***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 While integrated health care system has been proved an effective way to help improving patient health and system efficiency , the exact behaviour model and motivation approach are not so clear in poor rural areas where health human re sources and continuous service provision are urgently needed . To gather solid evidence , we initiated a comprehensive intervention project in Qianjiang District , southwest part of rural China in 2012 . And after one-year 's pilot , we developed an intervention package of team service , comprehensive pathway and prospect ive- and performance-based payment system . Methods To testify the potential influence of payment interventions , we use clustered r and omised controlled trial , 60 clusters are grouped into two treatment groups and one control group to compare the time and group differences . Difference-in-differences model and structural equation modelling will be used to analyse the intervention effects and pathway . The outcomes are : quality of care , disease burden , supplier cooperative behaviour and patient utilisation behaviour and system efficiency . Repeated multivariate variance analysis will be used to statistically examine the outcome differences . Discussion This is the first trial of its kind to prove the effects and efficiency of integrated care . Though we adopted r and omised controlled trial to gather the highest rank of evidence , still the fully r and omisation was hard to realise in health policy reform experiment . To compensate , the design er should take efforts on control for the potential confounders as much as possible . With this trial , we assume the effects will come from : ( 1 ) improvement on the quality of life through risk factors control and lifestyles change on patient 's behaviours ; ( 2 ) improvement on quality of care through continuous care and coordinated supplier behaviours ; ( 3 ) improvement on the system efficiency through active interaction between suppliers and patients . Conclusion The integrated care system needs collaborative work from different levels of caregivers . So it is extremely important to consider the supplier cooperative behaviour . In this trial , we introduced payment system to help the delivery system integration through providing financial incentives to motivate people to play their roles . Also , the multidisciplinary team , the multi-institutional pathway and system global budget and pay-for-performance payment system could afford as a solution RATIONALE , AIMS AND OBJECTIVES Acute myocardial infa rct ions ( MIs ) or heart attacks are the result of a complete or an incomplete occlusion of the lumen of the coronary artery with a thrombus . Prompt diagnosis and early coronary intervention results in maximum myocardial salvage , hence time to treat is of the essence . Adequate , accurate and complete information is vital during the early stages of admission of an MI patient and can impact significantly on the quality and safety of patient care . This study aim ed to record how clinical information between different clinical teams during the journey of a patient in the MI care pathway is captured and to review the flow of information within this care pathway . METHOD A prospect i ve , descriptive , structured observational study to assess ( i ) current  clinical information systems ( CIS ) utilization  and ( ii )  real-time information availability  within an acute cardiac care setting was carried out . Completeness and availability of patient information capture across four key stages of the MI care pathway were assessed prospect ively . RESULTS Thirteen separate information systems were utilized during the four phases of the MI pathway . Observations revealed fragmented CIS utilization , with users accessing an average of six systems to gain a complete set of patient information . Data capture was found to vary between each pathway stage and in both patient cohort risk groupings . The highest level of information completeness ( 100 % ) was observed only in the discharge stage of the MI care pathway . The lowest level of information completeness ( 58 % ) was observed in the admission stage . CONCLUSION The study highlights fragmentation , CIS duplication , and discrepancies in the current clinical information capture and data transfer across the MI care pathway in an acute cardiac care setting . The development of an integrated and user-friendly electronic data capture and transfer system would reduce duplication and would facilitate efficient and complete information provision at the point of care Background Ten years on from the National Institute of Health and Clinical Excellence ’ technology appraisal guideline on haemodialysis in 2002 ; the clinical community is yet to rise to the challenge of providing home haemodialysis ( HHD ) to 10 - 15 % of the dialysis cohort . The renal registry report , suggests underutilization of a treatment type that has had a lot of research interest and several publications worldwide on its apparent benefit for both physical and mental health of patients . An underst and ing of the drivers to introducing and sustaining the modality , from organizational , economic , clinical and patient perspectives is fundamental to realizing the full benefits of the therapy with the potential to provide evidence base for effective care models . Through the BASIC-HHD study , we seek to underst and the clinical , patient and carer related psychosocial , economic and organisational determinants of successful uptake and maintenance of home haemodialysis and thereby , engage all major stakeholders in the process . Design and methods We have adopted an integrated mixed methodology ( convergent , parallel design ) for this study . The study arms include a. patient ; b. organization ; c. carer and d. economic evaluation . The three patient study cohorts ( n = 500 ) include pre-dialysis patients ( 200 ) , hospital haemodialysis ( 200 ) and home haemodialysis patients ( 100 ) from geographically distinct NHS sites , across the country and with variable prevalence of home haemodialysis . The pre-dialysis patients will also be prospect ively followed up for a period of 12 months from study entry to underst and their journey to renal replacement therapy and subsequently , before and after studies will be carried out for a select few who do commence dialysis in the study period . The process will entail quantitative methods and ethnographic interviews of all groups in the study . Data collection will involve clinical and biomarkers , psychosocial quantitative assessment s and neuropsychometric tests in patients . Organizational attitudes and dialysis unit practice s will be studied together with perceptions of healthcare providers on provision of home HD . Economic evaluation of home and hospital haemodialysis practice s will also be undertaken and we will apply scenario ( " what … if " ) analysis using system dynamics modeling to investigate the impact of different policy choices and financial models on dialysis technology adoption , care pathways and costs . Less attention is often given to the patient ’s carers who provide informal support , often of a complex nature to patients afflicted by chronic ailments such as end stage kidney disease . Engaging the carers is fundamental to realizing the full benefits of a complex , home-based intervention and a qualitative study of the carers will be undertaken to elicit their fears , concerns and perception of home HD before and after patient ’s commencement of the treatment . The data sets will be analysed independently and the findings will be mixed at the stage of interpretation to form a coherent message that will be informing practice in the future . Discussion The BASIC-HHD study is design ed to assemble pivotal information on dialysis modality choice and uptake , investigating users , care-givers and care delivery processes and study their variation in a multi-layered analytical approach within a single health care system . The study results would define modality specific service and patient pathway re design . Study Registration This study has been review ed and approved by the Greater Manchester West Health Research Authority National Research Ethics Service ( NRES ) The study is on the NIHR ( CLRN ) portfolio Background The worldwide human re source gap in anesthesia services often presents a barrier to accessing life-saving and life-improving surgeries . This paper assessed the impact of a ketamine anesthesia package , Every Second Matters-Ketamine ( ESM-Ketamine ) ™ , for use in emergency and life-improving surgeries by non-anesthetist clinicians in a re source -limited setting when no anesthetist was available . Methods We analyzed prospect ively collected data from 193 surgeries constituting a pilot implementation of the ESM-Ketamine package , among three sub-district hospitals in Western Kenya . The study population comprises patients who required emergency or life-improving surgery when no anesthetist was available . Non-anesthetist clinicians in three sub-district hospitals underwent a 5-day training course in ESM-Ketamine complemented by checklists and an ESM-Ketamine Kit . Data were collected prospect ively every time the ESM-Ketamine pathway was invoked . The training cases , although primarily tubal ligations , were included . The primary outcome measures centered on capturing the ability to safely support emergency and life-improving surgeries , when no anesthetist was available , through invoking the ESM-Ketamine pathway . The registry was critically examined using st and ard descriptive and frequency analysis . Results 193 surgical procedures were supported using the ESM-Ketamine package by five ESM-Ketamine trained providers . Brief ( < 30 s ) patient desaturation below 92 % and hallucinations occurred in 16 out of 186 ( 8.6 % ) and 23 out of 190 patients ( 12.1 % ) , respectively . There were no reported major adverse events such as death , prolonged desaturations ( over 30 s ) , or injury result ing from ketamine use . Conclusion This study provides promising initial evidence that the ESM-Ketamine package can support emergency and life-improving surgeries in re source -limited setting s when no anesthetist is available BACKGROUND Venous thromboembolism is common in cancer patients and requires anticoagulation with low-molecular-weight heparin ( LMWH ) . Current data recommend LMWH for anticoagulation as far as 6 months , yet guidelines recommend LMWH beyond 6 months in patients who have ongoing or active cancer . This recommendation , based on expert consensus , has not been evaluated in a clinical study . OBJECTIVES ( 1 ) To identify the most clinical ly and cost-effective length of anticoagulation with LMWH in the treatment of cancer-associated thrombosis ( CAT ) ; ( 2 ) to identify practicalities of conducting a full r and omised controlled trial ( RCT ) with regard to recruitment , retention and outcome measurement ; and ( 3 ) to explore the barriers for progressing to a full RCT . DESIGN The Anticoagulation with Low-molecular-weight heparin In the treatment of Cancer-Associated Thrombosis ( ALICAT ) trial is a r and omised , multicentre , feasibility mixed- methods study with three components : ( 1 ) a RCT comparing ongoing LMWH treatment for CAT with cessation of LMWH at 6 months ' treatment ( current licensed practice ) in patients with locally advanced or metastatic cancer , consulted in three clinical setting s ( haematology out patients , oncology out patients and primary care ) ; ( 2 ) a nested qualitative study , including focus groups with clinicians to investigate attitudes for recruiting to the study and identify the challenges of progressing to a full RCT , and semistructured interviews with patients and relatives to explore their attitudes towards participating in the study , and potential barriers and concerns to participation ; and ( 3 ) a UK-wide survey exercise to develop a classification and enumeration system for the CAT models and pathways of care . SETTING A haematology out patients department , an oncology out patients department and primary care . PARTICIPANTS Patients with ongoing active or metastatic cancer who have received 6 months of LMWH for CAT .  INTERVENTIONS Ongoing LMWH treatment for CAT versus cessation of LMWH at 6 months ' treatment in patients with locally advanced or metastatic cancer . MAIN OUTCOME MEASURES ( i  ) The number of eligible patients over 12 months ; ( ii ) the number of recruited patients over 12 months ( target recruitment rate of 30 % of eligible patients ) ; and ( iii ) the proportion of r and omised participants with recurrent venous thromboembolisms ( VTEs ) during follow-up . RESULTS Following several delays in setting up the RCT component of the study , 5 out of 32 eligible patients consented to be r and omised to the RCT suggesting progression to a full RCT was not feasible . Reasons for non-consenting were primarily based on a fixed preference for continuing or discontinuing treatment after 6 months of anticoagulation , and a fear of r and omisation to their non-preferred option . Views were largely influenced by patients ' initial experience of CAT . Focus groups with clinicians revealed that they would be reticent to recruit to such a study as they had fixed views of best management despite the lack of evidence . Patient pathway modelling suggested that there is a broad heterogeneity of practice with respect to CAT management and co-ordination , with no consensus on which specialty should best manage such cases . CONCLUSIONS The results of the RCT reflect recruitment from the oncology site only and provide no recruitment data from haematology centres . However , it is unlikely that these other sites would have access to more eligible patients . The management of cancer-associated thrombosis beyond 6 months will remain a clinical challenge . As it is unlikely that a prospect i ve study will successfully recruit , other strategies to accrue relevant data are necessary . Currently the LONGHEVA ( Long-term treatment for cancer patients with deep-venous thrombosis or pulmonary embolism ) registry is in development to prospect ively evaluate this important and common clinical scenario . STUDY REGISTRATION This study is registered as clinical trials.gov number NCT01817257 and International St and ard R and omised Controlled Trial Number ( IS RCT N ) 37913976 . FUNDING DETAILS Funding for the ALICAT trial was provided by the Health Technology Assessment programme ( 10/145/01 ) in response to a themed funding call . The study was design ed in accordance with the initial funding brief and feedback from the review process Background Medical treatment in patient-centred care in oncology is broadly managed and regulated in terms of guideline development , cancer centres , and quality assurance by cancer registries . In contrast to this quality management cycle ( PDCA ) , there are no equal st and ards for patient-reported outcomes like quality of life ( QoL ) 
    Output:
    
Oncology is particularly prevalent due to its already well-established processes of care .