COPD patients ( 3.2 % female ; 71±10 yrs ( mean±sd ) ) were r and omly assigned to HH ( n=121 ) or conventional care ( n=101 ) . During HH , integrated care was delivered by a specialised nurse with the patient 's free-phone access to the nurse ensured for an 8‐week follow-up period . Mortality ( HH : 4.1 % ; controls : 6.9 % ) and hospital readmissions ( HH : 0.24±0.57 ; controls : 0.38±0.70 ) were similar in both groups . However , at the end of the follow-up period , HH patients showed : 1 ) a lower rate of ER visits ( 0.13±0.43 versus 0.31±0.62 ) ; and 2 ) a noticeable improvement of quality of life ( Δ St George 's Respiratory Question naire ( SGRQ ) , −6.9 versus −2.4 ) . Furthermore , a higher percentage of patients had a better knowledge of the disease ( 58 % versus 27 % ) , a better self-management of their condition ( 81 % versus 48 % ) , and the patient 's satisfaction was greater . The average overall direct cost per HH patient was 62 % of the costs of conventional care , essentially due to fewer days of inpatient hospitalisation ( 1.7±2.3 versus 4.2±4.1 days ) . A comprehensive home care intervention in selected chronic obstructive pulmonary disease exacerbations appears as cost effective . The home hospitalisation intervention  generates better outcomes at lower costs than conventional care 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 Chronic obstructive pulmonary disease ( COPD ) is a slowly progressive lung disease involving the airways and /or pulmonary parenchyma , result ing in a gradual loss of lung function . The symptoms of COPD range from chronic cough , sputum production , and wheezing to more severe symptoms , such as dyspnea , poor exercise tolerance , and signs or symptoms of right-sided heart failure . In the United States , COPD affects more than 5 % of the adult population and is the 4th leading cause of death and the 12th leading cause of morbidity ( 1 , 2 ) . The purpose of this guideline is to present the available evidence on the diagnosis and management of COPD . The target audience for this guideline is all physicians , and the target patient population is all adults with COPD . These recommendations are based on the systematic evidence review in this issue by Wilt and colleagues ( 3 ) and the Agency for Healthcare Research and Quality sponsored Minnesota Evidence -based Practice Center evidence report ( 4 ) . Methods The literature search included studies from MEDLINE and the Cochrane data base from 1966 to May 2005 ( 4 ) . In addition , search es for oxygen , inhaled therapies , and disease management were up date d through March 2007 . The exclusion criteria were children or individuals with asthma , restrictive lung disease , or 1-antitrypsin deficiency . The methods of Schulz and colleagues ( 5 ) were used to assess the quality of r and omized , controlled trials . Results from the individual studies were aggregated to produce pooled estimates . Heterogeneity was assessed by using the chi-square and I2 tests ( 6 ) , and the DerSimonianLaird r and om-effects model was used ( 7 ) . Details about the methods used for the systematic evidence review may be found in detail in the background paper by Wilt and colleagues in this issue ( 3 ) . This guideline grade s the evidence and recommendations by using the American College of Physicians ' clinical practice guidelines grading system adopted from the classification developed by the Grading of Recommendations , Assessment , Development , and Evaluation ( GRADE ) workgroup ( Table 1 ) . Table 1 . American College of Physicians ' Clinical Practice Guidelines Grading System The objective of this guideline is to analyze the evidence for the following questions : 1 . What is the value of clinical examination for prediction of airflow obstruction ( AO ) ? 2 . What is the incremental value of spirometry for case finding and diagnosis of adults who are COPD treatment c and i date s ? 3 . What management strategies are effective for the treatment for COPD ( inhaled therapies , pulmonary rehabilitation programs , and supplemental long-term oxygen therapy ) ? Clinical Examination for Prediction of Airflow Obstruction The National Health and Nutrition Examination Survey III and a systematic review of 19 studies examining the accuracy of clinical examination to predict AO were used to estimate the prevalence of COPD and AO and clinical diagnostic accuracy ( 8 , 9 ) . Cigarette smoking is the most common cause of COPD . A 70pack-year history of smoking was the best predictor of AO , with a positive likelihood ratio of 8.0 but a sensitivity of only 40 % . The literature showed that findings from physical examination also had high specificity ( > 90 % ) but poor sensitivity . In addition , sputum production or wheezing was also associated with an increased likelihood of AO . Evidence to assess the utility of combining items that were included in a clinical examination to predict AO showed that combinations of findings were more helpful for diagnosing the presence of AO ( 1015 ) . The best combination to exclude COPD included never having smoked , no reported wheezing , and no wheezing on examination . A patient with any combination of 2 findings ( 70pack-year history of smoking , history of COPD , or decreased breath sounds ) can be considered likely to have AO ( defined as FEV1 less than 60 % predicted or FEV1FVC ratio less than 0.60 ) ( positive likelihood ratio , 34 ) ( 915 ) . Incremental Value of Spirometry Spirometry may be useful to identify patients who may benefit from initiating therapy ( Table 2 ) . The evidence supports inhaled treatment in patients who have symptoms and FEV1 less than 60 % predicted . The literature also showed that respiratory symptom status is not a reliable indicator of the presence of AO . However , as spirometric values worsened , individuals reported more respiratory symptoms , such as cough , sputum , wheezing , or dyspnea . But 33 % of individuals with normal spirometric values reported respiratory symptoms . In addition , 21 % of individuals who had severe to very severe AO by spirometry reported no symptoms . Nearly 80 % of persons reporting any respiratory symptom had normal airflow , and only 3 % to 4 % had severe to very severe AO ( 8) . Table 2 . Spirometric Classifications of Chronic Obstructive Pulmonary Disease Evidence is insufficient to support widespread use of spirometry for testing adults with no respiratory symptoms , including those with current and past exposure to COPD risk factors . Spirometry may be beneficial in symptomatic adults who have an FEV1 greater than 60 % predicted for determining when to initiate therapy . The evidence does not support periodic spirometry after initiation of therapy to monitor ongoing disease status or to modify therapy . Furthermore , no high- quality evidence supports the use of obtaining and providing spirometry results to improve smoking cessation , identify and treat asymptomatic individuals to prevent future respiratory symptoms , or reduce spirometric decline in lung function . Inhaled Therapies Exacerbations The literature showed that monotherapy with long-acting inhaled -agonists , a long-acting inhaled anticholinergic , or inhaled corticosteroids was superior to placebo or short-acting anticholinergics in reducing exacerbations .  Tiotropium ( relative risk , 0.84 [ 95 % CI , 0.78 to 0.90 ] ) , long-acting -agonists ( relative risk , 0.87 [ CI , 0.82 to 0.93 ] ) , and corticosteroids ( relative risk , 0.85 [ CI , 0.75 to 0.96 ] ) reduce the relative risk for at least 1 exacerbation compared with placebo . However , ipratropium , a short-acting anticholinergic , was not superior to placebo ( relative risk , 0.95 [ CI , 0.78 to 1.15 ] ) . In comparison studies , long-acting -agonists were as effective as  ipratropium  ( relative risk , 0.89 [ CI , 0.72 to 1.10 ] ) ,  corticosteroids  ( relative risk , 1.06 [ CI , 0.84 to 1.34 ] ) , or a  long-acting anticholinergic ( tiotropium ) ( relative risk , 1.11 [ CI , 0.93 to 1.33 ] ) . Also , long-acting -agonists were slightly superior to dual D2 dopamine receptor2-agonist ( sibenadet ) ( relative risk , 0.80 [ CI , 0.63 to 1.02 ] ) , and tiotropium 
    Output:
    
Telehealthcare in COPD appears to have a possible impact on the quality of life of patients  and the number of times patients attend the emergency department and the hospital .