***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: Computer models of different strategies for the management of dyspepsia in primary care indicate that a ' test- and -treat ' approach is likely to be associated with the lowest costs and acceptable clinical outcomes . We present information on computer modelling studies and report the findings of a r and omised trial comparing a Helicobacter pylori test- and -treat strategy with referral to direct access endoscopy in the management of dyspepsia in general practice . We compared costs and clinical outcomes in patients managed for one year in study ( test- and -treat ) and control ( endoscopy ) practice s in south London . Patients aged less than 45 years presenting with persistent dyspepsia without alarm symptoms ( 141 study patients , 91 control patients ) were studied . In the one-year follow-up period there were 17 endoscopies in the study group : all the control patients underwent initial endoscopy and five further endoscopies were performed . None revealed peptic ulcer or cancer . Forty-three ( 30 % ) of the study patients compared with 16 ( 17 % ) of the controls were referred to hospital clinics ( p < 0.025 ) . The cost of management per patient for one year in the study group was 205.67 Pounds , compared with 404.31 Pounds in the control group ( p < 0.0001 ) . Clinical outcomes in both groups at one year were comparable . An H. pylori test- and -treat strategy for dyspeptic patients aged less than 45 , employing office-based serology testing , appears to be associated with substantially lower costs than initial endoscopy and with similar clinical outcomes Abstract Objective : To compare routine antenatal care provided by general practitioners and midwives with obstetrician led shared care . Design : Multicentre r and omised controlled trial . Setting : 51 general practice s linked to nine Scottish maternity hospitals . Subjects : 1765 women at low risk of antenatal complications . Intervention : Routine antenatal care by general practitioners and midwives according to a care plan and protocol s for managing complications . Main outcome measures : Comparisons of health service use , indicators of quality of care , and women 's satisfaction . Results : Continuity of carer was improved for the general practitioner and midwife group as the number of carers was less ( median 5 carers v 7 for shared care group , P<0.0001 ) and the number of routine visits reduced ( 10.9 v 11.7 , P<0.0001 ) . Fewer women in the general practitioner and midwife group had antenatal admissions ( 27 % ( 222/834 ) v 32 % ( 266/840 ) , P<0.05 ) , non-attendances ( 7 % ( 57 ) v 11 % ( 89 ) , P<0.01 ) and daycare ( 12 % ( 102 ) v 7 % ( 139 ) , P<0.05 ) but more were referred ( 49 % ( 406 ) v 36 % ( 305 ) , P<0.0001 ) . Rates of antenatal diagnoses did not differ except that fewer women in the general practitioner and midwife group had hypertensive disorders ( pregnancy induced hypertension , 5 % ( 37 ) v 8 % ( 70 ) , P<0.01 ) and fewer had labour induced ( 18 % ( 149 ) v 24 % ( 201 ) , P<0.01 ) . Few failures to comply with the care protocol occurred , but more Rhesus negative women in the general practitioner and midwife group did not have an appropriate antibody check ( 2.5 % ( 20 ) v 0.4 % ( 3 ) , P<0.0001 ) . Both groups expressed high satisfaction with care ( 68 % ( 453/663 ) v 65 % ( 430/656 ) , P=0.5 ) and acceptability of allocated style of care ( 93 % ( 618 ) v 94 % ( 624 ) , P=0.6 ) . Access to hospital support before labour was similar ( 45 % ( 302 ) v 48 % ( 312 ) visited labour rooms before giving birth , P=0.6 ) . Conclusion : Routine specialist visits for women initially at low risk of pregnancy complications offer little or no clinical or consumer benefit . Key messages Key messages Care by general practitioners and midwives improved continuity of care : there were fewer carers , non-attendances , and hospital admissions , and marginally fewer routine visits than with specialist led shared care ; incidences of hypertension , proteinuria , pre-eclampsia , and induction of labour were also lower Overall there were few deviations from the care protocol , but a greater proportion of Rhesus negative women in the general practitioner and midwife group did not have an appropriate check for antibodies The women in both trial groups were equally highly satisfied with all aspects of their care ; only a small minority of women in the general practitioner and midwife group said they would have liked to have seen a hospital doctor but did not Although there was no net benefit from routine specialist antenatal visits , over half of women developed some complication during their pregnancy ; in the general practitioner and midwife model of care , low risk women see a specialist when required and not at predefined routine In a two year trial general practitioners in the West Midl and s were provided with extended waiting time information for hospital consultation and treatment in general surgery . Selected general practitioners were sent monthly bulletins on  comparative times to  wait for both outpatient appointment and inpatient treatment throughout the region . Their referrals to consultant general surgeons were monitored , alongside those of a matched control group not receiving such information . Differences were found between the two groups which indicate the willingness of general practitioners to change their referral practice when adequate information is available . In addition , patients referred to their local hospital had longer waiting times than patients matched for clinical condition and district of origin who were sent to hospitals where it was indicated that a shorter wait might be expected Abstract Objective : To investigate the effect of clinical guidelines on the management of  infertility  across the primary care- secondary care interface . Design : Cluster r and omised controlled trial . Setting : General practice s and NHS hospitals accepting referrals for infertility in the Greater Glasgow Health Board area . Participants : All 221 general practice s in Glasgow ; 214 completed the trial . Intervention : General practice s in the intervention arm received clinical guidelines developed locally . Control practice s received them one year later . Dissemination of the guidelines included educational meetings . Main outcome measures : The time from presentation to referral , investigations completed in general practice , the number and content of visits as a hospital outpatient , the time to reach a management plan , and costs for referrals from the two groups . Results : Data on 689 referrals were collected . No significant difference was found in referral rates for infertility . Fewer than 1 % of couples were referred inappropriately early . Referrals from intervention practice s were significantly more likely to have all relevant investigations carried out ( odds ratio 1.32 , 95 % confidence interval 1.00 to 1.75 , P=0.025 ) . 70 % of measurements of serum progesterone concentrations during the midluteal phase and 34 % of semen analyses were repeated at least once in hospital , despite having been recorded as normal when checked in general practice . No difference was found in the proportion of referrals in which a management plan was reached within one year or in the mean duration between first appointment and date of management plan . NHS costs were not significantly affected . Conclusions : Dissemination of infertility guidelines by commonly used methods results in a modest increase in referrals having recommended investigations completed in general practice , but there are no detectable differences in outcome for patients or reduction in costs . Clinicians in secondary care tended to fail to respond to changes in referral practice by doctors . Guidelines that aim to improve the referral process need to be disseminated and implemented so as to lead to changes in both primary care and secondary care . What is already known on this topic Most previous research into clinical guidelines has focused on their development and implementation Evidence is lacking about the outcomes and costs associated with the use of clinical guidelines What this study adds Clinical guidelines that may alter the balance of care between general practice and hospital setting s require more intensive implementation than guidelines aim ed at either setting on its own The cost effectiveness of clinical guidelines should not be BACKGROUND Counselling in primary care setting s remains largely unevaluated . Such evaluation has been strongly recommended . AIM To determine the relative effectiveness and cost-effectiveness of generic counselling and usual general practitioner ( GP ) care for patients with minor mental health problems . METHOD A r and omized controlled trial and health economic evaluation were carried out in nine general practice s.  Access to generic counselling ( brief counselling , generally involving up to six 50-minute sessions ) was compared with usual GP care .  A total of 162 patients aged 16 years and over with diverse mental health problems ( excluding phobic conditions and psychoses ) were r and omized . The Hospital Anxiety and Depression ( HAD ) scale , COOP/WONCA ( World Organization of Family Doctors ) functional health assessment charts , and the delighted-terrible faces scale were used to assess outcome four months after r and omization . RESULTS The two groups were similar at baseline . There were significant improvements in both groups between r and omization and follow-up for most outcome measures , but no significant differences between the study arms . The 95 % confidence limits were narrow and excluded clinical ly significant effects . Under various assumptions concerning the cost of secondary care referrals and of counselling time , no clear cost advantage was associated with either intervention . CONCLUSIONS This pragmatic trial demonstrates no difference in functional or mental health outcome at four months between subjects offered access to counselling and those given usual care by their GP . There is no clear difference in the cost-effectiveness of the two interventions . Purchasers should take account of these findings in allocating re sources within primary care OBJECTIVE --To evaluate guidelines for general practice management and referral of infertile couples .  Guidelines were implemented with a disease specific reminder at the time of consultation ( the guidelines were embedded within a structured infertility management sheet for each couple ) . DESIGN --Pragmatic r and omised controlled trial . Participating practice s were r and omised to a group that received the guidelines and a control group . SETTING --82 general practice s in Grampian region . SUBJECTS--100 couples referred by general practitioners receiving the guideline and 100 couples referred by control general practitioners . MAIN OUTCOME MEASURES --Whether the general practitioner had taken a full sexual history and examined and investigated both partners appropriately . RESULTS --Characteristics of patients referred by study and control general practitioners did not differ significantly at baseline . Compliance with the guidelines increased for all targeted activities . General practitioners in the study group were more likely to take a sexual history ( for example , couples ' use of fertile period , 85 % v 69 % , p < 0.01 ) ; examine both partners ( female partner , 68 % v 52 % , p < 0.05 ; male partner 39 % v 13 % , p < 0.01 ) ; and investigate both partners ( day 21 progesterone , 72 % v 41 % , p < 0.001 ; semen analysis , 51 % v 41 % , p > 0.05 ) . Improvements were greater when general practitioners used the disease specific reminder . CONCLUSION --Receiving guidelines led to improvements in the process of care of infertile couples within general practice . This effect was enhanced when the guidelines were embedded in a structured infertility management sheet for each couple A r and omized controlled trial of  outpatient open-access physiotherapy  was carried out at West Cornwall Hospital during 1979/80 . The referral rate to consultant outpatient clinics for those patients offered open-access physiotherapy  was considerably lower than for the control group ( 17 per cent and 56 per cent respectively ) . Patients using the service received  physiotherapy  promptly although this did not result in shorter treatments . Those of the control group who eventually received physiotherapy had faced considerable delays . An analysis of self-reported information showed that patients receiving  open-access physiotherapy recovered more rapidly . Taken overall , the results support the concept of open-access physiotherapy OBJECTIVE --To assess the clinical and economic impact of surgery based near patient testing in general practice for six commonly used biochemical and bacteriological tests . DESIGN --After four months ' monitoring , equipment for two bacteriological and four biochemical tests was introduced without cost into 12 practice s using a crossover design . Structured request forms were used to monitor laboratory investigations . SETTING --12 general practice s in west midl and s and south west Thames with list sizes above 9000 . MAIN OUTCOME MEASURES --Investigation rates per 1000 consultations . Changes from baseline rates . Reasons for requesting investigations and provisional diagnoses . Cost per test and sensitivity of costs to rate of use . RESULTS --Investigation rates for the six tests rose by 16.5 % ( from 78.6/1000 consultations to 91.6/1000 ) when equipment was available in the surgery and reverted to baseline rates when it was withdrawn . The average weekly number of tests when equipment was available ranged from 0.5 to 10.5 ( mean 9.0 ) . Cholesterol tests were used as an addition to laboratory testing , usually for screening . Midstream urine analysis was often done in the surgery instead of in the laboratory , although 30 % of sample s were tested by both methods . Doctors ' reasons for investigation and conditions tested were largely unaffected by availability of surgery tests . Costs for surgery tests were higher for all tests except midstream urine . CONCLUSIONS --Availability of surgery based testing increased the number of tests performed . It was cost effective only for midstream urine analysis OBJECTIVES This study 
    Output:
    
Referral was not the primary outcome of interest in the majority of included studies .
Professional interventions generally had an impact on referral rates consistent with the intended change in clinician behaviour .
Similarly , specialist ' outreach ' or other primary care-based specialist provider schemes had at least a small effect upon referral rates to secondary care with the direction of effect being that intended or rational from a clinical and sociological perspective .
Organisational innovations in the structure of service provision need not increase total costs to the National Health Service ( NHS ) , even though costs associated with referral may increase .