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: RATIONALE , AIMS AND OBJECTIVES To assess the outcomes of a clinical decision support ( CDS ) intervention design ed for home care patients with high medication regimen complexity ( MRC ) and to examine correlates of CDS use . METHOD The CDS consisted of a computerized algorithm that identified high MRC patients  , electronic alerts and a care management module .  Nurses were r and omized upon identification of an eligible patient . Full intention to treat and intervention group-only analyses were completed . Regression-adjusted outcomes were hospitalization , emergency department use and reduction in MRC . RESULTS Five hundred nurses were r and omized with 7919 of their patients . Approximately 20 % of the intervention group was hospitalized versus 21 % in the control group ; 16.5 % versus 16.7 % had an emergency department visit ; and 6 % in each group dropped below the high MRC threshold . No statistically significant differences were found in the intention to treat analysis . Eighty-two percent of intervention nurses used the CDS but for only 42 % of their patients . Among intervention patients , CDS use ( vs. non-use ) was associated with reduced MRC and hospitalization .  CDS use was associated with various clinician and patient characteristics . CONCLUSION CDS use was limited , negating the impact of the intervention overall . Findings on correlates of CDS use and the relationship between CDS use and positive outcomes suggest that CDS use and outcomes could be enhanced by avoiding short patient lengths of stay , improving continuity of care , increasing reliance on salaried nurses and /or increasing per diem nurses ' incentives to use CDS This study was aim ed to investigate the effects of computerized decision support system in improving the prescription of drugs for cardiovascular prevention . A total of 197 Italian general practitioners were r and omly allocated to receive either the alerting computerized decision support system integrated into st and ard software ( intervention arm ) or the st and ard software alone ( control arm ) . Data on 21230 patients with diabetes , 3956 with acute myocardial infa rct ion , and 2158 with stroke were analysed . The proportion of patients prescribed with cardiovascular drugs and days of drug – drug interaction exposure were evaluated . Computerized decision support system significantly increased the proportion of patients with diabetes prescribed with antiplatelet drugs ( intervention : + 2.7 % vs. control : + 0.15 % ; p < 0.001 ) or lipidlowering drugs ( + 4.2 % vs. + 2.8 % ; p = 0.001 ) . A statistically significant decrease in days of potential interactions has been observed only among patients with stroke ( −1.2 vs. −0.5 days/person-year ; p = 0.001 ) . In conclusion , computerized decision support system  significantly increased the use of recommended cardiovascular drugs in diabetic patients , but it did not influence the exposure to potential Background — Indirect evidence shows that alerting users with clinical decision support systems seems to change behavior more than requiring users to actively initiate the system . However , r and omized trials comparing these methods in a clinical setting are lacking . We studied the effect of both alerting and on-dem and decision support with respect to screening and treatment of dyslipidemia based on the guidelines of the Dutch College of General Practitioners . Methods and Results — In a clustered r and omized trial design , 38 Dutch general practice s ( 77 physicians ) and 87 886 of their patients ( 39 433 men 18 to 70 years of age and 48 453 women 18 to 75 years of age ) who used the ELIAS electronic health record participated . Each practice was assigned to receive alerts , on-dem and support , or no intervention . We measured the percentage of patients screened and treated after 12 months of follow-up . In the alerting group , 65 % of the patients requiring screening were screened ( relative risk versus control=1.76 ; 95 % confidence interval , 1.41 to 2.20 ) compared with 35 % of patients in the on-dem and group ( relative risk versus control=1.28 ; 95 % confidence interval , 0.98 to 1.68 ) and 25 % of patients in the control group . In the alerting group , 66 % of patients requiring treatment were treated ( relative risk versus control=1.40 ; 95 % confidence interval , 1.15 to 1.70 ) compared with 40 % of patients ( relative risk versus control=1.19 ; 95 % confidence interval , 0.94 to 1.50 ) in the on-dem and group and 36 % of patients in the control group . Conclusion — The alerting version of the clinical decision support systems significantly improved screening and treatment performance for dyslipidemia by general practitioners 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 PURPOSE Dyslipidemia treatment dramatically decreases coronary heart disease risk in diabetes , yet only a minority of these patients are screened or achieve optimal low-density lipoprotein ( LDL ) cholesterol levels . Our aim was to increase the percentage of diabetic patients in whom lipid management was achieved through electronic and direct educational detailing . METHODS The study cohort comprised 884 diabetic patients at 12 primary care practice s. Practice sites were r and omized to one of three intervention groups : electronic educational detailing , direct ( face-to-face ) educational detailing , or control . Direct and electronic detailing were performed over a 12-month period . All sites were notified of our goal to enhance lipid testing among diabetic patients . Chart abstract ion was performed 15 months after the start of the intervention . For the entire population ( n=884 ) , the proportion of patients with lipid testing was calculated , and changes from pre- to postintervention were compared across groups . We compared pre- and postintervention LDL-cholesterol changes between groups using least square means to account for site variation . RESULTS Favorable provider actions increased significantly with the intervention ( + 22 % compared with + 6 % in controls , P=.01 ) . By logistic regression , electronic detailing increased the likelihood of lipid testing ( odds ratio 3.0 , confidence interval 1.6 - 5.7 ) , as did direct detailing ( odds ratio 1.8 , confidence interval 0.9 - 3.7 ) in patients with no preintervention LDL test ( n=432 ) . Lipid testing tended to increase to a greater extent at intervention sites ( + 23 % for the combination of electronic and direct detailing vs + 11 % for controls , P=.06 ) . CONCLUSIONS Brief educational detailing either through direct or electronic communication favorably impacts provider behavior regarding dyslipidemia care for diabetic patients Background Very few studies having decision support systems as an intervention report on patient outcomes for cardiovascular disease in the Western world . The potential role of decision support system for the management of blood pressure among Indian hypertensives remains unclear . We propose a cluster r and omised trial that aims to test the effectiveness and cost effectiveness of DSS among Indian hypertensive patients . Methods The trial design is a cluster r and omised community intervention trial , in which the participants would be adult male and female hypertensive patients , in the age group of 35 to 64 years , reporting to the Primary Health Care centres of Mahabubnagar district , And hra Pradesh , India . The objective of the study is to test the effectiveness and compare the cost effectiveness and cost utility among hypertensive subjects r and omized to receive either decision support system or a chart based algorithmic support system in urban and rural areas of a district in the state of And hra Pradesh , India ( baseline versus 12 months follow up ) . The primary outcome would be a comparison of the systolic blood pressure at 0 and 12 months among hypertensive patients r and omized to receive the decision support system or the chart based algorithmic support system . Computer generated r and omisation and an investigator and analyser blinded method would be followed . 1600 participants ; 800 to each arm ; each arm having eight clusters of hundred participants each have been recruited between 01 August 2011 - 01 March 2012 . A twelve month follow up will be completed by March 2013 and results are expected by April 2013 . Discussion This cluster r and omized community intervention trial on DSS will enable policy makers to find out the effectiveness , cost effectiveness and cost utility of decision support system for management of blood pressure among hypertensive patients in India . Most of the previous studies on decision support system have focused on physician performance , adherence and on preventive care reminders . The uniqueness of the proposed study lies in finding out the effectiveness of a decision support system on patient related outcomes .Trial registration CTRI/2012/03/002476 , Clinical Trial Registry - India Background Electronic guideline -based decision support systems have been suggested to successfully deliver the knowledge embedded in clinical practice guidelines . A number of studies have already shown positive findings for decision support systems such as drug-dosing systems and computer-generated reminder systems for preventive care services . Methods A systematic literature search ( 1990 to December 2008 ) of the English literature indexed in the Medline data base , Embase , the Cochrane Central Register of Controlled Trials , and CRD ( DARE , HTA and NHS EED data bases ) was conducted to identify evaluation studies of electronic multi-step guideline implementation systems in ambulatory care setting s. Important inclusion criterions were the multidimensionality of the guideline ( the guideline needed to consist of several aspects or steps ) and real-time interaction with the system during consultation . Clinical decision support systems such as one-time reminders for preventive care for which positive findings were shown in earlier review s were excluded . Two comparisons were considered : electronic multidimensional guidelines versus usual care ( comparison one ) and electronic multidimensional guidelines versus other guideline implementation methods ( comparison two ) . Results Twenty-seven publications were selected for analysis in this systematic review . Most design s were cluster r and omized controlled trials investigating process outcomes more than patient outcomes . With success defined as at least 50 % of the outcome variables being significant , none of the studies were successful in improving patient outcomes . Only seven of seventeen studies that investigated process outcomes showed improvements in process of care variables compared with the usual care group ( comparison one ) . No incremental effect of the electronic implementation over the distribution of paper versions of the guideline was found , neither for the patient outcomes nor for the process outcomes ( comparison two ) . Conclusions There is little evidence at the moment for the effectiveness of an increasingly used and commercialised instrument such as electronic multidimensional guidelines . After more than a decade of development of numerous electronic systems , research on the most effective implementation strategy for this kind of guideline -based decision support systems is still lacking . This conclusion implies a considerable risk towards inappropriate investments in ineffective implementation interventions and in suboptimal care BACKGROUND Optimal care for patients with diabetes is difficult to achieve in clinical practice . OBJECTIVE To evaluate the impact of a registry and decision support system on processes of care , and physiologic control . PARTICIPANTS R and omized trial with clustering at the practice level , involving 7,412 adults with diabetes in 64 primary care practice s in the Northeast . INTERVENTIONS Provider decision support ( reminders for overdue diabetes tests , alerts regarding abnormal results , and quarterly population reports with peer comparisons ) and patient decision support ( reminders and alerts ) . MEASUREMENTS AND MAIN RESULTS Process and physiologic outcomes were evaluated in all subjects . Functional status was evaluated in a r and om patient sample via question naire . We used multiple logistic regression to quantify the effect , adjusting for clustering and potential confounders . Intervention subjects were significantly more likely to receive guideline -appropriate testing for cholesterol ( OR = 1.39 ; [ 95%CI 1.07 , 1.80 ] P = 0.012 ) , creatinine ( OR = 1.40 ; [ 95%CI 1.06 , 1.84 ] P = 0.018 ) , and proteinuria ( OR = 1.74 ; [ 95%CI 1.13 , 1.69 ] P = 0.012 ) , but not A1C ( OR = 1.17 ; [ 95 % CI 0.80 , 1.72 ] P = 0.43 ) . 
    Output:
    
agent
Among CVRM patients , the results tended towards a beneficial effect of CDSS , but only LDL-c target attainment in diabetes patients reached statistical significance .
Prompting , integration into the electronical health record , patient empowerment , and medication support were related to more effective CVRM .
Conclusion We did not find a clear clinical benefit from CDSS in cardiovascular risk factor levels and target attainment .
Some features of CDSS seem more promising than others .
Clinical relevance of CDSS in CVRM might additionally be sought in the improvement of shared decision making and patient empowerment
***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: RATIONALE , AIMS AND OBJECTIVES To assess the outcomes of a clinical decision support ( CDS ) intervention design ed for home care patients with high medication regimen complexity ( MRC ) and to examine correlates of CDS use . METHOD The CDS consisted of a computerized algorithm that identified high MRC patients  , electronic alerts and a care management module .  Nurses were r and omized upon identification of an eligible patient . Full intention to treat and intervention group-only analyses were completed . Regression-adjusted outcomes were hospitalization , emergency department use and reduction in MRC . RESULTS Five hundred nurses were r and omized with 7919 of their patients . Approximately 20 % of the intervention group was hospitalized versus 21 % in the control group ; 16.5 % versus 16.7 % had an emergency department visit ; and 6 % in each group dropped below the high MRC threshold . No statistically significant differences were found in the intention to treat analysis . Eighty-two percent of intervention nurses used the CDS but for only 42 % of their patients . Among intervention patients , CDS use ( vs. non-use ) was associated with reduced MRC and hospitalization .  CDS use was associated with various clinician and patient characteristics . CONCLUSION CDS use was limited , negating the impact of the intervention overall . Findings on correlates of CDS use and the relationship between CDS use and positive outcomes suggest that CDS use and outcomes could be enhanced by avoiding short patient lengths of stay , improving continuity of care , increasing reliance on salaried nurses and /or increasing per diem nurses ' incentives to use CDS This study was aim ed to investigate the effects of computerized decision support system in improving the prescription of drugs for cardiovascular prevention . A total of 197 Italian general practitioners were r and omly allocated to receive either the alerting computerized decision support system integrated into st and ard software ( intervention arm ) or the st and ard software alone ( control arm ) . Data on 21230 patients with diabetes , 3956 with acute myocardial infa rct ion , and 2158 with stroke were analysed . The proportion of patients prescribed with cardiovascular drugs and days of drug – drug interaction exposure were evaluated . Computerized decision support system significantly increased the proportion of patients with diabetes prescribed with antiplatelet drugs ( intervention : + 2.7 % vs. control : + 0.15 % ; p < 0.001 ) or lipidlowering drugs ( + 4.2 % vs. + 2.8 % ; p = 0.001 ) . A statistically significant decrease in days of potential interactions has been observed only among patients with stroke ( −1.2 vs. −0.5 days/person-year ; p = 0.001 ) . In conclusion , computerized decision support system  significantly increased the use of recommended cardiovascular drugs in diabetic patients , but it did not influence the exposure to potential Background — Indirect evidence shows that alerting users with clinical decision support systems seems to change behavior more than requiring users to actively initiate the system . However , r and omized trials comparing these methods in a clinical setting are lacking . We studied the effect of both alerting and on-dem and decision support with respect to screening and treatment of dyslipidemia based on the guidelines of the Dutch College of General Practitioners . Methods and Results — In a clustered r and omized trial design , 38 Dutch general practice s ( 77 physicians ) and 87 886 of their patients ( 39 433 men 18 to 70 years of age and 48 453 women 18 to 75 years of age ) who used the ELIAS electronic health record participated . Each practice was assigned to receive alerts , on-dem and support , or no intervention . We measured the percentage of patients screened and treated after 12 months of follow-up . In the alerting group , 65 % of the patients requiring screening were screened ( relative risk versus control=1.76 ; 95 % confidence interval , 1.41 to 2.20 ) compared with 35 % of patients in the on-dem and group ( relative risk versus control=1.28 ; 95 % confidence interval , 0.98 to 1.68 ) and 25 % of patients in the control group . In the alerting group , 66 % of patients requiring treatment were treated ( relative risk versus control=1.40 ; 95 % confidence interval , 1.15 to 1.70 ) compared with 40 % of patients ( relative risk versus control=1.19 ; 95 % confidence interval , 0.94 to 1.50 ) in the on-dem and group and 36 % of patients in the control group . Conclusion — The alerting version of the clinical decision support systems significantly improved screening and treatment performance for dyslipidemia by general practitioners 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 PURPOSE Dyslipidemia treatment dramatically decreases coronary heart disease risk in diabetes , yet only a minority of these patients are screened or achieve optimal low-density lipoprotein ( LDL ) cholesterol levels . Our aim was to increase the percentage of diabetic patients in whom lipid management was achieved through electronic and direct educational detailing . METHODS The study cohort comprised 884 diabetic patients at 12 primary care practice s. Practice sites were r and omized to one of three intervention groups : electronic educational detailing , direct ( face-to-face ) educational detailing , or control . Direct and electronic detailing were performed over a 12-month period . All sites were notified of our goal to enhance lipid testing among diabetic patients . Chart abstract ion was performed 15 months after the start of the intervention . For the entire population ( n=884 ) , the proportion of patients with lipid testing was calculated , and changes from pre- to postintervention were compared across groups . We compared pre- and postintervention LDL-cholesterol changes between groups using least square means to account for site variation . RESULTS Favorable provider actions increased significantly with the intervention ( + 22 % compared with + 6 % in controls , P=.01 ) . By logistic regression , electronic detailing increased the likelihood of lipid testing ( odds ratio 3.0 , confidence interval 1.6 - 5.7 ) , as did direct detailing ( odds ratio 1.8 , confidence interval 0.9 - 3.7 ) in patients with no preintervention LDL test ( n=432 ) . Lipid testing tended to increase to a greater extent at intervention sites ( + 23 % for the combination of electronic and direct detailing vs + 11 % for controls , P=.06 ) . CONCLUSIONS Brief educational detailing either through direct or electronic communication favorably impacts provider behavior regarding dyslipidemia care for diabetic patients Background Very few studies having decision support systems as an intervention report on patient outcomes for cardiovascular disease in the Western world . The potential role of decision support system for the management of blood pressure among Indian hypertensives remains unclear . We propose a cluster r and omised trial that aims to test the effectiveness and cost effectiveness of DSS among Indian hypertensive patients . Methods The trial design is a cluster r and omised community intervention trial , in which the participants would be adult male and female hypertensive patients , in the age group of 35 to 64 years , reporting to the Primary Health Care centres of Mahabubnagar district , And hra Pradesh , India . The objective of the study is to test the effectiveness and compare the cost effectiveness and cost utility among hypertensive subjects r and omized to receive either decision support system or a chart based algorithmic support system in urban and rural areas of a district in the state of And hra Pradesh , India ( baseline versus 12 months follow up ) . The primary outcome would be a comparison of the systolic blood pressure at 0 and 12 months among hypertensive patients r and omized to receive the decision support system or the chart based algorithmic support system . Computer generated r and omisation and an investigator and analyser blinded method would be followed . 1600 participants ; 800 to each arm ; each arm having eight clusters of hundred participants each have been recruited between 01 August 2011 - 01 March 2012 . A twelve month follow up will be completed by March 2013 and results are expected by April 2013 . Discussion This cluster r and omized community intervention trial on DSS will enable policy makers to find out the effectiveness , cost effectiveness and cost utility of decision support system for management of blood pressure among hypertensive patients in India . Most of the previous studies on decision support system have focused on physician performance , adherence and on preventive care reminders . The uniqueness of the proposed study lies in finding out the effectiveness of a decision support system on patient related outcomes .Trial registration CTRI/2012/03/002476 , Clinical Trial Registry - India Background Electronic guideline -based decision support systems have been suggested to successfully deliver the knowledge embedded in clinical practice guidelines . A number of studies have already shown positive findings for decision support systems such as drug-dosing systems and computer-generated reminder systems for preventive care services . Methods A systematic literature search ( 1990 to December 2008 ) of the English literature indexed in the Medline data base , Embase , the Cochrane Central Register of Controlled Trials , and CRD ( DARE , HTA and NHS EED data bases ) was conducted to identify evaluation studies of electronic multi-step guideline implementation systems in ambulatory care setting s. Important inclusion criterions were the multidimensionality of the guideline ( the guideline needed to consist of several aspects or steps ) and real-time interaction with the system during consultation . Clinical decision support systems such as one-time reminders for preventive care for which positive findings were shown in earlier review s were excluded . Two comparisons were considered : electronic multidimensional guidelines versus usual care ( comparison one ) and electronic multidimensional guidelines versus other guideline implementation methods ( comparison two ) . Results Twenty-seven publications were selected for analysis in this systematic review . Most design s were cluster r and omized controlled trials investigating process outcomes more than patient outcomes . With success defined as at least 50 % of the outcome variables being significant , none of the studies were successful in improving patient outcomes . Only seven of seventeen studies that investigated process outcomes showed improvements in process of care variables compared with the usual care group ( comparison one ) . No incremental effect of the electronic implementation over the distribution of paper versions of the guideline was found , neither for the patient outcomes nor for the process outcomes ( comparison two ) . Conclusions There is little evidence at the moment for the effectiveness of an increasingly used and commercialised instrument such as electronic multidimensional guidelines . After more than a decade of development of numerous electronic systems , research on the most effective implementation strategy for this kind of guideline -based decision support systems is still lacking . This conclusion implies a considerable risk towards inappropriate investments in ineffective implementation interventions and in suboptimal care BACKGROUND Optimal care for patients with diabetes is difficult to achieve in clinical practice . OBJECTIVE To evaluate the impact of a registry and decision support system on processes of care , and physiologic control . PARTICIPANTS R and omized trial with clustering at the practice level , involving 7,412 adults with diabetes in 64 primary care practice s in the Northeast . INTERVENTIONS Provider decision support ( reminders for overdue diabetes tests , alerts regarding abnormal results , and quarterly population reports with peer comparisons ) and patient decision support ( reminders and alerts ) . MEASUREMENTS AND MAIN RESULTS Process and physiologic outcomes were evaluated in all subjects . Functional status was evaluated in a r and om patient sample via question naire . We used multiple logistic regression to quantify the effect , adjusting for clustering and potential confounders . Intervention subjects were significantly more likely to receive guideline -appropriate testing for cholesterol ( OR = 1.39 ; [ 95%CI 1.07 , 1.80 ] P = 0.012 ) , creatinine ( OR = 1.40 ; [ 95%CI 1.06 , 1.84 ] P = 0.018 ) , and proteinuria ( OR = 1.74 ; [ 95%CI 1.13 , 1.69 ] P = 0.012 ) , but not A1C ( OR = 1.17 ; [ 95 % CI 0.80 , 1.72 ] P = 0.43 ) . 
    Output:
    