Tackling Brain and Muscle Dysfunction in Acute Respiratory Distress Syndrome Survivors: NHLBI Workshop Report.

Acute respiratory distress syndrome (ARDS) is associated with long-term impairments in brain and muscle function that significantly impact the quality of life of those who survive the acute illness. The mechanisms underlying these impairments are not yet well understood, and evidence-based interventions to minimize the burden on patients remain unproved. The NHLBI of the NIH assembled a workshop in April 2023 to review the state of the science regarding ARDS-associated brain and muscle dysfunction, to identify gaps in current knowledge, and to determine priorities for future investigation. The workshop included presentations by scientific leaders across the translational science spectrum and was open to the public as well as the scientific community. This report describes the themes discussed at the workshop as well as recommendations to advance the field toward the goal of improving the health and well-being of ARDS survivors.

Leveraging Implementation Science to Advance Environmental Justice Research and Achieve Health Equity through Neighborhood and Policy Interventions.

Environmental justice research is increasingly focused on community-engaged, participatory investigations that test interventions to improve health. Such research is primed for the use of implementation science-informed approaches to optimize the uptake and use of interventions proven to be effective. This review identifies synergies between implementation science and environmental justice with the goal of advancing both disciplines. Specifically, the article synthesizes the literature on neighborhood-, community-, and policy-level interventions in environmental health that address underlying structural determinants (e.g., structural racism) and social determinants of health. Opportunities to facilitate and scale the equitable implementation of evidence-based environmental health interventions are highlighted, using urban greening as an illustrative example. An environmental justice-focused version of the implementation science subway is provided, which highlights these principles: Remember and Reflect, Restore and Reclaim, and Reinvest. The review concludes with existing gaps and future directions to advance the science of implementation to promote environmental justice.

Identifying Major Barriers to Home Dialysis (The IM-HOME Study): Findings From a National Survey of Patients, Care Partners, and Providers.

RATIONALE & OBJECTIVE: Developing strategies to improve home dialysis use requires a comprehensive understanding of barriers. We sought to identify the most important barriers to home dialysis use from the perspective of patients, care partners, and providers. STUDY DESIGN: This is a convergent parallel mixed-methods study. SETTING & PARTICIPANTS: We convened a seven-member advisory board of patients, care partners, and providers who collectively developed lists of major patient/care partner-perceived barriers and provider-perceived barriers to home dialysis. We used these lists to develop a survey that was distributed to patients, care partners, and providers-through the American Association of Kidney Patients and the National Kidney Foundation. The surveys asked participants to: 1) rank their top three major barriers (quantitative); and 2) describe barriers to home dialysis (qualitative). ANALYTICAL APPROACH: We compiled a list of the top three patient/care partner-perceived and top three provider-perceived barriers (quantitative) and conducted a directed content analysis of open-ended survey responses (qualitative). RESULTS: There were 522 complete responses (233 providers; 289 patients/care partners). The top three patient/care partner-perceived barriers were: fear of performing home dialysis; lack of space; and the need for home-based support. The top three provider-perceived barriers were: poor patient education; limited mechanisms for home-based support staff, mental health, and education; and lack of experienced staff. We identified nine themes through qualitative analysis: limited education; financial disincentives; limited resources; high burden of care; built environment/structure of care delivery that favor in-center hemodialysis; fear and isolation; perceptions of inequities in access to home dialysis; provider perspectives about patients; and patient/provider resiliency. LIMITATIONS: This was an online survey that is subject to non-response bias. CONCLUSIONS: The top three barriers to home dialysis for patient/care partners and providers incompletely overlap, suggesting the need for diverse strategies that simultaneously address patient-perceived barriers at home and provider-perceived barriers in the clinic.

Artificial Intelligence in Anesthetic Care: A Survey of Physician Anesthesiologists.

BACKGROUND: This study explored physician anesthesiologists' knowledge, exposure, and perceptions of artificial intelligence (AI) and their associations with attitudes and expectations regarding its use in clinical practice. The findings highlight the importance of understanding anesthesiologists' perspectives for the successful integration of AI into anesthesiology, as AI has the potential to revolutionize the field. METHODS: A cross-sectional survey of 27,056 US physician anesthesiologists was conducted to assess their knowledge, perceptions, and expectations regarding the use of AI in clinical practice. The primary outcome measured was attitude toward the use of AI in clinical practice, with scores of 4 or 5 on a 5-point Likert scale indicating positive attitudes. The anticipated impact of AI on various aspects of professional work was measured using a 3-point Likert scale. Logistic regression was used to explore the relationship between participant responses and attitudes toward the use of AI in clinical practice. RESULTS: A 2021 survey of 27,056 US physician anesthesiologists received 1086 responses (4% response rate). Most respondents were male (71%), active clinicians (93%) under 45 (34%). A majority of anesthesiologists (61%) had some knowledge of AI and 48% had a positive attitude toward using AI in clinical practice. While most respondents believed that AI can improve health care efficiency (79%), timeliness (75%), and effectiveness (69%), they are concerned that its integration in anesthesiology could lead to a decreased demand for anesthesiologists (45%) and decreased earnings (45%). Within a decade, respondents expected AI would outperform them in predicting adverse perioperative events (83%), formulating pain management plans (67%), and conducting airway exams (45%). The absence of algorithmic transparency (60%), an ambiguous environment regarding malpractice (47%), and the possibility of medical errors (47%) were cited as significant barriers to the use of AI in clinical practice. Respondents indicated that their motivation to use AI in clinical practice stemmed from its potential to enhance patient outcomes (81%), lower health care expenditures (54%), reduce bias (55%), and boost productivity (53%). Variables associated with positive attitudes toward AI use in clinical practice included male gender (odds ratio [OR], 1.7; P < .001), 20+ years of experience (OR, 1.8; P < .01), higher AI knowledge (OR, 2.3; P = .01), and greater AI openness (OR, 10.6; P < .01). Anxiety about future earnings was associated with negative attitudes toward AI use in clinical practice (OR, 0.54; P < .01). CONCLUSIONS: Understanding anesthesiologists' perspectives on AI is essential for the effective integration of AI into anesthesiology, as AI has the potential to revolutionize the field.

Gender and Pathways to Leadership in Academic Anesthesiology: A Qualitative Content Analysis of US Chairpersons' Curricula Vitae.

BACKGROUND: Women are underrepresented in medicine and academic anesthesiology, and especially in leadership positions. We sought to characterize career achievement milestones of female versus male academic anesthesiology chairs to understand possible gender-related differences in pathways to leadership. METHODS: We conducted a retrospective observational cross-sectional analysis. In November 2019, curricula vitae (CVs) were requested from then-current members of the US Association of Academic Anesthesiology Chairs. Data reflecting accomplishments up to the time of chair appointment were systematically extracted from CVs and analyzed using a mixed methods approach with qualitative content analysis supplemented by descriptive statistics and bivariate statistical testing. Missing data were not imputed. RESULTS: Seventy-two CVs were received from eligible individuals (response rate 67.3%). The respondent sample was 12.5% women (n = 9), 87.5% men (n = 63), and no transgender or nonbinary people; this is similar to the known gender balance in anesthesiology chairs in the United States. No statistically significant differences in objective markers of academic achievement at the time of chair appointment were evident for female versus male chairs, including time elapsed between the first faculty appointment and assumption of the chair role (median 25 vs 18 years, P = .06), number of publications at the time the chair was assumed (101 vs 69, P = .28), or proportion who had ever held a National Institutes of Health (NIH) grant as principal investigator (44.4% vs 25.4%, 0.25). Four phenotypes of career paths were discernible in the data: the clinician-administrator, the educator, the investigator, and the well-rounded scholar; these did not differ by gender. CONCLUSIONS: Female chairpersons who were members of the Association of Academic Anesthesiology Chairs in the United States demonstrated similar patterns of academic achievement as compared to male chairpersons at the time the position of chair was assumed, suggesting that they were equally qualified for the role as compared to men. Four patterns of career achievements were evident in the chairperson group, suggesting multiple viable pathways to this leadership position.

Why Epidemiology Is Incomplete Without Qualitative and Mixed Methods.

Epidemiology has traditionally used quantitative approaches to characterizing disease prevalence and studying the effects of medical and public health interventions. Despite the power of such methods, they leave important gaps in understanding population health that can be addressed using qualitative and mixed methods. In this commentary, I describe philosophical differences in qualitative and quantitative approaches to research and explain how they can be used together to strengthen epidemiologic inquiry.

The Reviewer Academy of the Society of Critical Care Medicine: Key Principles and Strategic Plan.

The Society of Critical Care Medicine (SCCM) Reviewer Academy seeks to train and establish a community of trusted, reliable, and skilled peer reviewers with diverse backgrounds and interests to promote high-quality reviews for each of the SCCM journals. Goals of the Academy include building accessible resources to highlight qualities of excellent manuscript reviews; educating and mentoring a diverse group of healthcare professionals; and establishing and upholding standards for insightful and informative reviews. This manuscript will map the mission of the Reviewer Academy with a succinct summary of the importance of peer review, process of reviewing a manuscript, and the expected ethical standards of reviewers. We will equip readers to target concise, thoughtful feedback as peer reviewers, advance their understanding of the editorial process and inspire readers to integrate medical journalism into diverse professional careers.

The Anesthesiology Physician-Scientist Pipeline: Current Status and Recommendations for Future Growth-An Initiative of the Anesthesia Research Council.

The limited number and diversity of resident physicians pursuing careers as physician-scientists in medicine has been a concern for many decades. The Anesthesia Research Council aimed to address the status of the anesthesiology physician-scientist pipeline, benchmarked against other medical specialties, and to develop strategic recommendations to sustain and expand the number and diversity of anesthesiology physician-scientists. The working group analyzed data from the Association of American Medical Colleges and the National Resident Matching Program to characterize the diversity and number of research-oriented residents from US and international allopathic medical schools entering 11 medical specialties from 2009 to 2019. Two surveys were developed to assess the research culture of anesthesiology departments. National Institutes of Health (NIH) funding information awarded to anesthesiology physician-scientists and departments was collected from NIH RePORTER and the Blue Ridge Medical Institute. Anesthesiology ranked eighth to tenth place of 11 medical specialties in the percent of "research-oriented" entering residents, defined as those with advanced degrees (Master's or PhDs) in addition to the MD degree or having published at least 3 research publications before residency. Anesthesiology ranked eighth of 11 specialties in the percent of entering residents who were women but ranked fourth of 11 specialties in the percent of entering residents who self-identified as belonging to an underrepresented group in medicine. There has been a 72% increase in both the total NIH funding awarded to anesthesiology departments and the number of NIH K-series mentored training grants (eg, K08 and K23) awarded to anesthesiology physician-scientists between 2015 and 2020. Recommendations for expanding the size and diversity of the anesthesiology physician-scientist pipeline included (1) developing strategies to increase the number of research intensive anesthesiology departments; (2) unifying the diverse programs among academic anesthesiology foundations and societies that seek to grow research in the specialty; (3) adjusting American Society of Anesthesiologists metrics of success to include the number of anesthesiology physician-scientists with extramural research support; (4) increasing the number of mentored awards from Foundation of Anesthesia Education and Research (FAER) and International Anesthesia Research Society (IARS); (5) supporting an organized and concerted effort to inform research-oriented medical students of the diverse research opportunities within anesthesiology should include the specialty being represented at the annual meetings of Medical Scientist Training Program (MSTP) students and the American Physician Scientist Association, as well as in institutional MSTP programs. The medical specialty of anesthesiology is defined by new discoveries and contributions to perioperative medicine which will only be sustained by a robust pipeline of anesthesiology physician-scientists.

Racial and Ethnic Patient Care Disparities in Anesthesiology: History, Current State, and a Way Forward.

Disparities in patient care and outcomes are well-documented in medicine but have received comparatively less attention in anesthesiology. Those disparities linked to racial and ethnic identity are pervasive, with compelling evidence in operative anesthesiology, obstetric anesthesiology, pain medicine, and critical care. This narrative review presents an overview of disparities in perioperative patient care that is grounded in historical context followed by potential solutions for mitigating disparities and inequities.

Does Masked Interviewing Encourage Holistic Review in Residency Selection? A Mixed-Methods Study.

Problem: Medical educators increasingly champion holistic review. However, in U.S. residency selection, holistic review has been difficult to implement, hindered by a reliance on standardized academic criteria such as board scores. Masking faculty interviewers to applicants' academic files is a potential means of promoting holistic residency selection by increasing the interview's ability to make a discrete contribution to evaluation. However, little research has directly analyzed the effects of masking on how residency selection committees evaluate applicants. This mixed-methods study examined how masking interviews altered residency selection in an anesthesiology program at a large U.S. academic medical center. Intervention: During the 2019-2020 residency selection season in the University of Pennsylvania's Department of Anesthesiology & Critical Care, we masked interviewers to the major academic components of candidates' application files (board scores, transcripts, letters) on approximately half of interview days. The intent of the masking intervention was to mitigate the tendency of interviewers to form predispositions about candidates based on standardized academic criteria and thereby allow the interview to make a more independent contribution to candidate evaluation. Context: Our examination of the masking intervention used a concurrent, partially mixed, equal-status mixed-methods design guided by a pragmatist approach. We audio-recorded selection committee meetings and qualitatively analyzed them to explore how masking affected the process of candidate evaluation. We also collected independent candidate ratings from interviewers and consensus committee ratings and statistically compared ratings of candidates interviewed on masked days to ratings from conventional days. Impact: In conventional committee meetings, interviewers focused on how to reconcile academic metrics and interviews, and their evaluations of interviews were framed according to predispositions about candidates formed through perusal of application files. In masked meetings, members instead spent considerable effort evaluating candidates' "fit" and whether they came off as tactful. Masked interviewers gave halting opinions of candidates and sometimes pushed for committee leaders to reveal academic information, leading to masking breaches. Higher USMLE Step 1 score and higher medical school ranking were statistically associated with more favorable consensus rating. We found no significant differences in rating outcomes between masked and conventional interview days. Lessons learned: Elimination of academic metrics during the residency interview phase does not straightforwardly promote holistic review. While critical reflection among medical educators about the fairness and utility of such metrics has been productive, research and intervention should focus on the more proximate topic of how programs apply academic and other criteria to evaluate applicants.

Does standardisation improve post-operative anaesthesia handoffs? Meta-analyses on provider, patient, organisational, and handoff outcomes.

Anaesthesia handoffs are associated with negative outcomes (e.g. inappropriate treatments, post-operative complications, and in-hospital mortality). To minimise these adverse outcomes, federal bodies (e.g. Joint Commission) have mandated handoff standardisation. Due to the proliferation of handoff interventions and research, there is a need to meta-analyze anaesthesia handoffs. Therefore, we performed meta-analyses on the provider, patient, organisational, and handoff outcomes related to post-operative anaesthesia handoff protocols. We meta-analysed 41 articles with post-operative anaesthesia handoffs that implemented a standardised handoff protocol. Compared to no standardisation, a standardised post-operative anaesthesia handoff changed provider outcomes with an OR of 4.03 (95% CI 3.20-5.08), patient outcomes with an OR of 1.49 (95% CI 1.32-1.69), organisational outcomes with an OR of 4.25 (95% CI 2.51-7.19), handoff outcomes with an OR of 8.52 (95% CI 7.05-10.31). Our meta-analyses demonstrate that standardised post-operative anaesthesia handoffs altered patient, provider, organisational, and handoff outcomes. Practitioner Summary: We conducted meta-analyses to assess the effects of post-operative anaesthesia handoff standardisation on provider, patient, organisational, and handoff outcomes. Our findings suggest that standardised post-operative anaesthesia handoffs changed all listed outcomes in a positive direction. We discuss the implications of these findings as well as notable limitations in this literature base.

Checklists and cognitive aids: underutilized and under-researched tools to promote patient safety and optimize clinician performance.

PURPOSE OF REVIEW: Checklists and other cognitive aids serve multiple purposes in the peri-operative setting and have become nearly ubiquitous in healthcare. This review lays out the evidence for their use, shortcomings and pitfalls to be aware of, and how technology and innovation may improve checklist and cognitive aid relevance and usability. RECENT FINDINGS: It has been difficult to show a direct link between the use of checklists alone and patient outcomes, but simulation studies have repeatedly demonstrated an association between checklist or cognitive aid use and improved performance. When implemented as part of a bundle of interventions, checklists likely have a positive impact, but the benefit of checklists and other cognitive aids may be both context- and user dependent. Advances in technology and automation demonstrate promise, but usability, design, and implementation research in this area are necessary to maximize effectiveness. SUMMARY: Cognitive aids like checklists are powerful tools in the perioperative and critical care setting. Further research and innovation may elevate what is possible by improving the usability and relevance of these tools, possibly translating into improved patient outcomes.

Choosing Wisely For Critical Care: The Next Five.

OBJECTIVES: To formulate new "Choosing Wisely" for Critical Care recommendations that identify best practices to avoid waste and promote value while providing critical care. DATA SOURCES: Semistructured narrative literature review and quantitative survey assessments. STUDY SELECTION: English language publications that examined critical care practices in relation to reducing cost or waste. DATA EXTRACTION: Practices assessed to add no value to critical care were grouped by category. Taskforce assessment, modified Delphi consensus building, and quantitative survey analysis identified eight novel recommendations to avoid wasteful critical care practices. These were submitted to the Society of Critical Care Medicine membership for evaluation and ranking. DATA SYNTHESIS: Results from the quantitative Society of Critical Care Medicine membership survey identified the top scoring five of eight recommendations. These five highest ranked recommendations established Society of Critical Care Medicine's Next Five "Choosing" Wisely for Critical Care practices. CONCLUSIONS: Five new recommendations to reduce waste and enhance value in the practice of critical care address invasive devices, proactive liberation from mechanical ventilation, antibiotic stewardship, early mobilization, and providing goal-concordant care. These recommendations supplement the initial critical care recommendations from the "Choosing Wisely" campaign.

A Partially Structured Postoperative Handoff Protocol Improves Communication in 2 Mixed Surgical Intensive Care Units: Findings From the Handoffs and Transitions in Critical Care (HATRICC) Prospective Cohort Study.

OBJECTIVE: To assess the effectiveness of standardizing operating room (OR) to intensive care unit (ICU) handoffs in a mixed surgical population. SUMMARY OF BACKGROUND DATA: Standardizing OR to ICU handoffs improves information transfer after cardiac surgery, but there is limited evidence in other surgical contexts. METHODS: This prospective interventional cohort study (NCT02267174) was conducted in 2 surgical ICUs in 2 affiliated hospitals. From 2014 to 2016, we developed, implemented, and assessed the effectiveness of a new standardized handoff protocol requiring bedside clinician communication using an information template. The primary study outcome was number of information omissions out of 13 possible topics, recorded by trained observers. Data were analyzed using descriptive statistics, bivariate analyses, and multivariable regression. RESULTS: We observed 165 patient transfers (68 pre-, 97 postintervention). Before standardization, observed handoffs had a mean 4.7 ±â€Š2.9 information omissions each. After standardization, information omissions decreased 21.3% to 3.7 ±â€Š1.9 (P = 0.023). In a pre-specified subanalysis, information omissions for new ICU patients decreased 36.2% from 4.7 ±â€Š3.1 to 3.0 ±â€Š1.6 (P = 0.008, interaction term P = 0.008). The decrement in information omissions was linearly associated with the number of protocol steps followed (P < 0.001). After controlling for patient stability, the intervention was still associated with reduced omissions. Handoff duration increased after standardization from 4.1 ±â€Š3.3 to 8.0 ±â€Š3.9 minutes (P < 0.001). ICU mortality and length of stay did not change postimplementation. CONCLUSION: Standardizing OR to ICU handoffs significantly improved information exchange in 2 mixed surgical ICUs, with a concomitant increase in handoff duration. Additional research is needed to identify barriers to and facilitators of handoff protocol adherence.

Nephrology in the Academic Intensive Care Unit: A Qualitative Study of Interdisciplinary Collaboration.

RATIONALE & OBJECTIVE: Collaboration between nephrology consultants and intensive care unit (ICU) teams is important in light of the high incidence of acute kidney injury in today's ICUs. Although there is considerable debate about how nephrology consultants and ICU teams should collaborate, communicative dynamics between the 2 parties remain poorly understood. This article describes interactions between nephrology consultants and ICU teams in the academic medical setting. STUDY DESIGN: Focused ethnography using semi-structured interviews and participant observation. SETTING & PARTICIPANTS: Purposive sampling was used to enroll nephrologists, nephrology fellows, and ICU practitioners across several roles collaborating in 3 ICUs (a medical ICU, a surgical ICU, and a cardiothoracic surgical ICU) of a large urban US academic medical center. Participant observation (150 hours) and semi-structured interviews (35) continued until theoretical saturation. ANALYTICAL APPROACH: Interview and fieldnote transcripts were coded in an iterative team-based process. Explanation was developed using an abductive approach. RESULTS: Nephrology consultants and surgical ICU teams exhibited discordant preferences about the aggressiveness of renal replacement therapy based on different understandings of physiology, goals of care, and acuity. Collaborative difficulties resulting from this discordance led to nephrology consultants often serving as dialysis proceduralists rather than diagnosticians in surgical ICUs and to consultants sometimes choosing not to express disagreements about clinical care because of the belief that doing so would not lead to changes in the course of care. LIMITATIONS: Aspects of this single-site study of an academic medical center may not be generalizable to other clinical settings and samples. Surgical team perspectives would provide further detail about nephrology consultation in surgical ICUs. The effects of findings on patient care were not examined. CONCLUSIONS: Differences in approach between internal medicine-trained nephrologists and anesthesia- and surgery-trained intensivists and surgeons led to collaborative difficulties in surgical ICUs. These findings stress the need for medical teamwork research and intervention to address issues stemming from disciplinary siloing rooted in long-term socialization to different disciplinary practices.

Fostering belonging in academic anaesthesiology: faculty and department chair perspectives on supporting women anaesthesiologists.

An increasing number of global initiatives aim to address the disconnection between the increasing number of women entering medicine and the persistence of gender imbalance in the physician anaesthesiologist workforce. This commentary complements the global movement's efforts to increase women's representation in academic anaesthesiology by presenting considerations for fostering inclusion for women in academic anaesthesiology from both the faculty and departmental leadership perspectives in a US academic anaesthesiology department.

The role of the interview in residency selection: A mixed-methods study.

CONTEXT: Residency programmes invest considerable time and resources in candidate interviews as a result of their perceived ability to reveal important social traits. However, studies examining the ability of interviews to predict resident performance have shown mixed findings, and the role of the interview in candidate evaluation remains unclear. This mixed-methods study, conducted in an anaesthesiology residency programme at a large academic medical centre, examined how interviews contributed to candidate assessment and whether the addition of behavioural questions to interviews altered their role in the evaluation process. METHODS: During the 2018-2019 residency selection season in the Department of Anesthesiology and Critical Care at the University of Pennsylvania, independent ratings for each interviewee were collected from faculty interviewers. Consensus ratings subsequently established by committee were also collected. Committee meetings were audiorecorded and transcribed for qualitative analysis. Behavioural questions were integrated into half of interview days. Ratings of candidates interviewed on behavioural question days were compared statistically with those of candidates interviewed on non-behavioural question days. RESULTS: Qualitative analysis showed that interviewers heavily emphasised candidates' application files in evaluating the interviews. Interviewers focused on candidates' academic records and favoured candidates whose interview behaviours were consistent with their applications and whose applications demonstrated similarities to interviewers' traits. The addition of behavioural questions demonstrated little ability to alter these dynamics. Quantitatively, there were no significant differences in candidate rating outcomes between behavioural and non-behavioural interviewing days, whereas a higher medical school rating and higher score on the United States Medical Licensing Examination Step 1 were associated with a more favourable consensus rating. CONCLUSIONS: Residency candidates' application files predisposed interviewers' experience and evaluation of interviews, preventing the interviews from providing discrete assessments of interpersonal qualities, even when behavioural questions were included. In the continued effort to perform well-rounded assessments of residency candidates, further research and reflection on the role of interviewing in evaluation are necessary.

Anesthesiologist Specialization and Use of General Anesthesia for Cesarean Delivery.

BACKGROUND: Guidelines for obstetric anesthesia recommend neuraxial anesthesia (i.e., spinal or epidural block) for cesarean delivery in most patients. Little is known about the association of anesthesiologist specialization in obstetric anesthesia with a patient's likelihood of receiving general anesthesia. The authors conducted a retrospective cohort study to compare utilization of general anesthesia for cesarean delivery among patients treated by generalist versus obstetric-specialized anesthesiologists. METHODS: The authors studied patients undergoing cesarean delivery for live singleton pregnancies from 2013 through 2017 at one academic medical center. Data were extracted from the electronic medical record. The authors estimated the association of anesthesiologist specialization in obstetric anesthesia with the odds of receiving general anesthesia for cesarean delivery. RESULTS: Of the cesarean deliveries in our sample, 2,649 of 4,052 (65.4%) were performed by obstetric-specialized anesthesiologists, and 1,403 of 4,052 (34.6%) by generalists. Use of general anesthesia differed for patients treated by specialists and generalists (7.3% vs. 12.1%; P < 0.001). After adjustment, the odds of receiving general anesthesia were lower among patients treated by obstetric-specialized anesthesiologists among all patients (adjusted odds ratio, 0.71; 95% CI, 0.55 to 0.92; P = 0.011), and in a subgroup analysis restricted to urgent or emergent cesarean deliveries (adjusted odds ratio, 0.75; 95% CI, 0.56 to 0.99; P = 0.049). There was no association between provider specialization and the odds of receiving general anesthesia in a subgroup analysis restricted to evening or weekend deliveries (adjusted odds ratio, 0.76; 95% CI, 0.56 to 1.03; P = 0.085). CONCLUSIONS: Treatment by an obstetric anesthesiologist was associated with lower odds of receiving general anesthesia for cesarean delivery; however, this finding did not persist in a subgroup analysis restricted to evening and weekend deliveries.

Scoping implementation science for the beginner: locating yourself on the "subway line" of translational research.

BACKGROUND: Beginners to the discipline of implementation science often struggle to determine whether their research questions "count" as implementation science. MAIN TEXT: In this paper, three implementation scientists share a heuristic tool to help investigators determine where their research questions fall in the translational research continuum. They use a "subway model" that envisions a journey to implementation research with stops along the way at efficacy and effectiveness research. CONCLUSIONS: A series of structured questions about intervention efficacy, effectiveness, and implementation can help guide researchers to select research questions and appropriate study designs along the spectrum of translational research.