Barriers to Adopting Evidence From Bayesian Adaptive Clinical Trials in Critical Care

CHEST Critical Care · 2026-03-07

Impacts of a Rural Hospital Global Budget Alternative Payment Model on Patterns of Cancer Surgery

Medical Care · 2026-05-01

BACKGROUND: Rural patients often experience barriers accessing high-quality surgical care. The Pennsylvania Rural Health Model (PARHM) aimed to improve rural health through all-payer hospital global budgets and transformation plans, which may influence hospitals' incentives and capacity to provide various surgical services, including cancer surgery. OBJECTIVES: Examine the association between PARHM and patterns of cancer surgery overall, by timing of entry into PARHM, and by cancer type. RESEARCH DESIGN: Stacked difference-in-differences (DID) models including hospital service area (HSA)-level propensity score weights, comparing patients living in HSAs with hospitals participating in PARHM to those in HSAs with eligible nonparticipating hospitals. SUBJECTS: Patients in eligible HSAs who had surgery between 2016 and 2023 for one of 11 cancers with evidence of surgical volume-outcome relationships. MEASURES: Surgery at a high-volume, Commission on Cancer (CoC) accredited, or National Cancer Institute (NCI)-designated hospital, and travel distance to the surgical hospital. RESULTS: The sample included 22,728 cancer surgeries for patients across 60 HSAs. Pooled estimates indicate no statistically significant differential changes in outcomes. In HSAs served by the 2019 cohort of PARHM hospitals (smaller and more remote facilities), PARHM was associated with a differential increase in surgery at CoC hospitals (DID estimate: 8.7 percentage points, 95% CI: 1.5- 16.0). We observed differential increases in surgery at CoC hospitals for colon and rectal cancers, and decreases in surgery at CoC and high-volume hospitals for liver cancer and at NCI centers for bladder cancer. CONCLUSION: PARHM had limited overall effects on surgical cancer care, with some variation across hospitals and cancer types.

Intelligent Reasoning Cues: A Framework and Case Study of the Roles of AI Information in Complex Decisions

2026-04-13 · 1 citations

Artificial intelligence (AI)-based decision support systems can be highly accurate yet still fail to support users or improve decisions. Existing theories of AI-assisted decision-making focus on calibrating reliance on AI advice, leaving it unclear how different system designs might influence the reasoning processes underneath. We address this gap by reconsidering AI interfaces as collections of intelligent reasoning cues: discrete pieces of AI information that can individually influence decision-making. We then explore the roles of eight types of reasoning cues in a high-stakes clinical decision (treating patients with sepsis in intensive care). Through contextual inquiries with six teams and a think-aloud study with 25 physicians, we find that reasoning cues have distinct patterns of influence that can directly inform design. Our results also suggest that reasoning cues should prioritize tasks with high variability and discretion, adapt to ensure compatibility with evolving decision needs, and provide complementary, rigorous insights on complex cases.

IP74-29 LONG-TERM IMPACTS OF COVID-19 HEALTH SYSTEM DISRUPTIONS ON OUTCOMES FOLLOWING MAJOR CANCER SURGERY

The Journal of Urology · 2026-04-27

Understanding the Influence of AI Information on Complex Sepsis Treatment Decisions

Open MIND · 2025-10-14

Decision support systems based on artificial intelligence (AI) have the potential to improve decision quality and efficiency in critical care. However, although AI systems have demonstrated promising accuracy in retrospective analyses of critical care patients, they have not yet delivered the promise of improved decisions in this domain. This study aims to investigate whether different types of AI information can positively influence critical care physicians’ decisions. It will consist of a survey of critical care physicians who are randomized to one of three AI conditions and asked to make decisions for a series of vignettes of patients with sepsis. We will measure the quality of the decisions as rated by a panel of sepsis experts and their perceptions of AI output quality.

Survival By Race/Ethnicity in Children and Adolescents/Young Adults with Relapsed/Refractory Hodgkin Lymphoma: A Pooled Analysis of Children's Oncology Group Trials

Klinische Pädiatrie · 2025-12-01

Variation in Corticosteroid Prescribing Practices for Patients With Septic Shock

Critical Care Explorations · 2025-02-21 · 2 citations

OBJECTIVES: Understanding sources of variation in acute care delivery may inform targeted strategies to promote evidence-uptake. We sought to characterize physician-level and ICU-level variation in corticosteroid prescribing for patients with septic shock. DESIGN: We performed a retrospective cohort study using the electronic health record of a multihospital health system. We identified ICU patients with septic shock admitted between 2018 and 2020. Using medication administration data, we determined which patients received corticosteroids within 2 days of vasopressor initiation. We linked each patient to their attending physician of record using digital signatures from clinical documentation. We then fit a hierarchical mixed-effects logistic regression model to identify factors associated with corticosteroid use and quantify variation in corticosteroid administration across physicians and ICUs. SETTING: Twenty-six ICUs across nine hospitals in the United States. PATIENTS: ICU patients with septic shock. MEASUREMENTS AND MAIN RESULTS: Of 5322 patients with vasopressor dependent septic shock, 1294 (24.3%) were treated with corticosteroids within 2 days of vasopressor initiation. We linked these patients to 174 unique attending physicians across 26 ICUs. At the ICU-level, median corticosteroid use was 21.8% (interquartile range [IQR], 18.5-25.7%). At the physician-level, median corticosteroid use was 22.0% (IQR, 11.9-32.7%). In the mixed-effects regression controlling for patient and physician characteristics, 16.5% of the variation in corticosteroid administration was attributable to the ICUs and 10.1% was attributable to the physicians. CONCLUSIONS: Both ICUs and physicians contribute to observed variation in the use of corticosteroids for vasopressor dependent septic shock. These findings underscore the need for multilevel interventions to standardize evidence-based practices in critical care.

Factors Associated With Readmission to Index vs. Non‐Index Hospitals After Major Cancer Surgery

Cancer Medicine · 2025-12-01

BACKGROUND: While receipt of surgery at regional referral centers is associated with improved perioperative outcomes, many vulnerable patients may experience barriers in accessing these hospitals. When these patients do manage to undergo surgery at referral centers, it remains unclear where they are readmitted to receive care when complications arise. Patients may be readmitted to the hospital where surgery was performed (index readmission) or to a different hospital (non-index readmission). This study examined whether factors associated with readmission to index versus non-index hospitals differ for patients undergoing surgery at referral centers compared to non-referral centers. METHODS: We used data from the Pennsylvania Cancer Registry and the Pennsylvania Health Care Cost Containment Council (PHC4) to identify patients who had major cancer surgery and were subsequently readmitted within 90 days. We fit a multivariable logistic regression model to identify factors associated with 90 day readmission to an index versus non-index hospital. We included an interaction term between referral center status and cancer type in this model. RESULTS: A total of 8215 patients were readmitted within 90 days of cancer surgery, of whom 78% (N = 6388) were readmitted to the index hospital. On multivariable analysis, factors associated with lower odds of index versus non-index readmission included older age, high Elixhauser comorbidity scores, and longer travel times. There was no significant difference in odds of index readmission when patients were treated at referral versus non-referral centers (OR = 0.77; 95% CI, 0.50-1.20). When assessing interactions, patients with lung cancer had lower odds of index readmission when treated at referral versus non-referral centers, relative to other cancers (OR = 0.59; 95% CI, 0.41-0.84). CONCLUSIONS: Higher clinical complexity and greater travel burdens were associated with lower odds of index readmission. Relative to other cancers, patients with lung cancer may be more likely to experience care fragmentation after undergoing surgery at a referral center.

Association of a State‐Wide Alternative Payment Model for Rural Hospitals With Bypass for Elective Surgeries

Health Services Research · 2025-01-30 · 1 citations

OBJECTIVE: This study aimed to measure the changes in rural hospital bypass for 11 common elective surgeries following the implementation of the Pennsylvania Rural Health Model (PARHM), a global budget payment model. STUDY SETTING AND DESIGN: We leveraged a natural experiment arising from the phase-in of PHARM in Pennsylvania. We conducted a comparative interrupted time series analysis to assess changes in rural hospital bypass, comparing trends in rural hospital bypass among patients in hospital service areas (HSAs) with PARHM-participating hospitals to patients in control HSAs with hospitals eligible for but not participating in PARHM. Analyses accounted for staggered entry into PARHM and examined outcomes up to 4 years post-entry. DATA SOURCES AND ANALYTIC SAMPLE: We used Pennsylvania all-payer visit-level inpatient discharge data (2016-2022) to measure rural hospital bypass, encompassing 175,138 surgeries. PRINCIPAL FINDINGS: The average bypass rate for elective surgeries was 59.9%, with an increasing trend observed during the study period. Overall, differential changes in bypass rates between PARHM-participating and control HSAs were not statistically significant, from a low of 0.53 percentage points (-8.17-9.22) among Cohort 2 HSAs and a high of 5.96 percentage points (-4.63-16.55) among Cohort 1 HSAs. However, among critical access hospitals, PARHM participation was associated with a significant relative increase in levels and trends in bypass rates compared to controls, from a low of 9.12 percentage points (2.45-15.79) among Cohort 1 HSAs and a high of 29.70 percentage points (12.54-46.86) among Cohort 2 HSAs. These relative increases were largely due to a stable rate in PARHM-participating HSAs and a marked decrease in control HSAs. CONCLUSIONS: This study fills a gap in the relationship between global budgets and hospital bypass. Although PARHM did not broadly alter rural bypass rates overall, the differential increase in bypass among HSAs with CAHs participating in PARHM suggests meaningful effect heterogeneity, warranting further research and analysis of impacts on patient outcomes.

OT06 | AHOD2131: A RANDOMIZED PHASE 3 RESPONSE‐ADAPTED TRIAL COMPARING STANDARD THERAPY TO IMMUNO‐ONCOLOGY FOR CHILDREN & ADULTS WITH NEWLY DIAGNOSED STAGE I/II HODGKIN LYMPHOMA

Hematological Oncology · 2025-06-01

J. Seelisch and B. Hu equally contributing author. Background: Chemotherapy with or without radiotherapy (RT) is the standard frontline treatment for early-stage (ES) classic Hodgkin lymphoma (cHL) and leads to outstanding cure rates. However, toxicities associated with both chemotherapy and RT are of concern especially as ES cHL overly affects adolescents and young adults. Encouragingly, the recent development of novel immunotherapy (IO) agents in the relapsed/refractory setting offers new potential treatment options in the frontline setting that aim to improve progression-free survival (PFS) and maintain overall survival (OS), while minimizing morbidity and mortality associated with RT and high cumulative doses of chemotherapy. Methods: AHOD2131 is a collaborative study developed between pediatric and medical oncology members of the National Cancer Institute’s National Clinical Trial Network groups, aiming to harmonize treatment approaches for ES cHL and to reach consensus around optimal study design for incorporating IO into frontline treatment. Study champions from each North American (NA) cooperative group [Children’s Oncology Group (COG), SWOG, ECOG-ACRIN, Alliance, NRG] and experts in imaging, radiation oncology, lymphoma biology and patient-reported outcomes were included. The resulting COG-led clinical trial represents the largest ES cHL trial in the history of NA cooperative groups and the first to enroll patients across the age continuum. AHOD2131 (NCT05675410; Figure) is a randomized, phase 3 trial for patients ages 5 to 60 years with newly diagnosed stage I and II cHL, investigating the addition of the CD30-antibody drug conjugate brentuximab vedotin (Bv) with PD-1 blockade (nivolumab) compared to standard chemotherapy +/- RT. AHOD2131 was activated in April 2023. As of 27 February 2025, 304 sites have activated, and 429 participants have enrolled. 224 patients (52%) are less than 18 years. Target enrollment is 1875 patients over 5 years. The primary objective of the study is to compare the PFS of patients treated through a response-adapted, superiority design with either standard therapy or IO (Bv + nivolumab). Patients will be stratified based on EORTC-defined favorable or unfavorable risk features at enrollment. At present, 132 (31%) of enrolled patients have favorable characteristics, and 288 (69%) have unfavorable. Based on response assessment by PET/CT (central review) after 2 cycles of ABVD, patients will be classified to PET2 positive (slow early response [SER], defined as 5-Point Score 4 or 5) or PET2 negative (rapid early response [RER]). Patients with SER will receive involved site RT while patients with RER receive systemic therapy only. Key secondary endpoint is a non-inferiority comparison of 12-year OS, with 11 additional secondary endpoints and 10 exploratory aims. Conclusion: AHOD2131 strengthens the effort between NA cooperative groups to conduct collaborative clinical trials and aims to harmonize an improved standard of care for ES cHL across the age continuum. Keywords: Hodgkin lymphoma; Hodgkin lymphoma (Pediatric, Adolescent, and Young Adult); ongoing trials No potential sources of conflict of interest.