***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: OBJECTIVES ( 1 ) To determine whether pre-operative assessment carried out by an appropriately trained nurse ( ATN ) is equivalent in quality to that carried out by a pre- registration house officer ( PRHO ) . ( 2 ) To assess whether pre- assessment s carried out by ATNs and PRHOs are equivalent in terms of cost . ( 3 ) To determine whether assessment s carried out by ATNs are acceptable to patients . ( 4 ) To investigate the quality of communication between senior medical staff and ATNs . DESIGN The study design was principally a prospect i ve r and omised equivalence trial but was accompanied by additional qualitative assessment of patient and staff perceptions , and an economic evaluation . SETTING The study was carried out at four NHS hospitals , three of which were teaching hospitals , in three NHS Trusts in Southampton , Sheffield and Doncaster . SUBJECTS All patients attending at one site for assessment prior to general anaesthetic for elective general , vascular , urological or breast surgery were potentially included in the study . Of 1907 patients who were r and omised , 1874 completed the study with a full evaluation . INTERVENTIONS The intervention consisted of a pre-operative assessment carried out by either an ATN or a PRHO . Of the patients who completed the study with a full evaluation , 926 patients were r and omised to the PRHO arm of the trial and 948 to the ATN arm . Three ATNs took part in the study , one from each centre , together with a total of 87 PRHOs . MAIN OUTCOME MEASURES Immediately following the initial assessment of a patient by a PRHO or an ATN , one of a number of clinical research fellows , all specialist registrars in anaesthetics , repeated the assessment and recorded it on a study form , together with a list of investigations required . The clinical research fellow then evaluated the competency of the initial assessor by comparing the quality of their assessment with their own . Any deficiencies in ordering of investigations and referral to other specialities were met in order to maximise patient care . Three areas of ATN and PRHO performance were judged separately , history taking , examination and ordering of tests , and each was grade d into one of four categories , the most important of which was under- assessment , which would possibly have affected peri-operative management . In the case of ordering of tests , it was possible to have both over- and under-assessed a patient on different tests . RESULTS The pre-operative assessment s carried out by the ATNs were essentially equivalent to those performed by the PRHOs in terms of under- assessment that might possibly have affected peri-operative management , although there was variation between the ATNs in terms of the quality of history taking . This may be related to the low number of patients seen at one study site . PRHOs ordered significantly more unnecessary tests than the ATNs . The substitution of ATNs for PRHOs was calculated to be cost neutral . The results of the qualitative assessment showed that the use of ATNs for pre-operative assessment was acceptable to patients ; however , there was no evidence that communication between senior medical staff and those carrying out pre-operative assessment s was improved by their introduction . CONCLUSIONS This study demonstrated no reason to inhibit the development of fully nurse-led pre-operative assessment , provided that the nurses are appropriately trained and maintain sufficient workload to retain skills . CONCLUSIONS -- IMPLICATION S FOR THE HEALTH SERVICE : ATNs provide an acceptable and efficient alternative to PRHOs for the purpose s of routine pre-operative assessment . Consideration will have to be given , however , to the positions of these nurses within the surgical team , and also to their career structure . CONCLUSIONS -- RECOMMENDATIONS FOR FUTURE RESEARCH : Further research is needed in the following areas : ( 1 ) the extent and type of training needed for nurses undertaking the  pre-operative assessment  role ; ( 2 ) the use , costs and benefits of routine pre-operative testing Objective : To investigate the potential impact for ambulance services of telephone assessment and triage for callers who present with non-serious problems ( Category C calls ) as classified by ambulance service call takers . Design : Pragmatic controlled trial . Calls identified using priority dispatch protocol s as non-serious were allocated to intervention and control groups according to time of call . Ambulance dispatch occurred according to existing procedures . During intervention sessions , nurses or paramedics within the control room used a computerised decision support system to provide telephone assessment , triage and , if appropriate , offer advice to permit estimation of the potential impact on ambulance dispatch . Setting : Ambulance services in London and the West Midl and s. Subjects : Patients for whom emergency calls were made to the ambulance services between April 1998 and May 1999 during four hour sessions sample d across all days of the week between 0700 and 2300 . Main outcome measures : Triage decision , ambulance cancellation , attendance at an emergency department . Results : In total , there were 635 intervention calls and 611 controls . Of those in the intervention group , 330 ( 52.0 % ) were triaged as not requiring an emergency ambulance , and 119 ( 36.6 % ) of these did not attend an emergency department . This compares with 55 ( 18.1 % ) of those triaged by a nurse or paramedic as requiring an ambulance ( odds ratio 2.62 ; 95 % CI 1.78 to 3.85 ) . Patients triaged as not requiring an emergency ambulance were less likely to be admitted to an inpatient bed ( odds ratio 0.55 ; 95 % CI 0.33 to 0.93 ) , but even so 30 ( 9.2 % ) were admitted . Nurses were more likely than paramedics to triage calls into the groups classified as not requiring an ambulance . After controlling for age , case mix , time of day , day of week , season , and ambulance service , the results of a logistic regression analysis revealed that this difference was significant with an odds ratio for nurses : paramedics of 1.28 ( 95 % CI 1.12 to 1.47 ) . Conclusions : The findings indicate that telephone assessment of Category C calls identifies patients who are less likely to require emergency department care and that this could have a significant impact on emergency ambulance dispatch rates . Nurses were more likely than paramedics to assess calls as requiring an alternative response to emergency ambulance despatch , but the extent to which this relates to aspects of training and professional perspective is unclear . However , consideration should be given to the acceptability , reliability , and cost consequences of this intervention before it can be recommended for full evaluation CONTEXT Endotracheal intubation ( ETI ) is widely used for airway management of children in the out-of-hospital setting , despite a lack of controlled trials demonstrating a positive effect on survival or neurological outcome . OBJECTIVE To compare the survival and neurological outcomes of pediatric patients treated with bag-valve-mask ventilation ( BVM )  with those of patients treated with BVM followed by ETI .  DESIGN Controlled clinical trial , in which patients were assigned to interventions by calendar day from March 15 , 1994 , through January 1 , 1997 . SETTING Two large , urban , rapid-transport emergency medical services ( EMS ) systems . PARTICIPANTS A total of 830 consecutive patients aged 12 years or younger or estimated to weigh less than 40 kg who required airway management ; 820 were available for follow-up . INTERVENTIONS Patients were assigned to receive either BVM ( odd days ; n = 410 ) or BVM followed by ETI ( even days ; n = 420 ) . MAIN OUTCOME MEASURES Survival to hospital discharge and neurological status at discharge from an acute care hospital compared by treatment group . RESULTS There was no significant difference in survival between the BVM group ( 123/404 [ 30 % ] ) and the ETI group ( 110/416 [ 26 % ] ) ( odds ratio [ OR ] , 0.82 ; 95 % confidence interval [ CI ] , 0.61 - 1.11 ) or in the rate of achieving a good neurological outcome  ( BVM , 92/404 [ 23 % ] vs ETI , 85/416 [ 20 % ] ) ( OR , 0.87 ; 95 % CI , 0.62 - 1.22 ) . CONCLUSION These results indicate that the addition of out-of-hospital ETI to a paramedic scope of practice that already includes BVM did not improve survival or neurological outcome of pediatric patients treated in an urban EMS system OBJECTIVE : To evaluate the effectiveness and cost effectiveness of specially trained physiotherapists in the assessment and management of defined referrals to hospital orthopaedic departments . DESIGN : R and omised controlled trial . SETTING : Orthopaedic outpatient departments in two hospitals . SUBJECTS : 481 patients with musculoskeletal problems referred for specialist orthopaedic opinion . INTERVENTIONS : Initial assessment and management undertaken by post-Fellowship junior orthopaedic surgeons , or by specially trained physiotherapists working in an extended role ( orthopaedic physiotherapy specialists ) . MAIN OUTCOME MEASURES : Patient centred measures of pain , functional disability and perceived h and icap . RESULTS : A total of 654 patients were eligible to join the trial , 481 ( 73.6 % ) gave their consent to be r and omised . The two arms ( doctor n = 244 , physiotherapist n = 237 ) were similar at baseline . Baseline and follow up question naires were completed by 383 patients ( 79.6 % ) . The mean time to follow up was 5.6 months after r and omisation , with similar distributions of intervals to follow up in both arms . The only outcome for which there was a statistically or clinical ly important difference between arms was in a measure of patient satisfaction , which favoured the physiotherapist arm . A cost minimisation analysis showed no significant differences in direct costs to the patient or NHS primary care costs . Direct hospital costs were lower ( p < 0.00001 ) in the physiotherapist arm ( mean cost per patient = 256 Pounds , n = 232 ) , as they were less likely to order radiographs and to refer patients for orthopaedic surgery than were the junior doctors ( mean cost per patient in arm = 498 Pounds , n = 238 ) . CONCLUSIONS : On the basis of the patient centred outcomes measured in this r and omised trial , orthopaedic physiotherapy specialists are as effective as post-Fellowship junior staff and clinical assistant orthopaedic surgeons in the initial assessment and management of new referrals to outpatient orthopaedic departments , and generate lower initial direct hospital costs Transnasal flexible laryngoscopy ( TFL ) is an examination of laryngeal anatomy and physiology using continuous light . TFL is being used increasingly by voice pathologists in treatment but with little scientific evidence to support it . The purpose of this study was to evaluate the effectiveness and efficiency of TFL as a therapeutic tool . The study used a prospect i ve r and omized controlled trial . Fifty dysphonic subjects were recruited and r and omly assigned to either a traditional treatment group or a TFL-assisted treatment group . The effectiveness of voice therapy in both treatment groups was measured with a package of voice outcome measures . Subjects in both treatment groups demonstrated statistically significant improvements after voice therapy ( perceptual auditory rating of voice quality measurement p < 0.01 ; instrumental electroglottographic measurement p < 0.01 ; patient question naire measurement p < 0.01 ) . The time taken to complete treatment in both groups was recorded . The average ( median ) time taken to complete voice therapy in the TFL-assisted treatment group was 2 hours less than in the traditional treatment group ( p < 0.01 ) . Voice therapy with TFL  as a therapy tool was effective and more efficient than traditional voice therapy 
    Output:
    
Conclusions : A range of extended practice roles for allied health professionals have been promoted and are being undertaken , but their health outcomes have rarely been evaluated .
There is also little evidence as to how best to introduce such roles , or how best to educate , support and mentor these practitioners