management research journal articles

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Research management articles within Nature

Nature Index | 17 April 2024

Researchers want a ‘nutrition label’ for academic-paper facts

An ‘at a glance’ approach to publication details, such as journal acceptance rates and the number of peer reviewers, would promote transparency, scientists say.

• Dalmeet Singh Chawla

Spotlight | 17 April 2024

How young people benefit from Swiss apprenticeships

Computational biologist Jitao David Zhang says that the country’s vocational training programme teaches key work and life skills.

• Jitao David Zhang

Career Column | 08 April 2024

How we landed job interviews for professorships straight out of our PhD programmes

Follow these tips for an uber-organized (and successful) job hunt.

• Violeta Rodriguez
•  &  Qimin Liu

How two PhD students overcame the odds to snag tenure-track jobs

Between us, we got several offers to lead labs before we had finished our PhDs.

Correspondence | 02 April 2024

Adopt universal standards for study adaptation to boost health, education and social-science research

• Dragos Iliescu
•  &  Samuel Greiff

How can we make PhD training fit for the modern world? Broaden its philosophical foundations

• Ganesh Alagarasan

Allow researchers with caring responsibilities ‘promotion pauses’ to make research more equitable

• Daniel H. Lowenstein

Career Feature | 02 April 2024

Africa’s postdoc workforce is on the rise — but at what cost?

Will a growth in postdoctoral positions across Africa cause bottlenecks, replicating the career-progression challenges faced by scientists elsewhere?

• Linda Nordling

Where I Work | 01 April 2024

How I use tide gauges to develop geospatial maps

Geographer Muh Aris Marfai collects reference data for Indonesia’s coastal areas to prepare for the impacts of climate change.

• Nikki Forrester

Correspondence | 26 March 2024

Superconductivity case shows the need for zero tolerance of toxic lab culture

• Juan Pablo Fuenzalida Werner

Cuts to postgraduate funding threaten Brazilian science — again

• Marcus F. Oliveira
•  &  Adriane R. Todeschini

Career Q&A | 26 March 2024

The beauty of what science can do when urgently needed

Working amid New York City’s pandemic response inspired Nili Ostrov’s approach to expanding the list of organisms that can be used in synthetic biology and engineering.

• Katherine Bourzac

Nature Index | 25 March 2024

Larger or longer grants unlikely to push senior scientists towards high-risk, high-reward work

A survey of US professors suggests that broad changes to grant schemes might be needed to incentivize new approaches to research.

Nature Index | 20 March 2024

Is AI ready to mass-produce lay summaries of research articles?

A surge in tools that generate text is allowing research papers to be summarized for a broad audience, and in any language. But scientists caution that major challenges remain.

• Kamal Nahas

News | 19 March 2024

Is the Mars rover’s rock collection worth $11 billion?

Budget woes force NASA to reassess Perseverance’s travel plan, and seek cheaper ways of getting samples back to Earth.

• Alexandra Witze

Career Column | 15 March 2024

People, passion, publishable: an early-career researcher’s checklist for prioritizing projects

Stuck between several lines of research? Here’s how we decide which ones to pursue, say Elizabeth Tenney, Jacqueline Chen and McKenzie Preston.

• Elizabeth Tenney
• , Jacqueline M. Chen
•  &  McKenzie Preston

Nature Index | 13 March 2024

Peer-replication model aims to address science’s ‘reproducibility crisis’

Researchers propose that independent attempts to replicate results should complement conventional peer review.

• James Mitchell Crow

Career Column | 13 March 2024

Being a parent is a hidden scientific superpower — here’s why

My lack of time and fresh perspective has made me a better, more focused scientist, says nutrition epidemiologist Lindsey Smith Taillie.

• Lindsey Smith Taillie

Editorial | 06 March 2024

Nature publishes too few papers from women researchers — that must change

This journal will double down on efforts to diversify the pool of corresponding authors and referees.

Perspective | 06 March 2024

Artificial intelligence and illusions of understanding in scientific research

The proliferation of artificial intelligence tools in scientific research risks creating illusions of understanding, where scientists believe they understand more about the world than they actually do.

• Lisa Messeri
•  &  M. J. Crockett

News Feature | 04 March 2024

What science says about hybrid working — and how to make it a success

How researchers can maximize creativity and connection in the ‘new normal’.

Career Column | 27 February 2024

How I made my lab meetings more inclusive with a rapid-relay technique

Johanna Joyce’s use of the ‘flashlight’ method has helped her lab members to connect and be more mindful about their science.

• Johanna Joyce

Nature Index | 26 February 2024

How institutions can tap into research managers’ potential

The editors of a book exploring the perspectives of research managers talk about how policymakers and institutional leaders can better support these essential professionals.

Editorial | 26 February 2024

Why it would be a dangerous folly to end US–China science pact

With renewal of the two countries’ decades-long science pact still on hold, there is too much talk about the risks of collaboration — and too little about the benefits.

Career Q&A | 26 February 2024

I help researchers build fantastic funding proposals — here’s how

Glòria García-Negredo supports scientists who are writing grant applications, and creates links between research groups.

• Miles Lizak

Career News | 26 February 2024

‘This is exclusion’: Florida law restricts hiring of researchers from seven countries

Policy that prohibits partnerships between state universities and ‘countries of concern’, including China, will erode competitiveness, faculty members say.

• Amanda Heidt

News | 12 February 2024

China conducts first nationwide review of retractions and research misconduct

Universities must declare all their retractions and launch investigations into misconduct cases; a Nature analysis reveals that since 2021 there have been more than 17,000 retractions with Chinese co-authors.

• Smriti Mallapaty

Career Feature | 07 February 2024

Could roving researchers help address the challenge of taking parental leave?

Institutions are taking notice of a handful of programmes designed to address the issues scientists face when choosing to take a long-term absence.

Correspondence | 06 February 2024

Best practice for LGBTQ+ data collection by STEM organizations

• Alexander L. Bond
•  &  Tyler L. Kelly

Editorial | 06 February 2024

Open science — embrace it before it’s too late

A UNESCO report laments the lack of progress in making science more collaborative. Greater awareness could aid efforts to achieve the UN’s Sustainable Development Goals.

News | 05 February 2024

JWST is most in-demand telescope ever — leaving many astronomers in the cold

Reviewers will probably approve only one in every nine research proposals submitted in latest application cycle.

Career Column | 01 February 2024

How to enhance lab-team efficiency with tools from the tech industry

Using freely available software can help to maximize productivity and avoid collaboration pain points.

• Lathan Liou
•  &  Akshay Swaminathan

Career Feature | 29 January 2024

How co-working labs reduce costs and accelerate progress for biotech start-ups

Shared lab spaces provide a streamlined launchpad, offering benches as well as a diverse network of industry mentors.

• Rachel Brazil

News | 24 January 2024

Leading US particle-physics lab faces uncertain future

Several organizations are vying for the contract to manage Fermilab, after it received failing grades from the US Department of Energy.

• Dan Garisto

Career Feature | 22 January 2024

The open-science movement for sharing laboratory materials gains momentum

Many researchers support open science, but how can they translate this view into behaviours to boost sharing?

Correspondence | 16 January 2024

Does generative AI help academics to do more or less?

• Richard Watermeyer
• , Donna Lanclos
•  &  Lawrie Phipps

Career Column | 16 January 2024

Organize your –80 °C freezer to save time and prevent frozen fingertips

Start the new year by sorting out your lab’s cold storage, to simplify purchasing, improve experiment planning and reduce the frequency of lost samples.

• Kelsey Alexandra Woodruff
•  &  Christina Marie Termini

Career Column | 04 January 2024

Start 2024 by asking: ‘Why do science?’

Step back from the usual lab-meeting format, and ask yourself and your colleagues why you all do what you do, say Mirko Treccani and Laura Veschetti.

• Mirko Treccani
•  &  Laura Veschetti

Career Feature | 13 December 2023

If you want something done right, do it yourself: the scientists who build their own tools

Three researchers who went out on a limb to bridge a gap in their field talk to Nature about how and why they went about designing their own, unique devices — and the challenges involved.

• Rachael Pells

Spotlight | 13 December 2023

How high-impact papers from Indian researchers are shaping science

Studies to tackle air quality in Delhi and solve the mystery of an emerging pathogen are among those helping to raise the profile of Indian science.

• Michael Eisenstein

World View | 12 December 2023

How to make data open? Stop overlooking librarians

Digital archivists are already experts at tackling the complex challenges of making research data open and accessible. We can help to smooth the transition.

• Jessica Farrell

Career Column | 08 December 2023

How to slay zombie research projects and move on

Find time to kill tasks that aren’t progressing, and beware taking on ones with unrealistic deadlines or deliverables.

• A. R. Siders
• , Nicola Ulibarri
•  &  Rebecca L. Nelson

News | 08 December 2023

Massive shake-up of French science system is biggest in decades

Billion-euro plan includes greater oversight for national research institutes and the creation of a top-level council to advise the president on science.

• Barbara Casassus

Nature Index | 07 December 2023

Women who travel boost research networks at home — but only in countries with high gender equity

Researchers moving between institutions in low- and middle-income countries can confer wide-reaching benefits on their colleagues.

• Natasha Gilbert

Nature Index | 06 December 2023

US agency launches experiments to find innovative ways to fund research

Caleb Watney explains how the National Science Foundation’s ‘science of science’ programme will find efficiencies and support ‘high-risk, high-reward’ studies.

Correspondence | 05 December 2023

Broaden scope of review boards to boost public trust

• Daniel Wyzynski

Article | 29 November 2023

Remote collaboration fuses fewer breakthrough ideas

Analysis of research articles and patent applications shows that members of teams that collaborate remotely are less likely to make breakthrough discoveries than members of on-site teams.

• , Carl Benedikt Frey
•  &  Lingfei Wu

Nature Index | 21 November 2023

City-based scientists get creative to tackle rural-research needs

Californian projects show how community engagement can break down urban–rural barriers in the United States.

• Virginia Gewin

Nature Index | 08 November 2023

United States and India are becoming science partners of choice

But collaborations are still hampered by bureaucracy and underfunding.

Correspondence | 07 November 2023

Community speaks up for science in the UK culture wars

• Katharine Hubbard

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Management Research

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Sustainability standards in rural entrepreneurships: the case of banana producers in Magdalena (Colombia)Estándares de sostenibilidad en emprendimientos rurales: El caso de los productores de banano en Magdalena (Colombia)Padrões de sustentabilidade em empreendimentos rurais: O caso dos produtores de banana em Magdalena (Colômbia)

This study aims to evaluate how the criteria of sustainability standards (SS) ensure the social dimension of corporate sustainability (CS) in rural entrepreneurships using the…

Empirical evidence for the validity of the job crafting scale (JCS) in a Portuguese setting Evidencia empírica de la validez de la job crafting scale (JCS) en una muestra de trabajadores Portugueses Evidência empírica de validade da versão Portuguesa da job crafting scale (JCS)

This study aims to adapt and validate the Job Crafting Scale (JCS), a measure based on the conceptualization of job crafting of the job demands–resources theory, for a sample of…

Holistic entrepreneurial inventory: a framework for the integration of spirituality in entrepreneurial performanceInventario emprendedor holístico: un marco para la integración de la espiritualidad en el desempeño emprendedorInventário emprendedor holístico: um framework para a integração da espiritualidade no desempenho emprendedor

This study aims to explore the constructs of spirituality (SP) and entrepreneurial performance (EP) and their measurements to identify their connections. Attending to the needs of…

Affective commitment in entrepreneurial students: person-oriented factors and subjective firm performanceCompromiso afectivo en estudiantes emprendedores: factores personales y desempeño empresarial subjetivoCompromisso afetivo em estudantes empreendedores: fatores pessoais e desempenho empresarial subjetivo

This study aims to address the effects of self-esteem and affective commitment on firm performance and whether these effects vary according to the gender and age of active…

Understanding the link: the competencies and motivations of nascent entrepreneurs to engage in sustainable entrepreneurship Comprender el vínculo: las competencias y motivaciones de los emprendedores nacientes para emprender un emprendimiento sostenible Entendendo o vínculo: as competências e as motivações dos empreendedores nascentes para se envolverem em empreendedorismo sustentável

This study aims to understand the relationship between entrepreneurial competencies (self-efficacy and social capital) and sustainable entrepreneurship and its incidence through…

Social entrepreneurship in young students promoted by Latin American universitiesEmprendimiento social en jóvenes estudiantes impulsado por las universidades de América LatinaEmpreendedorismo social em jovens estudantes promovido por universidades latino-americanas

The purpose of this study is to analyze the strategies that allow sowing social entrepreneurship initiatives among young university students in Latin America. This study will also…

The formalization of microenterprises in middle-income countries: informal institutions as a mechanism to address institutional incongruenceLa formalización de las microempresas en los países de ingresos medios: las instituciones informales como mecanismo para abordar la incongruencia institucionalA formalização de microempresas em países de renda média: instituições informais como mecanismo de enfrentamento da incongruência institucional

The purpose of this study is to investigate the role of sales, as a proxy for size, in moderating the impact of institutional incongruence between formal and informal institutions…

Characteristics of the leaders of social and environmental enterprises in Latin America and the relationship with the success of their businessesCaracterísticas de los líderes de emprendimientos sociales y ambientales en América Latina y la relación con el éxito de sus negociosCaracterísticas dos líderes de empreendedorismos sociais e ambientais em América Latina e a relação com o sucesso de seus negócios

This study aims to understand the leadership characteristics of founders of social and environmental enterprises in Latin America who have achieved business success with a focus…

When connecting ventures to international markets falls short: examining the root mechanisms of perceived inefficacy in market-driven poverty alleviation effortsCuando la conexión de emprendimientos a mercados internacionales se queda corta: examinando los mecanismos fundamentales de la ineficacia percibida en los esfuerzos de alivio de la pobreza impulsados por el mercadoQuando a conexão de empreendimentos aos mercados internacionais fica aquém: examinando os mecanismos fundamentais da ineficácia percebida nos esforços de alívio da pobreza impulsionados pelo mercado

The purpose of this paper is to study triadic market relations between an international aid agency (IAA), local ventures and the poor communities where they are embedded in order…

Senior entrepreneurship in Latin America: evaluation and support from entrepreneurship ecosystems approach Emprendimiento senior en América Latina: evaluación y apoyo desde el enfoque de ecosistemas de emprendimiento Empreendedorismo sênior na América Latina: avaliação e apoio a partir da abordagem de ecossistemas de empreendedorismo

The purpose of this study is to make an exploratory analysis of the impact of the entrepreneurial ecosystem (EE) as defined by Acs et al. (2014) on opportunity-driven senior…

The effect of women’s entrepreneurship on corporate social responsibilityEl efecto del emprendimiento de mujeres en la responsabilidad social empresarialO efeito do empreendedorismo feminino na responsabilidade social corporativa

The purpose of this paper is to identify the causal (not correlational) effect of women’s entrepreneurship on corporate social responsibility (CSR) practices in Latin America.

Informality as a choice to do legitimate business: evidence from Peruvian women in times of COVID-19

In developing countries, women microentrepreneurs are characterized as being informal, creating a challenge for the sustainability of their businesses. The purpose of this study…

Sustainability and women entrepreneurship through new business models: the case of microfranchises in post-peace agreement Colombia

This study aims to analyze the establishment of sustainable microfranchises by women victims of the conflict (WVC) entrepreneurs who suffered the consequences and impacts of the…

Fall seven times, stand up eight: the neuropsychological and managerial configurations of resilience

Resiliency is essential for achieving the necessary level of performance and ensuring the survival of a new business during difficult times. However, neither this characteristic…

Family social capital as a mediator between socioemotional wealth and entrepreneurial orientation: evidence from Mexican SMEs

The type of social capital among families involved in business, or family social capital, has both positive and negative effects on family firms. This paper aims to investigate…

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Operations Management Research

Advancing Practice through Theory

• Presents research that advances both theory and practice of operations management.
• Includes all aspects of operations management, from manufacturing and supply chain to health care and service operations.
• Welcomes a variety of research methodologies, including case, action, survey, mathematical modelling, simulation, etc.
• Matteo Kalchschmidt

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Volume 17, Issue 1

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Network working capital management, supply chain concentration, and corporate performance of focal companies.

• Zhefan Piao
• Zihan Zheng

Drivers of supply chain adaptability: insights into mobilizing supply chain processes. A multi-country and multi-sector empirical research

• Michiya Morita
• Jose A. D. Machuca
• Rafaela Alfalla-Luque

Supply chain capabilities matter: digital transformation and green supply chain management in post-pandemic emerging economies: A case from Egypt

• Ahmed Hamdy

Environmental sustainability consideration with just-in-time practices in industry 4.0 era – A state of the art

• Vivek Singhal
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One size does not fit all- Strategizing the vaccine supply chain in developing countries

• Abdul Salam Khan

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Management →

• 02 Apr 2024
• What Do You Think?

What's Enough to Make Us Happy?

Experts say happiness is often derived by a combination of good health, financial wellbeing, and solid relationships with family and friends. But are we forgetting to take stock of whether we have enough of these things? asks James Heskett. Open for comment; 0 Comments.

• Research & Ideas

Employees Out Sick? Inside One Company's Creative Approach to Staying Productive

Regular absenteeism can hobble output and even bring down a business. But fostering a collaborative culture that brings managers together can help companies weather surges of sick days and no-shows. Research by Jorge Tamayo shows how.

• 12 Mar 2024

Publish or Perish: What the Research Says About Productivity in Academia

Universities tend to evaluate professors based on their research output, but does that measure reflect the realities of higher ed? A study of 4,300 professors by Kyle Myers, Karim Lakhani, and colleagues probes the time demands, risk appetite, and compensation of faculty.

• 29 Feb 2024

Beyond Goals: David Beckham's Playbook for Mobilizing Star Talent

Reach soccer's pinnacle. Become a global brand. Buy a team. Sign Lionel Messi. David Beckham makes success look as easy as his epic free kicks. But leveraging world-class talent takes discipline and deft decision-making, as case studies by Anita Elberse reveal. What could other businesses learn from his ascent?

• 16 Feb 2024

Is Your Workplace Biased Against Introverts?

Extroverts are more likely to express their passion outwardly, giving them a leg up when it comes to raises and promotions, according to research by Jon Jachimowicz. Introverts are just as motivated and excited about their work, but show it differently. How can managers challenge their assumptions?

• 05 Feb 2024

The Middle Manager of the Future: More Coaching, Less Commanding

Skilled middle managers foster collaboration, inspire employees, and link important functions at companies. An analysis of more than 35 million job postings by Letian Zhang paints a counterintuitive picture of today's midlevel manager. Could these roles provide an innovation edge?

• 24 Jan 2024

Why Boeing’s Problems with the 737 MAX Began More Than 25 Years Ago

Aggressive cost cutting and rocky leadership changes have eroded the culture at Boeing, a company once admired for its engineering rigor, says Bill George. What will it take to repair the reputational damage wrought by years of crises involving its 737 MAX?

• 16 Jan 2024
• Cold Call Podcast

How SolarWinds Responded to the 2020 SUNBURST Cyberattack

In December of 2020, SolarWinds learned that they had fallen victim to hackers. Unknown actors had inserted malware called SUNBURST into a software update, potentially granting hackers access to thousands of its customers’ data, including government agencies across the globe and the US military. General Counsel Jason Bliss needed to orchestrate the company’s response without knowing how many of its 300,000 customers had been affected, or how severely. What’s more, the existing CEO was scheduled to step down and incoming CEO Sudhakar Ramakrishna had yet to come on board. Bliss needed to immediately communicate the company’s action plan with customers and the media. In this episode of Cold Call, Professor Frank Nagle discusses SolarWinds’ response to this supply chain attack in the case, “SolarWinds Confronts SUNBURST.”

• 02 Jan 2024

Do Boomerang CEOs Get a Bad Rap?

Several companies have brought back formerly successful CEOs in hopes of breathing new life into their organizations—with mixed results. But are we even measuring the boomerang CEOs' performance properly? asks James Heskett. Open for comment; 0 Comments.

• 12 Dec 2023

COVID Tested Global Supply Chains. Here’s How They’ve Adapted

A global supply chain reshuffling is underway as companies seek to diversify their distribution networks in response to pandemic-related shocks, says research by Laura Alfaro. What do these shifts mean for American businesses and buyers?

• 05 Dec 2023

What Founders Get Wrong about Sales and Marketing

Which sales candidate is a startup’s ideal first hire? What marketing channels are best to invest in? How aggressively should an executive team align sales with customer success? Senior Lecturer Mark Roberge discusses how early-stage founders, sales leaders, and marketing executives can address these challenges as they grow their ventures in the case, “Entrepreneurial Sales and Marketing Vignettes.”

• 31 Oct 2023

Checking Your Ethics: Would You Speak Up in These 3 Sticky Situations?

Would you complain about a client who verbally abuses their staff? Would you admit to cutting corners on your work? The answers aren't always clear, says David Fubini, who tackles tricky scenarios in a series of case studies and offers his advice from the field.

• 12 Sep 2023

Can Remote Surgeries Digitally Transform Operating Rooms?

Launched in 2016, Proximie was a platform that enabled clinicians, proctors, and medical device company personnel to be virtually present in operating rooms, where they would use mixed reality and digital audio and visual tools to communicate with, mentor, assist, and observe those performing medical procedures. The goal was to improve patient outcomes. The company had grown quickly, and its technology had been used in tens of thousands of procedures in more than 50 countries and 500 hospitals. It had raised close to $50 million in equity financing and was now entering strategic partnerships to broaden its reach. Nadine Hachach-Haram, founder and CEO of Proximie, aspired for Proximie to become a platform that powered every operating room in the world, but she had to carefully consider the company’s partnership and data strategies in order to scale. What approach would position the company best for the next stage of growth? Harvard Business School associate professor Ariel Stern discusses creating value in health care through a digital transformation of operating rooms in her case, “Proximie: Using XR Technology to Create Borderless Operating Rooms.”

• 28 Aug 2023

The Clock Is Ticking: 3 Ways to Manage Your Time Better

Life is short. Are you using your time wisely? Leslie Perlow, Arthur Brooks, and DJ DiDonna offer time management advice to help you work smarter and live happier.

• 15 Aug 2023

Ryan Serhant: How to Manage Your Time for Happiness

Real estate entrepreneur, television star, husband, and father Ryan Serhant is incredibly busy and successful. He starts his days at 4:00 am and often doesn’t end them until 11:00 pm. But, it wasn’t always like that. In 2020, just a few months after the US began to shut down in order to prevent the spread of the Covid-19 virus, Serhant had time to reflect on his career as a real estate broker in New York City, wondering if the period of selling real estate at record highs was over. He considered whether he should stay at his current real estate brokerage or launch his own brokerage during a pandemic? Each option had very different implications for his time and flexibility. Professor Ashley Whillans and her co-author Hawken Lord (MBA 2023) discuss Serhant’s time management techniques and consider the lessons we can all learn about making time our most valuable commodity in the case, “Ryan Serhant: Time Management for Repeatable Success.”

• 08 Aug 2023

The Rise of Employee Analytics: Productivity Dream or Micromanagement Nightmare?

"People analytics"—using employee data to make management decisions—could soon transform the workplace and hiring, but implementation will be critical, says Jeffrey Polzer. After all, do managers really need to know about employees' every keystroke?

• 01 Aug 2023

Can Business Transform Primary Health Care Across Africa?

mPharma, headquartered in Ghana, is trying to create the largest pan-African health care company. Their mission is to provide primary care and a reliable and fairly priced supply of drugs in the nine African countries where they operate. Co-founder and CEO Gregory Rockson needs to decide which component of strategy to prioritize in the next three years. His options include launching a telemedicine program, expanding his pharmacies across the continent, and creating a new payment program to cover the cost of common medications. Rockson cares deeply about health equity, but his venture capital-financed company also must be profitable. Which option should he focus on expanding? Harvard Business School Professor Regina Herzlinger and case protagonist Gregory Rockson discuss the important role business plays in improving health care in the case, “mPharma: Scaling Access to Affordable Primary Care in Africa.”

• 05 Jul 2023

How Unilever Is Preparing for the Future of Work

Launched in 2016, Unilever’s Future of Work initiative aimed to accelerate the speed of change throughout the organization and prepare its workforce for a digitalized and highly automated era. But despite its success over the last three years, the program still faces significant challenges in its implementation. How should Unilever, one of the world's largest consumer goods companies, best prepare and upscale its workforce for the future? How should Unilever adapt and accelerate the speed of change throughout the organization? Is it even possible to lead a systematic, agile workforce transformation across several geographies while accounting for local context? Harvard Business School professor and faculty co-chair of the Managing the Future of Work Project William Kerr and Patrick Hull, Unilever’s vice president of global learning and future of work, discuss how rapid advances in artificial intelligence, machine learning, and automation are changing the nature of work in the case, “Unilever's Response to the Future of Work.”

How Are Middle Managers Falling Down Most Often on Employee Inclusion?

Companies are struggling to retain employees from underrepresented groups, many of whom don't feel heard in the workplace. What do managers need to do to build truly inclusive teams? asks James Heskett. Open for comment; 0 Comments.

• 20 Jun 2023

Elon Musk’s Twitter Takeover: Lessons in Strategic Change

In late October 2022, Elon Musk officially took Twitter private and became the company’s majority shareholder, finally ending a months-long acquisition saga. He appointed himself CEO and brought in his own team to clean house. Musk needed to take decisive steps to succeed against the major opposition to his leadership from both inside and outside the company. Twitter employees circulated an open letter protesting expected layoffs, advertising agencies advised their clients to pause spending on Twitter, and EU officials considered a broader Twitter ban. What short-term actions should Musk take to stabilize the situation, and how should he approach long-term strategy to turn around Twitter? Harvard Business School assistant professor Andy Wu and co-author Goran Calic, associate professor at McMaster University’s DeGroote School of Business, discuss Twitter as a microcosm for the future of media and information in their case, “Twitter Turnaround and Elon Musk.”

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• v.20; 2019 Oct 25

Managing Ideas, People, and Projects: Organizational Tools and Strategies for Researchers

Samuel pascal levin.

1 Beverly, MA 01915, USA

Michael Levin

2 Allen Discovery Center at Tufts University, Suite 4600, 200 Boston Avenue, Medford, MA 02155-4243, USA

Primary Investigators at all levels of their career face a range of challenges related to optimizing their activity within the constraints of deadlines and productive research. These range from enhancing creative thought and keeping track of ideas to organizing and prioritizing the activity of the members of the group. Numerous tools now exist that facilitate the storage and retrieval of information necessary for running a laboratory to advance specific project goals within associated timelines. Here we discuss strategies and tools/software that, together or individually, can be used as is or adapted to any size scientific laboratory. Specific software products, suggested use cases, and examples are shown across the life cycle from idea to publication. Strategies for managing the organization of, and access to, digital information and planning structures can greatly facilitate the efficiency and impact of an active scientific enterprise. The principles and workflow described here are applicable to many different fields.

Graphical Abstract

Information Systems; Knowledge Management

Introduction

Researchers, at all stages of their careers, are facing an ever-increasing deluge of information and deadlines. Additional difficulties arise when one is the Principal Investigator (PI) of those researchers: as group size and scope of inquiry increases, the challenges of managing people and projects and the interlocking timelines, finances, and information pertaining to those projects present a continuous challenge. In the immediate term, there are experiments to do, papers and grants to write, and presentations to construct, in addition to teaching and departmental duties. At the same time, however, the PI must make strategic decisions that will impact the future direction(s) of the laboratory and its personnel. The integration of deep creative thought together with the practical steps of implementing a research plan and running a laboratory on a day-to-day basis is one of the great challenges of the modern scientific enterprise. Especially difficult is the fact that attention needs to span many orders of scale, from decisions about which problems should be pursued by the group in the coming years and how to tackle those problems to putting out regular “fires” associated with the minutiae of managing people and limited resources toward the committed goals.

The planning of changes in research emphasis, hiring, grant-writing, etc. likewise occur over several different timescales. The optimization of resources and talent toward impactful goals requires the ability to organize, store, and rapidly access information that is integrated with project planning structures. Interestingly, unlike other fields such as business, there are few well-known, generally accepted guidelines for best practices available to researchers. Here we lay out a conceptual taxonomy of the life cycle of a project, from brainstorming ideas through to a final deliverable product. We recommend methods and software/tools to facilitate management of concurrent research activities across the timeline. The goal is to optimize the organization, storage, and access to the necessary information in each phase, and, crucially, to facilitate the interconnections between static information, action plans, and work product across all phases. We believe that the earlier in the career of a researcher such tools are implemented and customized, the more positive impact they will exert on the productivity of their enterprise.

This overview is intended for anyone who is conducting research or academic scholarship. It consists of a number of strategies and software recommendations that can be used together or independently (adapted to suit a given individual's or group's needs). Some of the specific software packages mentioned are only usable on Apple devices, but similar counterparts exist in the Windows and Linux ecosystems; these are indicated in Table 1 (definitions of special terms are given in Table 2 ). These strategies were developed (and have been continuously updated) over the last 20 years based on the experiences of the Levin group and those of various collaborators and other productive researchers. Although very specific software and platforms are indicated, to facilitate the immediate and practical adoption by researchers at all levels, the important thing is the strategies illustrated by the examples. As software and hardware inevitably change over the next few years, the fundamental principles can be readily adapted to newer products.

Software Packages and Alternatives

A Glossary of Special Terms

Basic Principles

Although there is a huge variety of different types of scientific enterprises, most of them contain one or more activities that can be roughly subsumed by the conceptual progression shown in Figure 1 . This life cycle progresses from brainstorming and ideation through planning, execution of research, and then creation of work products. Each stage requires unique activities and tools, and it is crucial to establish a pipeline and best practices that enable the results of each phase to effectively facilitate the next phase. All of the recommendations given below are designed to support the following basic principles:

• • Information should be easy to find and access, so as to enable the user to have to remember as little as possible—this keeps the mind free to generate new, creative ideas. We believe that when people get comfortable with not having to remember any details and are completely secure in the knowledge that the information has been offloaded to a dependable system and will be there when they need it, a deeper, improved level of thinking can be achieved.
• • Information should be both organized hierarchically (accessible by drill-down search through a rational structure) and searchable by keywords.
• • Information should be reachable from anywhere in the world (but secure and access restricted). Choose software that includes a cell phone/tablet platform client.
• • No information should ever be lost—the systems are such that additional information does not clog up or reduce efficiency of use and backup strategies ensure disaster robustness; therefore, it is possible to save everything.
• • Software tools optimized for specific management tasks should be used; select those tools based on interoperability, features, and the ability to export into common formats (such as XML) in case it becomes expedient someday to switch to a newer product.
• • One's digital world should be organized into several interlocking categories, which utilize different tools: activity (to-dos, projects, research goals) and knowledge (static information).
• • One's activity should be hierarchically organized according to a temporal scale, ranging from immediate goals all the way to career achievement objectives and core mission.
• • Storage of planning data should allow integration of plans with the information needed to implement them (using links to files and data in the various tools).
• • There should be no stored paper—everything should be obtained and stored in a digital form (or immediately digitized, using one of the tools described later in this document).
• • The information management tasks described herein should not occupy so much time as to take away from actual research. When implemented correctly, they result in a net increase in productivity.

The Life Cycle of Research Activity

Various projects occupy different places along a typical timeline. The life cycle extends from creative ideation to gathering information, to formulating a plan, to the execution for the plan, and then to producing a work product such as a grant or paper based on the results. Many of these phases necessitate feedback to a prior phase, shown in thinner arrows (for example, information discovered during a literature search or attempts to formalize the work plan may require novel brainstorming). This diagram shows the product (end result) of each phase and typical tools used to accomplish them.

These basic principles can be used as the skeleton around which specific strategies and new software products can be deployed. Whenever possible, these can be implemented via external administration services (i.e., by a dedicated project manager or administrator inside the group), but this is not always compatible with budgetary constraints, in which case they can readily be deployed by each principal investigator. The PIs also have to decide whether they plan to suggest (or insist) that other people in the group also use these strategies, and perhaps monitor their execution. In our experience, it is most essential for anyone leading a complex project or several to adopt these methods (typically, a faculty member or senior staff scientist), whereas people tightly focused on one project and with limited concurrent tasks involving others (e.g., Ph.D. students) are not essential to move toward the entire system (although, for example, the backup systems should absolutely be ensured to be implemented among all knowledge workers in the group). The following are some of the methods that have proven most effective in our own experience.

Information Technology Infrastructure

Several key elements should be pillars of your Information Technology (IT) infrastructure ( Figure 2 ). You should be familiar enough with computer technology that you can implement these yourself, as it is rare for an institutional IT department to be able to offer this level of assistance. Your primary disk should be a large (currently, ∼2TB) SSD drive or, better, a disk card (such as the 2TB SSD NVMe PCIe) for fast access and minimal waiting time. Your computer should be so fast that you spend no time (except in the case of calculations or data processing) waiting for anything—your typing and mouse movement should be the rate-limiting step. If you find yourself waiting for windows or files to open, obtain a better machine.

Schematic of Data Flow and Storage

Three types of information: data (facts and datasets), action plans (schedules and to-do lists), and work product (documents) all interact with each other in defining a region of work space for a given research project. All of this should be hosted on a single PC (personal computer). It is accessed by a set of regular backups of several types, as well as by the user who can interact with raw files through the file system or with organized data through a variety of client applications that organize information, schedules, and email. See Table 2 for definitions of special terms.

One key element is backups—redundant copies of your data. Disks fail—it is not a question of whether your laptop or hard drive will die, but when. Storage space is inexpensive and researchers' time is precious: team members should not tolerate time lost due to computer snafus. The backup and accessibility system should be such that data are immediately recoverable following any sort of disaster; it only has to be set up once, and it only takes one disaster to realize the value of paranoia about data. This extends also to laboratory inventory systems—it is useful to keep (and back up) lists of significant equipment and reagents in the laboratory, in case they are needed for the insurance process in case of loss or damage.

The main drive should be big enough to keep all key information (not primary laboratory data, such as images or video) in one volume—this is to facilitate cloning. You should have an extra internal drive (which can be a regular disk) of the same size or bigger. Use something like Carbon Copy Cloner or SuperDuper to set up a nightly clone operation. When the main disk fails (e.g., the night before a big grant is due), boot from the clone and your exact, functioning system is ready to go. For Macs, another internal drive set up as a Time Machine enables keeping versions of files as they change. You should also have an external drive, which is likewise a Time Machine or a clone: you can quickly unplug it and take it with you, if the laboratory has to be evacuated (fire alarm or chemical emergency) or if something happens to your computer and you need to use one elsewhere. Set a calendar reminder once a month to check that the Time Machine is accessible and can be searched and that your clone is actually updated and bootable. A Passport-type portable drive is ideal when traveling to conferences: if something happens to the laptop, you can boot a fresh (or borrowed) machine from the portable drive and continue working. For people who routinely install software or operating system updates, I also recommend getting one disk that is a clone of the entire system and applications and then set it to nightly clone the data only , leaving the operating system files unchanged. This guarantees that you have a usable system with the latest data files (useful in case an update or a new piece of software renders the system unstable or unbootable and it overwrites the regular clone before you notice the problem). Consider off-site storage. CrashPlan Pro is a reasonable choice for backing up laboratory data to the cloud. One solution for a single person's digital content is to have two extra external hard drives. One gets a clone of your office computer, and one is a clone of your home computer, and then you swap—bring the office one home and the home one to your office. Update them regularly, and keep them swapped, so that should a disaster strike one location, all of the data are available. Finally, pay careful attention (via timed reminders) to how your laboratory machines and your people's machines are being backed up; a lot of young researchers, especially those who have not been through a disaster yet, do not make backups. One solution is to have a system like CrashPlan Pro installed on everyone's machines to do automatic backup.

Another key element is accessibility of information. Everyone should be working on files (i.e., Microsoft Word documents) that are inside a Dropbox or Box folder; whatever you are working on this month, the files should be inside a folder synchronized by one of these services. That way, if anything happens to your machine, you can access your files from anywhere in the world. It is critical that whatever service is chosen, it is one that s ynchronizes a local copy of the data that live on your local machine (not simply keeps files in the cloud) —that way, you have what you need even if the internet is down or connectivity is poor. Tools that help connect to your resources while on the road include a VPN (especially useful for secure connections while traveling), SFTP (to transfer files; turn on the SFTP, not FTP, service on your office machine), and Remote Desktop (or VNC). All of these exist for cell phone or tablet devices, as well as for laptops, enabling access to anything from anywhere. All files (including scans of paper documents) should be processed by OCR (optical character recognition) software to render their contents searchable. This can be done in batch (on a schedule), by Adobe Acrobat's OCR function, which can be pointed to an entire folder of PDFs, for example, and left to run overnight. The result, especially with Apple's Spotlight feature, is that one can easily retrieve information that might be written inside a scanned document.

Here, we focus on work product and the thought process, not management of the raw data as it emerges from equipment and experimental apparatus. However, mention should be made of electronic laboratory notebooks (ELNs), which are becoming an important aspect of research. ELNs are a rapidly developing field, because they face a number of challenges. A laboratory that abandons paper notebooks entirely has to provide computer interfaces anywhere in the facility where data might be generated; having screens, keyboards, and mice at every microscope or other apparatus station, for example, can be expensive, and it is not trivial to find an ergonomically equivalent digital substitute for writing things down in a notebook as ideas or data appear. On the other hand, keeping both paper notebooks for immediate recording, and ELNs for organized official storage, raises problems of wasted effort during the (perhaps incomplete) transfer of information from paper to the digital version. ELNs are also an essential tool to prevent loss of institutional knowledge as team members move up to independent positions. ELN usage will evolve over time as input devices improve and best practices are developed to minimize the overhead of entering meta-data. However, regardless of how primary data are acquired, the researcher will need specific strategies for transitioning experimental findings into research product in the context of a complex set of personal, institutional, and scientific goals and constraints.

Facilitating Creativity

The pipeline begins with ideas, which must be cultivated and then harnessed for subsequent implementation ( Altshuller, 1984 ). This step consists of two components: identifying salient new information and arranging it in a way that facilitates novel ideas, associations, hypotheses, and strategic plans for making impact.

For the first step, we suggest an automated weekly PubCrawler search, which allows Boolean searches of the literature. Good searches to save include ones focusing on specific keywords of interest, as well as names of specific people whose work one wants to follow. The resulting weekly email of new papers matching specific criteria complements manual searches done via ISI's Web of Science, Google Scholar, and PubMed. The papers of interest should be immediately imported into a reference manager, such as Endnote, along with useful Keywords and text in the Notes field of each one that will facilitate locating them later. Additional tools include DevonAgent and DevonSphere, which enable smart searches of web and local resources, respectively.

Brainstorming can take place on paper or digitally (see later discussion). We have noticed that the rate of influx of new ideas is increased by habituating to never losing a new idea. This can be accomplished by establishing a voicemail contact in your cell phone leading to your own office voicemail (which allows voice recordings of idea fragments while driving or on the road, hands-free) and/or setting up Endnote or a similar server-synchronized application to record (and ideally transcribe) notes. It has been our experience that the more one records ideas arising in a non-work setting, the more often they will pop up automatically. For notes or schematics written on paper during dedicated brainstorming, one tool that ensures that nothing is lost is an electronic pen. For example, the Livescribe products are well integrated with Evernote and ensure that no matter where you are, anything you write down becomes captured in a form accessible from anywhere and are safe no matter what happens to the original notebook in which they were written.

Enhancing scientific thought, creative brainstorming, and strategic planning is facilitated by the creation of mind maps: visual representations of spatial structure of links between concepts, or the mapping of planned activity onto goals of different timescales. There are many available mind map software packages, including MindNode; their goal is to enable one to quickly set down relationships between concepts with a minimum of time spent on formatting. Examples are shown in Figures 3 A and 3B. The process of creating these mind maps (which can then be put on one's website or discussed with the laboratory members) helps refine fuzzy thinking and clarifies the relationships between concepts or activities. Mind mappers are an excellent tool because their light, freeform nature allows unimpeded brainstorming and fluid changes of idea structure but at the same time forces one to explicitly test out specific arrangements of plans or ideas.

Mind Mapping

(A and B) The task of schematizing concepts and ideas spatially based on their hierarchical relationships with each other is a powerful technique for organizing the creative thought process. Examples include (A), which shows how the different projects in our laboratory relate to each other. Importantly, it can also reveal disbalances or gaps in coverage of specific topics, as well as help identify novel relationships between sub-projects by placing them on axes (B) or even identify novel hypotheses suggested by symmetry.

(C) Relationships between the central nervous system (CNS) and regeneration, cancer, and embryogenesis. The connecting lines in black show typical projects (relationships) already being pursued by our laboratory, and the lack of a project in the space between CNS and embryogenesis suggests a straightforward hypothesis and project to examine the role of the brain in embryonic patterning.

It is important to note that mind maps can serve a function beyond explicit organization. In a good mapped structure, one can look for symmetries (revealing relationships that are otherwise not obvious) between the concepts involved. An obvious geometric pattern with a missing link or node can help one think about what could possibly go there, and often identifies new relationships or items that had not been considered ( Figure 3 C), in much the same way that gaps in the periodic table of the elements helped identify novel elements.

Organizing Information and Knowledge

The input and output of the feedback process between brainstorming and literature mining is information. Static information not only consists of the facts, images, documents, and other material needed to support a train of thought but also includes anything needed to support the various projects and activities. It should be accessible in three ways, as it will be active during all phases of the work cycle. Files should be arranged on your disk in a logical hierarchical structure appropriate to the work. Everything should also be searchable and indexed by Spotlight. Finally, some information should be stored as entries in a data management system, like Evernote or DevonThink, which have convenient client applications that make the data accessible from any device.

Notes in these systems should include useful lists and how-to's, including, for example:

• • Names and addresses of experts for specific topics
• • Emergency protocols for laboratory or animal habitats
• • Common recipes/methods
• • Lists and outlines of papers/grants on the docket
• • Information on students, computers, courses, etc.
• • Laboratory policies
• • Materials and advice for students, new group members, etc.
• • Lists of editors, and preferred media contacts
• • Lists of Materials Transfer Agreements (MTAs), contract texts, info on IP
• • Favorite questions for prospective laboratory members

Each note can have attachments, which include manuals, materials safety sheets, etc. DevonThink needs a little more setup but is more robust and also allows keeping the server on one's own machine (nothing gets uploaded to company servers, unlike with Evernote, which might be a factor for sensitive data). Scientific papers should be kept in a reference manager, whereas books (such as epub files and PDFs of books and manuscripts) can be stored in a Calibre library.

Email: A Distinct Kind of Information

A special case of static information is email, including especially informative and/or actionable emails from team members, external collaborators, reviewers, and funders. Because the influx of email is ever-increasing, it is important to (1) establish a good infrastructure for its management and (2) establish policies for responding to emails and using them to facilitate research. The first step is to ensure that one only sees useful emails, by training a good Bayesian spam filter such as SpamSieve. We suggest a triage system in which, at specific times of day (so that it does not interfere with other work), the Inbox is checked and each email is (1) forwarded to someone better suited to handling it, (2) responded quickly for urgent things that need a simple answer, or (3) started as a Draft email for those that require a thoughtful reply. Once a day or a couple of times per week, when circumstances permit focused thought, the Draft folder should be revisited and those emails answered. We suggest a “0 Inbox” policy whereby at the end of a day, the Inbox is basically empty, with everything either delegated, answered, or set to answer later.

We also suggest creating subfolders in the main account (keeping them on the mail server, not local to a computer, so that they can be searched and accessed from anywhere) as follows:

• • Collaborators (emails stating what they are going to do or updating on recent status)
• • Grants in play (emails from funding agencies confirming receipt)
• • Papers in play (emails from journals confirming receipt)
• • Waiting for information (emails from people for whom you are waiting for information)
• • Waiting for miscellaneous (emails from people who you expect to do something)
• • Waiting for reagents (emails from people confirming that they will be sending you a physical object)

Incoming emails belonging to those categories (for example, an email from an NIH program officer acknowledging a grant submission, a collaborator who emailed a plan of what they will do next, or someone who promised to answer a specific question) should be sorted from the Inbox to the relevant folder. Every couple of weeks (according to a calendar reminder), those folders should be checked, and those items that have since been dealt with can be saved to a Saved Messages folder archive, whereas those that remain can be Replied to as a reminder to prod the relevant person.

In addition, as most researchers now exchange a lot of information via email, the email trail preserves a record of relationships among colleagues and collaborators. It can be extremely useful, even years later, to be able to go back and see who said what to whom, what was the last conversation in a collaboration that stalled, who sent that special protocol or reagent and needs to be acknowledged, etc. It is imperative that you know where your email is being stored, by whom, and their policy on retention, storage space limits, search, backup, etc. Most university IT departments keep a mail server with limited storage space and will delete your old emails (even more so if you move institutions). One way to keep a permanent record with complete control is with an application called MailSteward Pro. This is a front-end client for a freely available MySQL server, which can run on any machine in your laboratory. It will import your mail and store unlimited quantities indefinitely. Unlike a mail server, this is a real database system and is not as susceptible to data corruption or loss as many other methods.

A suggested strategy is as follows. Keep every single email, sent and received. Every month (set a timed reminder), have MailSteward Pro import them into the MySQL database. Once a year, prune them from the mail server (or let IT do it on their own schedule). This allows rapid search (and then reply) from inside a mail client for anything that is less than one year old (most searches), but anything older can be found in the very versatile MailStewardPro Boolean search function. Over time, in addition to finding specific emails, this allows some informative data mining. Results of searches via MailStewardPro can be imported into Excel to, for example, identify the people with whom you most frequently communicate or make histograms of the frequency of specific keywords as a function of time throughout your career.

With ideas, mind maps, and the necessary information in hand, one can consider what aspects of the current operations plan can be changed to incorporate plans for new, impactful activity.

Organizing Tasks and Planning

A very useful strategy involves breaking down everything according to the timescales of decision-making, such as in the Getting Things Done (GTD) philosophy ( Figure 4 ) ( Allen, 2015 ). Activities range from immediate (daily) tasks to intermediate goals all the way to career-scale (or life-long) mission statements. As with mind maps, being explicit about these categories not only force one to think hard about important aspects of their work, but also facilitate the transmission of this information to others on the team. The different categories are to be revisited and revised at different rates, according to their position on the hierarchy. This enables you to make sure that effort and resources are being spent according to priorities.

Scales of Activity Planning

Activities should be assigned to a level of planning with a temporal scale, based on how often the goals of that level get re-evaluated. This ranges from core values, which can span an entire career or lifetime, all the way to tactics that guide day-to-day activities. Each level should be re-evaluated at a reasonable time frame to ensure that its goals are still consistent with the bigger picture of the level(s) above it and to help re-define the plans for the levels below it.

We also strongly recommend a yearly personal scientific retreat. This is not meant to be a vacation to “forget about work” but rather an opportunity for freedom from everyday minutiae to revisit, evaluate, and potentially revise future activity (priorities, action items) for the next few years. Every few years, take more time to re-map even higher levels on the pyramid hierarchy; consider what the group has been doing—do you like the intellectual space your group now occupies? Are your efforts having the kind of impact you realistically want to make? A formal diagram helps clarify the conceptual vision and identify gaps and opportunities. Once a correct level of activity has been identified, it is time to plan specific activities.

A very good tool for this purpose, which enables hierarchical storage of tasks and subtasks and their scheduling, is OmniFocus ( Figure 5 ). OmniFocus also enables inclusion of files (or links to files or links to Evernote notes of information) together with each Action. It additionally allows each action to be marked as “Done” once it is complete, providing not only a current action plan but a history of every past activity. Another interesting aspect is the fact that one can link individual actions with specific contexts: visualizing the database from the perspective of contexts enables efficient focus of attention on those tasks that are relevant in a specific scenario. OmniFocus allows setting reminders for specific actions and can be used for adding a time component to the activity.

Project Planning

This figure shows a screenshot of the OmniFocus application, illustrating the nested hierarchy of projects and sub-projects, arranged into larger groups.

The best way to manage time relative to activity (and to manage the people responsible for each activity) is to construct Gantt charts ( Figure 6 ), which can be used to plan out project timelines and help keep grant and contract deliverables on time. A critical feature is that it makes dependencies explicit, so that it is clear which items have to be solved/done before something else can be accomplished. Gantt charts are essential for complex, multi-person, and/or multi-step projects with strict deadlines (such as grant deliverables and progress reports). Software such as OmniPlanner can also be used to link resources (equipment, consumables, living material, etc.) with specific actions and timelines. Updating and evaluation of a Gantt chart for a specific project should take place on a time frame appropriate to the length of the next immediate phase; weekly or biweekly is typical.

Timeline Planning

This figure shows a screenshot of a typical Gantt chart, in OmniPlan software, illustrating the timelines of different project steps, their dependencies, and specific milestones (such as a due date for a site visit or grant submission). Note that Gantt software automatically moves the end date for each item if its subtasks' timing changes, enabling one to see a dynamically correct up-to-date temporal map of the project that adjusts for the real-world contingencies of research.

In addition to the comprehensive work plan in OmniFocus or similar, it is helpful to use a Calendar (which synchronizes to a server, such as Microsoft Office calendar with Exchange server). For yourself, make a task every day called “Monday tasks,” etc., which contains all the individual things to be accomplished (which do not warrant their own calendar reminder). First thing in the morning, one can take a look at the day's tasks to see what needs to be done. Whatever does not get done that day is to be copied onto another day's tasks. For each of the people on your team, make a timed reminder (weekly, for example, for those with whom you meet once a week) containing the immediate next steps for them to do and the next thing they are supposed to produce for your meeting. Have it with you when you meet, and give them a copy, updating the next occurrence as needed based on what was decided at the meeting to do next. This scheme makes it easy for you to remember precisely what needs to be covered in the discussion, serves as a record of the project and what you walked about with whom at any given day (which can be consulted years later, to reconstruct events if needed), and is useful to synchronize everyone on the same page (if the team member gets a copy of it after the meeting).

Writing: The Work Products

Writing, to disseminate results and analysis, is a central activity for scientists. One of the OmniFocus library's sections should contain lists of upcoming grants to write, primary papers that are being worked on, and reviews/hypothesis papers planned. Microsoft Word is the most popular tool for writing papers—its major advantage is compatibility with others, for collaborative manuscripts (its Track Changes feature is also very well implemented, enabling collaboration as a master document is passed from one co-author to another). But Scrivener should be seriously considered—it is an excellent tool that facilitates complex projects and documents because it enables WYSIWYG text editing in the context of a hierarchical structure, which allows you to simultaneously work on a detailed piece of text while seeing the whole outline of the project ( Figure 7 ).

Writing Complex Materials

This figure shows a screenshot from the Scrivener software. The panel on the left facilitates logical and hierarchical organization of a complex writing project (by showing where in the overall structure any given text would fit), while the editing pane on the right allows the user to focus on writing a specific subsection without having to scroll through (but still being able to see) the major categories within which it must fit.

It is critical to learn to use a reference manager—there are numerous ones, including, for example, Endnote, which will make it much easier to collaborate with others on papers with many citations. One specific tip to make collaboration easier is to ask all of the co-authors to set the reference manager to use PMID Accession Number in the temporary citations in the text instead of the arbitrary record number it uses by default. That way, a document can have its bibliography formatted by any of the co-authors even if they have completely different libraries. Although some prefer collaborative editing of a Google Doc file, we have found a “master document” system useful, in which a file is passed around among collaborators by email but only one can make (Tracked) edits at a time (i.e., one person has the master doc and everyone makes edits on top of that).

One task most scientists regularly undertake is writing reviews of a specific subfield (or Whitepapers). It is often difficult, when one has an assignment to write, to remember all of the important papers that were seen in the last few years that bear on the topic. One method to remedy this is to keep standing document files, one for each topic that one might plausibly want to cover and update them regularly. Whenever a good paper is found, immediately enter it into the reference manager (with good keywords) and put a sentence or two about its main point (with the citation) into the relevant document. Whenever you decide to write the review, you will already have a file with the necessary material that only remains to be organized, allowing you to focus on conceptual integration and not combing through literature.

The life cycle of research can be viewed through the lens of the tools used at different stages. First there are the conceptual ideas; many are interconnected, and a mind mapper is used to flesh out the structure of ideas, topics, and concepts; make it explicit; and share it within the team and with external collaborators. Then there is the knowledge—facts, data, documents, protocols, pieces of information that relate to the various concepts. Kept in a combination of Endnote (for papers), Evernote (for information fragments and lists), and file system files (for documents), everything is linked and cross-referenced to facilitate the projects. Activities are action items, based on the mind map, of what to do, who is doing what, and for which purpose/grant. OmniFocus stores the subtasks within tasks within goals for the PI and everyone in the laboratory. During meetings with team members, these lists and calendar entries are used to synchronize objectives with everyone and keep the activity optimized toward the next step goals. The product—discovery and synthesis—is embodied in publications via a word processor and reference manager. A calendar structure is used to manage the trajectory from idea to publication or grant.

The tools are currently good enough to enable individual components in this pipeline. Because new tools are continuously developed and improved, we recommend a yearly overview and analysis of how well the tools are working (e.g., which component of the management plan takes the most time or is the most difficult to make invisible relative to the actual thinking and writing), coupled to a web search for new software and updated versions of existing programs within each of the categories discussed earlier.

A major opportunity exists for software companies in the creation of integrated new tools that provide all the tools in a single integrated system. In future years, a single platform will surely appear that will enable the user to visualize the same research structure from the perspective of an idea mind map, a schedule, a list of action items, or a knowledge system to be queried. Subsequent development may even include Artificial Intelligence tools for knowledge mining, to help the researcher extract novel relationships among the content. These will also need to dovetail with ELN platforms, to enable a more seamless integration of project management with primary data. These may eventually become part of the suite of tools being developed for improving larger group dynamics (e.g., Microsoft Teams). One challenge in such endeavors is ensuring the compatibility of formats and management procedures across groups and collaborators, which can be mitigated by explicitly discussing choice of software and process, at the beginning of any serious collaboration.

Regardless of the specific software products used, a researcher needs to put systems in place for managing information, plans, schedules, and work products. These digital objects need to be maximally accessible and backed up, to optimize productivity. A core principle is to have these systems be so robust and lightweight as to serve as an “external brain” ( Menary, 2010 )—to maximize creativity and deep thought by making sure all the details are recorded and available when needed. Although the above discussion focused on the needs of a single researcher (perhaps running a team), future work will address the unique needs of collaborative projects with more lateral interactions by significant numbers of participants.

Acknowledgments

We thank Joshua Finkelstein for helpful comments on a draft of the manuscript. M.L. gratefully acknowledges support by an Allen Discovery Center award from the Paul G. Allen Frontiers Group (12171) and the Barton Family Foundation.

• Allen D. Revised edition. Penguin Books; 2015. Getting Things Done: The Art of Stress-free Productivity. [ Google Scholar ]
• Altshuller G.S. Gordon and Breach Science Publishers; 1984. Creativity as an Exact Science: The Theory of the Solution of Inventive Problems. [ Google Scholar ]
• Menary R. MIT Press; 2010. The Extended Mind. [ Google Scholar ]

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Unpacking the Volunteer Experience: The Influence of Volunteer Management on Retention and Promotion of the Organization

• Jaclyn S. Piatak University of North Carolina at Charlotte
• Joanne G. Carman University of North Carolina at Charlotte

Volunteers play a vital role in nonprofit organizations. While considerable research examines volunteer recruitment and volunteer management, less is known about how to manage volunteers in such a way that inspires volunteers to continue to volunteer and to promote the organization. Using original survey data, we examine how volunteer experiences influence retention and volunteer promotion of the organization using the Net Promoter Score (NPS). The findings suggest that investing in training is paramount, along with making volunteers from diverse backgrounds feel welcome and included. Organizational support, very likely, plays a role too, in that interactions with paid staff and experience with the organization are positive predictors as well. These findings along with qualitative feedback from volunteers offer new insights on how to help nonprofit organizations bridge recruitment and retention efforts.

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Jaclyn S. Piatak is an Associate Professor in the Department of Political Science and Public Administration at the University of North Carolina at Charlotte. Her research focuses on public and nonprofit management, including human resource management and volunteering.

Joanne G. Carman is a Professor in the Department of Political Science and Public Administration at the University of North Carolina at Charlotte. Her research has appeared in a variety of journals including the American Journal of Evaluation, Canadian Journal of Program Evaluation, Nonprofit Management and Leadership , and Nonprofit and Voluntary Sector Quarterly .

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Main article content, management control systems and strategy: trends, gaps and opportunities for future research, asmamaw getie, padakanti laxmikantham, abebaw kassie.

The relationship between management control systems and strategy is widely researched with varied conceptualization of the relationship and diverse range of theories, methods, and contexts. This paper is an analytical review of literature aimed at documenting an understanding of the relationship between management control systems and strategies to comprehend existing knowledge, identify gaps, and sketch future research directions. Articles were located using keywords from the Scopus database and Google Scholar search engine for the period from 1997 to 2022. The review was conducted by classifying studies in the research context, theory, research approach with its paradigm, and understanding of the relationship between management control system and strategy. After classification, the contributions of research to the field and the lessons learned from these studies are discussed. The findings revealed that prior research mainly focused on the business sector of the developed market context, mainly illuminated by contingency and institutional theories, philosophical divides of realism and interpretive, and most of them assume a one-directional relationship between management control systems and strategy. The findings imply that further study can enhance understanding by researching in a different context, using robust alternative theories, a critical realist view of mixed methods research, and a bidirectional conceptualization of the relationship between Management control systems and Strategy.

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Published on 19.4.2024 in Vol 26 (2024)

Investigating the Cost-Effectiveness of Telemonitoring Patients With Cardiac Implantable Electronic Devices: Systematic Review

Authors of this article:

• Sarah Raes 1 , MSc   ; 
• Andrea Prezzi 1 , MSc   ; 
• Rik Willems 2 , PhD   ; 
• Hein Heidbuchel 3 , PhD   ; 
• Lieven Annemans 1 , PhD  

1 Department of Public Health and Primary Care, Ghent University, Gent, Belgium

2 Department of Cardiovascular Sciences, Universiteit Leuven, Leuven, Belgium

3 Department of Genetics, Pharmacology and Physiopathology of Heart, Blood Vessels and Skeleton (GENCOR), Antwerp University, Antwerp, Belgium

Corresponding Author:

Sarah Raes, MSc

Department of Public Health and Primary Care

Ghent University

Corneel Heymanslaan 10

Phone: 32 9 332 83 59

Email: [email protected]

Background: Telemonitoring patients with cardiac implantable electronic devices (CIEDs) can improve their care management. However, the results of cost-effectiveness studies are heterogeneous. Therefore, it is still a matter of debate whether telemonitoring is worth the investment.

Objective: This systematic review aims to investigate the cost-effectiveness of telemonitoring patients with CIEDs, focusing on its key drivers, and the impact of the varying perspectives.

Methods: A systematic review was performed in PubMed, Web of Science, Embase, and EconLit. The search was completed on July 7, 2022. Studies were included if they fulfilled the following criteria: patients had a CIED, comparison with standard care, and inclusion of health economic evaluations (eg, cost-effectiveness analyses and cost-utility analyses). Only complete and peer-reviewed studies were included, and no year limits were applied. The exclusion criteria included studies with partial economic evaluations, systematic reviews or reports, and studies without standard care as a control group. Besides general study characteristics, the following outcome measures were extracted: impact on total cost or income, cost or income drivers, cost or income drivers per patient, cost or income drivers as a percentage of the total cost impact, incremental cost-effectiveness ratios, or cost-utility ratios. Quality was assessed using the Consensus Health Economic Criteria checklist.

Results: Overall, 15 cost-effectiveness analyses were included. All studies were performed in Western countries, mainly Europe, and had primarily a male participant population. Of the 15 studies, 3 (20%) calculated the incremental cost-effectiveness ratio, 1 (7%) the cost-utility ratio, and 11 (73%) the health and cost impact of telemonitoring. In total, 73% (11/15) of the studies indicated that telemonitoring of patients with implantable cardioverter-defibrillators (ICDs) and cardiac resynchronization therapy ICDs was cost-effective and cost-saving, both from a health care and patient perspective. Cost-effectiveness results for telemonitoring of patients with pacemakers were inconclusive. The key drivers for cost reduction from a health care perspective were hospitalizations and scheduled in-office visits. Hospitalization costs were reduced by up to US $912 per patient per year. Scheduled in-office visits included up to 61% of the total cost reduction. Key drivers for cost reduction from a patient perspective were loss of income, cost for scheduled in-office visits and transport. Finally, of the 15 studies, 8 (52%) reported improved quality of life, with statistically significance in only 1 (13%) study ( P =.03).

Conclusions: From a health care and patient perspective, telemonitoring of patients with an ICD or a cardiac resynchronization therapy ICD is a cost-effective and cost-saving alternative to standard care. Inconclusive results were found for patients with pacemakers. However, telemonitoring can lead to a decrease in providers’ income, mainly due to a lack of reimbursement. Introducing appropriate reimbursement could make telemonitoring sustainable for providers while still being cost-effective from a health care payer perspective.

Trial Registration: PROSPERO CRD42022322334; https://tinyurl.com/puunapdr

Introduction

The implantation rates of cardiac implantable electronic devices (CIEDs), including pacemakers and implantable cardioverter-defibrillators (ICDs), have increased over the last decades due to expanded indications and a progressively aging population [ 1 ]. To evaluate the clinical status of the patient and device functioning, current guidelines recommend that older patients with pacemakers should be evaluated every 3 to 12 months and patients with ICDs should be evaluated every 3 to 6 months [ 2 ]. This regimen imposes a considerable burden on patients and physicians if the patient is required to be seen in person.

Telemonitoring, referring to the process of using telecommunication and information technology to monitor the health status of a patient and device function from a distance, can reduce this burden by replacing some in-office visits with transmissions from the patients’ home [ 3 ]. Existing research indicated that telemonitoring is safe (eg, experiencing equal major adverse events to standard care) [ 4 , 5 ]. The advantages of telemonitoring include fewer inappropriate shocks for patients with ICDs [ 4 , 6 ] and fewer hospitalizations for patients with atrial arrhythmias and strokes [ 4 , 6 , 7 ]. Moreover, there is a rapid detection of cardiovascular events and device malfunction [ 5 , 7 ], leading to a time reduction between clinical decision and intervention [ 8 ].

Besides the effectiveness of telemonitoring, patient experience is essential in high-quality health care services. Overall, patients with pacemakers on telemonitoring reported positive experiences comparable to the experience of patients with in-hospital monitoring [ 9 ]. Telemonitored patients with pacemakers tended to receive less information about their diagnosis but no significant differences were found in other items, such as confidence in clinicians, treatment decision involvement, treatment satisfaction, and waiting time before admission [ 9 ]. Another study indicated that telemonitoring of patients with a cardiac resynchronization therapy defibrillator (CRT-D) was time-saving for both patients and physicians [ 10 ].

Cost-effectiveness analyses are important to quantify the value of new interventions, informing both medical decision-making and public policy [ 11 ]. However, cost-effectiveness analyses depend on the perspective considered. The different perspectives are the health care payer perspective (eg, Medicare or Medicaid and British National Health Service), the patient perspective, the provider perspective (eg, physician), and the society perspective. The health care payer and societal perspectives differ from each other as the societal perspective includes indirect nonmedical costs (eg, transport) [ 12 ].

As cost-effectiveness analyses have shown heterogeneous results, it is still debatable whether telemonitoring is worth the investment relative to standard care. However, data on cost-effectiveness are important for health care payers to make decisions on the reimbursement of telemonitoring. Lack of reimbursement can be an important adoption barrier for new technology [ 13 , 14 ]. For these 2 reasons, this paper reviews the cost-effectiveness of telemonitoring, reviews how the results differ from different perspectives, and describes the key drivers of the cost-effectiveness of telemonitoring.

The review protocol was published by PROSPERO (International Prospective Register of Systematic Reviews; CRD42022322334). This systematic review was carried out in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) reporting guideline of 2020 [ 15 ], and the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) [ 16 ], which can be found in the Multimedia Appendix 1 . Guidelines for preparing a systematic review of health economic evaluations were followed [ 17 ].

Literature Search

For this review, PubMed, Embase, EconLit, and Web of Science Core Collection were systematically searched. The last search was performed on July 7, 2022. No filters (eg, publication date or type of study) were applied. Search strategies for all electronic databases can be found in Multimedia Appendix 2 .

Search strings were developed based on explorations of databases and previous reviews. The following key concepts were translated into strings: (1) CIEDs, (2) telemonitoring, and (3) economic evaluations (eg, cost-effectiveness analyses and cost-utility analyses). The latter was based on a validated search filter, designed to identify economic evaluations, and was broadened for this study to maximize sensitivity [ 18 ]. The search terms for CIEDs and telemonitoring were based on existing reviews [ 19 - 21 ].

Study Selection

Studies were included if their primary focus was on the cost-effectiveness of telemonitoring patients with a CIED. The eligibility criteria were defined a priori for study selection ( Textbox 1 ). The population, intervention, comparator, and outcome strategy was applied to describe the criteria. Only complete and peer-reviewed studies were included. Specific exclusion criteria included partial economic evaluations, systematic reviews or reports, and studies without standard care as a control group. Only studies published in English, Dutch, French, or German were eligible for inclusion. The reference lists of the included studies were searched manually to identify relevant studies. Two reviewers (SR and AP) independently screened the titles and abstracts of all records using Rayyan (Rayyan Systems Inc) [ 22 ]. After the initial screening, full texts were retrieved and screened for a second time. The second screening round was independently performed by 2 reviewers (SR and AP). Reasons for exclusion were documented ( Figure 1 ). For both screening rounds, reviewers were blinded from each other’s decision, and disagreements were resolved through discussion.

Inclusion criteria

• Cardiac implantable electronic devices: pacemaker, implantable cardioverter-defibrillator, cardiac resynchronization therapy defibrillator, cardiac resynchronization therapy pacemaker, and loop recorder
• Standard care
• Complete health economic evaluations (within-trial and model-based)
• All settings
• English, French, German, or Dutch

Exclusion criteria

• Implantable pulmonary artery pressure monitor
• Partial health economic evaluations (outcomes related to costs or effectiveness only)
• Systematic reviews, reports, commentaries, congress abstracts, protocols, and animal studies

Quality Assessment

Two researchers (SR and AP) independently evaluated the original papers using the Consensus Health Economic Criteria (CHEC) checklist to assess the risk of bias [ 23 ]. The CHEC checklist included 19 items. Any disagreement was resolved by discussion and consensus. Interpretation of the CHEC list can be found in Multimedia Appendix 3 . The included studies were classified into 4 quality categories: excellent (score of 100%), good quality (score between 75% and 100%), moderate quality (score between 50% and 75%), and low quality (score <50%) [ 24 ].

Synthesis of Results

The study characteristics and main outcomes of the original papers are presented in the Results section. SR extracted all data. A data extraction sheet was developed using an existing template [ 17 ]. The following information was extracted from the included studies: study identification, general study characteristics, results, and authors’ conclusion. The principal outcome measures were health outcomes, cost or income outcomes (eg, the impact on total cost or income, cost or income drivers, cost or income drivers per patient, and cost or income drivers as a percentage of the total cost impact), and incremental cost-effectiveness ratios (ICERs) or cost-utility ratios.

To facilitate comparison across studies, the following adjustments and interpretations were made. First, the cost or income outcomes were presented per patient per year, and different currencies were converted to US Dollar (reference year: 2019 and reference country: United States) [ 25 ]. Second, perspectives were categorized into the health care payer perspective, patient perspective, provider perspective, and societal perspective. For the purpose of our study, the provider includes physicians who are directly involved in the care of patients with CIED.

The selection process is shown in Figure 1 . From a total of 3305 publications, 15 (0.45%) unique publications were reviewed. Studies were excluded because one of the following reasons: (1) intervention: the paper did not describe telemonitoring patients with a CIED; (2) outcome: the paper contained only a cost analysis and not a cost-effectiveness analysis; and (3) study design or publication: the paper was a partial health economic evaluation, congress abstract, protocol, systematic review, animal study, or with no peer review.

Characteristics of the included studies can be found in Table 1 . All 15 (100%) studies had a primarily male population, except for the Nordland study, which had an almost equal sex distribution ( Table 1 ) [ 26 ]. The mean age of the population with pacemakers was between 75 (SD 24.64) and 81 (SD 6.47) years. The mean age of patients with an ICD or CRT-D was between 61 (SD 12.6) and 69 (SD not calculated) years, except for the PREDICT RM study, where >50% of the population was aged >75 years [ 27 ]. Furthermore, of the 15 studies, 1 (7%) included only older patients (with a mean age of 81 years) with pacemakers [ 28 ], and 2 (13%) ICD or CRT-D studies only included patients with heart failure [ 11 , 29 ].

a CIED: cardiac implantable electronic device.

b N/A: not applicable.

c Age was a discrete variable in this study (higher of lower than 75 years old).

d ICD: implantable cardioverter-defibrillator.

e TARIFF: Health Economics Evaluation Registry for Remote Follow-Up.

f CRT-D: cardiac resynchronization therapy defibrillator.

g EVOLVO: Evolution of Management Strategies of Heart Failure Patients With Implantable Defibrillators.

h MORE-CARE: Monitoring Resynchronization Devices and Cardiac Patients.

i CONNECT: Clinical Evaluation of Remote Notification to Reduce Time to Clinical Decision.

j ECOST: Effectiveness and Cost of ICD Follow-Up Schedule With Telecardiology.

k EuroEco: European Health Economic Trial on Home Monitoring in ICD Patients.

l VVI-ICD: single-chamber ICD.

m DDD-ICD: dual-chamber ICD.

n SAVE-HM: Socio-Economic Effects and Cost Saving Potential of Remote Patient Monitoring.

Study Designs

Tables 2 and 3 show the summary table of results. Of 15 studies, 11 (73%) were conducted in Europe [ 11 , 26 , 28 - 32 , 34 , 35 , 37 ], 3 (20%) in the United States [ 27 , 33 , 38 ], and 1 (7%) in Canada [ 36 ]. Of the 15 studies, 3 (20%) calculated the ICER [ 26 - 28 ], 1 (7%) calculated the cost-utility ratio [ 11 ], and 11 (73%) calculated the cost impact of telemonitoring. All studies analyzed the health care payer perspective, with 33% (5/15) analyzing the patient perspective [ 11 , 28 , 30 , 32 , 34 ], 13% (2/15) analyzing the societal perspective [ 33 , 35 ], and 13% (2/15) analyzing the provider perspective [ 13 , 30 ].

b RCT: randomized controlled trial.

c QALY: quality-adjusted life year.

d ICER: incremental cost-effectiveness ratio.

e SAVE-HM: Socio-Economic Effects and Cost Saving Potential of Remote Patient Monitoring.

f N/A: not applicable.

g ICD: implantable cardioverter-defibrillator.

h CRT-D: cardiac resynchronization therapy defibrillator.

i TARIFF: Health Economics Evaluation Registry for Remote Follow-Up.

j EVOLVO: Evolution of Management Strategies of Heart Failure Patients With Implantable Defibrillators.

k The values are statistically significant.

l MORE-CARE: Monitoring Resynchronization Devices and Cardiac Patients.

m QOL: quality of life.

n CONNECT: Clinical Evaluation of Remote Notification to Reduce Time to Clinical Decision.

o ECOST: Effectiveness and Cost of ICD Follow-Up Schedule With Telecardiology.

p SF-36: The 36-Item Short Form Survey.

q EuroEco: European Health Economic Trial on Home Monitoring in ICD Patients.

a If the perspective is health care system or patient, then cost and if the perspective is provider, then income .

b pp: per patient (in health care and patient perspectives) or per physician (in provider perspective).

c The values are statistically significant.

d SAVE-HM: Socio-Economic Effects and Cost Saving Potential of Remote Patient Monitoring.

e ED: emergency department.

f ICD: implantable cardioverter-defibrillator.

g CRT-D: cardiac resynchronization therapy defibrillator.

h TARIFF: Health Economics Evaluation Registry for Remote Follow-Up.

i EVOLVO: Evolution of Management Strategies of Heart Failure Patients With Implantable Defibrillators.

j MORE-CARE: Monitoring Resynchronization Devices and Cardiac Patients.

k Costs were recalculated per patient.

l CONNECT: Clinical Evaluation of Remote Notification to Reduce Time to Clinical Decision.

m ECOST: Effectiveness and Cost of ICD Follow-Up Schedule With Telecardiology.

n EuroEco: European Health Economic Trial on Home Monitoring in ICD Patients.

Intervention and Comparator

Telemonitoring entailed data transmission and data review. Table 4 shows the frequencies of data transmission, review, and in-office visits of the included studies. In 47% (7/15) of the studies, data were transmitted continuously or daily [ 26 , 28 , 30 , 31 , 34 , 35 ]; in 20% (3/15) studies, data were transmitted after a device alert [ 8 , 11 , 29 ]; and in 13% (2/15) studies, data were transmitted every 3 months [ 32 , 33 ]. In 20% (3/15) of the studies, data review was performed daily [ 28 , 34 , 35 ]; however, in 40% (6/15) of the studies, it was performed after a device alert was received [ 8 , 11 , 26 , 29 - 31 ]. Besides data transmission and review, telemonitoring included scheduled in-office visits. In 33% (5/15) of the studies, all scheduled in-office visits were based on the protocol [ 11 , 13 , 29 , 30 , 35 ]. In 7% (1/15) of the studies, at least 1 scheduled in-office visit was protocol based [ 37 ]. In 3 (20%) of the 15 studies, only 1 scheduled in-office visit was protocol based [ 32 - 34 ]. Protocol-based in-office visits are described in Table 4 .

b pp: per patient.

c TARIFF: Health Economics Evaluation Registry for Remote Follow-Up.

d EVOLVO: Evolution of Management Strategies of Heart Failure Patients With Implantable Defibrillators.

e MORE-CARE: Monitoring Resynchronization Devices and Cardiac Patients.

g ECOST: Effectiveness and Cost of ICD Follow-Up Schedule With Telecardiology.

h EuroEco: European Health Economic Trial on Home Monitoring in ICD Patients.

i Save-HM: Socio-Economic Effects and Cost Saving Potential of Remote Patient Monitoring.

j ICD: implantable-cardioverter defibrillator.

k N/A: not applicable.

Effectiveness

Effectiveness results of telemonitoring can be found in Table 2 . Of the 15 studies, 9 (60%) investigated a quality-adjusted life year (QALY) or quality of life (QOL) difference [ 11 , 26 - 30 , 33 , 34 ]. A total of 53% (8/15) of studies reported an increase in QALY or QOL [ 11 , 26 - 28 , 30 , 33 , 34 , 39 ], but the QALY or QOL increase was only statistically significant in 1 (13%; P =.03) of the 8 studies [ 26 - 28 , 30 , 33 , 34 ]. In contrast, only 1 (11%) of the 9 studies investigating QOL or QALY reported a significant decrease in QOL [ 29 ]. Comparing all studies, QALY differences ranged from 0.03 to 0.27 in patients with pacemakers and ranged from −1 to 0.64 in patients with ICD or CRT-D.

Besides QALY or QOL, several studies reported other health outcomes. Chew et al [ 36 ] indicated that the risk of death was lower with telemonitoring. Al-Khatib et al [ 33 ] reported that mortality and general patient satisfaction with telemonitoring were equal to those of standard care. Crossley et al [ 8 ] reported that the time between the clinical event and the clinical decision was 17.4 days shorter in patients with an ICD or CRT-D on telemonitoring than in those on standard care ( P <.001). Burri et al [ 31 ] indicated that telemonitoring patients with ICD or CRT-D led to fewer inappropriate shocks (−51%) and a reduction in battery exhaustion (−7%). Raatikainen et al [ 32 ] indicated that telemonitoring patients with an ICD reduced the average total time spent on device follow-up, with 17 minutes per patient per follow-up for physicians and 175 minutes per patient per follow-up for patients. Similarly, Dario et al [ 37 ] indicated that the time spent by physicians to treat the patient reduced by an average of 4.1 minutes per follow-up in patients with pacemakers and an average of 13.7 minutes per follow-up in patients with an ICD (SD was not reported).

Economic Impact

The results of the economic impact of telemonitoring are presented in Table 2 . Of the 15 studies, 4 (27%) investigated the cost impact of telemonitoring in patients with pacemakers [ 26 , 28 , 35 , 37 ]. From a health care payer perspective, 1 (25%) of the 4 pacemaker studies indicated that telemonitoring increased costs with US $2183 per patient per year (not statistically significant) mainly because of increased hospitalization costs [ 26 ]. A total of 2 (50%) of the 4 pacemaker studies indicated that telemonitoring reduced costs by US $8.9 and US $1054 per patient per year mainly because of a reduction in hospitalization and staff costs, respectively [ 28 , 37 ]. Therefore, hospitalizations reduced costs in the study by Dario et al [ 37 ] but increased costs in the study by Lopez-Villegas et al [ 26 ]. From a patient and societal perspective, the results indicated that telemonitoring reduced costs by US $11 and US $1113 per patient per year, respectively, mainly because of lower transport costs [ 28 , 35 ].

Of the 15 studies, 13 (87%) investigated the cost or income impact of telemonitoring in patients with an ICD or CRT-D [ 8 , 11 , 13 , 27 , 29 - 37 ]. A total of 11 (85%) of the 13 ICD or CRT-D studies investigated the cost impact of telemonitoring from a health care payer perspective, all indicating that telemonitoring reduced costs for patients with an ICD or CRT-D [ 8 , 11 , 13 , 27 , 29 - 32 , 34 , 36 , 37 ]. A total of 9 (82%) of the 11 health care payer perspective studies indicated that hospitalization was the largest driver for cost reduction for patients with an ICD or CRT-D [ 8 , 11 , 13 , 27 , 29 , 30 , 34 , 36 , 37 ]. The hospitalization cost reduced by up to US $912.3 per patient per year [ 34 ]. In addition, scheduled in-office visits were reported as a driver for cost reduction in 5 (45%) of the 11 health care payer perspective studies, as up to 61% of the total cost reduction was due to a decrease in the number of scheduled in-office visits [ 11 , 29 , 30 , 32 , 34 ]. Besides cost drivers that reduced costs, there were also drivers that increased costs. In 3 (27%) of the 11 health care payer perspective studies, unscheduled visits increased the total cost impact of telemonitoring [ 11 , 13 , 29 , 30 , 33 ]. A total of 3 (20%) of the 15 studies indicated that the cost reduction for scheduled in-office visits outweighed the cost increase for unscheduled in-office visits (−US $81.4 vs US $15.6, −US $45.4 vs US $7.8, and −US $44.1 vs US $14/patient/year) [ 11 , 29 , 30 ].

The results of 4 (31%) of the 13 ICD or CRT-D studies that investigated the cost impact of telemonitoring from the patients’ perspective [ 11 , 30 , 32 , 34 ] indicated that patient and caregiver loss of work or activity [ 30 ], scheduled in-office visits [ 11 ], and transport [ 34 ] were the largest drivers for cost reduction. The results of 2 (15%) of the 13 ICD or CRT-D studies that investigated the income impact of telemonitoring from a provider perspective indicated that the loss of reimbursed (scheduled) in-office visits was the most important factor for income loss due to telemonitoring [ 13 , 30 ], reducing income by up to €72.7 (US $77.21) per patient per year [ 30 ].

ICER and Cost-Utility Ratio

Results on ICER and the cost-utility ratio are presented in Table 2 . Of the 15 studies, 3 (20%) calculated the ICER from a health care payer perspective [ 26 - 28 ] and 1 (7%) calculated the cost-utility ratio from a health care payer perspective [ 11 ]. Of the 15 studies, 2 (13%) calculating ICER were conducted with patients with pacemakers [ 26 , 28 ]. Notably, of the 2 studies, 1 (50%) indicated that telemonitoring was cost-effective (ICER: US $270.09/QALY) [ 28 ], and 1 (50%) indicated that telemonitoring was not cost-effective (ICER: US $64,410/QALY) [ 26 ]. For patients with an ICD or CRT-D, of the 2 studies, 1 (50%) indicated that telemonitoring was cost-effective (ICER: US $12,069/QALY) [ 27 ] and 1 (50%) indicated that telemonitoring was dominant [ 11 ].

Critical Appraisal

The critical appraisal of the individual studies is provided in Tables 5 and 6 . Of the 15 studies, 1 (7%) was classified as excellent (score of 100%) [ 13 ], 8 (53%) had a good quality score (100%<score>75%) [ 26 , 28 , 30 , 31 , 33 , 34 , 36 , 37 ], and 6 (40%) had a moderate quality score (75%<score>50%) [ 8 , 11 , 27 , 29 , 32 , 35 ]. A total of 3 (20%) of the 15 studies scored the lowest, with 59% each [ 8 , 29 , 32 ]. More than 50% (>8/15) of the studies scored low for the items cost valuation (item 9) [ 11 , 27 - 32 , 34 , 35 , 37 ], discounting (item 14) [ 8 , 11 , 29 , 30 , 32 , 34 , 35 , 37 ], and no conflict of interest (item 18) [ 8 , 11 , 27 , 29 , 30 , 32 , 34 , 35 ]. All studies scored high on the items study population (item 1), study design (item 4), time horizon (item 10), outcome identification (item 11), outcome measurement (item 12), and ethics (item 19).

a EuroEco: European Health Economic Trial on Home Monitoring in ICD patients.

b TARIFF: Health Economics Evaluation Registry for Remote Follow-Up.

c ECOST: Effectiveness and Cost of ICD Follow-Up Schedule With Telecardiology.

d Sufficient attention was given to this aspect.

e Insufficient attention was given to this aspect.

a Save-HM: Socio-Economic Effects and Cost Saving Potential of Remote Patient Monitoring.

b EVOLVO: Evolution of Management Strategies of Heart Failure Patients With Implantable Defibrillators.

c MORE-CARE: Monitoring Resynchronization Devices and Cardiac Patients.

d CONNECT: Clinical Evaluation of Remote Notification to Reduce Time to Clinical Decision.

e Sufficient attention is given to this aspect.

f Insufficient attention is given to this aspect.

g N/A: not applicable.

Principal Findings and Comparison With Prior Work

The primary aim of this study was to investigate the cost-effectiveness of telemonitoring patients with an ICD or CRT-D and a pacemaker from different perspectives.

From a health care payer perspective, most studies indicated that telemonitoring was a cost-saving and effective alternative to standard care. The most important driver for cost reduction was hospitalizations, both in patients with a pacemaker and those with an ICD or CRT-D. The cost of hospitalizations was reduced by up to US $912.3 per patient per year [ 34 ]. Moreover, the reduction of scheduled in-office visits was the second most important cost-saving factor in most ICD or CRT-D studies, with up to 61% of the total cost reduction. Previous research indicated that up to 55% of the device follow-ups were routine checks with no actionable events or device programming [ 35 , 40 , 41 ]. Several researchers pointed out that most scheduled in-office visits could be replaced by telemonitoring without affecting the quality of care [ 7 , 34 ] and with potentially diagnosing >99.5% of arrhythmia and device problems [ 41 ]. Although scheduled in-office visits decreased, our results show that unscheduled in-office visits increased because of telemonitoring patients with an ICD or CRT-D, probably because of the possible faster detection of arrhythmia and device malfunction by telemonitoring [ 8 ]. However, in all studies analyzing both scheduled and unscheduled in-office visits, the cost reduction for scheduled in-office visits outweighed the cost increase for unscheduled in-office visits [ 11 , 29 , 30 ].

From a patient perspective, our results indicated that the reduction of professional activity, transport time, and costs due to scheduled in-office visits are the most important factors for cost reduction.

The provider perspective was investigated less frequently in the included studies, although it is very relevant. Owing to the reduction of scheduled in-office visits, providers will lose income with telemonitoring if no reimbursement exists for telemonitoring but only for in-office visits. As a result, providers will be stimulated to maintain the classic follow-up instead of telemonitoring. Of the 15 studies, 1 (7%) observed that the total cost for insurance payers does not increase in countries where telemonitoring is reimbursed [ 13 ]. As telemonitoring decreases the overall costs from a health care payer perspective, there is room for proper compensation for providers to transition from in-office care to remote care. Hence, correct compensation (which is possible while still saving on the overall health care cost) will stimulate providers to switch to telemonitoring as the desired care path for patients with a CIED.

All studies reported the effectiveness of telemonitoring. Of the 15 studies, 9 (60%) indicated a QALY or QOL difference. Furthermore, 89% (8/9) of these studies indicated an increase in QALYs or QOL for telemonitoring patients with pacemakers or ICD or CRT-D, ranging from −1 to 0.64. Some studies (3/9, 33%) indicated this QALY or QOL increase was the result of the reduced routine in-office visits [ 7 , 34 ]. However, the QALY or QOL increase was only statistically significant (and positive) in 1 (11%) of the 9 studies [ 11 ]. Nevertheless, patient questionnaires have demonstrated a high acceptance of telemonitoring among patients with pacemakers and those with ICDs [ 39 ]. Moreover, telemonitoring is reported to lead to an increased sense of security [ 39 ]. Furthermore, the results indicated that telemonitoring leads to fewer inappropriate shocks, an important determinant of QALY, in patients with an ICD or CRT-D [ 31 ].

The cost-effectiveness analyses may be sensitive to the heterogeneity among the organization of telemonitoring in different hospitals. This may include different devices, the number of transmissions, the configuration of alerts, and hospital visit scheduling [ 26 ]. It seems reasonable to expect that the efficiency of telemonitoring not only depends on the technology but also on the organization of the service. If hospitals see telemonitoring as an additional service, on top of standard care, less cost-savings may be seen than if hospitals see telemonitoring as a substitute for standard care. A radical organizational change could lead to larger cost-savings, as suggested by an observational study by Facchin et al [ 42 ]. Moreover, such radical change may include a strategy involving other physicians, such as general practitioners, and referring cardiologists, that is, an integrated health care delivery [ 37 ].

Furthermore, the comparison between studies is challenged by differences in study design. The Poniente study by Bautista-Mesa et al [ 28 ] followed up patients with pacemakers for 12 months and indicated a QALY increase of 0.09 for telemonitoring. However, after 5 years of follow-up, the results indicated a QALY decrease of 0.20 for telemonitoring. Bautista-Mesa et al [ 28 ] indicated that some of the telemonitoring benefits (eg, reduction of in-office visits) may not be appreciated in the long term. Therefore, the evolution of utilities may be different depending on the follow-up time. In addition, the results indicated that hospitalizations reduced costs in the study by Dario et al [ 37 ] but increased costs in the study by Lopez-Villegas et al [ 26 ]. This discrepancy might be explained because significantly fewer patients were included in the study by Lopez-Villegas et al (50 vs 2101 patients). None of the 25 patients in the conventional follow-up group were hospitalized, whereas 12% (3/25) of the patients were hospitalized in the remotely monitored group (all for pacemaker problems) [ 26 ]. Furthermore, the included studies relied disproportionally on male participants, except for the Nordland study [ 26 ]. This may be explained by the significant sex disparity in ICD implantation rates, pointed out by Ingelaere et al [ 43 ]. Ingelaere et al [ 43 ] could not completely explain these differences by prevalence differences of cardiomyopathies and imply a possible undertreatment of women. Another study [ 44 ] observed an undertreatment of women with coronary heart disease, as they are less likely to undergo coronary angiography. Therefore, men may undergo more expensive treatments than women. This can explain why the included cost-effectiveness studies may present an overly positive result. In addition, time differences may impact the quality and cost-effectiveness of telemonitoring, as telemonitoring may evolve over time. However, our results did not provide meaningful insights in this respect.

The cost-effectiveness analyses may be sensitive to the heterogeneity among health care systems. From a provider perspective, our results indicated that telemonitoring generates lesser profit than standard care in the absence of reimbursement. Therefore, the lack of reimbursement is generally perceived as a major implementation barrier to telemonitoring, affecting 80% of the centers [ 45 ]. Consequently, providers tend to continue with standard care instead of telemonitoring. However, from a health care payer perspective, our results indicated that telemonitoring was still cost-saving even with reimbursement [ 13 , 34 ]. To stimulate providers to use telemonitoring, provider compensation should be provided based on overall health care cost-savings, making telemonitoring possible if it is preferred as the way to deliver CIED follow-up care.

Limitations

Because of the large discrepancies between health care systems’ organization, costs, access, delivery, quality, and reimbursement of cardiac care, any generalization may be perceived as inaccurate [ 37 , 46 ]. For instance, the included studies were mainly performed in Western countries. The results may not be generalizable to non-Western countries. Therefore, the cost-effectiveness results are contingent on the context in which they were analyzed [ 46 ]. Another limitation of this research is that 40% (6/15) of the included studies are not randomized controlled trials. These studies may have unobserved confounding factors that cannot be controlled for. Finally, cost analyses were excluded in this study because of our research objective. However, future cost analyses could draw a lot of information from analyzing these excluded studies.

Conclusions

Telemonitoring patients with CIED may be a cost-effective alternative to standard follow-up. Moreover, telemonitoring may lead to a cost reduction from a health care and patient perspective, mainly by the reduction of hospitalizations and scheduled in-office visits. Owing to the reduction in scheduled in-office visits, providers’ income tends to decrease when implementing telemonitoring without proper reimbursement. Introducing appropriate reimbursement could make telemonitoring sustainable for providers, while still being cost-effective from a health care payer perspective.

Acknowledgments

The authors would like to thank Dr Ingrid Kremer of Maastricht University for her help in the manuscript review. This work was supported by the Fund for Scientific Research Flanders (Fonds Wetenschappelijk Onderzoek Vlaanderen, grant 1SC9322N, 2021). RW is supported as a postdoctoral clinical researcher by the Fund for Scientific Research Flanders (Fonds Wetenschappelijk Onderzoek Vlaanderen).

Data Availability

All data generated or analyzed during this study are included in this published article and its multimedia appendices.

Authors' Contributions

SR and LA were responsible for the conceptualization of the manuscript. SR, LA, RW, and HH acquired the financial support necessary for this paper and developed the methodology. SR analyzed and investigated the data. AP, LA, RW, and HH validated the results. SR was responsible for the first and final drafts. LA, RW, and HH were involved in editing the drafts. All authors approved the final manuscript.

Conflicts of Interest

RW reports research funding from Abbott, Biotronik, Boston Scientific, and Medtronic and speakers and consultancy fees from Medtronic, Boston Scientific, Biotronik, and Abbott. None of these payments were personal; all were handled through the University of Leuven. HH received personal lecture and consultancy fees from Abbott, Biotronik, Daiichi-Sankyo, Pfizer-BMS, Medscape, and Springer Healthcare Limited. He received unconditional research grants through the University of Antwerp and the University of Hasselt from Abbott, Bayer, Biotronik, Biosense Webster, Boston Scientific, Boehringer Ingelheim, Daicchi-Sankyo, Fibricheck or Qompium, Medtronic, and Pfizer-BMS, all outside the scope of this work. All other authors declare no other conflicts of interest.

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Abbreviations

Edited by T Leung; submitted 28.03.23; peer-reviewed by P Jeurissen, B Dechert; comments to author 07.09.23; revised version received 13.09.23; accepted 13.02.24; published 19.04.24.

©Sarah Raes, Andrea Prezzi, Rik Willems, Hein Heidbuchel, Lieven Annemans. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 19.04.2024.

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• Introduction
• Conclusions
• Article Information

The figure shows respondents recommendations for cases 1 and 2 (A), cases 3 and 4 (B), and cases 5 and 6 (C). Error bars indicate 95% CIs. In panel A, examination findings include dry (ie, dry mucus membranes), euvolemic (ie, moist mucous membranes and normal jugular venous pressure), and wet (elevated jugular venous pressure and bilateral pitting edema [grade +1]). In panel C, lactate findings include lactate decreasing (ie, initial lactate level of 36.94 mg/dL decreased to 24.32 mg/dL with fluids [to convert to millimoles per liter, multiply by 0.111]), lactate repeat pending (ie, initial lactate level of 36.94 mg/dL with repeat pending), and lactate increasing (ie, initial lactate level of 36.94 mg/dL increased to 48.65 mg/dL despite fluids). COPD indicates chronic obstructive pulmonary disease; CVC, central venous catheter; HFrEF, heart failure with reduced ejection fraction; MAP, mean arterial pressure; PICC, peripherally inserted central catheter; and PIV, peripheral venous catheter.

a Indicates P  < .05.

b Indicates P  < .001.

The figure shows the pooled route of vasopressor initiation for cases 1, 3, and 5, where baseline vascular access was 2 PIVs (A; based on 1127 vignettes), the route of vasopressor initiation for case 4, where baseline vascular access was a port (B; based on 390 vignettes), and the route of vasopressor initiation for case 6, where baseline vascular access was a PICC (C; based on 367 vignettes). Case 2 was not included in this analysis because the patient in case 2 had a preexisting new temporary central line, which was presumed to be the default route of vasopressor initiation. PICC indicates peripherally inserted central catheter; PIV, peripheral venous catheter. PIV only refers to starting the vasopressor peripherally; PIV bridge refers to starting the vasopressor peripherally but planning to place a new central line; and new central refers to placing a new central line before starting the vasopressor.

Patients in these cases were receiving norepinephrine through an 18-gauge peripheral venous catheter (PIV; location excluded the antecubital fossa). Respondents were asked if they would continue the vasopressor peripherally or place central access (ie, a temporary central line or peripherally inserted central catheter). Error bars denote 95% CIs. Case 7 was a 55-year-old female patient with cholecystitis; case 8 was a 70-year-old male patient with pneumonia; case 9 was a 65-year-old female patient with urosepsis; and case 10 was a 60-year-old male with cellulitis.

a Indicates P  < .001.

eAppendix 1. Outline of Randomized Clinical Factors

eAppendix 2. Full Survey

eMethods. Details of Logistic Regression Models

eTable 1. Association of Fluid Volume and MAP With Recommendations for Fluids and Vasopressors, Cases 1-6

eTable 2. Association of Randomized Clinical Factors With Recommendations for Fluids and Vasopressors

eTable 3. Characteristics of Survey Participants Compared to Characteristics of Society of Critical Care Medicine (SCCM) Providers Who Received the Survey

eFigure 1. Perceived Realism of Clinical Vignettes

eFigure 2. Self-Reported Usual Practices for Managing Patients With New Sepsis-Induced Hypotension

eFigure 3. Range of Respondent Answers Across Cases

eFigure 4. Range of Respondent Answers Across Cases Where Participants Saw the Same Fluid Volume Already Received

eTable 4. Association of Fluid Volume, MAP, and Case With Perceived Case Difficulty, Cases 1-6

eFigure 5. Overall Association of Fluid Volume and MAP With Recommendations for Fluids and Vasopressors, Cases 1-6

eTable 5. Additional Requested Factors for Fluid and Vasopressor Decisions, Cases 1-6

eTable 6. Association of Randomized Clinical Factors With Peripheral Vasopressor Initiation

eTable 7. Association of Randomized Clinical Factors With Recommendation to Place a Central Line in Patients Receiving Peripheral Vasopressors

eTable 8. Identified Themes From a Free-Text Question Eliciting Factors That Contributed to Respondents’ Decision to Place a Central Line in Patients on Peripheral Vasopressors, Cases 7-10

eFigure 6. Self-Reported Factor That Most Influences the Decision to Use Peripheral Vasopressors

eTable 9. Identified Themes From a Free-Text Question About Most Important Factors Impacting Decision About Peripheral Vasopressor Use

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Munroe ES , Weinstein J , Gershengorn HB, et al. Understanding How Clinicians Personalize Fluid and Vasopressor Decisions in Early Sepsis Management. JAMA Netw Open. 2024;7(4):e247480. doi:10.1001/jamanetworkopen.2024.7480

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Understanding How Clinicians Personalize Fluid and Vasopressor Decisions in Early Sepsis Management

• 1 Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan, Ann Arbor
• 2 VA Center for Clinical Management Research, Ann Arbor, Michigan
• 3 Division of Pulmonary, Critical Care, and Sleep Medicine, University of Miami Miller School of Medicine, Miami, Florida
• 4 Division of Critical Care Medicine, Albert Einstein College of Medicine, Bronx, New York
• 5 Department of Medicine, University of Michigan, Ann Arbor

Question   How do clinicians personalize decisions about fluid and vasopressor administration for patients in early stages of sepsis?

Findings   In this survey study of 550 US critical care clinicians, respondents relied on fluid volume already received more than other clinical factors (eg, respiratory status or lactate trend) to inform decisions about fluid and vasopressor administration. Most respondents chose to start vasopressors peripherally, with vasopressor dose, trend, and duration associated with the subsequent decision to place a central line.

Meaning   These findings suggest that fluid volume received is the predominant factor guiding ongoing fluid and vasopressor decisions. Future studies aimed at personalizing resuscitation in sepsis must account for fluid volume and should incorporate specific tools to help clinicians personalize care.

Importance   Recent sepsis trials suggest that fluid-liberal vs fluid-restrictive resuscitation has similar outcomes. These trials used generalized approaches to resuscitation, and little is known about how clinicians personalize fluid and vasopressor administration in practice.

Objective   To understand how clinicians personalize decisions about resuscitation in practice.

Design, Setting, and Participants   This survey study of US clinicians in the Society of Critical Care Medicine membership roster was conducted from November 2022 to January 2023. Surveys contained 10 vignettes of patients with sepsis where pertinent clinical factors (eg, fluid received and volume status) were randomized. Respondents selected the next steps in management. Data analysis was conducted from February to September 2023.

Exposure   Online Qualtrics clinical vignette survey.

Main Outcomes and Measures   Using multivariable logistic regression, the associations of clinical factors with decisions about fluid administration, vasopressor initiation, and vasopressor route were tested. Results are presented as adjusted proportions with 95% CIs.

Results   Among 11 203 invited clinicians, 550 (4.9%; 261 men [47.5%] and 192 women [34.9%]; 173 with >15 years of practice [31.5%]) completed at least 1 vignette and were included. A majority were physicians (337 respondents [61.3%]) and critical care trained (369 respondents [67.1%]). Fluid volume already received by a patient was associated with resuscitation decisions. After 1 L of fluid, an adjusted 82.5% (95% CI, 80.2%-84.8%) of respondents prescribed additional fluid and an adjusted 55.0% (95% CI, 51.9%-58.1%) initiated vasopressors. After 5 L of fluid, an adjusted 17.5% (95% CI, 15.1%-19.9%) of respondents prescribed more fluid while an adjusted 92.7% (95% CI, 91.1%-94.3%) initiated vasopressors. More respondents prescribed fluid when the patient examination found dry vs wet (ie, overloaded) volume status (adjusted proportion, 66.9% [95% CI, 62.5%-71.2%] vs adjusted proportion, 26.5% [95% CI, 22.3%-30.6%]). Medical history, respiratory status, lactate trend, and acute kidney injury had small associations with fluid and vasopressor decisions. In 1023 of 1127 vignettes (90.8%) where the patient did not have central access, respondents were willing to start vasopressors through a peripheral intravenous catheter. In cases where patients were already receiving peripheral norepinephrine, respondents were more likely to place a central line at higher norepinephrine doses of 0.5 µg/kg/min (adjusted proportion, 78.0%; 95% CI, 74.7%-81.2%) vs 0.08 µg/kg/min (adjusted proportion, 25.2%; 95% CI, 21.8%-28.5%) and after 24 hours (adjusted proportion, 59.5%; 95% CI, 56.6%-62.5%) vs 8 hours (adjusted proportion, 47.1%; 95% CI, 44.0%-50.1%).

Conclusions and Relevance   These findings suggest that fluid volume received is the predominant factor associated with ongoing fluid and vasopressor decisions, outweighing many other clinical factors. Peripheral vasopressor use is common. Future studies aimed at personalizing resuscitation must account for fluid volumes and should incorporate specific tools to help clinicians personalize resuscitation.

Sepsis is a major cause of morbidity and mortality, accounting for up to 1 in every 2 hospital deaths in the US. 1 , 2 Patients who develop sepsis-induced hypotension are typically treated using intravenous (IV) fluids, with vasopressors reserved for refractory hypotension and shock. 3 , 4 Traditional recommendations to administer vasopressors via central venous access have also historically limited how quickly vasopressors can be started. Because central lines take time to place, clinicians often rely on fluids to support blood pressure during central line placement. 5 , 6 However, there has been recent concern that aggressive fluid resuscitation and fluid overload may increase organ failure and mortality in patients with sepsis. 7 - 9 Concurrently, emerging data have demonstrated that administering vasopressors through peripheral IVs (PIVs) is safe, which may help facilitate earlier vasopressor initiation. 5 , 10 - 13 As a result, there has been increasing interest in restricting fluid volumes and starting vasopressors earlier. 14 , 15

To date, clinical trials comparing fluid-restrictive, early vasopressor treatment vs fluid-liberal strategies in patients with sepsis have yielded neutral results. 16 , 17 However, these trials have used generalized protocols and broad clinical criteria, rather than personalized approaches, to guide resuscitation. Little is known about how clinicians make decisions about fluid and vasopressor administration in practice. Understanding existing resuscitation approaches and how clinicians personalize resuscitation decisions is important to informing future clinical trials aimed at optimizing sepsis resuscitation.

In this study, we sought to determine clinical factors associated with clinician decisions about fluid administration, vasopressor initiation, and vasopressor route in early sepsis using a randomized vignette survey method. This survey design has been demonstrated to elicit preferences and predict behavior, providing insight into clinician decision-making. 18 - 20

This survey study was deemed exempt from review by the University of Michigan institutional review board because the study used an anonymous survey in accordance with the Common Rule. The study followed the American Association for Public Opinion Research ( AAPOR ) reporting guideline. 21 We conducted a randomized vignette survey through the Society of Critical Care Medicine (SCCM). The survey was administered in Qualtrics. We piloted the survey with a group of critical care physician researchers. After incorporating feedback, we tested the updated survey using cognitive interviewing sessions and iterative modification with 7 additional critical care physicians and advanced practice clinicians (APPs; eg, nurse practitioners and physician assistants) not included in the final survey.

The final survey was distributed on November 30, 2022, via email through the SCCM member list-serve to US-based physicians and APPs (as determined based on internal SCCM demographic information). The first page of the survey provided information about informed consent. A participant was deemed to have consented to the study if they proceeded to the next page. Responses were anonymous. A reminder email was sent 3 weeks later. The survey closed after 7 weeks. Respondents who completed the survey were offered the opportunity to enter a raffle for twenty $50 gift cards.

The survey consisted of 10 clinical vignettes followed by questions about general practices and demographics. Vignettes presented patients with sepsis and hypotension and were divided into 2 sections: fluid and vasopressor management (cases 1-6) and central line placement (cases 7-10). Vignette order was randomized within each section. Each vignette included randomized clinical factors (eAppendix 1 in Supplement 1) , which were selected based on literature review and clinical experience. Respondents had the option to comment on each case using a free-text response box. After completing all 10 vignettes, respondents were asked to assess case realism on a 4-point scale (unrealistic to very realistic) to self-report their usual sepsis resuscitation practices and to provide basic demographic information. The full survey is provided in eAppendix 2 in Supplement 1 .

Cases 1 to 6 assessed resuscitation practices and vasopressor initiation route. In each case, respondents were asked whether they would give additional fluid, start vasopressors, both, or neither. Respondents who chose to start vasopressors were asked what route they would use: PIV only, PIV as a bridge to a central venous catheter (CVC), or central access only (new CVC or preexisting central access, if applicable). Respondents were also asked to rate the difficulty of each case on a 5-point Likert scale.

Among cases 1 to 6, each set of 2 cases were paired (1 and 2, 3 and 4, and 5 and 6). Baseline vascular access was set in the question stem with each case pair having 1 case where the patient had only peripheral access (2 PIVs) and 1 case where the patient already had central access (temporary CVC, port, or peripherally inserted central catheter [PICC]). For all 6 cases, the amount of fluid the patient had already received (1 L, 2 L, or 5 L) and current mean arterial pressure (MAP; 52 mm Hg, 58 mm Hg, or 64 mm Hg) were randomized. Cases 1 and 2 included additional randomized factors related to an assessment of the patient’s volume status by clinical examination (dry, euvolemic, or wet) and past medical history (chronic obstructive pulmonary disease, heart failure with reduced ejection fraction [HFrEF], or kidney failure and receiving dialysis). Cases 3 and 4 included randomized supplemental oxygen support (room air, 6-L nasal cannula, or 50% face mask) and respiratory rate (20 breaths per minute, 30 breaths per minute, or 40 breaths per minute). Cases 5 and 6 included randomized laboratory-based factors: lactate trend after fluids (increasing, decreasing, or repeat pending) and acute kidney injury (AKI; no AKI, nonoliguric AKI, or oliguric AKI). Factors were individually randomized, so respondents could have theoretically seen the same conditions across cases (eg, 1 L of fluid in all cases 1-6, or dry examination in cases 1 and 2).

Cases 7 to 10 assessed clinician threshold for placing central access in patients with septic shock already receiving norepinephrine through an 18-gauge PIV. Respondents were asked whether they would continue norepinephrine through the PIV or place new central access. Vasopressor dose (0.08 μg/kg/min, 0.2 μg/kg/min, or 0.5 μg/kg/m), dose trend (decreasing, stable, or increasing), duration (8 hours or 24 hours), and PIV location (forearm or upper arm) were randomized for each case.

To ensure case realism, certain background characteristics (age, sex, and sepsis etiology) were provided but were not randomized. In cases 1 to 6, these fixed characteristics were similar within each case pair (eg, cases 1 and 2 presented patients with similar age and sex).

Respondents who completed at least 1 vignette were included in the analysis. Survey weighting was not used. Descriptive statistics were used to assess participant characteristics, usual practice, route of vasopressor initiation, and case realism. We used χ 2 tests of difference to compare participant demographics with available demographic information about SCCM members who were sent the survey (data provided by SCCM). Free-text comments were manually reviewed by 2 independent reviewers (E.M. and K.K.) to identify themes. Disagreements were resolved by discussion and input from a third reviewer (H.C.P.) as needed.

Participant responses following randomized factors were assessed using multivariable logistic regression models. For cases 1 to 6, we performed separate multivariable logistic regression models to assess the association of randomized clinical factors with respondent recommendations for additional fluids and vasopressors, both overall and for each case pair. The factors randomized in the case pair were included as covariates in the regressions (eg, in cases 1 and 2, fluid volume received, MAP, volume examination, and medical history). For cases 7 to 10, an overall multivariable logistic regression model was performed to assess the association of randomized factors (vasopressor dose, dose trend, duration, and PIV location) with the recommendation to place a central line. Case number was also included as a covariate in all models to capture differences related to case stems. Details of the regression models are provided in the eMethods in Supplement 1 . When more than 1 case was combined in a regression, a multilevel model was used to account for clustering by participant, with randomized factors treated as fixed effects and participant identification number treated as a random effect. Results are reported as an adjusted proportion of respondents with a 95% CI. These adjusted proportions of respondents represent average (mean) predicted probabilities, which were calculated using predictive margins after fitting each model. Odds ratios (ORs) are also provided in eTable 1 and eTable 2 in Supplement 1 . Statistical significance was a 2-sided P  < .05.

Data analysis was completed in StataMP version 17.0 (StataCorp) and Python version 3.10.9 (Python Software Foundation). Data analysis was conducted from February to September 2023.

The survey was electronically sent to 11 203 US-based SCCM member physicians and APPs, of whom 669 (6.0%) reviewed the study information page and 550 (4.9%) completed at least 1 vignette and were included. Of the 550 respondents (261 men [47.5%] and 192 women [34.9%]; 173 with >15 years of practice [31.5%]), 337 (61.3%) were physicians, 369 (67.1%) were critical care trained, and 294 (53.5%) were in academic practices. The remaining respondents were mostly APPs (101 respondents [18.4%]) and at practice locations other than an academic or private practice (91 respondents [16.6%]). Respondents had a range of experience levels and practice locations ( Table 1 ). Compared with available demographic information about SCCM members who received the survey invitation, respondents had a similar gender distribution and practice region; however, there was a lower percentage of physicians (337 [71.7%] vs 8804 [78.6%]) among survey respondents (eTable 3 in Supplement 1 ). The majority of respondents found the cases to be realistic (251 of 477 [52.6%] found cases very realistic and 204 of 477 [42.8%] found cases somewhat realistic) (eFigure 1 in Supplement 1 ).

In questions about usual practice, most respondents self-reported targeting MAP of 65 mm Hg or greater (408 respondents [86.4%]) and administering 2 to 3 L of initial fluid (360 respondents [76.4%]) (eFigure 2 in Supplement 1 ). Respondents were divided between starting vasopressors during (225 respondents [47.5%]) or after (246 respondents [51.9%]) initial fluid resuscitation. A minority (179 respondents [38.1%]) reported often or always placing a central line to start vasopressors.

Of the 550 respondents, 498 (90.5%) completed all cases 1 through 6. Responses varied across cases. Only 9 of the 498 respondents (1.8%) did not give fluids in any case and 22 (4.4%) gave fluids in all 6 cases. Similarly, 3 respondents (0.6%) did not start vasopressors in any case, while 134 (26.9%) started vasopressors in all 6 cases (eFigure 3 in Supplement 1 ). There was less response variation in cases where respondents saw the same fluid volume received; in cases with the same fluid volume received, 104 of 323 respondents (32.2%) to 154 of 328 (47.0%) of respondents’ recommendations for fluid depended on the case and 58 of 323 respondents (18.0%) to 161 of 346 (46.4%) of respondents’ recommendations for vasopressors depended on the case (eFigure 4 in Supplement 1 ). Reported Likert scale–based case difficulty was similar across cases and was not associated with fluid volume received or MAP. The adjusted proportion of respondents rating cases as difficult (ie, very difficult or somewhat difficult) ranged from 7.0% (95% CI, 4.8%-9.3%) to 13.1% (95% CI, 10.1%-16.1%) (eTable 4 in Supplement 1 ).

Fluid volume already received had the largest association with decisions about prescribing additional fluids and starting vasopressors. The overall adjusted proportion of respondents who prescribed additional fluid was 82.5% (95% CI, 80.2%-84.8%) after 1 L, 60.8% (95% CI, 57.7%-63.9%) after 2 L, and 17.5% (95% CI, 15.1%-19.9%) after 5 L ( P  < .001) (eTable 3 and eFigure 5 in Supplement 1 ). Conversely, the adjusted proportion of respondents who initiated vasopressors was 55.0% (95% CI, 51.9%-58.1%) after 1 L, 78.1% (95% CI, 75.5%-80.7%) after 2 L, and 92.7% (95% CI, 91.1%-94.3%) after 5 L ( P  < .001).

Clinical assessment of a patient’s volume status also had significant associations with fluid and vasopressor decisions. When a patient was assessed as having dry volume status, an adjusted 66.9% (95% CI, 62.5%-71.2%) of respondents prescribed additional fluid and an adjusted 70.8% (95% CI, 66.2%–75.3%) initiated vasopressors. Conversely, when the patient was assessed as having wet volume status (ie, overload), an adjusted 26.5% (95% CI, 22.3%-30.6%) of respondents prescribed additional fluid while an adjusted 89.3% (95% CI, 86.3%-92.2%) initiated vasopressors ( Figure 1 and eTable 4 in Supplement 1 ).

Several other factors had statistically significant but small associations with the recommendation for additional fluids including MAP, history of kidney failure and receiving dialysis, oxygen requirement, and respiratory rate. History of HFrEF, lactate trend, and AKI were not associated with changes fluid decisions ( Figure 1 and eTable 4 in Supplement 1 ).

MAP was associated with the decision to initiate vasopressors. The overall adjusted proportion of respondents initiating vasopressors when MAP levels were 52 mm Hg (85.2%; 95% CI, 83.1%-87.3%) or 58 mm Hg (80.9%; 95% CI, 78.6%-83.3%) were similar. In contrast, when MAP levels were 64 mm Hg, the adjusted proportion of respondents initiating vasopressors was only 59.1% (95% CI, 56.2%-62.1%) ( P  < .001) (eTable 3 and eFigure 5 in Supplement 1 ). Oxygen requirement, higher respiratory rate, rising lactate with fluids, and nonoliguric AKI all had significant but small associations with vasopressor initiation (favoring vasopressor use). History of kidney failure and receiving dialysis, HFrEF, downtrending lactate with fluids, and oliguric AKI were not associated with vasopressor initiation. Case number had a significant association with recommendation for fluids in case 1 vs 2 (adjusted OR, 0.63; 95% CI, 0.45-0.88; P  = .007) and vasopressors in case 3 vs 4 (adjusted OR, 0.66; 95%CI, 0.45-0.97; P  = .04) ( Figure 1 and eTable 4 in Supplement 1 ).

For cases 1 through 6, 189 respondents requested additional information using free-text comment boxes which were manually reviewed. The most commonly requested information was patient weight (requested by 48 respondents [8.7%]) and point-of-care ultrasonography (requested by 39 respondents [7.1%]) (eTable 5 in Supplement 1 ).

In most vignettes (1023 of 1127 [90.8%]) where the patient’s baseline vascular access was PIVs, respondents chose peripheral vasopressor initiation, primarily with a plan to bridge to central access (782 respondents [69.4%]) ( Figure 2 A). No patient factors were associated with the route of vasopressor initiation in these cases (eTable 6 in Supplement 1 ). When a preexisting PICC or port was present in the vignette, a majority of respondents chose this route for vasopressor initiation (PICC, 272 respondents [74.1%] vs port, 233 respondents [59.7%]) ( Figure 2 B and Figure 2 C).

Of the 550 respondents, 478 (86.9%) respondents completed all cases 7 through 10. Responses varied across cases with only 44 of the 478 respondents (9.2%) never placing a central line and 70 (14.6%) always placing a central line (eFigure 3 in Supplement 1 ). The adjusted proportion of respondents recommending a central line increased from 25.2% (95% CI, 21.8%-28.5%) for a lower dose of norepinephrine (0.08 µg/kg/min) to 78.0% (95% CI, 74.7%-81.2%) for a higher dose (0.50 µg/kg/min) ( P  < .001) ( Figure 3 and eTable 7 in Supplement 1 ). Vasopressor dose trend was also associated with the decision to place central access; an adjusted 36.3% (95% CI, 32.8%-39.9%) of respondents recommended a central line with decreasing dose vs an adjusted 71.0% (95% CI, 67.7%-74.2%) with increasing dose ( P  < .001). Duration of vasopressor infusion had a significant but smaller association; the adjusted proportion of respondents recommending a central line was 47.1% (95% CI, 44.0%-50.1%) at 8 hours vs an adjusted 59.5% (95% CI, 56.6%-62.5%) at 24 hours ( P  < .001). Location of the PIV in the forearm vs upper arm and case number were not significantly associated with a decision for central line placement. In free-text comments, "In free-text comments, 33 respondents commented on additional information they would use to make decisions about central line placement, including anticipated procedures, hospital resources, policy, and other indications for central access (eTable 8 in Supplement 1 ). The most important self-reported factor informing the use of peripheral vasopressors was personal practice (242 of 476 respondents [50.8%]), followed by hospital policy (136 of 476 respondents [28.6%]) (eFigure 6 and eTable 9 in Supplement 1 ).

In this randomized vignette survey study of US critical care clinicians, we found that fluid volume already received was associated with the largest changes in decisions to administer additional fluids or initiate vasopressors in patients with sepsis. In contrast, other clinical factors (past medical history, respiratory status, lactate trend, and AKI) had small associations with these resuscitation decisions. Most respondents chose to start vasopressors peripherally, with higher or increasing vasopressor dose and longer duration associated with the subsequent decision to place a central line.

Personalization has been proposed as the future of sepsis resuscitation. The recent CLOVERS 17 and CLASSIC 16 trials found that fluid-liberal vs fluid-restrictive, vasopressor-early approaches result in similar patient outcomes. However, these trials have been criticized for their generalized approach to resuscitation, leading experts to call for personalization. 22 , 23 At this time, there is no standard, accepted strategy for personalization. Many have suggested that clinical factors may help guide resuscitation. However, our study found that fluid volume received tended to outweigh other factors that would traditionally be considered for personalization, including volume status.

In our study, fluid volumes that respondents were willing to administer fell somewhere between 2 L to 5 L. Respondents self-reported administering 2 to 3 L in their usual practice. This finding aligned with case responses, where a majority of respondents prescribed fluid after 1 L, one-half prescribed fluid after 2 L, and few respondents prescribed fluid after 5 L, a volume associated with harm in retrospective studies and the maximal volume allowed in the fluid-liberal group of CLOVERS. 7 , 17 The fluid volumes respondents were willing to administer align with the Surviving Sepsis Campaign (SSC) guidelines, which suggest an initial fluid volume of 30 mL/kg, or 2 to 3 L in an average adult. 24 While we did not assess participant reasoning, in free-text responses, many respondents asked for patient weight, suggesting clinicians may be specifically using the 30 mL/kg guideline to make decisions about fluids or are using weight to personalize resuscitation.

Our results suggest that these fluid volumes are ingrained in practice and guide resuscitation decisions, while other clinical factors appear to play a much smaller role in personalizing resuscitation decisions, at least on average. For example, history of heart failure and kidney failure have historically been associated with increased risk for fluid overload. 25 However, in our study, history of kidney failure and receiving dialysis had a small association with fluid administration decisions while history of HFrEF had no association. This finding may reflect the fact that clinicians are willing to give fluids to patients with these comorbidities, which is potentially beneficial, given evidence that suggests fluids may decrease mortality in these patients. 26 In contrast, respiratory failure has been associated with harm from fluid resuscitation in sepsis trials in lower-resource settings. 27 - 29 Additionally, in the CLASSIC trial, 16 there was a signal for potential harm among patients on respiratory support in the fluid-liberal group. Yet, in our survey, oxygen requirement and respiratory rate only had small associations with resuscitation decisions, outweighed by fluid volume. Finally, there is some evidence to support guiding fluid resuscitation by lactate clearance, as suggested in the SSC guidelines. 24 , 30 , 31 Despite this guideline, we found that lactate trend was not associated with changes in clinical decision-making.

These findings may suggest that apart from fluid volume received, clinicians are not using clinical factors to personalize resuscitation decisions. However, there are several potential alternative explanations for this apparent lack of personalization ( Table 2 ). Importantly, our study only provides an average measure of personalization, measuring effects in the same direction. However, clinicians may be using clinical factors to personalize care in more nuanced ways. Indeed, we observed a range of responses across cases, even in cases where respondents saw the same fluid volume received (eg, all 1 L), which suggests potential unmeasured personalization was occurring.

There are also other tools besides clinical factors that can be used to personalize resuscitation. For example, dynamic measures of fluid-responsiveness may help determine when patients need more fluids vs vasopressors. While these tools have been validated to assess fluid-responsiveness, their role in improving patient outcomes in sepsis has not been well studied. 32 Yet, in free-text responses, many respondents requested dynamic fluid-responsiveness measures (eg, point-of-care ultrasonography or noninvasive cardiac output monitoring), suggesting that clinicians are using these bedside tools. More work is needed to understand how dynamic tools are used in practice and to determine their association with patient outcomes.

Our results also provide valuable information about peripheral vasopressor practices. We found that peripheral vasopressor initiation was commonly tolerated, with a vast majority of respondents willing to start vasopressors through a PIV if this was the patient’s only access. A number of respondents also chose to start vasopressors through a PIV over preexisting central access, perhaps due to concerns about line infections, although more work is needed to understand this observed practice. Decisions about peripheral vasopressor initiation were not associated with clinical factors, even hypotension severity, suggesting the decision about route of initiation was made independently from the decision to initiate vasopressors and may have been guided by other factors, such as personal practice or hospital policy. Beyond initiation, approximately one-half of respondents appeared willing to continue peripheral vasopressors in at least some patients, basing decisions about when to place a central line on vasopressor dose, trend, and duration, factors that are included in many hospital policies. 33 This finding suggests that many clinicians are comfortable using peripheral vasopressors at low doses for durations up to 24 hours, which aligns with available safety data. 34 , 35

This study has several limitations. First, it was a survey study and, thus, did not directly measure clinician practices. However, we used an evidence-based vignette survey method that has been shown to elicit preferences and predict behavior, allowing us to approximate clinical decision-making. 18 - 20 , 36 Furthermore, the majority of respondents found cases to be realistic. Second, while many clinical factors were randomized, fixed factors (eg, age) were included in cases to enhance their realism. However, for all but 2 case pairs where there was a small association, case was not associated with participant answers, suggesting these fixed factors were not associated with clinician decisions. Conversely, it is possible that factors that were not included in the vignettes (eg, dynamic measures of fluid-responsiveness) may have been important for guiding resuscitation decisions and, therefore, our results may only reflect how clinicians would practice in situations where they did not have access to their preferred bedside fluid assessment tools. We allowed free-text responses to help capture such other important factors. Additionally, survey response bias could limit generalizability. However, our cohort was characteristically similar to the SCCM members who received the survey, suggesting our findings may be at least generalizable to the community of critical care clinicians within SCCM. Further, randomization of case order helped protect against selection bias introduced by variation in survey response.

The findings of this survey study provide important insight into clinician decision-making in early sepsis resuscitation. Fluid volume already received was the predominant factor associated with decisions about additional fluids and vasopressors, outweighing many other clinical factors. Peripheral vasopressor use was common. Future trials aimed at personalizing resuscitation should account for the association of received fluid volume and should work to validate easily accessible bedside tools beyond clinical factors, such as dynamic fluid-responsiveness measures, to help guide personalization.

Accepted for Publication: February 21, 2024.

Published: April 19, 2024. doi:10.1001/jamanetworkopen.2024.7480

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2024 Munroe ES et al. JAMA Network Open .

Corresponding Author: Elizabeth S. Munroe, MD, MSc, 6301 Division of Pulmonary and Critical Care Medicine, Department of Medicine, Medical Science Research Building III, SPC 5642, Ann Arbor, MI 48109-5360 ( [email protected] ).

Author Contributions: Drs Munroe and Prescott had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Munroe, Valley, Prescott.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Munroe.

Critical review of the manuscript for important intellectual content: Weinstein, Gershengorn, Karlic, Seelye, Sjoding, Valley, Prescott.

Statistical analysis: Munroe, Weinstein, Karlic, Seelye.

Obtained funding: Prescott.

Administrative, technical, or material support: Seelye, Prescott.

Supervision: Seelye, Prescott.

Conflict of Interest Disclosures: Dr Gershengorn reported receiving personal fees from Gilead Sciences and the American College of Chest Physicians; serving on a COVID-19 therapeutics advisory panel; and working as an editor for the CHEST Critical Care journal of the American College of Chest Physicians outside the submitted work. Dr Seelye reported receiving grants from the Agency for Healthcare Research and Quality (AHRQ), VA Health Services Research & Development Services (VA HSR&D), and the Department of Defense outside the submitted work. Dr Sjoding reported having a patent for Computer Vision Technologies for Rapid Detection of Disease that is licensed to Airstrip but not currently active. Dr Prescott reported receiving grants from AHRQ, VA HSR&D, National Institutes of Health, and National Heart, Lung, and Blood Institute; personal fees from the Centers for Disease Control and Prevention and Blue Cross Blue Shield of Michigan; and serving as a developer of the Surviving Sepsis Campaign guidelines for the Society of Critical Care Medicine outside the submitted work. No other disclosures were reported.

Funding/Support: This study was supported by the National Institutes of Health (grant Nos. T32 HL 007749, F32HL172463, and L30 HL 170379 to Dr Munroe), National Institutes of Health (grant No. T32 HL 007749 to the University of Michigan Division of Pulmonary &Critical Care Medicine), and the University of Miami Hospital and Clinics Data Analytics Research Team. This study was also supported with resources and use of facilities at the Ann Arbor VA Medical Center.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. This manuscript reflects the views of the authors and does not represent the views of the Department of Veterans Affairs or the US government.

Data Sharing Statement: See Supplement 2 .

Additional Contributions: The authors thank Cainnear Hogan, MSW (Institution); Taylor Whittington, MPH (Institution) and John Donnelly, PhD (Institution), for their contributions to study planning and survey administration. None of these individuals received compensation for their work. The authors also thank the clinicians who completed the survey and the Society of Critical Care Medicine for their assistance administering the study survey.

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