***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 
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    ***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 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 OBJECTIVE To assess outcomes of using a clinical pathway for managing patients with fractured neck of femur . DESIGN Prospect i ve , pseudor and omised , controlled trial . SETTING St Vincent 's Hospital , Melbourne , Victoria ( a tertiary referral , university teaching hospital ) , 1 October 1997 to 30 November 1998 . PARTICIPANTS 111 patients ( 80 women and 31 men ; mean age , 81 years ) admitted via the emergency department with a primary diagnosis of fractured neck of femur . INTERVENTIONS Management guided by a clinical pathway ( 55 patients ) or established st and ard of care ( control group , 56 patients ) . MAIN OUTCOME MEASURES Timing of referrals and discharge planning ; total length of stay ; and complication and readmission rates within 28 days of discharge . RESULTS Patients managed according to the clinical pathway had a shorter total stay ( 6.6 versus 8.0 days ; P = 0.03 ) , even if assessment for placement by the Aged Care Assessment Service was required ( 9.5 versus 13.6 days ; P = 0.03 ) . There were no significant differences in complication and readmission rates between pathway and control patients ( complication rates , 24 % versus 36 % ; P = 0.40 ; readmission rates , 4 % versus 11 % ; P = 0.28 ) . CONCLUSION Coordinated multidisciplinary care of patients with fractured neck of femur reduces length of stay without increasing complications UNLABELLED In traditional practice patterns , physicians take care of all clinical decisions , such as diagnosis , treatment , and recovery . In the Nippon Medical School Hospital a clinical pathway for distal gastrectomy patients , recorded as a post-operative care map , was introduced in August 2000 . In January 2001 the post-operative management was analyzed and st and ardization of practice was carried out with printed order sets , such as drugs and infusion solutions . The aim of this study was to evaluate the clinical significance of the clinical pathway for gastrectomy patients by employing st and ardized postoperative management and printed order sets . PATIENTS AND METHODS From January 2001 to December 2001 , 87 patients underwent distal ( 43 ) , total ( 28 ) , proximal ( 7 ) and partial gastrectomy ( 9 ) for gastric cancer ( stage IA : 47 , IB : 9 , II : 7 , IIIA : 8 , IIIB 2 , IV : 10 ) and gastrointestinal stromal tumor ( 4 ) . These patients were r and omly assigned to either the main building or the east building of our hospital . In the main building 38 patients were looked after using traditional practice ( control group ) . In the east building 47 patients were looked after according to the clinical pathway ( path group ) and 2 patients were excluded from the path group because of neo-adjuvant chemotherapy and severe heart failure . Aspects of the patients ' outcomes , including length of stay , the first day of the diet , morbidity , and medical costs , were compared between the path group and the control group . All data were expressed as means+/-st and ard deviation . Statistical analyses were made using Student t-test , Mann-Whitney U-test , and chi(2 ) test , and the 5%level was chosen for statistical significance . RESULTS The length of the hospital stay was 27.1+/-10.0 and 40.8+/-26.1 days ( p<0.005 ) and the length of post-operative stay was 18.1+/-9.5 and 28.2+/-22.3 days ( p<0.01 ) in the path group and the control group , respectively . The post-operative day when the diet was started for the path and control groups was 6.8+/-8.9 and 8.2+/-7.2 , respectively ; however , the length of the intravenous infusion for the two groups was 11.8+/-1.1 and 16.5+/-1.2 days ( p<0.01 ) , respectively . There was no statistically significant difference in the morbidity rate between the path group ( 3/47 ) and the control group ( 5/38 ) . The total cost was 1,502,587 yen + /-41,650 in the path group and 1,932,197 yen + /-131,030 in the control ( p<0.001 ) . CONCLUSION A clinical pathway for gastrectomy patients proved useful to optimize their postoperative care , including medication management and diet education . It is suggested that the implementation of a st and ardized clinical pathway for gastrectomy patients reduced the length of the hospital stay and the medical costs OBJECTIVE Because of recent increases in health care costs , cost containment has become a important issue in medical practice . We evaluated the effect on cost and clinical outcome with the implementation of clinical care pathway for transurethral resection of the prostate ( TURP ) patients .  MATERIAL S & METHODS Our series consists of 69 consecutive patients treated with TURP between June 1 , 1999 and March 31 , 2000 . The patients were divided into two groups at r and om . Thirty-two patients were treated on the clinical pathway ( pathway group ) and 37 patients were not placed on the  clinical pathway program ( non-pathway group ) . Total hospital charges , average length of stay and clinical outcomes were compared in two groups . RESULTS The average of total hospital charges ( insurance points ) and average length of stay were 48,424.2 point , and 12.7 days for the pathway group , and 55.365.5 point , and 14.7 days for non-pathway group respectively . Postoperative complications and rehospitalization did not differ between two groups . DISCUSSION With the implementation of the clinical care pathway , average hospital charges and length of stay were reduced . The clinical pathway program is considered to be a good tool for health care cost management . This methodology can be applied to all patients . However , when we make the clinical pathway program , we take into account the individuality of each patients Abstract INTRODUCTION : In an era of dwindling hospital re sources and increasing medical costs , safe reduction in postoperative stay has become a major focus to optimize utilization of healthcare re sources . Although several protocol s have been reported to reduce postoperative stay , no Level I evidence exists for their use in routine clinical practice . METHODS : Sixty-four patients undergoing laparotomy and intestinal or rectal resection  were r and omly assigned to a pathway of controlled rehabilitation with early ambulation and diet or to traditional postoperative care .  Time to discharge from hospital , complication and readmission rates , pain level , quality of life , and patient satisfaction scores were determined at the time of discharge and at 10 and 30 days after surgery . Subgroups were defined to evaluate those who derived the optimal benefit from the protocol . RESULTS : Pathway patients spent less total time in the hospital after surgery ( 5.4 vs. 7.1 days ; P = 0.02 ) and less time in the hospital during the primary admission than traditional patients . Patients younger than 70 years old had greater benefits than the overall study group ( 5 vs. 7.1 days ; P = 0.01 ) . Patients treated by surgeons with the most experience with the pathway spent significantly less time in the hospital than did those whose surgeons were less experienced with the pathway ( P = 0.01 ) . There was no difference between pathway and traditional patients for readmission or complication rates , pain score , quality of life after surgery , or overall satisfaction with the hospital stay . CONCLUSIONS : Patients scheduled for a laparotomy and major intestinal or rectal resection  are suitable for management by a pathway of controlled rehabilitation with early ambulation and diet . Pathway patients have a shorter hospital stay , with no adverse effect on patient satisfaction , pain scores , or complication rates . Patients younger than 70 years of age derive the optimal benefit , and increased surgeon experience improves outcome Background . Clinical pathways for asthma are tools that have the potential to improve compliance with nationally recognized management guidelines , but their effect on patient outcomes has not been 
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The aim of this study was to identify the circumstances in which ICPs are effective , for whom and in what context s. Methods A systematic review of high- quality r and omised controlled trials published between 1980 and 2008 ( March ) evaluating  ICP use in child and adult population s in the full range of healthcare setting s. RESULTS 1 For relatively predictable trajectories of care ICPs can be effective in supporting proactive care management and ensuring that patients receive relevant clinical interventions and /or assessment s in a timely manner .
This can lead to improvements in service quality and service efficiency without adverse consequences for patients .
2 ICPs are an effective mechanism for promoting adherence to guidelines or treatment protocol s thereby reducing variation in practice .
3 ICPs can be effective in improving documentation of treatment goals , documentation of communication with patients , carers and health professionals .
4 ICPs can be effective in improving physician agreement about treatment options .
5 ICPs can be effective in supporting decision-making when they incorporate a decision-aide .
6 The evidence considered in this review indicates that ICPs may be particularly effective in changing professional behaviours in the desired direction , where there is scope for improvement or where roles are new .
7 Even in context s in which health professionals are already experienced with a particular pathway , ICP use brings additional beneficial effects in directing professional practice in the desired direction .
8 ICPs may be less effective in bringing about service quality and efficiency gains in variable patient trajectories .
9 ICPs may be less effective in bringing about quality improvements in circumstances in which services are already based on best evidence and multidisciplinary working is well established .
10 Depending on their purpose , the benefits of ICPs may be greater for certain patient subgroups than others .
11 We do not know whether the costs of ICP development and implementation are justified by any of their reported benefits .
12 ICPs may need supporting mechanisms to underpin their implementation and ensure their adoption in practice , particularly in circumstances in which ICP use is a significant change in organisational culture .
13 ICP documentation can introduce scope for new kinds of error .
Conclusions ICPs are most effective in context s where patient care trajectories are predictable .
Their value in setting s in which recovery pathways are more variable is less clear .
ICPs are most effective in bringing about behavioural changes where there are identified deficiencies in services ; their value in context s where inter-professional working is well established is less certain .