Military Health System Data Repository Research Articles

Does Trauma Heighten the Risk of Hematologic Malignancies? a Retrospective Study of U.S. Combat Veterans

Introduction: Multiple case reports have described lymphomas and plasma cell neoplasms developing after trauma 1-4. It has been hypothesized that trauma-induced inflammation may contribute to the neoplasia, and that the site of trauma may serve as the nidus (locus minoris resistentiae) 1, 5. However, to our knowledge there are no studies demonstrating causality. Traumatic injuries sustained during combat have been linked with higher rates of hypertension, coronary artery disease, diabetes mellitus and chronic kidney disease 6. Whether severe injury also increases the risk of hematologic malignancies is unknown. We hypothesized that combat injured veterans have higher rates of lymphoma and plasma cell dyscrasias than un-injured combat veterans. Methods: This was a retrospective cohort study of US military personnel injured during combat operations in Iraq or Afghanistan from 2002-2015 extracted from the Department of Defense (DoD) Trauma Registry. Patients were excluded if they died in theater, had multiple battle injuries, had pre-existing cancer diagnoses or missing data. A comparator arm of deployed and un-injured Iraq and Afghanistan combat veterans was obtained from the Military Health System Data Repository (MDR) matched for year of birth, branch of service, and sex. Cancer diagnoses were defined using International Classification of Diseases, Ninth Revision (ICD-9) and Tenth Revision (ICD-10) Clinical Modification codes obtained from both the DoD and the Veterans Health Administration through the MDR and the Veterans Informatics and Computing Infrastructure, respectively. Malignancy classifications by ICD codes are demonstrated in Table 1 and broken down into aggressive B-cell lymphomas, indolent B-cell lymphomas, Hodgkin lymphoma, T-cell lymphomas and plasma cell dyscrasias. Statistical analyses were performed with the chi-square test and fisher's exact test. This study was approved by the IRB at David Grant USAF Medical Center. Results: There were 9,654 subjects each in the injured and un-injured cohorts. Baseline demographics are demonstrated in Table 2. The mean age was 26 and most patients were junior enlisted, members of the Army, males, and of non-Hispanic white ethnicity/race. The average post-trauma follow-up time was 5.3 years. Overall rates of aggressive B-cell lymphomas, indolent B-cell lymphomas, Hodgkin lymphoma, T-cell lymphomas and plasma cell dyscrasias were low, as demonstrated in Table 3, and there were no statistically significant differences in incidence rates between the two cohorts. Discussion: Traumatic injuries can activate innate immune responses involving inflammatory cytokines, complement, coagulation and dendritic cells, resulting in a pro-inflammatory state 7. Preclinical studies reveal that such inflammation may hamper T-cell immune-surveillance needed to eradicate malignancy 8. However, in our cohort of severely injured combat veterans, rates of lymphomas and plasma cell dyscrasias were not increased over un-injured combat veterans. Strengths of this study include a well-characterized cohort with a matched comparator arm enabling vigorous examination of the impacts of traumatic injuries on cancer. Limitations include retrospective design and relatively short follow up. It is possible that differences will emerge with longer follow up. Conclusions: Despite critical combat trauma injuries being associated with a heightened risk of multiple chronic comorbidities, they do not appear to heighten the risk of lymphoid or plasma cell neoplasms within the first 5-years. The opinions and assertions expressed herein are those of the authors and do not necessarily reflect the official policy or position of the U.S. Air Force, David Grant USAF Medical Center, the Uniformed Services University or the Department of Defense.

Comparison of Military Health System Data Repository and American College of Surgeons National Surgical Quality Improvement Program-Pediatric

BackgroundGiven the rarity of pediatric surgical disease, it is important to consider available large-scale data resources as a means to better study and understand relevant disease-processes and their treatments. The Military Health System Data Repository (MDR) includes claims-based information for > 3 million pediatric patients who are dependents of members and retirees of the United States Armed Services, but has not been externally validated. We hypothesized that demographics and selected outcome metrics would be similar between MDR and the previously validated American College of Surgeons National Surgical Quality Improvement Program-Pediatric (NSQIP-P) for several common pediatric surgical operations.MethodsWe selected five commonly performed pediatric surgical operations: appendectomy, pyeloplasty, pyloromyotomy, spinal arthrodesis for scoliosis, and facial reconstruction for cleft palate. Among children who underwent these operations, we compared demographics (age, sex, and race) and clinical outcomes (length of hospital stay [LOS] and mortality) in the MDR and NSQIP-P, including all available overlapping years (2012–2014).ResultsAge, sex, and race were generally similar between the NSQIP-P and MDR. Specifically, these demographics were generally similar between the resources for appendectomy (NSQIP-P, n = 20,602 vs. MDR, n = 4363; median age 11 vs. 12 years; female 40% vs. 41%; white 75% vs. 84%), pyeloplasty (NSQIP-P, n = 786 vs. MDR, n = 112; median age 0.9 vs. 2 years; female 28% vs. 28%; white 71% vs. 80%), pyloromyotomy, (NSQIP-P, n = 3827 vs. MDR, n = 227; median age 34 vs. < 1 year, female 17% vs. 16%; white 76% vs. 89%), scoliosis surgery (NSQIP-P, n = 5743 vs. MDR, n = 95; median age 14.2 vs. 14 years; female 75% vs. 67%; white 72% vs. 75%), and cleft lip/palate repair (NSQIP-P, n = 6202 vs. MDR, n = 749; median age, 1 vs. 1 year; female 42% vs. 45%; white 69% vs. 84%). Length of stay and 30-day mortality were similar between resources. LOS and 30-day mortality were also similar between datasets.ConclusionFor the selected common pediatric surgical operations, patients included in the MDR were comparable to those included in the validated NSQIP-P. The MDR may comprise a valuable clinical outcomes research resource, especially for studying infrequent diseases with follow-up beyond the 30-day peri-operative period.

Mental Health Disorders and Hyperthyroidism in the Pediatric Population.

* Abbreviation: ADHD — : attention-deficit/hyperactivity disorder Hyperthyroidism (particularly Graves’ disease) affects people of all ages, with symptomatology including restlessness and inability to focus, anxiety, weight loss, tachycardia, heat intolerance, diaphoresis, and diarrhea. The conventional wisdom is that symptoms resolve once the hyperthyroidism is adequately treated. However, authors of some reports suggest that with respect to mental health, this may not be the case. In this issue, Zader et al1 investigate this question and conclude that children with hyperthyroidism have a higher prevalence of attention-deficit/hyperactivity disorder (ADHD), adjustment disorder, anxiety, bipolar disorder, depression, and suicidality. The authors used the Military Health System Data Repository to identify children aged 10 to 18 years in the military system for ≥1 month who had International Classification of Diseases, Ninth Revision or International Classification of Diseases, 10th Revision codes for hyperthyroidism and the aforementioned mental health conditions. The Military Health System Data Repository included >2.5 million children, with a total of nearly 2500 children with hyperthyroidism during a 9-year interval. Compared with children without hyperthyroidism, the prevalence ratios of mental health conditions in those with hyperthyroidism ranged from … Address correspondence to Rebecca Schneider Aguirre, MD, PhD, Division of Pediatric Endocrinology, Riley Hospital for Children, 705 Riley Hospital Dr, Room 5960, Indianapolis, IN 46202. E-mail: rsaguirr{at}iupui.edu

Does Disordered Sleep Moderate the Relationship Between Pain, Disability and Downstream Health Care Utilization in Patients With Low Back Pain?: A Longitudinal Cohort From the US Military Health System.

Prospective cohort. The purpose of this study was to evaluate the influence of disordered sleep on the relationship between pain and health care utilization (HCU) and pain-related disability and HCU in individuals with low back pain (LBP). Disordered sleep and pain influence LBP outcomes, but their relationship with health care seeking after an episode of LBP has not been investigated and could help identify who is at risk for long-term medical care. This study included patients with LBP participating in a self-management class at a large US military hospital between March 1, 2010 and December 4, 2012. Pain intensity, disability (Oswestry Disability Index), and sleepiness (Epworth Sleepiness Scale) were captured at baseline. Medical visits for a sleep disorder in the 12 months before the class and LBP-related healthcare utilization for the 12 months following the class were abstracted from the Military Health System Data Repository. Separate multivariate analyses evaluating pain intensity and disability as predictors of HCU were developed, with sleepiness and the presence of a sleep disorder as potential moderators. Analyses were adjusted for age, sex, history of back pain, and mental health comorbidities. A total of 757 consecutive participants were included, with 195 (26.8%) diagnosed with a subsequent sleep disorder. Sleepiness was not a significant predictor of HCU. The main effects of disability, pain intensity, and presence of a sleep disorder were significant across all analyses, with higher disability, pain intensity, and presence of a sleep disorder associated with higher predicted visits and costs for LBP. The presence of a sleep disorder was not a significant moderator in any model. Higher pain intensity and disability predicted higher pain-related HCU in the year following a LBP self-management class. The presence of a sleep disorder diagnosis, as recorded in medical records, had a significant independent effect on LBP-related health care visits and costs beyond the influences of pain intensity, disability, and other key demographic and health-related characteristics, but did not moderate these relationships. 3.

Mental Health Conditions and Hyperthyroidism.

To evaluate the proportion of pediatric patients with concurrent diagnoses of hyperthyroidism and mental health conditions (MHCs) by using the Military Health System database. We hypothesized that the prevalence of mental health disorders would be higher in patients with hyperthyroidism compared with in the nonhyperthyroid population. The prevalence of hyperthyroidism and MHCs was calculated by using data extracted from the Military Health System Data Repository on military beneficiaries between 10 and 18 years old who were eligible to receive care for at least 1 month during fiscal years 2008 through 2016. Prevalence ratios were used to compare MHC diagnoses in those with versus without a diagnosis of hyperthyroidism. There were 1894 female patients and 585 male patients diagnosed with hyperthyroidism during the study period. Prevalence ratios for MHCs in those with versus without hyperthyroidism ranged from 1.7 (attention-deficit/hyperactivity disorder [ADHD]) to 4.9 (bipolar disorder). Strikingly, suicidality was nearly 5 times more likely in patients diagnosed with hyperthyroidism than in patients who were never diagnosed with hyperthyroidism. For each of the MHCs examined, with the exception of suicidality, the MHC diagnosis was more commonly made before the diagnosis of hyperthyroidism, with the highest proportion of patients being diagnosed with ADHD before receiving a diagnosis of hyperthyroidism (68.3%). There is a clear association between hyperthyroidism and each of the following MHCs: ADHD, adjustment disorder, anxiety, bipolar disorder, depression, and suicidality. This study highlights the need to consider this association when evaluating patients with overlapping symptoms and for effective mental health screening tools and resources for clinicians.

Utility of catastrophizing, body symptom diagram score and history of opioid use to predict future health care utilization after a primary care visit for musculoskeletal pain.

Self-report information about pain and pain beliefs are often collected during initial consultation for musculoskeletal pain. These data may provide utility beyond the initial encounter, helping provide further insight into prognosis and long-term interactions of the patient with the health system. The aim of this study was to determine if pain catastrophizing and pain-related body symptoms can predict future health care utilization. This was a longitudinal cohort study. Baseline data were collected after receiving initial care for a musculoskeletal disorder in a multidisciplinary clinic within a large military hospital. Subjects completed the Pain Catastrophizing Scale, a region-specific disability measure, numeric pain rating scale and a body symptom diagram. Health care utilization data for 1 year prior and after the visit were extracted from the Military Health System Data Repository. Multivariable regression models appropriate for skewed and count data were developed to predict (i) musculoskeletal-specific medical visits, (ii) 12-month opioid use, (iii) musculoskeletal-specific medical costs and (iv) total medical costs. We investigated whether a pain catastrophizing × body symptom diagram interaction improved prediction, and developed separate models for opioid-naïve individuals and those with a history of opioid use in an exploratory analysis. Pain catastrophizing but not body symptom diagram was a significant predictor of musculoskeletal visits, musculoskeletal costs and total medical costs. Exploratory analyses suggest these relationships are most robust for patients with a history of opioid use. Pain catastrophizing can identify risk of high health care utilization and costs, even after controlling for common clinical variables. Addressing pain catastrophizing in the primary care setting may help to mitigate future health care utilization and costs, while improving clinical outcomes. These results provide direction for future validation studies in larger and more traditional primary care settings.

The two-year incidence of hip osteoarthritis after arthroscopic hip surgery for femoroacetabular impingement syndrome

BackgroundOne of the reported goals of hip preservation surgery is to prevent or delay the onset of osteoarthritis. This includes arthroscopic surgery to manage Femoroacetabular Impingement (FAI) Syndrome. The purpose of this study was to describe the prevalence of clinically-diagnosed hip OA within 2 years after hip arthroscopy for FAI syndrome, and 2) determine which variables predict a clinical diagnosis of OA after arthroscopy.MethodsObservational analysis of patients undergoing hip arthroscopy between 2004 and 2013, utilizing the Military Health System Data Repository. Individuals with prior cases of osteoarthritis were excluded. Presence of osteoarthritis was based on diagnostic codes rendered by a medical provider in patient medical records. Adjusted odds ratios (95% CI) for an osteoarthritis diagnosis were reported for relevant clinical and demographic variables.ResultsOf 1870 participants in this young cohort (mean age 32.2 years), 21.9% (N = 409) had a postoperative clinical diagnosis of hip osteoarthritis within 2 years. The 3 significant predictors in the final model were older age (OR = 1.04; 95%CI = 1.02, 1.05), male sex (OR = 1.31; 95%CI = 1.04, 1.65), and having undergone an additional hip surgery (OR = 2.33; 95% CI = 1.72, 3.16). Military status and post-surgical complications were not risk factors.ConclusionA clinical diagnosis of hip osteoarthritis was found in approximately 22% of young patients undergoing hip arthroscopy in as little as 2 years. These rates may differ when using alternate criteria to define OA, such as radiographs, and likely underestimate the prevalence. A more comprehensive approach, considering various criteria to detect OA will likely be necessary to accurately identify the true rates. Females were at lower risk, while increasing age and multiple surgeries increased the risk for an OA diagnosis. OA onset still occurs after “hip preservation” surgery in a substantial number of individuals within 2 years. This should be considered when estimating rates of disease prevention after surgery. Prospective trials with sound methodology are needed to determine accurate rates and robust predictors of osteoarthritis onset after hip preservation surgery.

Postpartum Opioid Use Among Military Health System Beneficiaries: Lessons for the Nation [19R

INTRODUCTION: The opioid epidemic in the US has been given much attention in recent years. The most common source of prescription opioids, among people who misuse them, is through family or friends, implicating that healthcare providers are likely overprescribing. METHODS: We evaluated postpartum opioid prescriptions at discharge among patients insured by TRICARE using the Military Health System Data Repository. The primary outcome compared the prevalence of opioid prescription at discharge for postpartum patients within civilian purchased care and direct military treatment facilities. Secondary outcomes investigated mode of delivery and demographics for those receiving opioid prescriptions. We included women age 15-49 years old insured by TRICARE between 2010-2015 with a pregnancy-related postpartum discharge diagnosis. We excluded abortive pregnancy outcomes and incomplete data sets. We extracted data using ICD-9 and CPT codes, and performed logistic regression using SAS 9.4. RESULTS: Postpartum patients receiving civilian purchased care were more likely to be discharged with an opioid prescription compared to direct care (OR 3.9, 95% CI 3.8-3.99). Asian race was least likely to receive an opioid prescription postpartum (OR 0.79, 95% CI 0.75-0.83). Age 15-19 had a lower odds of opioid prescription at discharge. CONCLUSION: Our data indicates that women who are cared for in civilian facilities were more likely to be prescribed an opioid at time of discharge when compared to military facilities. Factors such as race and age were also associated with opioid prescribing practices. OB/GYNs may be overprescribing opioids postpartum, and this study highlights areas for improvement.

Arthroscopy for Management of Femoroacetabular Impingement Syndrome in the Military Health System: A 10-Year Epidemiological Overview of Cases with 2-year Follow-up

With the rapid rise in arthroscopy rates for the management of Femoroacetabular Impingement (FAI) Syndrome, it is important to understand current surgical rates and the impact of these surgeries within the Military Health System (MHS). The purpose of this study was to provide an epidemiological descriptive summary of hip arthroscopy for FAI Syndrome in the MHS and describe perioperative healthcare utilization variables. Eligible beneficiaries ages 18-50, undergoing hip arthroscopy with 2-year follow-up after surgery were included. Healthcare utilization data were abstracted from the MHS Data Repository (MDR) from June 2003 to July 2015, and included all visits, costs, procedures, and prescriptions taking place in both military and civilian hospitals worldwide. 1870 patients were included (mean age 32.2 years; 55.5% male). 51.7% of the procedures took place in military versus 48.3% in civilian hospitals. Mean hip-related healthcare costs in the 2-year following surgery were $15,434 per patient. Patients had a median of 3 opioid prescriptions and 72% had a comorbidity present after surgery. Generally, rates of surgery grew annually from 66 cases in 2004 to 422 cases in 2013. Overall complication rates were comparable to other published reports. Procedures in both military and civilian hospitals had the same rates of femoroplasty and labral repairs, however acetabuloplasty procedures occurred at a higher rate in military (18.9%) vs civilian (14.7%) hospitals. Only 58.8% of patients had physical therapy in the year prior to surgery, while 82.7% had it after surgery. Additionally, 50% of patients had received opioid prescriptions in the 1 year prior to surgery, while 38.9% had 3 or greater opioid prescriptions beyond the initial perioperative fill within the 2-year follow-up. Rates of arthroscopy have grown in the MHS over the last decade. Complication rates are similar to those reported in other populations and settings. Utilization of physical therapy was much more likely after surgery than prior to it. Opioid use was high prior to surgery and many individuals continued to receive opioid prescriptions beyond the initial perioperative period.

Association Between Dietary Supplement Use and ICD-9-CM Code Classification in Active Duty US Navy and Marine Corps Service Members.

This study is the first to our knowledge to examine associations of survey-reported dietary supplement use with medical record diagnoses, rather than retrospective self-reported supplement use at the time of the medical encounter or case reports of adverse events. Dietary supplement (DS) use and adverse events associations in US Navy and Marine Corps personnel remains unknown. This study assessed associations of DS use in active duty (AD) personnel with ICD-9-CM diagnostic codes from outpatient medical encounters from the Military Health System Data Repository (MDR). This cross-sectional investigation used a one-time survey of DS use among AD conducted August through December 2014. Survey data were matched to MDR data accessed in September 2016, and associations between the survey responses and diagnoses were analyzed. Statistical significance was set at alpha level 0.005, and 99.5% confidence intervals (CIs) were calculated. MDR data were matched with survey results for 1,708 personnel. Multivariable logistic regression analyses examined whether use of specific classes of supplements was associated with disease. Results revealed significant associations between vitamin supplement use and ICD-9-CM-diagnosed diseases of the nervous system (odds ratio [OR]: 1.72, 99.5% CI: 1.11-2.68) and diseases of the musculoskeletal system and connective tissue (OR: 1.59, 99.5% CI: 1.17-2.17). Joint health supplement category use was associated with diseases of the musculoskeletal system and connective tissue (OR: 1.81, 99.5% CI: 1.12-2.94) and injury and poisoning (OR: 1.82, 99.5% CI: 1.10-3.04). The percentages of service members with diseases in specific ICD-9-CM diagnostic categories were similar to those reported in other studies using military medical data. There is a greater prevalence of dietary supplement use by the service members who participated in this survey compared with the general population, with 73% of US Navy and Marine Corps personnel reporting use of dietary supplements one or more times per week compared to the estimated 50% of all Americans currently using some form of dietary supplement. The DoD ensures the optimal readiness, performance, and health of its military service members, thus future longitudinal evaluation of dietary supplement use by this population will test the preliminary findings of this study.

New ACC/AHA Blood Pressure Guidelines and the Operational Readiness of Naval Aviators and Aircrew.

INTRODUCTION: Hypertension, also known as high blood pressure, is the "silent killer" and may lead to more severe conditions if left unmanaged. Hypertension in service members of the U.S. military has the potential to negatively impact readiness. The aim of this study was to assess the potential impact to readiness of active duty Naval aviators and aircrew under the new 2017 ACC/AHA blood pressure guidelines.METHODS: This cross-sectional study used the Military Health System Data Repository for 2015. The population included all active duty Naval aviators and aircrew. The absolute number and proportion of those with hypertension were compared based on previous Joint National Committee 7 and 2017 ACC/AHA guidelines. Impact to readiness was calculated based on lost work days and the number of individuals with hypertension that fit the criteria to be medically grounded according to the U.S Naval Aeromedical Reference and Waiver Guide.RESULTS: Hypertension diagnoses will increase by 2904 individuals (599%) in the 23,492 Naval aviators and aircrew included in the population. Impact to readiness will result in an estimate of 510 lost work days.CONCLUSION: The 2017 ACC/AHA hypertension guidelines will lead to a dramatic increase in hypertension diagnoses in this population. Depending on the U.S. Navy disposition on hypertension, the impact can be minor or substantial, but the early opportunity for care made available with the 2017 ACC/AHA guidelines may provide long-term benefits of a healthy fighting force worth the immediate impact to readiness.Johnson MC, Banaag AL, Condie KJ, Servies TE, Pérez Koehlmoos TL. New ACC/AHA blood pressure guidelines and the operational readiness of Naval aviators and aircrew. Aerosp Med Hum Perform. 2019; 90(4):409-414.

Testosterone replacement therapy is associated with an increased risk of urolithiasis.

To determine whether TRT in men with hypogonadism is associated with an increased risk of urolithiasis. We conducted a population-based matched cohort study utilizing data sourced from the Military Health System Data Repository (a large military-based database that includes beneficiaries of the TRICARE program). This included men aged 40-64years with no prior history of urolithiasis who received continuous TRT for a diagnosis of hypogonadism between 2006 and 2014. Eligible individuals were matched using both demographics and comorbidities to TRICARE enrollees who did not receive TRT. The primary outcome was 2-year absolute risk of a stone-related event, comparing men on TRT to non-TRT controls. There were 26,586 pairs in our cohort. Four hundred and eighty-two stone-related events were observed at 2years in the non-TRT group versus 659 in the TRT group. Log-rank comparisons showed this to be a statistically significant difference in events between the two groups (p < 0.0001). This difference was observed for topical (p < 0.0001) and injection (p = 0.004) therapy-type subgroups, though not for pellet (p = 0.27). There was no significant difference in stone episodes based on secondary polycythemia diagnosis, which was used as an indirect indicator of higher on-treatment testosterone levels (p = 0.14). We observed an increase in 2-year absolute risk of stone events among those on TRT compared to those who did not undergo this hormonal therapy. These findings merit further investigation into the pathophysiologic basis of our observation and consideration by clinicians when determining the risks and benefits of placing patients on TRT.

Prenatal use of medications for gastroesophageal reflux disease and early childhood fracture risk.

Gastroesophageal reflux disease is a common condition in pregnancy and is often managed with medications. Specific medications have been linked to osteoporosis and fragility fracture in older adults. This study assessed whether maternal use of antireflux medications is associated with early childhood fracture. TRICARE beneficiaries during pregnancy were retrospectively identified using the Military Health System Data Repository and pharmacy data. Mother and infant data were linked; children with continuous enrollment for the first 5years of life were included. Differences in the children's fracture risk were analyzed through multivariate analysis, adjusting for region, rank, and military branch of service. A total of 378150 patients comprised the final cohort with 3.3% (n=12479) prescribed antireflux medications during pregnancy. A significant decrease in fracture rate was found among children of women who were prescribed antireflux medications during pregnancy compared with those who were not (0.8% vs 1.2%, RR=0.70, 95% CI 0.58-0.85). There was no difference in fracture risk between histamine type 2 receptor antagonists and proton pump inhibitors. A significantly increased fracture incidence was seen in pregnancies with multiple gestations (RR=1.38, 95% CI 1.04-1.85). There was no identified difference in fracture risk for women with gestational diabetes, preeclampsia, preterm or low birthweight, chronic hypertension, induction, or breech presentation when compared to women without these conditions. We found no increase in early childhood fracture risk with maternal antireflux medication use. This suggests that prenatal exposure to antireflux medications does not affect fetal bones to a clinically significant extent.

Section 718 (Telemedicine): Virtual Health Outcomes From Regional Health Command Europe.

Section 718 of the Fiscal Year 2017 (FY17) National Defense Authorization Act (NDAA) outlines many reportable telemedicine outcomes. While the Military Health System Data Repository (MDR) and the Management and Reporting Tool M2 provide some telemedicine analyses, there are many outcomes that neither the MDR nor M2 provide. Understanding patient and provider attitudes towards telehealth and specialty-specific usage may assist initial or ongoing telehealth lines of effort within Defense Health Agency Medical Treatment Facilities (DHA MTFs). A retrospective descriptive analysis of synchronous virtual health (VH) encounters and results from three internally developed telehealth surveys for calendar year (CY) 2016 was conducted. Three thousand seven hundred and seventy-eight synchronous VH visits for 2,962 unique patients were completed by 142 providers located within 27 distinct specialty clinics. 89.8% of patients were adults and 75.9% were Active Duty. Skill type I and II medical providers conducted 1,827 new consultations, 1,187 follow-up visits, and 371 readiness exams. Overall, specialty-specific VH use ranged from less than 1% to 39.9%. Patient satisfaction was 98% while provider satisfaction ranged from 91% to 93%. Additionally, significant intangible savings were recognized. Regional medical centers conducting synchronous VH will require both internal and external data sources to report Section 718 outcomes required by Congress. As the anticipated demand for direct provider-to-patient telehealth increases, understanding these outcomes may aid initial and ongoing efforts in other military treatment facilities conducting synchronous VH.

Incidence and Characteristics of Humeral Shaft Fractures After Subpectoral Biceps Tenodesis.

Background:Biceps tenodesis is a procedure that can address biceps and labral pathology. While there is an increased risk of humeral fracture after biceps tenodesis, it has been described only in case reports.Purpose:To identify the incidence, demographics, and characteristics of humeral shaft fractures after biceps tenodesis.Study Design:Case series; Level of evidence, 4.Methods:The US Military Health System Data Repository was searched for patients with a Current Procedural Terminology code for biceps tenodesis between January 2013 and December 2016. The cohort of identified patients was then searched for those assigned a code for humeral fracture per the International Classification of Diseases, 9th Revision and 10th Revision. The electronic health records and radiographs of patients who were diagnosed with a humeral fracture were then evaluated to confirm that the fracture was related to the biceps tenodesis. Records were then reviewed for patient demographics, radiographs, operative reports, and clinical notes.Results:A total of 15,085 biceps tenodeses were performed between January 2013 and December 2016. There were 11 postoperative and 1 intraoperative humeral fractures. The incidence of fracture was <0.1%. All fractures were extra-articular spiral fractures that propagated through the tenodesis site. Eight patients were treated with functional bracing, 3 with open reduction and internal fixation, and 1 with a soft tissue biceps tenodesis revision. Of 8 patients successfully treated nonoperatively, 6 regained full range of shoulder motion. Only 2 of the 4 patients who required operative treatment regained full range of shoulder motion.Conclusion:Humeral shaft fracture after biceps tenodesis is a rare complication that occurs in 7.9 out of 10,000 cases. Fractures occurred after various methods of fixation, including suture anchor, cortical button, and interference screw. Most patients were initially treated nonoperatively, and those who healed usually achieved full range of motion; however, those who required operative intervention often had restricted range of motion on final follow-up. Future studies should determine risk factors for fracture after biceps tenodesis.

Body Mass Index Effect on Health Service Utilization Among Active Duty Male United States Army Soldiers.

Obesity and overweight, defined as body mass index (BMI) of 30.0 and above or 25.0-29.9, respectively, are of significant concern to the military population, due to their associated comorbidities and potential for impaired readiness. In 2016, the US Army reported a prevalence of 17.3% obesity and 52.9% overweight among soldiers, despite both physical demands of the job and Department of Defense (DoD) guidelines which recommend separation from service for those unable to meet body composition standards. This study examines the health service utilization of active duty, male Army soldiers in order to determine the prevalence of obesity and overweight and to estimate the effects of these conditions on readiness. This was a cross-sectional study utilizing fiscal year (FY) 2015 TRICARE claims and military treatment facility (MTF) encounter data obtained from the Military Health System Data Repository (MDR), for 467,732 US Army male Soldiers on active duty. We obtained basic demographic information (age, race, and rank) from the Defense Enrollment Eligibility Reporting System (DEERS). Next, we calculated BMI for this cohort by matching patients to their vital statistics of height and weight measurements. Finally, we obtained their health service utilization by querying and matching patients to their healthcare claims in 2015 by major diagnostic category. More than half (51.2%) of subjects had overweight, 28.9% had normal weight, 19.7% had obesity, and less than 1% had underweight. Soldiers with overweight and obesity were most common among the 25-34 years age range and enlisted ranks. Normal weight and underweight soldiers had a median of 7 healthcare visits in FY 2015, compared with 8 for soldiers with overweight and 12 for those with obesity. Soldiers with obesity, but not overweight, had a disproportionately greater number of healthcare encounters for diagnostic categories including musculoskeletal; mental health; ear, nose, and throat; and endocrine system. In contrast, soldiers with obesity had disproportionately fewer healthcare encounters for multiple significant trauma and for infectious and parasitic diseases. More than 70% of soldiers had overweight or obesity in FY 2015, showing the highest prevalence yet measured for these conditions. Previous reports of lower prevalence may be due to the inclusion of circumference-based body fat assessments, which have been criticized for inaccuracy. In our study, disproportionately high health service use by soldiers with obesity suggests decreased readiness, as these soldiers may experience both poorer health and lose necessary training time due to increased provider visits. Proportional usage by soldiers with overweight suggests the protective effect of regular physical activity, though these soldiers should be monitored to ensure that they do not progress to obesity. Additional research should establish the burden of cost, absenteeism, and presenteeism of obesity on the MHS, as well as developing more appropriate field tests for body fat assessment and BMI standards to better support military readiness.

Abstract P5-13-13: Non-clinical drivers of variation in preoperative MRI utilization for breast cancer

Abstract Background: Preoperative MRI utilization in breast cancer treatment has increased significantly over the past two decades but its use continues to have inter-provider variability and disputed clinical indications. The objective of this study was to evaluate non-clinical factors associated with preoperative breast MRI utilization. Methods: This study utilized claims from the Military Health System Data Repository (MDR) on TRICARE Prime beneficiaries, from fiscal years 2006-2015. TRICARE provides health benefits for Active Duty service members, retirees, and their dependents at both military (direct care with salaried physicians) and civilian (purchased care with fee-for-service physicians) treatment facilities. We studied patients aged 25-64 years old with a breast cancer diagnosis who had undergone mammogram/breast ultrasound alone or with subsequent breast MRI prior to surgery. Patient demographics and treatment characteristics were abstracted from the data. The National Center for Health Statistics (NCHS) urban-rural classification was used to determine the urbanization level of the treatment facility. Adjusted multivariate logistic regression tests were used to identify independent factors associated with preoperative breast MRI utilization. Results: Of the 25,656 identified patients, 64.4% of patients (n=16,511) received preoperative mammogram/breast ultrasound alone while 35.6% of patients (n=9,145) underwent additional MRI after mammographic and/or ultrasound imaging. On multivariable analysis, younger age, presence of two or more comorbidities, active duty or retired beneficiary category, officer rank (surrogate for socioeconomic status), Air Force service branch, metropolitan location, and purchased care were associated with increased likelihood of preoperative MRI utilization. Nonmetropolitan location and Navy service branch were associated with decreased MRI use. Odds Ratio95% Confidence IntervalAge Group (Ref: 55-64 years)25-34 years1.851.60-2.15 35-44 years1.591.47-1.72 45-54 years1.271.19-1.35Charlson Comorbidity Index (Ref 0-1)2+2.472.33-2.61Beneficiary Category (Ref: Dependent)Active Duty1.201.04-1.38 Retired1.231.09-1.40Rank (Ref: Senior Enlisted)Junior Enlisted0.930.78-1.11 Junior Officer1.251.14-1.37 Senior Officer1.481.36-1.60 Warrant Officer1.231.06-1.42Service Branch (Ref: Army)Air Force1.101.03-1.18 Navy0.920.85-0.99 Marines0.950.84-1.07 Coast Guard1.070.89-1.29Urban-Rural Classification (Ref: Medium Metropolitan)Large Central Metropolitan1.801.68-1.93 Large Fringe Metropolitan1.591.47-1.71 Small Metropolitan0.650.59-0.71 Micropolitan0.400.34-0.46 Noncore0.250.18-0.34Treatment Facility Care Setting (Ref: Direct Care)Purchased Care1.601.48-1.73 Conclusions: After controlling for expected clinical risk factors, patients were more likely to receive additional MRI when treated at larger metropolitan facilities or through the purchased, fee-for-service system. Both associations may point toward non-clinical incentives to perform MRI in the treatment of breast cancer. Citation Format: Pak LM, Banaag A, Koehlmoos TP, Haider AH, Learn PA. Non-clinical drivers of variation in preoperative MRI utilization for breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-13-13.

Estimating seasonal onsets and peaks of bronchiolitis with spatially and temporally uncertain data.

RSV bronchiolitis (an acute lower respiratory tract viral infection in infants) is the most common cause of infant hospitalizations in the United States (US). The only preventive intervention currently available is monthly injections of immunoprophylaxis. However, this treatment is expensive and needs to be administered simultaneously with seasonal bronchiolitis cycles in order to be effective. To increase our understanding of bronchiolitis timing, this research focuses on identifying seasonal bronchiolitis cycles (start times, peaks, and declinations) throughout the continental US using data on infant bronchiolitis cases from the US Military Health System Data Repository. Because this data involved highly personal information, the bronchiolitis dates in the dataset were "jittered" in the sense that the recorded dates were randomized within a time window of the true date. Hence, we develop a statistical change point model that estimates spatially varying seasonal bronchiolitis cycles while accounting for the purposefully introduced jittering in the data. Additionally, by including temperature and humidity data as regressors, we identify a relationship between bronchiolitis seasonality and climate. We found that, in general, bronchiolitis seasons begin earlier and are longer in the southeastern states compared to the western states with peak times lasting approximately 1 month nationwide.

Differences in Characteristics and Downstream Drug Use Among Opioid-Naïve and Prior Opioid Users with Low Back Pain.

Recent clinical practice guidelines have suggested conservative treatment approaches, including physical therapy, are indicated as first-line treatment for patients with low back pain (LBP); however, LBP continues to be managed with opioids, despite decreases in function, morbidity, and insignificant improvements in pain. The primary purpose was to compare characteristics and downstream medication use between patients with LBP with prior opioid exposure vs. those who were opioid-naïve. The secondary purpose was to explore the role of prior opioid use by LBP disability. Seven hundred and nine participants in a LBP self-management class were evaluated utilizing self-report data at baseline and longitudinal claims data from the Military Health System Data Repository. Participants were dichotomized into opioid-naïve and prior opioid use groups and then further divided into low and high disability groups based on Oswestry Disability Index (ODI) scores. Patient characteristics, comorbidities, and medication use were compared between groups. Prior opioid users had significantly higher baseline ODI and Fear Avoidance Beliefs Questionnaire physical activity subscale and work subscale scores as well as pre-index instances of mental health disorders, chronic pain, and insomnia than opioid-naïve individuals. Prior opioid users filled significantly more pain medication prescriptions in the year after the index date than did opioid-naïve individuals. Prior opioid users were significantly more likely to be taking opioids at 1year after the index date, regardless of disability level. In patients presenting with LBP, prior opioid exposure appears to be related to increased analgesic use (opioid and non-opioid) and longitudinal analgesic utilization at 1year after the index date.

Comorbidities in the first 2 years after arthroscopic hip surgery: substantial increases in mental health disorders, chronic pain, substance abuse and cardiometabolic conditions

ObjectivesWe aimed to identify the rate of seven comorbidities (mental health disorders, chronic pain, substance abuse disorders, cardiovascular disorders, metabolic syndrome, systemic arthropathy and sleep disorders) that occurred within 2...