Civilian Providers Research Articles

Comparing Military and Civilian Dentists' Treatment Planning Decisions: A Pilot Study.

Clinical decision-making varies among dentists. However, the literature is limited and narrow in scope regarding the variation between public and private sector dentists. Because both types of dentists' decisions can directly influence military dental readiness, it is important to understand the potential differences in diagnosis, treatment planning, and the delivery of care. The purpose of this pilot study was to compare treatment planning recommendations between civilian and military providers. Patient-level data from the 2018 Recruit Surveillance, a stratified, cross-sectional study of 1,208 randomly selected U.S. Air Force recruits, were used to evaluate treatment planning outcomes for the 2 provider groups (2 civilians; seven military providers). Treatment planning outcomes included type of noninvasive, operative, and oral surgery treatment recommended, temporomandibular disorder referrals, and orthodontic referrals. Patient demographic variables included age, gender, education, race/ethnicity, and military component ("status"). Data were examined both at the tooth level and patient level for statistical significance. Multivariate analyses were performed with statistically significant variables included in each final model for patient-level data. Data were analyzed with logistic regression and Poisson regression (alpha = 0.05). Bivariate logistic regression analyses were performed for tooth-level data. Significant differences were found between military and civilian dentists' treatment planning decisions (P < .05) for both patient-level and tooth-level data. Adjusted for significant bivariate predictors of patient demographics at the patient level, civilian dentists were more likely to refer patients for orthodontic treatment, prescribe remineralization for sound tooth surfaces, incipient caries, and carious teeth, and prescribe direct restorations for teeth with 3 to 5 carious surfaces instead of single crowns compared to military dentists. Additionally, civilian dentists were less likely to prescribe sealants for sound tooth surfaces or carious teeth. No statistically significant difference in treatment planning outcomes was observed between civilian and military dentists for sealants for incipient caries, single crowns, or extraction of third molars. At the tooth level, civilian dentists were more likely to prescribe remineralization for sound tooth surfaces, remineralization instead of sealants for carious surfaces, and extraction of third molars. No statistically significant differences were noted between civilian and military providers for recommending sealant or remineralization for teeth with incipient caries or prescribing a single crown versus placing a direct restoration on posterior teeth with 3 to 5 carious surfaces. Significant differences in treatment planning outcomes between civilian and military providers exist. Civilian providers are more likely to refer patients for orthodontic treatment and prescribe remineralization, direct restorations instead of single crowns, and third molar extractions, while military providers are more likely to prescribe sealants for sound tooth surfaces or carious teeth. Therefore, comparisons of treatment planning outcomes between civilian and military providers warrant further research.

Type-specific whole blood still has a role in the era of low-titer O universal donor transfusion for severe trauma hemorrhage.

Whole blood can be ABO-type specific (type-specific whole blood (TSWB)) or low-titer O universal donor (low-titer O whole blood (LTOWB)). Having previously used LTOWB, the US Armed Forces Blood Program began using TSWB in 1965 as a method of increasing the donor pool. In contrast to military practice, the Association for the Advancement of Blood and Biotherapies formerly the American association of blood banks (AABB), from its first guidelines in 1958 until 2018, permitted only TSWB. Attempting to reduce time to transfusion, the US military reintroduced LTOWB in the deployed environment in 2015; this practice was endorsed by the AABB in 2018 and is progressively being implemented by military and civilian providers worldwide. Low-titer O whole blood is the only practical solution prehospital. However, there are several reasons to retain the option of TSWB in hospitals with a laboratory. These include (1) as-yet ill-defined risks of immunological complications from ABO-incompatible plasma (even when this has low titers of anti-A and -B), (2) risks of high volumes of LTOWB including published historical advice (based on clinical experience) not to transfuse type-specific blood for 2 to 3 weeks following a substantial LTOWB transfusion, (3) uncertainty as to the optimal definition of "low titer," and (4) expanding the potential donor pool by allowing type-specific transfusion. Several large randomized controlled trials currently underway are comparing LTOWB with component therapy, but none address the question of LTOWB versus TSWB. There are sufficient data to suggest that the additional risks of transfusing LTOWB to non-group O recipients should be avoided by using TSWB as soon as possible. Combined with the advantage of maintaining an adequate supply of blood products in times of high demand, this suggests that retaining TSWB within the civilian and military blood supply system is desirable. TSWB should be preferred when patient blood group is confirmed in facilities with a hematology laboratory, with LTOWB reserved for patients whose blood group is unknown.

Insider Threats to the Military Health System: A Systematic Background Check of TRICARE West Providers.

To address the pandemic, the Defense Health Agency (DHA) expanded its TRICARE civilian provider network by 30.1%. In 2022, the DHA Annual Report stated that TRICARE's provider directories were only 80% accurate. Unlike Medicare, the DHA does not publicly reveal National Provider Identification (NPI) numbers. As a result, TRICARE's 9.6 million beneficiaries lack the means to verify their doctor's credentials. Since 2013, the Department of Health and Human Services' (HHS) Office of Inspector General (OIG) has excluded 17,706 physicians and other providers from federal health programs due to billing fraud, neglect, drug-related convictions, and other offenses. These providers and their NPIs are included on the OIG's List of Excluded Individuals and Entities (LEIE). Patients who receive care from excluded providers face higher risks of hospitalization and mortality. We sought to assess the extent to which TRICARE screens health care provider names on their referral website against criminal databases. Between January 1-31, 2023, we used TRICARE West's provider directory to search for all providers within a 5-mile radius of 798 zip codes (38 per state, ≥10,000 residents each, randomly entered). We then copied and pasted all directory results' first and last names, business names, addresses, phone numbers, fax numbers, degree types, practice specialties, and active or closed statuses into a CSV file. We cross-referenced the search results against US and state databases for medical and criminal misconduct, including the OIG-LEIE and General Services Administration's (GSA) SAM.gov exclusion lists, the HHS Office of Civil Rights Health Insurance Portability and Accountability Act (HIPAA) breach reports, 15 available state Medicaid exclusion lists (state), the International Trade Administration's Consolidated Screening List (CSL), 3 Food and Drug Administration (FDA) debarment lists, the Federal Bureau of Investigation's (FBI) list of January 6 federal defendants, and the OIG-HHS list of fugitives (FUG). Our provider search yielded 111,619 raw results; 54 zip codes contained no data. After removing 72,156 (64.65%) duplicate entries, closed offices, and non-TRICARE West locations, we identified 39,463 active provider names. Within this baseline sample group, there were 2398 (6.08%) total matches against all exclusion and sanction databases, including 2197 on the OIG-LEIE, 2311 on the GSA-SAM.gov list, 2 on the HIPAA list, 54 on the state Medicaid exclusion lists, 69 on the CSL, 3 on the FDA lists, 53 on the FBI list, and 10 on the FUG. TRICARE's civilian provider roster merits further scrutiny by law enforcement. Following the National Institute of Standards and Technology 800, the DHA can mitigate privacy, safety, and security clearance threats by implementing an insider threat management model, robust enforcement of the False Claims Act, and mandatory security risk assessments. These are the views of the author, not the Department of Defense or the US government.

Possible Measures to Estimate Military Airspace Capacity

Controlled airspace have a capacity value to ensure safe and efficient management of air traffic. The capacity value represents the maximum number of aircraft that can safely operate within a given airspace over a certain period of time, while maintaining the required level of safety and efficiency. From a civilian air traffic control point of view, it is crucial to have a clear understanding of the capacity value of each airspace. This information helps controllers to effectively manage the traffic flow within the airspace and avoid overloading, which can lead to delays, increased fuel consumption and potential safety risks. Additionally, knowing the capacity value of an airspace can also help controllers to make valid decisions when it comes to scheduling flights, route planning and managing air traffic during peak periods. By understanding the importance of the capacity values of an airspace controlled by a civilian provider, it is essential to have capacity values in airspace under military control as well in order to complete the given military operations successfully. In my study, I would like to present the aspects of the possible determination of the capacity value of military airspace.

Recognizing and Serving Military Families in Your Community.

Providers who are not in proximity to military bases or posts cannot assume that they do not have military-connected families in their practices. Military families face many unique challenges and risks. It is important that civilian providers support the physical and psychological well-being of this population.

Abstract B074: Evaluating nursing knowledge and readiness in providing care for post-9/11 veterans in civilian healthcare settings: A quality improvement project

Abstract Over three-million military service members deployed overseas in support of the post-9/11 Global War on Terror since 2001. Of those, 7,057 have been killed in action, 30,177 have committed suicide, 279,652 died from ill-defined and unknown medical causes, and 520,966 have been diagnosed with cancer. Post-9/11 veterans are 192.75% more likely to be diagnosed with cancer when compared to their civilian counterparts and are more likely to utilize civilian providers (75%) than the Department of Veterans Affairs for health care concerns. The purpose of this quality improvement project is to investigate the level of nurse knowledge, beliefs, and perceptions related to providing health care to post-9/11 veterans in civilian care settings. A descriptive project design with a 15-question survey was implemented. The survey was sent to registered nurses practicing in civilian care settings. A sample of 537 registered nurses practicing in civilian care settings responded. Findings included that 93% incorrectly chose mental health conditions as the most likely occurring condition in post-9/11 veterans, while 7% correctly chose medical illnesses as most prevalent. Nurse respondents reported a perceived prevalence of post-traumatic stress occurring more often than cancer and malignancies at a ratio of 19:1. These findings highlight the high potential for cognitive biases which may lead to misdiagnoses and delayed diagnoses in post-9/11 veterans presenting for care with medical symptoms, furthering the need for education. This quality improvement project revealed significant gaps in civilian nurses’ clinical knowledge in screening, assessing, identifying, treating, and recommending resources for post-9/11 veterans and medical-related conditions. Citation Format: Chelsey Simoni, Jack Ratliff. Evaluating nursing knowledge and readiness in providing care for post-9/11 veterans in civilian healthcare settings: A quality improvement project [abstract]. In: Proceedings of the 15th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2022 Sep 16-19; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr B074.

Central disorders of hypersomnolence: diagnostic discrepancies between military and civilian sleep centers.

The majority of active-duty service members obtain insufficient sleep, which can influence diagnostic evaluations for sleep disorders, including disorders of hypersomnolence. An incorrect diagnosis of hypersomnia may be career ending for military service or lead to inappropriate medical care. This study was conducted to assess the rates at which narcolepsy (Nc) and idiopathic hypersomnia (IH) are diagnosed by military vs civilian sleep disorders centers. This retrospective study utilized claims data from the Military Health System Data Repository. The analyses compared diagnostic rates of military personnel by provider type-either civilian provider or military provider-from January 1, 2016 to December 31, 2019. Three diagnostic categories for Nc and IH: Nc or IH, Nc only, and IH only, were assessed with multivariate logistic regression models. We found that among service members evaluated for a sleep disorder, the odds ratios of a positive diagnosis at a civilian facility vs a military facility for Nc or IH was 2.1, for Nc only was 2.1, and IH only was 2.0 over the 4-year period. Civilian sleep specialists were twice as likely to diagnose central disorders of hypersomnolence compared to military specialists. Raising awareness about this discrepancy is critical given the occupational and patient care-related implications of misdiagnoses. Thomas CL, Vattikuti S, Shaha D, etal. Central disorders of hypersomnolence: diagnostic discrepancies between military and civilian sleep centers. J Clin Sleep Med. 2022;18(10):2433-2441.

Proportion of Navy Recruits Diagnosed With Symptomatic Stress Fractures During Training and Monetary Impact of These Injuries.

Lower extremity stress fractures result in lost time from work and sport and incur costs in the military when they occur in service members. Hypovitaminosis D has been identified as key risk factor in these injuries. An estimated 33% to 90% of collegiate and professional athletes have deficient vitamin D levels. Other branches of the United States military have evaluated the risk factors for stress fractures during basic training, including vitamin D deficiency. To the best of our knowledge, a study evaluating the correlation between these injuries and vitamin D deficiency in US Navy recruits and a cost analysis of these injuries has not been performed. Cutbacks in military medical staffing mean more active-duty personnel are being deferred for care to civilian providers. Consequently, data that previously were only pertinent to military medical providers have now expanded to the nonmilitary medical community. We therefore asked: (1) What proportion of US Navy recruits experience symptomatic lower extremity stress fractures, and what proportion of those recruits had hypovitaminosis vitamin D on laboratory testing? (2) What are the rehabilitation costs involved in the treatment of lower extremity stress fractures, including the associated costs of lost training time? (3) Is there a cost difference in the treatment of stress fractures between recruits with lower extremity stress fractures who have vitamin D deficiency and those without vitamin D deficiency? We retrospectively evaluated the electronic medical record at Naval Recruit Training Command in Great Lakes, IL, USA, of all active-duty males and females trained from 2009 until 2015. We used ICD-9 and ICD-10 diagnosis codes to identify those diagnosed with symptomatic lower extremity stress fractures. Data collected included geographic region of birth, preexisting vitamin D deficiency, vitamin D level at the time of diagnosis, medical history, BMI, age, sex, self-reported race or ethnicity, hospitalization days, days lost from training, and the number of physical therapy, primary care, and specialty visits. To ascertain the proportion of recruits who developed symptomatic stress fractures, we divided the number of recruits who were diagnosed with a stress fracture by the total number who trained over that span of time, which was 204,774 individuals. During the span of this study, 45% (494 of 1098) of recruits diagnosed with a symptomatic stress fracture were female and 55% (604 of 1098) were male, with a mean ± SD age of 24 ± 4 years. We defined hypovitaminosis D as a vitamin D level lower than 40 ng/mL. Levels less than 40 ng/mL were defined as low normal and levels less than 30 ng/mL as deficient. Vitamin D levels were obtained at the discretion of the individual treating provider without standardization of protocol. Cost was defined as physical therapy visits, primary care visits, orthopaedic visits, diagnostic imaging costs, laboratory costs, hospitalizations, if applicable, and days lost from training. Diagnostic studies and laboratory tests were incorporated as indirect costs into initial and follow-up physical therapy visits. Evaluation and management code fee schedules for initial visits and follow-up visits were used as direct costs. We obtained these data from the Centers for Medicare & Medicaid Services website. Per capita cost was calculated by taking the total cost and dividing it by the study population. Days lost from training is based on a standardized government military salary of recruits to include room and board. We found that 0.5% (1098 of 204,774) of recruits developed a symptomatic lower extremity stress fracture. Of the recruits who had vitamin D levels drawn at the time of stress fracture, 95% (416 of 437 [95% confidence interval (CI) 94% to 98%]; p > 0.99) had hypovitaminosis D (≤ 40 ng/mL) and 82% (360 of 437 [95% CI 79% to 86%]; p > 0.99) had deficient levels (≤ 30 ng/mL) on laboratory testing, when evaluated. The total treatment cost was USD 9506 per recruit. Days lost in training was a median of 56 days (4 to 108) for a per capita cost of USD 5447 per recruit. Recruits with deficient vitamin D levels (levels ≤ 30 ng/mL) incurred more physical therapy treatment costs than did those with low-normal vitamin D levels (levels 31 to 40 ng/mL) (mean difference USD 965 [95% CI 2 to 1928]; p = 0.049). The cost of lost training and rehabilitation associated with symptomatic lower extremity stress fractures represents a major financial burden. Screening for and treatment of vitamin D deficiencies before recruit training could offer a cost-effective solution to decreasing the stress fracture risk. Recognition and treatment of these deficiencies has a role beyond the military, as hypovitaminosis and stress fractures are common in collegiate or professional athletes. Level III, prognostic study.

The Effect of COVID-19 on the Mental Health of Military Connected Children and Adolescents.

With a growing body of literature describing the coronavirus disease 2019 (COVID-19) pandemic's effect on children and adolescents, there remain few official reports regarding mental health in military connected youth. With sparse literature available specifically in youth associated with the Armed Forces, published studies on global child and adolescent mental health during the COVID-19 pandemic are first reviewed. Military connected youth have unique needs and experiences. Implications of pandemic-related stressors on their mental health are suggested based on analysis of disaster and deployment literature. Military members have continued to move and deploy throughout the pandemic. Uniformed families have high risk factors for mental health concerns. Managing the mental health of military connected youth will fall heavily on civilian providers, both in primary and subspecialty practices. As such, vigilance for psychological health concerns and familiarity with military resources are vital for the mental wellness of our military pediatric patients. [Pediatr Ann. 2022;51(4):e138-e143.].

COVID-19 Impact on Delivery of Rehabilitation For Persons With Traumatic Brain Injury

Research ObjectivesTo describe how the COVID-19 pandemic influenced treatment practices for chronic pain in persons with traumatic brain injury (TBI) and facilitators and barriers to rehabilitation care.DesignA descriptive, qualitative study.SettingTraumatic brain injury model systems (TBIMS) civilian and Veterans facilities.ParticipantsThe secondary analysis included providers consisting of rehabilitation therapists (physical therapists, speech language pathologists, and occupational therapists), medical doctors, nurses, clinical and neuro psychologists, and resource managers (n=63) for persons with TBI and chronic pain.InterventionsN/A.Main Outcome MeasuresA semi-structured qualitative telephone interview consisted of 13 questions asking about treatment practices and facilitators and barriers to rehabilitation for people with TBI and chronic pain during the COVID-19 pandemic.ResultsThe COVID-19 pandemic impacted treatment practice across civilian and VA TBIMS facilities. Thematic analysis revealed that the main changes to treatment practices were switching to virtual visits, the impact of COVID-19 precautions such as social distancing and wearing masks had on providing treatment, and in some cases, treatment was halted. Facilitators to care included improved communication between providers and their patients, the increase in use of telehealth to provide care, and increased access to providers. Barriers to rehabilitation care identified by mainly civilian providers included COVID-19 visitor restrictions on family involvement, and the lack of access patients had to their providers during this time, specifically with cancelled appointments or wait lists. Both civilian and VA providers described how COVID-19 logistics for cleaning and social distance impacted scheduling and the number of patients who could be seen.ConclusionsThe global COVID-19 pandemic served as a major disruptor to provision of healthcare. The switch from mainly in person care to the use of telehealth to deliver care was a major transition for providers and patients. Future research on the impact of telehealth on patient outcomes and when to use telehealth versus in person is needed.Author(s) DisclosuresThis work is supported by the National Institute on Disability, Independent Living, and Rehabilitation Research (90DPTB0017 and 90DPTB0008) and General Dynamics Health Solutions (W91YTZ-13-C-0015; HT0014-19-C-0004).

Military and Civilian Sector Practice Patterns for Short-Term Travelers' Diarrhea Self-Treatment in Adults.

ABSTRACT.The Deployment and Travel Medicine Knowledge, Attitude, Practice and Outcomes Study investigates the various clinician and traveler contributions to medical outcomes within the U.S. Military Health System. Travelers’ diarrhea is among the most common travel-related illnesses, making travelers’ diarrhea self-treatment (TDST) important for traveler health. A cohort of 80,214 adult travelers receiving malaria chemoprophylaxis for less than 6 weeks of travel were identified within the U.S. Department of Defense Military Health System Data Repository. Associated prescriptions for TDST medications within 2 weeks of chemoprophylaxis prescriptions were identified. Prescription patterns were compared by service member versus beneficiary status and site of care, military facility versus civilian facility. At military facilities, medical provider demographics were analyzed by clinical specialty and categorized as travel medicine specialists versus nonspecialists. Overall, there was low prescribing of TDST, particularly among civilian providers and military nonspecialists, despite guidelines recommending self-treatment of moderate to severe travelers’ diarrhea. This practice gap was largest among service member travelers, but also existed for beneficiaries. Compared with nonspecialists, military travel medicine specialists were more likely to prescribe a combination of an antibiotic and antimotility agent to beneficiaries, more likely to provide any form of TDST to service members, and more likely to prescribe azithromycin than quinolones when using antibiotics. Our study suggests that enhancing provider knowledge and use of travelers’ diarrhea treatment recommendations combined with improved access to formal travel medicine services may be important to increase the quality of care.

Shared Decision-Making During Labor and Birth Among Low-Risk, Active Duty Women in the U.S. Military.

The cesarean birth rate of 24.7% in the Military Health System (MHS) is lower than the national rate of 31.7%. However, the MHS rate remains higher than the 15-19% threshold associated with optimal maternal and neonatal outcomes. For active duty servicewomen, increased morbidity associated with cesarean birth is likely to affect the ability to meet the demands of assigned missions. Several decision-points occur during pregnancy and after the onset of labor that can affect the likelihood of cesarean birth including choice of provider, choice of hospital, timing of admission, and type of fetal monitoring. Evidence suggests the overuse of labor interventions may be associated with cesarean birth. Shared decision-making (SDM) is a strategy that can be used to carefully consider the risks, benefits, and alternatives of each labor intervention and is shown to be associated with positive patient outcomes. Most existing evidence explores SDM as an interaction that occurs between women and their providers. Few studies have explored the role of stakeholders such as spouses, family members, friends, labor and delivery nurses, and doulas. Furthermore, little is known about the process of SDM during labor and childbirth in the hospital setting, particularly for active duty women in the U.S. military. The purpose of this study was to propose a framework that explains the process of SDM during labor and childbirth in the hospital setting for active duty women in the U.S. military. A qualitatively driven mixed-methods approach was conducted to propose a framework that explains the process of SDM during labor and childbirth in the hospital setting for active duty women in the U.S. military. Servicewomen were recruited from September 2019 to April 2020. Semi-structured interviews were analyzed using a constructivist grounded theory approach. Participants also completed the SDM Questionnaire (SDM-Q-9). Interviews were conducted with 14 participants. The sample included servicewomen from the Air Force (n = 7), Army (n = 4), and Navy (n = 3). Two participants were enlisted and the remainder were officers. Ten births occurred at military treatment facilities (MTFs) and four births took place at civilian facilities. The mean score on the SDM Questionnaire was 86.7 (±11.6), indicating a high level of SDM. Various stakeholders (e.g., providers, labor and delivery nurses, doulas, spouses, family members, and friends) were involved in SDM at different points during labor and birth. The four stages of SDM included gathering information, identifying preferences, discussing options, and making decisions. Events that most often involved SDM were deciding when to travel to the hospital, deciding when to be admitted, and selecting a strategy for pain management. Military factors involved in SDM included sources of information, selecting and working with civilian providers, and delaying labor interventions to allow time for an active duty spouse to travel to the hospital. SDM during labor and birth in the hospital setting is a multi-stage process that involves a variety of stakeholders, including the woman, members of her social and support network, and healthcare professionals. Future research is needed to explore perspectives of other stakeholders involved in SDM.

The impact of military sexual trauma on parent-infant bonding in a sample of perinatal women veterans.

BackgroundThe experience of sexual assault and harassment during military service (military sexual trauma [MST]) is associated with increased risk for perinatal and reproductive health problems among women veterans. The objective of this study was to examine the associations between mothers’ MST exposure and mother‐infant bonding, as well as to examine whether there are any salient sociodemographic or military service characteristics among women veterans with greater impairment to mother‐infant bonding, including stress during pregnancy and posttraumatic stress disorder (PTSD) diagnosis.MethodsThis study was a secondary analysis of data collected from prospective, longitudinal study of women veterans using VHA maternity care benefits at 15 VHA medical centers across the US between January 2016 and February 2020. Participants were 697 pregnant veterans using VHA maternity care benefits.ResultsMST was associated with higher maternal depression, and higher maternal depression was associated with poorer mother‐infant bonding. The effect of MST on bonding was indirect through depression. PTSD diagnosis and life stressors during pregnancy also had significant indirect pathways with bonding through maternal depression.ConclusionsResults underscore the need for access to high quality and trauma‐informed perinatal mental health treatment for women veterans, for education on the unique risks conveyed by MST provided to civilian providers treating this population outside VA, and for further research to understand how to ameliorate the harmful effects of MST on perinatal women veterans and their children.

Understanding Civilian Mental Health Providers' Knowledge in Providing Care for Active Duty Service Members: Opportunities for Improvement.

There are a growing number of civilian mental health providers who are treating active duty service members (ADSM) from referrals of local emergency rooms, directly from military installations, or when a military mental health program is unavailable. Civilian providers may be unprepared to address issues that are unique to this population. The purpose of this quality improvement project was to develop and implement a survey-based knowledge assessment, in order to assess civilian psychiatric advanced practice nurse's (APN) perceptions, knowledge, and practice of treating ADSMs. The investigator developed and validated a survey that was posted on the American Psychiatric Nurses Association All-Purpose Discussion Forum, and the snowball technique was utilized to enhance psychiatric APN colleague recruitment. Seventy-eight participants scored extremely low with average score of 40.4%; however, the psychiatric APNs who received formal training from the Department of Defense on unique mental health issues of ADSMs scored significantly higher (49.6%) than participants without the formal training (38.2%; p = .03). Understanding the knowledge gap of psychiatric APNs as it relates to the care of ADSMs will allow educators to recommend available trainings or develop trainings that are tailored to meet their needs.

Gender differences in barriers to mental healthcare for UK military veterans: a preliminary investigation

IntroductionLimited UK research focuses on female military veterans’ gender-related experiences and issues when accessing civilian mental healthcare support. This study sought to illuminate a preliminary understanding of any gender differences...

123 A Novel Way of Thinking About Blast Injury Classification

Abstract Introduction Blast injuries present unique challenges to civilian and military healthcare providers because of the complex and often severe nature of injuries spanning numerous anatomical regions, tissue types, and organ systems. Due to these factors, we devised a novel wound-focused classification system for implementation during triage and management of blast injuries to optimize outcomes and applied this system to patients treated at an ABA-certified burn center over 5 years. Methods A retrospective analysis of patients treated by an ABA-certified burn center for blast-related injuries from September 1, 2014 to October 31, 2019 was performed. Demographics, mechanism and distribution of injuries, interventions, and outcomes were evaluated. Injuries were classified using a wound-focused classification comprised of four zones: 1) areas closest to blast epicenter that had total or near-total tissue loss from the blast; 2) adjacent areas with thermal and chemical burns; 3) distant sites with shrapnel-related wounds; 4) injuries arising from barotrauma. Results We identified 64 patients who were mostly male (84%), averaging 38 ± 14 years old. Injury mechanisms included fireworks (19%), industrial accidents (16%), volatile fuels and drug labs (45%), and others including can, battery, lighter explosions (20%). All mechanisms had equivalent frequency of Zone 2 injuries with an average TBSA of 17 ± 18%. Drug-related blasts caused the highest TBSA (34 ± 23%) and the most full-thickness burns (33% vs average 23%). Fireworks had over five times (17% vs. 3%) more Zone 3 and three times (25% vs 8%) more Zone 4 injuries compared to the other mechanisms. Upper extremities were involved at twice the rate of other body regions (43% vs 19%). Patients presenting to our burn team over 24 hours after initial injury had infections in 50% of cases – a four-fold increase compared to non-delayed presentations (50% vs 13%). Overall, 45% required surgery (32% grafting, 3% flaps) but 100% of the drug-related blasts needed surgical intervention. Some patients (58%) required ICU admission with the highest rate (83%) in the drug-related group. Conclusions Blast injuries most often required admission for management of the Zone 2 component. Each blast mechanism resulted in distinct distributions of injury although fireworks had the greatest number of Zone 1, 3, and 4 injuries. Firework blasts were often less severe and more likely to present delayed with infectious complications. Larger blast mechanisms including drug-related lab explosions as well as industrial blasts had the highest rates of ICU admission, TBSA, full thickness depth, upper extremity involvement, and need for surgical intervention.

Screening for Military Service History and Risk for Suicide in a Civilian Internal Medicine Clinic

More than half of United States military veterans receive medical care outside the Veterans Health Administration. Civilian providers do not routinely screen for military service history or increased risk for suicide in veterans. This quality improvement project used the model for improvement to implement screening for military service history and suicide risk using the “VA/DoD Clinical Practice Guideline for the Assessment and Management of Patients at Risk for Suicide” in a civilian clinic. Four hundred ninety-three of 845 patients were evaluated; 13% (n = 64) were identified as veterans. Of the veterans identified, 73.4% (n = 47) required additional screening for suicide risk, and 7.7% (n = 3) were identified as at risk for suicide.

Building Community Capacity to Care for Military and Veteran Families: The Star Behavioral Health Providers Program

Service members, veterans, and their families frequently have difficulties finding trained behavioral health providers who have knowledge of military culture and issues specific to the military population. This paper documents the design, implementation, effectiveness, and proximal outcomes of the Star Behavioral Health Providers training program (SBHP). We created SBHP as a dissemination effort in response to elevated levels of mental health problems among community-dwelling military and veteran families (CDMVF), limitations in provider capacity in the Departments of Defense (DoD) and Veterans Affairs (VA), and uneven preparation of civilian providers to serve military and veteran families. The goals of the initiative were to: Improve the preparation of community-based professionals to work with CDMVF. Increase providers’ use of evidence-informed information and practices. Strengthen the behavioral health infrastructure for treating CDMVF. The program provides military-specific training to community-based behavioral health providers and provides a mechanism for those seeking such services to find trained providers. Evaluation data, though limited by the lack of comparison or control groups, provided correlational evidence consistent with each program goal.

Tommies, Food, and Drink: A Microhistory, 1914–18

This article uses a diary kept by a First World War soldier, Vince Schürhoff, to explore the British Army’s food culture. It examines his journey through seven food contexts, the evolution of his cooking and consumption, and interaction with French food culture. This microhistory of everyday life demonstrates the centrality of food in the men’s lives both emotionally and socially as well as physiologically. Additionally, it provides valuable insights into the relationships that formed around eating between the soldiers themselves and also with civilian providers. His rich account confirms the role of food as a key factor in the men’s expression of the sometimes-shocking differences between military and civilian worlds.

Service Impact on Veteran Health: Case Examples From Recent Eras

The impact and health outcomes of each war or era present differently in each veteran and are unpredictable in timing of presentation. Civilian providers may not be well versed in taking a military history, the unique approach recommended for interacting with veteran patients, and the specific health implications of each military era. This article describes the unique attributes of veteran clients. Two recent military eras are discussed, and their potential impact on health is presented using case examples. Resources for practice with patients who have served in the military are presented.