Strategies to Improve Management of Acute Watery Diarrhea during a Military Deployment: A Cost Effectiveness Analysis

Andrew J Schrader,Mark S Riddle,David R Tribble

doi:10.4269/ajtmh.17-0196

Abstract

.To inform policy and decision makers, a cost-effectiveness model was developed to predict the cost-effectiveness of implementing two hypothetical management strategies separately and concurrently on the mitigation of deployment-associated travelers’ diarrhea (TD) burden. The first management strategy aimed to increase the likelihood that a deployed service member with TD will seek medical care earlier in the disease course compared with current patterns; the second strategy aimed to optimize provider treatment practices through the implementation of a Department of Defense Clinical Practice Guideline. Outcome measures selected to compare management strategies were duty days lost averted (DDL-averted) and a cost effectiveness ratio (CER) of cost per DDL-averted (USD/DDL-averted). Increasing health care and by seeking it more often and earlier in the disease course as a stand-alone management strategy produced more DDL (worse) than the base case (up to 8,898 DDL-gained per year) at an increased cost to the Department of Defense (CER $193). Increasing provider use of an optimal evidence-based treatment algorithm through Clinical Practice Guidelines prevented 5,299 DDL per year with overall cost savings (CER −$74). A combination of both strategies produced the greatest gain in DDL-averted (6,887) with a modest cost increase (CER $118). The application of this model demonstrates that changes in TD management during deployment can be implemented to reduce DDL with likely favorable impacts on mission capability and individual health readiness. The hypothetical combination strategy evaluated prevents the most DDL compared with current practice and is associated with a modest cost increase.

Highlights

Acute watery diarrhea (AWD) has been a significant problem for militaries across the world for centuries
The goals of this study are 3-fold: 1) to describe the cost-effectiveness of increasing healthcare seeking behavior by deployed service members with travelers’ diarrhea (TD) in terms of the cost of averting lost duty time compared with observed health use practices, 2) to describe the cost-effectiveness associated with increasing health care provider use of effective loperamide-adjuncted single-dose antibiotic regimens compared with current use rates and choice of multiday/ multidose regimens in treatment TD, and 3) to evaluate the cost-effectiveness of an integrated deployment health management program that considers both improved provider management and increased healthcare seeking behavior compared with current HCSB and management practices for treatment of TD
In a single deployment of 50,000 service members deploying for an average duration of 3.5 months, 50,575 episodes of TD occurred with a management cost to the military healthcare system of $2,974,311 (US dollars, USD)

Summary

Introduction

Acute watery diarrhea (AWD) has been a significant problem for militaries across the world for centuries. AWD continues to affect military service men and women when deployed to developing countries.[2] There can be serious ramifications to a military mission if even just a handful of a unit’s troop strength is rendered nonmission capable for even a day. Despite knowledge of germ theory and efforts toward increasing field sanitation and hygiene measures, the proportionate morbidity of TD as a disease and nonbattle injury has changed very little in deployed military units.[2]

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Conclusion