Building to learn: Information technology innovations to enable rapid pragmatic evaluation in a learning health system.

Background: Learning health systems (LHSs) iteratively generate evidence that can be implemented into practice to improve care and produce generalizable knowledge. Pragmatic clinical trials fit well within LHSs as they combine real-world data and experiences with a degree of methodological rigor which supports generalizability. Objectives: We established a pragmatic clinical trial unit ("RapidEval") to support the development of an LHS. To further advance the field of LHS, we sought to further characterize the role of health information technology (HIT), including innovative solutions and challenges that occur, to improve LHS project delivery. Methods: During the period from December 2021 to February 2023, eight projects were selected out of 51 applications to the RapidEval program, of which five were implemented, one is currently in pilot testing, and two are in planning. We evaluated pre-study planning, implementation, analysis, and study closure approaches across all RapidEval initiatives to summarize approaches across studies and identify key innovations and learnings by gathering data from study investigators, quality staff, and IT staff, as well as RapidEval staff and leadership. Implementation Results: Implementation approaches spanned a range of HIT capabilities including interruptive alerts, clinical decision support integrated into order systems, patient navigators, embedded micro-education, targeted outpatient hand-off documentation, and patient communication. Study approaches include pre-post with time-concordant controls (1), randomized stepped-wedge (1), cluster randomized across providers (1) and location (3), and simple patient level randomization (2). Conclusions: Study selection, design, deployment, data collection, and analysis required close collaboration between data analysts, informaticists, and the RapidEval team.

Single-Center Experiences: A Comparison of Intracorporeal and Extracorporeal Anastomosis Outcomes in Right Hemicolectomy.

Background Anastomosis formed in minimally invasive laparoscopic right hemicolectomy (LRH) may be achieved intra-corporeally (ICA) or extra-corporeally (ECA). This study compared the return of bowel function and other associated early patient outcomes and morbidity rates after an ICA or ECA in LRH. Methodology The study conducted a single-center retrospective cohort study of elective LRH from January 2021 to September 2023. Patient demographics, surgical techniques, and outcomes were analyzed using IBM SPSS Statistics for Windows, Version 29.0 (IBM Corp., Armonk, NY). Results Ninety participants underwent LRH, and the anastomotic type was evenly distributed - with male patients comprising 53 (58.9%) of the total. The mean age was 64 (standard deviation [SD] ±16.8) years, and the median body mass index (BMI) was 27.0 (interquartile range [IQR] = 7.8). The mean follow-up period was 5.1 (SD ± 6.0) months. Univariate analysis showed that ICA had a shorter time for return of bowel function (P < 0.01). Additionally, ICA was associated with lower pain scores (P < 0.01), low morbidity (P = 0.02), and shorter hospital stays (P = 0.01). When comparing ICA to ECA, no significant difference was observed for procedure duration (P = 0.13), anastomotic leak (AL, P = 1.00), surgical-site infections (P = 0.36), lymph node yield (P = 0.26), and any-cause mortality. Multivariate logistic regression, controlling for statistically insignificant confounding factors, revealed that ECA was significantly and independently associated with increased time to first flatus (odds ratio [OR] 2.3, P = 0.01) and higher average postoperative pain (OR 1.5, P = 0.02) compared to ICA. Conclusions This single-center experience showed that ICA is associated with a quicker return to normal bowel function and low morbidity outcomes. ICA participants were positively associated with clinically relevant and health economics outcomes of shorter hospital stays without significantly adding to the procedure's duration times or compromising principles of oncological resection yield.

Post COVID-19 clinical manifestations and its risk factors among patients in a Northern District in Kerala, India.

Background: The novel virus SARS-CoV-2 has caused a pandemic of coronavirus disease 2019 (COVID-19). There is emerging evidence of post-COVID-19 manifestations among patients who sustain acute COVID-19. Most studies report fatigue, dyspnea, and myalgia as the common symptoms; however, currently, there is limited knowledge of these post-COVID manifestations and their risk factors, especially in India. Methods: A descriptive cross-sectional study was conducted among patients who had attended the district post-COVID clinic, Wayanad district, Kerala, from October 2020 to June 2021. Data were collected by direct/telephonic patient interviews and from their existing case records, using a pretested semi-structured proforma. Results: The sample size was 667. The mean age of the study population was 45 years (standard deviation [SD]: 14.55). The majority of the population presented with dyspnea (48%), fatigue (32%), and cough (25.6%). Mental health problems were also reported in 6% of participants. The respiratory system was commonly involved (61.2%). Around one-third of the patients (36.4%) had dyspnea on exertion and 11.8% had dyspnea at rest. One-fifth of the population reported aggravation of pre-existing co-morbidity and half of the respondents had persistence of at least one symptom after 6 months. There exist statistically significant associations between identified risk factors, especially gender, increasing age, the severity of COVID-19 infection, history of tobacco/alcohol use, and co-morbidities with outcomes. Conclusion: As post-COVID syndrome is a multisystem disease, integrated rehabilitation is required with targeted intervention for survivors based on their symptoms and needs.

Acalabrutinib Versus Investigator's Choice in Relapsed/Refractory Chronic Lymphocytic Leukemia: Final ASCEND Trial Results.

Acalabrutinib is a Bruton tyrosine kinase inhibitor approved for patients with chronic lymphocytic leukemia (CLL). ASCEND is the pivotal phase 3 study of acalabrutinib versus investigator's choice of idelalisib plus rituximab (IdR) or bendamustine plus rituximab (BR) in patients with relapsed/refractory (R/R) CLL. In the primary ASCEND analysis (median 16.1-month follow-up), acalabrutinib showed superior efficacy with an acceptable tolerability profile versus IdR/BR; here, we report final ~4 year follow-up results. Patients with R/R CLL received oral acalabrutinib 100 mg twice daily until progression or unacceptable toxicity, or investigator's choice of IdR or BR. A total of 310 patients (acalabrutinib, n = 155; IdR, n = 119; BR, n = 36) were enrolled. At median follow-up of 46.5 months (acalabrutinib) and 45.3 months (IdR/BR), acalabrutinib significantly prolonged investigator-assessed progression-free survival (PFS) versus IdR/BR (median, not reached [NR] vs 16.8 months; P < 0.001); 42-month PFS rates were 62% (acalabrutinib) versus 19% (IdR/BR). Median overall survival (OS) was NR (both arms); 42-month OS rates were 78% (acalabrutinib) versus 65% (IdR/BR). Adverse events led to drug discontinuation in 23%, 67%, and 17% of patients in the acalabrutinib, IdR, and BR arms, respectively. Events of clinical interest (acalabrutinib vs IdR/BR) included all-grade atrial fibrillation/flutter (8% vs 3%), all-grade hypertension (8% vs 5%), all-grade major hemorrhage (3% vs 3%), grade ≥3 infections (29% vs 29%), and second primary malignancies excluding nonmelanoma skin cancer (7% vs 2%). At ~4 years follow-up, acalabrutinib maintained favorable efficacy versus standard-of-care regimens and a consistent tolerability profile in patients with R/R CLL.

Extended chemothromboprophylaxis use in colorectal cancer surgery: a literature review.

Venous thromboembolism (VTE) is a potentially fatal condition associated with chronic morbidity. Patients undergoing colorectal cancer surgery have an especially high rate of VTE postoperatively. This risk continues to be elevated for up to 3 months after discharge, hence arises the question of extended thromboprophylaxis (ETP). The objective of this literature review is to summarize the current literature on ETP post colorectal cancer surgery. The results of five randomized controlled trials (RCT), several meta-analysis and five major guidelines are outlined and examined. The literature overwhelmingly supports the use of ETP in colorectal cancer surgery. The key limitation of the evidence base is the use of objective tests to diagnose VTE which also detect asymptomatic events. However, this surrogate marker has been reliably shown to correlate with symptomatic VTE. In other high-risk populations such as orthopaedic patients, similar research has led to the use of routinely prescribed ETP. There is evidence now that the use of ETP is cost-effective in reducing morbidity and mortality from VTE in colorectal cancer patients. However, despite strong evidence on the benefits of ETP in colorectal cancer surgery, it is not yet a routine clinical practice. Future research is required to determine the optimal duration of chemothromboprophylaxis in different subgroups within colorectal cancer patients such as patients with rectal cancer only or those undergoing minimally invasive surgery.

Hepatic metastasis of anal squamous cell carcinoma.

A 50-year-old woman was diagnosed with anal squamous cell carcinoma following a colonoscopy performed for positive test from the National Bowel Screening Programme. During the staging imaging, it was discovered to have a liver lesion that was atypical for metastasis. She underwent a segmental liver resection, and histopathology showed the liver lesion as a metastatic squamous cell carcinoma. We aim to discuss the incidence, presentation and management strategies for this rare hepatic metastasis of anal squamous cell carcinoma.

Cochlear implant outcomes in the very elderly.

PURPOSE: Managing hearing health in older adults has become a public health imperative, and cochlear implantation is now the standard of care for aural rehabilitation when hearing aids no longer provide sufficient benefit. The aim of our study was to compare speech performance in cochlear implant patients ≥80 years of age (Very Elderly) to a younger elderly cohort between ages 65-79 years (Less Elderly). MATERIALS AND METHODS: Data were collected from 53 patients ≥80 years of age and 92 patients age 65-79 years who underwent cochlear implantation by the senior author between April 1, 2017 and May 12, 2020. The primary outcome measure compared preoperative AzBio Quiet scores to 6-month post-activation AzBio Quiet results for both cohorts. RESULTS: Very Elderly patients progressed from an average AzBio Quiet score of 22% preoperatively to a score of 45% in the implanted ear at 6-months post-activation (p < 0.001) while the Less Elderly progressed from an average score of 27% preoperatively to 60% at 6-months (p < 0.001). Improvements in speech intelligibility were statistically significant within each of these cohorts (p < 0.001). Comparative statistics using independent samples t-test and evaluation of effect size using the Hedges' g statistic demonstrated a significant difference for average improvement of AzBio in quiet scores between groups with a medium effect size (p = 0.03, g = 0.35). However, when the very oldest patients (90+ years) were removed, the statistical difference between groups disappeared (p = 0.09). CONCLUSIONS: When assessing CI performance, those over age 65 are typically compared to younger patients; however, this manuscript further stratifies audiometric outcomes for older CI recipients in a single-surgeon, high-volume practice. Our data indicates that for speech intelligibility, patients between age 65-79 perform similarly to CI recipients 80-90 years of age and should not be dismissed as potential cochlear implant candidates.

The impact of sarcopenia on outcomes in patients with inflammatory bowel disease undergoing colorectal surgery.

INTRODUCTION: Sarcopenia is an independent predictor of poor post-operative outcomes following major surgery. Inflammatory bowel disease (IBD) consists of Crohn's disease (CD) and ulcerative colitis (UC), which are chronic inflammatory conditions involving the gastrointestinal system. Evidence demonstrates that up to 60% of patients with IBD have sarcopenia. Despite advances in medical management, more than 15% of patients with UC and 80% with CD eventually require surgical intervention. The primary aim of the study was to assess the impact of sarcopenia on post-operative anastomotic leak rates. METHODS: A retrospective cohort study of patients at Royal Perth Hospital who underwent major abdominal surgery for management of IBD between January 2010 and December 2020 was performed. Sarcopenia was assessed according to the skeletal muscle index at the level of the third lumbar vertebrae using the cut off 52.4 and 38.5 cm2 /m2 for men and women, respectively. RESULTS: A total of 147 patients were included. The prevalence of sarcopenia within the study population was 36.1%. Patients with sarcopenia were significantly taller (P = 0.025) and were more likely to be on pre-operative steroid medications (P = 0.045). There was no difference in the remaining baseline characteristics between sarcopenic and non-sarcopenic patients. Patients with sarcopenia were more likely to develop a post-operative anastomotic leak (OR:11.303, 95% CI, 1.53-83.51, P = 0.017), grade IV complications (OR:6.79, 95%CI:1.1-43.6, P = 0.044) and require total parenteral nutrition (TPN) (OR:3.212, 95% CI:1.3-8.1, P = 0.013). CONCLUSIONS: Sarcopenia significantly increases the risk of major post-operative complications for patients with IBD undergoing colorectal surgery.

Decentralized Cochlear Implant Programming Network Improves Access, Maintains Quality, and Engenders High Patient Satisfaction.

OBJECTIVE: Cochlear implants have become a powerful tool in managing patients with moderate to profound sensorineural hearing loss and lack of benefit from hearing aids. Currently, less than 10% of people who would benefit from a CI receive the treatment. This lack of access is multi-factorial yet largely due in part to an inadequate referral system. The purpose of the current study was to evaluate speech outcomes and patient satisfaction for adult cochlear implant (CI) recipients in a single-surgeon, high volume CI center that uses a decentralized network (DCN) of private practice programming audiologists. STUDY DESIGN: Retrospective case series. SETTING: Tertiary otology/neurotology practice. PATIENTS: Adult CI recipients implanted between April 2017 and August 2019. INTERVENTIONS: Surgical/rehabilitative. MAIN OUTCOME MEASURES: Speech outcomes (AzBio quiet) were evaluated 6-months post implantation. Patients were surveyed to determine satisfaction with programming services, surgical services, and CI benefit. RESULTS: The senior author (A.J.) performed 223 CI operations: 136 (61%) were programmed at the CI center and 84 (38%) at outside audiology clinics through a DCN. The 6-month speech outcomes (AzBio, quiet) revealed similar scores regardless of where programming services were received; CI center: 25% pre-op versus 55% post-op; DCN: 24% pre-op versus 59% post-op. Additionally, patients reported high-levels of satisfaction with programming services, surgical services, and CI benefit. CONCLUSION: A decentralized network of well-trained private practice audiologists who identify CI candidates and program their devices after surgery 1) improves patient access to cochlear implantation, 2) maintains excellent speech outcomes, and 3) engenders high levels of patient satisfaction.

Psychiatric phenotypes associated with hyperprolinemia: A systematic review.

Hyperprolinemia Type I and II are genetic metabolic disorders caused by disrupted proline degradation. It has been suggested that hyperprolinemia is associated with increased risk of developmental and mental disorders but detailed information on the psychiatric phenotype in hyperprolinemic patients is limited. Following PRISMA guidelines, we carried out a systematic review to clarify psychiatric phenotypes in patients with hyperprolinemia. We screened 1753 studies and included 35 for analysis, including 20 case reports and 15 case-control and cohort studies. From these studies, a common psychiatric phenotype is observed with a high prevalence of developmental delay, intellectual disability, autism spectrum disorders, and psychosis spectrum disorders. In most cases, a genetic cause of hyperprolinemia was known, these included mutations in the PRODH and ALDH4A1 genes and deletions of chromosome 22q11.2. No evidence for a biochemical phenotype-clinical phenotype correlation was found; that is, no association between higher proline levels and specific psychiatric phenotypes was observed. This suggests that genomic and environmental factors are likely to contribute to clinical outcomes. More studies are needed to clarify whether hyperprolinemia is a primary causal factor underlying the increased risk of developing psychiatric disorders seen in patients with hyperprolinemia, or whether hyperprolinemia and psychiatric disorders are both consequences of a shared underlying mechanism.

Cochlear Implant Outcomes in Elderly Recipients During the COVID-19 Pandemic.

OBJECTIVE: To evaluate the potential significance of social distancing and quarantine precautions for COVID-19 on speech outcomes, missed appointments, wear time, and exposure to various sound environments in the first 6 months following activation for elderly cochlear implant (CI) recipients. STUDY DESIGN: Retrospective cohort. SETTING: Tertiary private practice. PATIENTS: Fifty cochlear implant recipients ≥65 years were evaluated. A Control Group consisted of 26 patients implanted between November 2, 2018 and February 18, 2019 while the Pandemic Group included 24 patients implanted between November 1, 2019 and February 17, 2020. INTERVENTION: Rehabilitative. MAIN OUTCOME MEASURES: Preoperative and 6-month postoperative AzBio sentence scores in quiet were compared between groups along with the number of missed appointments as well as datalogged information regarding average CI wear time and average hours in various sound environments such as quiet, speech, and speech-in-noise. RESULTS: The Control Group averaged 36.5% improvement for AzBio in quiet scores while the Pandemic Group averaged only 17.2% improvement, a difference that was both statistically and clinically significant (p = 0.04; g = 0.64). Patients in the Pandemic Group were nearly twice as likely to miss CI programming appointments than the Control Group. The Pandemic Group wore their CI 1.2 less hours per day on average, and while the Pandemic Group spent similar times in quiet and speech environments to the Control Group, the Pandemic Group spent less time in speech with presence of background noise. CONCLUSIONS: While social distancing and quarantine measures are crucial to limiting spread of COVID-19, these precautions may have negatively impacted early speech performance for elderly cochlear implant recipients. Missed CI programming appointments, decreased sound processor wear time, and reduced exposure to complex listening environments such as speech in the presence of background noise were more common in the Pandemic Group than in the Control Group operated the year prior.

Early Osia® 2 bone conduction hearing implant experience: Nationwide controlled-market release data and single-center outcomes.

PURPOSE: Bone conduction hearing devices are a well-established treatment option for conductive or mixed hearing losses as well as single-sided deafness. The Osia® 2 System is an active osseointegrated device where a surgically implanted titanium fixture supports a newly developed piezoelectric actuator that is placed under the skin. METHODS: Nationwide data collected during a controlled-market release (CMR) of the Cochlear™ Osia® 2 System as well as outcomes at single, tertiary-level private practice Otology/Neurotology center were retrospectively reviewed. Key learnings from surgeons and audiologists are discussed. RESULTS: During the CMR period, 23 surgeons performed 44 operations on 43 recipients. The mean age of recipients was 44 years and mean surgery duration was 52 min. The most commonly used incision was postauricular but anterior to the device (78%). Five complications were observed during the CMR, none of which were device related. Twenty-one audiologists performed 33 Osia® 2 activations during the CMR. The mean age of this group was 47 years, and the mean duration of each activation appointment was 55 min. Single-center data at the authors' institution demonstrated an average additional PTA4 gain with the Osia® 2 patients of 9.6 dB compared to Baha Attract and 10.2 dB compared to Baha Connect. CONCLUSION: The Cochlear™ Osia® 2 System represents a significant advance in auditory osseointegrated implant technology. Digital piezoelectric stimulation delivers high power outputs, improves high frequency gain for optimal speech perception, and maintains safety while providing excellent patient satisfaction.

ED RAPID: A Novel Children's Hospital Direct Admission Process Utilizing the Emergency Department.

INTRODUCTION: Direct hospital admission of children without evaluation in the emergency department (ED) is common, but few guidelines exist to maximize safety by assessing patient stability. This report describes a novel approach to support patient safety. METHODS: An interdisciplinary children's hospital team developed a brief ED-based evaluation process called the ED Rapid Assessment of Patients Intended for Inpatient Disposition (ED RAPID). It entails a brief evaluation of vital signs and clinical stability by the ED attending physician and nurse. Children deemed stable are admitted to inpatient wards, whereas those requiring immediate intervention undergo full ED evaluation and disposition. We assessed outcomes for all children evaluated through this process from March 2013 through February 2015. RESULTS: During the study period, we identified 715 patients undergoing ED RAPID evaluation. Of these, we directly admitted 691 (96.4%) to the hospital ward after ED RAPID evaluation; median ED treatment time was 4.0 minutes. We transitioned 24 (3.4%) to full ED evaluation, 14 (2.0%) because a ward bed was unavailable, and 10 (1.4%) for clinical reasons identified in the evaluation. We admitted four of the 10 stopped (40% of stops, 0.6% of total) to an intensive care unit, and 6 (60% of stops, 0.8% of total) to the hospital ward after ED care. Eight children (1.1%) admitted to the hospital ward after ED RAPID evaluation required a transfer to an intensive care unit within 12 hours. CONCLUSION: The ED RAPID evaluation process for children directly admitted to the hospital was feasible and effective in this setting.

ASCEND: Phase III, Randomized Trial of Acalabrutinib Versus Idelalisib Plus Rituximab or Bendamustine Plus Rituximab in Relapsed or Refractory Chronic Lymphocytic Leukemia.

PURPOSE: Acalabrutinib, a highly selective, potent, Bruton tyrosine kinase inhibitor, was evaluated in this global, multicenter, randomized, open-label, phase III study in patients with relapsed/refractory (R/R) chronic lymphocytic leukemia (CLL). METHODS: Eligible patients, aged ≥ 18 years with R/R CLL, were randomly assigned 1:1 centrally and stratified by del(17p) status, Eastern Cooperative Oncology Group performance status score, and number of prior lines of therapy. Patients received acalabrutinib monotherapy or investigator's choice (idelalisib plus rituximab [I-R] or bendamustine plus rituximab [B-R]). The primary end point was progression-free survival (PFS) assessed by an independent review committee (IRC) in the intent-to-treat population. Key secondary end points included IRC-assessed overall response rate, overall survival, and safety. RESULTS: From February 21, 2017, to January 17, 2018, a total of 398 patients were assessed for eligibility; 310 patients were randomly assigned to acalabrutinib monotherapy (n = 155) or investigator's choice (n = 155; I-R, n = 119; B-R, n = 36). Patients had received a median of two prior therapies (range, 1-10). After a median follow-up of 16.1 months (range, 0.03-22.4 months), median PFS was significantly longer with acalabrutinib monotherapy (PFS not reached) compared with investigator's choice (16.5 months [95% CI, 14.0 to 17.1 months]; hazard ratio, 0.31 [95% CI, 0.20 to 0.49]; P < .0001). Estimated 12-month PFS was 88% (95% CI, 81% to 92%) for acalabrutinib and 68% (95% CI, 59% to 75%) for investigator's choice. Serious adverse events occurred in 29% of patients (n = 44 of 154) treated with acalabrutinib monotherapy, 56% (n = 66 of 118) with I-R, and 26% (n = 9 of 35) with B-R. Deaths occurred in 10% (n = 15 of 154), 11% (n = 13 of 118), and 14% (n = 5 of 35) of patients receiving acalabrutinib monotherapy, I-R, and B-R, respectively. CONCLUSION: Acalabrutinib significantly improved PFS compared with I-R or B-R and has an acceptable safety profile in patients with R/R CLL.

Hearing Preservation in Elderly Cochlear Implant Recipients.

OBJECTIVE: Examine hearing preservation rates in cochlear implant recipients 72 years and older. STUDY DESIGN: Retrospective case series. SETTING: Tertiary otology/neurotology practice. PATIENTS: Cochlear implant recipients 72 years and older who are candidates for hearing preservation and were implanted between April 2017 and June 2018 INTERVENTION:: Surgical/rehabilitative. MAIN OUTCOME MEASURES: Hearing was measured preoperatively and 6 months after cochlear implantation. RESULTS: Between April 2017 and June 2018, 125 cochlear implant operations were performed by the senior author (A.J.). Of these patients, 62 were over age 72 and comprehensive pre- and postoperative residual hearing data were available on 24 patients. Although several methods for calculating hearing preservation are evaluated, our practice has found that hearing preservation techniques should be used in all patients having even a single frequency ≤85 dB HL between 125 and 2000 Hz before surgery. Using this method, 60% of recipients had at least one postoperative threshold ≤85 dB HL, and more importantly, over 80% of these patients subsequently used an electroacoustic MAP. CONCLUSION: Despite concerns about cochlear fragility in elderly patients, preservation of residual hearing is feasible in cochlear implant recipients 72 years and older. This suggests that the vast majority of patients, including an elderly cohort, can benefit from soft surgery techniques.

The Admission Conference Call: A Novel Approach to Optimizing Pediatric Emergency Department to Admitting Floor Communication.

Optimizing information sharing at transfer of care between teams is an important target for the improvement of patient safety. Traditional emergency department (ED)-to-floor handoffs do not support a shared mental model between physicians, residents, and nurses. This report describes and evaluates acceptance of a novel process for coordinating physician and nursing handoff calls for patients being admitted to an inpatient floor from a children's hospital ED. METHODS: The Admission Conference Call (ACC) is a single conference call including attendings, residents, and nurses from the ED and inpatient teams, currently used for 29.8% of admissions from one ED. Physicians and nurses were surveyed to assess perception of its effects on patient care. RESULTS: A total of 653 ACCs were conducted during 2017. The survey was completed by 43 nurses and 89 physicians. Mean Likert scale findings were in favor of the process supporting safe patient care (4.5/5; standard deviation [SD], 0.6); none said it increased risk. Ratings favored the process improving interdisciplinary alignment (4.0/5; SD, 0.8) and the benefits outweighing the inconvenience (3.9/5; SD, 0.9). Respondents were neutral on the effect of the ACC on throughput time (3.0/5; SD, 1.0). Logistical concerns were expressed; mean satisfaction was 6.8/10 (SD, 2.1). Free text comments varied widely, from pride to frustration. CONCLUSION: The Admission Conference Call is a well-accepted alternative to a traditional multiple call process. Most participants believe it supports safe patient care. Further research is necessary to confirm measurable effects on patient outcomes, but this project provides encouragement to institutions considering innovative approaches.