Active Duty Service Members Research Articles

P-1384. Rates of Follow-Up Testing for Chlamydia trachomatis and Neisseria gonorrhoeae Among Active-Duty Service Members

Abstract Background All patients who test positive for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) should get retested at three months to evaluate for re-infection. The United States military has previously been reported to have high rates of CT and GC, but follow-up rates have not been established for active-duty service members (ADSM) who test positive for CT or GC. This study evaluates factors associated with follow-up CT or GC testing in ADSM. Methods Positive cases of CT and GC among ADSM who were stationed at Joint Base San Antonio between January and June 2023 were evaluated. Demographic characteristics, location of testing, and the presence of symptoms were described. A patient was determined to have had follow-up testing if they had a repeat CT/GC test within 3-12 months after their initial positive test. Follow-up rates were compared among groups based on demographics, clinical setting of testing, and presence of symptoms using chi-square or Fisher’s exact test. Results Of the 200 ADSM who tested positive for CT or GC during the study period, 101 (51%) were male and the median age was 23 [IQR: 20-26] (Table 1). Women were significantly more likely to receive follow-up testing as compared to men (71% vs. 51%; p=0.003), without significant difference in follow-up testing by clinic, race, service, or original STI organism (Table 2). Women who were symptomatic at time of initial test were significantly more likely than symptomatic men to have a follow-up test (76% vs. 49%; p=0.003), but this difference did not hold for asymptomatic patients (64% vs. 53%, p=0.28) (Table 3). Conclusion Despite standardized follow-up testing recommendations, there were significantly lower follow-up testing rates in men, with the greatest difference in testing in patients who were symptomatic at presentation. While ADSM have universal access to care, the difference in follow-up testing between men and women based on presence of symptoms reinforces concerns about stigma in obtaining treatment and follow-up. Future work should study how standardization of guidelines in these populations promotes improvement in follow-up testing. Disclosures All Authors: No reported disclosures

P-151. Cutaneous Larva Migrans Within the United States Military Health System and Association with International Travel

Abstract Background Cutaneous larva migrans (CLM) is a parasitic dermatitis which occurs after zoonotic hookworm larva from the soil penetrate the skin. CLM is most common in tropical and sub-tropical regions of the world and in returning travelers from those regions. Within the United States (U.S.) autochthonous cases of CLM have been reported, however the epidemiology is not well-described. We seek to describe the epidemiology of CLM and association with geographic location and international travel within the U.S. military health system. Methods We performed a retrospective cohort study of active duty service members and their family members who had a diagnosis code of hookworm between October 2012 and September 2018. Of the initial cohort (n = 272), 61 (22.4%) were diagnosed with CLM. Results Most patients in this study were male (65.5%), active duty (55.7%), and white (45.9%) [Table 1]. Patients’ ages ranged from 1 to 56 years (mean 24.6) with 80.3% of patients 18 years of age or older. All the patients were born within the United States. Most were diagnosed by their primary care manager, however 19.7% were diagnosed via emergency or urgent care. Patients reported preceding travel to tropical and subtropical world regions in 32.8% of cases: Caribbean (13.1%), Africa (6.6%), Mexico and Central America (6.6%), South America (3.3%) and Japan (3.3%) [Figure 1]. After excluding those with preceding international travel, 67.2% of patients had autochthonous CLM. Of the autochthonous cases, more patients were diagnosed or had preceding travel in the southeast U.S. (68.3%) compared with the western U.S. (19.5%), southwest U.S. (9.8%), or northeast U.S. (2.4%) [Figure 2]. States with the highest number of cases were Florida (26.7%), Georgia (14.6%), North Carolina (9.8%), Texas (9.8%), Washington (7.3%) and Hawaii (7.3%). Based on the reported literature, we found a lower number of cases with preceding international travel than expected. Most autochthonous cases within the U.S. were from the southeast and coastal regions. Conclusion CLM should be considered in the U.S. even in patients without recent international travel. These findings are useful in providing nationwide data on the epidemiology of CLM and allowing for informed preventative counseling to travelers and non-travelers within the U.S. Disclosures Alison Helfrich, DO, MPH, Moderna: Stocks/Bonds (Public Company)|Sanofi: Stocks/Bonds (Public Company)

Sex Differences in Early/Unplanned Separation Among US Service Members With a History of Mild Traumatic Brain Injury.

To investigate the incidence of early/unplanned (E/U) separations following mild traumatic brain injury (mTBI) and assess whether sex impacts the hazard of separation. Military Health System (MHS). Active duty service members (N=75,730) with an initial mTBI diagnosis in military records between January 2011 and January 2018. Retrospective cohort study of electronic health records in the MHS. Cause-specific Cox proportional hazards models were used with sex at birth as the primary predictor. Early/unplanned (E/U) separation, defined as military separation attributed to disability, misconduct, poor performance, death, or other medical circumstances, within 2 years following the initial mTBI. Incidence of E/U separation within 2 years following mTBI was 13.7% (11.0% in women and 14.2% in men). Disability and misconduct separations were most common. Female service members had lower adjusted hazards for any E/U separation (Hazard Ratio [HR]=0.65; 95% Confidence Interval [CI]: 0.61,0.69), disability separation (HR=0.71; 95% CI: 0.65, 0.78), misconduct separation (HR=0.40; 95% CI: 0.36, 0.45), and poor performance separation (HR=0.84; 95% CI: 0.72, 0.99), compared to males, but had higher adjusted hazards for separations due to other medical circumstances (HR=1.24; 95% CI: 1.04, 1.48). Male and female service members had different hazards of E/U separation following mTBI. Separating early may increase the risk of adverse health and socioeconomic outcomes, so additional research is needed on why these separations occur and why they may be impacting men and women differently.

The Association Between Disordered Eating and Musculoskeletal Injury Among Marine Officers Upon Entry to the Basic School.

Active duty service members (ADSMs) may be at heightened risk for eating disorders (EDs) and sub-clinical disordered eating (DE). ADSMs are also at a high risk for musculoskeletal injury (MSK-I). Given the risk for EDs/DE among ADSMs as well as robust physical requirements of military training, additional research is needed to elucidate links between DE and risk for MSK-I among ADSMs. The aim of the present study was to assess the prevalence of DE and associations with MSK-I among Marine Corps officers entering a 6 month leadership course. The current cross-sectional study is part of a large, prospective study, the Initiation of Marine Physiological Assessment of Combat Training (IMPACT) study. Participants completed the Eating Disorder Examination-Questionnaire Short (EDE-QS) and self-reported the presence of a recent (≤6 months) MSK-I upon entry to an officer training course. A logistic regression was used to assess the association between elevated DE (EDE-QS ≥15) and recent MSK-I, adjusting for age, race, sex, and commissioning source. N = 1,382 officers (11.6% female, MAge: 24.8 ± 2.9 years, 26.6% racial/ethnic minority) completed the questionnaires. Seven percent had elevated DE (EDE-QS score ≥15) (female: 10.6%, male: 6.9%, P = .10); 18.3% self-reported recent MSK-I (female: 26.3%, male: 17.3%; P = .009). Females had 17% greater odds of MSK-I compared to males (aOR: 1.17, 95% CI: 1.03-1.33, P = .02). Moreover, females with elevated DE had greater odds of MSK-I than males with elevated DE (aOR= 1.38); among females, odds of MSK-I were greatest among those with elevated DE (aOR= 1.35). In this sample of Marine officers, DE was associated with greater odds of a recent MSK-I among women only. Results align with previously reported relationships between DE and skeletal health in female athletes. Prospective research is needed to elucidate the temporal nature of these relationships.

Insights Into the Health of Postpartum Airmen From the U.S. Air Force Fitness Database.

Physical fitness is an integral part of military readiness, and failure to meet military Physical Fitness Assessment (PFA) standards can severely damage or end careers. Postpartum active duty service members experience a drop in PFA scores and passing rates compared to their pre-pregnancy assessments. Each branch recently extended recovery time to 12 months, but more research is required to see if this change alone is enough to return both active duty and reserve component postpartum personnel to their own preconception PFA outcomes (scores, passing rates, and injury rates) and those of a control group of nullpartum female airmen. The Air Force Fitness Management System II database contains PFA records including demographic data and PFA outcomes among airmen from the total force: active duty, Air Force Reserve (AFR), and Air National Guard (ANG). We extracted data from 2015 to 2019 for three successive PFAs per individual, consisting of 12,971 records for perinatal Airmen and 308,155 records for nulliparous female airmen. We calculated overall PFA scores, passing rates, and exemption rates for active duty and AFR/ANG postpartum and nullpartum airmen, and then performed regressions to determine if differences between these groups persisted when accounting for demographic and prior physical fitness variables. Although 92% of postpartum airmen scored high enough to pass the PFA, their scores decreased from pretest scores by a larger margin than those for nullpartum airmen. Out of a possible 100 points, postpartum AFR/ANG members' scores decreased more (-4.5 points) than active duty scores (-2.8 points), while nullpartum members' scores decreased by -0.4 and -0.7, respectively. Nullpartum passing rates remained stable but decreased for both active duty and AFR/ANG postpartum airmen (-4% and -8%). Active duty postpartum airmen experienced a larger increase in component exemptions, which may indicate injury, (+8%) than nullpartum female airmen (+6%). These results were maintained when we controlled for age, officer status, previous pregnancies, and prior physical fitness. Compared with active duty nullpartum female airmen, active duty and AFR/ANG postpartum women had lower scores (-3.23, -6.79), and more than twice the odds of failure (2.44 and 5.42 times higher). AFR/ANG generally are less than half as likely to have a component exemption, but active duty postpartum airmen had 29% higher odds of having a component exemption than nullpartum active duty airmen. Even with a 12-month recovery period, postpartum airmen fare worse on all PFA outcome dimensions studied compared to nulliparous airmen and with preconception selves. Perinatal airmen with more experience, education, and access to resources have better PFA outcomes. The U.S. Air Force should consider a comprehensive maternal wellness program including physical fitness programming and medical preventative health accessible to total force perinatal airmen. This would increase operational readiness, retainability, and well-being while decreasing musculoskeletal injuries and associated medical costs.

Patterns and Predictors of COVID-19 Vaccine Uptake Among U.S. Active Duty Service Members, 2020-2022: Implications for Future Pandemics.

Vaccine mandates have been used to minimize the duty days lost and deaths attributable to infectious disease among active duty Service members (ADSMs). In response to the global COVID-19 pandemic, in August 2021, the U.S. DoD issued a COVID-19 vaccine mandate for all ADSMs. This study aimed to investigate COVID-19 vaccine uptake among the ADSM population, as well as factors associated with timing of COVID-19 vaccine receipt. This study included ADSMs on active duty between January 1, 2020, and June 30, 2022. Univariate analyses investigated associations between demographic factors (age, sex, race, ethnicity, branch of service, rank, and state of residence) and COVID-19 diagnosis with the following outcomes: (1) time to primary series initiation in relation to the DoD vaccine mandate, (2) time between doses of the 2-dose primary series, and (3) time between booster eligibility and receipt. This research received an exempt determination by the USU Human Research Protection Program. In total, 1,799,466 ADSMs were included, with 90% receiving ≥1 COVID-19 vaccine dose during the study period and 77% initiating the primary series prior to the mandate. Over 80% of ADSMs received a complete primary series, with 96% of those adhering to the recommended regimen. The history of COVID-19 diagnosis was associated with the later receipt of all doses. COVID-19 vaccine uptake was high among all ADSMs, with the majority initiating the primary series before the mandate. The high vaccine uptake among ADSMs shown here may be used as a guide to both military and civilian pandemic policy and outreach efforts related to enhanced vaccine uptake.

Posttraumatic Stress Disorder and Weight Loss in Male and Female Active-duty Service Members: A Weight Management Study.

Overweight and obesity are critical public health concerns with relevance to U.S. military personnel, as active duty service members must meet physical fitness and body composition standards. Biological sex and posttraumatic stress disorder (PTSD) diagnosis may affect service members' weight management efforts, but it is unclear what contribution each of these factors independently or in combination have on weight loss. Addressing this gap in knowledge, the current study used multilevel models to examine the effects of sex and self-reported PTSD diagnosis on change in weight of active duty Navy service members (n = 178, 61% female, 24% PTSD) over the course of and after a behavioral weight management intervention. On average, participants' weights decreased significantly during the intervention (P < .001), and there was a significant sex-by-PTSD interaction effect such that male participants without a self-reported PTSD diagnosis and female participants with a self-reported PTSD diagnosis lost significantly more weight during the intervention than their counterparts (P = .015). The main effects of sex and self-reported PTSD diagnosis on weight change during the intervention were nonsignificant (P's ≥ .24). While weight remained stable on average during the follow-up period (P = .28), female sex marginally predicted weight loss during the follow-up period (P = .07), whereas self-reported PTSD diagnosis and the sex-by-PTSD interaction were not significant (P's ≥ .16). These results highlight the importance of considering both sex and PTSD diagnosis as factors that together may influence the efficacy of behavioral weight management programs for active duty service members. NCT01757847.

Comparison of Glenoid Bone Loss After Unidirectional Versus Combined Shoulder Instability in a Military Population.

While glenoid bone loss (GBL) after anterior shoulder instability correlates with poor functional outcomes, the specific effects of GBL in posterior and combined-type shoulder instability remain poorly characterized, especially in a high-risk military population. The purpose of this study was to compare GBL between unidirectional anterior or posterior instability versus combined-type instability in active-duty servicemembers. It was hypothesized that total GBL and GBL in the direction of instability would be greater in those with combined-type instability compared with unidirectional instability. Cross-sectional study; Level of evidence, 3. Active-duty servicemembers who underwent shoulder stabilization surgery between January 2010 and December 2019 were eligible for inclusion. Patients with multidirectional instability, concomitant rotator cuff tears, osteochondritis dissecans of the glenoid or humeral head, superior labral anterior-posterior tears, biceps pathologies, and humeral avulsion of the glenohumeral ligament were excluded. Patients were grouped according to direction of instability (anterior, posterior, or combined), and patient characteristics, instability characteristics, suture anchor use, and GBL were compared between the 3 cohorts. In total, 117 patients met the study inclusion criteria. The mean patient age was 29 years, 89.7% were male, the dominant extremity was involved in 63.2%, 65.8% attributed their injuries to a singular traumatic event, and the mean follow-up was 7.9 years. There was no significant difference regarding patient characteristics, injury mechanism, or follow-up time between the 3 cohorts. As compared with the combined-type instability cohort, mean anterior GBL was greater in the anterior instability cohort (8.00% ± 4.40% vs 4.98% ± 5.26% for combined; P = .012), while mean posterior GBL was greater in the posterior instability cohort (7.44% ± 4.54% vs 4.86% ± 5.69% for combined; P = .024). There was no significant difference in mean total GBL between the combined-type (9.84% ± 7.82%) and either of the unidirectional cohorts (anterior: 8.00% ± 4.40% [P = .231]; posterior: 7.44% ± 4.54% [P = .082]). GBL in the direction of instability was found to be significantly greater in the unidirectional versus combined-type instability cohorts.

Residual symptoms following trauma-focused treatment for comorbid posttraumatic stress disorder and major depressive disorder.

Despite effective psychotherapy options for posttraumatic stress disorder (PTSD), some patients do not fully respond, and even among those reporting substantial improvement, residual symptoms following treatment are common. Psychiatric conditions frequently co-occur with PTSD, yet research on residual symptoms among comorbid samples is lacking. This study examined residual symptoms of PTSD and depression among 71 active duty service members with PTSD and comorbid major depressive disorder (MDD). As part of a clinical trial, participants were randomized to cognitive processing therapy (CPT) or a novel treatment designed to address PTSD and comorbid MDD, behavioral activation-enhanced CPT (BA+CPT). Analyses compared individual residual symptoms between treatments and groups based on PTSD and MDD diagnostic status at posttreatment. For both PTSD and MDD, the conditional probabilities for each residual symptom did not differ between CPT and BA+CPT, suggesting treatment type did not influence which symptoms persisted. For the 36 service members who lost their PTSD diagnosis at posttreatment, conditional probabilities of residual PTSD symptoms were highest for sleep problems, concentration difficulties, and hypervigilance; for MDD symptoms, conditional probabilities were highest for sleep problems, concentration difficulties, and low energy. These most common residual symptoms were identical for the 31 service members who lost their MDD diagnosis at posttreatment. Residual symptoms observed among service members with PTSD and comorbid MDD mirrored those commonly identified among single disorder PTSD or MDD samples. Identifying and addressing residual symptoms most meaningful to patients will maximize benefit from PTSD treatment.

Updates in Human Papillomavirus Vaccination to Improve Medical Readiness in Active Duty Service Members.

Human papillomavirus (HPV) is the most common sexually transmitted infection in the United States and is associated with the development of genital warts, precancerous lesions, and cancers of the oropharynx, anus, penis, vulva, vagina, and cervix. HPV-associated diseases are preventable through vaccination. An Australian nationwide vaccination program will effectively eliminate cervical cancer as a public health concern by the year 2035. Despite safety and efficacy data, vaccination against HPV is not mandatory for military service members. Active duty service women are more likely to test positive for HPV when compared to dependents, and veterans diagnosed with HPV-associated cancers have higher health care resource utilization and costs. Even if a patient has a prior HPV infection, vaccination at the time of HPV diagnosis or following treatment can reduce recurrence of HPV and dysplasia. In addition, patients with a history of cancer have a higher incidence of secondary HPV-associated malignancies and should be offered vaccination or re-vaccination if they received a hematopoietic stem-cell transplant. Improving HPV vaccination rates within the military health system requires a multidisciplinary approach. Providers should use every opportunity to recommend HPV vaccination, including recommending HPV vaccines for individuals who do not have a record of HPV vaccination. The electronic health record can be utilized to generate prompts for vaccine reminders, and clinics should stock HPV vaccines to allow for easy administration. Additionally, adoption of an opt-out policy for HPV vaccines rather than mandatory vaccination may be an acceptable alternative to increase HPV vaccination while allowing active duty service members to retain autonomy.

Factors Associated With Return to Activity After Concussion Among Female Service Academy Members: Findings From the NCAA-DoD CARE Consortium.

Service academy members are at high risk for concussions as a result of participation in both sports and military-specific training activities. Approximately 17% of active duty service members are female, and they face unique challenges in achieving timely recovery from concussions. Understanding the unique characteristics affecting return to unrestricted activity (RTA) among female service academy members is imperative for the ever-growing proportion of females across the U.S. military. The goal of this analysis was to determine how specific injury and individual characteristics of concussion affect 2 RTA protocol events in female service academy members: time to protocol initiation and time to protocol completion. All data were collected as part of the National Collegiate Athletic Association (NCAA) and the DoD Concussion Assessment, Research and Education Consortium. We examined data from female U.S. military service academy members at the 4 U.S. Service Academy sites who sustained a concussion between Fall 2014 and Spring 2020 (N = 752). Return to unrestricted activity protocol initiation time was defined as the time from injury to when cadets were cleared to begin gradual RTA, while RTA protocol completion time was defined as the time from injury to when cadets were cleared to RTA. Multivariable Cox regression analyses were used to determine the effect of 4 characteristics on RTA event times: (1) service academy members' NCAA status (e.g., student athlete), (2) prior history of concussion, (3) reporting time of concussion, and (4) sport-related concussion (SRC) or non-SRC. Because of missing data, 520 cadets were included in the model of RTA protocol initiation and 556 were included in the model of RTA protocol completion. Chi-squared analyses assessed interactions between reporting time, NCAA status, and SRC or non-SRC. Service academy members who were NCAA athletes (hazard ratio [95% CI](HR [95% CI]): 1.58 [1.32, 1.90]), immediately reported their injury (HR [95% CI]: 1.40 [1.18, 1.67]), or had an SRC (HR [95% CI]: 1.29 [1.08, 1.54]) were significantly more likely to have initiated or completed the RTA protocol on any given day post-concussion compared to those who were not NCAA athletes, delayed reporting their injury, or had a non-SRC, respectively. We observed that among those with SRCs, a greater proportion of NCAA service academy members immediately reported their injury (53.9%) compared to non-NCAA (37.3%, P < .001); there was no difference in the proportion of NCAA and non-NCAA service academy members with non-SRCs who immediately reported their injury (P = .18). A greater proportion of female service academy members who sustained SRCs and were NCAA athletes reported their injuries immediately, which was associated with a greater likelihood of RTA protocol initiation and completion on any given day after injury. This may be attributable to easy and timely access to medical personnel (e.g., athletic trainers) or the presence of individuals trained in identifying concussion (e.g., coaches). Future initiatives among female service academy members should include improved access to medical care across a variety of injury settings and education on the importance of early reporting after concussion.

Informing peer support programs for active duty military spouses of U.S. Army soldiers

LAY SUMMARY With 50% of active duty service members being married, spouses are critical in supporting military readiness. Yet, because of the nature of military service, spouses experience numerous challenges, including education and career progression, parenting and child care, managing family separation during deployment and training, and accessibility of health care. Peer support programs can develop a sense of community, provide support for shared challenges, and offer access to resources. Building on a peer support program with Veteran spouses, this study identified the challenges and needs of active duty spouses to inform adaptation of the program. Five focus groups were conducted on Zoom with 35 active duty military spouses to understand their main concerns and preferences for a peer support program. Major themes identified were challenges of military life, benefits of military life, and recommendations for peer support programming. This study’s findings will be used to adapt and develop a peer support program to be tested with military spouses of U.S. Army soldiers in a study funded by the U.S. Department of Defense.

Inequities in Physical Therapy Receipt of US Service Members and Veterans With Low Back Pain.

To investigate inequities in time to physical therapy (PT) for patients with low back pain (LBP). Retrospective observational study using data from the Department of Defense and Veterans Health Administration clinical and administrative data repositories derived from medical records, claims, and enrolment data. Military Health System, Veterans Health Administration, and civilian health care facilities. Active duty service members, veterans, and retirees seeking health care for LBP between January 2017 and December 2020, with no LBP diagnoses for at least 1 year prior (N=1,252,959). Not applicable. Time to-outpatient PT evaluation within 13 weeks of LBP diagnosis. Approximately 9.4% of included patients received an outpatient PT evaluation from a physical therapist within 13 weeks of diagnosis. In a piecewise exponential additive model, many covariates were time-varying, such that the probability of PT receipt varied throughout the 13-week period. Black, Latinx, and American Indian and Alaskan Native patients had lower probabilities of PT receipt than White patients from 1 to 3-6 weeks after index diagnosis. At 5 and 7 weeks, Black and Latinx patients, respectively, were more likely to receive PT than White patients, which continued until the end of the observation period. Patients assigned female relative to patients assigned male relative had a higher probability of initiating PT across the entire observation window, as did active duty service members, relative to retired service members and veterans. Inequities in the timing and receipt of PT exist in the US Military Health System and Veterans Health Administration by race and ethnicity, assigned sex, and beneficiary group. Standardizing referral and practice patterns, improving accessibility of PT services, and encouraging health-seeking behavior may help alleviate the inequities in initiating PT.

Comparison of crisis response planning and treatment as usual for active duty service members at risk for suicide: Study protocol for a stepped-wedge cluster randomized trial in a military treatment facility.

Suicide is one of the leading causes of death among U.S. service members, and rates of suicide among military personnel have increased over the past two decades. To address this serious issue, effective preventive treatments are needed in settings where at-risk service members are frequently seen, such as emergency departments and inpatient psychiatric units. This study will compare the longitudinal effects of crisis response planning (CRP) and treatment as usual (TAU) on suicidal thoughts and behaviors among active duty service members seeking emergent care for suicidality at a military treatment facility. The current study is conducted through a consortium, Augmenting Suicide Prevention Interventions for Service Members. This article details an ongoing stepped-wedge cluster randomized clinical trial that compares rates of suicidal thoughts and behaviors among service members at risk for suicide following care from CRP-trained providers versus untrained providers (i.e., TAU). Participants complete assessments at pretreatment and every 3 months up to 1 year. Primary outcomes include suicide attempts and behaviors, and suicidal ideation is a secondary outcome. Moderators of treatment effects will also be examined. The methodological development of this trial is discussed, along with clinical and ethical considerations for suicide prevention research in emergency, inpatient, and military treatment settings. Providing evidence-based treatment for suicidality that addresses service members' unique needs is crucial to reduce suicide rates and facilitate mental health recovery in this population. This study aims to inform future implementation and dissemination of CRP in healthcare systems to ultimately decrease suicide among service members. NCT05795764.

Incidence and Predictors of Postpartum Depression Diagnoses among Active-Duty U.S. Army Soldiers.

Introduction: Understanding the incidence and predictors of postpartum depression (PPD) among active-duty service members is critical given the importance of this population and its unique stressors. Methods: We conducted a retrospective cohort study of all active-duty U.S. Army soldiers with a record of at least one live-birth delivery between January 2012 and December 2013. Multivariate logistic regression models were used to estimate associations between demographic, health-related, and military-specific variables and diagnoses of PPD in the total population (N = 4,178) as well as in a subpopulation without a record of depression before delivery (N = 3,615). Results: The overall incidence of PPD diagnoses was 15.9% (N = 664 cases) among the total population and 10.4% (N = 376 cases) among those without prior depression. Statistically significant predictors of PPD in the adjusted model included lower pay grade, a higher number of prior deployments, a higher number of child dependents, tobacco use, and a history of depression or anxiety before or during pregnancy. For soldiers without a history of depression, lower pay grade, and a history of anxiety before or during pregnancy were significantly associated with PPD. Conclusions: Knowing the predictors of overall and novel onset PPD diagnoses in this population could help establish clearer guidelines on PPD prevention, screening, management, and return to duty.

Lower Extremity Musculoskeletal Injuries in United States Active Duty Service Members: Prevalence/Incidence, Health Care Utilization, and Cost Analysis Spanning Fiscal Years 2016-2021.

Lower Extremity musculoskeletal injuries (LE MSKIs) represent a significant portion of overuse injuries in active duty service members (ADSMs). However, variations in study methods and research gaps related to LE MSKIs have prevented Department of Defense (DoD) leaders from assessing the burden of these conditions. The purpose of this study was to report the incidence, prevalence, and types of LE MSKIs sustained by ADSMs across four branches of service and describe associated health care utilization and private sector costs. This was a retrospective, longitudinal population study, including ADSMs from the Air Force, Army, Marine Corps, and Navy. Prevalence and incidence rates for LE MSKIs, associated health care utilization, and costs were obtained by querying electronic health records (EHR) from military treatment facilities (MTFs), private sector care (PC) claims, and theater medical data from the Military Health System Data Repository (MDR) from October 1, 2015 to September 30, 2021 (FY16-21). Utilization associated with LE MSKIs in both the direct care (DC) and PC settings was classified into mutually exclusive outpatient encounter categories and acute inpatient stays. PC costs related to LE MSKIs were captured for each year. In FY21, LE MSKIs occurred in 25.3% of ADSMs (n = 378,615). A higher proportion of females sustained an LE MSKI (33.3%), compared to males (23.7%). From FY16-21, the Army had the highest annual prevalence of LE MSKIs (30.9-35.5%), followed by the Air Force (23.8-31.0%), Marine Corps (23.4-27.0%), and Navy (17.2-19.8%). Incidence rate patterns were similar, with the Army sustaining LE MSKIs at 320 to 377 injuries per 1,000 person-years, followed by the Air Force (241-318), Marines (255-288), and Navy (173-203). Overuse/non-specific MSKIs of the knee were the most common injury type and body region affected, respectively. There were 10,675,543 DC and 1,875,307 PC outpatient encounters from FY16-21 with a primary or secondary diagnosis of LE MSKI. The Air Force was most reliant on PC, with 21.5 to 36.8% of LE MSKI-related encounters occurring outside MTFs during FY16-21. Over $99 million was paid by TRICARE on LE MSKI in FY21 alone with Same Day Surgeries accounting for almost half ($48 million) of this total. Among U.S. ADSMs, LE MSKIs remain highly prevalent and costly. We observed disparities across the Services in the prevalence and incidence of LE MSKIs, and their respective reliance on the private sector for management of these conditions. Findings from this work may support military leaders and MSKI researchers who seek to reduce the impact of LE MSKIs on the readiness and overall health of the U.S. Military.

Burden of Musculoskeletal Injuries in U.S. Active Duty Service Members: A 12-Year Study Spanning Fiscal Years 2010-2021.

Musculoskeletal injuries (MSKIs) represent the most substantial and enduring threat to U.S. military readiness. Previous studies have focused on narrow surveillance periods, single branches of service, and used variable approaches for MSKI identification and classification. Therefore, the goals of this retrospective population study were to report the incidence, prevalence, and types of MSKIs sustained by active duty service members (ADSMs) across four Services in direct care (DC) and private sector care (PC) settings over fiscal years (FYs) 2010-2021, and to quantify and describe associated health care utilization and PC costs over the same period. This study included ADSMs from the Air Force, Army, Marine Corps, and Navy. Prevalence and incidence rates for Head/Neck, Upper Extremity (UE), Spine (upper back, middle back, lower back, pelvic), and Lower Extremity (LE) MSKIs in ADSMs, associated health care utilization, and PC costs were derived by querying electronic health records from DC, PC claims, and theater medical data from the Military Health System Data Repository. Patient episodes of care and associated PC costs related to MSKIs in DC and PC settings were classified into mutually exclusive outpatient encounter categories and acute inpatient stays, body regions, and Services. Over FY10-21, the most prevalent MSKIs were LE (24-29%) followed by Spine (17-20%), UE (14-16%), and Head/Neck (6-8%). Across FY10-21, soldiers were more likely to sustain LE MSKI than Airmen (risk ratio 1.12-1.30) and Marines demonstrated an increasing risk of LE MSKI prevalence and incidence (relative to Airmen) over the study period. The rise in prevalence of LE, Spine, UE, and Head/Neck MSKIs over FY10-21 was accompanied by increased health care utilization and reliance on PC care, especially same-day surgeries (SDS). PC reliance for SDS increased across body regions from FY10 to its peak in FY20 (Head/Neck: 22.7% to 49.7%, Spine: 37.1% to 57.0%, LE: 38.6% to 51.5%, UE: 40.4% to 53.5%). In FY21, the MHS incurred the highest PC costs for LE MSKIs ($132,242,289), followed by Spine ($98,738,863), UE ($92,118,071), and Head/Neck ($42,718,754). To our knowledge, this is the first population study of MSKIs in ADSMs spanning the ICD-10 CM transition (FY15-16) that includes the four Services. Across Services, MSKIs in the U.S. military remain a prevalent and persistent problem. Consistent with prior research, the LE was the most common and costly body region affected by MSKIs. Service members with MSKIs demonstrated an increasing reliance on PC for MSKI care, particularly SDS, over the study period. Expanding future research efforts to include all Services to assess risk factors and patient outcomes for treatments across DC and PC settings is vital to mitigate the threat posed by MSKIs to the readiness of the U.S. Armed Forces.

Musculoskeletal Injuries in Female U.S. Active Duty Service Members: Prevalence/Incidence, Health Care Utilization, and Cost Analysis Spanning Fiscal Years 2016-2021.

Musculoskeletal injuries (MSKIs) are highly prevalent and costly conditions among active duty service members (ADSMs), and female service members sustain these injuries at a higher rate than men. However, lack of women-specific research regarding MSKIs in the U.S. military has limited Department of Defense (DoD) leadership from assessing and addressing the burden of these conditions. The purposes of this study were to report the incidence, prevalence, and types of MSKIs sustained by female ADSMs across the four services in direct care (DC) and private sector care (PC) settings from fiscal years (FYs) 2016 through 2021 and to quantify and describe the health care utilization and private sector costs associated with MSKIs in women over the same period. This retrospective, longitudinal population study included ADSMs from the Air Force, Army, Marine Corps, and Navy. Prevalence and incidence rates for Head/Neck, Upper Extremity (UE), Spine, and Lower Extremity (LE) MSKIs in female ADSMs, associated health care utilization, and private sector costs were derived by querying electronic health records from military treatment facilities, PC claims, and theater medical data from the Military Health System Data Repository from October 1, 2015 to September 30, 2021 (FY16-21). Health care utilization associated with MSKIs among female ADSMs for each body region in DC and PC settings was classified into mutually exclusive outpatient encounter categories and acute inpatient stays. PC MSKI-associated costs in service women were captured for each year and categorized by service, body region, and setting. In FY21, 10.8% (n = 27,976) of female ADSMs sustained Head/Neck MSKI, 16.3% (n = 42,294) UE MSKI, 23.6% (n = 61,048) Spine MSKI, and 33.3% (n = 86,235) LE MSKI. Across the study period, female ADSMs had a 25%-29% higher risk of any MSKI (risk ratio (RR) 1.25-1.29) relative to men. Female soldiers had the highest annual prevalence of MSKIs (62.1%-66.4%), while female Marines had the highest risk of MSKI relative to men (RR 1.40-1.47) for all four major body regions. From FY16 to FY21, the body region with the highest risk of MSKI relative to men was Head/Neck (RR 1.61-1.63), while the region with the lowest relative risk was UE (RR 1.05-1.10). LE MSKIs represented the most common and costly type of injury in female ADSMs, with 406,997 outpatient DC and 87,374 PC encounters in FY21. Total PC costs of LE MSKI for female ADSMs were $30,643,535 in FY21 alone. This is the first population-level assessment of MSKI prevalence, incidence rates, health care utilization, and PC costs over a 6-year period for service women in the military health system (MHS). Female ADSMs sustain MSKIs at a higher rate than their male counterparts. Given the critical role of service women in the military, MHS leaders, researchers, and public health officials should continue to explore the underlying causes of these disparities in MSKI rates between the sexes, by expanding research efforts to all services and military settings.

Musculoskeletal Head and Neck Injuries in U.S. Active Duty Service Members: Prevalence/Incidence, Health Care Utilization, and Cost Analysis Spanning Fiscal Years 2016-2021.

Active duty service members (ADSMs) of the U.S. Armed Forces are uniquely at risk for musculoskeletal injuries (MSKIs) of the Head/Neck region, including the eye and face, from training with head gear, donning Kevlar, operating aircraft, and maintaining sitting or standing postures for prolonged durations. The purposes of this descriptive study were to report the prevalence/incidence, health care utilization, and health care costs attributable to Head/Neck MSKIs across the Services from fiscal years (FYs) 2016 to 2021. This was a retrospective, longitudinal population study, including ADSMs from the Air Force, Army, Marine Corps, and Navy. Prevalence and incidence rates for Head/Neck MSKIs, associated health care utilization, and private sector costs were obtained by querying electronic health records from military treatment facilities, private sector care (PC) claims, and theater medical data from October 1, 2015 to September 30, 2021 (FYs 16-21), using the Military Health System Data Repository. Utilization associated with Head/Neck MSKIs in both the direct care and PC settings was classified into mutually exclusive outpatient encounter categories and acute inpatient stays. PC costs related to Head/Neck MSKIs were captured for each year. In FY21, 109,683 ADSMs sought care for Head/Neck MSKIs, representing 7.3% of the U.S. Armed Forces. The prevalence of Head/Neck MSKIs ranged from 6.9 to 7.8% during FY16-21, with the highest annual prevalence among the Air Force (8.0-9.4%) and Army (7.9-8.8%). Within direct care across the services, Soldiers presented for the highest proportion (45.9-47.9%) of outpatient encounters for Head/Neck MSKI annually. The Air Force relied most heavily on PC for outpatient Head/Neck MSKI care, which accounted for $9,134,741 in PC costs and comprised 37.2% of all PC encounters in FY21. This retrospective, descriptive study established prevalence/incidence, health care utilization, and PC costs for Head/Neck MSKIs across the services from FY16-21, emphasizing the burden of Head/Neck MSKIs among the U.S. Armed Forces, with PC costs amounting to $42,912,940 in FY21 alone.

Musculoskeletal Spine Injuries in U.S. Active Duty Service Members: Prevalence/Incidence, Healthcare Utilization, and Cost Analysis Spanning Fiscal Years 2016-2021.

Low back pain and musculoskeletal injuries (MSKIs) of the Spine are the most common reason for U.S. active duty service members (ADSMs) to seek medical care. The purposes of this descriptive study were to report the prevalence/incidence, health care utilization, and health care costs attributable to Spine (thoracic, lumbar, sacral, and pelvic) MSKIs across the four major branches of service from Fiscal Years (FY) 2016 to 2021. This was a retrospective, longitudinal population study, including ADSMs from the Air Force, Army, Marine Corps, and Navy. Prevalence and incidence rates for Spine MSKIs, associated health care utilization, and costs were obtained by querying electronic health records (EHRs) from military treatment facilities, private sector care (PC) claims, and theater medical data from the Military Health System Data Repository from October 1, 2015 to September 30, 2021 (FY16-21). Utilization associated with Spine MSKIs in both the direct care (DC) and PC settings was classified into mutually exclusive outpatient encounter categories and acute inpatient stays. PC costs related to Spine MSKIs were captured per year. In FY21, 269,301 ADSMs sought care for Spine MSKI, representing 18.0% of the U.S. Armed Forces. The prevalence of Spine MSKIs ranged from 17.4 to 19.5% during FY16-21, with the highest annual prevalence among the Army (20.7-22.9%) and Air Force (19.0-22.6%). Across the study period, Soldiers had the highest share (47.8-50.4%) of DC outpatient encounters for Spine MSKI (primary or secondary diagnosis). The Air Force relied most heavily on PC for outpatient Spine MSKI care across the study period, where in FY21 Airmen accounted for 36.5% of the outpatient PC Spine MSKI encounters totaling $21,140,935 in PC costs. In FY21, total PC costs for Spine MSKI totaled $99,317,832. This retrospective, descriptive study establishes prevalence/incidence, health care utilization, and PC costs for Spine MSKIs across the Services from FY16-21 and highlights the burden of Spine MSKIs among the U.S. Armed Forces, with costs amounting to over $99 million in PC reliance in FY21 alone.