***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 : Palliative care for people with life-limiting non-malignant disease is increasingly prioritised . People with end-stage chronic obstructive pulmonary disease are among a key group of non-cancer patients likely to benefit from specialist palliative care , but it remains uncertain whether the needs of this group are met by existing services . Aim : To evaluate the experiences of patients with chronic obstructive pulmonary disease who accessed specialist palliative care .  Design : Data from semi-structured interviews were analysed using a hermeneutic phenomenological approach . Setting / participants : Eight patients accessing specialist palliative care within one city in North West Engl and . Results : Perceived benefits of specialist palliative care included reduced frequency of hospital admission , improved physical and psychological symptoms , reduced social isolation and a broadened physical environment . Participants were mainly aware of their poor prognosis , but discussion of referral to palliative care sometimes caused distress owing to the historical associations between dying and hospice care . Following engagement with services , participants ’ perceptions changed : palliative care was associated with social inclusion and opportunities to engage in reciprocal and altruistic social action . Negative associations were replaced by uncertainty and anxiety about the prospect of discharge . Conclusions : Much within existing services works well for people with chronic obstructive pulmonary disease , but opportunities to enhance palliative care for this underserved group remain . Future research might focus on prospect ively evaluating the impact of key components of palliative care on core patient-centred outcomes . Additionally , work must be done to raise awareness of the benefits of specialist palliative care for non-cancer patients , as negative associations can form a barrier to access Background Supporting 21st century health care and the practice of evidence -based medicine ( EBM ) requires ubiquitous access to clinical information and to knowledge-based re sources to answer clinical questions . Many questions go unanswered , however , due to lack of skills in formulating questions , crafting effective search strategies , and accessing data bases to identify best levels of evidence . Methods This r and omized trial was design ed as a pilot study to measure the relevancy of search results using three different interfaces for the PubMed search system . Two of the search interfaces utilized a specific framework called PICO , which was design ed to focus clinical questions and to prompt for publication type or type of question asked . The third interface was the st and ard PubMed interface readily available on the Web . Study subjects were recruited from interns and residents on an inpatient general medicine rotation at an academic medical center in the US . Thirty-one subjects were r and omized to one of the three interfaces , given 3 clinical questions , and asked to search PubMed for a set of relevant articles that would provide an answer for each question . The success of the search results was determined by a precision score , which compared the number of relevant or gold st and ard articles retrieved in a result set to the total number of articles retrieved in that set . Results Participants using the PICO templates ( Protocol A or Protocol B ) had higher precision scores for each question than the participants who used Protocol C , the st and ard PubMed Web interface . ( Question 1 : A = 35 % , B = 28 % , C = 20 % ; Question 2 : A = 5 % , B = 6 % , C = 4 % ; Question 3 : A = 1 % , B = 0 % , C = 0 % ) 95 % confidence intervals were calculated for the precision for each question using a lower boundary of zero . However , the 95 % confidence limits were overlapping , suggesting no statistical difference between the groups . Conclusion Due to the small number of search es for each arm , this pilot study could not demonstrate a statistically significant difference between the search protocol s. However there was a trend towards higher precision that needs to be investigated in a larger study to determine if PICO can improve the relevancy of search results In the GRADE approach , r and omized trials start as high- quality evidence and observational studies as low- quality evidence , but both can be rated down if most of the relevant evidence comes from studies that suffer from a high risk of bias . Well-established limitations of r and omized trials include failure to conceal allocation , failure to blind , loss to follow-up , and failure to appropriately consider the intention-to-treat principle . More recently recognized limitations include stopping early for apparent benefit and selective reporting of outcomes according to the results . Key limitations of observational studies include use of inappropriate controls and failure to adequately adjust for prognostic imbalance . Risk of bias may vary across outcomes ( e.g. , loss to follow-up may be far less for all-cause mortality than for quality of life ) , a consideration that many systematic review s ignore . In deciding whether to rate down for risk of bias -- whether for r and omized trials or observational studies -- authors should not take an approach that averages across studies . Rather , for any individual outcome , when there are some studies with a high risk , and some with a low risk of bias , they should consider including only the studies with a lower risk of bias PURPOSE An American Society of Clinical Oncology ( ASCO ) provisional clinical opinion ( PCO ) offers timely clinical direction to ASCO 's membership following publication or presentation of potentially practice -changing data from major studies . This PCO addresses the integration of palliative care services into st and ard oncology practice at the time a person is diagnosed with metastatic or advanced cancer . CLINICAL CONTEXT Palliative care is frequently misconstrued as synonymous with end-of-life care . Palliative care is focused on the relief of suffering , in all of its dimensions , throughout the course of a patient 's illness . Although the use of hospice and other palliative care services at the end of life has increased , many patients are enrolled in hospice less than 3 weeks before their death , which limits the benefit they may gain from these services . By potentially improving quality of life ( QOL ) , cost of care , and even survival in patients with metastatic cancer , palliative care has increasing relevance for the care of patients with cancer . Until recently , data from r and omized controlled trials ( RCTs ) demonstrating the benefits of palliative care in patients with metastatic cancer who are also receiving st and ard oncology care have not been available . RECENT DATA Seven published RCTs form the basis of this PCO . PROVISIONAL CLINICAL OPINION Based on strong evidence from a phase III RCT , patients with metastatic non-small-cell lung cancer should be offered concurrent palliative care and st and ard oncologic care at initial diagnosis . While a survival benefit from early involvement of palliative care has not yet been demonstrated in other oncology setting s , substantial evidence demonstrates that palliative care-when combined with st and ard cancer care or as the main focus of care-leads to better patient and caregiver outcomes . These include improvement in symptoms , QOL , and patient satisfaction , with reduced caregiver burden . Earlier involvement of palliative care also leads to more appropriate referral to and use of hospice , and reduced use of futile intensive care . While evidence clarifying optimal delivery of palliative care to improve patient outcomes is evolving , no trials to date have demonstrated harm to patients and caregivers , or excessive costs , from early involvement of palliative care . Therefore , it is the Panel 's expert consensus that combined st and ard oncology care and palliative care should be considered early in the course of illness for any patient with metastatic cancer and /or high symptom burden . Strategies to optimize concurrent palliative care and st and ard oncology care , with evaluation of its impact on important patient and caregiver outcomes ( eg , QOL , survival , health care services utilization , and costs ) and on society , should be an area of intense research . NOTE ASCO 's provisional clinical opinions ( PCOs ) reflect expert consensus based on clinical evidence and literature available at the time they are written and are intended to assist physicians in clinical decision making and identify questions and setting s for further research . Because of the rapid flow of scientific information in oncology , new evidence may have emerged since the time a PCO was su bmi tted for publication . PCOs are not continually up date d and may not reflect the most recent evidence . PCOs can not account for individual variation among patients and can not be considered inclusive of all proper methods of care or exclusive of other treatments . It is the responsibility of the treating physician or other health care provider , relying on independent experience and knowledge of the patient , to determine the best course of treatment for the patient . Accordingly , adherence to any PCO is voluntary , with the ultimate determination regarding its application to be made by the physician in light of each patient 's individual circumstances . ASCO PCOs describe the use of procedures and therapies in clinical trials and can not be assumed to apply to the use of these interventions in the context of clinical practice . ASCO assumes no responsibility for any injury or damage to persons or property arising out of or related to any use of ASCO 's PCOs , or for any errors or omissions PURPOSE Previous studies report that early palliative care is associated with clinical benefits , but there is limited evidence on economic impact . This article addresses the research question : Does timing of palliative care have an impact on its effect on cost ? PATIENTS AND METHODS Using a prospect i ve , observational design , clinical and cost data were collected for adult patients with an advanced cancer diagnosis admitted to five US hospitals from 2007 to 2011 . The sample for economic evaluation was 969 patients ; 256 were seen by a palliative care consultation team , and 713 received usual care only .  Sub sample s were created according to time to consult after admission . Propensity score weights were calculated , matching the treatment and comparison arms specific to each sub sample on observed confounders . Generalized linear models with a γ distribution and a log link were applied to estimate the mean treatment effect on cost within sub sample s. RESULTS Earlier consultation is associated with a larger effect on total direct cost . Intervention within 6 days is estimated to reduce costs by -$1,312 ( 95 % CI , -$2,568 to -$56 ; P = .04 ) compared with no intervention and intervention within 2 days by -$2,280 ( 95 % CI , -$3,438 to -$1,122 ; P < .001 ) ; these reductions are equivalent to a 14 % and a 24 % reduction , respectively , in cost of hospital stay . CONCLUSION Earlier palliative care consultation during hospital admission is associated with lower cost of hospital stay for patients admitted with an advanced cancer diagnosis . These findings are consistent with a growing body of research on quality and survival suggesting that early palliative care should be more widely implemented OBJECTIVE The purpose of this study was to underst and oncology clinicians ' perspectives about the care of advanced cancer patients following the completion of the ENABLE II ( Educate , Nurture , Advise , Before Life Ends ) r and omized clinical trial ( RCT ) of a  concurrent oncology palliative care model . METHOD This was a qualitative interview study of 35 oncology clinicians about their approach to patients with advanced cancer and the effect of the ENABLE II RCT .  RESULTS Oncologists believed that integrating palliative care at the time of an advanced cancer diagnosis enhanced patient care and complemented their practice . Self- assessment of their practice with advanced cancer patients comprised four themes : ( 1 ) treating the whole patient , ( 2 ) focusing on quality versus quantity of life , ( 3 ) “ some patients just want to fight , ” and ( 4 ) helping with transitions ; timing is everything . Five themes comprised oncologists ' views on the complementary role of palliative care : ( 1 ) “ refer early and often , ” ( 2 ) referral challenges : “ Palliative ” equals “ hospice ” ; “ Heme patients are different , ” ( 3 ) palliative care as consultants or co-managers , ( 4 ) palliative care “ shares the load , ” and ( 5 ) ENABLE II facilitated palliative care integration . SIGNIFICANCE OF RESULTS Oncologists described the RCT as holistic and complementary , and as a significant factor in adopting concurrent care as a st and ard of care 
    Output:
    
Based on the multi-dimensional scope of palliative care , we chose QoL as the primary outcome , despite an expected heterogeneity among the QoL outcomes .