***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: 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 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 BACKGROUND Out-patient services are trying to achieve effective and efficient health care in overcrowded , busy clinic setting s. " One stop " and " open access " clinics have been advocated as a way of improving out-patient services . OBJECTIVES Our aim was to evaluate the effectiveness and efficiency of a guideline -based open access urological investigation service . METHODS General practice s were r and omized to receive either referral guidelines and access to the investigation service for lower urinary tract symptoms ( LUTS ) or referral guidelines and access to the investigation service for microscopic haematuria ( MH ) . The study population comprised 66 general practice s in the Grampian region of Scotl and referring 959 patients . The outcome measures were compliance with guidelines ( number of recommended investigations completed ) , number of general practice consultations , the number and case mix of referrals , waiting time to initial hospital appointment , and the number of patients with a management decision reached at initial appointment and discharged by 12 months after referral . RESULTS GPs ' compliance with referral guidelines increased ( difference in means 0.5 ; 95 % confidence interval 0.2 - 0.8 , P < 0.001 ) . Approximately 50 % of eligible patients were referred through the new system . The number and case mix of referrals were similar . The intervention reduced the waiting time from referral to initial out-patient appointment ( ratio of means 0.7 ; 0.5 - 0.9 , patients with LUTS only ) and increased the number of patients who had a management decision reached at initial appointment ( odds ratio 5.8 ; 2.9 - 11.5 , P < 0.00001 , both conditions ) . Patients were more likely to be discharged within 12 months ( odds ratio 1.7 ; 0.9 - 3.3 , P = 0.11 ) . There were no significant changes detected in patient outcomes . Overall the new service was probably cost saving to the NHS . CONCLUSIONS The guideline -based open access investigation service streamlined the process of out-patient referral , result ing in a more efficient service with reduced out-patient waiting times , fewer out-patient and investigation appointments and release of specialist and clinic time AIM To evaluate the impact of structured form letters for general practitioner to emergency department ( ED ) communication . METHOD STUDY POPULATION one hundred and fifty-five GPs with practice s in the Liverpool local government area in metropolitan Sydney and patients referred by them to ED at Liverpool over five months from June to October 1998 . DESIGN r and omised control trial of GPs as unit of r and omisation ; intervention GPs were encouraged to follow a structured proforma for their written communication with the ED . Control GPs were left to usual referral procedures . The ED was encouraged to fax a brief report back to GPs using the form . Impact measures : the quality of the referral letters was evaluated using a checklist that included : reason for referral ; examination finding ; medical history ; investigations ; psychosocial history ; allergies ; drugs given in the surgery and present medication . Surveys were sent every month to GPs to assess communication from the ED and adverse events observed by GPs . RESULTS Most letters from GPs to the ED contained information on reasons for referral , medical history and examination findings . Reasons for referral were present in 95 % of the intervention group GPs ' letters compared with 99 % of those of the control group . Investigations were included with 27 % and present medications in 37 % . Letters from GPs in the intervention group were more likely to contain a psychosocial history than those in the control group ( 13 % compared with 1 % ) . Most GPs reported receiving a letter from the ED although this was rarely by fax ; most were brought to them by the patient . Phone calls were received by about one in five GPs each month . Most GPs found both of these to be useful . There were no differences between communication received by GPs in the intervention and control groups . CONCLUSION This study demonstrates that improvements to communication between GPs and EDs are difficult and may require a systemic change within general practice and the hospital . Electronic systems may allow the sort of reciprocal communication required to establish and sustain improvement BACKGROUND Methods are needed to ensure that those patients referred from primary to secondary care are those most likely to benefit . In-house referral is the referral of a patient by a general practitioner to another general practitioner within the same practice for a second opinion on the need for secondary care referral . OBJECTIVE To describe whether in-house referral is practical and acceptable to patients , and the health outcomes for patients . METHODS Practice s were r and omized into an intervention or a control group . In intervention practice s , patients with certain conditions who were about to be referred to secondary care  were referred in-house . If the second clinician agreed referral was appropriate the patient was referred on to secondary care . In control practice s patients were referred in the usual fashion .  Patient satisfaction and health status was measured at the time of referral , 6 months and one year . RESULTS Eight intervention and seven control practice s took part . For the 177 patients referred in-house , 109 ( 61 % ) were judged to need referral on to secondary care . For patient satisfaction , the only difference between the groups studied was that at 12 months patients who had been referred in-house reported themselves as being more satisfied than those referred directly to hospital . For health status , the only difference found was that at the time of referral , patients who had been referred in-house and judged to need hospital referral reported themselves as being less able on the ' Physical function ' subscale of the SF-36 than patients who were referred in-house and judged to not need hospital referral . CONCLUSION In-house referral is acceptable to patients and provides a straightforward method of addressing uncertainty over the need for referral from primary to secondary care As part of a cluster r and omised trial to assess an alternative model of cancer genetics services , we gathered data on all referrals from general practitioners ( GPs ) to cancer genetics services in South East Scotl and over a 4-year period . The referral rate per 1000 patients  rose by 48 % from 0.21 in the 2-year period before the trial to 0.31 during the trial . This increase was much greater in the trial group offered the GP clinic service ( 64 % increase compared to a 38 % increase in those referred to the regional service ) . Thus , the offer of a more local service appeared to have a marked effect on GP management of these women . Referral rates to cancer genetics services from general practice s varied widely with higher referral rates from practice s with more female partners . There was a negative correlation between referral rates and practice area deprivation scores . However , this was not found during the trial in the group which offered clinics in general practice , the provision of clinic appointments nearer to the homes of more socially deprived women result ing in improved access to women from deprived areas . The interaction with the GP appears to be associated with an inappropriate level of interest in and expectation of the appropriateness of genetic testing . The provision of the clinics within general practice did not result in higher levels of confidence among GPs in managing these women Objective : To assess the effects of joint consultation on referral behaviour of general practitioners ( GPs ) in a prospect i ve cohort study . Methods : All patients with rheumatological complaints that 17 participating GPs , from the area of the University Hospital Maastricht , wanted to refer during a two year inclusion period ( n=166 ) were eligible for inclusion . These patients were either referred to the outpatient clinic  , or presented at a joint consultation held every six weeks at the practice of the GP  , where groups of three GPs presented their patients to a visiting , consulting rheumatologist . The number of patients referred by each GP a year at the end of the trial , comparing participating and non-participating GPs , was the main outcome measure . Results : During two years of inclusion , the 17 participating GPs presented 166 patients . The number of patients referred by each GP a year decreased for the participating GPs by 62 % at the end of the whole study . By contrast , non-participating GPs maintained the same rate of referral . The range of diagnoses remained proportionally the same throughout the study , with the exception of fibromyalgia . The referral rate of this diagnosis decreased significantly ( p=0.001 ) . Conclusions : Joint consultation seems to be a good strategy in influencing the referral behaviour of GPs in the area of rheumatology . The decrease in referral is substantial and can subsequently lead to a reduction of waiting lists OBJECTIVE --To investigate the effects on general practitioners ' activities of a change in their remuneration from a capitation based system to a mixed fee per item and capitation based system . DESIGN --Follow up study with data collected from contact sheets completed by general practitioners in one period before ( March 1987 ) a change in their remuneration system and two periods after ( March 1988 , November 1988 ) , with a control group of general practitioners with a  mixed fee per item and capitation based system  throughout . SETTING --General practice s in Copenhagen city ( index group ) and Copenhagen county ( control group ) . SUBJECTS--265 General practitioners in Copenhagen city , of whom 100 were selected r and omly from the 130 who agreed to participate ( 10 exclusions ) and 326 general practitioners in Copenhagen county . MAIN OUTCOME MEASURES --Number of consultations ( face to face and by telephone ) and renewals of prescriptions , diagnostic and curative services , and specialist and hospital referrals per 1000 enlisted patients in one week . RESULTS --Of the 75 general practitioners who completed all three sheets , four were excluded for incomplete data . Total contact rates per 1000 patients listed rose significantly compared with the rates before the change index in the city ( 100.0 before the change v 111.7 ( 95 % confidence interval 106.4 to 117.4 after the change ) and over the same time in the control group ( 100.0 
    Output:
    
Active local educational interventions involving secondary care specialists and structured referral sheets are the only interventions shown to impact on referral rates based on current evidence .
The effects of ' in-house ' second opinion and other intermediate primary care based alternatives to outpatient referral appear promising