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: The effect of pharmaceutical care on the prevention , detection , and resolution of medication-related problems in high-risk patients in a rural community was studied . Adult patients who received care at clinics in a medically underserved area of Alabama and who were identified as being at high risk of medication-related adverse events were r and omly assigned to a control group or an intervention group . The control group received st and ard medical care , and the intervention group received pharmaceutical care , including a medical record review , a medication history review , pharmacotherapeutic evaluation , and patient medication education and monitoring over a one-year period .  A total of 69 patients completed the study ( 33 in the intervention group and 36 in the control group ) . The percentage of patients responding to hypertension , diabetes , dyslipidemia , and anticoagulation therapy increased significantly in the intervention group and declined in the control group . Ratings for inappropriate prescribing improved in all 10 domains evaluated in the intervention group but worsened in 5 domains in the control group . There were no significant differences between the groups at 12 months in health-related quality of life or medication misadventures . Medication compliance scores improved in the intervention group but not in the control group . Medication knowledge increased in the intervention group and decreased in the control group . Pharmaceutical care in a rural , community-based setting appeared to reduce inappropriate prescribing , enhance disease management , and improve medication compliance and knowledge without adversely affecting health-related quality of life Background — Even in high-performing health systems , some patients with diabetes mellitus have poor blood pressure ( BP ) control because of poor medication adherence and lack of medication intensification . We examined whether the Adherence and Intensification of Medications intervention , a pharmacist-led intervention combining elements found in efficacy studies to lower BP , improved BP among patients with diabetes mellitus with persistent hypertension and poor refill adherence or insufficient medication intensification in 2 high-performing health systems . Methods and Results — We conducted a prospect i ve , multisite cluster r and omized pragmatic trial with r and omization of 16 primary care teams at 5 medical centers ( 3 Veterans Affairs and 2 Kaiser Permanente ) to the Adherence and Intensification of Medications intervention or usual care . The primary outcome was relative change in systolic BP ( SBP ) , comparing 1797 intervention with 2303 control team patients , from 6 months preceding to 6 months after the 14-month intervention period . We examined shorter-term changes in SBP as a secondary outcome . The mean SBP decrease from 6 months before to 6 months after the intervention period was ≈9 mm Hg in both arms . Mean SBPs of eligible intervention patients were 2.4 mm Hg lower ( 95 % CI : −3.4 to −1.5 ; P<0.001 ) immediately after the intervention than those achieved by control patients . Conclusions — The Adherence and Intensification of Medications program more rapidly lowered SBPs among intervention patients , but usual-care patients achieved equally low SBP levels by 6 months after the intervention period . These findings show the importance of evaluating in different real-life clinical setting s programs found in efficacy trials to be effective before urging their widespread adoption in all setting s. Clinical Trial Registration — URL : http:// clinical trials.gov . Unique identifier : NCT00495794 Purpose To assess whether VA MEDIC-E ( Veterans Affairs Multi-disciplinary Education and Diabetes Intervention for Cardiac risk reduction[EM DASH ] Extended for 6 months ) , a pharmacist-led shared medical appointments program , could improve attainment of target goals for hypertension , hyperglycemia , hyperlipidemia , and tobacco use in patients with type 2 diabetes compared to st and ard primary care after 6 months of intervention . Methods A r and omized , controlled trial of VA MEDIC-E ( n = 50 ) versus st and ard primary care ( n = 49 ) in veterans with type 2 diabetes , hemoglobin A1c ( A1C ) > 7 % , blood pressure ( BP ) > 130/80 mmHg , and low density lipoprotein cholesterol ( LDL-C ) > 100mg/dl ( 2.59 mmol/l ) in the previous 6 months was conducted . The VA MEDIC-E intervention consisted of 4 weekly group sessions followed by 5 monthly booster group sessions . Each 2-hour session included 1 hour of multidisciplinary diabetes specific healthy lifestyle education and 1 hour of pharmacotherapeutic interventions performed by a clinical pharmacist . Evaluation measures included lab values of A1C , LDL cholesterol , BP , and goal attainment of these values , and diabetes self-care behavior question naires at 6 months . Results The r and omization groups were similar at baseline in all cardiovascular risk factors except for LDL , which was significantly lower in the MEDIC-E arm . At 6 months , significant improvements from baseline were found in the intervention arm for exercise , foot care , and goal attainment of A1C , LDL-C , and BP but not in the control arm . Conclusions The results of this study demonstrate that the pharmacist-led group intervention program for 6 months was an efficacious and sustainable collaborative care approach to managing diabetes and reducing associated cardiovascular risk The purpose of this study was : ( 1 ) to record GP opinions , practice s and outcomes for the care of Type 2 Diabetes Mellitus ( DM2 ) , ( 2 ) compare practice facilities and process of care with a criterion of recommended competent care and ( 3 ) determine if there were any differences between vocationally registered and non-vocationally registered GPs . A r and om sample of 204 metropolitan doctors from 124 practice s was selected and an audit performed on 467 of their patient records . GPs pursued good blood sugar control and advocated lifestyle changes before hypoglycaemic drugs . Over 80 % regard uncomplicated DM2 as a condition for general practice management . However , only 15 % conducted an annual diabetes check , 9 % had a diabetic register , 6 % a diabetic recall system and 8 % used a diabetic health care checklist for monitoring their patients . The most commonly recorded processes of medical audit in the previous 12 months were : blood pressure ( 94 % ) , duration of diabetes ( 72 % ) , blood glucose ( 70 % ) , diet ( 66 % ) , body weight ( 56 % ) , HBA1c ( 52 % ) and ophthalmoscopy ( 50 % ) . The least commonly recorded processes of care were body mass index ( 5 % ) , inspection of the feet ( 18 % ) , enquiries about vaginitis or impotence ( 23 % ) . The amount of exercise , alcohol and tobacco was recorded in only 34 % of records . Hypoglycaemic drugs were used appropriately but the most commonly used drugs for treating hypertension in DM2 patients were thiazide diuretics and beta-blockers .  Vocationally registered ( VR ) doctors had better records , higher process of care scores and more were willing to participate in the study than non-vocationally registered ( NVR ) doctors . However , there was no difference in metabolic control between patients from either group . The use of a Diabetic Health Care Checklist would improve diabetes care especially in the search for early complications and in the recording of HBA1c and other metabolic parameters . The drugs commonly used to control hypertension can have adverse effects on glucose and lipid metabolism and should be replaced with glucose and lipid neutral drugs Purpose The purpose of this study was to determine whether “ clinical inertia”—inadequate intensification of therapy by the provider — could contribute to high A1C levels in patients with type 2 diabetes managed in a primary care site . Methods In a prospect i ve observational study , management was compared in the Medical Clinic , a primary care site supervised by general internal medicine faculty , and the Diabetes Clinic , a specialty site supervised by endocrinologists . These municipal hospital clinics serve a common population that is largely African American , poor , and uninsured . Results Four hundred thirty-eight African American patients in the Medical Clinic and 2157 in the Diabetes Clinic were similar in average age , diabetes duration , body mass index , and gender , but A1C averaged 8.6 % in the Medical Clinic versus 7.7 % in the Diabetes Clinic ( P < .0001 ) . Use of pharmacotherapy  was less intensive in the Medical Clinic ( less use of insulin ) , and when patients had elevated glucose levels during clinic visits , therapy was less than half as likely to be advanced in the Medical Clinic compared to the Diabetes Clinic ( P < .0001 ) . Intensification rates were lower in the Medical Clinic regardless of type of therapy ( P < .0001 ) , and intensification of therapy was independently associated with improvement in A1C ( P < .001 ) . Conclusions Medical Clinic patients had worse glycemic control , were less likely to be treated with insulin , and were less likely to have their therapy intensified if glucose levels were elevated . To improve diabetes management and glycemic control nationwide , physicians in training and generalists must learn to overcome clinical inertia , to intensify therapy when appropriate , and to use insulin when clinical ly indicated OBJECTIVE To examine the effect of case management on glycemic control and behavioral outcomes in adults with Type 2 diabetes in China . METHODS Participants were r and omly assigned to a 1-year case management ( CM ) group ( n=60 ) or control group ( n=60 ) . Monthly case management visits included identifying individuals ' diabetes-related problems , setting goals , planning self-care , and evaluating progress . During a 1-year follow-up , all participants attended visits every 3 months without intervention . RESULTS In the CM vs. the control group , HbA1c was reduced at 6 months compared to baseline ( P=0.034 ) , with trends at 12 and 24 months , and empowerment ability improved ( P<0.05 ) . Also in the CM vs. controls , total self-care behaviors , the frequency of exercise , blood glucose testing , and foot care were higher ( P<0.001 ) at 12 months , and the percentage of individuals with HbA1c ≤7.0 % was higher ( P=0.035 ) at 24 months . CONCLUSION The case management intervention in China was effective at 6 months and , based on trends in HbA1c at 12 and 24 months and results for behavioral outcomes , the intervention shows promise and warrants more research . PRACTICE IMPLICATION S A case management approach can enhance behavior change and glycemic control in Chinese with diabetes Summary In primary care it is difficult to treat the growing number of non-insulin-dependent diabetic ( NIDDM ) patients according to (inter)national guidelines . A prospect i ve , controlled cohort study was design ed to assess the intermediate term ( 2 years ) effect of structured NIDDM care in general practice with and without ‘ diabetes service ’ support on glycaemic control , cardiovascular risk factors , general well-being and treatment satisfaction . The ‘ diabetes service ’ , supervised by a diabetologist , included a patient registration system , consultation facilities of a dietitian and diabetes nurse educator , and protocol ized blood glucose lowering therapy advice which included home blood glucose monitoring and insulin therapy . In the study group ( SG ; 22 general practice s ) , 350 known NIDDM patients over 40 years of age ( 206 women ; mean age 65.3 ± SD 11.9 ; diabetes duration 5.9 ± 5.4 years ) were followed for 2 years . The control group ( CG ; 6 general practice s ) consisted of 68 patients ( 28 women ; age 64.6 ± 10.3 ; diabetes duration 6.3 ± 6.4 years ) . Mean HbAlc ( reference 4.3 - 6.1 % ) fell from 7.4 to 7.0 % in SG and rose from 7.4 to 7.6 % in CG during follow-up ( p = 0.004 ) . The percentage of patients with poor control ( HbA1c>8.5 % ) shifted from 21.4 to 11.7 % in SG , but from 23.5 to 27.9 % in CG ( p = 0.008 ) . Good control ( HbAlc > 7.0 % ) was achieved in 54.3 % ( SG ; at entry 43.4 % ) and 44.1 % ( CG ; at entry 54.4 % ) ( p = 0.013  ) . Insulin therapy was started in 29.7 % ( SG ) and 8.8 % ( CG ) of the patients ( p = 0.000 ) with low risk of severe hypoglycaemia ( 0.019/patient year ) . Mean levels of total and HDL-cholesterol ( SG ) , triglycerides ( SG ) and diastolic blood pressure ( SG + CG ) and the percentage of smokers ( SG ) declined significantly , but the prevalence of these risk factors remained high . General well-being ( SG ) did not change during intensified therapy . Treatment satisfaction ( SG ) tended to improve . Implementation of structured care , including education and therapeutic advice , results in sustained good glycaemic control in the majority of NIDDM patients in primary care , with low risk of hypoglycaemia . Lowering cardiovascular risk requires more than reporting results and referral to guidelines . [ Diabetologia 
    Output:
    
agent
Through this review , we found two key health system barriers to effective T2DM care and management : financial constraints faced by the patient and limited access to health services and medication .
This review points to the importance of reducing , or possibly eliminating , out-of-pocket costs for diabetes medication and self-monitoring supplies .
***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: The effect of pharmaceutical care on the prevention , detection , and resolution of medication-related problems in high-risk patients in a rural community was studied . Adult patients who received care at clinics in a medically underserved area of Alabama and who were identified as being at high risk of medication-related adverse events were r and omly assigned to a control group or an intervention group . The control group received st and ard medical care , and the intervention group received pharmaceutical care , including a medical record review , a medication history review , pharmacotherapeutic evaluation , and patient medication education and monitoring over a one-year period .  A total of 69 patients completed the study ( 33 in the intervention group and 36 in the control group ) . The percentage of patients responding to hypertension , diabetes , dyslipidemia , and anticoagulation therapy increased significantly in the intervention group and declined in the control group . Ratings for inappropriate prescribing improved in all 10 domains evaluated in the intervention group but worsened in 5 domains in the control group . There were no significant differences between the groups at 12 months in health-related quality of life or medication misadventures . Medication compliance scores improved in the intervention group but not in the control group . Medication knowledge increased in the intervention group and decreased in the control group . Pharmaceutical care in a rural , community-based setting appeared to reduce inappropriate prescribing , enhance disease management , and improve medication compliance and knowledge without adversely affecting health-related quality of life Background — Even in high-performing health systems , some patients with diabetes mellitus have poor blood pressure ( BP ) control because of poor medication adherence and lack of medication intensification . We examined whether the Adherence and Intensification of Medications intervention , a pharmacist-led intervention combining elements found in efficacy studies to lower BP , improved BP among patients with diabetes mellitus with persistent hypertension and poor refill adherence or insufficient medication intensification in 2 high-performing health systems . Methods and Results — We conducted a prospect i ve , multisite cluster r and omized pragmatic trial with r and omization of 16 primary care teams at 5 medical centers ( 3 Veterans Affairs and 2 Kaiser Permanente ) to the Adherence and Intensification of Medications intervention or usual care . The primary outcome was relative change in systolic BP ( SBP ) , comparing 1797 intervention with 2303 control team patients , from 6 months preceding to 6 months after the 14-month intervention period . We examined shorter-term changes in SBP as a secondary outcome . The mean SBP decrease from 6 months before to 6 months after the intervention period was ≈9 mm Hg in both arms . Mean SBPs of eligible intervention patients were 2.4 mm Hg lower ( 95 % CI : −3.4 to −1.5 ; P<0.001 ) immediately after the intervention than those achieved by control patients . Conclusions — The Adherence and Intensification of Medications program more rapidly lowered SBPs among intervention patients , but usual-care patients achieved equally low SBP levels by 6 months after the intervention period . These findings show the importance of evaluating in different real-life clinical setting s programs found in efficacy trials to be effective before urging their widespread adoption in all setting s. Clinical Trial Registration — URL : http:// clinical trials.gov . Unique identifier : NCT00495794 Purpose To assess whether VA MEDIC-E ( Veterans Affairs Multi-disciplinary Education and Diabetes Intervention for Cardiac risk reduction[EM DASH ] Extended for 6 months ) , a pharmacist-led shared medical appointments program , could improve attainment of target goals for hypertension , hyperglycemia , hyperlipidemia , and tobacco use in patients with type 2 diabetes compared to st and ard primary care after 6 months of intervention . Methods A r and omized , controlled trial of VA MEDIC-E ( n = 50 ) versus st and ard primary care ( n = 49 ) in veterans with type 2 diabetes , hemoglobin A1c ( A1C ) > 7 % , blood pressure ( BP ) > 130/80 mmHg , and low density lipoprotein cholesterol ( LDL-C ) > 100mg/dl ( 2.59 mmol/l ) in the previous 6 months was conducted . The VA MEDIC-E intervention consisted of 4 weekly group sessions followed by 5 monthly booster group sessions . Each 2-hour session included 1 hour of multidisciplinary diabetes specific healthy lifestyle education and 1 hour of pharmacotherapeutic interventions performed by a clinical pharmacist . Evaluation measures included lab values of A1C , LDL cholesterol , BP , and goal attainment of these values , and diabetes self-care behavior question naires at 6 months . Results The r and omization groups were similar at baseline in all cardiovascular risk factors except for LDL , which was significantly lower in the MEDIC-E arm . At 6 months , significant improvements from baseline were found in the intervention arm for exercise , foot care , and goal attainment of A1C , LDL-C , and BP but not in the control arm . Conclusions The results of this study demonstrate that the pharmacist-led group intervention program for 6 months was an efficacious and sustainable collaborative care approach to managing diabetes and reducing associated cardiovascular risk The purpose of this study was : ( 1 ) to record GP opinions , practice s and outcomes for the care of Type 2 Diabetes Mellitus ( DM2 ) , ( 2 ) compare practice facilities and process of care with a criterion of recommended competent care and ( 3 ) determine if there were any differences between vocationally registered and non-vocationally registered GPs . A r and om sample of 204 metropolitan doctors from 124 practice s was selected and an audit performed on 467 of their patient records . GPs pursued good blood sugar control and advocated lifestyle changes before hypoglycaemic drugs . Over 80 % regard uncomplicated DM2 as a condition for general practice management . However , only 15 % conducted an annual diabetes check , 9 % had a diabetic register , 6 % a diabetic recall system and 8 % used a diabetic health care checklist for monitoring their patients . The most commonly recorded processes of medical audit in the previous 12 months were : blood pressure ( 94 % ) , duration of diabetes ( 72 % ) , blood glucose ( 70 % ) , diet ( 66 % ) , body weight ( 56 % ) , HBA1c ( 52 % ) and ophthalmoscopy ( 50 % ) . The least commonly recorded processes of care were body mass index ( 5 % ) , inspection of the feet ( 18 % ) , enquiries about vaginitis or impotence ( 23 % ) . The amount of exercise , alcohol and tobacco was recorded in only 34 % of records . Hypoglycaemic drugs were used appropriately but the most commonly used drugs for treating hypertension in DM2 patients were thiazide diuretics and beta-blockers .  Vocationally registered ( VR ) doctors had better records , higher process of care scores and more were willing to participate in the study than non-vocationally registered ( NVR ) doctors . However , there was no difference in metabolic control between patients from either group . The use of a Diabetic Health Care Checklist would improve diabetes care especially in the search for early complications and in the recording of HBA1c and other metabolic parameters . The drugs commonly used to control hypertension can have adverse effects on glucose and lipid metabolism and should be replaced with glucose and lipid neutral drugs Purpose The purpose of this study was to determine whether “ clinical inertia”—inadequate intensification of therapy by the provider — could contribute to high A1C levels in patients with type 2 diabetes managed in a primary care site . Methods In a prospect i ve observational study , management was compared in the Medical Clinic , a primary care site supervised by general internal medicine faculty , and the Diabetes Clinic , a specialty site supervised by endocrinologists . These municipal hospital clinics serve a common population that is largely African American , poor , and uninsured . Results Four hundred thirty-eight African American patients in the Medical Clinic and 2157 in the Diabetes Clinic were similar in average age , diabetes duration , body mass index , and gender , but A1C averaged 8.6 % in the Medical Clinic versus 7.7 % in the Diabetes Clinic ( P < .0001 ) . Use of pharmacotherapy  was less intensive in the Medical Clinic ( less use of insulin ) , and when patients had elevated glucose levels during clinic visits , therapy was less than half as likely to be advanced in the Medical Clinic compared to the Diabetes Clinic ( P < .0001 ) . Intensification rates were lower in the Medical Clinic regardless of type of therapy ( P < .0001 ) , and intensification of therapy was independently associated with improvement in A1C ( P < .001 ) . Conclusions Medical Clinic patients had worse glycemic control , were less likely to be treated with insulin , and were less likely to have their therapy intensified if glucose levels were elevated . To improve diabetes management and glycemic control nationwide , physicians in training and generalists must learn to overcome clinical inertia , to intensify therapy when appropriate , and to use insulin when clinical ly indicated OBJECTIVE To examine the effect of case management on glycemic control and behavioral outcomes in adults with Type 2 diabetes in China . METHODS Participants were r and omly assigned to a 1-year case management ( CM ) group ( n=60 ) or control group ( n=60 ) . Monthly case management visits included identifying individuals ' diabetes-related problems , setting goals , planning self-care , and evaluating progress . During a 1-year follow-up , all participants attended visits every 3 months without intervention . RESULTS In the CM vs. the control group , HbA1c was reduced at 6 months compared to baseline ( P=0.034 ) , with trends at 12 and 24 months , and empowerment ability improved ( P<0.05 ) . Also in the CM vs. controls , total self-care behaviors , the frequency of exercise , blood glucose testing , and foot care were higher ( P<0.001 ) at 12 months , and the percentage of individuals with HbA1c ≤7.0 % was higher ( P=0.035 ) at 24 months . CONCLUSION The case management intervention in China was effective at 6 months and , based on trends in HbA1c at 12 and 24 months and results for behavioral outcomes , the intervention shows promise and warrants more research . PRACTICE IMPLICATION S A case management approach can enhance behavior change and glycemic control in Chinese with diabetes Summary In primary care it is difficult to treat the growing number of non-insulin-dependent diabetic ( NIDDM ) patients according to (inter)national guidelines . A prospect i ve , controlled cohort study was design ed to assess the intermediate term ( 2 years ) effect of structured NIDDM care in general practice with and without ‘ diabetes service ’ support on glycaemic control , cardiovascular risk factors , general well-being and treatment satisfaction . The ‘ diabetes service ’ , supervised by a diabetologist , included a patient registration system , consultation facilities of a dietitian and diabetes nurse educator , and protocol ized blood glucose lowering therapy advice which included home blood glucose monitoring and insulin therapy . In the study group ( SG ; 22 general practice s ) , 350 known NIDDM patients over 40 years of age ( 206 women ; mean age 65.3 ± SD 11.9 ; diabetes duration 5.9 ± 5.4 years ) were followed for 2 years . The control group ( CG ; 6 general practice s ) consisted of 68 patients ( 28 women ; age 64.6 ± 10.3 ; diabetes duration 6.3 ± 6.4 years ) . Mean HbAlc ( reference 4.3 - 6.1 % ) fell from 7.4 to 7.0 % in SG and rose from 7.4 to 7.6 % in CG during follow-up ( p = 0.004 ) . The percentage of patients with poor control ( HbA1c>8.5 % ) shifted from 21.4 to 11.7 % in SG , but from 23.5 to 27.9 % in CG ( p = 0.008 ) . Good control ( HbAlc > 7.0 % ) was achieved in 54.3 % ( SG ; at entry 43.4 % ) and 44.1 % ( CG ; at entry 54.4 % ) ( p = 0.013  ) . Insulin therapy was started in 29.7 % ( SG ) and 8.8 % ( CG ) of the patients ( p = 0.000 ) with low risk of severe hypoglycaemia ( 0.019/patient year ) . Mean levels of total and HDL-cholesterol ( SG ) , triglycerides ( SG ) and diastolic blood pressure ( SG + CG ) and the percentage of smokers ( SG ) declined significantly , but the prevalence of these risk factors remained high . General well-being ( SG ) did not change during intensified therapy . Treatment satisfaction ( SG ) tended to improve . Implementation of structured care , including education and therapeutic advice , results in sustained good glycaemic control in the majority of NIDDM patients in primary care , with low risk of hypoglycaemia . Lowering cardiovascular risk requires more than reporting results and referral to guidelines . [ Diabetologia 
    Output:
    