You will be presented with a collection of medical randomized controlled trial (RCT) reports addressing a shared clinical question -- for instance, the efficacy of a medical intervention on a disease or condition. Given the titles and abstracts of these reports, your task is to generate the conclusion of the systematic review article synthesizing the key findings. Your conclusion should be a few sentences long. In your response, include only the conclusion and no other text. The RCT reports are below.



Title 1:
Complex health care decisions with older patients in general practice: patient-centeredness and prioritization in consultations following a geriatric assessment.
Abstract 1:
OBJECTIVE To examine to what extent general practitioners in consultations after a geriatric assessment set shared health priorities with older patients experiencing multimorbidity and to what extent this was facilitated through patient-centered behavior . METHODS Observation of consultations embedded in a cluster r and omized controlled trial,(1 ) in which 317 patients from 41 general practice s received the  STEP assessment followed by a care planning consultation with their GPs . GPs in the intervention group used a structured procedure for setting health ( care ) priorities in contrast to control GPs . A sample of 43 consultations ( 24 intervention ; 19 control ) were recorded , transcribed and analyzed with regard to priority setting and patient-centeredness . RESULTS Patient-centeredness was only moderately apparent in consultations dealing with complex care plans for older patients with multimorbidity . The shared determination of health priorities seemed unusual for both doctors and patients and was rarely practice d , albeit more frequently in intervention consultations . CONCLUSION Setting health care priorities with patients experiencing multimorbidity is ethically desirable and medically appropriate . Yet a short structured guide for doctors can not easily achieve this . PRACTICE IMPLICATION S More research is needed in regard to h and ling complex health needs of older patients . It requires a professional approach and training in patient-centered holistic care planning


Title 2:
Impact of a priority-setting consultation on doctor-patient agreement after a geriatric assessment: cluster randomised controlled trial in German general practices.
Abstract 2:
BACKGROUND General Practitioners ( GPs ) often have to simultaneously tackle multiple health problems of older patients . A patient-centred process that engages the patient in setting health priorities for treatment is needed . We investigated whether a structured priority- setting consultation reconciles the often-differing doctor-patient views on the importance of problems . DESIGN Cluster r and omised controlled trial with 40 GPs and their 317 consecutively recruited older patients . PROCEDURE Following a geriatric assessment , patients and doctors independently rated the importance of each uncovered problem . GPs then selected priorities with their patients in a consultation . Trained intervention GPs held a structured consultation and utilised the list of uncovered patient problems with their importance ratings to agree priorities . Untrained control GPs only used the patient 's problem list without importance ratings . MAIN OUTCOME Doctor-patient agreement on independent importance ratings two weeks after the priority- setting consultation . ANALYSIS Weighted kappa ( κw ) and multilevel logistic regression model . RESULTS Intervention GPs and their patients determined mutual priorities for 20 % of individual problems . In this process , GPs often succeeded in convincing their patients of the importance of vaccinations , lifestyle and cognitive issues . Likewise , patients convinced their GPs to prioritise their social and functional problems . Further treatment plans ensued in 84 % of these priority areas . The regression model adjusting for clusters and baseline characteristics did not demonstrate significant differences in doctor-patient agreement on problems between groups a two weeks later . CONCLUSION Differing views on the importance of health problems between GPs and older patients were not sustainably reconciled . The special consultation facilitated identification of priority problems for treatment despite differences in perceived importance of problems between patients and GPs . German clinical trials register drks 00000792


Title 3:
Effectiveness and cost-effectiveness of a proactive, goal-oriented, integrated care model in general practice for older people. A cluster randomised controlled trial: Integrated Systematic Care for older People—the ISCOPE study
Abstract 3:
Background : older people often experience complex problems . Because of multiple problems , care for older people in general practice needs to shift from a ‘ problem-based , disease-oriented ’ care aim ing at improvement of outcomes per disease to a ‘ goal -oriented care ’ , aim ing at improvement of functioning and personal quality of life , integrating all healthcare providers . Feasibility and cost-effectiveness of this proactive and integrated way of working are not yet established . Design : cluster r and omised trial . Participants : all persons aged ≥75 in 59 general practice s ( 30 intervention , 29 control ) , with a combination of problems , as identified with a structured postal question naire with 21 questions on four health domains . Intervention : for participants with problems on ≥3 domains , general practitioners ( GPs ) made an integrated care plan using a functional geriatric approach . Control practice s : care as usual . Outcome measures : ( i ) quality of life ( QoL ) , ( ii ) activities of daily living , ( iii ) satisfaction with delivered health care and ( iv ) cost-effectiveness of the intervention at 1-year follow-up . Trial registration : Netherl and s trial register , NTR1946 . Results : of the 11,476 registered eligible older persons , 7,285 ( 63 % ) participated in the screening . One thous and nine hundred and twenty-one ( 26 % ) had problems on ≥3 health domains . For 225 r and omly chosen persons , a care plan was made . No beneficial effects were found on QoL , patients ' functioning or healthcare use/costs . GPs experienced better overview of the care and stability , e.g. less unexpected dem and s , in the care . Conclusions : GPs prefer proactive integrated care . ‘ Horizontal ’ care using care plans for older people with complex problems can be a valuable tool in general practice . However , no direct beneficial effect was found for older persons


Title 4:
Integrated primary care for patients with mental and physical multimorbidity: cluster randomised controlled trial of collaborative care for patients with depression comorbid with diabetes or cardiovascular disease
Abstract 4:
Objective To test the effectiveness of an integrated collaborative care model for people with depression and long term physical conditions . Design Cluster r and omised controlled trial . Setting 36 general practice s in the north west of Engl and . Participants 387 patients with a record of diabetes or heart disease , or both , who had depressive symptoms ( ≥10 on patient health question aire-9 ( PHQ-9 ) ) for at least two weeks . Mean age was 58.5 ( SD 11.7 ) . Participants reported a mean of 6.2 ( SD 3.0 ) long term conditions other than diabetes or heart disease ; 240 ( 62 % ) were men ; 360 ( 90 % ) completed the trial .  Interventions Collaborative care included patient preference for behavioural activation , cognitive restructuring , grade d exposure , and /or lifestyle advice , management of drug treatment , and prevention of relapse . Up to eight sessions of psychological treatment were delivered by specially trained psychological wellbeing practitioners employed by Improving Access to Psychological Therapy services in the English National Health Service ; integration of care was enhanced by two treatment sessions delivered jointly with the practice nurse . Usual care was st and ard clinical practice provided by general practitioners and practice nurses . Main outcome measures The primary outcome was reduction in symptoms of depression on the self reported symptom checklist-13 depression scale ( SCL-D13 ) at four months after baseline assessment . Secondary outcomes included anxiety symptoms ( generalised anxiety disorder 7 ) , self management ( health education impact question naire ) , disability ( Sheehan disability scale ) , and global quality of life ( WHOQOL-BREF ) . Results 19 general practice s were r and omised to collaborative care and 20 to usual care ; three practice s withdrew from the trial before patients were recruited . 191 patients were recruited from practice s allocated to collaborative care , and 196 from practice s allocated to usual care . After adjustment for baseline depression score , mean depressive scores were 0.23 SCL-D13 points lower ( 95 % confidence interval −0.41 to −0.05 ) in the collaborative care arm , equal to an adjusted st and ardised effect size of 0.30 . Patients in the intervention arm also reported being better self managers , rated their care as more patient centred , and were more satisfied with their care . There were no significant differences between groups in quality of life , disease specific quality of life , self efficacy , disability , and social support . Conclusions Collaborative care that incorporates brief low intensity psychological therapy delivered in partnership with practice nurses in primary care can reduce depression and improve self management of chronic disease in people with mental and physical multimorbidity . The size of the treatment effects were modest and were less than the prespecified effect but were achieved in a trial run in routine setting s with a deprived population with high levels of mental and physical multimorbidity . Trial registration IS RCT N80309252


Title 5:
Effects of guided care on family caregivers.
Abstract 5:
PURPOSE Guided Care ( GC ) is a model of health care for multimorbid older adults that is provided by a registered nurse who works with the patients ' primary care physician ( PCP ) . The purpose of this study was to determine whether GC improves patients ' primary caregivers '  depressive symptoms , strain , productivity , and perceptions of the quality of care recipients ' chronic illness care . DESIGN AND METHODS A cluster-r and omized controlled trial of GC was conducted within 14 PCP teams . The study sample included 196 primary caregivers who completed baseline and 18-month surveys and whose care recipients remained alive and enrolled in the GC study for 18 months . Caregiver outcomes included the following : depressive symptoms ( Center for Epidemiological Studies -Depression scale ) , strain ( Modified Caregiver Strain Index ) , the quality of care recipients ' chronic illness care [ Patient Assessment of Chronic Illness Care ( PACIC ) ] , and personal productivity ( Work Productivity and Activity Impairment question naire , adapted for caregiving ) . RESULTS In multivariate regression models , between-group differences in depression , strain , work productivity , and regular activity productivity were not statistically significant after 18 months , but GC caregivers reported the overall quality of their recipients ' chronic illness care to be significantly higher ( adjusted beta = 0.40 , 95 % confidence interval : 0.14 - 0.67 ) . Quality was significantly higher in 4 of 5 PACIC subscales , reflecting the dimensions of goal setting , coordination of care , decision support , and patient activation . IMPLICATION S GC improved the quality of chronic illness care received by multimorbid care recipients but did not improve caregivers ' depressive symptoms , affect , or productivity


Title 6:
The Effects of Guided Care on the Perceived Quality of Health Care for Multi-morbid Older Persons: 18-Month Outcomes from a Cluster-Randomized Controlled Trial
Abstract 6:
BACKGROUND The quality of health care for older Americans with chronic conditions is suboptimal . OBJECTIVE To evaluate the effects of “ Guided Care ” on patient-reported quality of chronic illness care . DESIGN Cluster-r and omized controlled trial of Guided Care in 14 primary care teams . PARTICIPANTS Older patients of these teams were eligible to participate if , based on analysis of their recent insurance cl aims , they were at risk for incurring high health-care costs during the coming year . Small teams of physicians and their at-risk older patients were r and omized to receive either Guided Care ( GC ) or usual care (UC).INTERVENTION“Guided Care ” is design ed to enhance the quality of health care by integrating a registered nurse , trained in chronic care , into a primary care practice to work with 2–5 physicians in providing comprehensive chronic care to 50–60 multi-morbid older patients . MEASUREMENTS Eighteen months after baseline , interviewers blinded to group assignment administered the Patient Assessment of Chronic Illness Care ( PACIC ) survey by telephone . Logistic and linear regression was used to evaluate the effect of the intervention on patient-reported quality of chronic illness care . RESULTS Of the 13,534 older patients screened , 2,391 ( 17.7 % ) were eligible to participate in the study , of which 904 ( 37.8 % ) gave informed consent and were cluster-r and omized . After 18 months , 95.3 % and 92.2 % of the GC and UC recipients who remained alive and eligible completed interviews . Compared to UC recipients , GC recipients had twice greater odds of rating their chronic care highly ( aOR = 2.13 , 95 % CI = 1.30–3.50 , p = 0.003 ) . CONCLUSION Guided Care  improves self-reported quality of chronic health care for multi-morbid older persons


Title 7:
Early effects of "Guided Care" on the quality of health care for multimorbid older persons: a cluster-randomized controlled trial.
Abstract 7:
BACKGROUND The quality of health care for older Americans with multiple chronic conditions is suboptimal . We design ed " Guided Care " ( GC ) to enhance quality of care by integrating a registered nurse , intensively trained in chronic care , into primary care practice s to work with physicians in providing comprehensive chronic care to 50 - 60 multimorbid older patients . METHODS We hypothesized that GC would improve the quality of health care for this population . In 2006 , we began a cluster-r and omized controlled trial of GC at eight practice s ( n = 49 physicians ) . Older patients of these practice s were eligible to participate if they were at risk for using health services heavily during the coming year . Teams of two to five physicians and their at-risk older patients were r and omized to either GC or usual care ( UC ) . Six months after baseline , participants rated the quality of their health care by answering vali date d closed-ended questions from telephone interviewers who were masked to group assignment . RESULTS Of the 13,534 older patients screened , 2391 ( 17.7 % ) were eligible to participate in the study , of which 904 ( 37.8 % ) gave informed consent and were cluster-r and omized . After 6 months , 93.8 % and 93.2 % of the GC and UC participants who remained alive and eligible completed telephone interviews . GC participants were more likely than UC participants to rate their care highly ( adjusted odds ratio = 2.0 , 95 % confidence interval , 1.2 - 3.4 , p = .006 ) , and primary care physicians were more likely to be satisfied with their interactions with chronically ill older patients and their families ( p < .05 ) . CONCLUSIONS GC improves important aspects of the quality of health care for multimorbid older persons . Additional data will become available as this trial continues
Explicit attention for goal setting or priority setting by a professional was a common element in these multifactorial interventions .
Conclusions Collaborative goal setting and /or priority setting can probably best be integrated in complex care interventions .