Department Of Defense Beneficiaries Research Articles

Epithelial ovarian cancer survival by race and ethnicity in an equal-access healthcare population

BackgroundPrevious studies in the general population observed that compared with non-Hispanic White women, Pacific Islander and Black women have higher age-adjusted mortality rates from epithelial ovarian cancer (EOC), while Asian American patients have lower mortality. We investigated whether race and ethnicity is associated with differences in EOC survival in a United States Military population where patients have equal access to healthcare.MethodsThis retrospective study included women diagnosed with EOC between 2001 and 2018 among Department of Defense beneficiaries. Hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated using Cox proportional hazards regression models adjusting for age and year of diagnosis, histology and stage.ResultsIn our study population of 1230 invasive EOC cases (558 non-Hispanic White, 74 non-Hispanic Black, 73 Asian, 30 Pacific Islander and 36 Hispanic cases), 63% of the women died (all-cause death) after a mean = 4.8 years (SD = 4.1) of follow-up following diagnosis. Compared with non-Hispanic White cases, Asian cases had better overall survival, HR = 0.76 (95% CI = 0.58–0.98), whereas there were no differences in survival for other racial and ethnic groups.ConclusionsThese findings highlight the need to investigate how differences in access to healthcare may influence observed racial and ethnic disparities for EOC.

National Trends in Cochlear Implantation Across the Department of the Defense: A Case for Inclusion as a General Otolaryngology Core Competency.

With ongoing national expansions in cochlear implantation (CI) candidacy criteria, more patients qualify for CI today than ever before. Among US veterans and military service members, the prevalence of qualifying degrees of hearing loss secondary to occupational noise exposure exceeds the general population. The primary aim of the current work was to evaluate CI trends across the military health system. Database review. Military and civilian practices. Department of Defense (DoD) beneficiaries who underwent CI. CI rates between 2010 and 2019. A total of 3,573 cochlear implant operations were performed among DoD beneficiaries from 2010 to 2019. A majority of patients (55%) were older than 64 years, with the next most commonly implanted age group being 0 to 4 years of age (14%). From 2010 to 2019, annual CI increased at a rate of 7.9% per year for all implantation over the study period ( r = 0.97, p < 0.0001); there was a statistically significant difference of this rate compared with tympanoplasty, which was used as a reference procedure (rate, -1.9%; p = 0.03). This trend was similar for beneficiaries implanted both in military (11.9% per year, r = 0.77, p = 0.009) and civilian facilities (7.7% per year, r = 0.96, p < 0.0001); there was no statistically significant difference between the annual growth rates of these groups ( p = 0.68). Although the number of devices implanted is rapidly increasing among DoD beneficiaries, reported national utilization rates remain low. This disparity likely exists in the general public, considering the aging demographic in the West and continual expansions in US Federal Drug Administration labeling. These data suggest that widespread expansion of the procedure to general otolaryngology practices will be required to meet current and future demands for CI. For this reason, CI should be considered for "key indicator" designation among residency training programs.

Psychedelic-Assisted Therapy in Military and Veterans Healthcare Systems: Clinical, Legal, and Implementation Considerations.

This review discusses the current and projected landscape of psychedelic-assisted therapy (PAT), with a focus on clinical, legal, and implementation considerations in Department of Defense (DoD) and Department of Veterans Affairs (VA) healthcare systems. 3,4-Methylenedioxymethamphetamine (MDMA)- and psilocybin-assisted therapy have shown promising outcomes in efficacy, safety, tolerability, and durability for PTSD and depression, respectively. MDMA-assisted therapy is already approved by the Food and Drug Administration (FDA) on an Expanded Access ("compassionate use") basis for PTSD, with full approval projected for 2024. Psilocybin-assisted therapy is projected to be FDA-approved for depression soon thereafter. Other psychedelics are in earlier stages of development. The VA is currently conducting PAT clinical trials. Although there are clear legal pathways for the VA and DoD to conduct PAT trials, a number of implementation barriers exist, such as the very high number of clinical hours necessary to treat each patient, resource requirements to support treatment infrastructure, military-specific considerations, and the high level of evidence necessary for PAT to be recommended in clinical practice guidelines. Ongoing considerations are whether and how PAT will be made available to VA and DoD beneficiaries, feasibility and cost-effectiveness, and ethical safeguards that must be implemented to prioritize access to PAT given the likelihood of extremely limited initial availability. However, with imminent FDA approval of PATs and considerable national interest in these treatments, DoD and VA policymakers must be prepared with clearly delineated policies and plans for how these healthcare systems will approach PAT.

Clustered cases of human adenovirus types 4, 7, and 14 infections in US Department of Defense Beneficiaries during the 2018–2019 season

Human adenoviruses (HAdV) are genetically diverse and can infect a number of tissues with severities varied from mild to fatal. HAdV types 3, 4, 7, 11, 14, 21, and 55 were associated with acute respiratory illnessesoutbreaks in the United States and in other countries. The risk of outbreaks can be effectively controlled by HAdV vaccination or mitigated by screening and preventive measures. During the influenza season 2018-2019, the DoD Global Respiratory Pathogen Surveillance Program (DoDGRS) received 24 300 respiratory specimens. HAdV samples that produced positive cytopathic effects in viral cultivation were subjected to next-generation sequencing for genome sequence assembly, genome typing, whole genome phylogeny, and sequence comparative analyses. A variety of HAdV types were identified in this study, including HAdV types 1-7, 14, 55, and 56. HAdV types 4, 7, and 14 were found in clustered cases in Colorado, Florida, New York, and South Carolina. Comparative sequence analyses of these isolates revealed the emergence of novel genetic mutations despite the stability of adenovirus genomes. Genomic surveillance of HAdV suggested possible undetected outbreaks and shed light on prevalence, genetic divergence, and viral evolution of HAdV. Continued surveillance will inform risk assessment and countermeasures.

Acupuncture for Plantar Fasciopathy: A Randomized Controlled Trial

Objective: Plantar fasciopathy has a lifetime prevalence of 10% in the general population and can have a significant impact on quality of life. This research was conducted determine if a quick and simple acupuncture technique + a home-exercise program would reduce pain and improve function more than a home-exercise program alone. Materials and Methods: A randomized controlled trial was conducted at 2 U.S. Air Force military treatment facilities. Department of Defense beneficiaries ≥18 years' old with PF were recruited; 94 subjects were randomized to home exercise only (control) or home exercise + acupuncture (intervention). The intervention group had a acupuncture every 2 weeks for 4 treatments. There was no blinding. Patients initially in the control group were allowed to cross over to acupuncture after the initial 12-week study. Primary outcomes were pain reduction and improved functioning. Scores were obtained at baseline, each visit, and 6 weeks post-treatment. Results: The control group had a 21% reduction in pain scores (p < 0.05) at the study's end. The intervention group had a >50% reduction in pain score immediately after acupuncture during the visits (p < 0.05) and a 37% reduction at the study's end (p < 0.01). Subjects who crossed over to acupuncture had a >50% reduction of pain score acutely and a 30% reduction at 12 weeks post-acupuncture (p < 0.05). Function scores improved but were not statistically different (p = 0.535). Conclusions: A simple acupuncture technique acutely reduced pain by >50% in plantar fasciopathy and, when combined with a home-exercise program, achieved greater sustained clinically significant reduction in pain at 12 weeks than a home-exercise program alone.

2197. Genomic Surveillance for Human Adenovirus Infections among Department of Defense Beneficiaries in the 2018-2019 Season

Abstract Background Human adenoviruses (family Adenoviridae, genus Mastadenovirus) (HAdV) species B, C and E cause acute respiratory illnesses (ARI). In particular, respiratory HAdV types 3, 4, 7, 11, 14, 21 and 55 were associated with ARI outbreaks in the US and in other countries. The risk of outbreaks can be effectively controlled by implementation of the live HAdV types 4 and 7 vaccines or mitigated by screening and preventive measures. Methods During the influenza season 2018 – 2019, the DoD Global Respiratory Pathogen Surveillance Program (DoDGRS) received 24,300 specimens from its surveillance network. In total, 322 (1.3%) respiratory specimens were positive for HAdV in molecular assays. HAdV samples that produced positive cytopathic effects (CPE) in subsequent viral cultivation were subjected to next-gen sequencing (NGS) for genome sequence assembly, HAdV genome typing, whole genome phylogeny, and sequence comparative analyses to identify sequence insertions, deletions and amino acid mutations. Results Out of 166 viral culture samples available for NGS, whole genome sequences were obtained for 161 isolates. A variety types of HAdV were identified, including HAdV-1 (N = 15), HAdV-2 (N = 26), HAdV-3 (N = 60), HAdV-4 (N = 13), HAdV-5 (N = 6), HAdV-6 (N = 3), HAdV-7 (N = 12), HAdV-14 (N = 10), HAdV-55 (N = 1), and HAdV-56 (N = 1). HAdV types 4, 7 and 14, which were reported causing ARI outbreaks in the US military and other congregate settings, were found in clustered cases in several US states. Comparative sequence analyses of these isolates revealed the emergence of novel genetic mutations despite the stability of adenovirus genomes. Conclusion Routine clinical respiratory pathogen diagnostics or molecular surveillance of respiratory diseases detect adenovirus without determination of HAdV type. Human adenoviruses are genetically diverse and can infect a number of tissues with severities varied from mild to fatal. Enhanced genomic surveillance of HAdV in the US and worldwide will shed light on prevalence, genetic divergence, and viral evolution of human adenoviruses and inform timely risk assessment and countermeasures. Disclosures All Authors: No reported disclosures.

2204. Pathogen Co-infections and Trends in Influenza-like Illness in PAIVED

Abstract Background The Pragmatic Assessment of Influenza Vaccine Effectiveness in the Department of Defense (DoD) (PAIVED) is a multicenter, multiservice study assessing influenza vaccine effectiveness in active-duty service members, retirees, and dependents. In its fourth season (2021/22), PAIVED offers a unique opportunity to examine influenza-like illness (ILI) trends prior to and during the COVID-19 pandemic in a prospectively followed, well-defined cohort. Methods Over the past 4 influenza seasons, PAIVED has enrolled DoD beneficiaries who were randomized to receive egg-based, cell-based, or recombinant-derived influenza vaccine. Participants provided some basic demographic information and were then sent a weekly text or email that inquired about ILI symptoms, defined as 1) having cough or sore throat, plus 2) feeling feverish/having chills or having body aches/fatigue. Participants with ILI completed a daily symptom diary for one week and submitted a nasal swab for PCR-based pathogen detection. Table 1.Demographic characteristics of PAIVED participants over four seasonsFigure 1.Percent of PAIVED participants with influenza-like illness, SARS-CoV-2, influenza, and rhinovirus identified in swab samples collected over four seasons. Results Over the 4 seasons, 15,449 participants were followed for ILI (Table 1) with 3,407 participants reporting a total of 3,985 ILIs. For the 2021/22 season, ILI reports peaked in January (Figure 1). Overall, 4.7% of episodes had more than one pathogen identified (Table 2). Among the 122 coinfections identified to date, most were coinfections with rhinoviruses (91/122, 75%), including rhinovirus coinfections with seasonal coronaviruses (29, 24%), metapneumovirus (18, 15%), SARS-CoV-2 (17, 14%), and influenza (14, 11%). SARS-CoV-2 and influenza were found together in one sample. The lab data will continue to be processed for the current season (2021/22). Table 2.Pathogens identified in PAIVED nasal swabs over four seasons Conclusion ILI rates were lowest during the third year (2020/21), consistent with national influenza surveillance reports of influenza and outpatient ILI activity, suggesting that measures taken to reduce transmission of SARS-CoV-2 reduced the spread of other respiratory viruses. The emergence of the SARS-CoV-2 omicron variant in December 2021 was associated with higher ILI rates. Among those individuals for whom a sample was collected, coinfections were highest in 2018/19. Data collection and specimen analysis are ongoing for 2021/22. Disclosures Jitendrakumar Modi, MD, GlaxoSmithKline: I am a paid speaker for GSK. I do not speak for their flu brand. Timothy Burgess, MD, MPH, AstraZeneca: The HJF, in support of the USU IDCRP, was funded to conduct or augment unrelated Phase III Mab and vaccine trials as part of US Govt. COVID19 response.

The Case Against Stapedectomy as a Core Competency for General Practice: A Study of Care Patterns in the Department of Defense.

Stapedectomy remains a key indicator case reportable to the Accreditation Council of Graduate Medical Education despite the decline in the incidence of otosclerosis over the last half century. This study compared the rates of stapedectomy performed by otolaryngologists at academic and nonacademic centers. Retrospective review. Tertiary referral academic centers, nonacademic centers, and civilian purchased-care across the Department of Defense between 2015 and 2020. Department of Defense beneficiaries with otosclerosis near a military treatment facility with an otolaryngologist. Stapedectomy (Current Procedural Terminology codes 69,660, 69,661, and 69,662). Number of stapedectomies performed by setting. From 2015 to 2020, 426 stapedectomies were performed at or near a military treatment facility with an otolaryngologist (274 directly by military otolaryngologists, 152 by community providers). Military providers performed 94% of stapedectomies at or near military academic centers, versus only 30% at or near nonacademic centers ( p < 0.0001). Among the 60 stapedectomies performed at nonacademic centers, only 30 were performed by general otolaryngologists (7% of all stapedectomies performed; 11% of procedures by military providers) while the rest were performed by fellowship-trained otologist or neurotologist. Low stapes surgical volume by military general otolaryngologists reinforces recent epidemiologic trends and suggests that few general otolaryngologists graduate residency with sufficient competency to pursue independently performing stapedectomy or have difficulty maintaining competency after graduation.

Abstract PO-229: Racial/ethnic differences in tumor characteristics among endometrial cancer patients in an equal-access healthcare population

Abstract Introduction: Endometrial cancer is the most prevalent gynecologic malignancy. Compared with White women, endometrial cancer incidence is 30% lower in Black women yet mortality is 80% higher. In retrospective review of young women, [MM1] Black women (&amp;lt;50 years old) presented with more advanced clinical stage and more aggressive histologic subtypes. Multivariable analysis adjusting for these factors showed that risk of mortality[MM2] is 19% higher in Black women than their White counterparts. Native Hawaiian/Pacific Islander race has also been associated with worse survival when compared to their White counterparts. In this retrospective review of endometrial cancer patients treated within the Military Health System we assessed whether there were racial/ethnic disparities in tumor characteristics [MM3] in a system that provides equal access to healthcare and treatment. Methods: The study population included women diagnosed with endometrial cancer among US Department of Defense beneficiaries reported in the Automated Central Tumor Registry (ACTUR) database between 2001-2018. We evaluate differences in tumor characteristics by self-reported racial/ethnic group using the Chi-square test or Fisher test for small sample sizes (a two tailed P&amp;lt;0.05 was considered statistically significant). Results: After excluding women who had non-invasive tumors, non-epithelial histology and those who were not represented in the five major racial/ethnic groups for this study, the study population included 2574 women diagnosed with invasive endometrial cancer (including 1729 Non-Hispanic White[ZA4], 318 Asian, 286 Black, 140 Pacific Islander and 101 Hispanic White women). We observed differences in histology, stage and grade by racial/ethnic group (P&amp;lt;0.001). Specifically, comparing age-standardized endometrial tumor characteristics by racial/ethnic groups we observed that Black women had a lower proportion of endometrioid histology (56%) as compared with other racial/ethnic groups (≥70.6% endometrioid). Black, Hispanic and Pacific Islander women had a higher proportion of distant stage and poorly differentiated (grade 3-4) disease (≥8.9% distant stage; ≥30.5% poorly differentiated) versus (≤5.7% distant stage; ≤23.8% poorly differentiated) in White and Asian women. Conclusions: Endometrial cancer is common and population-wide screening is not recommended which makes it a good case-study for the value of access to care when patients identify concerning symptoms (bleeding, spotting). In our analysis of endometrial cancer cases in an equal-access healthcare environment, there appear to be racial/ethnic disparities among Black, Hispanic and Pacific Islander women. Our review affirms prior data showing more aggressive histology, grade and stage at diagnosis. Further studies will focus on whether these patterns persist among women with endometrioid histology tumors. The views expressed in this abstract are those of the author and do not reflect the official policy of the Department of Army/Navy/Air Force, Department of Defense, or U.S. Government. Citation Format: Daniel Desmond, Zhaohui Arter, Jeffrey Berenberg, Melissa Merritt. Racial/ethnic differences in tumor characteristics among endometrial cancer patients in an equal-access healthcare population [abstract]. In: Proceedings of the AACR Virtual Conference: 14th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2021 Oct 6-8. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr PO-229.

Inactivated influenza vaccine effectiveness among department of defense beneficiaries aged 6 months-17 years, 2016-2017 through 2019-2020 influenza seasons.

A test-negative case-control study was conducted to assess inactivated influenza vaccine effectiveness (VE) in children aged 6 months-17 years. The database was developed from the US Department of Defense Global Respiratory Pathogen Surveillance Program over four consecutive influenza seasons from 2016 to 2020. A total of 9,385 children including 4,063 medically attended, laboratory-confirmed influenza-positive cases were identified for VE analysis. A generalized linear mixed model with logit link and binomial distribution was used to estimate the VE. The adjusted VE for children was 42% [95% confidence interval (CI): 37–47%] overall, including 55% (95% CI: 47–61%) for influenza A(H1N1)pdm09, 37% (95% CI: 28–45%) for influenza A(H3N2), and 49% (95% CI: 41–55%) for influenza B. The analysis by age groups indicated that the adjusted VE in children aged 6 months-4 years was higher against influenza A(H1N1)pdm09 and influenza B, and comparable against influenza A(H3N2), compared to those in children aged 5–17 years. Further age-stratified analysis showed that the VE against any types of influenza was low and non-significant for children aged 6–11 months (33%; 95% CI:-2-56%), but it was high (54%; 95% CI: 34–67%) in children aged 12–23 months, and then declined linearly with increasing age. In conclusion, the inactivated influenza vaccination was moderately effective against influenza infection, based on the analysis from a large number of children aged 6 months-17 years over multiple influenza seasons.

Epithelial ovarian cancer survival by race/ethnicity in an equal-access healthcare population.

e18525 Background: Previous studies in the general population have observed that compared with Non-Hispanic White (NHW) women, Pacific Islander (PI) and Non-Hispanic Black (NHB) women have higher age-adjusted mortality rates from epithelial ovarian cancer (EOC), while Asian Americans (AS) have lower mortality. It is unknown whether these patterns reflect biological differences, environmental exposure or perhaps access to care. Our objective was to investigate whether self-reported race/ethnicity is associated with differences in EOC survival in a Military population where patients have equal access to healthcare. Methods: The study population included women diagnosed with EOC (ovarian, fallopian tube and primary peritoneal cancers) among US Department of Defense beneficiaries reported in the Automated Central Tumor Registry Database (year of diagnosis range: 2001-18). Hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated using Cox proportional hazards regression models following participants from their date of diagnosis until last contact or censoring, whichever occurred first. Multivariable models were adjusted for covariates selected a priori because of their known influence on risk of EOC death; age at diagnosis (continuous), histology, stage and receipt of the first course of chemotherapy treatment. We adjusted for year of diagnosis (continuous) to account for possible changes in treatment over time. Results: The study population included 1151 patients diagnosed with EOC: 796 NHW, 111 NHB, 130 AS, 49 PI and 65 Hispanic (HS). All EOC patients had complete information on age at diagnosis, stage and chemotherapy treatment. During a median (interquartile range) follow-up of 3.5 years (1.8-6.7), 702 EOC patients (61%) died of all causes. When comparing crude EOC patient characteristics by racial/ethnic group, NHW had the highest frequency of EOC leading to death (58% vs. &lt; 49% in other groups). There also were differences in histology; NHW and NHB had a higher frequency of serous tumors ( &gt; 56% of EOCs vs. &lt; 52% in other groups); PI had a high proportion of endometrioid histology (14% of EOCs vs. &lt; 11% in others); 10% of EOCs among AS had clear cell histology (vs. &lt; 9% in others). HS had a high percentage of local disease (23% vs. &lt; 20% in others). In multivariable survival analysis adjusting for clinical factors, we observed that compared with NHW, there were no differences in EOC survival by race/ethnicity: AS, HR = 0.80 (95% CI = 0.61-1.05); NHB, HR = 0.96 (95% CI = 0.72-1.28); PI, HR = 0.92 (95% CI = 0.58-1.46); and HS, HR = 0.82 (95% CI = 0.56-1.21). Conclusions: We observed no racial/ethnic disparities in EOC survival in a Military equal access treatment environment. These results highlight the importance of studying how differences in access to healthcare may impact observed racial/ethnic disparities for EOC.

207. Travel Related Risk Behaviors and Antibiotic Use among Older Travelers

BackgroundOlder travelers (≥ 60 years) are a unique risk population for travel related infections and adverse events from antibiotics. We evaluated the differences in travel characteristics, exposures, illnesses and antibiotic use among older travelers and those between 18 – 59 y using a prospective, observational cohort of US Department of Defense (DoD) beneficiaries traveling outside the US for ≤ 6.5 months (TravMil).MethodsAdult DoD beneficiaries were enrolled pre-travel. Itineraries limited to Western/Northern Europe, Canada, or New Zealand and active duty personnel on military travel were excluded. Demographics, itineraries and prescriptions were abstracted. A post-travel survey collected information on exposures and illnesses (travelers’ diarrhea (TD), influenza-like illness (ILI) or febrile illness). Categorical variables were analyzed using chi-square or Fishers exact test and the Mann-U Whitney test was used for continuous variables.ResultsOf the 1468 travelers, 755 were ≥ 60y and 719 were < 60y. Asia (35%) and South/Central America (28%) were the most common travel regions. Older travelers were more likely to be Caucasian (80% vs. 67%), male (52% vs. 39%) and travel for tourism (84% vs. 51%) (p< 0.05). Younger travelers were more likely engage in risk behaviors (e.g. consume poorly cooked meat or seafood (16% vs 9%) or street vendor food (26% vs 8.6%), wade in fresh water (24% vs. 18%), and non-compliance with malaria prophylaxis (22% vs 12%) (p< 0.05). Older travelers had a lower incidence of TD (18% vs 24%), and a higher proportion of cases with loose stool or mild TD that did not interfere with daily activities (63% vs. 51%) (p< 0.05). Inappropriate antibiotic use for loose stool or mild TD were similar among the two age groups (67% vs 59%). Non-significant trends of lower incidence and mild infections were observed for ILI and febrile illness in older travelers.ConclusionOlder travelers were less likely to engage in risk behaviors, had a lower TD incidence and reported mild diarrheal symptoms. Inappropriate antibiotic use for loose stool or mild TD was common in both age groups. Enhancing antibiotic stewardship is important for older travelers to prevent potential side effects, drug interactions and antibiotic resistance.Disclosures All Authors: No reported disclosures

1500. At Risk Drinking Is Common Among HIV-Infected Department of Defense (DoD) Beneficiaries But Was Not Associated with Prevalent GC/CT Infections

BackgroundAt-risk drinking and sexually transmitted infections (STIs) are both common among HIV-infected patients. Nearly 50% of subjects in the US Military Natural History Study (NHS), a cohort of HIV-infected DoD beneficiaries, report alcohol misuse. Nonetheless, few studies have examined whether at-risk drinking, a modifiable risk factor, is associated with STIs in this population. We examined the relationship between alcohol use and prevalent gonorrhea (GC) and chlamydia (CT) infections.MethodsConsented NHS subjects underwent genitourinary (GU) and extragenital nucleic acid amplification testing (NAAT) for GC/CT infections and responded to a behavioral survey to describe substance use and sexual risk. At-risk drinking was defined as consumption of >4 drinks/day or 14 drinks/week. Logistic regression was used to examine the association of at risk drinking and GC/CT infections.ResultsA total of 472 men were included with a median age of 41 years (IQR 31, 51); 44% were African American. Male sexual partners were reported by 90%. At-risk drinking (54%) and having sex while drunk in the last 6 months (21%) was commonly reported. Overall, 15% (n = 70) had either GC or CT infection. With respect to anatomic site, 11% had anorectal infections (GC = 4%; CT = 7%), 5.3% had pharyngeal infection (GC 3.8%; CT −1.4%) and, 2.3% had GU infection (GC 0.6%; CT 1.7%). In univariate analysis, younger age, multiple male sexual partners, having sex while drunk, and concurrent partnership were associated with STI diagnosis. In the adjusted model, multiple male partners and concurrent sex remained significant (see table).ConclusionAt-risk drinking remains common in the NHS; however, it was not associated with GC/CT infections. We observed a high prevalence of GC/CT infection, emphasizing the importance of ongoing screening of this high-risk population. Although strategies to reduce alcohol use are unlikely to reduce STIs in our population, these strategies are necessary to reduce other adverse health consequences associated with alcohol use.CharacteristicsOdds Ratio (95% CI)Age per 10-year increase0.81(0.64,1.02)Male sex partner (last 3 months)NoneRef1–44.1 (1.2–13.6)>55.5 (1.5–21.1)Concurrent sex (last 3 months)NoRefYes2.03 (1.04–3.96)Disclosures All authors: No reported disclosures.

Assisted Reproductive Technology and the Reproductive Endocrinology and Infertility Specialist in the U.S. Military.

The U.S. military mirrors the U.S. population given the diverse ethnic and cultural backgrounds of the service members. Active-duty military members, veterans, and Department of Defense beneficiaries can be negatively impacted by infertility.

Contemporary Factors Associated with the Use of Laparoscopy for Inguinal Hernia Repair Among Department of Defense Beneficiaries.

The factors that contribute to variation in utilization of laparoscopic inguinal hernia repair are unknown. We sought to determine the current usage patterns of laparoscopic and open surgery in the elective repair of uncomplicated unilateral inguinal hernia in a large population with universal health care coverage comprised of Department of Defense (DoD) beneficiaries. The DoD Military Health System Data Repository (MDR) tracks health care delivered to a universally insured population of active/reserve/retired members of the U.S. Armed Services and their dependents. The MDR was queried for elective unilateral inguinal hernia repair among adult patients between 2008 and 2014. The primary outcome was laparoscopic (vs. open) approach to hernia repair. We conducted univariable and multivariable analyses of patient- and systems-level factors associated with approach to inguinal hernia repair. This research was approved by our institutional review board prior to commencement of the study and need for informed consent was waived given the design of this study. Among 37,742 elective uncomplicated unilateral inguinal hernia repairs, 35% (n = 13,114) were performed laparoscopically. In 2014, 40% of inguinal hernia repairs were performed laparoscopically, compared with 27% of repairs in 2008 (P < 0.01). In multivariable analysis, laparoscopic hernia repair was more likely for male patients (OR = 1.38, 95% CI = 1.23-1.54, P < 0.01), military (vs. civilian) institutions (OR = 1.34, 95% CI = 1.28-1.41, P < 0.01), active-duty officers (vs. active-duty enlisted; OR = 1.21, 95% CI = 1.12-1.30, P < 0.01), and more recent year of surgery (P < 0.01). Laparoscopic repair was significantly less likely among patients with greater than one comorbidity (vs. none; OR = 0.68, 95% CI = 0.61-0.76, P < 0.01). In a large, universally insured population of military service members and their dependents, laparoscopic inguinal repair is increasingly used and was preferred over open repair for younger, healthier, active-duty patients and those treated within the military (vs. non-military) care system.

Breast Cancer Treatment and Survival Among Department of Defense Beneficiaries: An Analysis by Benefit Type and Care Source.

Use of treatment for breast cancer is dependent on the patient's cancer characteristics and willingness to undergo treatment and provider treatment recommendations. Receipt of breast cancer treatment varies by insurance status and type. It is not clear whether different benefit types and care sources differ in breast cancer treatment and outcomes among Department of Defense beneficiaries. The objectives of this study are to assess whether receipt of breast cancer treatment varied by benefit type (TRICARE Prime vs non-Prime) or care source (direct care, purchased care, and both) and to examine whether survival and recurrence differed by benefit type and/or care source among female Department of Defense beneficiaries with the disease. Study subjects were women aged 40-64 yr, diagnosed with malignant breast cancer between 2003 and 2007. Multivariable logistic regression analyses were conducted to assess the likelihood of receiving treatment by benefit type or care source. Multivariable Cox proportional hazard models were used to investigate differences in survival and recurrence by benefit type or care source. A total of 2,668 women were included in this study. Those with Prime were more likely to have chemotherapy, radiation, hormone therapy, breast-conserving surgery, surveillance mammography, and recurrence than women with non-Prime. Survival was high, with 94.86% of those with Prime and 92.58% with non-Prime alive at the end of the study period. Women aged 50-59 yr with non-Prime benefit type had better survival than women with Prime of the same age. No survival differences were seen by care source. In regard to recurrence, women aged 60-64 yr with TRICARE Prime were more likely to have recurrent breast cancer than women with non-Prime. Additionally, women aged 50-59 yr who used purchased care were less likely to have a recurrence than women who used direct care only. To our knowledge, this is the first study to examine breast cancer treatment and survival by care source and benefit type in the Military Health System. In this equal access health care system, no differences in treatment, except mastectomy, by benefit type, were observed. There were no overall differences in survival, although patients with non-Prime tended to have better survival in the age group of 50-59 yr. In regard to care source, women who utilized mostly purchased care or utilized both direct and purchased care were more likely to receive certain types of treatment, such as chemotherapy and radiation, as compared with women who used direct care only. However, survival did not differ between different care sources. Future research is warranted to further investigate variations in breast cancer treatment and its survival gains by benefit type and care source among Department of Defense beneficiaries.

Patient Attitudes Regarding ART and Insurance Coverage in the Military Health Care System

Objective: Assisted reproductive technology is an established infertility treatment which is not routinely covered by most health insurance programs including the health insurance program for the United States Department of Defense (DOD); TRICARE. The purpose of this study is to examine patient opinions regarding assisted reproductive services and insurance coverage in the military health care system. Methods: An anonymous, randomly distributed cross-sectional survey of patients presenting for care at five different outpatient clinics was completed at Madigan Army Medical Center from February to May 2015. The surveys queried patients on insurance coverage for in-vitro fertilization. In addition, demographic data was obtained for each respondent. Chi-square, Student’s t-test, and logistic regression were used for statistical analysis. A P value of 0.05 was considered significant. Results: 598 surveys were distributed with 527 completed and returned (88%). 59% of respondents believe that TRICARE should cover some portion of advanced reproductive treatments, and 69% of respondents would support coverage even if there were an increased personal cost associated with providing this coverage regardless of whether they had a personal need for this service. In addition, more respondents from the infertility clinic (75%) supported TRICARE coverage of advanced reproductive technology to those from other clinics (55%). Respondents under age 40 (72%) supported TRICARE insurance coverage of advanced reproductive technology compared to those (44.7% of respondents) aged 41 or greater. Conclusion: Among DOD beneficiaries surveyed, a majority support insurance benefits for advanced reproductive technologies.

Retrospective Analysis of the Post-Operative Changes in Higher-Order Aberrations: A Comparison of the WaveLight EX500 to the VISX S4 Laser in Refractive Surgery.

In an attempt to maximize treatment outcomes, refractive surgery techniques are being directed toward customized ablations to correct not only lower-order aberrations but also higher-order aberrations specific to the individual eye. Measurement of the entirety of ocular aberrations is the most definitive means to establish the true effect of refractive surgery on image quality and visual performance. Whether or not there is a statistically significant difference in induced higher-order corneal aberrations between the VISX Star S4 (Abbott Medical Optics, Santa Ana, California) and the WaveLight EX500 (Alcon, Fort Worth, Texas) lasers was examined. A retrospective analysis was performed to investigate the difference in root-mean-square (RMS) value of the higher-order corneal aberrations postoperatively between two currently available laser platforms, the VISX Star S4 and the WaveLight EX500 lasers. The RMS is a compilation of higher-order corneal aberrations. Data from 240 total eyes of active duty military or Department of Defense beneficiaries who completed photorefractive keratectomy (PRK) or laser in situ keratomileusis (LASIK) refractive surgery at the Wilford Hall Ambulatory Surgical Center Joint Warfighter Refractive Surgery Center were examined. Using SPSS statistics software (IBM Corp., Armonk, New York), the mean changes in RMS values between the two lasers and refractive surgery procedures were determined. A Student t test was performed to compare the RMS of the higher-order aberrations of the subjects' corneas from the lasers being studied. A regression analysis was performed to adjust for preoperative spherical equivalent. The study and a waiver of informed consent have been approved by the Clinical Research Division of the 59th Medical Wing Institutional Review Board (Protocol Number: 20150093H). The mean change in RMS value for PRK using the VISX laser was 0.00122, with a standard deviation of 0.02583. The mean change in RMS value for PRK using the WaveLight EX500 laser was 0.004323, with a standard deviation of 0.02916. The mean change in RMS value for LASIK using the VISX laser was 0.00841, with a standard deviation of 0.03011. The mean change in RMS value for LASIK using the WaveLight EX500 laser was 0.0174, with a standard deviation of 0.02417. When comparing the two lasers for PRK and LASIK procedures, the p values were 0.431 and 0.295, respectively. The results of this study suggest no statistically significant difference concerning induced higher-order aberrations between the two laser platforms for either LASIK or PRK. Overall, the VISX laser did have consistently lower induced higher-order aberrations postoperatively, but this did not reach statistical significance. It is likely the statistical significance of this study was hindered by the power, given the relatively small sample size. Additional limitations of the study include its design, being a retrospective analysis, and the generalizability of the study, as the Department of Defense population may be significantly different from the typical refractive surgery population in terms of overall health and preoperative refractive error. Further investigation of visual outcomes between the two laser platforms should be investigated before determining superiority in terms of visual image and quality postoperatively.

Comparison of Clinical Features in a Population of Basic Military Trainees Versus the General Department of Defense Beneficiary Population Presenting With Influenza.

Upper respiratory tract infection (URI) is a well-documented cause of morbidity, extra expense, and lost training time among basic military trainees (BMTs). The goal of this study was to characterize the clinical presentation of influenza in the BMT population and to better understand how this presentation differs from that of the general Department of Defense (DoD) beneficiary population (non-BMTs). Clinical and demographic data were collected in a prospective study that enrolled DoD beneficiaries presenting to medical treatment facilities in San Antonio, Texas, with URI symptoms between January 2005 and March 2011. Vital signs and symptom duration were collected at the time of enrollment along with basic demographic information. Among 4,448 participants enrolled, 466 (10.5%) tested positive for influenza: 198 of 3,103 BMTs (6.4%) vs. 268 of 1,345 non-BMTs (20%) (p < 0.01); 412 of 466 had complete data for nine symptom-related variables. BMTs were more likely to be Caucasian males and younger than non-BMTs. BMTs had a higher temperature at the time of presentation (101.5°F vs. 100.5°F, p < 0.01). BMTs presented less frequently than non-BMTs with chills (79.7% vs. 94.4%, p < 0.01), malaise (62.1% vs. 87.0%, p < 0.01), nausea (30.2% vs. 43.0%, p < 0.01), and vomiting (12.1% vs. 21.7%, p = 0.01). Multiple logistic regression analysis showed that BMTs were less likely to have the four symptoms compared to non-BMTs even after controlling for gender and age (chills: odds ratio [OR] = 0.3, 95% confidence interval [CI] = 0.1-0.6, p < 0.01; malaise: OR = 0.5, 95% CI = 0.3-0.8, p < 0.01; nausea: OR = 0.5, 95% CI = 0.3-0.8, p < 0.01; vomiting: OR = 0.4, 95% CI = 0.2-0.8, p < 0.01). Although there was no difference in the frequency of subjective fever between the two groups, reported duration of fever was significantly shorter in BMTs than non-BMTs: median of 1 day (range 0-10) vs. 2 days (range 0-8) (p < 0.01). BMTs presented with a composite symptom index mean of 6.2 (standard deviation = 1.4) symptoms, whereas non-BMTs presented with a mean of 6.9 (standard deviation = 1.3) symptoms (p < 0.01). The pretest probability of a BMT presenting with URI symptoms having influenza is significantly lower than that for the general DoD beneficiary population. BMTs with influenza presented sooner, with higher fever, and with fewer overall symptoms than the general DoD beneficiary population. These differences are likely attributable to early reporting and response bias and less likely attributed to age. Military efforts to identify BMTs with suspected influenza infection early and to refer them for treatment promptly are efficacious.

Benefit Type and Care Source in Relation to Mammography Screening and Breast Cancer Stage at Diagnosis Among DoD Beneficiaries.

Type of insurance and out-of-pocket costs influence the use of medical care. Specifically, type of insurance can impact an individual's likelihood of receiving a screening mammogram. Additionally, variation in tumor stage at diagnosis exists for patients with different types of insurance. It is not clear whether different benefit types and care sources differ in breast cancer care and outcomes among Department of Defense (DoD) beneficiaries. The objective of this study was to examine differences in screening mammography and tumor stage at diagnosis between different benefit types (TRICARE Prime vs. non-Prime) and among different care sources (direct care, purchased care, and both) in the DoD Military Health System. Study subjects were women 40 to 64 years of age, diagnosed with malignant breast cancer between 2003 and 2007. Multivariable logistic regression analyses were conducted to assess differences by benefit type and care source in receipt of screening mammography before diagnosis and tumor stage at diagnosis. A total of 2,668 women were included in this study. Patients with Prime were more likely to receive a screening mammography and have an earlier tumor stage than those with non-Prime. Women with direct care were more likely to have an earlier tumor stage but less likely to receive a screening mammogram than those with purchased care. In an equal access health care system, the use of mammography screening and tumor stage at diagnosis may differ by benefit type and care source among DoD beneficiaries. To our knowledge, this was the first study to assess mammography screening and tumor stage differences by benefit type and care source in the Military Health System. Although underlying reasons for the differences are not clear, they may be related to out-of-pocket costs, distance from medical treatment facilities, and frequency of doctor visits for other medical problems. Further research is needed to assess these differences and related factors among DoD beneficiaries.