{"id":"https://openalex.org/W7204838749","doi":"https://doi.org/10.64898/2026.08.27.26361548","title":"The effectiveness of point of care high sensitivity troponin testing to improve Emergency Department flow: a multi-centre controlled interrupted time series","display_name":"The effectiveness of point of care high sensitivity troponin testing to improve Emergency Department flow: a multi-centre controlled interrupted time series","publication_year":2026,"publication_date":"2026-08-31","ids":{"openalex":"https://openalex.org/W7204838749","doi":"https://doi.org/10.64898/2026.08.27.26361548"},"language":"en","primary_location":{"id":"doi:10.64898/2026.08.27.26361548","doi":"https://doi.org/10.64898/2026.08.27.26361548","is_oa":true,"landing_page_url":"https://doi.org/10.64898/2026.08.27.26361548","pdf_url":null,"source":{"id":"https://openalex.org/S3005729997","display_name":"medRxiv","issn_l":null,"issn":null,"is_oa":false,"is_in_doaj":false,"is_core":true,"listed_in":["cwts-core"],"host_organization":null,"host_organization_name":null,"host_organization_lineage":["https://openalex.org/P4310315909"],"host_organization_lineage_names":["Cold Spring Harbor Laboratory Press"],"type":"repository"},"license":"cc-by-nc","license_id":"https://openalex.org/licenses/cc-by-nc","version":"acceptedVersion","is_accepted":true,"is_published":false,"raw_source_name":"medRxiv","raw_type":"posted-content"},"volume":null,"type":"preprint","is_traditional":true,"indexed_in":["crossref"],"open_access":{"is_oa":true,"oa_status":"green","oa_url":"https://doi.org/10.64898/2026.08.27.26361548","any_repository_has_fulltext":true},"authorships":[{"author_position":"first","author":{"id":"https://openalex.org/A5059664356","display_name":"Ryan D. McHenry","orcid":"https://orcid.org/0000-0002-7627-8450","observed_orcids":["https://orcid.org/0000-0002-7627-8450"]},"institutions":[{"id":"https://openalex.org/I4210158502","display_name":"Queen Elizabeth University Hospital","ror":"https://ror.org/04y0x0x35","country_code":"GB","type":"healthcare","lineage":["https://openalex.org/I2800201399","https://openalex.org/I4210158502"]},{"id":"https://openalex.org/I7882870","display_name":"University of Glasgow","ror":"https://ror.org/00vtgdb53","country_code":"GB","type":"education","lineage":["https://openalex.org/I7882870"]}],"countries":["GB"],"is_corresponding":false,"raw_author_name":"Ryan McHenry","raw_affiliation_strings":["Emergency Department, \u01eaueen Elizabeth University Hospital, Glasgow, UK","School of Health and Wellbeing, University of Glasgow, Glasgow, UK"],"raw_orcid":"https://orcid.org/0000-0002-7627-8450","affiliations":[{"raw_affiliation_string":"Emergency Department, \u01eaueen Elizabeth University Hospital, Glasgow, UK","institution_ids":["https://openalex.org/I4210158502"]},{"raw_affiliation_string":"School of Health and Wellbeing, University of Glasgow, Glasgow, UK","institution_ids":["https://openalex.org/I7882870"]}]},{"author_position":"middle","author":{"id":"https://openalex.org/A5134347956","display_name":"Andrew Saunders","orcid":null,"observed_orcids":[]},"institutions":[{"id":"https://openalex.org/I4210158502","display_name":"Queen Elizabeth University Hospital","ror":"https://ror.org/04y0x0x35","country_code":"GB","type":"healthcare","lineage":["https://openalex.org/I2800201399","https://openalex.org/I4210158502"]}],"countries":["GB"],"is_corresponding":false,"raw_author_name":"Andrew Saunders","raw_affiliation_strings":["Emergency Department, \u01eaueen Elizabeth University Hospital, Glasgow, UK"],"raw_orcid":null,"affiliations":[{"raw_affiliation_string":"Emergency Department, \u01eaueen Elizabeth University Hospital, Glasgow, UK","institution_ids":["https://openalex.org/I4210158502"]}]},{"author_position":"middle","author":{"id":"https://openalex.org/A5133860337","display_name":"Faheem Ahmad","orcid":"https://orcid.org/0000-0003-3886-2936","observed_orcids":["https://orcid.org/0000-0003-3886-2936"]},"institutions":[{"id":"https://openalex.org/I4210158502","display_name":"Queen Elizabeth University Hospital","ror":"https://ror.org/04y0x0x35","country_code":"GB","type":"healthcare","lineage":["https://openalex.org/I2800201399","https://openalex.org/I4210158502"]}],"countries":["GB"],"is_corresponding":false,"raw_author_name":"Faheem Ahmad","raw_affiliation_strings":["The Department of Cardiology, \u01eaueen Elizabeth University Hospital, Glasgow, UK"],"raw_orcid":null,"affiliations":[{"raw_affiliation_string":"The Department of Cardiology, \u01eaueen Elizabeth University Hospital, Glasgow, UK","institution_ids":["https://openalex.org/I4210158502"]}]},{"author_position":"last","author":{"id":"https://openalex.org/A5126502811","display_name":"Daniel Mackay","orcid":"https://orcid.org/0000-0001-5381-7098","observed_orcids":["https://orcid.org/0000-0001-5381-7098"]},"institutions":[{"id":"https://openalex.org/I7882870","display_name":"University of Glasgow","ror":"https://ror.org/00vtgdb53","country_code":"GB","type":"education","lineage":["https://openalex.org/I7882870"]}],"countries":["GB"],"is_corresponding":false,"raw_author_name":"Daniel Mackay","raw_affiliation_strings":["School of Health and Wellbeing, University of Glasgow, Glasgow, UK"],"raw_orcid":null,"affiliations":[{"raw_affiliation_string":"School of Health and Wellbeing, University of Glasgow, Glasgow, UK","institution_ids":["https://openalex.org/I7882870"]}]}],"institutions":[],"countries_distinct_count":1,"institutions_distinct_count":2,"corresponding_author_ids":[],"corresponding_institution_ids":[],"apc_list":null,"apc_paid":null,"fwci":null,"has_fulltext":false,"cited_by_count":0,"citation_normalized_percentile":null,"cited_by_percentile_year":null,"biblio":{"volume":null,"issue":null,"first_page":null,"last_page":null},"is_retracted":false,"is_paratext":false,"is_xpac":false,"primary_topic":{"id":"https://openalex.org/T11095","display_name":"Emergency and Acute Care Studies","score":0.9911999702453613,"subfield":{"id":"https://openalex.org/subfields/2711","display_name":"Emergency Medicine"},"field":{"id":"https://openalex.org/fields/27","display_name":"Medicine"},"domain":{"id":"https://openalex.org/domains/4","display_name":"Health Sciences"}},"topics":[{"id":"https://openalex.org/T11095","display_name":"Emergency and Acute Care Studies","score":0.9911999702453613,"subfield":{"id":"https://openalex.org/subfields/2711","display_name":"Emergency Medicine"},"field":{"id":"https://openalex.org/fields/27","display_name":"Medicine"},"domain":{"id":"https://openalex.org/domains/4","display_name":"Health Sciences"}},{"id":"https://openalex.org/T11773","display_name":"Healthcare Operations and Scheduling Optimization","score":0.006200000178068876,"subfield":{"id":"https://openalex.org/subfields/1803","display_name":"Management Science and Operations Research"},"field":{"id":"https://openalex.org/fields/18","display_name":"Decision Sciences"},"domain":{"id":"https://openalex.org/domains/2","display_name":"Social Sciences"}},{"id":"https://openalex.org/T10292","display_name":"Acute Myocardial Infarction Research","score":0.0007999999797903001,"subfield":{"id":"https://openalex.org/subfields/2705","display_name":"Cardiology and Cardiovascular Medicine"},"field":{"id":"https://openalex.org/fields/27","display_name":"Medicine"},"domain":{"id":"https://openalex.org/domains/4","display_name":"Health Sciences"}}],"keywords":[{"id":"https://openalex.org/keywords/emergency-department-crowding","display_name":"emergency department overcrowding","score":0.9079999923706055},{"id":"https://openalex.org/keywords/exit-block","display_name":"exit block","score":0.9039999842643738},{"id":"https://openalex.org/keywords/emergency-department-throughput","display_name":"emergency department throughput","score":0.7749999761581421},{"id":"https://openalex.org/keywords/sampling-interval","display_name":"sampling interval","score":0.621999979019165},{"id":"https://openalex.org/keywords/emergency-department-occupancy","display_name":"emergency department occupancy","score":0.7179999947547913},{"id":"https://openalex.org/keywords/length-of-hospital-stay","display_name":"length of hospital stay","score":0.9359999895095825},{"id":"https://openalex.org/keywords/interrupted-time-series-design","display_name":"interrupted time series design","score":0.6779999732971191},{"id":"https://openalex.org/keywords/emergency-department-patient-flow","display_name":"emergency department patient flow","score":0.32199999690055847},{"id":"https://openalex.org/keywords/underpowered-studies","display_name":"underpowered studies","score":0.3499999940395355},{"id":"https://openalex.org/keywords/falsification-tests","display_name":"falsification tests","score":0.5270000100135803}],"concepts":[{"id":"https://openalex.org/C71924100","wikidata":"https://www.wikidata.org/wiki/Q11190","display_name":"Medicine","level":0,"score":0.8242999911308289},{"id":"https://openalex.org/C2780724011","wikidata":"https://www.wikidata.org/wiki/Q1295316","display_name":"Emergency department","level":2,"score":0.792900025844574},{"id":"https://openalex.org/C2780089965","wikidata":"https://www.wikidata.org/wiki/Q39046682","display_name":"Interrupted time series","level":3,"score":0.5845999717712402},{"id":"https://openalex.org/C194828623","wikidata":"https://www.wikidata.org/wiki/Q2861470","display_name":"Emergency medicine","level":1,"score":0.5536999702453613},{"id":"https://openalex.org/C2909024267","wikidata":"https://www.wikidata.org/wiki/Q39046682","display_name":"Interrupted Time Series Analysis","level":2,"score":0.5055999755859375},{"id":"https://openalex.org/C23131810","wikidata":"https://www.wikidata.org/wiki/Q818574","display_name":"Observational study","level":2,"score":0.46380001306533813},{"id":"https://openalex.org/C149333683","wikidata":"https://www.wikidata.org/wiki/Q5189188","display_name":"Crowding","level":2,"score":0.40139999985694885},{"id":"https://openalex.org/C2777120189","wikidata":"https://www.wikidata.org/wiki/Q780067","display_name":"Triage","level":2,"score":0.39500001072883606},{"id":"https://openalex.org/C36036425","wikidata":"https://www.wikidata.org/wiki/Q7846262","display_name":"Troponin","level":3,"score":0.3677000105381012},{"id":"https://openalex.org/C64841741","wikidata":"https://www.wikidata.org/wiki/Q491983","display_name":"Point-of-care testing","level":2,"score":0.35679998993873596},{"id":"https://openalex.org/C168563851","wikidata":"https://www.wikidata.org/wiki/Q1436668","display_name":"Randomized controlled trial","level":2,"score":0.34769999980926514},{"id":"https://openalex.org/C176217482","wikidata":"https://www.wikidata.org/wiki/Q860554","display_name":"Metric (unit)","level":2,"score":0.34360000491142273},{"id":"https://openalex.org/C144469398","wikidata":"https://www.wikidata.org/wiki/Q24785650","display_name":"Troponin T","level":3,"score":0.3240000009536743},{"id":"https://openalex.org/C51915194","wikidata":"https://www.wikidata.org/wiki/Q17075487","display_name":"Point of care","level":2,"score":0.31540000438690186},{"id":"https://openalex.org/C2781385661","wikidata":"https://www.wikidata.org/wiki/Q4677918","display_name":"Acute care","level":3,"score":0.29679998755455017},{"id":"https://openalex.org/C545542383","wikidata":"https://www.wikidata.org/wiki/Q2751242","display_name":"Medical emergency","level":1,"score":0.288100004196167},{"id":"https://openalex.org/C203092338","wikidata":"https://www.wikidata.org/wiki/Q1340863","display_name":"Clinical endpoint","level":3,"score":0.2865000069141388},{"id":"https://openalex.org/C2780665704","wikidata":"https://www.wikidata.org/wiki/Q959298","display_name":"Intervention (counseling)","level":2,"score":0.28610000014305115},{"id":"https://openalex.org/C140779682","wikidata":"https://www.wikidata.org/wiki/Q210868","display_name":"Sampling (signal processing)","level":3,"score":0.28380000591278076},{"id":"https://openalex.org/C129848803","wikidata":"https://www.wikidata.org/wiki/Q2564360","display_name":"Sample size determination","level":2,"score":0.28360000252723694},{"id":"https://openalex.org/C27415008","wikidata":"https://www.wikidata.org/wiki/Q7256382","display_name":"Psychological intervention","level":2,"score":0.2833000123500824},{"id":"https://openalex.org/C72563966","wikidata":"https://www.wikidata.org/wiki/Q1303415","display_name":"Cohort","level":2,"score":0.2768999934196472},{"id":"https://openalex.org/C44249647","wikidata":"https://www.wikidata.org/wiki/Q208498","display_name":"Confidence interval","level":2,"score":0.2694000005722046},{"id":"https://openalex.org/C2780367336","wikidata":"https://www.wikidata.org/wiki/Q4808618","display_name":"Assay sensitivity","level":3,"score":0.26339998841285706}],"mesh":[],"locations_count":1,"locations":[{"id":"doi:10.64898/2026.08.27.26361548","doi":"https://doi.org/10.64898/2026.08.27.26361548","is_oa":true,"landing_page_url":"https://doi.org/10.64898/2026.08.27.26361548","pdf_url":null,"source":{"id":"https://openalex.org/S3005729997","display_name":"medRxiv","issn_l":null,"issn":null,"is_oa":false,"is_in_doaj":false,"is_core":true,"listed_in":["cwts-core"],"host_organization":null,"host_organization_name":null,"host_organization_lineage":["https://openalex.org/P4310315909"],"host_organization_lineage_names":["Cold Spring Harbor Laboratory Press"],"type":"repository"},"license":"cc-by-nc","license_id":"https://openalex.org/licenses/cc-by-nc","version":"acceptedVersion","is_accepted":true,"is_published":false,"raw_source_name":"medRxiv","raw_type":"posted-content"}],"best_oa_location":{"id":"doi:10.64898/2026.08.27.26361548","doi":"https://doi.org/10.64898/2026.08.27.26361548","is_oa":true,"landing_page_url":"https://doi.org/10.64898/2026.08.27.26361548","pdf_url":null,"source":{"id":"https://openalex.org/S3005729997","display_name":"medRxiv","issn_l":null,"issn":null,"is_oa":false,"is_in_doaj":false,"is_core":true,"listed_in":["cwts-core"],"host_organization":null,"host_organization_name":null,"host_organization_lineage":["https://openalex.org/P4310315909"],"host_organization_lineage_names":["Cold Spring Harbor Laboratory Press"],"type":"repository"},"license":"cc-by-nc","license_id":"https://openalex.org/licenses/cc-by-nc","version":"acceptedVersion","is_accepted":true,"is_published":false,"raw_source_name":"medRxiv","raw_type":"posted-content"},"sustainable_development_goals":[{"score":0.9940000176429749,"id":"https://metadata.un.org/sdg/3","display_name":"Good health and well-being"}],"study_designs":[],"awards":[],"funders":[],"has_content":{"pdf":false,"grobid_xml":false},"content_urls":null,"referenced_works_count":33,"referenced_works":["https://openalex.org/W1901379098","https://openalex.org/W1963921006","https://openalex.org/W2002793853","https://openalex.org/W2009428399","https://openalex.org/W2035720094","https://openalex.org/W2078639378","https://openalex.org/W2104233517","https://openalex.org/W2111366073","https://openalex.org/W2130823724","https://openalex.org/W2137761428","https://openalex.org/W2148892351","https://openalex.org/W2489491205","https://openalex.org/W2791404642","https://openalex.org/W2883382548","https://openalex.org/W2883904009","https://openalex.org/W2891819831","https://openalex.org/W2963031921","https://openalex.org/W2965689387","https://openalex.org/W3169407454","https://openalex.org/W3194472989","https://openalex.org/W4205611220","https://openalex.org/W4206439534","https://openalex.org/W4220700636","https://openalex.org/W4230897592","https://openalex.org/W4385984544","https://openalex.org/W4403431962","https://openalex.org/W4409309544","https://openalex.org/W4411428467","https://openalex.org/W4417175089","https://openalex.org/W7128609863","https://openalex.org/W7133967872","https://openalex.org/W7161828068","https://openalex.org/W7222927801"],"related_works":["https://openalex.org/W7167418790","https://openalex.org/W7203594990","https://openalex.org/W7104177508","https://openalex.org/W7164165562","https://openalex.org/W2037864585","https://openalex.org/W7223563083","https://openalex.org/W4409309544","https://openalex.org/W4399692982","https://openalex.org/W7203786992","https://openalex.org/W7222927801"],"abstract_inverted_index":{"Abstract":[0],"Background":[1],"Emergency":[2,372],"Department":[3,373],"(ED)":[4,374],"crowding":[5,31,375,500,634],"is":[6,366,376,549,579],"an":[7,510,532],"international":[8],"crisis":[9],"primarily":[10],"driven":[11,378,635],"by":[12,32,290,379,420,636],"exit":[13,637],"block.":[14],"Point":[15],"of":[16,74,136,142,147,174,353,387,401,467,485,490,522,537,592,609],"care":[17,388,572],"(POC)":[18,389],"cardiac":[19,320],"biomarker":[20,321],"testing":[21,60,112,322,390,543,595],"and":[22,42,61,69,97,133,159,230,251,297,314,323,360,588,600],"reduced":[23,62,324,454],"sampling":[24,63,117,325,455],"intervals":[25,64,118,326],"have":[26,409],"been":[27],"proposed":[28],"to":[29,53,70,121,179,189,218,228,235,255,293,310,346,393,433,441,475,482,551,581],"mitigate":[30],"improving":[33],"throughput,":[34],"but":[35],"whole-ED":[36,66,202,331,462,486,633],"operational":[37,354,413,567],"impacts":[38],"remain":[39],"poorly":[40],"understood,":[41],"evaluations":[43,352],"often":[44],"rely":[45],"on":[46,369],"vulnerable":[47,345,580],"observational":[48],"designs.":[49,554],"This":[50],"study":[51,287,295,447,471,557],"aimed":[52],"assess":[54],"whether":[55],"introducing":[56],"POC":[57,109,319,450],"high-sensitivity":[58,110,451],"troponin":[59,111,452],"changed":[65],"flow":[67,203],"metrics,":[68],"test":[71],"the":[72,190,193,206,237,244,248,256,259,269,272,281,294,308,334,470,483,514,523,590,604,607],"robustness":[73],"interrupted":[75,87,425],"time":[76,88,426],"series":[77,89,427],"(ITS)":[78,428],"methodology":[79],"in":[80,102,116,200,221,243,271,348,417,499,505,513,518,534,569],"this":[81,370,446,556],"setting.":[82],"Methods":[83],"A":[84],"multi-centre":[85],"controlled":[86,506],"(CITS)":[90],"across":[91],"two":[92],"large":[93,535],"urban":[94],"intervention":[95,106,191,194,215,492,539],"EDs":[96],"one":[98,214,491],"untreated":[99,207,238,273,511],"control":[100,208,239,260,299],"ED":[101,127],"Glasgow,":[103],"UK.":[104],"The":[105,170,286],"combined":[107],"whole-blood":[108],"with":[113,158,162],"a":[114,140,175,180,264,304],"reduction":[115],"from":[119,616],"3":[120],"2":[122],"hours.":[123],"Outcomes":[124],"included":[125],"daily":[126],"admissions,":[128,463],"mean":[129,134,222],"occupancy,":[130,132,464],"maximum":[131,231],"length":[135,466],"stay.":[137],"Analyses":[138],"used":[139,432],"window":[141,296],"120":[143],"days":[144],"either":[145,210],"side":[146],"each":[148],"implementation":[149],"date.":[150],"Effects":[151],"were":[152,183,502,526],"evaluated":[153],"using":[154,585],"segmented":[155],"ITS":[156,341,578,622],"models,":[157],"without":[160],"controls,":[161,359,587],"permutation":[163],"tests":[164,530],"against":[165,205],"147":[166],"pre-intervention":[167],"placebo":[168],"dates.":[169],"minimum":[171],"detectable":[172],"effects":[173],"similar":[176],"study,":[177],"applied":[178],"national":[181,305],"dataset,":[182],"simulated.":[184],"Results":[185],"Across":[186],"483,412":[187],"presentations":[188],"sites,":[192],"produced":[195,241],"no":[196],"statistically":[197,495],"significant":[198,496],"change":[199],"any":[201],"metric":[204],"at":[209,247,280],"site.":[211],"Analysed":[212],"alone,":[213],"site":[216,283,493,619],"appeared":[217],"show":[219],"reductions":[220,242,270],"occupancy":[223,232],"(\u22126.08,":[224],"95%":[225],"CI":[226],"\u221212.04":[227],"\u22120.12)":[229],"(\u22127.60,":[233],"\u221214.47":[234],"\u22120.73);":[236],"department":[240,274,512],"same":[245,249,515,524],"direction":[246,525],"date,":[250],"both":[252],"estimates":[253],"attenuated":[254],"null":[257],"once":[258],"was":[261,288,336,472],"applied.":[262],"Under":[263],"pre-specified":[265],"14-day":[266],"transition":[267],"specification":[268],"reached":[275],"statistical":[276],"significance":[277],"while":[278],"those":[279],"treated":[282],"did":[284,327,458],"not.":[285],"limited":[289,298],"power":[291],"due":[292,481],"pool.":[300],"Simulation":[301],"demonstrated":[302,412],"that":[303,501,576,628],"dataset":[306],"has":[307],"potential":[309,605],"provide":[311],"operationally":[312],"feasible":[313],"clinically":[315],"important":[316],"findings.":[317],"Conclusion":[318],"not":[328,410,459,503],"detectably":[329,460],"improve":[330,461],"flow,":[332],"though":[333,469],"design":[335],"underpowered.":[337],"More":[338],"importantly,":[339],"uncontrolled":[340,424,577],"designs":[342,429,584],"are":[343,391,430],"highly":[344],"confounding":[347],"complex":[349,435],"healthcare":[350,436],"systems;":[351],"interventions":[355,384,437,568,630],"must":[356,573,640],"utilise":[357],"concurrent":[358,586],"routinely":[361],"report":[362],"falsification":[363,542,593],"tests.":[364],"What":[365,445],"already":[367],"known":[368,439],"topic":[371],"largely":[377],"\u2018exit":[380],"block\u2019,":[381],"yet":[382],"throughput":[383,629],"like":[385],"point":[386],"marketed":[392],"im-":[394],"prove":[395],"patient":[396],"flow.":[397],"Real-world":[398],"effectiveness":[399],"studies":[400],"rapid":[402],"rule-out":[403],"strategies":[404],"for":[405,606],"myocardial":[406],"in-":[407],"farction":[408],"consistently":[411],"improvements,":[414],"particu-":[415],"larly":[416],"systems":[418],"constrained":[419],"downstream":[421],"pressures.":[422],"Single,":[423],"frequently":[431],"evaluate":[434],"despite":[438],"vulnerabilities":[440],"un-":[442],"measured":[443],"confounding.":[444],"adds":[448],"Implementing":[449],"alongside":[453,509],"inter-":[456],"vals":[457],"or":[465,562,621],"stay,":[468],"critically":[473],"underpowered":[474],"detect":[476],"plausible,":[477],"smaller":[478],"effect":[479,533],"sizes":[480],"dilution":[484],"metrics.":[487],"Uncontrolled":[488],"analysis":[489],"generated":[494],"apparent":[497],"improvements":[498],"replicated":[504],"analy-":[507],"sis":[508],"health":[516],"board,":[517],"which":[519],"esti-":[520],"mates":[521],"obtained.":[527],"Conventional":[528],"model-based":[529,546],"declared":[531],"proportions":[536],"pre-":[538],"dates,":[540],"so":[541],"rather":[544],"than":[545],"inference":[547],"alone":[548],"required":[550],"interpret":[552],"these":[553],"How":[555],"might":[558],"affect":[559],"research,":[560],"practice":[561],"policy":[563],"Methodologically,":[564],"researchers":[565],"evaluating":[566,613],"emer-":[570],"gency":[571],"be":[574,641],"aware":[575],"confounding,":[582],"consider":[583,603],"mandate":[589],"use":[591],"(placebo)":[594],"as":[596],"routine":[597],"practice.":[598],"Policymakers":[599],"clinicians":[601],"should":[602,626],"influence":[608],"system-wide":[610],"shocks":[611],"when":[612],"positive":[614],"results":[615],"uncontrolled,":[617],"single-":[618],"before-and-after":[620],"studies.":[623],"Operational":[624],"managers":[625],"recognise":[627],"cannot":[631],"overcome":[632],"block;":[638],"resources":[639],"directed":[642],"accordingly.":[643]},"counts_by_year":[],"updated_date":"2026-11-04T10:54:05.112534","created_date":"2026-09-01T00:00:00"}
