***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: Objective To compare the cost effectiveness of  nurses and doctors in performing upper gastrointestinal endoscopy and flexible sigmoidoscopy .  Design As part of a pragmatic r and omised trial , the economic analysis calculated incremental cost effectiveness ratios , and generated cost effectiveness acceptability curves to address uncertainty . Setting 23 hospitals in the United Kingdom . Participants 67 doctors and 30 nurses , with a total of 1888 patients , from July 2002 to June 2003 . Intervention Diagnostic upper gastrointestinal endoscopy and flexible sigmoidoscopy carried out by doctors or nurses . Main outcome measure Estimated health gains in QALYs measured with EQ-5D . Probability of cost effectiveness over a range of decision makers ’ willingness to pay for an additional quality adjusted life year ( QALY ) . Results Although differences did not reach traditional levels of significance , patients in the doctor group gained 0.015 QALYs more than those in the nurse group , at an increased cost of about £ 56 ( € 59 , $ 78 ) per patient . This yields an incremental cost effectiveness ratio of £ 3660 ( € 3876 , $ 5097 ) per QALY . Though there is uncertainty around these results , doctors are probably more cost effective than nurses for plausible values of a QALY . Conclusions Though upper gastrointestinal endoscopies and flexible sigmoidoscopies carried out by doctors cost slightly more than those by nurses and improved health outcomes only slightly , our analysis favours endoscopies by doctors . For plausible values of decision makers ’ willingness to pay for an extra QALY , endoscopy delivered by nurses is unlikely to be cost effective compared with endoscopy delivered by doctors . Trial registration International st and ard RCT One hundred seven patients in an acute care setting who had lay sitters to provide the constant observation judged necessary to meet their safety needs were studied to determine the effect of psychiatric liaison nurse specialist ( PLNS ) consultation on nursing care and the use of sitters . After placement in either a suicidal or nonsuicidal group , subjects were r and omly assigned to receive consultation or not . Outcome variables of number of sitter shifts , number of nursing note observations , number of patient and sitter incidents and length of hospital stay were considered . Multiple analysis of variance indicated no significant differences among the groups for number of sitter shifts or number of nursing note observations . A significant main effect for group on length of hospital stay was found with suicidal patients having a significantly shorter hospital stay . Number of patients and sitter incidents were too small for analysis AIM To determine the effect on quality of life and cost effectiveness of specialist nurse early supported discharge for women undergoing major abdominal and /or pelvic surgery for benign gynaecological disease compared with routine care . STUDY DESIGN R and omised controlled trial comparing  specialist nurse supported discharge with routine hospital care in gynaecology . The SF-36 , a generic health status question naire , was used to measure women 's evaluation of their health state before surgery and at 6 weeks after surgery . A further question naire scoring patient symptoms , milestones of recovery , information given and satisfaction , was administered prior to discharge from hospital and at 6 weeks thereafter . SETTING Gynaecology service at the Western Infirmary Glasgow , part of North Glasgow University , NHS Trust . PARTICIPANTS One hundred and eleven women scheduled for major abdominal or pelvic surgery for benign gynaecological disease . MAIN OUTCOME MEASURES SF-36 health survey question naire baseline scores were reported before surgery and at 6 weeks follow-up . Complications , length of hospital stay , readmission , information on discharge support and satisfaction of women were recorded at discharge from hospital and at 6 weeks follow-up . A cost consequence analysis was conducted based on the perspective of the NHS . RESULTS The addition of a specialist nurse to routine hospital care in gynaecology significantly reduced the post-operative length of hospital stay p = 0.001 , improved information delivery and satisfaction of women . The specialist nurse supported discharge group was associated with significantly lower total costs to the NHS than routine care result ing principally from the difference in the cost of the post-operative length of stay . CONCLUSIONS Women undergoing major abdominal and pelvic surgery were discharged home earlier with provision of support from a specialist gynaecology nurse . The results of this study suggest that duration of hospital stay can be shortened by the introduction of a specialist nurse without introducing any adverse physical and psychological effects . This process of care is associated with receipt of information on health and lifestyle issues and maintenance of high levels of patient satisfaction and demonstrates the effectiveness of the specialist nurse role in the provision of health information for women . Earlier hospital discharge at 48 h after major abdominal and pelvic surgery is an acceptable , cost effective alternative to current routine practice in the absence of further r and omised evidence PURPOSE Several r and omized trials have found that discharge planning improves outcomes for hospitalized patients . We do not know if adding a clinical nurse specialist ( CNS ) to physician teams in hospitals that already have discharge planning services makes a difference . METHODS In 2 teaching hospitals , patients were r and omly assigned to regular hospital care or care with a clinical nurse specialist . The clinical nurse specialist facilitated hospital care by retrieving preadmission information , arranging in-hospital consultations and investigations , organizing postdischarge follow-up visits , and checking up on patients postdischarge with a telephone call . In-hospital outcomes included mortality and length of stay . Postdischarge outcomes included time to readmission or death , patient satisfaction , and the risk of adverse event . Adverse events were poor outcomes due to medical care rather than the natural history of disease . RESULTS A total of 620 sequential patients were r and omized ( CNS n = 307 , control n = 313 ) , of which 361 were followed after discharge from hospital ( CNS n = 175 , control n = 186 ) . The groups were similar for the probability of in-hospital death ( CNS 9.3 % vs control 9.7 % ) or being discharged to the community ( 58.0 % vs 60.0 % ) . The groups did not differ for postdischarge outcomes including readmission or death ( 21.6 % vs 15.6 % ; P = 0.16 ) or risk of adverse event ( 23.6 % vs 22.8 % ) . Mean [ SD ] patient ratings of overall quality of care on a scale of 10 was higher in the clinical nurse specialist group ( 8.2 [ 2.2 ] vs 7.6 [ 2.4 ] ; P = 0.052 ) . CONCLUSION The addition of a clinical nurse specialist to a medical team improved patient satisfaction but did not impact hospital efficiency or patient safety Context People with chronic conditions may need tailored , practical help for managing their conditions . Contribution This 12-month trial of assistance with managing systolic- dysfunction heart failure r and omly assigned 406 ethnically diverse adults from Harlem , New York , to usual care or nurse management .  Nurses counseled nurse management patients about sodium intake , fluid buildup , medication adherence , and self-management of symptoms ; served as a bridge between patients and physicians ; and regularly called patients to discuss problems . Compared with usual care patients , nurse management patients had fewer hospitalizations and better functioning . Implication s Nurse management can improve some outcomes in ethnically diverse patients with systolic-dysfunction heart failure in ambulatory practice s. The Editors Heart failure disproportionately affects black and elderly people and is a leading cause of hospitalization among people 65 years of age or older ( 1 , 2 ) . Although effective therapies can improve functioning and survival in patients with systolic dysfunction , many patients may not be receiving the full benefit of existing knowledge ( 35 ) . Patients play a critical role in managing a chronic condition , such as heart failure . Patients may not realize that specific symptoms are related to heart failure or that adhering to medications and diet can reduce symptoms and life-threatening episodes ( 6 ) . Evidence -based guidelines for systolic dysfunction recommend that physicians not only offer patients effective therapies but also teach them the importance of adherence and self-monitoring ( 3 , 4 ) . Clinicians have fallen short in prescribing angiotensin-converting enzyme inhibitors and -blockers for patients with systolic dysfunction ( 5 , 7 , 8) . When prescribed , the doses have often been lower than those proven to convey greater benefits ( 3 , 9 ) . Clinicians have also documented counseling only a fraction of patients with heart failure about self-management ( 10 , 11 ) . System-related factors may also influence patients ' ability to obtain quality care ( 12 , 13 ) . Systematic review s of clinical behavior change have suggested that interventions targeted to specific problems are more likely to be successful ( 14 , 15 ) . On the basis of shortfalls identified in patient self-management and clinical care in Harlem , New York , a predominately nonwhite area , we tailored a nurse management intervention to address documented problems and evaluated its effectiveness in a r and omized , controlled trial . Our trial among primarily minority patients addresses important gaps in the literature . We targeted problems documented among patients with heart failure in Harlem , enrolled patients from ambulatory care practice s , r and omly assigned patients to either nurse management or usual care , and evaluated the patients ' subsequent health-related outcomes . We hypothesized that patients in the  focused nurse management program  would have fewer hospitalizations and report better functioning than patients in usual care . Methods Development of the Intervention During interviews with patients with heart failure at Mount Sinai Hospital , New York , New York , patients reported inadequate underst and ing of heart failure and their role in managing it ( 6 ) . Less than half of patients followed a very-low-salt diet , and only about one quarter weighed themselves daily . Regarding clinical management , medical records noted prescriptions for an angiotensin-converting enzyme inhibitor or hydralazinedinitrate combination in 82 % of 322 consecutive black patients with documented systolic dysfunction who were scheduled for visits at the general medicine clinic at Harlem Hospital from February 1995 through February 1997 . The prescribed doses , however , equaled or exceeded those found to be efficacious in clinical trials in only 26 % of these patients ( 3 ) . In design ing a nurse management intervention to address these problems , we built on a Stanford University program that evaluated primarily privately insured patients at Kaiser Permanente in northern California ( 16 , 17 ) . We adapted their question naire on the frequency of foods eaten to incorporate those that are common among African-American and Hispanic people in Harlem . Setting s and Recruitment All 4 hospitals in Harlem , the area 's major providers , collaborated in the trial : 1 large private academic medical center ( 1171 beds ) , 2 medium-sized municipal hospitals ( 286 beds and 363 beds ) , and 1 smaller private community hospital ( 200 beds ) . In 2000 , these hospitals had 521 , 267 , 218 , and 168 discharges for the heart failure diagnosis-related group ( code 127 ) , respectively . All are not-for-profit institutions . The trial had the following inclusion criteria : adults 18 years of age or older ; systolic dysfunction documented on a cardiac test ( echocardiography , radionuclide ventriculography , myocardial stress sestamibi or thallium stress testing , or left-heart catheterization ) ; English- language or Spanish- language speakers ; community-dwelling at enrollment ; and current patient in a general medicine , geriatrics , or cardiology clinic or office at a participating site . Exclusion criteria were medical conditions that prevented interaction with the nurse , including blindness , deafness , or cognitive impairment ; medical conditions requiring individualized management that might differ from st and ard protocol , namely pregnancy , renal dialysis , or terminal illness ; or procedures that corrected systolic dysfunction , such as heart transplantation . Of the 216 clinicians ( 209 physicians and 7 physicians ' assistants or nurse practitioners ) in participating practice s , 1 clinician declined permission to recruit his patients . The institutional review boards for each site approved the study . We identified patients with International Classification of Diseases , Ninth Revision , Clinical Modification ( ICD-9-CM ) , and diagnosis-related group codes on outpatient or inpatient billings for heart failure , March 1999 through February 2001 , who had at least 1 clinician visit to a participating practice and impaired systolic dysfunction . We defined impaired systolic dysfunction as a left ventricular ejection fraction less than 0.40 or moderately or severely reduced systolic dysfunction on echocardiography , radionuclide ventriculography , myocardial stress sestamibi or thallium stress testing , or left-heart catheterization . We obtained clinicians ' permission to recruit specific patients and sent each approved patient a letter from the site 's physician coordinator . Bilingual recruiters telephoned eligible patients or approached them at scheduled clinician appointments . The recruiter confirmed each patient 's eligibility , obtained written informed consent to participate in the study , conducted the baseline survey , and telephoned the project manager for the treatment group assignment . The recruiter conveyed the assignment to the patient and , for each nurse management patient , scheduled the in-person appointment with a nurse . We provided telephone service for 3 patients who did not have it so we could telephone patients in both treatment groups every 3 months for data on end points and so nurse management patients could participate in the intervention . R and omization and Treatment Groups The project 's statistician used a computer-generated , r and om-number sequence without blocking or stratification to central ly determine r and omization assignments and concealed treatment group assignments in sealed , opaque envelopes . Usual care patients 
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We found no evidence that the addition of specialist nurses to nursing staff reduces patient death rates , attendance at the emergency department , or readmission rates , but it is likely to result in shorter patient hospital stays , and reductions in pressure ulcers .
The evidence in relation to the impact of replacing Registered Nurses with unqualified nursing assistants on patient outcomes is very limited .
However , it is suggested that specialist support staff , such as dietary assistants , may have an important impact on patient outcomes .
Self-scheduling and primary nursing may reduce staff turnover .
The introduction of team midwifery ( versus st and ard care ) may reduce medical procedures in labour and result in a shorter length of stay without compromising maternal or perinatal safety .
The findings suggest interventions relating to hospital nurse staffing models may improve some patient outcomes , particularly the addition of specialist nursing and specialist support roles to the nursing workforce .
Interventions relating to hospital nurse staffing models may also improve staff-related outcomes , particularly the introduction of primary nursing and self-scheduling .