Amanda Jane Reich

BACKGROUND: State emergency medical services (EMS) and trauma systems determine prehospital triage, transport, trauma center designation, data reporting, and quality improvement, yet their contemporary organization has not been systematically characterized. We sought to describe state-level EMS and trauma system structures, policies, resources, and perceived gaps across the United States. METHODS: We conducted a cross-sectional survey of EMS and trauma system leaders in all 50 states and the District of Columbia from July 2025 through March 2026. A 56-item instrument utilizing categorical, Likert-type, rank-order, and free-text items assessed oversight, prehospital triage and transport, clinical protocols, trauma center verification, registries, quality improvement, and funding. Respondents were recruited by email and phone. Multiple respondents could contribute complementary domain-level information to a single state profile. Responses were summarized descriptively. RESULTS: All 51 jurisdictions participated. Most states reported a state EMS medical director (84%), statewide trauma triage protocols (84%), and mandatory participation in their state trauma registry (88%). However, operational coordination varied: only 29% had a centralized trauma communications center, only 6% of states reported a single point of contact for helicopter EMS dispatch, and 35% required a certificate of need for new helicopter services. Trauma center verification relied on American College of Surgeons (ACS) verification in 59% of states, while others used state-administered processes. More than half of states rated EMS financial resources in the two lowest adequacy categories, and 55% reported that their trauma system required at least moderate improvement. Rural populations were most frequently identified as underserved (96%) and as experiencing worse outcomes (92%). CONCLUSIONS: State EMS and trauma systems share broad adoption of national clinical standards but differ substantially in governance, coordination, verification, data integration, and funding. LEVEL OF EVIDENCE AND STUDY TYPE: Level V, Prognostic/epidemiological.

Purpose: Prostate cancer (PCa) mortality disparities are partly driven by unequal access to care. Transportation barriers may limit access to definitive treatment. We studied how driving travel time affects receipt of definitive PCa treatment. Materials and Methods: We conducted a cohort study of men with non‐metastatic PCa (2000–2015; follow‐up through 2018) across the metropolitan area cancer registries of seven US states. Travel time was estimated using Google Maps isochrones representing driving time thresholds to reach the hospital appended to geomasked residential addresses. Outcomes were “no treatment,” “radical surgery,” or “radiotherapy”. Covariate‐adjusted multinomial logistic regression with interaction terms assessed modification by sociodemographic factors. Results: The study included 132,939 men, of whom 37.0% received no treatment, 41.0% underwent surgery, and 22.0% received radiotherapy. Longer driving time (≥ 90 min vs. < 30 min) was associated with higher radical prostatectomy (aOR: 1.08, 95% CI: 1.03, 1.12), but lower radiotherapy (0.72, 95% CI: 0.69–0.76). Subgroup analyses revealed higher surgery associated with longer driving times among those in nSES Q1 (aOR: 1.33, 95% CI: 1.21–1.45) vs. Q5 (aOR: 0.94, 95% CI: 0.86–1.04), those in low (aOR: 1.16, 95% CI: 1.09–1.24) vs. high (aOR: 1.03, 95% CI: 0.98–1.09) population density areas, and those with regional (aOR: 1.30, 95% CI: 1.14–1.48) vs. localized (aOR: 1.05, 95% CI: 1.00–1.09) disease. Longer driving time was mostly associated with lower odds of radiotherapy across sociodemographic subgroups. Conclusions: Higher travel time was associated with lower radiotherapy receipt, but higher surgery use in deprived and rural patients, warranting further investigation.

Objective: The objective of this study was to determine whether perioperative continuation of code status limitations is associated with early postoperative mortality and to characterize postoperative code-status trajectories preceding early deaths. Summary Background Data: Decisions about perioperative management of do-not-resuscitate (DNR) orders are common, yet their relationship to early postoperative outcomes remains poorly understood. Methods: This was a retrospective cohort study conducted from March 2024 to June 2025 across 5 hospitals within a single academic health system. We included adults aged 18 years or older who presented for a procedure under anesthesia with a code status other than full code. The exposure was perioperative code status (reversal to full code vs. not full code). The primary outcome was all-cause mortality within 3 days of the procedure. The secondary outcome was use of invasive hemodynamic monitoring. Associations were estimated using multivariable logistic regression. Results: Among 2833 eligible patients, none were excluded. The median age was 79 years (IQR, 70–86), and 59% were women. Of 2833 patients, 2323 (82%) reversed to full code perioperatively, and 510 (18%) remained not full code. Forty-four patients (1.6%) died within 3 days. Three-day mortality occurred in 15 of 510 patients (2.9%) who remained not full code and in 29 of 2,323 patients (1.2%) who reversed to full code. After adjustment for age, sex, ASA physical status, operative stress score, and race, not full code status was associated with higher odds of 3-day mortality (adjusted odds ratio, 2.18; 95% CI, 1.14–4.16), corresponding to an adjusted absolute risk difference of 1.43% (95% CI, 0.06%–2.95%). Among patients who died within 3 days and remained hospitalized, 34 of 42 (81%) died after transition to comfort-focused care. Invasive hemodynamic monitoring was more common among patients who remained not full code (adjusted absolute risk difference, 3.74%; 95% CI, 0.91%–6.93%). Conclusions: Among adults presenting for a procedure with code-status limitations, continuation of a nonfull code status was associated with higher early postoperative mortality. This pattern reflects downstream clinical trajectories and treatment decisions rather than missed opportunities for perioperative rescue.

Background and Methods: Cancer interventions are traditionally described as either “curative” or “palliative,” but evolving cancer biology and new treatments have transformed some cancers into chronic diseases where surgery plays a non‐curative, disease‐targeted role. We conducted semi‐structured interviews with cancer surgeons via purposive snowball sampling, exploring two hypothetical scenarios and discussing “disease‐control” surgery as a category of neither palliative nor curative surgical intent. Interviews were thematically analyzed. Results: Eighteen surgeons from 16 US institutions described how evolving cancer treatment paradigms challenge existing language for surgical intent. “Disease‐control” surgery captured new adjuvant surgical roles including debulking to improve systemic therapy efficacy, resection of treatment‐resistant disease, and “resetting the clock” for indolent tumors. Surgical goals are increasingly defined by individual patients' broader multidisciplinary treatment trajectory. Conclusions: Traditional “curative” versus “palliative” categories inadequately describe contemporary cancer surgery. New frameworks aligned with current understandings of cancer biology and new treatment modalities may facilitate clearer communication about surgical goals and enable developing appropriate research outcome measures. Discussion: These findings highlight a need for standardized surgical intent terminology. Broader validation through multidisciplinary stakeholder engagement is needed to refine and implement this proposed framework.

PURPOSE: To understand from patients, care partners (P/CPs), and physicians the ideal timing of specialty palliative care (SPC) involvement. METHODS: Using a framework of phenomenology and care ethics, we analyzed interviews through a thematic analysis approach. Two investigators independently coded transcripts of recorded interviews. P/CPs were recruited from a single hospital clinic from multiple different oncologists. Physicians were recruited via purposeful snowball sampling based on their knowledge and expertise. RESULTS: Thirty-one participants were recruited: 14 (45%) P/CPs and 17 (55%) clinicians. The mean age of P/CP was 49 years, whereas clinicians' mean age was 44 years. Half of P/CPs were female, and a similar portion of clinicians (53%) were female. More than half of patients had gliomas (57%), and all clinicians were physicians who had practiced neuro-oncology for a mean of 12 years. We identified four themes: (1) Participants felt patients would have benefited from earlier SPC, but there were slight differences in timing based on brain tumor type and grade; (2) neuro-oncology patients have unique supportive care needs compared to other cancers; (3) specialty knowledge of neuro-oncology is important to P/CP for advance care planning, prognostication, and anticipatory guidance; and (4) the broadly intensive role played by care partners in neuro-oncology means they have equally heavy supportive needs. CONCLUSION: This is one of the first studies to explore timing of SPC for patients with CNS tumors. P/CPs and clinicians agreed that early, time-based SPC is beneficial for management of high-grade tumors. Increasing knowledge of neuro-oncology among SPC clinicians working with this population is an area for further study.

Background: A growing number of emergency general surgery (EGS) admissions comprise of adults age 65 years and older, who are more likely to experience missed or delayed diagnoses, and subsequently worse postoperative outcomes. We aimed to ascertain the perspectives of clinicians on the diagnostic challenges unique to older adults with EGS conditions and strategies to improve feedback. Methods: In this qualitative study, semi‐structured focus groups were conducted with frontline clinicians with experience in providing high volume care to older adult EGS patients to explore diagnostic challenges, tools, and feedback strategies. Questions focused on clinical gaps and approaches, tools, and the mechanisms in place to provide feedback on patient diagnosis and assessment. Focus groups were transcribed and qualitatively analyzed using an inductive approach. Results: Twenty‐two clinicians participated in one of six focus groups. Clinicians reported three key diagnostic challenges: nontextbook presentations, comorbidities, and older‐age specific complications. Nondiagnostic factors remained high priorities including functional health status, patient preferences, family involvement, and health related social needs. Practical tools addressing these gaps included the use of multidisciplinary expertise, surgical risk calculators, cognitive assessments, functional health assessments, and protocols guiding goals of care discussions. Participants shared barriers and facilitators for implementation of these tools. Conclusion: Frontline clinicians identified several high priority considerations unique in EGS for older adults. To address these, context‐specific tools and strategies were detailed and inform ongoing work to incorporate feedback and solutions into frontline settings. Future work in quality improvement should incorporate these high priority areas into existing quality improvement frameworks.

Purpose: Prostate cancer (PCa) mortality disparities are partly driven by unequal access to care. Transportation barriers may limit access to definitive treatment. We studied how driving travel time affects receipt of definitive PCa treatment. Materials and Methods: We conducted a cohort study of men with non-metastatic PCa (2000 - 2015; follow-up through 2018) across the metropolitan area cancer registries of seven US states. Travel burden was estimated using Google Maps isochrones representing driving time thresholds to reach the hospital appended to geomasked residential addresses. Outcomes were “no treatment, “ “radical surgery,” or “radiotherapy”. Covariate-adjusted multinomial logistic regression with interaction terms assessed modification by sociodemographic factors. Results: The study included 132,939 men, of whom 37.0% received no treatment, 41.0% underwent surgery, and 22.0% received radiotherapy. Longer driving time (≥90 min vs <30 min) was associated with higher radical prostatectomy (aOR: 1.07, 95% CI: 1.03, 1.12), but lower radiotherapy (0.72, 95% CI: 0.69 - 0.76). Subgroup analyses revealed higher surgery associated with longer driving times among those in nSES Q1 (aOR: 1.33, 95% CI: 1.21-1.45) vs Q5 (aOR: 0.94, 95% CI: 0.86-1.04), those in low (aOR: 1.16, 95% CI: 1.09-1.24) vs high (aOR: 1.03, 95% CI: 0.98-1.09) population density areas, and those with regional (aOR: 1.30, 95% CI: 1.14-1.48) vs localized (aOR: 1.05, 95% CI: 1.00 -1.09) disease. Longer driving time was mostly associated with lower odds of radiotherapy across sociodemographic subgroups. Conclusions: Higher travel burden was associated with lower radiotherapy receipt, but greater surgery use in deprived and rural patients, which warrants further investigation.

Chiapas is a state in southern Mexico that faces significant challenges in healthcare delivery. Strengthening the surgical system requires a comprehensive understanding of all health system domains and the contextual factors that influence care delivery. This study used qualitative methods to identify factors related to both gaps and successes in surgical care in Chiapas, Mexico. Semi-structured interviews were conducted with 23 participants at 15 public and private hospitals. Participants consisted of nurses, physicians, surgeons, and hospital administrators. Interviews were transcribed, and a codebook was developed and applied to all interviews. Recurring themes were identified and described using thematic analysis. Four themes characterizing the challenging context through which care is delivered were identified: referral system challenges, workforce shortages, insufficiencies in perioperative and nonoperative care, and waste and mismanagement of resources. Three themes related to innovations and workarounds were identified: efforts to maximize resources and reduce waste, strategies to reduce language barriers, and planning to account for clinical needs in situations of limited access and emergencies. Gaps and challenges within the surgical system of Chiapas lead to challenges in care delivery across all domains of the health system. However, several solutions have emerged among local providers. Insight into these factors can be used in planning efforts to improve access to safe and effective surgical care.