***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: Objective To assess the effect of home based telehealth interventions on the use of secondary healthcare and mortality . Design Pragmatic , multisite , cluster r and omised trial comparing telehealth with usual care , using data from routine administrative data sets . General practice was the unit of r and omisation . We allocated practice s using a minimisation algorithm , and did analyses by intention to treat . Setting 179 general practice s in three areas in Engl and . Participants 3230 people with diabetes , chronic obstructive pulmonary disease , or heart failure recruited from practice s between May 2008 and November 2009 . Interventions Telehealth involved remote exchange of data between patients and healthcare professionals as part of patients ’ diagnosis and management . Usual care reflected the range of services available in the trial sites , excluding telehealth . Main outcome measure Proportion of patients admitted to hospital during 12 month trial period . Results Patient characteristics were similar at baseline . Compared with controls , the intervention group had a lower admission proportion within 12 month follow-up ( odds ratio 0.82 , 95 % confidence interval 0.70 to 0.97 , P=0.017 ) . Mortality at 12 months was also lower for intervention patients than for controls ( 4.6 % v 8.3 % ; odds ratio 0.54 , 0.39 to 0.75 , P<0.001 ) . These differences in admissions and mortality remained significant after adjustment . The mean number of emergency admissions per head also differed between groups ( crude rates , intervention 0.54 v control 0.68 ) ; these changes were significant in unadjusted comparisons ( incidence rate ratio 0.81 , 0.65 to 1.00 , P=0.046 ) and after adjusting for a predictive risk score , but not after adjusting for baseline characteristics . Length of hospital stay was shorter for intervention patients than for controls ( mean bed days per head 4.87 v 5.68 ; geometric mean difference −0.64 days , −1.14 to −0.10 , P=0.023 , which remained significant after adjustment ) . Observed differences in other forms of hospital use , including notional costs , were not significant in general . Differences in emergency admissions were greatest at the beginning of the trial , during which we observed a particularly large increase for the control group . Conclusions Telehealth is associated with lower mortality and emergency admission rates . The reasons for the short term increases in admissions for the control group are not clear , but the trial recruitment processes could have had an effect . Trial registration number International St and ard R and omised Controlled Trial Number Register IS RCT N43002091 summary We conducted a qualitative evaluation of the introduction of a telenursing service . The service used an analogue videophone linked with a physiological monitoring device , which allowed the transmission of data between the patient 's home and the hospital . A research er kept a detailed diary of day-to-day activity for the first year of the project . Computer software for  qualitative data analysis was used to code the text and the analysis followed the principles of constant comparison . The diary entries documented how the commercially available equipment was adapted to suit the organization and content of the nurses ’ work . The nurses made a number of suggestions to improve the user-friendliness of the equipment . The technology , the existing home care service ( the comparison arm of the study ) and the r and omized controlled trial itself all underwent continuous change . The traditionalr and omized control design of trial has limitations in this situation , and there is a need for more realistic trial design An ethnographic ( participant observation ) study was undertaken of the socio-technical processes involved in the implementation , within a r and omized controlled trial , of a home telehealth nursing service for patients with chronic obstructive pulmonary disease ( COPD ) . Ethnographic field notes were taken about technology-related tasks and the interplay between the research team and the 12 nurses who were to use the telehealth equipment .  Views of the technology were linked to views of professional self-image and status . The technology was sometimes seen as unhelpful in establishing effective relationships with patients . Considerable work by all participants , over a period of months , was required to develop the technology in ways that minimized the risk to the stability of the specialist service and existing nurse – patient relationships . Our work highlights the complex problems that health professionals encounter when they try to integrate new technologies into routine service delivery . The concerns arising from the interplay of new technology with existing professional practice s and relationships go beyond simple issues of training We have established a r and omized controlled trial of  home telecare .  The intervention aims to address a growing problem in the National Health Service ( NHS ) , that is , high admission rates of patients with exacerbations of chronic obstructive pulmonary disease ( COPD ) . Equipment procurement for the trial has been difficult , as no single supplier was able to meet the project 's full requirements . The fact that the service is provided by existing clinical NHS staff has advantages when considering the generalizability of the results within the NHS . However , there are also disadvantages , since existing staff have little research experience . Considerable time has been required to help staff familiarize themselves with the equipment and become comfortable with its use . This has posed a barrier to the implementation of the service A r and omized controlled trial of home telecare for the management of acute exacerbations of chronic obstructive pulmonary disease has been undertaken in the north-west of Engl and . A videophone was used that communicates via the ordinary telephone network . The intervention period for each participant was two weeks . Participants in the telecare arm of the trial were asked to complete logbooks to record their experiences of each telecare encounter . A simple , self-completed , 10–item question naire was used that consisted of a Likert scale , ranging from 1 ( totally disagree ) to 5 ( totally agree ) . Fourteen nurses completed 150 logbooks and 22 patients completed 145 logbooks . These results demonstrate significant differences in perception between patients and their health-care providers with regard to telecare encounters across all the domains addressed . Participating patients consistently demonstrated more positive views of the telecare encounters than their health-care providers Objectives : To perform a process evaluation of a r and omized controlled trial ( RCT ) of home telecare for the management of acute exacerbations of chronic obstructive pulmonary disease ( COPD ) , using the normalization process model ( NPM ) as an explanatory framework . Methods : Semi-structured interviews were carried out with patients ( n = 9 ) and nurses ( n = 11 ) participating in a RCT . A framework approach to data analysis was used . Results : The telecare service did not provide an interactional advantage for the nurses providing this service and did not fit with the nurses ' views of the most appropriate or preferred use of their skills . The telecare service seemed unlikely to become normalized as part of routine healthcare delivery , because the nursing team lacked confidence that it was a safe way to provide healthcare in this context and it was not perceived as improving efficiency . Discussion : The NPM effectively mapped onto the study findings and explained those factors that inhibited the routine delivery of COPD services by telecare 
    Output:
    
Identified factors affecting staff acceptance centred on the negative impact of service change , staff-patient interaction , credibility and autonomy , and technical issues .
If telehealth is to be implemented , studies indicate that the lack of acceptance of this new way of working may be a key barrier .