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• 07 May 2024
• Cold Call Podcast

Lessons in Business Innovation from Legendary Restaurant elBulli

Ferran Adrià, chef at legendary Barcelona-based restaurant elBulli, was facing two related decisions. First, he and his team must continue to develop new and different dishes for elBulli to guarantee a continuous stream of innovation, the cornerstone of the restaurant's success. But they also need to focus on growing the restaurant’s business. Can the team balance both objectives? Professor Michael I. Norton discusses the connections between creativity, emotions, rituals, and innovation – and how they can be applied to other domains – in the case, “elBulli: The Taste of Innovation,” and his new book, The Ritual Effect.

• 26 Apr 2024

Deion Sanders' Prime Lessons for Leading a Team to Victory

The former star athlete known for flash uses unglamorous command-and-control methods to get results as a college football coach. Business leaders can learn 10 key lessons from the way 'Coach Prime' builds a culture of respect and discipline without micromanaging, says Hise Gibson.

• 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

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.”

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Research Roundup: How the Pandemic Changed Management

• Mark C. Bolino,
• Jacob M. Whitney,
• Sarah E. Henry

Lessons from 69 articles published in top management and applied psychology journals.

Researchers recently reviewed 69 articles focused on the management implications of the Covid-19 pandemic that were published between March 2020 and July 2023 in top journals in management and applied psychology. The review highlights the numerous ways in which employees, teams, leaders, organizations, and societies were impacted and offers lessons for managing through future pandemics or other events of mass disruption.

The recent pandemic disrupted life as we know it, including for employees and organizations around the world. To understand such changes, we recently reviewed 69 articles focused on the management implications of the Covid-19 pandemic. These papers were published between March 2020 and July 2023 in top journals in management and applied psychology.

• Mark C. Bolino is the David L. Boren Professor and the Michael F. Price Chair in International Business at the University of Oklahoma’s Price College of Business. His research focuses on understanding how an organization can inspire its employees to go the extra mile without compromising their personal well-being.
• JW Jacob M. Whitney is a doctoral candidate in management at the University of Oklahoma’s Price College of Business and an incoming assistant professor at Kennesaw State University. His research interests include leadership, teams, and organizational citizenship behavior.
• SH Sarah E. Henry is a doctoral candidate in management at the University of Oklahoma’s Price College of Business and an incoming assistant professor at the University of South Florida. Her research interests include organizational citizenship behaviors, workplace interpersonal dynamics, and international management.

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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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University of Doha for Science and Technology @ 2022

Differences in quality of anticoagulation care delivery according to ethnoracial group in the United States: A scoping review

• Open access
• Published: 11 May 2024

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• Sara R. Vazquez   ORCID: orcid.org/0000-0002-9267-8980 1 ,
• Naomi Y. Yates 2 ,
• Craig J. Beavers 3 , 4 ,
• Darren M. Triller 3 &
• Mary M. McFarland 5  

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Anticoagulation therapy is standard for conditions like atrial fibrillation, venous thromboembolism, and valvular heart disease, yet it is unclear if there are ethnoracial disparities in its quality and delivery in the United States. For this scoping review, electronic databases were searched for publications between January 1, 2011 – March 30, 2022. Eligible studies included all study designs, any setting within the United States, patients prescribed anticoagulation for any indication, outcomes reported for ≥ 2 distinct ethnoracial groups. The following four research questions were explored: Do ethnoracial differences exist in 1) access to guideline-based anticoagulation therapy, 2) quality of anticoagulation therapy management, 3) clinical outcomes related to anticoagulation care, 4) humanistic/educational outcomes related to anticoagulation therapy. A total of 5374 studies were screened, 570 studies received full-text review, and 96 studies were analyzed. The largest mapped focus was patients’ access to guideline-based anticoagulation therapy (88/96 articles, 91.7%). Seventy-eight articles made statistical outcomes comparisons among ethnoracial groups. Across all four research questions, 79 articles demonstrated favorable outcomes for White patients compared to non-White patients, 38 articles showed no difference between White and non-White groups, and 8 favored non-White groups (the total exceeds the 78 articles with statistical outcomes as many articles reported multiple outcomes). Disparities disadvantaging non-White patients were most pronounced in access to guideline-based anticoagulation therapy (43/66 articles analyzed) and quality of anticoagulation management (19/21 articles analyzed). Although treatment guidelines do not differentiate anticoagulant therapy by ethnoracial group, this scoping review found consistently favorable outcomes for White patients over non-White patients in the domains of access to anticoagulation therapy for guideline-based indications and quality of anticoagulation therapy management. No differences among groups were noted in clinical outcomes, and very few studies assessed humanistic or educational outcomes.

Graphical Abstract

Scoping Review: Differences in quality of United States anticoagulation care delivery by ethnoracial group. AF = atrial fibrillation; AMS = anticoagulation management service; DOACs = direct oral anticoagulants; INR = international normalized ratio; PSM = patient self-management; PST = patient self-testing

Avoid common mistakes on your manuscript.

Introduction

It is well-established that in the United States (US) ethnoracial disparities exist in various aspects of health care. Specifically, persons identifying with an ethnoracial minority group may have more challenging access to health care, worse clinical outcomes, and higher dissatisfaction with care compared to White persons [ 1 , 2 , 3 , 4 , 5 ]. There are differences by ethnoracial group in the prevalence of the three most common indications for which anticoagulants are prescribed, stroke prevention in atrial fibrillation (AF), treatment of venous thromboembolism (VTE), and valvular heart disease [ 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 ]. Specifically, VTE is most prevalent in Black patients compared to White and Asian patients, whereas AF is most prevalent in White patients compared to Black, Asian, and Hispanic patients [ 9 , 10 , 15 ]. Calcific heart valve disease has the most relevance to the US population, and epidemiologic data has shown that aortic stenosis is more prevalent in White patients compared to Black, Asian, and Hispanic patients [ 17 ]. Despite these epidemiologic differences, there is no evidence to suggest there should be any difference in treatment strategies across ethnoracial patient groups.

While studies have demonstrated genotypic differences that may result in different warfarin dose requirements[ 18 ], and early studies may indicate genotypic differences in direct oral anticoagulant (DOAC) response [ 19 ], no US-based labeling or guidelines recommend a difference in prescription or delivery of anticoagulation care based on race or ethnicity. However, it is unclear if there are in fact differences in the type and quality of anticoagulation therapy, which is standard of care for each of these conditions [ 20 , 21 , 22 , 23 , 24 ]. Anticoagulants remain in the top three classes of drugs causing adverse drug events (primarily bleeding) in the United States, according to the 2014 National Action Plan for Adverse Drug Event Prevention. One of the goals of the National Action Plan was to identify patient populations at higher risk for these adverse drug events to inform the development of targeted harm reduction strategies [ 25 ]. If ethnoracial minority patients are receiving sub-optimal anticoagulation therapy in certain measurable areas of anticoagulation quality, it is vital to highlight the areas of disparity so that these can be explored and care optimized. Anticoagulation providers often have high frequency contact with their patients and can be a reliable connection between disproportionately affected patients and a system in need of change. Systematic reviews of ethnoracial disparities in AF and VTE have been conducted. The AF review assessed AF prevalence among racial groups as well as differences in symptoms and management, including stroke prevention with warfarin or DOACs [ 9 ]. The VTE review specifically assessed VTE prevalence and racial differences in COVID-19 and did report the use of any prophylactic anticoagulation, but this was not part of the analysis [ 26 ]. No review of racial disparities in quality of anticoagulation therapy was found in search results conducted prior to protocol.

In this study we aimed to identify any potential ethnoracial disparities in anticoagulation care quality in the US. The decision to limit the study to a US population was based on our observation that the US has a unique history of interactions between racial and ethnic groups that may not necessarily be reflected by studies conducted in other countries. Additionally, health care delivery systems vary widely across the world, and we wanted to include the data most relevant to the potential racial disparities existing in the US health care system. The term “race” was used to identify a group of people with shared physical characteristics believed to be of common ancestry whereas the term “ethnicity” refers to a group of people with shared cultural traditions [ 27 ]. We recognize these terms may be far more complex. In order to encompass both the physical and cultural aspects of a patient’s identity we have chosen to use the term “ethnoracial” for this study [ 27 ]. Highlighting existing differences will serve as a stimulus for institutions and clinicians to assess current services, implement quality improvement measures, and inform future research efforts to deliver optimal anticoagulation care for all patients. The scoping review protocol was registered December 22, 2021 to Open Science Framework, https://doi.org/10.17605/OSF.IO/9SE7H [ 28 ].

We conducted this scoping review with guidance from the 2020 version of the JBI Manual for Evidence Synthesis and organized to Arksey's five stages: 1) identifying the research question, 2) identifying relevant studies, 3) study selection, 4) charting the data and 5) collating, summarizing and reporting the results [ 29 , 30 ]. For transparency and reproducibility, we followed the PRISMA-ScR and PRISMA-S reporting guidelines in reporting our results [ 31 ]. We used Covidence (Veritas Health Innovation,) an online systematic reviewing platform to screen and select studies. Citation management and duplicate detection and removal was accomplished with EndNote, version 19 (Clarivate Analytics.) Data was charted from our selected studies using REDCap, an electronic data capture tool hosted at the University of Utah [ 32 ].

Literature searching

An information specialist developed and translated search strategies for the online databases using a combination of keywords and controlled subject headings unique to each database along with team feedback. Peer review of the strategies was conducted by library colleagues using the PRESS guidelines. [ 33 ] Electronic databases searched included Medline (Ovid) 2011–2022, Embase (embase.com) 2011–2022, CINAHL Complete (Ebscohost) 2011–2022, Sociological Abstracts (ProQuest) 2011–2022, International Pharmaceutical Abstracts (Ovid) 2011–2022, Scopus (scopus.org) 2011–2022 and Web of Science Core Collection (Clarivate Analytics) 2011–2022. Limits included a date range from January 1, 2011 to March 30—April 19, 2022, as not all database results were exported on the same day. See Supplemental File 1 for detailed search strategies. A search of grey literature was not conducted due to time and resource constraints.

Study Selection

For inclusion, each study required two votes by independent reviewers for screening of titles and abstracts followed by full-text review. A third reviewer provided the deciding vote. Data extraction was performed by two independent reviewers, and consensus on any discrepancies was reached via discussion between the reviewers. The data form was piloted by two team members using sentinel articles prior to data extraction.

Eligible studies included all types of study designs in any setting with a population of patients of any age or gender located within the US who were prescribed anticoagulant therapy for any indication, published between January 1, 2011 – March 30, 2022 in order to capture contemporary and clinically relevant practices.

We defined the following research questions for this scoping review as described in Table  1 .

Studies must have reported any of these anticoagulation care delivery outcomes for at least 2 distinct racial or ethnic groups. We excluded genotyping studies and non-English language articles at full text review, as we had no funding for translation services. In checking references of included studies, no additional studies met inclusion criteria. In accordance with scoping review methodology, no quality assessment of included studies was conducted as our goal was to rapidly map the literature. As this is a scoping review of the literature, no aggregate or pooled analysis was performed; however, for ease of interpretation, when assessing for the directionality of the outcomes in the various studies, we categorized studies into Favoring White Group, Favoring Non-White Group, and No Differences Among Ethnoracial Groups. If studies had mixed outcomes of favoring one group for one outcome and no difference for another, then the study was categorized with the favoring group.

A PRISMA flow diagram in Fig.  1 depicts search results, exclusions, and inclusions. The search strategies retrieved 6900 results with 1526 duplicates removed. Following title and abstract screening of 5374 references, 570 articles received full-text review. The most common reason for the exclusion of 474 studies was that outcomes were not reported for two distinct ethnoracial groups (171 studies). Ninety-six studies underwent data extraction.

PRISMA Flow Diagram

Study characteristics-overall

Fifty of the 96 studies were published between 2011 and 2018 (an average of 6.25 articles per year that compared outcomes between two ethnoracial groups) and 43 of 96 studies were published in the years 2019–2021 (average 14.3 articles per year; 2022 excluded here because only 4 months of data was captured) (Fig.  2 ). Most studies analyzed an outpatient population (65.6%) for an indication of stroke prevention in AF (67.7%) in patients taking warfarin (71.9%) or DOACs (49.0%). Study population size was heterogenous, ranging from a study size of 24 patients to over 1.3 million patients (median 5,238 patients) in the 69 studies that reported population size by racial group. When stratified by size, 60.9% of the articles in the scoping review (42 articles) represented < 10,000 patients (Table  2 ).

Number of Articles by Publication Year. *2022 excluded from this figure since the search period did not capture the entire year

Study characteristics-by ethnoracial group

There were 50 studies (52.1%) where race or ethnicity was either mentioned in the title or objective of the article, with 24 of these published over the 7-year period 2011–2018 and 26 published over the 3-year period 2019 to first quarter 2022. The method for reporting race or ethnicity was unclear or unspecified in most studies (77.1%) and 16 articles (16.7%) utilized self-reporting of race or ethnicity. Most studies analyzed White or Caucasian racial groups (94.8%), followed by Black or African-American (80.2%), and many studies grouped all other racial groups into an “Other” category (41.7%) (Fig.  3 ).

Number of Articles by Ethnoracial Groups. *For study inclusion, a study had to compare outcomes for least two distinct ethnoracial groups 

White patients accounted for a median 77% of study populations, Black patients 9.5%, Hispanic/Latino patients 6.2%, “Other” racial groups 5.3%, and Asian patients 2.5%.

Study outcomes-overall

Of the 4 research questions, most studies included in this review analyzed patients’ access to guideline-based anticoagulation therapy (88/96 articles, 91.7%), clinical outcomes (42/96 articles, 43.8%), or quality of anticoagulation management (24/96 articles, 25.0%), while very few addressed humanistic or educational outcomes (5/96 articles, 5.2%) (Fig.  4 ). Many studies addressed multiple outcomes within the single study.

Number of Articles Mapped by Research Question

Seventy-eight of the 96 included studies provided statistical comparisons between ethnoracial groups, and these data are presented below.

Outcomes for research question 1: Do ethnoracial differences exist in access to guideline-based anticoagulation therapy?

Anticoagulation for a guideline-based indication.

This question focused on patients who had an indication for anticoagulation actually receiving an anticoagulant, specifically AF and VTE prophylaxis (based on risk stratification) and acute VTE. The majority of the AF studies (25/34 studies) demonstrated White patients receiving anticoagulation at significantly higher rates compared to non-White patients [ 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 ], while the six VTE studies largely demonstrated no difference among ethnoracial groups [ 61 , 62 , 63 , 64 , 65 , 66 ].

DOACs as first-line therapy for AF or VTE

Eighteen individual studies statistically assessed the outcome of DOAC as first-line therapy (compared to warfarin) for AF (15 studies), VTE treatment (2 studies), or both indications (1 study). Twelve of the 15 AF studies showed a significantly higher proportion of White patients received DOACs as first-line therapy compared to non-White patients [ 36 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 54 , 55 , 67 , 68 ]. Of those 12, 9 specifically compared White patients to Black patients. Both VTE treatment studies and the study that assessed both AF and VTE indications showed significantly higher DOAC prescribing rates for White patients compared to Black patients [ 69 , 70 , 71 ].

Anticoagulant therapy adherence/persistence

The eight studies that addressed anticoagulation therapy adherence/persistence showed variability in outcome directionality by ethnoracial group: 5 no difference [ 41 , 72 , 73 , 74 , 75 ], 2 showed better treatment adherence/persistence for White patients compared to Black patients[ 76 ] or non-White patients [ 77 ], and one showed better treatment adherence/persistence for White patients compared to Hispanic patients, but no difference in White versus Black patients [ 78 ].

Figure  5 summarizes the outcome directionality for Research Question 1 regarding access to guideline-based anticoagulation therapy. Overall, the areas of disparity identified included anticoagulation for atrial fibrillation and preferential use of DOAC therapy for AF and VTE treatment.

Outcome Directionality for the 4 Research Questions and their Subcategories. AC = anticoagulant; AMS = anticoagulation management service; INR = international normalized ratio; PST = patient self-testing; PSM = patient self-management

Research question 2: Do ethnoracial differences exist in the quality of anticoagulation therapy management?

A total of 21 studies assessed quality of anticoagulation therapy management: Warfarin time in therapeutic range (TTR)/INR (International Normalized Ratio) control 12 studies, appropriate anticoagulant dosing 3 studies, enrollment in an anticoagulation management service 5 studies, and PST/PSM one study.

In statistical comparisons of INR control in warfarin patients, all 12 studies (7 assessed mean or median TTR, 5 assessed other measures of INR control such as days spent above/below range, gaps in INR monitoring) showed White patients had favorable INR control compared to non-White patients (most comparisons included Black patients) [ 41 , 75 , 79 , 80 , 81 , 82 , 83 , 84 , 85 , 86 , 87 ]. Enrollment in an anticoagulation management service was statistically compared among ethnoracial groups in 5 studies, and this opportunity favored White patients compared to other racial groups in four of the five [ 41 , 82 , 86 , 88 ]. Two of the three studies that statistically analyzed appropriate anticoagulant dosing showed a higher rate of appropriate DOAC dosing in White patients compared to non-White patients [ 41 , 89 ], and the third showed no difference among ethnoracial groups for enoxaparin dosing in the emergency department [ 90 ]. The one study assessing access to PST/PSM showed that more White patients used PST compared to Black or Hispanic patients[ 91 ] (Fig.  5 ).

Research question 3: Do ethnoracial differences exist in the clinical outcomes related to anticoagulation care?

Articles assessing clinical outcomes among ethnoracial groups primarily assessed bleeding (15 articles) or thrombosis (9 articles) outcomes, and 8 articles assessing anticoagulation related hospitalization or mortality. One article addressed a net clinical outcome including major bleeding, stroke or systemic embolism, and death from any cause. This was included in the bleeding outcomes category so that it was not double-counted in the other two outcome categories. Additional details about the 24 unique studies that statistically assessed clinical outcomes including the study design, population size, ethnoracial groups studied, anticoagulants used, and statistical outcomes measured can be found in Supplementary Tables 1 and 2 .

Sixteen studies statistically assessed bleeding outcomes of varying definitions (major bleeding 13 studies, clinically relevant non-major bleeding 3 studies, any bleeding 3 studies, bleeding otherwise defined 3 studies). Six studies demonstrated no difference in bleeding outcomes by ethnoracial group [ 55 , 92 , 93 , 94 , 95 , 96 ]9 reported that White patients had lower rates of bleeding compared to Black or Asian patients,[ 53 , 80 , 83 , 85 , 97 , 98 , 99 , 100 , 101 ]. In the remaining study, Asian patients had a more favorable net clinical outcome compared to non-Asian patients [ 102 ].

Nine studies statistically assessed thrombosis outcomes among ethnoracial groups, including stroke/systemic embolism (5 studies), recurrent VTE (3 studies), or any thrombosis (1 study). The stroke outcomes by racial group were heterogeneous, with 3 studies showing better outcomes for White patients compared to Black patients[ 103 , 104 , 105 ] and two studies showing no difference in outcomes when White patients were compared to Non-White patients [ 55 , 95 ]. In three of the four VTE studies there were no differences in outcomes by ethnoracial group [ 61 , 93 , 96 ], and in one study White patients had more favorable outcomes compared to Black patients [ 106 ].

Nine studies assessed anticoagulation-related hospitalizations or mortality by ethnoracial group. Outcomes were mixed, as four studies showed no difference in hospitalizations or mortality among ethnoracial groups,[ 89 , 95 , 96 , 107 ], three studies showed White patients had a lower rate of hospitalizations[ 85 , 105 ] or mortality[ 104 , 105 ] Another study showed lower rate of mortality or hospice after intracranial hemorrhage in Black and Other race patients [ 108 ].(Fig.  5 ).

Research question 4: Do ethnoracial differences exist in the humanistic/educational outcomes related to anticoagulation therapy?

The five studies reporting this category of outcomes were heterogeneous. Of the two studies assessing anticoagulation knowledge, one showed no difference by ethnoracial group [ 109 ], and the other favored the non-White group in appropriately estimating bleeding risk [ 110 ]. One study assessed an atrial fibrillation quality of life score at 2-year follow-up after AF diagnosis and found the outcomes favored White patients [ 79 ]. Another study assessed satisfaction with VTE care and found no difference among ethnoracial groups [ 111 ]. A third study found no difference in the percentage of racial groups having a cost conversation when initiating DOAC therapy (78% Whites, 72.2% non-Whites)[ 112 ] (Fig.  5 ).

Overall outcome directionality for all four research questions is shown in Fig.  6 . A total of 79 articles demonstrated favorable outcomes for White patients compared to non-White patients, 38 articles showed no difference between White and non-White groups, and 8 articles had outcomes favoring non-White groups (the total exceeds the 78 articles with statistical outcomes as many articles reported multiple outcomes). The biggest areas of disparity between White and non-White groups are access to guideline-based anticoagulation therapy and quality of anticoagulation therapy management. Clinical outcomes relating to anticoagulation care had the least difference among ethnoracial groups. Relatively few studies assessed potential ethnoracial disparities in humanistic and educational outcomes.

Outcome Directionality for All 4 Research Questions

This scoping review assessing ethnoracial differences in the quality of anticoagulation care and its delivery to patients in the United States encompassed eleven full years of literature and resulted in the inclusion of 96 studies, 78 of which contained statistical outcomes comparisons among ethnoracial groups. The most common reason for study exclusion was that outcomes were not reported for at least two distinct ethnoracial groups. We observed that beginning in 2019 and following the racial unrest of 2020, the density of articles addressing ethnoracial disparities in anticoagulation care more than doubled. During the entire study period, half of studies had race or ethnicity as the focus or objective of the paper, but this was largely driven by articles published after 2019.

Only 16% of included articles documented self-reporting of racial identity, with most of the remainder using an unspecified method for documenting racial identity. It is likely that many studies utilize demographic information extracted from an electronic medical record (EMR), but it is often unclear if that is truly self-reported race. A second element this scoping review identified was that many studies analyzed two or three ethnoracial groups and then categorized all others into a heterogenous “Other” category. For example, frequently studies would categorize patients as White, Black, and “Other.” It is unclear whether those in a racial category labeled as “Other” had an unknown or missing racial identity in the EMR, or intentionally chose not to disclose. It is also likely that study investigators decided to classify ethnoracial groups with lower population sizes into a miscellaneous category. There were few studies (15%) that specifically assessed patients identifying as Native American/Alaska Native, Native Hawaiian/Pacific Islander, and multiracial. While Hispanic/Latino is an ethnicity, most studies categorized it as a separate “race” category. Of the 37 studies that analyzed “Asian” patient populations, none specifically defined “Asian” beyond that. The US Census Bureau defines “Asian” race as a person having origins of the Far East, Southeast Asia, or the Indian subcontinent [ 113 ]. This broad definition encompasses many different ethnicities which could represent variability in health outcomes if better defined and more frequently analyzed. These may be opportunities for EMR systems to improve transparency for how race, ethnicity, and language preference are captured and for those designing research studies to be thoughtful and intentional about analyzing the ethnoracial identities of the study population, perhaps in alignment with the minimum 5 racial categories utilized by the US Census Bureau, the National Institutes of Health, and the Office of Management and Budget (White, Black, American Indian/Alaska Native, Asian, Native Hawaiian/Pacific Islander, with permission for a “some other race” category and the option to select multiple races) [ 113 ]. Since 2017 Clinicaltrials.gov has required the reporting of race/ethnicity if collected, and there is good compliance with this requirement, but less so in publication of the work [ 114 ].

We examined the proportion of ethnoracial groups represented for each of the disease states in the studies included in this scoping review, relative to disease state prevalence and found a discrepancy. For AF, prevalence in White patients was 11.3%, in Black patients 6.6%, and in Hispanic patients 7.8% [ 15 ]. However, the representation in AF studies in this review were 74% White, 13% Black, and 8% Hispanic. Assessing VTE incidence by race is more difficult, as studies have shown regional and time variation, with Black patients typically having a higher incidence compared to other ethnoracial groups [ 16 ]. In this review, however, of the studies assessing VTE treatment or prophylaxis, only 16% of the patient population identified as Black, whereas 70% identified as White. There were only 3 studies that assessed a valvular heart disease population, making ethnoracial group representation difficult to assess.

The majority of studies captured in this review analyzed patients in the outpatient setting, for the anticoagulation indication of stroke prevention in AF, taking either warfarin or DOAC. Few studies involved the acute care setting or injectable anticoagulants, representing an area for future study of potential ethnoracial disparities.

Overall, the majority of studies in this scoping review addressed ethnoracial disparities in patients’ access to guideline-based anticoagulation therapy, clinical outcomes related to anticoagulation care, and quality of anticoagulation management. A research gap identified was more study is needed to assess gaps in educational outcomes such as anticoagulation and disease state knowledge, shared decision-making willingness and capability, and humanistic outcomes such as quality of life or satisfaction with anticoagulation therapy.

In analyzing the first research question regarding ethnoracial differences in access to guideline-based anticoagulation therapy, the majority of studies addressed use of any anticoagulation for stroke prevention in AF in patients above a threshold risk score and the preferential use of DOACs as first-line therapy instead of warfarin for AF. In both categories, patients in a non-White ethnoracial group (particularly Black patients) received recommended therapy less often than patients identified as White. It is unclear why this is the case. It could be on the patient, provider, and/or system level. It is possible that some studies more successfully adjusted for covariates than others. Sites or settings with systematic processes like order sets or clinical decision support systems in place for standard prescribing may be more successful in equitably prescribing indicated therapies. In one large study in the Veterans Affairs population of AF patients, even after adjusting for numerous variables that included clinical, demographic, socioeconomic, prescriber, and geographic site factors, DOAC prescribing remained lower in Asian and Black patients when compared with White patients. The authors in that study postulate that non-White populations may be less receptive to novel therapies due to historical mistrust of the health care system or have reduced access to education about the latest treatments, and they give the example of direct-to-consumer advertising [ 42 ]. It has also previously been demonstrated that prescribing of oral anticoagulation and particularly DOACs is lower in non-White patients [ 41 ]. These are difficult to capture as standard covariates, which is why further study is needed. We examined the publication dates for both access categories to see if perhaps there was a lack of contemporary data skewing the outcomes. However, for both anticoagulation for a guideline-based indication and DOACs as first-line therapy, the majority of articles came from the time period 2019–2021 (24 of 40 articles, and 15 of 18 articles, respectively), well after guideline updates preferentially recommended DOACs [ 34 , 35 ]. Also, there were relatively few studies addressing guideline-based therapy for VTE treatment and prophylaxis, making assessment of disparities difficult. Regarding access, it is well established that race and ethnicity often determine a patient’s socioeconomic status and that low socioeconomic status and its correlates (e.g., reduced education, income, and healthcare access) are associated with poorer health outcomes [ 115 ]. However, at each level of income or education, Black patients experience worse health outcomes than Whites [ 116 ]. So, low socioeconomic status does not fully explain poorer health outcomes for non-White individuals.

After examining access to appropriate and preferred anticoagulation therapy, the second research question of this scoping review examined potential ethnoracial disparities in the quality of anticoagulation therapy management. INR control measures such as time in therapeutic INR range are a surrogate measure of both thrombotic and bleeding outcomes and frequently used as a way to assess quality of warfarin therapy. The studies identified in this review showed clear disparity between White and non-White patient groups (especially Black patients), however all twelve studies comparing TTR among ethnoracial groups were published prior to 2019. This could be due to the decline in warfarin prescribing relative to increases in DOAC prescribing [ 117 , 118 , 119 ], but there remain patient populations that require or choose warfarin, so this marker of anticoagulation control remains relevant and requires continued reassessment. There were relatively few studies assessing other markers of anticoagulation management quality such as anticoagulation management service enrollment, appropriate DOAC dosing, and access to quality improvement strategies like PST or PSM. Few studies assessed educational outcomes, yet this may have relevance to the above anticoagulation care quality question. For those patients who remain on warfarin, dietary Vitamin K consistency is an example of a key educational point that links directly to INR control. It is unclear if there are disparities in this type of education among ethnoracial groups that may have more far-reaching effects.

Of note, clinical outcomes related to anticoagulant therapy seemed to have the fewest areas of disparity, although the number of articles was small. This suggests that if patients have access to high quality anticoagulation therapy, there is a promising sign that optimal clinical outcomes can be achieved for all ethnoracial groups.

There are some limitations of this scoping review that warrant consideration. First, we chose fairly broad inclusion criteria (all anticoagulants, all study types) because a review of this type had never been performed before. This resulted in a relatively large number of included articles for a scoping review. Second, there is likely a high degree of heterogeneity among patient populations and outcomes definitions. However, as this is a scoping review with the goal to present an overview of the literature and not report on composite outcomes, a risk of bias assessment was not performed. Third is our decision to group patients into White and non-White groups for assessment of outcome directionality. In doing so, we may have missed subtle differences in outcomes between various non-White ethnoracial groups. Fourth, in our main search we included all studies that reported outcomes, but due to scope, we only reported outcome directionality for studies that statistically compared outcomes between ethnoracial groups. Finally, due to the large number of studies that required review and analysis, this was a lengthy undertaking and we are certain that additional studies have been published since the closure of our search period.

In line with the 2014 National Action Plan for Adverse Drug Event Prevention’s goal of identifying patient populations at higher risk of adverse drug events, this scoping review highlights several areas where quality of anticoagulation care can be optimized for all patients. Future research opportunities in ethnoracial differences in the quality of anticoagulation care are summarized in Table  3 . While the scoping review focused exclusively on the evaluation of peer-reviewed manuscripts, the heterogeneity of terminology and methodologies identified in the published papers may have implications for national health policy relating to the quality and safety of care (e.g.the Medicare Quality Payment Program) [ 120 ]. To accurately and reliably quantify important disparities in AC-related care and support effective improvement initiatives, attention and effort will need to be invested across the full continuum of quality measure development [ 121 ], measure endorsement [ 122 ], measure selection, and status assignment within value-based payment programs (e.g., required/optional, measure weighting) [ 123 ]. The findings of the scoping review may be of utility to such efforts, and the development and implementation of suitable quality measures will likely be of value to future research efforts in this important therapeutic area.

Conclusions

Treatment guidelines do not recommend differentiating anticoagulant therapy by ethnoracial group, yet this scoping review of the literature demonstrates consistent directionality in favor of White patients over non-White patients in the domains of access to anticoagulation therapy for guideline-based indications, prescription of preferred anticoagulation therapies, and quality of anticoagulation therapy management. These data should serve as a stimulus for an assessment of current services, implementation of quality improvement measures, and inform future research to make anticoagulation care quality more equitable.

Data Availability

Data are available on request from the corresponding author.

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Acknowledgements

The authors wish to acknowledge the following individuals for their work in screening articles for this scoping review: April Allen, PharmD, CACP; Allison Burnett, PharmD, PhC, CACP; Stacy Ellsworth, RN, MSN, CCRC; Danielle Jenkins, MBA, RN, BSN, CRNI; Amanda Katz, MBA; Lea Kistenmacher, Julia Mulheman, PharmD; Surhabi Palkimas, PharmD, MBA; Terri Schnurr, RN, CCRC; Deborah Siegal, MD, MSc, FRCPC; Kimberly Terry, PharmD, BCPS, BCCCP; and Terri Wiggins, MS.

The authors wish to acknowledge the support of the Anticoagulation Forum in the development of this manuscript. The Anticoagulation Forum is a non-profit organization dedicated to improving the quality of care for patients taking antithrombotic medications.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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All authors contributed to the study conception and design. Material preparation was performed by Sara Vazquez, Naomi Yates, and Mary McFarland. Data collection and analysis were performed by Sara Vazquez, Naomi Yates, Craig Beavers, and Darren Triller. The first draft of the manuscript was written by Sara Vazquez and all authors edited subsequent drafts. All authors read and approved the final manuscript.

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Vazquez, S.R., Yates, N.Y., Beavers, C.J. et al. Differences in quality of anticoagulation care delivery according to ethnoracial group in the United States: A scoping review. J Thromb Thrombolysis (2024). https://doi.org/10.1007/s11239-024-02991-2

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The health benefits and business potential of digital therapeutics

Around the world, the burden of chronic disease is increasing at a rapid pace. Unfortunately, most of these conditions are irreversible and need to be managed through lifelong medication use. However, many patients struggle with adhering to prescribed medications and implementing the behavioral and lifestyle changes that are needed to manage their diseases and stabilize their conditions. Often, physicians and other healthcare providers have little ability to monitor the extent to which patients are following their recommendations and maintaining treatment regimens. As a result, disease burdens at a population level are higher than they should be.

These challenges have created a need for compre­hensive disease management solutions that are best enabled by digital technologies. In 2021, global digital health funding grew 79 percent over the previous year to reach $57.2 billion. 1 State of digital health 2021 report , CB Insights, January 20, 2022. Much attention and funding have flowed toward digital therapeutics , which can include multiple points of intervention along the patient journey, including monitoring, medication adherence, behavioral engagement, person­alized coaching, and real-time custom health recommendations. Within digital health, funding for digital therapeutics (including solutions for mental health) has grown at an even faster pace—up 134 percent from the prior year to reach $8.9 billion in 2021. 2 Heather Landi, “Global digital health funding skyrockets to $57.2B with record cash for mental health, telehealth,” Fierce Healthcare,January 21, 2022.

The impact potential here is significant, both in terms of clinical outcomes and economic benefits for stakeholders and societies. For example, research has shown that digital disease management can drive a 45 percent reduction in the three-month rate of major adverse cardiovascular events (MACEs) and a 50 percent reduction in the 30-day readmission rates for patients after acute myocardial infarction (AMI). 3 Jerilyn K. Allen et al., “Digital health intervention in acute myocardial infarction,” Circulation: Cardiovascular Quality and Outcomes , July 15, 2021, Volume 14, Issue 7; Pawel Buszman et al., “Managed care after acute myocardial infarction (MC-AMI) reduces total mortality in 12-month follow-up—results from Poland’s National Health Fund Program of Comprehensive Post-MI Care—A population-wide analysis,” Journal of Clinical Medicine , 2020, Volume 9, Issue 10. Similarly, it can help lower hemoglobin A1c (HbA1c) levels by one percentage point among patients with type 2 diabetes. 4 Marcy K. Abner et al., “A novel intervention including individualized nutritional recommendations reduces hemoglobin A1c level, medication use, and weight in type 2 diabetes,” JMIR Diabetes , 2017, Volume 2, Issue 1. These data points illustrate the extent to which digital disease manage­ment can help save lives while also keeping patients healthier, which reduces costs for many stake­holders, including the patients themselves.

Research has shown that digital disease management can drive a 45 percent reduction in the three-month rate of major adverse cardiovascular events (MACEs) and a 50 percent reduction in the 30-day readmission rates for patients.

Many players are trying to disrupt the disease management space and develop new innovative models to manage chronic diseases. New-age start-ups bring radical, unconstrained perspectives, while incumbents contribute a much more detailed understanding of the challenges and various stake­holders. Ultimately, both start-ups and incumbents have critical roles to play in disrupting the space and scaling up solutions.

Digital therapeutics can play an important role in chronic-disease management

The burden of chronic diseases has been increasing globally and is expected to continue. Chronic diseases (such as cardiovascular disease, cancer, diabetes, and respiratory disease) were causes or contributing factors in 75 percent of worldwide deaths in 2010 and 79 percent in 2020. By 2030, experts predict that chronic diseases will contribute to as much as 84 percent of total global mortality (exhibit).

Poor monitoring of and adherence to prescribed medications undermine the management of chronic diseases. According to a 2021 global study, compliance among patients with type 2 diabetes ranges from 69 to 79 percent. 5 Diagnosis-related groups (DRG) treatment data: compliance (medication possession ratio) among patients with type 2 diabetes ranges between 69 to 79 percent for top-20 type 2 diabetes drugs; compliance rates for cancers according to a study on 52,450 patients was 37 percent. Patients were found to be most compliant in the 50- to 59-year-old range (49 percent compliant), with decreased compliance at the extremes of age. See Joseph Blansfield et al., “Analyzing the impact of compliance with national guidelines for pancreatic cancer care using the National Cancer Database,” Journal of Gastrointestinal Surgery , August 2018, Volume 22, Issue 8; Nathan Levitan, “Industry Voices—Here’s how AI is impacting the delivery of cancer care right now,” Fierce Healthcare, June 28, 2019.

Of course, chronic diseases need to be managed not only by medication but also with regular monitoring and lifestyle changes. Hence, providers need better end-to-end solutions that proactively and comprehensively monitor patient health, as well as encourage behavioral changes to improve adherence to prescribed medications, diet, and lifestyles.

Digital technologies can play an important role in improving disease management by tackling these challenges. The potential for digital therapeutics to have a big impact is evidenced by the fact that almost two-thirds of the global population now has internet access.

Research has shown that digital solutions for disease management can drive better outcomes for patients living with chronic diseases. Examples include the following:

• A study of ten thousand patients by the Poland National Health Fund showed a 45 percent reduction in three-month MACE rate and a 40 percent reduction in 12-month mortality rate achieved through managed care after AMI. The study involved cardiac rehabilitation with physician guidance, counseling sessions on lifestyle modification, education on the associated risk factors, therapy, and in-person relaxation sessions. 6 “Managed care after acute myocardial infarction,” 2021.
• A study by the Mayo Clinic in partnership with Healarium showed a reduction in three-month rehospitalizations and emergency department visits of 40 percent for patients following AMI, a weight reduction of 4.0 kilograms, and a 10.8-millimeter reduction in systolic blood pressure. The study involved tracking of vitals, diet, and physical activity, setting reminders and goals, information on current health status, and educational courses for patients. 7 Thomas G. Allison et al., “Digital health intervention as an adjunct to cardiac rehabilitation reduces cardiovascular risk factors and rehospitalizations, Journal of Cardiovascular Translational Research , 2015, Volume 8, Issue 5.
• A US study of more than one thousand patients by Johns Hopkins and Corrie Health showed a 50 percent reduction in the 30-day readmission rate in patients following AMI attained through digital-health-based interventions. The study involved continuous monitoring of vitals with the help of connected devices; educational content on procedures, risk factors, and lifestyle modifications; medication management through reminders and tracking adherence; connection with the care team; mood tracking; and the ability to check the side effects of medication. 8 “Digital health intervention in acute myocardial infarction,” 2021.
• A one percentage-point reduction in HbA1c levels was shown in patients with type 2 diabetes who participated in an online patient community as part of Virta Health’s ten-week nonrandomized parallel arm study with 262 outpatients. The patients were given individualized nutritional recommendations through dedicated health coaches, continuous glucose monitoring kits, and online counseling with doctors. 9 “A novel intervention including individualized nutritional recommendations reduces hemoglobin A1c level,” 2017.

Eight key elements of impactful digital therapeutics solutions

Strong digital therapeutics solutions typically contain most or all of the following eight elements:

• Regular monitoring, measurement, and feedback through connected medical devices . Devices such as smart inhalers for respiratory conditions or continuous glucose monitors for diabetes can provide patients with nudges and alerts for out-of-range readings. For example, Boston-based Biofourmis applies digital therapeutics through the continuous monitoring of connected medical devices. The company offers a doctor-prescribed digital platform approved by the US Food and Drug Administration for patients suffering from chronic heart conditions. Its unique wearable devices offer specialty chronic heart care management, including automated medication management combined with a multidisciplinary remote clinical-care team. In 2022, the company was valued at $1.3 billion.
• Keeping payers and providers in the loop. When patients grant access to their vital statistics, insurance companies, caregivers, and employers can reward them for progress in stabilizing or improving chronic health conditions. For example, Livongo, a program from Teladoc Health, allows patients with diabetes to monitor their condition regularly and send alerts via Bluetooth to an app on their own and their caregiver’s phones if readings exceed normal ranges. Over time, patients enrolled with Livongo have achieved a 0.8 percentage-point drop in HbA1c for diabetics, a 10.0-millimeter hemoglobin drop in blood pressure for patients with hypertension, a 1.8-point drop in body mass index, and a 7.0 percent drop in weight. Livongo allows payers and providers to identify and reward good behavior, as well as deter or penalize poor adherence to health plans prescribed by providers.
• Personalized coaching and support . Patients can connect with specific coaches to obtain a personalized diet and exercise plan tailored to their chronic illnesses. This can be very effective from a therapeutic standpoint. A meta-analysis of digital health interventions on blood pressure management showed that digital counseling alongside antihypertensive medical therapy reduced systolic blood pressure by 50 percent relative to controls. 10 Ella Huszti et al., “Advancing digital health interventions as a clinically applied science for blood pressure reduction: A systematic review and meta-analysis,” Canadian Journal of Cardiology , May 2020, Volume 36, Issue 5. For example, Hinge Health has built a $6.2 billion business that offers wearable sensors combined with personalized exercise therapy and one-on-one health coaching.
• Gamified behavioral modification. Digital therapeutics solutions can include gamified challenges and incentives to track and drive adherence to prescribed diets, lifestyle practices, and medications. For example, Discovery, a South African health insurance company, encourages its members to make healthier choices through its Vitality behavioral change program that combines data analytics with rewards and incentives for healthier lifestyle choices.
• Building a thriving community . An active virtual patient community can drive adherence by challenging and motivating patients to live up to their own health goals. For instance, one study of seven thousand patients with amyotrophic lateral sclerosis (ALS), multiple sclerosis, Parkinson’s disease, HIV, fibromyalgia, or mood disorders found that nearly 60 percent thought the PatientsLikeMe health network helped give them a better understanding of the side effects of medications. The study also found that nearly a quarter of patients with mood disorders needed less inpatient care thanks to their use of the PatientsLikeMe site. 11 “PatientsLikeMe,” Agency for Healthcare Research and Quality, accessed January 2023.
• Health mall. A recent McKinsey survey found that 90 percent of healthcare leaders believe that patients interacting with digital health ecosystems want an integrated journey rather than point experiences or solutions. 12 Stefan Biesdorf, Ulrike Deetjen, and Basel Kayyali, “ Digital health ecosystems: Voices of key healthcare leaders ,” McKinsey, October 12, 2021. Healthcare companies can meet this desire for integration by offering digital health malls that include access to prescribed medications, health supplements, wellness products, and diagnostic tests at the click of a button.
• Patient education . Digital education materials can give patients and their family members information on disease conditions, treatment options, diet, and healthy lifestyle choices. For instance, the Midday app launched by Mayo Clinic and digital health start-up Lisa Health provides support, including educational content, to women experiencing menopause. 13 Tia R. Ford, “Lisa Health launches Midday, an app leveraging AI to personalize the menopause journey, in collaboration with Mayo Clinic,” Mayo Clinic, July 19, 2022.
• Advanced analytics to predict and prevent health events . Organizations are working now to build data algorithms that could identify and predict triggers for healthcare events. They could suggest when to take preventative action or where lifestyle and behavioral changes might forestall adverse events.

How incumbents can thrive in the digital therapeutics space

Digital therapeutics have tremendous potential to reduce disease burdens, deliver better clinical outcomes, help providers make more informed treatment decisions, and improve patients’ lives by offering better ways to manage chronic health conditions. Digital therapeutics also offer incumbents access to new sections of the healthcare value chain and a way to play in the much larger end-to-end healthcare market. Given these opportunities, healthcare and pharma incumbents may wish to explore ways to compete and win in this space.

Incumbents have certain inherent advantages in building digital therapeutics offerings. They already have direct access to patients, plus deep knowledge of the pain points in the disease management journey. They also fully understand the disease science that needs to be integrated into the digital health offering.

Still, incumbents also have some work to do to be competitive in digital therapeutics. To successfully launch and scale an offering, they may need to recruit or upskill employees with skills in product development, design, technology, medicine, data science, and strategic partnerships. Incumbents should plan to spend from three to five years building their digital capabilities and inculcating their new digital workforce with the culture, vision, mission, and values to compete successfully against nimble start-ups.

Incumbents that move quickly still have an opportunity to gain a first-mover advantage in the growing digital therapeutics sector, where promising start-ups can receive multibillion-dollar valuations. By developing their own digital therapeutics offerings, incumbents may also find themselves in a stronger position to protect their core businesses from being disrupted by others.

Chirag Adatia is a partner in McKinsey’s Gurugram office, where Samarth Shah is a consultant. Ralf Dreischmeier  is a senior partner in the London office.  Kirtika Sharma is a partner in the Mumbai office.

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Lending standards can be too tight for too long, research finds

Betsy Vereckey

May 14, 2024

The economy plays a huge role in lending trends, which is why it’s harder to get a loan in a recession than it is during a boom time.

Lending standards were loose during the lending boom of the mid-2000s, for example, when credit spreads and default rates were low. And standards were relatively tight during the credit crunch in 2008 – 2009, when default rates were high, and they continued to be tight even during the recovery that followed, so credit spreads also remained high.

What was notable was that lending standards were notably slow to loosen up — even after the turmoil began to ease in 2009 and into 2010, said finance professor  Jonathan A. Parker,  a co-director of the MIT Golub Center for Finance and Policy and the MIT Consumer Finance Initiative .

New research from Parker and his co-authors suggests that some of the persistence of tightness after a shock is self-inflicted. When banks try to protect themselves by increasing their due diligence in evaluating potential borrowers, they set off a chain reaction whereby other banks do the same and worsen the credit crunch. 

Parker, Michael J. Fishman of Northwestern University, and Ludwig Straub of Harvard unpack this ripple effect in “ A Dynamic Theory of Lending Standards ,” examining the effort banks take to screen out bad borrowers. The researchers created a model that examines the effects of tight lending standards versus loose lending standards and shows what can happen when banks go the extra mile to acquire a plethora of information on borrowers and condition their lending on that information. Here’s what they found:

• By not funding people who are less creditworthy, tighter standards worsen the pool of potential borrowers who are looking for loans, which in turn creates an even bigger incentive for banks to employ tight standards in the future.
• Tighter standards in a good market are inefficient. They amplify and prolong downturns, decrease overall lending, and increase credit spreads.

The following insights led the researchers to those conclusions.

Lending standards are inefficient when they’re too tight

When the economy is good, banks rely less on consumers’ private information to make loans, Parker said. They rely more on publicly available information, which is an efficient and low-cost way to acquire data to assess loan applicants.

But when there’s a financial shock to credit markets, or when banks have to be selective about the loans they make because of balance sheet constraints or management concerns about leverage, banks put in more work to evaluate potential borrowers.

The researchers found that this can lead to a domino effect that causes banks to keep up their tough due diligence persistently, even after economic conditions improve. This makes loans more costly to make and means that credit markets get stuck with high interest rates that borrowers end up having to pay. 

If the market is in good shape, less due diligence makes more sense. Over-diligence slows down the process, costs the banks more money — an expense they pass on to borrowers — and reduces their ability to lend to worthy borrowers.

Counterintuitively, in credit markets where most potential borrowers are creditworthy, “less checking would make the loans actually cheaper for those good borrowers who would’ve gotten through the tight lending standards, who would have gotten loans either way,” Parker said.

This is especially relevant right now because there are a lot of commercial real estate losses on bank balance sheets and there is lingering concern about the fiscal health of banks following the year-ago collapse of Silicon Valley Bank and two other large regional lenders.

“There’s a bunch of regulatory concern about the loans that banks are making right now,” Parker said. And that concern is causing banks to put in more effort than necessary when checking a borrower’s history. 

The real estate market is another sore spot. Lending standards are currently tight , especially in commercial real estate.

“When you have people with reasonably good credit scores who are putting a down payment down on a house that’s a good piece of collateral, it doesn’t make sense for banks to be doing a lot of evaluation of whether that loan is going to pay off or not,” Parker said.

“The chances that [a loan] will fail are very small. Some of them will default and lose a little bit of money, but that will be a rare event,” he said.

The government should intervene when lending standards are too tight

Parker said that it can be beneficial to have the government relax lending standards when they’re too tight for too long. Lending standards, for example, were too tight for too long following the 2008 – 2009 financial crisis, Parker said.

In a high interest rate environment, the government could temporarily support the lending market with a temporary loan guarantee program funded by a tax on loan payments. In 2009, the government purchased mortgage-backed securities, which pool borrowers, and took over Fannie Mae and Freddie Mac so they could continue to insure mortgages.

Fintechs are adding additional pressure  

Financial technology startups are now lending like banks, approving loans with just a few taps on a cellphone — but without the same degree of regulation. For example, short-term point-of-sale lending, known as “ buy now, pay later ,” is carving some safe loans out of the credit card space and stealing market share. These companies make loans with a soft credit check based on “what is being purchased, where it’s being bought, and maybe even when,” Parker said.

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Buy now, pay later loans — which allow consumers to break up payment into four installments — began to soar in popularity during the online spending boom spurred by the pandemic. Amid high credit card interest rates , these loans remain popular with people who want to keep a low credit card balance.

Parker said that might push credit card interest rates higher: As some of the better credit risks are carved out of banks’ lending pool, credit card companies might tighten lending standards and reduce credit to marginal borrowers.

“This is a very active place in the economy today, where there are lots of fintech lenders that are working on developing new lending models,” Parker said. For example, SoFi, an online finance company that specializes in student loan refinancing, connects borrowers with investors who want to lend them money.

Parker said that traditional banks should be aware that their borrower pool is being influenced by the arrival of these companies, perhaps more than they realize.

The arrival of buy now, pay later “changes how competitive credit cards are,” Parker said, because the “loans that they’re making are effectively different and separate” from the ones the banks are making.

If buy now, pay later works, “some safe loans would presumably be carved out of the credit card space and satisfied by buy now, pay later,” Parker said. “There are still a bunch of questions about exactly how this is going. But credit card interest rates might end up a little bit higher because some of the better credit risks are being removed from their lending pool.”

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Professor Emeritus David Lanning, nuclear engineer and key contributor to the MIT Reactor, dies at 96

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David Lanning, MIT professor emeritus of nuclear science and engineering and a key contributor to the MIT Reactor project, passed away on April 26 at the Lahey Clinic in Burlington, Massachusetts, at the age of 96.

Born in Baker, Oregon, on March 30, 1928, Lanning graduated in 1951 from the University of Oregon with a BS in physics. While taking night classes in nuclear engineering, in lieu of an available degree program at the time, he started his career path working for General Electric in Richland, Washington. There he conducted critical-mass studies for handling and designing safe plutonium-bearing systems in separation plants at the Hanford Atomic Products Operation, making him a pioneer in nuclear fuel cycle management.

Lanning was then involved in the design, construction, and startup of the Physical Constants Testing Reactor (PCTR). As one of the few people qualified to operate the experimental reactor, he trained others to safely assess and handle its highly radioactive components.

Lanning supervised experiments at the PCTR to find the critical conditions of various lattices in a safe manner and conduct reactivity measurements to determine relative flux distributions. This primed him to be an indispensable asset to the MIT Reactor (MITR), which was being constructed on the opposite side of the country.

An early authority in nuclear engineering comes to MIT

Lanning came to MIT in 1957 to join what was being called the “MIT Reactor Project” after being recruited by the MITR’s designer and first director, Theos “Tommy” J. Thompson, to serve as one of the MITR’s first operating supervisors. With only a handful of people on the operations team at the time, Lanning also completed the emergency plan and startup procedures for the MITR, which achieved criticality on July 21, 1958.

In addition to becoming a faculty member in the Department of Nuclear Engineering in 1962, Lanning’s roles at the MITR went from reactor operations superintendent in the 1950s and early 1960s, to assistant director in 1962, and then acting director in 1963, when Thompson went on sabbatical.

In his faculty position, Lanning took responsibility for supervising lab subjects and research projects at the MITR, including the Heavy Water Lattice Project. This project supported the thesis work of more than 30 students doing experimental studies of sub-critical uranium fuel rods — including Lanning’s own thesis. He received his PhD in nuclear engineering from MIT in fall 1963.

Lanning decided to leave MIT in July 1965 and return to Hanford as the manager of their Reactor Neutronics Section. Despite not having plans to return to work for MIT, Lanning agreed when Thompson requested that he renew his MITR operator’s license shortly after leaving.

“Because of his thorough familiarity with our facility, it is anticipated that Dr. Lanning may be asked to return to MIT for temporary tours of duty at our reactor. It is always possible that there may be changes in the key personnel presently operating the MIT Reactor and the possible availability of Dr. Lanning to fill in, even temporarily, could be a very important factor in maintaining a high level of competence at the reactor during its continued operation,” Theos J. Thompson wrote in a letter to the Atomic Energy Commission on Sept. 21, 1965

One modification, many changes

This was an invaluable decision to continue the MITR’s success as a nuclear research facility. In 1969 Thompson accepted a two-year term appointment as a U.S. atomic energy commissioner and requested Lanning to return to MIT to take his place during his temporary absence. Thompson initiated feasibility studies for a new MITR core design and believed Lanning was the most capable person to continue the task of seeing the MITR redesign to fruition.

Lanning returned to MIT in July 1969 with a faculty appointment to take over the subjects Thompson was teaching, in addition to being co-director of the MITR with Lincoln Clark Jr. during the redesign. Tragically, Thompson was killed in a plane accident in November 1970, just one week after Lanning and his team submitted the application for the redesign’s construction permit.

Thompson’s death meant his responsibilities were now Lanning’s on a permanent basis. Lanning continued to completion the redesign of the MITR, known today as the MITR-II. The redesign increased the neutron flux level by a factor of three without changing its operating power — expanding the reactor’s research capabilities and refreshing its status as a premier research facility.

Construction and startup tests for the MITR-II were completed in 1975 and the MITR-II went critical on Aug. 14, 1975. Management of the MITR-II was transferred the following year from the Nuclear Engineering Department to its own interdepartmental research center, the Nuclear Reactor Laboratory , where Lanning continued to use the MITR-II for research.

Beyond the redesign

In 1970, Lanning combined two reactor design courses he inherited and introduced a new course in which he had students apply their knowledge and critique the design and economic considerations of a reactor presented by a student in a prior term. He taught these courses through the late 1990s, in addition to leading new courses with other faculty for industry professionals on reactor safety.

Co-author of over 70 papers , many on the forefront of nuclear engineering, Lanning’s research included studies to improve the efficiency, cycle management, and design of nuclear fuel, as well as making reactors safer and more economical to operate.

Lanning was part of an ongoing research project team that introduced and demonstrated digital control and automation in nuclear reactor control mechanisms before any of the sort were found in reactors in the United States. Their research improved the regulatory barriers preventing commercial plants from replacing aging analog reactor control components with digital ones. The project also demonstrated that reactor operations would be more reliable, safe, and economical by introducing automation in certain reactor control systems. This led to the MITR being one of the first reactors in the United States licensed to operate using digital technology to control reactor power.

Lanning became professor emeritus in May 1989 and retired in 1994, but continued his passion for teaching through the late 1990s as a thesis advisor and reader. His legacy lives on in the still-operational MITR-II, with his former students following in his footsteps by working on fuel studies for the next version of the MITR core. 

Lanning is predeceased by his wife of 60 years, Gloria Lanning, and is survived by his two children, a brother, and his many grandchildren .

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