Historical Staffing and Performance of US Role II and III Surgical Facilities: Implications for Spine Casualty Care in Future Large Scale Combat Operations.

This study evaluated whether patients treated with bisphosphonates in the US Military Health System were more compliant with treatment given monthly versus weekly. While medication compliance did improve with treatment given monthly, overall compliance with bisphosphonates was still suboptimal suggesting the need for further strategies to improve compliance with treatment for osteoporosis. The study objective was to evaluate the relationship between bisphosphonate dosing interval and medication compliance among new users initiating oral bisphosphonates. We conducted a retrospective observational cohort study of administrative claims data in the US Military Health System to examine medication compliance among 22,363 new users of oral bisphosphonates starting weekly (68%) or monthly (32%) therapy. Medication compliance during the first year of treatment was measured using two methods: (1) medication possession ratio (MPR) with compliance defined as ≥80% of days covered and (2) time to first gap of more than 30 days following initiation. Logistic regression and a proportional hazards model were used to detect differences in medication compliance between cohorts. After the first year of therapy, 57% of subjects were not compliant with bisphosphonates (MPR <80%), while 84% experienced a gap in treatment of more than 30 days. After adjustment for study covariates, the odds of a patient being compliant with treatment was 21% higher among monthly users compared to weekly users (OR 1.207, 95% confidence interval (CI) 1.119-1.257). Similarly, the risk of experiencing a 30-day gap in treatment was 6% lower among monthly users compared to weekly users (HR 0.934, 95% CI 0.905-0.964). Patients receiving oral bisphosphonates on a monthly basis showed higher rates of medication compliance compared to weekly dosing in our study. However, compliance with bisphosphonates among all new users was suboptimal, suggesting the need for improved strategies to enhance compliance with oral bisphosphonates in the US Military Health System.

BackgroundBloodstream infections (BSI) are associated with inpatient morbidity in the United States. We sought to characterize the epidemiology of common bacterial BSIs in individuals receiving care within the US Military Health System (MHS), which actively prospectively captures clinical and microbiological data from both retired and active-duty US Uniformed Service members and their beneficiaries.MethodsWe performed a retrospective cohort study analyzing MHS patients with blood cultures positive for all bacterial pathogens, between January 2010 and December 2019. Microbiological data captured by the Navy and Marine Corpse Public Health Center, excluding cultures isolating contaminants, were retrospectively collated with clinical and demographic data from the MHS Data Repository. ResultsThe most frequent nine bacterial pathogens, as well as Acinetobacter spp. represented 17,206 episodes of BSI from 14,531 individuals. The cohort was predominantly male (59.4%) and ≥65 years old (48.7%). Most individuals were retired (N=5,249) or active duty (N=1,418) service members and their dependents (N=5,236). Median Updated Charlson Comorbidity Index Score was 2. Chronic pulmonary disease was the most frequent comorbid condition. Hospital admission was associated with 13,733 (79.8%) BSI episodes, including 5,870 admissions to the ICU. Overall, inpatient mortality was 8.3%. E. coli (29.7%, N= 5,114) was isolated with the highest frequency, followed by S. aureus (22.4%, N=3,853). Further, 9.5% of E. coli and 36.9% of S. aureus isolates were resistant to ceftriaxone and oxacillin, respectively. Beta-hemolytic streptococci represented the highest percentage (6.3%) of recurrent BSI episodes occurring at least 14 days post-initial BSI. Males or Native American race were most commonly infected with S. aureus. E. coli BSI was most common in all other demographic categories. Frequency of Bacterial Blood Stream Infections in the US Military Health SystemThe most frequent nine bacterial pathogens, as well as Acinetobacter spp. in the US Military Health System.ConclusionWe assessed the epidemiologic features of all individuals with BSI receiving care in the MHS over a 10-year period. We noted demographic differences in the occurrence of microbiological causes of BSI including S. aureus. Further assessments are underway into BSI-related risk factors for occurrence, antimicrobial resistance and mortality, after controlling for comorbidities and disease severity.DisclosuresAll Authors: No reported disclosures

The goal was to evaluate institutional inequities in the US Military Health System in knee arthroplasty receipt within three years of knee osteoarthritis diagnosis when accounting for other treatments received (eg, physical therapy, medications). In this retrospective observational cohort study, medical record data of patients (n=29,734) who received a primary osteoarthritis diagnosis in the US Military Health System between January 2016 and January 2020 were analyzed. Data included receipt of physical therapy one year before diagnosis and up to three years after diagnosis, prediagnosis opioid and nonopioid prescription receipt, health-related factors associated with levels of racism, and the primary outcome, knee arthroplasty receipt within three years after diagnosis. In a generalized additive model with time-varying covariates, Asian and Pacific Islander (incidence rate ratio [IRR] 0.58, 95% confidence interval [CI] 0.45-0.74), Black (IRR 0.52, 95%CI 0.46-0.59), and Latine (IRR 0.66, 95%CI 0.52-0.85) patients experienced racialized inequities in knee arthroplasty receipt, relative to white patients (all P < 0.001). In the present sample, Asian and Pacific Islander, Black, and Latine patients were significantly less likely to receive a knee arthroplasty, relative to white patients. Taken together, system-level resources are needed to identify and address mechanisms underlying institutional inequities in knee arthroplasty receipt, such as factors related to systemic and structural, institutional, and personally mediated racism.

Literature Review. The goal of this study was to provide a comprehensive outline of spinal injuries that may transpire over the course of military service from traumatic to repetitive stress injuries and chronic sequalae. We considered studies that assessed spinal injuries in the combat and non-combat settings as reported in the literature over the last 15-20 years. Military service places servicemembers under substantial physical demands, while also exposing them to dangerous, unpredictable environments. As a result, servicemembers are at an increased risk of spinal injuries from combat-related trauma and other causes. They may have different care needs and recovery profiles when compared to civilians with spinal disorders. We performed a review of the available literature on spinal injuries and spinal care in the Military Health System from 2001-present. The studies discussed in this review were primarily focused on the conflicts in both Iraq and Afghanistan from over ten years ago and do not fully capture the present-day advancements in military technology that may have an impact on the potential for spinal injuries. The long-term effects of sustained military service and the relative influence of high demand versus sedentary military occupations on the development of spinal disorders remains poorly understood. Given the changing nature of military service, both with respect to the demographic in uniform and the ever-evolving nature of modern combat, we believe that only a long-term prospective observational study dedicated to the surveillance of spinal problems could effectively answer these questions. Further research into the present-day characterization of spinal injuries is warranted given the advancements in both military technology and spine care that have occurred over the last ten years.

Hysterectomy inequities between black and white patients in the US military health system: A retrospective cohort study

ObjectiveTo describe demographics, causative pathogens, hospitalisation, mortality and antimicrobial resistance (AMR) of bacterial bloodstream infections (BSIs) among beneficiaries in the global US Military Health System (MHS), a single-provider healthcare system...

Cancer is one of the leading causes of morbidity and mortality in the USA, contributing largely to US healthcare spending. Provision of services (direct or purchased) and insurance benefit type may impact cost for cancer care. As a common cause of cancer in both men and women, we aim to compare colon cancer treatment costs between insurance benefit types and care sources in the US Military Health System (MHS) to better understand whether and to what extent these system factors impact cancer care costs. Department of Defense Central Cancer Registry records and MHS Data Repository administrative claims were used to identify MHS beneficiaries aged 18-64 who were diagnosed with primary colon adenocarcinoma and received treatment between 2003 and 2008. The data linkage was approved by the Institutional Review Boards of the Walter Reed National Military Medical Center, the Defense Health Agency, and the National Institutes of Health. Costs to the MHS for each claim related to cancer treatment were extracted from the linked data and adjusted to 2008 USD. We used quantile regression models to compare median cancer treatment costs between benefit types and care sources (direct, purchased, or both), adjusted for demographic, tumor, and treatment characteristics. The median per capita (n = 801) costs for colon cancer care were $60,321 (interquartile range $24,625, $159,729) over a median follow-up of 1.7 years. The model-estimated treatment costs were similar between benefit types. Patients using direct care had significantly lower estimated median costs [$34,145 (standard error $4,326)] than patients using purchased care [$106,395 ($10,559)] or both care sources [$82,439 ($13,330)], controlled for patient demographic, tumor, and treatment characteristics. Differences in cost by care source were noted for patients with later stage tumors and by treatment type. Relative costs were 2-3 times higher for purchased care compared to direct care for patients with late-stage tumors and for patients receiving chemotherapy or radiation treatment. In the MHS, median cost for colon cancer treatment was lower in direct care compared to purchased care or patients using a combination of direct and purchased care. The variation in cancer treatment costs between care sources may be due to differences in treatment incentives or capabilities. Additional studies on cost differences between direct and purchased services are needed to understand how provision of care affects cancer treatment costs and to identify possible targets for cost reduction.

With the rising costs of cancer care, it is critical to evaluate the overall cost-efficiency of care in real-world settings. In the United States, breast cancer accounts for the largest portion of cancer care spending due to high incidence and prevalence. The purpose of this study is to assess the relationship between breast cancer costs in the first 6 months after diagnosis and clinical outcomes by care source (direct or purchased) in the universal-access US Military Health System (MHS). We conducted a retrospective analysis of data from the Department of Defense Central Cancer Registry and MHS Data Repository administrative records. The institutional review boards of the Walter Reed National Military Medical Center and the Defense Health Agency reviewed and approved the data linkage. We used the linked data to identify women aged 40-64 who were diagnosed with pathologically-confirmed breast cancer between 2003 and 2007 with at least 1 year of follow-up through December 31, 2008. We identified cancer treatment from administrative data using relevant medical procedure and billing codes and extracted costs paid by the MHS for each claim. Multivariable Cox proportional hazards models estimated hazards ratios (HR) and 95% confidence intervals (CI) for recurrence or all-cause death as a function of breast cancer cost in tertiles. The median cost per patient (n = 2,490) for cancer care was $16,741 (interquartile range $9,268, $28,742) in the first 6 months after diagnosis. In direct care, women in the highest cost tertile had a lower risk for clinical outcomes compared to women in the lowest cost tertile (HR 0.58, 95% CI 0.35, 0.96). When outcomes were evaluated separately, there was a statistically significant inverse association between higher cost and risk of death (p-trend = 0.025) for women receiving direct care. These associations were not observed among women using purchased care or both care sources. In the MHS, higher breast cancer costs in the first 6 months after diagnosis were associated with lower risk for clinical outcomes in direct care, but not in purchased care. Organizational, institutional, and provider-level factors may contribute to the observed differences by care source. Replication of our findings in breast and other tumor sites may have implications for informing cancer care financing and value-based reimbursement policy.

Glioma is the most common malignant brain cancer. Accessibility to health care is an important factor affecting cancer outcomes in the US general population. The US Military Health System (MHS) provides universal health care to its beneficiaries. It is unknown whether this universal health care has translated into improved survival outcomes among MHS beneficiaries with glioma. This study compared the overall survival of patients with glioma in the MHS with the overall survival of patients with glioma in the general population. The MHS cases were identified from the Department of Defense's Automated Central Tumor Registry (ACTUR). Glioma cases from the general population were identified from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program. SEER cases were matched 2:1 to ACTUR cases by age, sex, race, histology, and diagnosis year. All cases had histologically confirmed glioma diagnosed between January 1, 1987, and December 31, 2013. A Kaplan-Meier analysis was conducted to compare survival between the ACTUR and SEER cases. Multivariable Cox proportional hazards models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs). The study included 2231 glioma cases from ACTUR and 4462 cases from SEER. ACTUR cases exhibited significantly better overall survival than SEER cases (HR, 0.74; 95% CI, 0.67-0.83). The survival advantage of the ACTUR patients was observed in most subgroups stratified by age, sex, race, diagnosis year, and histology. For glioblastoma, the survival advantage was observed in both the pre- and post-temozolomide periods. Universal MHS health care may have translated into improved survival outcomes in glioma. Future studies are warranted to identify factors contributing to the improved survival.

Cardiac glycosides such as digoxin, digitoxin and ouabain are still used around the world to treat patients with chronic heart failure with reduced ejection fraction (HFrEF) and/or atrial fibrillation (AF). However, in the US, only digoxin is licensed for treating these illnesses, and the use of digoxin for this group of patients is increasingly being replaced in the US by a new standard of care with groups of more expensive drugs. However, ouabain and digitoxin, and less potently digoxin, have also recently been reported to inhibit SARS-CoV-2 virus penetration into human lung cells, thus blocking COVID-19 infection. COVID-19 is known to be a more aggressive disease in patients with cardiac comorbidities, including heart failure. We therefore considered the possibility that digoxin might provide at least a measure of relief from COVID-19 in digoxin-treated heart failure patients. To this end, we hypothesized that treatment with digoxin rather than standard of care might equivalently protect heart failure patients with regard to diagnosis of COVID-19, hospitalization and death. To test this hypothesis, we conducted a cross-sectional study by using the US Military Health System (MHS) Data Repository to identify all MHS TRICARE Prime and Plus beneficiaries aged 18-64years with a heart failure (HF) diagnosis during the period April 2020 to August 2021. In the MHS, all patients receive equal, optimal care without regard to rank or ethnicity. Analyses included descriptive statistics on patient demographics and clinical characteristics, and logistic regressions to determine likelihood of digoxin use. We identified 14,044 beneficiaries with heart failure in the MHS during the study period. Of these, 496 were treated with digoxin. However, we found that both digoxin-treated and standard-of-care groups were equivalently protected from COVID-19. We also noted that younger active duty service members and their dependents with HF were less likely to receive digoxin compared with older, retired beneficiaries with more comorbidities. The hypothesis of equivalent protection by digoxin treatment of HF patients in terms of susceptibility to COVID-19 infection appears to be supported by the data.

Background: Cancers of unknown primary (CUP), a group of heterogenous metastatic cancers lacking a known primary site, have poor prognosis. This study compared survival by histologic type, patient characteristics, and treatment in the U.S. Military Health System (MHS), which provides universal care to its members. Methods: Patients diagnosed with CUP were identified from the U.S. Department of Defense’s Automated Central Tumor Registry. Median survival with 95% confidence intervals was calculated for demographic and treatment variables by histologic type. A multivariable accelerated failure time model estimated time ratios and 95% confidence intervals. Results: The study included 3,358 CUP patients. The most prevalent CUP in this study was well and moderately differentiated adenocarcinomas. Median survival varied by histologic type with squamous cell carcinoma having the longest at 25.1 months and poorly differentiated carcinomas having the shortest at 3.0 months. For each histologic type, survival was generally similar by sex and active-duty status. Younger patients tended to have longer survival than those aged 65 years or older. Women with well and moderately differentiated adenocarcinoma had longer survival than their male counterparts. Generally, there were no racial differences in survival except poorer survival for Blacks than Whites with other histologic types. Patents with chemotherapy and radiation treatment generally had improved survival whereas patients with squamous cell carcinoma who received chemotherapy had shorter survival than those without. Conclusion: Survival generally did not differ between racial groups, which may be related to equal healthcare access despite racial background. Further studies are warranted to better understand how survival in the MHS compares with that in the general U.S. population. Disclaimer: The contents of this publication are the sole responsibility of the authors and do not necessarily reflect the views, opinions or policies of USUHS, HJF, the DoD or the Departments of the Army, Navy or Air Force. Mention of trade names, commercial products or organizations does not imply endorsement by the US Government. Citation Format: Julie A. Bytnar, Jie Lin, Joel T. Moncur, Craig D. Shriver, Kangmin Zhu. Cancers of unknown primary: survival by histologic type, demographic features, and treatment in the US Military Health System. [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 4209.

Racialized and beneficiary inequities in medication to treat opioid use disorder receipt within the US Military Health System

Racial disparities in time to surgery (TTS) after a breast cancer diagnosis and whether these differences account for disparities in overall survival have been understudied in the US population. To compare TTS in non-Hispanic black (NHB) and non-Hispanic white (NHW) women with breast cancer and to examine whether racial differences in TTS may explain possible racial disparities in overall survival in a universal health care system. Retrospective cohort identified from the Department of Defense Central Cancer Registry and Military Health System Data Repository linked databases containing records between January 1, 1998, and December 31, 2008, of 998 NHB women and 3899 NHW women who received a diagnosis of stages I to III breast cancer and underwent breast-conserving surgery (BCS) or mastectomy in the US Military Health System during the study period. Data analyses were conducted from July 5, 2017, to December 29, 2017. The main outcome was time to breast cancer surgery. Non-Hispanic black and NHW women were compared at the 25th, 50th (median), 75th, and 90th percentiles of TTS by using multivariable quantile regression. Cox proportional hazards regression models were used to estimate hazard ratios (HRs) and 95% CIs for all-cause death in NHB compared with NHW women after controlling for potential confounders first without and then with TTS. Among the 4887 NHB and NHW women in the cohort, the mean (SD) age was 50.0 (9.4) years. The median TTS was 21 days (95% CI, 20.6-21.4 days) among NHW women and 22 days (95% CI, 20.6-23.4 days) among NHB women. Non-Hispanic black women had a significantly greater estimated TTS at the 75th (3.6 days; 95% CI, 1.6-5.5 days) and 90th (8.9 days; 95% CI, 5.1-12.6 days) percentiles than NHW women in multivariable models. The estimated differences were similar by surgery type. Non-Hispanic black women had a higher adjusted risk for death (HR, 1.45; 95% CI, 1.06-2.01) compared with NHW women among patients receiving breast-conserving surgery. The risks were similar between races among those receiving mastectomy (HR, 1.06; 95% CI, 0.76-1.48). The HRs remained similar after adding TTS to the Cox proportional hazards regression models. This study's results indicate that time to breast cancer surgery was delayed for NHB compared with NHW women in the Military Health System. However, the racial differences in TTS did not explain the observed racial differences in overall survival among women who received breast-conserving surgery.

Access to care is associated with cancer survival. The US Military Health System (MHS) provides universal health care to all beneficiaries. However, it is unknown whether survival among patients with bone sarcoma in a health system providing universal care is better than that in the general population. The aim of the study was to compare survival of patients with bone sarcoma in the US MHS with that of the US general population. The MHS data were obtained from the Department of Defense Automated Central Tumor Registry (ACTUR). The US general population data were obtained from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) registry. Adult patients were defined as those aged 25 years or older with a histologically confirmed musculoskeletal bone sarcoma diagnosed from January 1, 1987, to December 31, 2013. Kaplan-Meier survival curves and multivariable Cox proportional hazards models were used to compare the overall survival of the two populations. The final analysis included 2,273 bone sarcoma cases from ACTUR and 9,092 bone sarcoma cases from SEER. ACTUR patients had significant lower 5-year all-cause death (hazard ratio = 0.72; 95% CI, 0.66 to 0.78) after adjustment for the potential confounders. ACTUR patients with bone sarcoma also exhibited significantly lower risk of all-cause death during the entire follow-up period than the SEER patients (hazard ratio = 0.75; 95% CI, 0.6 to 0.81). MHS beneficiaries with bone sarcoma may have longer survival than SEER patients. Our findings support the role of universal access to high-quality care in improving bone sarcoma outcomes.

The US Military Health System (MHS) provides universal health care to beneficiaries. Few studies have evaluated the potential influence of access to universal care on survival outcomes for sarcoma. This study compared the survival of adult patients with soft-tissue sarcoma in the MHS with the US general population. MHS data were obtained from the Department of Defense Automated Central Tumor Registry (ACTUR). US population data were obtained from the National Cancer Institute's Surveillance, Epidemiology, and End Results registry. Patients who were 25 years or older with a histologically confirmed musculoskeletal soft-tissue sarcoma were matched based on age, sex, and race. Kaplan-Meier survival curves and Cox proportional hazards models were used to compare 5-year survival in the two groups. Adult patients in ACTUR had markedly lower 5-year mortality for soft-tissue sarcomas (hazard ratio=0.82; 95% confidence interval, 0.73 to 0.92) after adjustment for potential confounders. Lower 5-year mortality was found in most demographic subgroups for ACTUR patients compared with Surveillance, Epidemiology, and End Results patients. Five-year survival in the MHS compared with the US general population may suggest an important role of universal health care in improving the survival of patients with soft-tissue sarcoma.