human
***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 African Americans suffer disproportionately from diabetes complications , but little research has focused on how to improve diabetic control in this population . There are also few or no data on a combined primary care and community-based intervention approach . METHODS We r and omly assigned 186 urban African Americans with type 2 diabetes ( 76 % female , mean A SD age 59 A 9 years ) to 1 of 4 parallel arms : ( 1 ) usual care only ; ( 2 ) usual care + nurse case manager ( NCM ) ; ( 3 ) usual care + community health worker ( CHW ) ; ( 4 ) usual care + nurse case manager/community health worker team . Using the framework of the Precede-Proceed behavioral model , interventions included patient counseling regarding self-care practice s and physician reminders . RESULTS The 2-year follow-up visit was completed by 149 individuals ( 84 % ) . Compared to the Usual care group , the NCM group and the CHW group had modest declines in HbA(1c ) over 2 years ( 0.3 and 0.3 % , respectively ) , and the combined NCM/CHW group had a greater decline in HbA(1c ) ( 0.8 % . P = 0.137 ) . After adjustment for baseline differences and /or follow-up time , the combined NCM/CHW group showed improvements in triglycerides ( -35.5 mg/dl ; P = 0.041 ) and diastolic blood pressure , compared to the usual care group ( -5.6 mmHg ; P = 0.042 ) . CONCLUSIONS Combined NCM/CHW interventions may improve diabetic control in urban African Americans with type 2 diabetes . Although results were clinical ly important , they did not reach statistical significance . This approach deserves further attention as a means to reduce the excess risk of diabetic complications in African Americans OBJECTIVE To assess the effects of web-based care management on glucose and blood pressure control over 12 months in patients with poorly controlled diabetes . RESEARCH DESIGN AND METHODS For this study , 104 patients with diabetes and HbA(1c ) ( A1C ) > or = 9.0 % who received their care at a Department of Veterans Affairs medical center were recruited . All participants completed a  diabetes education class  and were r and omized to continue with their usual care ( n = 52 ) or receive web-based care management ( n = 52 ) . The web-based group received a notebook computer , glucose and blood pressure monitoring devices , and access to a care management website . The website provided educational modules , accepted uploads from monitoring devices , and had an internal messaging system for patients to communicate with the care manager . RESULTS Participants receiving web-based care management had lower A1C over 12 months ( P < 0.05 ) when compared with education and usual care . Persistent website users had greater improvement in A1C when compared with intermittent users ( -1.9 vs. -1.2 % ; P = 0.051 ) or education and usual care ( -1.4 % ; P < 0.05 ) . A larger number of website data uploads was associated with a larger decline in A1C ( highest tertile -2.1 % , lowest tertile -1.0 % ; P < 0.02 ) . Hypertensive participants in the web-based group had a greater reduction in systolic blood pressure ( P < 0.01 ) . HDL cholesterol rose and triglycerides fell in the web-based group ( P < 0.05 ) . CONCLUSIONS Web-based care management may be a useful adjunct in the care of patients with poorly controlled diabetes OBJECTIVE To evaluate the impact of systematic patient evaluation and patient and provider feedback on the processes and intermediate outcomes of diabetes care in Independent Practice Association model internal medicine practice s. RESEARCH DESIGN AND METHODS Nine practice s providing care to managed care patients were r and omly assigned as intervention or comparison sites . Intervention-site subjects had Annual Diabetes Assessment Program ( ADAP ) assessment s ( HbA(1c  ) , blood pressure , lipids , smoking , retinal photos , urine microalbumin , and foot examination ) at years 1 and 2 . Comparison-site subjects had ADAP assessment s at year 2 . At Intervention sites , year 1 ADAP results were review ed with subjects , mailed to providers , and incorporated into electronic medical records with guideline -generated suggestions for treatment and follow-up . Medical records were evaluated for both groups for the year before both the year 1 and year 2 ADAP assessment s. Processes and intermediate outcomes were compared using linear and logistic mixed hierarchical models . RESULTS Of 284 eligible subjects , 103 of 173 ( 60 % ) at the Intervention sites and 71 of 111 ( 64 % ) at the comparison sites participated ; 83 of 103 ( 81 % ) of the intervention-site subjects returned for follow-up at year 2 . Performance of the six recommended assessment s improved in intervention-site subjects at year 2 compared with year 1 ( 5.8 vs. 4.3 , P = 0.0001 ) and compared with comparison-site subjects at year 2 ( 4.2 , P = 0.014 ) . No significant changes were noted in intermediate outcomes . CONCLUSIONS The ADAP significantly improved processes of care but not intermediate outcomes . Additional interventions are needed to improve intermediate outcomes BACKGROUND In the Medicare Modernization Act of 2003 , Congress required the Centers for Medicare and Medicaid Services to test the commercial disease-management model in the Medicare fee-for-service program . METHODS The Medicare Health Support Pilot Program was a large , r and omized study of eight commercial programs for disease management that used nurse-based call centers . We r and omly assigned patients with heart failure , diabetes , or both to the intervention or to usual care ( control )  and compared them with the use of a difference-in-differences method to evaluate the effects of the commercial programs on the quality of clinical care , acute care utilization , and Medicare expenditures for Medicare fee-for-service beneficiaries . RESULTS The study included 242,417 patients ( 163,107 in the intervention group and 79,310 in the control group ) . The eight commercial disease-management programs did not reduce hospital admissions or emergency room visits , as compared with usual care . We observed only 14 significant improvements in process-of-care measures out of 40 comparisons . These modest improvements came at substantial cost to the Medicare program in fees paid to the disease-management companies ( $ 400 million ) , with no demonstrable savings in Medicare expenditures . CONCLUSIONS In this large study , commercial disease-management programs using nurse-based call centers achieved only modest improvements in quality -of-care measures , with no demonstrable reduction in the utilization of acute care or the costs of care Purpose This study developed and tested a culturally appropriate , church-based intervention to improve diabetes self-management . Research Design and Methods This was a r and omized trial conducted at 24 African American churches in central North Carolina . Churches were r and omized to receive the special intervention ( SI ; 13 churches , 117 participants ) or the minimal intervention ( MI ; 11 churches , 84 participants ) . The SI included an 8-month intensive phase , consisting of 1 individual counseling visit , 12 group sessions , monthly phone contacts , and 3 encouragement postcards , followed by a 4-month reinforcement phase including monthly phone contacts . The MI received st and ard educational pamphlets by mail . Outcomes were assessed at 8 and 12 months ; the primary outcome was comparison of 8-month A1C levels . Results At baseline , the mean age was 59 years , A1C 7.8 % , and body mass index 35.0 kg/m2 ; 64 % of participants were female . For the 174 ( 87 % ) participants returning for 8-month measures , mean A1C ( adjusted for baseline and group r and omization ) was 7.4 % for SI and 7.8 % for MI , with a difference of 0.4 % ( 95 % confidence interval [ CI ] , 0.1 - 0.6 , P = .009 ) . In a larger model adjusting for additional variables , the difference was 0.5 % ( 95 % CI , 0.2 - 0.7 , P < .001 ) . At 12 months , the difference between groups was not significant . Diabetes knowledge and diabetes-related quality of life significantly improved in the SI group compared with the MI group . Among SI participants completing an acceptability question naire , intervention components and material s were rated as highly acceptable . Conclusions The church-based intervention was well received by participants and improved short-term metabolic control Poor adjustment to diabetes in older African American women may result from uncertainty , stemming from a lack of information about self-care activities , a complexity of self-care activities , comorbid conditions , and a lack of re sources . This study evaluated a telephone intervention to reduce uncertainty ( through problem-solving strategies , information , cognitive reframing , and improved patient — provider communication)—namely , to measure its effects on diabetes self-care and psychosocial adjustment .  Sixty-eight older African American women were r and omly assigned to an experimental group and a control group . The experimental group received the intervention for 4 weeks , and the control group received usual care .  Psychosocial adjustment and self-care were measured in all participants at baseline and 6 weeks postbaseline . The experimental group reported increased participation in exercise ( self-care component ; p < .001 ) and improvement in psychosocial adjustment ( p < .001 ) . Thus , reducing the uncertainty related to diabetes self-care improves self-care exercise , as well as psychosocial adjustment OBJECTIVE The objective of this study was to assess the impact of active versus usual monitoring of algorithmic insulin titration and point-of-care ( POC ) versus laboratory HbA1c ( A1C ) measurement on glycemic control in primary care . RESEARCH DESIGN AND METHODS The Glycemic Optimization with Algorithms and Labs at Point of Care ( GOAL A1C ) study was a 24-week , r and omized , parallel-group , four-arm , open-label study of 7,893 adults with type 2 diabetes uncontrolled by oral antidiabetic agents and requiring insulin . Patients were r and omly assigned by investigators from 2,164 sites in the U.S. to insulin glargine with either 1 ) usual ( no unsolicited contact between visits ) insulin titration using a simple algorithm with laboratory A1C testing , 2 ) usual titration with POC A1C testing , 3 ) active ( weekly monitored ) titration with laboratory A1C testing , or 4 ) active titration with POC A1C testing . Outcome measures included a change in A1C and fasting self-monitoring of blood glucose ( SMBG ) levels , percentage of patients achieving A1C < 7.0 % , and hypoglycemia frequency . RESULTS Significant A1C and SMBG reductions were observed in all arms ( P < 0.0001 ) . Compared with usual insulin titration , active titration achieved greater A1C reduction ( 1.5 vs. 1.3 % ; P < 0.0001 ) , SMBG reduction ( 88 vs. 79 mg/dl ; P < 0.0001 ) , and proportion of patients achieving A1C < 7.0 % ( 38 vs. 30 % ; P < 0.0001 ) . Among patients receiving active titration , POC A1C testing was associated with an increase in the proportion achieving an A1C < 7.0 % ( 41 % for POC vs. 36 % for laboratory ; P < 0.0001 ) . Hypoglycemia rates were low ( usual vs. active groups : 3.7 vs. 6.0 all confirmed episodes/patient-year [ P < 0.001 ] ; 0.09 vs. 0.14 severe episodes/patient-year [ NS ] ) . CONCLUSIONS In a predominantly primary care setting , addition of insulin glargine using a simple algorithm achieved significant improvements in glycemic control in patients with type 2 diabetes in all four study arms . Active titration result ed in significant incremental improvements in glycemic control , and , among patients receiving active titration , POC A1C testing result ed in a greater portion achieving A1C < 7.0 % BACKGROUND Patient education is a cornerstone of treatment in diabetes mellitus , but there is not unanimity of opinion as to how it should be delivered . OBJECTIVE To determine whether a single , intensive group educational program would improve glycosylated hemoglobin ( HbA(1c ) ) levels when compared with passive education . METHODS A total of 106 patients with HbA(1c ) levels greater than 8.5 % were r and omized to either an intensive ( n = 50 ) or a passive education ( n = 56 ) group . The intensive education group received 3.5 days of a structured curriculum involving a physician , nurse , nutritionist , pharmacist , exercise physiologist , and a social worker . The passive education group received material sent by mail every 3 months providing basic information on topics related to diabetes management . Patients continued care with their diabetes care provider during the study period . Levels of HbA(1c ) were measured at baseline and 3 , 6 , and 12 months after r and omization . A matched control group of individuals who declined participation also had HbA(1c ) levels measured at baseline and 12 months . RESULTS Mean + /- SD HbA(1c ) levels fell significantly ( P<.001 ) from baseline ( 9.9 % + /- 1.3 % ) in both the intensive ( -2.0 % ) and passive ( - 
    Output:
    
agent
Less frequently reported were quality of life , patient satisfaction , self-care , and healthcare utilization .
Most care management modalities were carved out from primary care .
Conclusions Most care management programs for patients with type 2 diabetes are ' carved-out ' , accomplish limited effects on metabolic outcomes , and have unknown effects on patient important outcomes .
***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 African Americans suffer disproportionately from diabetes complications , but little research has focused on how to improve diabetic control in this population . There are also few or no data on a combined primary care and community-based intervention approach . METHODS We r and omly assigned 186 urban African Americans with type 2 diabetes ( 76 % female , mean A SD age 59 A 9 years ) to 1 of 4 parallel arms : ( 1 ) usual care only ; ( 2 ) usual care + nurse case manager ( NCM ) ; ( 3 ) usual care + community health worker ( CHW ) ; ( 4 ) usual care + nurse case manager/community health worker team . Using the framework of the Precede-Proceed behavioral model , interventions included patient counseling regarding self-care practice s and physician reminders . RESULTS The 2-year follow-up visit was completed by 149 individuals ( 84 % ) . Compared to the Usual care group , the NCM group and the CHW group had modest declines in HbA(1c ) over 2 years ( 0.3 and 0.3 % , respectively ) , and the combined NCM/CHW group had a greater decline in HbA(1c ) ( 0.8 % . P = 0.137 ) . After adjustment for baseline differences and /or follow-up time , the combined NCM/CHW group showed improvements in triglycerides ( -35.5 mg/dl ; P = 0.041 ) and diastolic blood pressure , compared to the usual care group ( -5.6 mmHg ; P = 0.042 ) . CONCLUSIONS Combined NCM/CHW interventions may improve diabetic control in urban African Americans with type 2 diabetes . Although results were clinical ly important , they did not reach statistical significance . This approach deserves further attention as a means to reduce the excess risk of diabetic complications in African Americans OBJECTIVE To assess the effects of web-based care management on glucose and blood pressure control over 12 months in patients with poorly controlled diabetes . RESEARCH DESIGN AND METHODS For this study , 104 patients with diabetes and HbA(1c ) ( A1C ) > or = 9.0 % who received their care at a Department of Veterans Affairs medical center were recruited . All participants completed a  diabetes education class  and were r and omized to continue with their usual care ( n = 52 ) or receive web-based care management ( n = 52 ) . The web-based group received a notebook computer , glucose and blood pressure monitoring devices , and access to a care management website . The website provided educational modules , accepted uploads from monitoring devices , and had an internal messaging system for patients to communicate with the care manager . RESULTS Participants receiving web-based care management had lower A1C over 12 months ( P < 0.05 ) when compared with education and usual care . Persistent website users had greater improvement in A1C when compared with intermittent users ( -1.9 vs. -1.2 % ; P = 0.051 ) or education and usual care ( -1.4 % ; P < 0.05 ) . A larger number of website data uploads was associated with a larger decline in A1C ( highest tertile -2.1 % , lowest tertile -1.0 % ; P < 0.02 ) . Hypertensive participants in the web-based group had a greater reduction in systolic blood pressure ( P < 0.01 ) . HDL cholesterol rose and triglycerides fell in the web-based group ( P < 0.05 ) . CONCLUSIONS Web-based care management may be a useful adjunct in the care of patients with poorly controlled diabetes OBJECTIVE To evaluate the impact of systematic patient evaluation and patient and provider feedback on the processes and intermediate outcomes of diabetes care in Independent Practice Association model internal medicine practice s. RESEARCH DESIGN AND METHODS Nine practice s providing care to managed care patients were r and omly assigned as intervention or comparison sites . Intervention-site subjects had Annual Diabetes Assessment Program ( ADAP ) assessment s ( HbA(1c  ) , blood pressure , lipids , smoking , retinal photos , urine microalbumin , and foot examination ) at years 1 and 2 . Comparison-site subjects had ADAP assessment s at year 2 . At Intervention sites , year 1 ADAP results were review ed with subjects , mailed to providers , and incorporated into electronic medical records with guideline -generated suggestions for treatment and follow-up . Medical records were evaluated for both groups for the year before both the year 1 and year 2 ADAP assessment s. Processes and intermediate outcomes were compared using linear and logistic mixed hierarchical models . RESULTS Of 284 eligible subjects , 103 of 173 ( 60 % ) at the Intervention sites and 71 of 111 ( 64 % ) at the comparison sites participated ; 83 of 103 ( 81 % ) of the intervention-site subjects returned for follow-up at year 2 . Performance of the six recommended assessment s improved in intervention-site subjects at year 2 compared with year 1 ( 5.8 vs. 4.3 , P = 0.0001 ) and compared with comparison-site subjects at year 2 ( 4.2 , P = 0.014 ) . No significant changes were noted in intermediate outcomes . CONCLUSIONS The ADAP significantly improved processes of care but not intermediate outcomes . Additional interventions are needed to improve intermediate outcomes BACKGROUND In the Medicare Modernization Act of 2003 , Congress required the Centers for Medicare and Medicaid Services to test the commercial disease-management model in the Medicare fee-for-service program . METHODS The Medicare Health Support Pilot Program was a large , r and omized study of eight commercial programs for disease management that used nurse-based call centers . We r and omly assigned patients with heart failure , diabetes , or both to the intervention or to usual care ( control )  and compared them with the use of a difference-in-differences method to evaluate the effects of the commercial programs on the quality of clinical care , acute care utilization , and Medicare expenditures for Medicare fee-for-service beneficiaries . RESULTS The study included 242,417 patients ( 163,107 in the intervention group and 79,310 in the control group ) . The eight commercial disease-management programs did not reduce hospital admissions or emergency room visits , as compared with usual care . We observed only 14 significant improvements in process-of-care measures out of 40 comparisons . These modest improvements came at substantial cost to the Medicare program in fees paid to the disease-management companies ( $ 400 million ) , with no demonstrable savings in Medicare expenditures . CONCLUSIONS In this large study , commercial disease-management programs using nurse-based call centers achieved only modest improvements in quality -of-care measures , with no demonstrable reduction in the utilization of acute care or the costs of care Purpose This study developed and tested a culturally appropriate , church-based intervention to improve diabetes self-management . Research Design and Methods This was a r and omized trial conducted at 24 African American churches in central North Carolina . Churches were r and omized to receive the special intervention ( SI ; 13 churches , 117 participants ) or the minimal intervention ( MI ; 11 churches , 84 participants ) . The SI included an 8-month intensive phase , consisting of 1 individual counseling visit , 12 group sessions , monthly phone contacts , and 3 encouragement postcards , followed by a 4-month reinforcement phase including monthly phone contacts . The MI received st and ard educational pamphlets by mail . Outcomes were assessed at 8 and 12 months ; the primary outcome was comparison of 8-month A1C levels . Results At baseline , the mean age was 59 years , A1C 7.8 % , and body mass index 35.0 kg/m2 ; 64 % of participants were female . For the 174 ( 87 % ) participants returning for 8-month measures , mean A1C ( adjusted for baseline and group r and omization ) was 7.4 % for SI and 7.8 % for MI , with a difference of 0.4 % ( 95 % confidence interval [ CI ] , 0.1 - 0.6 , P = .009 ) . In a larger model adjusting for additional variables , the difference was 0.5 % ( 95 % CI , 0.2 - 0.7 , P < .001 ) . At 12 months , the difference between groups was not significant . Diabetes knowledge and diabetes-related quality of life significantly improved in the SI group compared with the MI group . Among SI participants completing an acceptability question naire , intervention components and material s were rated as highly acceptable . Conclusions The church-based intervention was well received by participants and improved short-term metabolic control Poor adjustment to diabetes in older African American women may result from uncertainty , stemming from a lack of information about self-care activities , a complexity of self-care activities , comorbid conditions , and a lack of re sources . This study evaluated a telephone intervention to reduce uncertainty ( through problem-solving strategies , information , cognitive reframing , and improved patient — provider communication)—namely , to measure its effects on diabetes self-care and psychosocial adjustment .  Sixty-eight older African American women were r and omly assigned to an experimental group and a control group . The experimental group received the intervention for 4 weeks , and the control group received usual care .  Psychosocial adjustment and self-care were measured in all participants at baseline and 6 weeks postbaseline . The experimental group reported increased participation in exercise ( self-care component ; p < .001 ) and improvement in psychosocial adjustment ( p < .001 ) . Thus , reducing the uncertainty related to diabetes self-care improves self-care exercise , as well as psychosocial adjustment OBJECTIVE The objective of this study was to assess the impact of active versus usual monitoring of algorithmic insulin titration and point-of-care ( POC ) versus laboratory HbA1c ( A1C ) measurement on glycemic control in primary care . RESEARCH DESIGN AND METHODS The Glycemic Optimization with Algorithms and Labs at Point of Care ( GOAL A1C ) study was a 24-week , r and omized , parallel-group , four-arm , open-label study of 7,893 adults with type 2 diabetes uncontrolled by oral antidiabetic agents and requiring insulin . Patients were r and omly assigned by investigators from 2,164 sites in the U.S. to insulin glargine with either 1 ) usual ( no unsolicited contact between visits ) insulin titration using a simple algorithm with laboratory A1C testing , 2 ) usual titration with POC A1C testing , 3 ) active ( weekly monitored ) titration with laboratory A1C testing , or 4 ) active titration with POC A1C testing . Outcome measures included a change in A1C and fasting self-monitoring of blood glucose ( SMBG ) levels , percentage of patients achieving A1C < 7.0 % , and hypoglycemia frequency . RESULTS Significant A1C and SMBG reductions were observed in all arms ( P < 0.0001 ) . Compared with usual insulin titration , active titration achieved greater A1C reduction ( 1.5 vs. 1.3 % ; P < 0.0001 ) , SMBG reduction ( 88 vs. 79 mg/dl ; P < 0.0001 ) , and proportion of patients achieving A1C < 7.0 % ( 38 vs. 30 % ; P < 0.0001 ) . Among patients receiving active titration , POC A1C testing was associated with an increase in the proportion achieving an A1C < 7.0 % ( 41 % for POC vs. 36 % for laboratory ; P < 0.0001 ) . Hypoglycemia rates were low ( usual vs. active groups : 3.7 vs. 6.0 all confirmed episodes/patient-year [ P < 0.001 ] ; 0.09 vs. 0.14 severe episodes/patient-year [ NS ] ) . CONCLUSIONS In a predominantly primary care setting , addition of insulin glargine using a simple algorithm achieved significant improvements in glycemic control in patients with type 2 diabetes in all four study arms . Active titration result ed in significant incremental improvements in glycemic control , and , among patients receiving active titration , POC A1C testing result ed in a greater portion achieving A1C < 7.0 % BACKGROUND Patient education is a cornerstone of treatment in diabetes mellitus , but there is not unanimity of opinion as to how it should be delivered . OBJECTIVE To determine whether a single , intensive group educational program would improve glycosylated hemoglobin ( HbA(1c ) ) levels when compared with passive education . METHODS A total of 106 patients with HbA(1c ) levels greater than 8.5 % were r and omized to either an intensive ( n = 50 ) or a passive education ( n = 56 ) group . The intensive education group received 3.5 days of a structured curriculum involving a physician , nurse , nutritionist , pharmacist , exercise physiologist , and a social worker . The passive education group received material sent by mail every 3 months providing basic information on topics related to diabetes management . Patients continued care with their diabetes care provider during the study period . Levels of HbA(1c ) were measured at baseline and 3 , 6 , and 12 months after r and omization . A matched control group of individuals who declined participation also had HbA(1c ) levels measured at baseline and 12 months . RESULTS Mean + /- SD HbA(1c ) levels fell significantly ( P<.001 ) from baseline ( 9.9 % + /- 1.3 % ) in both the intensive ( -2.0 % ) and passive ( - 
    Output:
    