Congenital microcoria deletion in mouse links Sox21 dysregulation to disease and suggests a role for TGFB2 in glaucoma and myopia.

Congenital microcoria (MCOR) is a rare hereditary developmental defect of the iris dilator muscle frequently associated with high axial myopia and high intraocular pressure (IOP) glaucoma. The condition is caused by submicroscopic rearrangements of chromosome 13q32.1. However, the mechanisms underlying the failure of iris development and the origin of associated features remain elusive. Here, we present a 3D architecture model of the 13q32.1 region, demonstrating that MCOR-related deletions consistently disrupt the boundary between two topologically associating domains (TADs). Deleting the critical MCOR-causing region in mice reveals ectopic Sox21 expression precisely aligning with Dct, each located in one of the two neighbor TADs. This observation is consistent with the TADs' boundary alteration and adoption of Dct regulatory elements by the Sox21 promoter. Additionally, we identify Tgfb2 as a target gene of SOX21 and show TGFΒ2 accumulation in the aqueous humor of an MCOR-affected subject. Accumulation of TGFB2 is recognized for its role in glaucoma and potential impact on axial myopia. Our results highlight the importance of SOX21-TGFB2 signaling in iris development and control of eye growth and IOP. Insights from MCOR studies may provide therapeutic avenues for this condition but also for glaucoma and high myopia conditions, affecting millions of people.

Eviction-driven infanticide and sexually selected adoption and infanticide in a neotropical parrot.

Infanticide and adoption have been attributed to sexual selection, where an individual later reproduces with the parent whose offspring it killed or adopted. While sexually selected infanticide is well known, evidence for sexually selected adoption is anecdotal. We report on both behaviors at 346 nests over 27 y in green-rumped parrotlets (Forpus passerinus) in Venezuela. Parrotlets are monogamous with long-term pair bonds, exhibit a strongly male-biased adult sex ratio, and nest in cavities that are in short supply, creating intense competition for nest sites and mates. Infanticide attacks occurred at 256 nests in two distinct contexts: 1) Attacks were primarily committed by nonbreeding pairs (69%) attempting to evict parents from the cavity. Infanticide attacks per nest were positively correlated with population size and evicting pairs never adopted abandoned offspring. Competition for limited nest sites was a primary cause of eviction-driven infanticide, and 2) attacks occurred less frequently at nests where one mate died (31%), was perpetrated primarily by stepparents of both sexes, and was independent of population size. Thus, within a single species and mating system, infanticide occurred in multiple contexts due to multiple drivers. Nevertheless, 48% of stepparents of both sexes adopted offspring, and another 23% of stepfathers exhibited both infanticide and long-term care. Stepfathers were often young males who subsequently nested with widows, reaching earlier ages of first breeding than competitors and demonstrating sexually selected adoption. Adoption and infanticide conferred similar fitness benefits to stepfathers and appeared to be equivalent strategies driven by limited breeding opportunities, male-biased sex ratios, and long-term monogamy.

Family secrets: Experiences and outcomes of participating in direct-to-consumer genetic relative-finder services.

In recent decades, genetic genealogy has become popular as a result of direct-to-consumer (DTC) genetic testing. Some DTC genetic testing companies offer genetic relative-finder (GRF) services that compare the DNA of consenting participants to identify genetic relatives among them and provide each participant a list of their relative matches. We surveyed a convenience sample of GRF service participants to understand the prevalence of discoveries and associated experiences. Almost half (46%) of the 23,196 respondents had participated in GRF services only for non-specific reasons that included interest in building family trees and general curiosity. However, most (82%) also learned the identity of at least one genetic relative. Separately, most respondents (61%) reported learning something new about themselves or their relatives, including potentially disruptive information such as that a person they believed to be their biological parent is in fact not or that they have a sibling they had not known about. Respondents generally reported that discovering this new information had a neutral or positive impact on their lives, and most had low regret regarding their decision to participate in GRF services. Yet some reported making life changes as a result of their discoveries. Compared to respondents making other types of discoveries, those who learned that they were donor conceived reported the highest decisional regret and represented the largest proportion reporting net-negative consequences for themselves. Our findings indicate that discoveries from GRF services may be common and that the consequences for individuals, while generally positive, can be far-reaching and complex.

Scientific selection: A century of increasing crop varietal diversity in US wheat.

A prevalent and persistent biodiversity concern is that modern cropping systems lead to an erosion in crop genetic diversity. Although certain trait uniformity provides advantages in crop management and marketing, farmers facing risks from change in climate, pests, and markets are also incentivized to adopt new varieties to address complex and spatially variable genetics, environment, and crop management interactions to optimize crop performance. In this study, we applied phylogenetically blind and phylogenetically informed diversity metrics to reveal significant increases in both the spatial and temporal diversity of the US wheat crop over the past century. Contrary to commonly held perceptions on the negative impact of modern cropping systems on crop genetic diversity, our results demonstrated a win-win outcome where the widespread uptake of scientifically selected varieties increased both crop production and crop diversity.

Extension services can promote pasture restoration: Evidence from Brazil's low carbon agriculture plan.

Innovation and improved practices in the livestock sector represent key opportunities tomeet global climate goals. This paper provides evidence that extension services can pro-mote pasture restoration in cattle ranching in Brazil. We use a randomized controlledtrial implemented in the context of the ABC Cerrado (a large-scale program launched in2014 aimed at fostering technology adoption through a combination of training andtechnical assistance) to examine the effects of different types of extension on agriculturalpractices, input use, and productivity. Providing technical assistance to previously trainedproducers promoted pasture restoration, induced farmers to use inputs more intensively,helped them to improve their management and soil conservation practices, and substan-tially increased revenues. A cost­benefit calculation indicates that US$1 invested in theABC Cerrado program increased profits by US$1.08 to $1.45. Incorporating carbonsavings amplifies this return considerably.

From the laboratory to the consumer: Innovation, supply chain, and adoption with applications to natural resources.

We analyze the transition from innovative ideas to final marketed products. This transition occurs through two synergetic supply chains for innovation and products. Basic concepts are developed, tested, upscaled, and introduced to commercial use in the innovation supply chain. Then, the products are produced and delivered to the consumer through the product supply chain. We argue that product markets trace their birth to product innovations. These markets tend to start as noncompetitive, which rewards innovators. Credit access and risk determine the reliance on contracting and product diffusion over space and time. The innovation and product supply chains are encouraged and facilitated by public policies, such as support for research and education, intellectual property rights protection, low barriers to trade, science-based regulation, and well-functioning capital markets. We argue for multidisciplinary research incorporating knowledge from economics, business, and engineering to better understand the evolution of innovative companies and supply chains. This understanding will help the development of policies to address challenges of climate change and food security among others.

Encouraging voluntary government action via a solar-friendly designation program to promote solar energy in the United States.

SignificanceDue to market and system failures, policies and programs at the local level are needed to accelerate the renewable energy transition. A voluntary environmental program (VEP), such as SolSmart, can encourage local governments to adopt solar-friendly best practices. Unlike previous research, this study uses a national sample, more recent data, and a matched control group for difference-in-differences estimation to quantify the causal impact of a VEP in the public, rather than private, sector. We offer empirical evidence that SolSmart increased installed solar capacity and, with less statistical significance, the number of solar installations. The results inform the design of sustainability-focused VEPs and future research to understand the causal pathways between local governments' voluntary actions and solar market development.

Deimplementation of Ineffective and Harmful Medical Practices: A Data-Driven Commentary.

Deimplementation is the discontinuation or abandonment of medical practices that are ineffective or of unclear effectiveness, ranging from simply unhelpful to harmful. With epidemiology expanding to include more translational sciences, epidemiologists can contribute to deimplementation through defining evidence, establishing causality, and advising on study design. An estimated 10-30% of healthcare practices have minimal to no benefit to patients and should be targeted for deimplementation. The steps in deimplementation are: 1) identify low-value clinical practices, 2) facilitate the deimplementation process, 3) evaluate deimplementation outcomes, and 4) sustain deimplementation, each of which is a complex project. Deimplementation science involves researchers, healthcare and clinical stakeholders, and patient and community partners affected by the medical practice. Increasing collaboration between epidemiologists and implementation scientists is important to optimizing health care delivery.

Quasi-experimental methods for pharmacoepidemiology: difference-in-differences and synthetic control methods with case studies for vaccine evaluation.

Difference-in-differences and synthetic control methods have become common study designs for evaluating the effects of changes in policies, including health policies. They also have potential for providing real-world effectiveness and safety evidence in pharmacoepidemiology. To effectively add to the toolkit of the field, however, designs-including both their benefits and drawbacks-must be well understood. Quasi-experimental designs provide an opportunity to estimate the average treatment effect on the treated without requiring the measurement of all possible confounding factors, and to assess population-level effects. This requires, however, other key assumptions, including the parallel trends or stable weighting assumptions, a lack of other concurrent events that could alter time trends, and an absence of contamination between exposed and unexposed units. The targeted estimands are also highly specific to the settings of the study, and combining across units or time periods can be challenging. Case studies are presented for 3 vaccine evaluation studies, showcasing some of these challenges and opportunities in a specific field of pharmacoepidemiology. These methods provide feasible and valuable sources of evidence in various pharmacoepidemiologic settings and can be improved through research to identify and weigh the advantages and disadvantages in those settings. This article is part of a Special Collection on Pharmacoepidemiology.

A scoping review of evidence on routine cervical cancer screening in South Asia: investigating factors affecting adoption and implementation.

NEED: Cervical cancer is a major global public health issue, particularly affecting low and middle-income countries, distinctly in the South Asian region. This geographical region lacks a well-organized routine cervical screening program. Consequently, this scoping review aimed to investigate the evidence on factors influencing the adoption and implementation of routine cervical cancer screening in South Asia. METHODS: Adopting the "Arksey and O'Malley and Levac et al." methodology, databases such as PubMed, CINAHL, Web of Science, and Scopus were scrutinized in the pursuit of relevant studies. Subsequently, the collected data were synthesized by adopting the Consolidated Framework for Implementation Research (CFIR) model. RESULTS: A total of 837 records were initially identified and screened for eligibility, including 55 studies. The successful adoption and implementation of cervical cancer screening in South Asia encounter numerous obstacles within the health system, including the absence of a comprehensive program protocol for screening, inadequate health infrastructure, and the presence of multiple sociocultural factors, such as social stigma, low levels of education, and concerns related to modesty. CONCLUSION: To optimize adoption and implementation, it is imperative to construct a customized policy framework that incorporates a risk communication strategy tailored to the specific contexts of these nations. Drawing insights from the experiences of South Asian countries in executing cervical cancer screening programs can inform the formulation of policies for similar healthcare initiatives aimed at facilitating the expansion of HPV vaccination efforts.

Permanently infertile couples and family building-a cross-sectional survey in Denmark.

STUDY QUESTION: Which decision-making factors influence family building among permanently infertile couples? SUMMARY ANSWER: Ethical, legal, and financial considerations outweigh genetic relatedness in decision-making, favouring domestic gestational surrogacy, if this were possible, over international options. WHAT IS KNOWN ALREADY: Permanent infertility affects 4-5% of people in the fertile age. Their family-building options include adoption, surrogacy, uterus transplantation, foster care, and intentional multiple parenthood. However, in most countries, including Denmark, legal barriers constrain these methods due to surrogacy restrictions, suspended international adoptions, and the experimental status of uterus transplantation. Despite existing research on surrogacy, adoption, and specific causes of permanent infertility, a significant gap remains in our understanding of how couples with permanent infertility make family-building decisions within these limited frameworks. STUDY DESIGN, SIZE, DURATION: This cross-sectional study with 150 permanently infertile Danish participants was conducted from June to November 2023 using an online questionnaire. Multiple strategies, such as online forums, fertility clinics, hospital departments, and snowballing, were used to recruit a diverse sample. PARTICIPANTS/MATERIALS, SETTING, METHODS: The study included couples aged 26-50 years facing permanent infertility due to the following primary causes: women without a uterus (15%), women with a non-functional uterus (47%) or women for whom pregnancy would be life-threatening (9%), male couples (16%), transgender partner couples (2%), and other causes (11%). The survey collected data on demographics, reproductive history, family-building choices, and communication strategies. Closed questions were analysed using descriptive statistics. MAIN RESULTS AND THE ROLE OF CHANCE: Among 150 respondents, 41% had used transnational surrogacy, 27% adoption, 14% chose to remain childless, and 19% were undecided. Critical factors on family-building decisions were ethical, legal, and financial concerns which ranked higher than genetic relatedness. Despite the complexity of family building, most participants were open about their child's origin and received social support. If all family-building methods were legal and available in Denmark, domestic gestational surrogacy would be the preferred method, with uterus transplantation and remaining childless being least popular. LIMITATIONS, REASONS FOR CAUTION: The sample size is relatively small, despite the use of a variety of recruitment strategies. Nevertheless, this has ensured a diverse cohort representing the different reasons for infertility and family-building choices. It is important to note that the strategies may have favoured individuals achieving parenthood. WIDER IMPLICATIONS OF THE FINDINGS: The finding of our study reveals a notable gap between available family-building options in Denmark and the preferences of couples facing permanent infertility. These insights could be instrumental for organizations reviewing and developing family-building frameworks. Furthermore, for healthcare professionals guiding couples experiencing infertility issues in their attempts to build a family, an understanding of these preferences is essential to facilitate informed decisions about their future family plans. STUDY FUNDING/COMPETING INTEREST(S): The project was financed by the Independent Research Fund Denmark. The authors have no conflict of interest to declare. TRIAL REGISTRATION NUMBER: N/A.

The Ambulatory Diabetes Outreach Program (ADOP): Rigorous Evaluation of a Pharmacist and Nurse-Led Care Model.

BACKGROUND: Although several systematic reviews found that ambulatory diabetes mellitus (DM) interventions involving pharmacists generally yielded better outcomes than the ones that did not, existing studies have limitations in rigor and study design. OBJECTIVE: To examine the intention-to-treat effects of the Ambulatory Diabetes Outreach Program (ADOP) on participants' A1c values and healthcare utilization over a 52-month follow-up period. DESIGN: Difference-in-differences with staggered adoption. Specifically, we employed the Callaway and Sant'Anna's "group-time average treatment effect" estimator using not-yet treated as controls adjusting for patient's age, BMI, sex, race, comorbidity, payor, and socio-economic status. PARTICIPANTS: All patients with at least one ADOP treatment encounter from July 2017 to October 2021, regardless of program completion or length of exposure to the program. INTERVENTION: ADOP, a collaborative population health program led by pharmacists and nurse specialists to provide individualized type 2 DM management and education within a large and diverse health system. MAIN MEASURES: Patients' A1c values and healthcare utilization, including inpatient admission, inpatient days, and numbers of visits to the emergency department, urgent care, and primary care in recent 6 months. KEY RESULTS: ADOP participation was associated with an overall average reduction of 1.04 percentage points (95%CI - 1.12, - 0.95) in A1c level. Similar A1c reductions were also observed in the subgroups by sex and race/ethnicity. An average of 2 months were required to reach the overall average effect, which persisted over 4 years. Compared to the respective utilization levels pre-intervention, participants also had average reductions in inpatient admissions by 32.4%, inpatient days by 81.6%, visits to the emergency department by 21.6%, and primary care by 17.9%. CONCLUSIONS: The results suggest that a collaborative model of pharmacist and nurse-led type 2 DM intervention was effective in improving A1c outcomes and reducing healthcare utilization in the long term.

Factors Associated with Veteran Self-Reported Use of Digital Health Devices.

BACKGROUND: Digital health devices (DHDs), technologies designed to gather, monitor, and sometimes share data about health-related behaviors or symptoms, can support the prevention or management of chronic conditions. DHDs range in complexity and utility, from tracking lifestyle behaviors (e.g., pedometer) to more sophisticated biometric data collection for disease self-management (e.g., glucometers). Despite these positive health benefits, supporting adoption and sustained use of DHDs remains a challenge. OBJECTIVE: This analysis examined the prevalence of, and factors associated with, DHD use within the Veterans Health Administration (VHA). DESIGN: National survey. PARTICIPANTS: Veterans who receive VHA care and are active secure messaging users. MAIN MEASURES: Demographics, access to technology, perceptions of using health technologies, and use of lifestyle monitoring and self-management DHDs. RESULTS: Among respondents, 87% were current or past users of at least one DHD, and 58% were provided a DHD by VHA. Respondents 65 + years were less likely to use a lifestyle monitoring device (AOR 0.57, 95% CI [0.39, 0.81], P = .002), but more likely to use a self-management device (AOR 1.69, 95% [1.10, 2.59], P = .016). Smartphone owners were more likely to use a lifestyle monitoring device (AOR 2.60, 95% CI [1.42, 4.75], P = .002) and a self-management device (AOR 1.83, 95% CI [1.04, 3.23], P = .037). CONCLUSIONS: The current analysis describes the types of DHDs that are being adopted by Veterans and factors associated with their adoption. Results suggest that various factors influence adoption, including age, access to technology, and health status, and that these relationships may differ based on the functionalities of the device. VHA provision of devices was frequent among device users. Providing Veterans with DHDs and the training needed to use them may be important factors in facilitating device adoption. Taken together, this knowledge can inform future implementation efforts, and next steps to support patient-team decision making about DHD use.

Implementation of WHO guidelines for cervical cancer screening, diagnosis and treatment: knowledge and perceptions of health providers from Argentina.

BACKGROUND: The 2021 World Health Organization (WHO) guidelines on cervical cancer screening and treatment provide countries with evidence-based recommendations to accelerate disease elimination. However, evidence shows that health providers' adherence to screening guidelines is low. We conducted a study in Argentina to analyze health providers' knowledge and perceptions regarding the 2021 WHO Guidelines. METHODS: A qualitative study was conducted based on individual, semi-structured interviews with health providers specializing in gynecology (n = 15). The themes explored were selected and analyzed using domains and constructs of the Consolidated Framework for Implementation Research. RESULTS: Although health providers perceive WHO as a reliable institution, they do not know the 2021 guidelines, its supporting evidence, and its elaboration process. Their clinical practice is mainly guided by local recommendations developed by national professional medical associations (PMAs). For interviewees, WHO guidelines should be disseminated through health authorities and national PMAs, mainly through in-service training. Health providers had a positive assessment regarding WHO Recommendation 1 (screen, triage, and treatment for women aged 30 + with HPV-testing every 5 to 10 years) and perceived a favorable climate for its implementation. HPV-testing followed by triage was considered a low-complexity practice, enabling a better detection of HPV, a better selection of the patients who will need diagnosis and treatment, and a more efficient use of health system resources. However, they suggested adapting this recommendation by removing screening interval beyond 5 years. WHO Recommendation 2 (screen-and-treat approach with HPV-testing for women aged 30 + every 5 to 10 years) was predominantly rejected by interviewees, was considered an algorithm that did not respond to women's needs, and was not adequate for the Argentinean context. Regarding the HPV-test modality, clinician-collected tests were the preferred mode. Health providers considered that HPV self-collection should be used primarily among socially vulnerable women to increase screening coverage. CONCLUSION: WHO guidelines should be widely disseminated among health providers, especially in settings that could benefit from a screen-and-treat approach. Identifying areas of partnership and collaboration with PMAs in implementing WHO guidelines is essential.

Differences in influencing mechanism of clinicians' adoption behavior for liver cancer screening technology between the leading and subordinate hospitals within medical consortiums.

BACKGROUND: Medical consortiums have been extensively established to facilitate the integration of health resources and bridge the technical gap among member institutions. However, some commonly appropriate technologies remain stagnant in subordinate hospitals, although they have been routinely applied in leading hospitals. Besides, the mechanism underlying differences in clinicians' adoption behavior at different levels of institutions was unknown. Therefore, this study aimed to investigate the differences in influencing mechanisms of clinicians' hepatic contrast-enhanced ultrasound technology (CEUS) utilization behavior between leading and subordinate hospitals within medical consortiums, thus providing clues for expanding effective and appropriate technologies within integrated care systems. METHODS: A self-designed scale was developed based on the theory of planned behavior (TPB). A multistage sampling method was applied to investigate clinicians who were aware of CEUS and worked in liver disease-related departments within the sampled medical institutions. The final sample size was 289. AMOS 24.0 software was used to construct multi-group structural equation modeling (SEM) to validate the hypotheses and determine the mechanism of hepatic CEUS utilization. RESULTS: It revealed that behavioral intention significantly influenced adoption behavior, regardless of whether it was in leading hospitals or subordinate hospitals (ß = 0.283, p < 0.001). Furthermore, behavioral attitude (ß = 0.361, p < 0.001) and perceived behavioral control (ß = 0.582, p < 0.001) exerted significant effects on adoption behavior through behavioral intention. However, in leading hospitals, subjective norm had a significant positive effect on behavioral intention (ß = 0.183, p < 0.01), while it had a significant negative impact on behavioral intention in the subordinate hospitals (ß = -0.348, p < 0.01). CONCLUSION: To effectively translate the adoption intention into actual behavior, it is recommended to elucidate the demand and facilitators involved in the process of health technology adoption across leading and subordinate hospitals. Additionally, bolstering technical support and knowledge dissemination within subordinate hospitals while harnessing the influential role of key individuals can further enhance this transformative process.

The Detection of Environmental Influences on Academic Achievement Appears to Depend on the Analytic Approach.

One long-standing analytic approach in adoption studies is to examine correlations between features of adoptive homes and outcomes of adopted children (hereafter termed 'measured environment correlations') to illuminate environmental influences on those associations. Although results from such studies have almost uniformly suggested modest environmental influences on adopted children's academic achievement, other work has indicated that adopted children's achievement is routinely higher than that of their reared-apart family members, often substantially so. We sought to understand this discrepancy. We examined academic achievement and literacy-promotive features of the home in 424 yoked adoptive/biological families participating in the Early Growth and Development Study (EGDS; i.e., adopted children, adoptive mothers, birth mothers, and biological siblings of the adopted children remaining in the birth homes) using an exhaustive modeling approach. Results indicated that, as anticipated, adopted children scored up to a full standard deviation higher on standardized achievement tests relative to their birth mothers and reared-apart biological siblings. Moreover, these achievement differences were associated with differences in the literacy-promotive features of the adoptive and birth family homes, despite minimal measured environment correlations within adoptive families. A subsequent simulation study highlighted noise in measured environmental variables as an explanation for the decreased utility of measured environment correlations. We conclude that the field's heavy focus on measured environment correlations within adoptive families may have obscured detection of specific environmental effects on youth outcomes, and that future adoption studies should supplement their measured environment analyses with mean differences between reared-apart relatives.

Disentangling the roles of age and knowledge in early language acquisition: A fine-grained analysis of the vocabularies of infant and child language learners.

The words that children learn change over time in predictable ways. The first words that infants acquire are generally ones that are both frequent and highly imageable. Older infants also learn words that are more abstract and some that are less common. It is unclear whether this pattern is attributable to maturational factors (i.e., younger children lack sufficiently developed cognitive faculties needed to learn abstract words) or linguistic factors (i.e., younger children lack sufficient knowledge of their language to use grammatical or contextual cues needed to figure out the meaning of more abstract words). The present study explores this question by comparing vocabulary acquisition in 53 preschool-aged children (M = 51 months, range = 30-76 months) who were adopted from China and Eastern Europe after two and half years of age and 53 vocabulary-matched infant controls born and raised in English speaking families in North America (M = 24 months, range = 16-33 months). Vocabulary was assessed using the MB-CDI Words and Sentences form, word frequency was estimated from the CHILDES database, and imageability was measured using adult ratings of how easily words could be pictured mentally. Both groups were more likely to know words that were both highly frequent and imageable (resulting in an over-additive interaction). Knowledge of a word was also independently affected by the syntactic category that it belongs to. Adopted preschoolers' vocabulary was slightly less affected by imageability. These findings were replicated in a comparison with a larger sample of vocabulary-matched controls drawn from the MB-CDI norming study (M = 22 months, range = 16-30 months; 33 girls). These results suggest that the patterns of acquisition in children's early vocabulary are primarily driven by the accrual of linguistic knowledge, but that vocabulary may also be affected by differences in early life experiences or conceptual knowledge.

Implementation Requires Evaluation of Adoption: Lessons From a Multimodal Pain Regimen Order Set.

INTRODUCTION: Multimodal pain regimen (MMPR) protocols are the standard of care per the 2020 Trauma Quality Improvement Program guidelines. MMPR implementation methodology in trauma services has not been reported. The primary objective of this study was to evaluate the adoption of an MMPR order set at a level 1 trauma center and to describe its implementation. We hypothesized that order set utilization would be about 50%, and barriers to adoption would be related to personal biases. METHODS: This was a mixed-methods study at a level 1 trauma center. We retrospectively evaluated MMPR utilization from July 1, 2021 to February 28, 2022. Agile implementation was the method used to implement a clinical decision support tool for the MMPR: a flow chart order set in the electronic medical record. This methodology utilizes short experiment sprints during which data are collected to guide the next iterations. During this process quantitative as well as qualitative data were collected. This included end user testing of the order set and a survey distributed to surgical residents about the order set. Manual thematic network analysis was employed to identify basic and organizing themes from the survey responses. RESULTS: A total of 587 trauma patients were admitted during the study period and 95 patients (16.2%) had MMPR ordered through the order set. The survey response rate was 19% (13/68). We identified ease of use, desire for options, inadequate education, and assumption of personal expertise as the four basic themes from the survey. These basic themes were further analyzed to two organizing themes: heuristics and overconfidence bias. CONCLUSIONS: The MMPR order set was easy to use but had low adoption at our center in the first 8 months of implementation. Agile implementation methodology provided an ideal framework to identify reasons for low adoption and guide the next sprint to address personal biases, improve heuristics, and provide effective education and dissemination. Evaluation of utilization and qualitative analysis are key components to ensuring clinical decision support tool adoption.

Modeling the Adoption of 5760 Clinical Studies Into Practice Across 5 Surgical Specialties.

INTRODUCTION: No studies exist that explore the factors that influence the process of synthesizing new knowledge into perioperative standards of care and the operating room. We sought to model the adoption of clinical research into surgical practice and identify modifiable factors influencing the latency of this translation. METHODS: We created a data set comprised of all UpToDate articles between 2011 and 2020, sampled at 3-mo intervals, to explore how research is incorporated at the point-of-care (POC)-studying 5760 new references from 204 journals across five surgical specialties, compared to all uncited articles published during the same interval. UpToDate authors serve as specialty curators of the vast surgical literature, with an audience of more than a million clinicians in over 180 countries across 3200 institutions. Unlike society guidelines, UpToDate also provides the necessary granularity to quantify the time in bringing research to the bedside. Our main outcomes are citation rates and time-to-citation, split by specialty, journal, article type, and topics. We also model the influence of impact factor, geography, and funding and, finally, propose new impact indices to help with prioritizing surgical literature. RESULTS: We highlight variation in adoption of clinical research by specialty. We show, despite representing a lower quality of evidence, surgical case reports are one of the most cited article types. Furthermore, most clinical trials (94%-100%) in surgical journals are never incorporated into POC reference lists. While few, pragmatic trials were the most likely to be cited of any article type in any surgical specialty (40%). Journal impact factor did not correlate with time-to-citation or proportion of articles cited in three of five surgical specialties, suggesting differences in how specialties synthesize/value research from specialty journals. Our two metrics, the Clinical Relevancy and Immediacy Indices, were defined to capture this impact/relevance to surgical practice. Of the five surgical subspecialties, gynecology references were >5-fold more likely to get cited, had a larger fraction of higher quality evidence incorporated, and demonstrated more success with POC adoption of practice guidelines. We also quantified the cost of translating research to surgical practice per specialty and generated maps that highlight institutions successful in translating research to the POC. The higher expenditure of National Institutes of Health funding in gynecology may reflect the cost of higher quality research per citation. CONCLUSIONS: Understanding translational latency is the first step to exposing blocks that slow the adoption of research into everyday surgical practice and to understanding why increasing research funding has not yielded comparative gains in surgical outcomes. Our approach reveals new methods to monitoring the efficiency of research investments and evaluating the efficacy of policies influencing the translation of research to surgical practice.

Facilitators and Barriers in the Implementation and Adoption of Patient-Reported Outcomes Measurements in Daily Practice.

OBJECTIVES: At the Erasmus Medical Center, patient-reported outcomes measures (PROMs) are implemented on a hospital-wide scale. However, less than half of the patients and healthcare professionals (HCPs) use these PROMs. Therefore, this study aimed to investigate facilitators and barriers for adoption of PROMs to develop guidance around implementation. METHODS: A mixed-methods study with a combination of interviews and focus groups and questionnaires was conducted, involving patients, both PROM nonresponders and PROM responders, HCPs, and medicine students and nurse specialists in training (hereafter "students"). Interview transcripts were subjected to thematic content analysis. Subsequently, questionnaires were developed and presented to all stakeholders to validate the findings. Finally, identified themes and implementation recommendations were presented in a final questionnaire to the Value-Based Healthcare Erasmus Medical Center expert group to prioritize findings. RESULTS: Interviews were conducted with 15 patients, 14 HCPs and 4 students, and 2 focus groups with 5 students. The questionnaire was completed by 370 of 999 responders (37.0%), 173 of 1395 nonresponders (12.5%), and 44 of 194 HCPs (22.7%), and 40 students were reached via an open link. The identified facilitators and barriers were grouped into 4 overarching themes: training on PROMs at different levels in the education of (future) HCPs, motivate and reduce the burden for the HCP, implement generic and disease-specific PROMs simultaneously, and motivate, activate, and reduce the patient burden. CONCLUSIONS: Providing end users with digital tools, implementation support, and a clear hospital-wide vision is important, yet this does not guarantee successful adoption of PROMs. Successful adoption necessitates ongoing efforts to engage, motivate, and train end users.