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 Brief interventions for  problem drinking  in medical setting s are effective but rarely conducted , mainly due to insufficient time . A stepped care approach ( starting with a very brief intervention and intensifying efforts in case of no success ) could save re sources and enlarge effectiveness ; however , research is lacking . The present study compares a full care brief intervention for patients with at-risk drinking , alcohol abuse or dependence with a stepped care approach in a r and omized controlled trial . METHODS Participants were proactively recruited from general practice s in two northern German cities . In total , 10,803 screenings were conducted ( refusal rate : 5 % ) . Alcohol use disorders according to DSM-IV were assessed with the Munich-Composite International Diagnostic Interview ( M-CIDI ) . Eligible participants were r and omly assigned to one of three conditions : ( 1 ) stepped care ( SC ) : a computerized intervention plus up to three 40-min telephone-based interventions depending on the success of the previous intervention ; ( 2 ) full-care ( FC ) : a computerized intervention plus a fixed number of four 30-min telephone-based interventions that equals the maximum of the stepped care intervention ; ( 3 ) an untreated control group ( CG ) .  Counseling effort in the intervention conditions and quantity/frequency of drinking were assessed at 12-month follow-up . RESULTS SC participants received roughly half of the amount of intervention in minutes compared to FC participants . Both groups did not differ in drinking outcomes . Compared to CG , intervention showed small to medium effect size for at-risk drinkers . CONCLUSIONS Study results reveal that a stepped care approach can be expected to increase cost-effectiveness of brief interventions for individuals with at-risk drinking OBJECTIVE Brief intervention for patients with unhealthy alcohol use  is a prevention priority in the United States , but most eligible patients do not receive it . This study evaluated an electronic alcohol-counseling clinical reminder at a single Veterans Affairs general medicine clinic . METHOD The systems-level intervention evaluated in this study consisted of making the clinical reminder , which facilitated medical record documentation of brief intervention among patients who screened positive for unhealthy alcohol use , available to providers on one ( of two ) r and omly selected hallways . Secondary electronic data were extracted for all patients who visited the clinic ( October 1 , 2002 , to September 30 , 2005 ) . The proportion of patients with clinical -reminder use was evaluated among patients who screened positive for unhealthy drinking and were assigned to intervention hallway providers ( " descriptive cohort " ) . Adjusted logistic regression evaluated the association between the intervention and resolution of unhealthy drinking at follow-up among all screen-positive patients who completed a second Alcohol Use Disorders Identification Test Consumption question naire 18 months or longer after the first ( " outcomes cohort " ) . RESULTS Eligible patients ( N= 22,863 ) included 10,392 controls and 12,471 in the intervention group . Fifteen percent ( 398 of 2,640 ) of descriptive cohort patients with unhealthy drinking had clinical -reminder use , which varied by severity ( 14 % [ n = 302 of 2,165 ] with mild/moderate and 20 % [ n = 96 of 475 ] with severe unhealthy drinking , p = .001 ) . Only 39 % ( 156 of 398 ) of patients with clinical -reminder use had documented brief intervention ; advice to abstain was most common . Access to the clinical reminder was not significantly associated with resolution of unhealthy drinking in 1,358 patients in the outcomes cohort . CONCLUSIONS Availability of a clinical reminder to facilitate brief intervention did not , alone , result in substantial use of the clinical reminder . More active implementation efforts may be needed to get brief interventions onto the agenda of busy primary care providers Background Alcohol screening and brief intervention for unhealthy alcohol use has not been consistently delivered in primary care as part of preventive healthcare . Objective To explore whether telephone-based intervention delivered by a health educator is efficacious in reducing  at-risk drinking among older adults in primary care setting s. Design Secondary analyses of data from a r and omized controlled trial . Participants Subjects r and omized to the intervention arm of the trial ( n = 310 ) . Interventions Personalized risk reports , advice from physicians , booklet about alcohol and aging , and up to three telephone calls from a health educator . All interventions were completed before the three-month follow-up . Measurements Risk outcomes ( at-risk or not at-risk ) at 3 and 12 months after enrollment . Main results In univariate analyses , compared to those who remained at risk , those who achieved not at-risk outcome at 3 months were more likely to be women , Hispanic or non-white , have lower levels of education , consume less alcohol , drink less frequently , and have lower baseline number of risks . In mixed-effects logistic regression models , completing all three health educator calls increased the odds of achieving not at-risk outcome compared to not completing any calls at 3 months ( OR 5.31 ; 95 % CI 1.92–14.7 ; p = 0.001 ) , but not at 12 months ( OR 2.01 ; 95 % CI 0.71–5.67 ; p = 0.18 ) . Conclusions Telephone-based intervention delivered by a health educator was moderately efficacious in reducing at-risk drinking at 3 months after enrollment among older adults receiving a multi-faceted intervention in primary care setting s ; however , the effect was not sustained at 12 months Purpose : This article describes the development , implementation , and effectiveness of 2 interactive websites design ed to support health behavior change around healthy eating , physical activity , smoking , and use of alcohol for primary care patients . Methods : Patients from 6 primary care practice s were recruited and r and omized to a basic website ( including a health assessment with feedback of the results and educational material s about health behavior change ) or an enhanced website that included the features of the basic site plus an action planning component . Patients were prompted to return for follow-up assessment s at 3 and 6 months after enrollment . Results : Of 7706 participants , 169 ( 2.2 % ) targeted for recruitment actually used the website . Both web-based interventions seemed to assist patients with making positive changes in their behavior , especially activity level and healthful diet . There were no significant differences in the effectiveness of the basic and enhanced websites . Conclusions : Interactive behavior-change technology interventions can assist primary care patients and practice s in health behavior change activities . Difficulties with patient recruitment and the lack of added effectiveness of the enhanced website suggest that such interventions work better if integrated into the interaction between primary care clinicians and patients rather than as a st and alone intervention Objectives To evaluate the 12-month costs and quality -adjusted life years ( QALYs ) gained to the Italian National Health Service of facilitated access to a website for hazardous drinkers compared with a st and ard face-to-face brief intervention ( BI ) . Design R and omised 1:1 non-inferiority trial . Setting Practice s of 58 general practitioners ( GPs ) in Italy . Participants Of 9080 patients ( > 18 years old ) approached to take part in the trial , 4529 ( 49·9 % ) logged on to the website and 3841 ( 84.8 % ) undertook online screening for hazardous drinking . 822 ( 21.4 % ) screened positive and 763 ( 19.9 % ) were recruited to the trial . Interventions Patients were r and omised to receive either a face-to-face BI or access via a brochure from their GP to an alcohol reduction website ( facilitated access ) . Primary and secondary outcome measures The primary outcome is the cost per QALY gained of facilitated access compared with face-to-face . A secondary analysis includes total costs and benefits per 100 patients , including number of hazardous drinkers prevented at 12 months . Results The average time required for the face-to-face BI was 8 min ( 95 % CI 7.5 min to 8.6 min ) . Given the maximum time taken for facilitated access of 5 min , face-to-face is an additional 3 min : equivalent to having time for another GP appointment for every three patients referred to the website . Complete case analysis adjusting for baseline the difference in QALYs for facilitated access is 0.002 QALYs per patient ( 95 % CI −0.007 to 0.011 ) . Conclusions Facilitated access to a website to reduce hazardous drinking costs less than a face-to-face BI given by a GP with no worse outcomes . The lower cost of facilitated access , particularly in regards to investment of time , may facilitate the increase in provision of BIs for hazardous drinking . Trial registration number NCT01638338 ; Post- results Background Healthcare reform in the United States is encouraging Federally Qualified Health Centers and other primary -care practice s to integrate treatment for addiction and other behavioral health conditions into their practice s. The potential of mobile health technologies to manage addiction and comorbidities such as HIV in these setting s is substantial but largely untested . This paper describes a protocol to evaluate the implementation of an E-Health integrated communication technology delivered via mobile phones , called Seva , into primary -care setting s. Seva is an evidence -based system of addiction treatment and recovery support for patients and real-time caseload monitoring for clinicians . Methods / Design Our implementation strategy uses three models of organizational change : the Program Planning Model to promote acceptance and sustainability , the NIATx quality improvement model to create a welcoming environment for change , and Rogers ’s diffusion of innovations research , which facilitates adaptations of innovations to maximize their adoption potential . We will implement Seva and conduct an intensive , mixed- methods assessment at three diverse Federally Qualified Healthcare Centers in the United States . Our non-concurrent multiple-baseline design includes three periods — pretest ( ending in four months of implementation preparation ) , active Seva implementation , and maintenance — with implementation staggered at six-month intervals across sites . The first site will serve as a pilot clinic . We will track the timing of intervention elements and assess study outcomes within each dimension of the Reach , Effectiveness , Adoption , Implementation , and Maintenance framework , including effects on clinicians , patients , and practice s. Our mixed- methods approach will include quantitative ( e.g. , interrupted time-series analysis of treatment attendance , with clinics as the unit of analysis ) and qualitative ( e.g. , staff interviews regarding adaptations to implementation protocol ) methods , and assessment of implementation costs . Discussion If implementation is successful , the field will have a proven technology that helps Federally Qualified Health Centers and affiliated organizations provide addiction treatment and recovery support , as well as a proven strategy for implementing the technology . Seva also has the potential to improve core elements of addiction treatment , such as referral and treatment processes . A mobile technology for addiction treatment and accompanying implementation model could provide a cost-effective means to improve the lives of patients with drug and alcohol problems . Trial registration Clinical Trials.gov ( NCT01963234 ) Veterans from conflicts such as the wars in Iraq and Afghanistan commonly return with behavioral health problems , including posttraumatic stress disorder ( PTSD ) and hazardous or harmful substance use . Unfortunately , many veterans experience significant barriers to receiving evidence -based treatment , including poor treatment motivation , concerns about stigma , and lack of access to appropriate care . To address this need , the current study developed and evaluated a web-based self-management intervention based on cognitive behavioral therapy ( CBT ) , targeting PTSD symptoms and hazardous substance use in a group of symptomatic combat veterans enrolled in VA primary care . Veterans with PTSD/subthreshold PTSD and hazardous substance use were r and omized to  primary care treatment as usual ( TAU ; n = 81 ) or to  TAU plus a web-based CBT intervention called Thinking Forward ( n = 81 ) . Thinking Forward consisted of 24 sections ( approximately 20 minutes each ) , accessible over 12 weeks . Participants completed baseline and 4- , 8- , 12- , 16- , and 24-week follow-up assessment s. Three primary outcomes of PTSD , alcohol and other drug use , and quality of life were examined . Significant treatment effects were found for heavy drinking , but not for PTSD or quality of life . The effect of the intervention on heavy drinking was mediated by intervening increases in coping , social support , self-efficacy , and hope for the future . These results demonstrate the promise of a web-based , self-management intervention for difficult-to-engage OEF/OIF veterans with behavioral health and substance use concerns Background Computer technologies hold promise for implementing alcohol screening , brief intervention , and referral to treatment ( SBIRT ) . Questions concerning the most effective and appropriate SBIRT model remain . Objective The aim of this study was to evaluate the impact of a computerized SBIRT system called the Health Evaluation and Referral Assistant ( HERA ) on risky alcohol use treatment initiation . Methods Alcohol users ( N=319 ) presenting to an emergency department ( ED ) were considered for enrollment . Those enrolled ( n=212 ) were r and omly assigned to the HERA , to complete a patient-administered assessment using a tablet computer , or a minimal-treatment control , and were followed for 3 months . Analyses compared alcohol treatment provider contact , treatment initiation , treatment completion , and alcohol use across condition using univariate comparisons , generalized estimating equations ( GEEs ) , and post hoc chi-square analyses . Results HERA participants ( n=212 ; control=115 ; intervention=97 ) did not differ between conditions on initial contact with an alcohol treatment 
    Output:
    
agent
***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 Brief interventions for  problem drinking  in medical setting s are effective but rarely conducted , mainly due to insufficient time . A stepped care approach ( starting with a very brief intervention and intensifying efforts in case of no success ) could save re sources and enlarge effectiveness ; however , research is lacking . The present study compares a full care brief intervention for patients with at-risk drinking , alcohol abuse or dependence with a stepped care approach in a r and omized controlled trial . METHODS Participants were proactively recruited from general practice s in two northern German cities . In total , 10,803 screenings were conducted ( refusal rate : 5 % ) . Alcohol use disorders according to DSM-IV were assessed with the Munich-Composite International Diagnostic Interview ( M-CIDI ) . Eligible participants were r and omly assigned to one of three conditions : ( 1 ) stepped care ( SC ) : a computerized intervention plus up to three 40-min telephone-based interventions depending on the success of the previous intervention ; ( 2 ) full-care ( FC ) : a computerized intervention plus a fixed number of four 30-min telephone-based interventions that equals the maximum of the stepped care intervention ; ( 3 ) an untreated control group ( CG ) .  Counseling effort in the intervention conditions and quantity/frequency of drinking were assessed at 12-month follow-up . RESULTS SC participants received roughly half of the amount of intervention in minutes compared to FC participants . Both groups did not differ in drinking outcomes . Compared to CG , intervention showed small to medium effect size for at-risk drinkers . CONCLUSIONS Study results reveal that a stepped care approach can be expected to increase cost-effectiveness of brief interventions for individuals with at-risk drinking OBJECTIVE Brief intervention for patients with unhealthy alcohol use  is a prevention priority in the United States , but most eligible patients do not receive it . This study evaluated an electronic alcohol-counseling clinical reminder at a single Veterans Affairs general medicine clinic . METHOD The systems-level intervention evaluated in this study consisted of making the clinical reminder , which facilitated medical record documentation of brief intervention among patients who screened positive for unhealthy alcohol use , available to providers on one ( of two ) r and omly selected hallways . Secondary electronic data were extracted for all patients who visited the clinic ( October 1 , 2002 , to September 30 , 2005 ) . The proportion of patients with clinical -reminder use was evaluated among patients who screened positive for unhealthy drinking and were assigned to intervention hallway providers ( " descriptive cohort " ) . Adjusted logistic regression evaluated the association between the intervention and resolution of unhealthy drinking at follow-up among all screen-positive patients who completed a second Alcohol Use Disorders Identification Test Consumption question naire 18 months or longer after the first ( " outcomes cohort " ) . RESULTS Eligible patients ( N= 22,863 ) included 10,392 controls and 12,471 in the intervention group . Fifteen percent ( 398 of 2,640 ) of descriptive cohort patients with unhealthy drinking had clinical -reminder use , which varied by severity ( 14 % [ n = 302 of 2,165 ] with mild/moderate and 20 % [ n = 96 of 475 ] with severe unhealthy drinking , p = .001 ) . Only 39 % ( 156 of 398 ) of patients with clinical -reminder use had documented brief intervention ; advice to abstain was most common . Access to the clinical reminder was not significantly associated with resolution of unhealthy drinking in 1,358 patients in the outcomes cohort . CONCLUSIONS Availability of a clinical reminder to facilitate brief intervention did not , alone , result in substantial use of the clinical reminder . More active implementation efforts may be needed to get brief interventions onto the agenda of busy primary care providers Background Alcohol screening and brief intervention for unhealthy alcohol use has not been consistently delivered in primary care as part of preventive healthcare . Objective To explore whether telephone-based intervention delivered by a health educator is efficacious in reducing  at-risk drinking among older adults in primary care setting s. Design Secondary analyses of data from a r and omized controlled trial . Participants Subjects r and omized to the intervention arm of the trial ( n = 310 ) . Interventions Personalized risk reports , advice from physicians , booklet about alcohol and aging , and up to three telephone calls from a health educator . All interventions were completed before the three-month follow-up . Measurements Risk outcomes ( at-risk or not at-risk ) at 3 and 12 months after enrollment . Main results In univariate analyses , compared to those who remained at risk , those who achieved not at-risk outcome at 3 months were more likely to be women , Hispanic or non-white , have lower levels of education , consume less alcohol , drink less frequently , and have lower baseline number of risks . In mixed-effects logistic regression models , completing all three health educator calls increased the odds of achieving not at-risk outcome compared to not completing any calls at 3 months ( OR 5.31 ; 95 % CI 1.92–14.7 ; p = 0.001 ) , but not at 12 months ( OR 2.01 ; 95 % CI 0.71–5.67 ; p = 0.18 ) . Conclusions Telephone-based intervention delivered by a health educator was moderately efficacious in reducing at-risk drinking at 3 months after enrollment among older adults receiving a multi-faceted intervention in primary care setting s ; however , the effect was not sustained at 12 months Purpose : This article describes the development , implementation , and effectiveness of 2 interactive websites design ed to support health behavior change around healthy eating , physical activity , smoking , and use of alcohol for primary care patients . Methods : Patients from 6 primary care practice s were recruited and r and omized to a basic website ( including a health assessment with feedback of the results and educational material s about health behavior change ) or an enhanced website that included the features of the basic site plus an action planning component . Patients were prompted to return for follow-up assessment s at 3 and 6 months after enrollment . Results : Of 7706 participants , 169 ( 2.2 % ) targeted for recruitment actually used the website . Both web-based interventions seemed to assist patients with making positive changes in their behavior , especially activity level and healthful diet . There were no significant differences in the effectiveness of the basic and enhanced websites . Conclusions : Interactive behavior-change technology interventions can assist primary care patients and practice s in health behavior change activities . Difficulties with patient recruitment and the lack of added effectiveness of the enhanced website suggest that such interventions work better if integrated into the interaction between primary care clinicians and patients rather than as a st and alone intervention Objectives To evaluate the 12-month costs and quality -adjusted life years ( QALYs ) gained to the Italian National Health Service of facilitated access to a website for hazardous drinkers compared with a st and ard face-to-face brief intervention ( BI ) . Design R and omised 1:1 non-inferiority trial . Setting Practice s of 58 general practitioners ( GPs ) in Italy . Participants Of 9080 patients ( > 18 years old ) approached to take part in the trial , 4529 ( 49·9 % ) logged on to the website and 3841 ( 84.8 % ) undertook online screening for hazardous drinking . 822 ( 21.4 % ) screened positive and 763 ( 19.9 % ) were recruited to the trial . Interventions Patients were r and omised to receive either a face-to-face BI or access via a brochure from their GP to an alcohol reduction website ( facilitated access ) . Primary and secondary outcome measures The primary outcome is the cost per QALY gained of facilitated access compared with face-to-face . A secondary analysis includes total costs and benefits per 100 patients , including number of hazardous drinkers prevented at 12 months . Results The average time required for the face-to-face BI was 8 min ( 95 % CI 7.5 min to 8.6 min ) . Given the maximum time taken for facilitated access of 5 min , face-to-face is an additional 3 min : equivalent to having time for another GP appointment for every three patients referred to the website . Complete case analysis adjusting for baseline the difference in QALYs for facilitated access is 0.002 QALYs per patient ( 95 % CI −0.007 to 0.011 ) . Conclusions Facilitated access to a website to reduce hazardous drinking costs less than a face-to-face BI given by a GP with no worse outcomes . The lower cost of facilitated access , particularly in regards to investment of time , may facilitate the increase in provision of BIs for hazardous drinking . Trial registration number NCT01638338 ; Post- results Background Healthcare reform in the United States is encouraging Federally Qualified Health Centers and other primary -care practice s to integrate treatment for addiction and other behavioral health conditions into their practice s. The potential of mobile health technologies to manage addiction and comorbidities such as HIV in these setting s is substantial but largely untested . This paper describes a protocol to evaluate the implementation of an E-Health integrated communication technology delivered via mobile phones , called Seva , into primary -care setting s. Seva is an evidence -based system of addiction treatment and recovery support for patients and real-time caseload monitoring for clinicians . Methods / Design Our implementation strategy uses three models of organizational change : the Program Planning Model to promote acceptance and sustainability , the NIATx quality improvement model to create a welcoming environment for change , and Rogers ’s diffusion of innovations research , which facilitates adaptations of innovations to maximize their adoption potential . We will implement Seva and conduct an intensive , mixed- methods assessment at three diverse Federally Qualified Healthcare Centers in the United States . Our non-concurrent multiple-baseline design includes three periods — pretest ( ending in four months of implementation preparation ) , active Seva implementation , and maintenance — with implementation staggered at six-month intervals across sites . The first site will serve as a pilot clinic . We will track the timing of intervention elements and assess study outcomes within each dimension of the Reach , Effectiveness , Adoption , Implementation , and Maintenance framework , including effects on clinicians , patients , and practice s. Our mixed- methods approach will include quantitative ( e.g. , interrupted time-series analysis of treatment attendance , with clinics as the unit of analysis ) and qualitative ( e.g. , staff interviews regarding adaptations to implementation protocol ) methods , and assessment of implementation costs . Discussion If implementation is successful , the field will have a proven technology that helps Federally Qualified Health Centers and affiliated organizations provide addiction treatment and recovery support , as well as a proven strategy for implementing the technology . Seva also has the potential to improve core elements of addiction treatment , such as referral and treatment processes . A mobile technology for addiction treatment and accompanying implementation model could provide a cost-effective means to improve the lives of patients with drug and alcohol problems . Trial registration Clinical Trials.gov ( NCT01963234 ) Veterans from conflicts such as the wars in Iraq and Afghanistan commonly return with behavioral health problems , including posttraumatic stress disorder ( PTSD ) and hazardous or harmful substance use . Unfortunately , many veterans experience significant barriers to receiving evidence -based treatment , including poor treatment motivation , concerns about stigma , and lack of access to appropriate care . To address this need , the current study developed and evaluated a web-based self-management intervention based on cognitive behavioral therapy ( CBT ) , targeting PTSD symptoms and hazardous substance use in a group of symptomatic combat veterans enrolled in VA primary care . Veterans with PTSD/subthreshold PTSD and hazardous substance use were r and omized to  primary care treatment as usual ( TAU ; n = 81 ) or to  TAU plus a web-based CBT intervention called Thinking Forward ( n = 81 ) . Thinking Forward consisted of 24 sections ( approximately 20 minutes each ) , accessible over 12 weeks . Participants completed baseline and 4- , 8- , 12- , 16- , and 24-week follow-up assessment s. Three primary outcomes of PTSD , alcohol and other drug use , and quality of life were examined . Significant treatment effects were found for heavy drinking , but not for PTSD or quality of life . The effect of the intervention on heavy drinking was mediated by intervening increases in coping , social support , self-efficacy , and hope for the future . These results demonstrate the promise of a web-based , self-management intervention for difficult-to-engage OEF/OIF veterans with behavioral health and substance use concerns Background Computer technologies hold promise for implementing alcohol screening , brief intervention , and referral to treatment ( SBIRT ) . Questions concerning the most effective and appropriate SBIRT model remain . Objective The aim of this study was to evaluate the impact of a computerized SBIRT system called the Health Evaluation and Referral Assistant ( HERA ) on risky alcohol use treatment initiation . Methods Alcohol users ( N=319 ) presenting to an emergency department ( ED ) were considered for enrollment . Those enrolled ( n=212 ) were r and omly assigned to the HERA , to complete a patient-administered assessment using a tablet computer , or a minimal-treatment control , and were followed for 3 months . Analyses compared alcohol treatment provider contact , treatment initiation , treatment completion , and alcohol use across condition using univariate comparisons , generalized estimating equations ( GEEs ) , and post hoc chi-square analyses . Results HERA participants ( n=212 ; control=115 ; intervention=97 ) did not differ between conditions on initial contact with an alcohol treatment 
    Output:
    