***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 Primary health care research is under pressure to be accountable to funders in terms of benefits for practice and policy . However , methods to assess the impact of primary health care research must be appropriate to use with the diverse topics , setting s and approaches of this sector . This project explored the feasibility of using the Buxton and Hanney Payback Framework to determine the impact of a stratified r and om sample ( n = 4 ) of competitively funded , primary health care research projects . Methods The project conducted telephone interviews based on the Payback Framework with leaders of the research teams and nominated users of their research , used bibliometric methods for assessing impact through publication outputs and obtained documentary evidence of impact where possible . The purpose was to determine the effectiveness of the data collection methods and the applicability of the Payback Framework , and any other issues which arose around the assessment of impact of primary health care research . Results and discussion The thirteen interviews were re source intensive to organise conduct and analyse but provided better information about impact than bibliometric analysis or documentary analysis . Bibliometric analysis of the papers published from the four projects was hampered by the inclusion of only one of the journals in major citation indexes . Document analysis provided more evidence of dissemination than of impact . The payback framework and logic model were a sound basis for assessing impact . Chief investigators and nominated users of research provided substantial information relevant to the impact categories closest to their spheres of influence and awareness , but less about the impact their research had on the wider health sector , population health or economic benefits . An additional category of impact emerged from the interviews , that of strengthening research networks which could enhance the impact of later work . The framework provided rich information about the pathways to impact , better underst and ing of which may enhance impact . Conclusion It is feasible to use the Buxton and Hanney Payback framework and logic model to determine the proximal impacts of primary health care research . Though re source intensive , telephone interviews of chief investigators and nominated users provided rich information OBJECTIVES To determine the comparative effectiveness and cost-effectiveness of conventional ventilatory support versus extracorporeal membrane oxygenation ( ECMO ) for severe adult respiratory failure . DESIGN A multicentre , r and omised controlled trial with two arms . SETTING The ECMO centre at Glenfield Hospital , Leicester , and approved conventional treatment centres and referring hospitals throughout the UK . PARTICIPANTS Patients aged 18 - 65 years with severe , but potentially reversible , respiratory failure , defined as a Murray lung injury score > or = 3.0 , or uncompensated hypercapnoea with a pH < 7.20 despite optimal conventional treatment . INTERVENTIONS Participants were  r and omised to conventional management ( CM ) or  to consideration of ECMO . MAIN OUTCOME MEASURES The primary outcome measure was death or severe disability at 6 months . Secondary outcomes included a range of hospital indices : duration of ventilation , use of high frequency/oscillation/jet ventilation , use of nitric oxide , prone positioning , use of steroids , length of intensive care unit stay , and length of hospital stay - and ( for ECMO patients only ) mode ( venovenous/veno-arterial ) , duration of ECMO , blood flow and sweep flow . RESULTS A total of 180 patients ( 90 in each arm ) were r and omised from 68 centres . Three patients in the conventional arm did not give permission to be followed up . Of the 90 patients r and omised to the ECMO arm , 68 received that treatment . ECMO was not given to three patients who died prior to transfer , two who died in transit , 16 who improved with conventional treatment given by the ECMO team and one who required amputation and could not therefore be heparinised . Ninety patients entered the CM ( control ) arm , three patients later withdrew and refused follow-up ( meaning that they were alive ) , leaving 87 patients for whom primary outcome measures were available . CM consisted of any treatment deemed appropriate by the patient 's intensivist with the exception of extracorporeal gas exchange . No CM patients received ECMO , although one received a form of experimental extracorporeal arteriovenous carbon dioxide removal support ( a clear protocol violation ) . Fewer patients in the ECMO arm than in the CM arm had died or were severely disabled 6 months after r and omisation , [ 33/90 ( 36.7 % ) versus 46/87 ( 52.9 % ) respectively ] . This equated to one extra survivor for every six patients treated . Only one patient ( in the CM arm ) was known to be severely disabled at 6 months . Patients allocated to ECMO incurred average total costs of 73,979 pounds compared with 33,435 pounds for those undergoing CM ( UK prices , 2005 ) . A lifetime model predicted the cost per quality -adjusted life-year ( QALY ) of ECMO to be 19,252 pounds ( 95 % confidence interval 7622 pounds to 59,200 pounds ) at a discount rate of 3.5 % . Lifetime QALYs gained were 10.75 for the ECMO group compared with 7.31 for the conventional group . Costs to patients and their relatives , including out of pocket and time costs , were higher for patients allocated to ECMO . CONCLUSIONS Compared with CM , transferring adult patients with severe but potentially reversible respiratory failure to a single centre specialising in the treatment of severe respiratory failure for consideration of ECMO significantly increased survival without severe disability . Use of ECMO in this way is likely to be cost-effective when compared with other technologies currently competing for health re sources . TRIAL REGISTRATION Current Controlled Trials IS RCT N47279827 OBJECTIVES To determine the comparative effectiveness and cost-effectiveness of three dressing products , N-A , Inadine and Aquacel , for patients with diabetic foot ulcers , as well as the feasibility and consequences of less frequent dressing changes by health-care professionals . DESIGN A multicentre , prospect i ve , observer-blinded , parallel group , r and omised controlled trial , with three arms . SETTING Established expert multidisciplinary clinics for the management of diabetic foot ulcers across the UK . PARTICIPANTS Patients over age 18 with type 1 or type 2 diabetes with a chronic ( present for at least 6 weeks ) full-thickness foot ulcer ( on or below the malleoli ) not penetrating to tendon , periosteum or bone , and with a cross-sectional area between 25 and 2500 mm(2 ) . INTERVENTIONS Participants were r and omised 1:1:1 to treatment with one of N-A ( a non-adherent , knitted , viscose filament gauze ) , Inadine ( an iodine-impregnated dressing ) , both traditional dressings , or Aquacel , a newer product . MAIN OUTCOME MEASURES The primary outcome measure was the number of ulcers healed in each group at week 24 . Secondary measures included time to healing , new ulcerations , major and minor amputations , and episodes of secondary infection . RESULTS A total of 317 patients were r and omised . After 88 withdrawals , 229 remained evaluable . A greater proportion of smaller ( 25 - 100 mm(2 ) ulcers healed within the specified time ( 48.3 % versus 37.3 % ; p = 0.048 ) . There was , however , no difference between the three dressings in terms of percentage healed by 24 weeks , or in the mean time to healing , whether analysed on the basis of intention to treat ( Inadine 44.4 % , N-A 38.7 % , Aquacel 44.7 % ; not significant ) or per protocol ( Inadine 55.2 % , N-A 59.4 % , Aquacel 63.0 % ; not significant ) . There was no difference in the quality of healing , as reflected in the incidence of recurrence within 12 weeks . Likewise , there was no difference in the incidence of adverse events , although a greater proportion of those r and omised to the non-adherent dressings were withdrawn from the study ( 34.9 % versus 29.1 % Aquacel and 19.4 % Inadine ; p = 0.038 ) . The only statistically significant difference found in the health economic analysis was the cost associated with the provision of dressings ( mean cost per patient : N-A 14.85 pounds , Inadine 17.48 pounds , Aquacel 43.60 pounds ) . The higher cost of Aquacel was not offset by the fewer dressings required . There was no difference in measures of either generic or condition-specific measures of quality of life . However , there was a significant difference in the change in pain associated with dressing changes between the first and second visits , with least pain reported by those receiving non-adherent dressings ( p = 0.012 ) . There was no difference in the costs of professional time , and this may relate to the number of dressing changes undertaken by non-professionals . Fifty-one per cent of all participants had at least one dressing change undertaken by themselves or a non-professional carer , although this ranged from 22 % to 82 % between the different centres . CONCLUSIONS As there was no difference in effectiveness , there is no reason why the least costly of the three dressings could not be used more widely across the UK National Health Service , thus generating potentially substantial savings . The option of involving patients and non-professional carers in changing dressings needs to be assessed more formally and could be associated with further significant reductions in health-care costs . TRIAL REGISTRATION Current Controlled Trials IS RCT N78366977 OBJECTIVES To determine whether cognitive behavioural therapy ( CBT ) in addition to antispasmodic treatment offers a cost-effective benefit to primary care patients with irritable bowel syndrome ( IBS ) and to identify predictors of outcome . DESIGN This was a r and omised controlled trial in primary care of the addition of CBT to st and ard general practice management of IBS , using the antispasmodic agent mebeverine hydrochloride . The study set out to compare the addition of a st and ardised package of IBS-specific CBT to treatment with mebeverine hydrochloride . SETTING Ten general practice s , serving a population of around 45,000 patients , located principally in south London , with some patients resident in north London . PARTICIPANTS Patients identified as having IBS by their GPs , aged between 17 and 54 ( mean 34 ) years and predominantly white ; 82 % were female and half had had IBS for more than 5 years . INTERVENTIONS Practice nurses delivered CBT in a r and omised trial of the addition of CBT to mebeverine in patients who had IBS of moderate or greater severity after 2 weeks of GP care and 4 weeks of mebeverine . The Symptom Severity Scale ( SSS ) was used to identify patients with moderate or severe IBS . Patients who continued to report moderate or severe IBS after 4 weeks of mebeverine at a dose of 270 mg three times a day were r and omised to receive six sessions of CBT in addition to mebeverine ( 72 patients ) or mebeverine alone ( 77 patients ) . These patients were followed at 3 , 6 and 12 months after treatment . As part of the baseline evaluation , blood tests for antiendomysial and antigliadin antibodies were carried out on 141 patients to determine the prevalence of coeliac disease in this population . MAIN OUTCOME MEASURES The principal outcome measure was the SSS . Others included the Hospital Anxiety and Depression Scale , psychopathology , the Work and Social Adjustment Scale ( WASA , disability ) , a modified version of the Illness Perception Question naire ( illness perceptions ) , the Beliefs about Medicine Question naire ( attitudes to medication ) , the Reported Adherence to Medication Scale ( adherence to prescribed medication ) , the Client Service Receipt Inventory ( economic analysis ) , the Cognitive Scale for Functional Bowel Disorders ( illness cognitions ) and the Behaviour Scale for IBS ( IBS coping behaviour ) . RESULTS The addition of CBT produced a significant benefit compared with the mebeverine-only group at 3 months after treatment on all outcome measures , except for the adherence to medication scales . The difference between the groups was 107.8 points on the SSS , 24.5 points on question 4 of the SSS and 6.3 points on the WASA , representing therapeutic gains of approximately 20 % , 28 % and 40 % , respectively . However , there was also evidence that these improvements began to wane , so that at 6 and 12 months follow-up significant therapeutic benefit of the addition of CBT could only be detected on question 4 of the SSS and on the WASA . The behaviour scale for IBS detected significant , positive changes in coping behaviours at up to 6 months after treatment . Three factors predicting a poor outcome were identified : male gender , believing that IBS had serious consequences and belief in an external aetiology , all of which were associated with greater than average disability at follow-up . The addition of CBT to mebeverine did not reduce overall treatment or social costs . The nested study on testing for coeliac disease provides cautious support for the inclusion of antiendomysial and antigliadin antibody testing in the investigation of patients thought to have IBS . CONCLUSIONS Specially trained practice nurses can provide effective  CBT  to primary care patients with a clinical diagnosis of IBS , which although effective does not reduce service or social costs . Using a variety of measures the beneficial therapeutic effects of the addition of CBT to antispasmodic therapy persist for up to 6 months . Future research might include studies of the long-term follow-up of IBS patients treated with CBT , cost-benefit analyses comparing CBT with other therapeutic approaches to IBS , and evaluating means of training both non-specialist health professionals and GPs to deliver CBT Background Meta-analyses show collaborative care models ( CCMs ) with nurse care management are effective for improving primary care for depression . This study aim ed to develop CCM 
    Output:
    
Monetisation of impact , an increasingly popular approach , shows a high return from research but relies heavily on assumptions about the extent to which health gains depend on research .
The literature , as review ed here , provides very few instances of a r and omised trial playing a major role in stopping the use of a new technology .
The few trials funded by the HTA programme that may have played such a role were outliers .
The selection of case studies , such as in the REF , but also more generally , tends to be biased towards high-impact rather than low-impact stories .
Experience for other industries indicate that much can be learnt from the latter .
FUNDING The National Institute for Health Research HTA programme