***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: Background Diabetes is a chronic medical condition accompanied by a considerable health-related quality of life ( HRQL ) burden . The purpose of this analysis was to use generic measures of HRQL to describe HRQL deficits associated with varying degrees of severity of type 2 diabetes . Methods The R AND -12 physical and mental health composites ( PHC and MHC , respectively ) and Health Utilities Index Mark 3 ( HUI3 ) were self-completed by 372 subjects enrolled in a prospect i ve , controlled study of an intervention to improve care for individuals with type 2 diabetes in rural communities . Analysis of covariance was used to assess differences in HRQL according to disease severity and control of blood glucose . Disease severity was defined in terms of treatment intensity , emergency room visits and absenteeism from work specifically attributable to diabetes . To control for potential confounding , the analysis was adjusted for important sociodemographic and clinical characteristics . Results The PHC and MHC were significantly lower for individuals treated with insulin as compared to diet alone ( PHC : 41.01 vs 45.11 , MHC : 43.23 vs 47.00 , p < 0.05 ) . Individuals treated with insulin had lower scores on the vision , emotion and pain attributes of the HUI3 than individuals managed with oral medication or diet . The PHC , MHC , pain attribute and overall score on the HUI3 captured substantial decrements in HRQL associated with absenteeism from work due to diabetes , while the burden associated with emergency room utilization for diabetes was seen in the PHC and HUI3 pain attribute . Conclusions We concluded that generic measures of HRQL captured deficits associated with more severe disease in type 2 diabetes OBJECTIVE To determine whether using the chronic care model ( CCM ) in an underserved community leads to improved clinical and behavioral outcomes for people with diabetes . RESEARCH DESIGN AND METHODS This multilevel , cluster- design , r and omized controlled trial examined the effectiveness of a CCM-based intervention in an underserved urban community . Eleven primary care practice s , along with their patients , were r and omized to three groups : CCM intervention ( n = 30 patients ) , provider education only ( PROV group ) ( n = 38 ) , and usual care ( UC group ) ( n = 51 ) . RESULTS A marked decline in HbA(1c ) was observed in the CCM group ( -0.6 % , P = 0.008 ) but not in the other groups . The magnitude of the association remained strong after adjustment for clustering ( P = 0.01 ) . The same pattern was observed for a decline in non-HDL cholesterol and for the proportion of participants who self-monitor blood glucose in the CCM group ( non-HDL cholesterol : -10.4 mg/dl , P = 0.24 ; self-monitor blood glucose : + 22.2 % , P < 0.0001 ) , with statistically significant between-group differences in improvement ( non-HDL cholesterol : P = 0.05 ; self-monitor blood glucose : P = 0.03 ) after adjustment . The CCM group also showed improvement in HDL cholesterol ( + 5.5 mg/dl , P = 0.0004 ) , diabetes knowledge test scores ( + 6.7 % , P = 0.07 ) , and empowerment scores ( + 2 , P = 0.02 ) . CONCLUSIONS These results suggest that implementing the CCM in the community is effective in improving clinical and behavioral outcomes in patients with diabetes OBJECTIVE To examine individual- and plan-level factors related to improved diabetes care and outcomes between 1999 and 2001 among elderly Medicare managed care beneficiaries with diabetes . STUDY DESIGN Retrospective analysis of Medicare and individual-level Health Plan and Employer Data Information Set data . METHODS We merged  Medicare demographic information with person-level data regarding 6 comprehensive diabetes care measures  provided by the National Committee on Quality Assurance for Medicare managed care enrollees for 1999 . Then we identified those beneficiaries for whom comprehensive diabetes care information was also reported in 2001 , and determined the improvement for each measure . Data on persons not meeting the comprehensive diabetes care criteria in 1999 were analyzed to determine the factors associated with appropriate care and outcomes in 2001 . RESULTS Of the 174 combinations of individual- or plan-level factors and comprehensive diabetes care measures , 167 showed significant improvements . Nonetheless , for most of the 6 comprehensive diabetes care measures , poor care occurred more frequently for black patients than for white patients , among individuals in for-profit versus not for profit plans , and among individuals in independent practice association plans compared with group and staff model plans . Among the beneficiaries whose healthcare failed to meet the comprehensive diabetes care guidelines in 1999 , by 2001 , care guidelines were met in approximately three fourths for hemoglobin A1c and low-density lipoprotein cholesterol testing , but in only one half for eye examinations , low-density lipoprotein cholesterol control , and nephropathy monitoring . CONCLUSIONS Between 1999 and 2001 , care of elderly Medicare patients with diabetes improved , including among individuals who previously had not received appropriate care . However , more improvement is needed to achieve e quality among members of all race groups and plan types BACKGROUND : Interactive Health Communication Applications ( IHCAs ) are computer-based , usually web-based health information packages for patients that combine information with at least one of social support , decision support , or behaviour change support . These are innovations in health care and their effects on health are uncertain . OBJECTIVES : To assess the effects of IHCAs for people with chronic disease . SEARCH STRATEGY : We design ed a four-part search strategy . First , we search ed electronic bibliographic data bases for published work ; second , we search ed the grey literature and third , we search ed for ongoing and recently completed clinical trials in the appropriate data bases . Finally , research ers of included studies were contacted , and reference lists from relevant primary and review articles were followed up . As IHCAs require relatively new technology , the search commenced at 1990 where possible . SELECTION CRITERIA : R and omised controlled trials ( RCTs ) of Interactive Health Communication Applications for adults and children with chronic disease . DATA COLLECTION AND ANALYSIS : One review er screened abstract s. Two review ers screened all c and i date studies to determine eligibility , apply quality criteria , and extract data from included studies . Authors of included RCTs were contacted for missing data . Results of RCTs were pooled using a r and om effects model and st and ardised mean differences ( SMDs ) were calculated to provide net effect sizes . MAIN RESULTS : We screened 24,757 unique citations and retrieved 958 papers for further assessment , yielding 28 RCTs involving 4042 participants . One of these had an inadequate method of concealment of allocation , and sensitivity analyses were performed to determine the effects of including or excluding these data in the meta-analyses . Results in the abstract are from the meta-analyses excluding data from this study .IHCAs were found to have a positive effect on knowledge ( SMD 0.49 ; 95 % confidence interval ( CI ) 0.14 to 0.84 ) and on social support ( SMD 0.47 ; 95 % CI 0.28 to 0.66 ) . IHCAs were found to have no effect on self-efficacy ( SMD 0.15 ; 95 % CI -0.13 to 0.43 ) or behavioural outcomes ( SMD -0.09 ; 95 % CI -0.49 to 0.32 ) . IHCAs had a negative effect on clinical outcomes ( SMD -0.32 ; 95 % CI -0.63 to -0.02 ) . REVIEW ERS ' CONCLUSIONS : The number and range of IHCAs is increasing rapidly ; however there is a shortage of high quality evaluative data . Consumers who wish to increase their knowledge or social support amongst people with a similar problem may find an IHCA helpful . However , consumers whose primary aim is to achieve optimal clinical outcomes should not use an IHCA at present . Further research is needed to determine the reason for this negative effect on clinical outcomes , whether an optimal IHCA can achieve behaviour change and improved health outcomes , and if so , what are the essential features of such an IHCA , and the extent to which they differ according to patient group or condition Abstract Objective : To assess the effect of a multifaceted intervention directed at general practitioners on six year mortality , morbidity , and risk factors of patients with newly diagnosed type 2 diabetes . Design : Pragmatic , open , controlled trial with r and omisation of practice s to structured personal care or routine care ; analysis after 6 years . Setting : 311 Danish practice s with 474 general practitioners ( 243 in intervention group and 231 in comparison group ) . Participants : 874 ( 90.1 % ) of 970 patients aged ≥40 years who had diabetes diagnosed in 1989 - 91 and survived until six year follow up . Intervention : Regular follow up and individualised goal setting supported by prompting of doctors , clinical guidelines , feedback , and continuing medical education . Main outcome measures : Predefined clinical non-fatal outcomes , overall mortality , risk factors , and weight . Results : Predefined non-fatal outcomes and mortality were the same in both groups . The following risk factor levels were lower for intervention patients than for comparison patients ( median values ) : fasting plasma glucose concentration ( 7.9 v 8.7 mmol/l , P=0.0007 ) , glycated haemoglobin ( 8.5 % v 9.0 % , P<0.0001 ; reference range 5.4 - 7.4 % ) , systolic blood pressure ( 145 v 150 mm Hg , P=0.0004 ) , and cholesterol concentration ( 6.0 v 6.1 mmol/l , P=0.029 , adjusted for baseline concentration ) . Both groups had lost weight since diagnosis ( 2.6 v 2.0 kg ) . Metformin was the only drug used more frequently in the intervention group ( 24 % ( 110/459 ) v 15 % (61/415)).Intervention doctors arranged more follow up consultations , referred fewer patients to diabetes clinics , and set more optimistic goals . Conclusions : In primary care , individualised goals with educational and surveillance support may for at least six years bring risk factors of patients with type 2 diabetes to a level that has been shown to reduce diabetic complications but without weight gain . What is already known on this topic Evidence is increasing that control of hyperglycaemia , hypertension , and dyslipidaemia may postpone the development of diabetic complications in patients with type 2 diabetes Maintaining good control over a long period can be difficult What this study adds Structured individualised personal care with educational and surveillance support for general practitioners reduced levels of risk factors in type 2 diabetic patients after six years Risk factors were reduced to a level that has been shown to have a beneficial effect on diabetic complications Participants also showed modest weight PURPOSE To evaluate the effects of a collaborative case management intervention for patients with poorly controlled type 2 diabetes on glycemic control , intermediate cardiovascular outcomes , satisfaction with care , and re source utilization . METHODS We conducted a r and omized controlled trial at two Department of Veterans Affairs Medical Centers involving 246 veterans with diabetes and baseline hemoglobin A(1C ) ( HbA(1C ) ) levels > or=7.5 % . Two nurse practitioner case managers worked with patients and their primary care providers , monitoring and coordinating care for the intervention group for 18 months through the use of telephone contacts , collaborative goal setting , and treatment algorithms . Control patients received educational material s and usual care from their primary care providers . RESULTS At the conclusion of the study , both case management and control patients remained under poor glycemic control and there was little difference between groups in mean exit HbA(1C ) level ( 9.3 % vs. 9.2 % ; difference = 0.1 % ; 95 % confidence interval : -0.4 % to 0.7 % ; P = 0.65 ) . There was also no evidence that the intervention result ed in improvements in low-density lipoprotein cholesterol level or blood pressure control or greater intensification in medication therapy . However , intervention patients were substantially more satisfied with their diabetes care , with 82 % rating their providers as better than average compared with 64 % of patients in the control group ( P = 0.04 ) . CONCLUSION An intervention of collaborative case management did not improve key physiologic outcomes for high-risk patients with type 2 diabetes . The type of patients targeted for intervention , organizational factors , and program structure are likely critical determinants of the effectiveness of case management . Health systems must underst and the potential limitations before expending substantial re sources on case management , as the expected improvements in outcomes and downstream cost savings may not always be realized 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 . 
    Output:
    
Conclusions There is large diversity in diabetes care programmes and related quality indicators .
From this review and our analysis on the mutual relationship between diversity in diabetes care programmes and the conceptualization of high quality diabetes care , we conclude that no single conceptual framework used to date provides a comprehensive overview of attributes of high quality diabetes care linked to quality indicators at the structure , process and outcome level .