***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 Early interventions proved to be able to improve prognosis in acute stroke patients . Prompt identification of symptoms , organised timely and efficient transportation towards appropriate facilities , become essential part of effective treatment . The implementation of an evidence based pre-hospital stroke care pathway may be a method for achieving the organizational st and ards required to grant appropriate care . We performed a systematic search for studies evaluating the effect of pre-hospital and emergency interventions for suspected stroke patients and we found that there seems to be only a few studies on the emergency field and none about implementation of clinical pathways . We will test the hypothesis that the adoption of emergency clinical pathway improves early diagnosis and referral in suspected stroke patients . We design ed a cluster r and omised controlled trial ( C- RCT ) , the most powerful study design to assess the impact of complex interventions . The study was registered in the Current Controlled Trials Register : IS RCT N41456865 – Implementation of pre-hospital emergency pathway for stroke – a cluster r and omised trial . Methods / design Two-arm cluster-r and omised trial ( C- RCT ) . 16 emergency services and 14 emergency rooms were r and omised either to arm 1 ( comprising a training module and administration of the guideline ) , or to arm 2 (  no intervention , current practice ) . Arm 1 participants ( 152 physicians , 280 nurses , 50 drivers ) attended an  interactive two sessions course with continuous medical education CME credits on the contents of the clinical pathway . We estimated that around 750 patients will be met by the services in the 6 months of observation . This duration allows recruiting a sample of patients sufficient to observe a 30 % improvement in the proportion of appropriate diagnoses . Data collection will be performed using current information systems . Process outcomes will be measured at the cluster level six months after the intervention . We will assess the guideline recommendations for emergency and pre-hospital stroke management relative to : 1 ) promptness of interventions for hyperacute ischaemic stroke ; 2 ) promptness of interventions for hyperacute haemorrhagic stroke 3 ) appropriate diagnosis . Outcomes will be expressed as proportions of patients with a positive CT for ischaemic stroke and symptoms onset < = 6 hour admitted to the stroke unit . Discussion The fields in which this trial will play are usually neglected by R and omised Controlled Trial ( RCT ) . We have chosen the Cluster-r and omised Controlled Trial ( C- RCT ) to address the issues of contamination , adherence to real practice , and community dimension of the intervention , with a complex definition of clusters and an extensive use of routine data to collect the outcomes Background and Purpose — Integrated care pathways ( ICP ) may not reduce disability , institutionalization , or duration of hospitalization compared with conventional multidisciplinary team ( MDT ) care in organized stroke rehabilitation . Their potential to improve patient heath status or satisfaction with care is not known . Methods — A comparison of quality of life , caregiver strain , and patient/caregiver satisfaction at 6 months after stroke was undertaken in 152 stroke patients r and omized to receive ICP or MDT care .  Differences in processes of care were recorded with the use of a predefined schedule . Multivariate analyses were undertaken to identify the effect of age , sex , stroke severity , functional status , mood , and use of care pathway on quality of life score . Results — The 2 groups were comparable for baseline characteristics of age , sex , stroke severity , and initial disability . MDT care was characterized by greater emphasis on return of higher function and caregiver needs compared with ICP . EuroQol Visual Analogue Scale ( EQ-VAS ) scores were higher in the MDT group ( median , 72 versus 63;P < 0.005 ) , who also had higher scores for EuroQol dimension of social functioning ( P = 0.014 ) . Higher EQ-VAS scores were independently related to MDT care ( P = 0.04 ) , Rankin score ( P = 0.01 ) , and psychological function ( P < 0.0001 ) but not to age , sex , or stroke severity . There were no significant differences in patient or caregiver satisfaction between the 2 setting s. Conclusions — Better quality of life in patients receiving conventional MDT care may be attributable to improved social functioning and greater attention to higher function and caregiver needs during rehabilitation OBJECTIVE to evaluate whether integrated care pathways improve the processes of care in stroke rehabilitation . DESIGN comparison of processes of care data collected in a r and omized controlled trial . PARTICIPANTS acute stroke patients undergoing rehabilitation r and omized to receive integrated care pathways management ( n=76 ) or conventional multidisciplinary care ( n=76 ) . MEASUREMENTS proportion of patients meeting recommended st and ards for processes of care using a vali date d stroke audit tool . RESULTS integrated care pathways methodology was associated with higher frequency of stroke specific assessment s , notably testing for inattention ( 84 % versus 60 % ; P=0.015 ) and nutritional assessment ( 74 % versus 22 % , P<0.001 ) . Documentation of provision of certain information to patients /carers ( 89 % versus 70 % ; P=0.024 ) and early discharge notification to general practitioners ( 80 % versus 45 % ; P<0.001 ) were also more common in this group . There were no significant differences in the processes of interdisciplinary co-ordination and patient management between the integrated care pathways group and the control group . CONCLUSION integrated care pathways may improve assessment and communication , even in specialist stroke setting BACKGROUND AND PURPOSE Integrated Care Pathway ( ICP ) is an organized , goal -defined , and time-managed plan that has the potential of facilitating timely interdisciplinary coordination , improving discharge planning , and reducing length of hospital stay . METHODS An ICP for stroke rehabilitation based on evidence of best practice , professional st and ards , and existing infrastructure was developed . Its effectiveness was tested in 152 stroke patients undergoing rehabilitation who were r and omized to receive ICP care coordinated by an experienced nurse ( n=76 ) or conventional multidisciplinary care ( n=76 ) . RESULTS The age , sex , premorbid functional ability , and stroke characteristics of the 2 groups were comparable . There were no differences in mortality rates ( 10 [ 13 % ] versus 6 [ 8 % ] ) , institutionalization ( 10 [ 13 % ] versus 16 [ 21 % ] ) , or length of hospital stay ( 50+/-19 versus 45+/-23 days ) between patients receiving ICP or multidisciplinary care . Patients receiving conventional multidisciplinary care improved significantly faster between 4 and 12 weeks ( median change in Barthel Activities of Daily Living Index 6 versus 2 ; P<0.01 ) and had higher Quality of Life scores at 12 weeks ( 65 versus 59 ; P=0.07 ) and 6 months ( 72 versus 63 ; P<0.005 ) . There were no significant differences in the mean duration of physiotherapy ( 42.8+/-41.2 versus 39.4+/-36.4 hours ) or occupational therapy ( 8.5+/-7.5 versus 8.0+/-7.5 hours ) received between the 2 groups . CONCLUSIONS ICP management offered no benefit over conventional multidisciplinary care on a stroke rehabilitation unit . Functional recovery was faster and Quality of Life outcomes better in patients receiving conventional multidisciplinary care Background Across the developed world , we are witnessing an increasing emphasis on the need for more closely coordinated forms of health and social care provision . Integrated care pathways ( ICPs ) have emerged as a response to this aspiration and are believed by many to address the factors which contribute to service integration . ICPs map out a patient 's journey , providing coordination of services for users . They aim to have : ' the right people , doing the right things , in the right order , at the right time , in the right place , with the right outcome ' . The value for ICPs in supporting the delivery of care across organisational boundaries , providing greater consistency in practice , improving service continuity and increasing collaboration has been advocated by many . However , there is little evidence to support their use , and the need for systematic evaluations in order to measure their effectiveness has been widely identified . A recent Cochrane review assessed the effects of ICPs on functional outcome , process of care , quality of life and hospitalisation costs of in patients with acute stroke , but did not specifically focus on service integration or its derivatives . To the best of our knowledge , no such systematic review of the literature exists . Objectives To systematic ally review all high‐ quality studies which have evaluated the impact of care pathway technologies on ' service integration ' and its derivatives in stroke care To examine how elements of service integration are defined in such studies To examine the type of evidence utilised to measure service integration To analyse the weight of evidence used to support cl aims about the effectiveness of ICPs on improving service integration To produce recommendations for ICP developers , users and evaluators . Inclusion criteria Types of participants The review focused on the care of adult patients who had suffered a stroke . It included the full spectrum of services ‐ acute care , rehabilitation and long‐term support ‐ in hospital and community setting s. Types of intervention(s)/phenomena of interest Integrated care pathways were the intervention of interest , defined for the purpose of this review as ' a multidisciplinary tool to improve the quality and efficiency of evidence based care and is used as a communication tool between professionals to manage and st and ardise the outcome orientated care ' . Here ' multidisciplinary ' is taken to refer to the involvement of two or more disciplines . Types of outcomes Service integration ' was the outcome of interest however , this was defined and measured in the selected studies . Types of studies This review was concerned with how ' service integration ' was defined in evaluations of ICPs ; the type of evidence utilised in measuring the impact of the intervention and the weight of evidence to support the effectiveness of care pathway technologies on ' service integration ' . Studies that made an explicit link between ICPs and service integration were included in the review . Evidence generated from r and omised controlled trials , quasi‐experimental , qualitative and health economics research was sought . The search was limited to publications after 1980 , coinciding with the emergence of ICPs in the healthcare context . Assessment for inclusion of foreign papers was based on the English‐ language abstract , where available . These were included only if an English translation was available . Exclusion criteria This review excluded studies that : focused only on a single aspect of stroke care ( e.g. dysphasia ) evaluated ICPs as part of a wider program of service development did not make an explicit link between ICPs and service integration did not meet the definition of ICP utilised for the purpose s of the review focused exclusively on the outcomes of variance analysis Search strategy In order to avoid replication , the Joanna Briggs Institute for Evidence Based Nursing and Midwifery Data base and the Cochrane Library were search ed to establish that no systematic review s existed and none were in progress . A three‐stage search strategy was then used to identify both published and unpublished studies ( see Appendix III ) . Data collection Our search strategy located 2123 papers , of which 39 were retrieved for further evaluation . We critically appraised seven papers , representing five studies . These were all evaluation studies and , as is typical in this field , comprised a range of study design s and data collection methods . Owing to the diversity of the study types included in the review , we developed a single‐ appraisal checklist and data ‐ extraction tool which could be applied to all research design s.32 The tool drew on the Joanna Briggs Institute ( JBI ) appraisal checklists for experimental studies and interpretive and critical research , and also incorporated specific information and issues which were relevant for our purpose s ( see Appendix VI ) . This extends the thinking outlined in Lyne et al.31 in which , drawing on Campbell and Stanley 's classic paper , the case is made for developing an appraisal tool which is applicable to all types of evaluation , irrespective of study design . In assessing the quality of the papers , we were sympathetic to the method ological challenges of evaluating complex interventions such as ICPs . We were also cognisant of the very real constraints in which service evaluations are frequently undertaken in healthcare context s. In accordance with the aims of this particular review , we have included studies , which are method ologically weaker than is typical of many systematic review s because , in our view , in the absence of stronger evidence , they yield useful information . Data synthesis Given the heterogeneity of the included studies , meta‐ analysis and /or qualitative synthesis was not possible . A narrative summary of the study findings is presented . Results ICPs can be effective in ensuring that patients receive relevant clinical interventions and /or assessment s in a timely manner , although these improvements may reflect better documentation rather than actual changes in practice . ICPs can be effective in improving the documentation of rehabilitation goals , documentation of communication with patients , carers ( diagnosis , prognosis and follow‐up arrangements ) and documentation of notification of primary care physicians of discharge . However , this can create additional burdens of work for staff . Early studies of  ICP‐managed care in the acute stroke context have demonstrated reduced length of stay without any associated adverse effects on discharge destination , morbidity or mortality . These effects do not reach statistical significance , however , and may reflect wider changes in service provision and a general trend towards reduced length of hospital stay . While later studies in the acute and rehabilitation context s do not reveal any significant reduction in length of stay , they do report greater documented use of certain clinical interventions and assessment s , suggesting that ICPs can be effective in mobilising hospital re sources around the patient . ICPs implemented in the context of acute stroke care can be effective in reducing the occurrence of urinary tract infections , although we do not know whether this can be attributed to improved service integration . ICP management in stroke rehabilitation may not be flexible enough to meet diverse patient needs and can result in insufficient attention to higher‐level functioning and carer needs influencing perceptions of quality of life . ICP management may assist in clarifying role boundaries and a shared underst and ing of the work , but this can result in some members of the disciplinary team perceiving that their contribution is not appropriately reflected in the documentation . There is some evidence that ICPs may be effective in changing professional behaviours in the desired direction where there is scope for improvement , but in situations in which mult 
    Output:
    
On the basis of the evidence considered in the review we suggest that ICPs can be considered as having a multiple role as directing , coordinating , organising , decision-making , and accumulating devices .
In addition , because ICPs accumulate information , it seems reasonable to infer that they also function as ' distributing devices ' by circulating information to users of the pathway , although no definitive evidence is provided in the studies review ed to support this assertion .
Our review indicates that ICPs can have positive effects on service quality and efficiency as a result of their functions .
They are effective in supporting the timely implementation of clinical interventions and the mobilisation of re sources around the patient without incurring additional increases in length of stay .
They also have value in supporting implementation of best practice guidelines and protocol s by translating these into a format which is suitable for daily use by busy health professionals , thereby improving inter and intra-professional consensus and reducing unacceptable variations in clinical practice .
Because they function as accumulating and distributing devices ICPs may also bring about improvements in documentation , which in turn augments their coordinating effects .