The article, authored by Ashley D. Kendall of the University of Illinois Chicago, Noah Robinson of XRHealth USA, Robin J. Mermelstein of the University of Illinois Chicago, and Steven D. Hollon of Vanderbilt University, makes a deceptively simple point with far-reaching consequences. When a mental health app is tested against a treatment control — a comparison condition that itself contains some active therapeutic ingredient, such as psychoeducation, mood tracking, relaxation exercises or generic support — the trial is not measuring whether the app works. It is measuring whether the app works better than another intervention that may already deliver a meaningful share of the benefit. A null result in that context is not evidence of treatment failure. It may simply be evidence that two modestly effective treatments are, on average, equally effective.

The authors ground this argument in decades of psychotherapy research, a literature that digital mental health has often ignored when importing the randomized controlled trial as its gold standard. Landmark studies in face-to-face therapy, including the widely cited 2010 JAMA analysis by Fournier and colleagues on antidepressant medication and psychotherapy, established long ago that the difference between an active treatment and a credible control tends to shrink as controls become more structurally similar to treatments. Meta-analytic work by Cuijpers and colleagues on psychotherapy for depression reached the same conclusion: the choice of control condition can swing effect sizes dramatically, and pill placebos, psychological placebos and waitlists produce systematically different estimates of how well a therapy works. In other words, the problem Kendall and her colleagues describe is not unique to apps. It is an old and well-understood feature of clinical trials design that the app field has largely failed to absorb.

The technical logic is straightforward. A treatment control in a mental health app trial is not inert. It typically involves contact with researchers, expectation of benefit, structured engagement with content derived from therapeutic principles, and regular self-monitoring — all of which are known to produce symptom improvement on their own. When the active app and the control app both reduce symptoms by a comparable amount, the trial’s statistical machinery reports no significant difference. But the absolute benefit experienced by participants in both arms may be substantial. Reporting that result as a treatment failure conflates comparative advantage with clinical efficacy, two entirely different questions. The first asks whether the app beats a competitor; the second asks whether it helps people relative to no treatment at all. Treatment controls are designed to answer the first question, yet their results are routinely interpreted as answers to the second.

This interpretive habit has real-world costs. Apps that fail to beat treatment controls may be deprioritized by funders, rejected by regulators, passed over by health systems and dismissed by clinicians, even when the trials show that users improved meaningfully. Meanwhile, the enormous unmet need in mental health care — driven by workforce shortages, cost barriers and geographic inequity — means that even modestly effective scalable tools could deliver enormous public health value. The Comment argues that holding apps to a standard of superiority over other active interventions is a standard that many established, widely reimbursed psychotherapies would themselves struggle to meet, particularly against well-constructed psychological placebos. Chambless and Hollon’s influential 1998 framework for establishing empirically supported treatments recognized this problem nearly thirty years ago, emphasizing that efficacy must be demonstrated against appropriate comparison conditions and that equivalence to an established treatment can itself constitute evidence of effectiveness.

The authors also point to a related distortion: expectation effects and common factors. Any intervention that engages a person in a structured effort to feel better recruits hope, motivation, self-efficacy and the therapeutic alliance in diluted form. These ingredients are not noise to be controlled away; they are part of why psychological treatments work. A treatment control deliberately packages many of them. When both arms of a trial contain them, the measured difference between arms reflects only the incremental contribution of the app’s specific content over and above a foundation of generic benefit. For interventions whose mechanisms overlap heavily with those of their controls — as is often the case for apps built on behavioral activation, cognitive restructuring or mindfulness — small incremental effects are close to a statistical inevitability, not a signal of clinical worthlessness.

What, then, should the field do instead? The Comment calls for a diversification of trial designs rather than an abandonment of rigor. Single-case experimental designs, in which each participant serves as their own control across staggered phases of exposure to the intervention, can isolate within-person change with far fewer participants and are well suited to digital platforms that can randomize in real time. Sequential multiple assignment randomized trials, described in recent methodological reviews by Collins and colleagues, allow researchers to evaluate adaptive interventions in which the app’s content changes in response to a user’s progress. Hybrid effectiveness-implementation designs, formalized by Curran and colleagues, evaluate both whether an intervention works and how it functions in real-world care settings, providing information that traditional efficacy trials systematically omit. Dismantling and additive designs can determine which components of an app contribute to benefit, rather than asking only whether the whole package beats a competitor.

The authors also emphasize the value of alternative control strategies borrowed from other areas of medicine. Work by Mulla, Guyatt and colleagues on the interpretation of trials against active comparators shows that non-inferiority and equivalence designs, properly powered and pre-specified, can establish that a new treatment preserves most of the benefit of an existing one while offering advantages in cost, access or tolerability. For mental health apps, whose defining advantages are scalability and low marginal cost, demonstrating equivalence to clinician-delivered care in a non-inferiority framework may be a far more informative and honest question than chasing small superiority effects against enriched controls. Furukawa and colleagues’ work on minimally important differences provides the statistical scaffolding: what matters clinically is not whether a p-value crosses a threshold, but whether the difference between arms — or the improvement within an arm — exceeds the smallest change patients would consider meaningful.

The timing of this intervention matters. The digital mental health sector has matured rapidly, with recent syntheses by Torous and colleagues in World Psychiatry and by Linardon and colleagues mapping a crowded landscape of apps, growing regulatory attention and persistent uncertainty about which products deserve clinical endorsement. A 2022 analysis by Goldberg and colleagues found that while app-based interventions show pooled benefits for depression and anxiety, effects measured against active controls were markedly smaller than those measured against waitlists — precisely the pattern the new Comment predicts. As health systems begin to prescribe apps and payers consider reimbursement, getting the evaluation framework right is no longer an academic quibble. Misreading null superiority results could throttle the pipeline of accessible care just when demand for it has never been higher.

None of this means the authors are asking for a lower bar. They are asking for a more precise one. An app that helps users improve but does no better than a thoughtful control deserves scrutiny of its mechanisms, its engagement design and its incremental value — not a blanket verdict of failure. Conversely, the framework they propose would still condemn apps that produce no meaningful improvement at all, and non-inferiority and single-case designs are arguably more demanding than the status quo, requiring explicit specification of what counts as a clinically meaningful change. The core message is statistical as much as clinical: a null difference between two active treatments is an uninformative result about efficacy, and decades of psychotherapy research already knew it. Digital mental health, the Comment suggests, will only fulfill its promise once its trials start asking the questions its technology can actually answer.

Subject of Research: Evaluation methodology for mental health app clinical trials

Article Title: Failure to outperform treatment controls does not imply treatment failure for mental health apps

Article References: Failure to outperform treatment controls does not imply treatment failure for mental health apps. (n.d.). https://doi.org/10.1038/s44220-026-00715-4

Image Credits: AI Generated

DOI: 10.1038/s44220-026-00715-4

Keywords: mental health apps, digital mental health, treatment controls, randomized controlled trials, clinical trial design, psychotherapy research, non-inferiority trials, effect sizes, Nature Mental Health, outcomes research, implementation science, depression and anxiety

Vestibular schwannomas, also called acoustic neuromas, affect roughly one in every 100,000 people each year. Although benign and often slow-growing, these tumors sit in the cerebellopontine angle, a cramped compartment at the base of the brain where the auditory and vestibular nerves exit the brainstem. As they enlarge, they can press against these nerves and surrounding structures, producing progressive hearing loss on one side, tinnitus, imbalance, and in larger cases facial weakness or life-threatening brainstem compression. Management options span a spectrum: watchful waiting with serial magnetic resonance imaging, stereotactic radiosurgery using precisely focused radiation beams, or microsurgical resection through one of several skull-base approaches. Each strategy carries distinct risks and benefits, and the choice depends on tumor size, hearing status, patient age, and patient preference. Over the past half-century, management trends in the United States have shifted markedly, with observation and radiosurgery claiming growing shares of newly diagnosed patients while open surgery has become more selective.

Clinicians have accumulated a substantial body of evidence on how these treatments affect hearing, facial nerve function, vertigo, and overall quality of life. Longitudinal studies and large cross-sectional surveys have compared disease-specific quality of life across microsurgery, radiosurgery, and observation, generally finding that patient-reported outcomes converge over time and that factors such as vertigo, anxiety, and hearing status often matter more to patients than the treatment modality itself. What has been far less studied is the economic experience of the patient behind the MRI scans and audiograms. Earlier investigations into the socioeconomic impact of acoustic neuroma surgery, some dating back to the late 1990s, documented that a meaningful fraction of patients reduced their working hours or left the workforce, and European registry data have shown that vertigo in particular predicts future work disability. Meanwhile, a parallel literature on cost-effectiveness has compared the health-system costs of surgery, radiosurgery, and surveillance, including lifetime cost modeling and analyses of screening MRI protocols for asymmetric hearing loss.

What those cost analyses capture is the perspective of insurers and health systems: procedure fees, imaging expenses, hospital stays, and follow-up care. They do not capture what economists and oncologists have come to call financial toxicity, the cumulative personal financial strain experienced by patients and families, including out-of-pocket costs, lost wages, debt, and the psychological distress that accompanies them. In cancers such as breast, prostate, thyroid, and head and neck malignancy, financial toxicity has emerged as a clinically relevant patient-reported outcome, associated in some studies with worse quality of life and even with treatment nonadherence. Validated instruments now exist to measure it, most prominently the Comprehensive Score for financial Toxicity, an eleven-item questionnaire whose acronym COST reflects its purpose, and the Financial Distress Questionnaire, which grades distress from none to severe. The Ohio State team recognized that no study had systematically applied these tools to vestibular schwannoma patients, whose benign diagnosis and varied management pathways might produce a very different financial profile from malignant cancer.

To fill that gap, the researchers designed a cross-sectional survey and distributed it through the Acoustic Neuroma Association, a national patient support organization whose membership provided access to individuals across the spectrum of treatment experiences. The questionnaire asked respondents about their personal finances and employment before and after tumor management, with particular emphasis on financial toxicity as measured by the COST instrument and the Financial Distress Questionnaire. By the time the study closed, 41 respondents had fully completed the survey. The demographic profile skewed older and female: 24 participants, or 59 percent, were older than fifty at the time of their intervention, and 33 participants, or 80 percent, were women. Treatment distribution reflected contemporary practice patterns, with 29 respondents, 71 percent, reporting microsurgical resection of their tumor, 9 respondents, 22 percent, reporting radiation therapy, and 3 respondents, 7 percent, describing a combination of both modalities.

The employment findings were striking even if the financial scores were not. After initiation of management, 11 respondents, or 27 percent, experienced a change in employment altogether, while 17 respondents, or 41 percent, reported a change in their duties at work, a category that encompassed reduced hours, diminished activity, or new unemployment. In other words, more than four in ten patients felt the tumor or its treatment reshape their working lives in some tangible way. This aligns with older socioeconomic studies and with more recent European data showing that vestibular schwannoma and its management can affect employment status, work capacity, and productivity, with predictors including age, gender, tumor size, and persistent symptoms such as dizziness. Yet when the researchers quantified the subjective financial burden using validated scales, the picture softened considerably.

On the COST questionnaire, which scores financial toxicity on a scale where lower numbers indicate greater distress, the median score among respondents was 32, with an interquartile range of 15 to 39. On the Financial Distress Questionnaire, only 4 respondents, or 10 percent, were classified as having moderate financial toxicity, and just 2 respondents, or 5 percent, reported severe financial toxicity. Taken together, the results suggest that although employment disruption is common after vestibular schwannoma management, the ultimate financial toxicity of these changes appears limited, with few patients experiencing substantial personal financial hardship. The authors caution, however, that the survey design cannot disentangle whether this relative resilience reflects the benign nature of the disease, the demographics of the respondent pool, the structure of insurance coverage in the United States, or the support resources available through patient advocacy networks.

The study carries important caveats that the researchers themselves emphasize. A sample of 41 self-selected respondents recruited through a patient support organization is small and unlikely to be representative of the broader vestibular schwannoma population, which includes many patients under observation who may never join advocacy groups. Cross-sectional surveys also capture a snapshot rather than a trajectory, so they cannot track how financial toxicity evolves from diagnosis through treatment and recovery, nor can they establish causal links between a specific treatment modality and later financial outcomes. The collected data are not publicly available, though the authors note they may be shared upon request pending appropriate institutional approval and a data use agreement. The study was conducted without internal or external funding, was deemed exempt by The Ohio State University institutional review board, and all participants provided electronic consent before taking part.

Even with those limitations, the research opens a conversation that neuro-oncology has largely avoided. As treatment decisions for vestibular schwannoma increasingly become shared decisions between patients and multidisciplinary teams, information about the likely personal economic consequences of surgery, radiosurgery, or observation could prove as valuable to patients as hearing preservation rates or facial nerve outcomes. The authors call for prospective studies with larger and more diverse cohorts to better identify the risk factors that predispose individual patients to personal financial difficulty, whether those risks involve younger age at diagnosis, pre-treatment employment in physically demanding work, vertigo that persists after treatment, or gaps in insurance coverage. For now, the message for patients facing a vestibular schwannoma diagnosis is cautiously reassuring: the tumor may change how you work, but for most people in this survey, it did not devastate the household balance sheet. Bridging the gap between employment disruption and financial resilience, and understanding who falls through it, is the task the researchers say must come next.

Subject of Research: The personal financial impact and financial toxicity of vestibular schwannoma management in surveyed patients

Article Title: Assessing the personal financial impact of vestibular schwannoma management

Article References: Macielak, R. J., Liu, W., Andresen, N. S., Ren, Y., Dodson, E. E., Prevedello, D. M., Adunka, O. F., Wu, K. C., & Schoo, D. P. (2026). Assessing the personal financial impact of vestibular schwannoma management. Journal of Neuro-Oncology, 179(2), Article 76. https://doi.org/10.1007/s11060-026-05797-9

Image Credits: AI Generated

DOI: 10.1007/s11060-026-05797-9

Keywords: vestibular schwannoma, acoustic neuroma, financial toxicity, microsurgery, radiosurgery, employment, COST questionnaire, Financial Distress Questionnaire, quality of life, patient survey, neuro-oncology, outcomes research

The premise behind QITI is deceptively simple but technically demanding. NSQIP has long served as one of the most rigorous surgical outcomes registries in the world, capturing standardized preoperative risk factors, operative details, and thirty-day postoperative outcomes across hundreds of hospitals. What NSQIP traditionally did not do, however, was tie those outcomes to the specific trainees who participated in each operation. QITI was created to close that gap, adding structured fields that identify the postgraduate year level of the resident involved in each case. By linking trainee identity and experience level to meticulously audited outcomes, the initiative aims to transform a hospital quality program into a living laboratory for surgical education, giving residents and program directors access to the same kind of risk-adjusted performance data that practicing surgeons encounter in their professional lives.

The new analysis is a retrospective study of NSQIP cases with completed QITI fields spanning July 2013 through July 2025. The scale is striking: 190 participating institutions contributed cases, and 1,412,068 met the study’s inclusion criteria, of which 1,098,264 involved residents in the postgraduate years one through five, the core of general surgery training. The research team, led by Caroline O. Smolkin of the American College of Surgeons’ Division of Research and Optimal Patient Care, together with colleagues from institutions including Northwell Health, the University at Buffalo, Zucker School of Medicine, Vanderbilt, the University of Pennsylvania, and UCLA, conducted descriptive analyses of case volume, institutional participation, operative case mix, and postoperative outcomes stratified by postgraduate year. They then applied multivariable regression models to assess the association between trainee seniority and outcomes after adjusting for the standard NSQIP preoperative risk factors that account for differences in patient sickness at the time of surgery.

One of the clearest findings concerns the changing texture of the operative experience as residents progress. The case mix increased in complexity across postgraduate year levels, a pattern consistent with the graduated responsibility that training programs are designed to provide. Junior residents predominantly logged procedures that form the foundation of technical surgical competence, while senior residents participated in longer, more physiologically demanding operations. Yet the data also revealed continuity: certain index procedures, notably laparoscopic appendectomy and laparoscopic cholecystectomy, remained common at every training level. These operations, among the most frequently performed emergency general surgery procedures in the country, appear to function as a throughline of residency, providing recurring opportunities for deliberate practice from the first year through the fifth, with each repetition layered onto progressively deeper mastery.

The outcomes analysis produced a finding that at first glance might alarm patients: unadjusted complication rates increased stepwise with postgraduate year level, a statistically robust trend across the cohort. The apparent interpretation, that more senior residents are associated with worse outcomes, would be profoundly misleading, and the study’s technical design was built precisely to expose why. Senior residents are assigned to longer and more complex cases on sicker patients, and those operations carry higher baseline risk regardless of who stands at the table. Raw, unadjusted comparisons conflate the characteristics of the case with the characteristics of the trainee, which is why risk adjustment is the essential analytic lens for any investigation of resident involvement in surgery.

After the researchers adjusted for standard preoperative risk factors, most of the differences in complication rates across training levels attenuated, indicating that much of the raw disparity reflects case selection rather than trainee performance. However, the adjustment did not erase every signal. Cases involving fifth-year residents remained significantly associated with higher odds of select outcomes, including intubation, prolonged ventilation, renal complications, cardiac complications, readmission, overall morbidity, and mortality. This residual association most plausibly reflects the fact that chief residents participate in the highest-acuity operations in the hospital, where prolonged operative times and complex physiology drive complications independent of the individual performing the procedure. Prior research has linked prolonged operative duration to increased complications, and chief-resident cases are disproportionately represented among such lengthy, high-complexity operations. A sensitivity analysis restricted to the years 2022 through 2024 showed fewer significant associations, suggesting that these patterns are not immutable features of training but may shift with case mix, supervision practices, and evolving educational structures.

Beyond the epidemiology, the study carries a pointed argument about the purpose of outcome data in education. Surgical training in the United States is steadily shifting toward competency-based frameworks, in which progression is justified by demonstrated ability rather than time served, and toward outcomes-informed models in which real clinical data inform assessment. Milestones developed by the Accreditation Council for Graduate Medical Education and recommendations from national bodies such as the Blue Ribbon II Committee have emphasized the need for meaningful, data-grounded evaluation. QITI offers a substrate for that ambition at a scale no single program could match. Because the registry standardizes definitions of complications, captures thirty-day outcomes through trained reviewers, and applies validated risk-adjustment methodology, the comparisons it generates reflect the same statistical machinery that hospital quality departments and national benchmarking reports use, giving residents authentic exposure to the data environment of modern surgical practice.

The authors frame this as an opportunity to prepare trainees for the quality reports they will encounter as independent surgeons. Practicing surgeons today receive surgeon-specific outcome profiles, participate in departmental quality reviews, and are increasingly held to public and payer-driven performance metrics. A resident who has learned to interpret odds ratios, understand what risk adjustment does and does not capture, and contextualize benchmarked complication rates enters practice with a form of literacy that traditional apprenticeship never provided. Previous studies built on QITI data have explored whether chief resident autonomy is safe for patients and have tracked individual residents’ outcomes over time, and NSQIP-based quality improvement curricula have shown that residents can engage productively with registry data as an educational exercise. The new national review demonstrates that the underlying infrastructure is feasible and sustainable at scale, sustained across more than a decade and nearly two hundred institutions.

The findings also contribute to a long-running debate about patient safety and trainee involvement. Numerous studies across specialties have examined whether resident participation harms outcomes, with results varying by procedure, specialty, and analytic method. What distinguishes the QITI approach is that it does not treat resident involvement as a binary exposure but as a graded continuum tied to audited national data, allowing educators to characterize progression in operative complexity and link it to outcomes with unusual granularity. The study’s authors suggest that QITI may serve as a valuable platform for competency-based surgical education and future trainee feedback systems, potentially enabling programs to benchmark their residents against national distributions and to ground promotion decisions in outcome-informed evidence, while acknowledging that outcome data must always be interpreted alongside direct assessments of technical skill and clinical judgment.

For a profession in which the central paradox has always been that expertise is acquired by doing, and doing carries risk, the study offers a data-driven path through that tension. By demonstrating that nearly one and a half million resident-linked cases can be collected, risk-adjusted, and analyzed at national scale, the American College of Surgeons team has shown that the machinery built to make surgery safer for patients can simultaneously make education more transparent, more evidence-based, and more closely aligned with the realities surgeons face after graduation. The residual signals associated with the most senior trainees serve less as a warning than as a reminder that context matters: complexity, not competence, drives many of the differences that raw numbers reveal. As surgical education continues its shift toward competency-based and outcomes-informed models, the Quality In-Training Initiative stands as evidence that the data infrastructure for that transformation already exists, measured one case at a time across the operating rooms of America.

Subject of Research: The American College of Surgeons Quality In-Training Initiative as a national platform linking surgical resident participation to risk-adjusted patient outcomes for quality improvement education

Article Title: How the American College of Surgeons Quality In-Training Initiative helps quality improvement education focusing on safety: a national review of 1,412,068 surgeon trainee cases

Article References: Smolkin, C. O., Hobika, G., Grieco, A., Matthews, A., Fordham, M. J., Sfakianos, M. G., Terhune, K., Kelz, R. R., & Ko, C. Y. (2026). How the American College of Surgeons Quality In-Training Initiative helps quality improvement education focusing on safety: a national review of 1,412,068 surgeon trainee cases. Global Surgical Education – Journal of the Association for Surgical Education, 5(1), Article 178. https://doi.org/10.1007/s44186-026-00583-7

Image Credits: AI Generated

DOI: 10.1007/s44186-026-00583-7

Keywords: surgical education, resident outcomes, ACS NSQIP, Quality In-Training Initiative, quality improvement, patient safety, risk adjustment, competency-based education, surgical training, postoperative complications, graduate medical education, outcomes research