Military Treatment Facilities Research Articles

Neuropsychological deficit profiles for service members with mild traumatic brain injury

ABSTRACT Background Neuropsychological deficits are generally assessed in terms of absolute level of functioning, e.g. high average, average, low average, although there is increased interest in calculating indices of relative degree of decline, e.g. mild, moderate, severe. Objective To examine differences in demographic, psychiatric, and military-specific characteristics for relative degree of decline in neuropsychological profiles attributed to traumatic brain injuries (TBIs) among service members (SMs). Methods Data were drawn from an existing clinical database of 269 SMs who received neuropsychological evaluations for TBI (Wechsler Test of Adult Reading, Wechsler Adult Intelligence Scale, California Verbal Learning Test, Delis-Kaplan Executive Function System) at a military treatment facility between 2013 and 2018. Independent sample t-tests and one-way ANOVA tests with pairwise comparisons were performed. Results Memory and problem-solving abilities were the most and least affected domains, respectively. Greater relative decline was observed among male and White SMs and those with post-traumatic stress disorder (PTSD). By contrast, there were no differences in relative decline according to military rank or work status. Conclusion Relative degree of decline after TBI among SMs is differentially impacted according to neuropsychological domain, with greater impairment among male and White SMs as well as those with PTSD.

Identification of an Outbreak Cluster of Extensively Antibiotic-Resistant GC1 Acinetobacter baumannii Isolates in U.S. Military Treatment Facilities.

An outbreak involving an extensively antibiotic-resistant Acinetobacter baumannii strain in three military treatment facilities was identified. Fifty-nine isolates recovered from 30 patients over a 4-year period were found among a large collection of isolates using core genome multilocus sequence typing (MLST). They differed by only 0 to 18 single nucleotide polymorphisms (SNPs) and carried the same resistance determinants except that the aphA6 gene was missing in 25 isolates. They represent a novel sublineage of GC1 lineage 1 that likely originated in Afghanistan. IMPORTANCE A. baumannii is recognized as one of the most important nosocomial pathogens, and carbapenem-resistant strains pose a particularly difficult treatment challenge. Outbreaks linked to this pathogen are reported worldwide, particularly during periods of societal upheaval, such as natural disasters and conflicts. Understanding how this organism enters and establishes itself within the hospital environment is key to interrupting transmission, but few genomic studies have examined these transmissions over a prolonged period. Though historical, this report provides an in-depth analysis of nosocomial transmission of this organism across continents and within and between different hospitals.

Development of a Joint Professional Practice Model for the Total Nursing Force of the United States Military: Describing an Evidence-Based Process Across Multiple Entities.

Professional practice models are a hallmark of professional organizations. Creating a model that can apply across contexts, however, can be a challenge. This article describes the process that a team of nurse leaders and researchers used to create a professional practice model that would serve active-duty and civilian nurses working in military treatment facilities.

Racial Differences in Severe Maternal Morbidity Exist for Tricare Beneficiaries [ID: 1377133

INTRODUCTION: Maternal morbidity and mortality rates in the United States have increased in the last two decades with a disproportionate effect on women of color. Military Tricare coverage models universal health care access; however, in studies looking at births in military treatment facilities, disparities still exist for women of color. This study analyzes maternal delivery outcomes for all women with Tricare coverage including deliveries in the civilian sector. METHODS: Data from 6.2 million births in the Centers for Disease Control and Prevention WONDER Linked Birth/Infant Death Records for 2017–2019 were analyzed for all-cause morbidity (transfusions, perineal lacerations, uterine rupture, unplanned hysterectomy, and intensive care unit admissions), severe maternal morbidity (SMM) (excludes lacerations), and SMM excluding transfusion. Risk ratios were calculated comparing overall maternal morbidity rates between Tricare, Medicaid, self-pay, and private insurance. In addition, risk ratios were calculated between insurance types stratified by race. RESULTS: Compared to private insurance, Tricare insurance had significantly reduced risk of all-cause maternal morbidity. Compared to White women, Black women with Tricare and all other insurances had a decreased risk of all-cause morbidity, but a significantly increased risk of SMM and SMM without transfusion. Asian women had significant increased risk of all-cause, SMM and SMM without transfusion. There was no significant difference in the risk of morbidity for women of color with Tricare insurance compared to women of color with Medicaid, private, or self-pay insurance. CONCLUSION: The risk of severe maternal morbidity remains elevated for women of color despite access to Tricare health insurance.

A New Registry for Genetic Diagnosis of Inborn Errors of Immunity within the Military Health System

Genotypic definition of monogenic inborn errors of immunity (IEIs) continues to accelerate with broader access to next generation sequencing, underscoring this aggregated group of disorders as a major health burden impacting both civilian and military populations. At an estimated prevalence of 1 in 1200 individuals, IEIs affect ~8,000 patients within the Military Health System (MHS). Despite access to targeted gene/exome panels at military treatment facilities, most affected patients never receive a definitive genetic diagnosis that would significantly improve clinical care. To address this gap, we established the first registry of IEI patients within the MHS with the goal of identifying known and novel pathogenic genetic defects to increase diagnosis rates and enhance clinical care. Using the registry, a research protocol was opened in July 2022. Since July we have enrolled 75 IEI patients encompassing a breadth of phenotypes including severe and recurrent infections, bone marrow failure, autoimmunity/autoinflammation, atopic disease, and malignancy. Enrolled patients provide blood and bone marrow samples for whole genome, ultra-deep targeted panel and comprehensive transcriptome sequencing, plus cryopreservation of peripheral blood mononuclear cells for future functional studies. We are also implementing and developing analytical methods for identifying and interrogating non-coding and structural variants. Suspected pathogenic variants are adjudicated by a clinical molecular geneticist using state-of-the-art analysis pipelines. These analyses subsequently inform in vitro experiments to validate causative mutations using cell reporter systems and primary patient cells. Clinical variant validation and return of genetic results are planned with genetic counseling provided. As a proof of principle, this integrated genetic evaluation pipeline revealed a novel, candidate TLR7 nonsense variant in two adolescent brothers who both endured critical COVID-19 pneumonia, requiring mechanical ventilation and extracorporeal membrane oxygenation. Our protocol is therefore poised to greatly enrich clinical genetics resources available in the MHS for IEI patients, contributing to better diagnosis rates, informed family counseling, and targeted treatments that collectively improve the health and readiness of the military community. Moreover, our efforts should yield new mechanistic insights on immune pathogenesis for a broad variety of known and novel IEIs.

Critical COVID-19 disease explained by type I interferon autoantibodies found in patients within the Military Health System.

Abstract Neutralizing auto-antibodies (auto-Abs) that target type I interferons (IFN), a group of cytokines that induce innate immune responses upon viral infection, are found within approximately 10–20% of patients with critical COVID-19. We sought to determine if neutralizing type I IFN auto-Abs contribute to severe COVID-19 in patients within the Military Health System (MHS). The Epidemiology, Immunology, and Clinical Characteristics of Emerging Infectious Diseases with Pandemic Potential (EPICC) cohort collected demographic data, clinical data and sera from SARS-CoV-2 infected patients enrolled across 10 U.S. military treatment facilities. We screened sera collected <21 days post-symptom onset from 214 COVID-19 inpatients and 312 COVID-19 outpatients for IFN auto-Ab positivity and neutralizing activity using Luminex and intracellular flow cytometry, respectively. Similar to previous reports, we detected neutralizing auto-Abs against IFN-α and/or IFN-ω in a significantly higher frequency of inpatients (9 total, 4.2%) versus outpatients (1, 0.32%) (p=0.009). Remarkably, IFN auto-Abs persisted 6–12 months post-infection in most inpatients, including several with a prior history of autoimmune disease. Among inpatients, multivariate logistic regression analyses demonstrated that type I IFN auto-Abs were associated with a greater risk of severe and critical COVID-19 (adjusted odds ratio (aOR) = 16.40 and 6.44, respectively) after adjusting for age, sex and comorbidity burden. Our results confirm a robust association between critical COVID-19 and the presence of type I IFN auto-Abs, which may predispose to other severe respiratory viral infections that cause substantial morbidity and mortality in the MHS. This work was supported by awards from the Defense Health Program (HU00012020067) and the National Institute of Allergy and Infectious Disease (HU00011920111). The protocol was executed by the Infectious Disease Clinical Research Program (IDCRP), a Department of Defense (DoD) program executed by the Uniformed Services University of the Health Sciences (USUHS) through a cooperative agreement by the Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc. (HJF).

Advanced Cervical Neoplasia Rates in Young Service Members: Implications of Primary HPV Screening for Military Readiness [ID: 1380248

INTRODUCTION: The new American Cancer Society (ACS) cervical cancer screening guidelines dissuade cervical cancer screening in women younger than 25, and may become universal national screening guidelines. We queried the incidence of advanced cervical dysplasia and carcinoma in military service members to determine the readiness implications of these recommendations. METHODS: A retrospective cohort study using the Military Health System (MHS) Data Repository and Management Analysis and Reporting Tool (MDR/M2) was performed to identify active-duty patients aged 21–25 diagnosed with cervical dysplasia and cancer across all military treatment facilities (MTFs) from January 1, 2017 to December 31, 2021. Additionally, patient age, human papillomavirus (HPV) infection status, and treatment type were collected. RESULTS: Only active-duty patients treated in a MTF fulfilling the above criteria were captured. In the 5 years of data collection, there were 955 active-duty women who met the inclusion criteria. Moderate to severe cervical dysplasia accounted for 62.3%, while carcinoma in situ and cervical cancer accounted for 35.6%, and 2.1%, respectively. The majority of patients did not have HPV testing or vaccination status encoded; therefore, this endpoint was eliminated from analysis. CONCLUSION: There are a militarily significant number of cases of advanced cervical lesions among young service members. If the new ACS guidelines are adopted, service members with treatable precancerous conditions will evade or delay detection, resulting in cancers that compromise readiness, increase cost, and compromise the health of military women. Mandatory HPV vaccination should be considered if ACS guidelines are adopted.

Provider Adherence to Aspirin Prophylaxis Recommendations in Pregnancy at a Single Military Treatment Facility [ID: 1380223

INTRODUCTION: Preeclampsia complicates 2–8% of pregnancies and is a major contributor to maternal and perinatal morbidity and mortality. Aspirin (ASA) is known to decrease rates of preeclampsia in patients at risk for developing the disease. We examined provider compliance with the U.S. Preventive Services Task Force risk-based aspirin prophylaxis guidelines at our institution and identified a need for improvement. METHODS: For quality improvement, we implemented provider education, updated patient history forms, and an embedded ASA checklist within our note template. We retrospectively reviewed demographics, medical/obstetric history, and candidacy/prescription placement for two patient groups at their first prenatal visit. The first was the preintervention group (January 1 to June 30, 2019; N=434) and the second was the postintervention group (July 1 to September 30, 2021; N=284). Preintervention and postintervention data were then compared to determine whether rates of compliance with ASA prophylaxis guidelines improved. RESULTS: A similar proportion of patients met criteria for ASA prophylaxis preintervention (43.1%, 95% CI 38.5–47.8%) and postintervention (46.8%, 95% CI 41.1–52.6%, P=.36), with similar proportions of patients who qualified with one high risk factor versus multiple moderate risk factors. There were significantly more patients who qualified for aspirin and were not identified in the preintervention group (67.9%, 95% CI 60.9–74.2%) than in the postintervention group (18.8%, 95% CI 13.0–26.3%, P<.0001). This improvement was even more pronounced in patients who only qualified by moderate risk factors (preintervention [79.7%, 95% CI 72.5–85.5%] versus postintervention [21.2%, 95% CI 14.7–29.7%]). CONCLUSION: The implementation of provider education, updated patient history forms, and an ASA checklist significantly improved provider adherence to ASA prophylaxis recommendations.

Craniotomies at an overseas military treatment facility: Maintaining readiness for the unit and the surgeon

IntroductionCraniotomy and craniectomy are common neurosurgical procedures with wide applications in both civilian and military practice. Skill maintenance for these procedures is required for military providers in the event they are called to support forward deployed service members suffering from combat and non-combat injuries. The presents investigation details the performance of such procedures at a small, overseas military treatment facility (MTF). Materials and methodsA retrospective review of craniotomy procedures performed at an overseas military treatment facility (MTF) over a 2-year period (2019–2021) was performed. Patient and procedural data were collected for all elective and emergent craniotomies including surgical indications, outcomes, complications, military rank, and impact on duty status and tour curtailment. ResultsA total of 11 patients underwent a craniotomy or craniectomy procedure with an average follow-up of 496.8 days (range 103–797). Seven of the 11 patients were able to undergo surgery, recovery, and convalesce without transfer to a larger hospital network or MTF. Of the 6 patients that were active duty (AD), one returned to full duty while three separated and two remain in partial duty status at latest follow-up. There were four complications in four patients with one death. ConclusionsIn this series, we demonstrate that cranial neurosurgical procedures can be performed safely and effectively while at an overseas MTF. There are potential benefits to the AD service members, their unit, and family as well as to the hospital treatment team and surgeon as this represents a clinical capability requisite to maintain trauma readiness for future conflicts.

Risk Stratification to Support Antibiotic Stewardship and Breastfeeding Exclusivity in a Military Treatment Facility

ObjectiveTo safely reduce unnecessary antibiotic exposure in neonates exposed to chorioamnionitis and inadequately treated Group B Streptococcus (GBS) using the early-onset sepsis (EOS) calculator for risk stratification and a 36-hour antibiotic duration. DesignEvidence-based quality improvement initiative. Setting/Local ProblemObstetric service at a midsized military treatment facility with approximately 2,000 births annually and no standard process for neonatal EOS risk assessment. ParticipantsClinical nurse specialist, physicians, nursing leadership, unit-level nursing champions, and nurses assigned to the mother–baby and labor and delivery units. Intervention/MeasurementsAn interdisciplinary working group created a protocol to institute an EOS risk assessment calculator, a note for the electronic heath record, and interdisciplinary education for all staff providing care to neonates in our facility. ResultsBefore implementation of the EOS calculator, 97.6% of neonates exposed to chorioamnionitis or inadequate maternal GBS treatment received antibiotics; after implementation, the mean rate dropped to 32%. Exclusive breastfeeding rates before discharge in neonates exposed to chorioamnionitis or inadequate maternal GBS treatment also increased during this time, from 40% to a mean of 89%. After implementation, there were no readmissions to our institution for culture-proven sepsis within 14 days of discharge. ConclusionMultidisciplinary team-led implementation of the EOS calculator and of shortened antibiotic duration were associated with safely reduced antibiotic exposure in well-appearing neonates exposed to chorioamnionitis and GBS. In addition, dramatically improved rates of exclusive breastfeeding at discharge were observed in this population.

Increased maternal morbidity and mortality among Asian American and Pacific Islander women in the military health system

Rates of maternal morbidity and mortality experienced by women in the United States have been shown to vary significantly by race, most commonly attributed to differences in access to healthcare and socioeconomic status. Recent data showed that Asian Pacific Islanders have the highest rate of maternal morbidity despite having a higher socioeconomic status. In the military, women of all races are granted equal access to healthcare, irrespective of socioeconomic class. We hypothesized that within the military, there would be no racial disparities in maternal outcomes because of universal healthcare. This study aimed to evaluate if universal access to healthcare, as seen in the military healthcare system, leads to similar rates of maternal morbidity regardless of racial or ethnic background. This was a retrospective cohort study of data from the National Perinatal Information Center reports obtained from participating military treatment facilities from April 2019 to March 2020 and included 34,025 deliveries. We compared racial differences in the incidence of each of the following 3 outcomes: postpartum hemorrhage, severe maternal morbidity among women with postpartum hemorrhage including transfusion, and severe maternal morbidity among women with postpartum hemorrhage excluding transfusion. A total of 41 military treatment facilities (a list of participating military treatment facilities are provided in the Appendix) provided data that were included. There was an increased rate of postpartum hemorrhage (relative risk, 1.73; 95% confidence interval, 1.45-2.07), severe maternal morbidity including transfusion (relative risk, 1.22; 95% confidence interval, 0.93-1.61), and severe maternal morbidity excluding transfusion (relative risk, 1.97; 95% confidence interval, 1.02-3.8) among Asian Pacific Islander women when compared with Black or White women. Even with equal access to healthcare in the military, Asian Pacific Islander women experience statistically significant increased rates of postpartum hemorrhage and severe maternal morbidity excluding transfusion when compared with Black or White women. The increased rates of severe maternal morbidity including transfusion were not statistically significant.

Gender Differences in the Association of Trauma Exposure and Firearm Availability Among Active Duty Servicemembers and Military Retirees

Introduction: This study examines the relationship between traumatic experiences and firearm availability, a known suicide risk factor, for both male and female active duty servicemembers and military retirees in the United States. Availability of firearms was predicted to differ by gender, with male servicemembers having elevated rates of firearm availability compared to female servicemembers. It was also expected that experiences of trauma would be associated with higher availability of firearms in both male and female servicemembers and military retirees. Methods: Survey respondents included 1,869 active-duty and military retiree participants recruited from six different primary care clinics located within various military treatment facilities. Analyses compared associations among trauma exposure, firearm availability, and gender. Results: Both male and female servicemembers and retirees reported elevated rates of firearm availability, with men reporting the highest rates of available firearms. There was a significant interaction between gender and firearm availability on trauma type; men with available firearms reported elevated levels of directly experienced trauma. When controlling for covariates, men with available firearms reported highest levels of “happened to me” trauma exposure for fire and explosion and sudden violent death. Discussion: Men who positively endorse firearm availability have the highest rates of directly experienced traumatic events among active duty military personnel and retirees. Firearm availability, trauma exposure, and perceptions of safety for both genders are discussed.

Case Volume and Readiness to Deploy: Clinical Opportunities for Active-Duty Surgeons Outside of Military Hospitals.

The Military Health System (MHS) uses a readiness program that identifies the knowledge, skills, and abilities (KSAs) necessary for surgeons to provide combat casualty care. Operative productivity is assigned an objective score based on case type and complexity and totaled to assess overall readiness. As of 2019, only 10.1% of surgeons met goal readiness threshold. At one tertiary military treatment facility (MTF), leadership has taken an aggressive approach toward increasing readiness by forming military training agreements (MTAs) and allowing Off Duty Employment (ODE). We sought to quantify the efficacy of this approach. Operative logs from 2021 were obtained from surgeons assigned to the MTF. Operations were assigned CPT codes and processed through the KSA calculator (Deloitte; London, UK). Each surgeon was then surveyed to identify time away from clinical duties for deployment or military training. Nine surgeons were present in 2021 and spent an average of 10.1 weeks (19.5%) abroad. Surgeons performed 2,348 operations (Average [Avg] 261 ± 95) including 1,575 (Avg 175; 67.1%) at the MTF, 606 (Avg 67.3; 25.8%) at MTAs, and 167 (Avg 18.6, 7.1%) during ODE. Adding MTA and ODE caseloads increased KSA scores by 56% (17,765 ± 7,889 vs 11,391 ± 8,355). Using the MHS threshold of 14,000, 3 of 9 (33.3%) surgeons met the readiness threshold from MTF productivity alone. Including all operations, 7 of 9 (77.8%) surgeons met threshold. Increased use of MTAs and ODE significantly augments average caseloads. These operations provide considerable benefit and result in surgeon readiness far exceeding the MHS average. Military leadership can maximize the chances of meeting readiness goals by encouraging clinical opportunities outside the MTF.

Findings from the development of a nursing joint professional practice model for the U.S. military

BackgroundBy 2022 the Defense Health Agency became responsible for administration of all military treatment facilities (MTFs), which were previously managed by their respective military services. However, three different service-specific nursing professional practice models currently govern nursing practice in MTFs. PurposeTo describe the literature search, review, and synthesis of evidence which informed the JPPM and provide some of the most actionable findings. MethodsA team of tri-service nurses developed the JPPM by conducting six rigorous systematic reviews to synthesize evidence pertaining to relevant model components. DiscussionA total of 51,360 titles and abstracts were initially screened. Data were extracted from 540 included articles. The team then developed standards for five JPPM components: evidence-based practice, safety and quality, leadership development, healthy work environment, and operational readiness. ConclusionThe JPPM is a meaningful framework that will help create a mutual professional identity and shared vision to promote a unified nursing force in U.S. military settings.

Postoperative Venous Thromboembolism Following Hysterectomy in the Department of Defense.

Hysterectomy is the most common major gynecologic procedure performed in the USA. Surgical complications, such as venous thromboembolism (VTE), are known risks that can be mitigated by preoperative risk stratification and perioperative prophylaxis. Based on recent data, the current post-hysterectomy VTE rate is found to be 0.5%. Postoperative VTE significantly impacts health care costs and patients' quality of life. Additionally, for active duty personnel, it can negatively impact military readiness. We hypothesize that the incidence of post-hysterectomy VTE rates will be lower within the military beneficiary population because of the benefits of universal health care coverage. The Military Health System (MHS) Data Repository and Management Analysis and Reporting Tool was used to conduct a retrospective cohort study of postoperative VTE rates within 60 days of surgery among women who underwent a hysterectomy at a military treatment facility between October 1, 2013, and July 7, 2020. Patient demographics, Caprini risk assessment, preoperative VTE prophylaxis, and surgical details were obtained by chart review. Statistical analysis was performed using the chi-squared test and Student t-test. Among the 23,391 women who underwent a hysterectomy at a military treatment facility from October 2013 to July 2020, 79 (0.34%) women were diagnosed with VTE within 60 days of their surgery. This post-hysterectomy VTE incidence rate (0.34%) is significantly lower than the current national rate (0.5%, P < .0015). There were no significant differences in postoperative VTE rates with regard to race/ethnicity, active duty status, branch of service, or military rank. Most women with post-hysterectomy VTE had a moderate-to-high (4.29 ± 1.5) preoperative Caprini risk score; however, only 25% received preoperative VTE chemoprophylaxis. MHS beneficiaries (active duty personnel, dependents, and retirees) have full medical coverage with little to no personal financial burden for their health care. We hypothesized a lower VTE rate in the Department of Defense because of universal access to care and a presumed younger and healthier population. The postoperative VTE incidence was significantly lower in the military beneficiary population (0.34%) compared to the reported national incidence (0.5%). Additionally, despite all VTE cases having moderate-to-high preoperative Caprini risk scores, the majority (75%) received only sequential compression devices for preoperative VTE prophylaxis. Although post-hysterectomy VTE rates are low within the Department of Defense, additional prospective studies are needed to determine if stricter adherence to preoperative chemoprophylaxis can further reduce post-hysterectomy VTE rates within the MHS.

A Contemporary Analysis of Combat-related Urological Injuries: Data From the Department of Defense Trauma Registry.

There has been little to no literature published on combat-related genitourinary injuries beyond 2013. With the goal of enhancing medical readiness prior to deployment and making recommendations to improve the long-term rehabilitation of service members as they become civilians, we sought to describe the incidence of combat-related genitourinary injuries and interventions from January 1, 2007, to March 17, 2020. We conducted a retrospective analysis of the Department of Defense Trauma Registry, which is a prospectively maintained database, for the time between 2007 and 2020. We used predefined search criteria to primarily identify any casualties that arrived at a military treatment facility with urological-based injuries. The registry contained 25,897 adult casualties, of which 7.2% sustained urological injuries. The median age was 25. Explosive injuries (64%) and firearms (27%) predominated. The median injury severity score was 18 (IQR 10-29). Most patients survived until hospital discharge (94%). The most frequently injured organs were the scrotum (60%), testes (53%), penis (30%), and kidneys (30%). Massive transfusion protocols were activated in 35% of all patients who sustained a urological injury and accounted for 28% of all protocols between 2007 and 2020. The incidence of genitourinary trauma persistently increased for both military and civilian personnel as the U.S. remained actively engaged in major military conflicts during this period. Patients with genitourinary trauma in this data set were often associated with high injury severity scores and required an increased number of immediate and long-term resources for survival and rehabilitation.

Quasi-experimental Controlled Study on the Effect of Autism Resource Clinic Guardian Attendance at a Military Treatment Facility.

Autism spectrum disorder (ASD) is a complex neurodevelopmental condition that requires multidisciplinary care. Evidence-based practice indicates that early intervention may improve long-term ASD outcomes. The Autism Resource Clinic (ARC) provides an educational session for guardians empowering them to build a personalized ASD team for their child. We examined the impact of guardian attendance of an ARC at a Military Treatment Facility on time to initiation of patient services and guardian stress level. A quasi-experimental controlled study was conducted comparing a group of guardians attending the ARC with a group of guardians not attending the ARC following a child's initial ASD diagnosis. ARC speakers included medical, county/state, community/military, and advocacy experts. Surveys were completed at diagnosis, 1, 2, and 3 mo postdiagnosis. Initiation of patient services and Parental Stress Scale scores were compared between groups using independent samples t-test, chi-square tests, or nonparametric tests, as appropriate. Use of Applied Behavioral Analysis was significantly higher among ARC attendees vs. nonattendees (73.3% vs. 33.3%, P = 0.028). County early intervention was more frequent among ARC attendees versus nonattendees (40% vs. 13.3%, P = 0.09). Of borderline significance, median time to initiation of genetics services was greater in ARC attendees vs. nonattendees (106 vs. 65.5, P = 0.10). The two groups did not differ on changes in Parental Stress Scale score from baseline to follow-up months 1, 2, or 3. Although ARC did not influence time to initiation of patient services or guardian stress level, attendance of ARC was associated with more frequent use of Applied Behavioral Analysis services and county early intervention services. This pilot study is unique as it targets guardians of ASD patients within military treatment facilities. Study limitations include data collection during the coronavirus disease 2019 pandemic, sequential evaluation of experimental and control groups, sample size and generalizability. A large, multicenter, randomized controlled trial is required to better assess the impact of this educational opportunity among military populations.

Single-Center Experience With the Seraph-100® Microbind® Affinity Blood Filter in Patients With SARS-CoV-2 Infection and Septic Shock at a Military Treatment Facility.

Coronavirus disease 2019 (COVID-19) infection is characterized by a dysregulated inflammatory response, which may result in severe hemodynamic instability and septic shock. The Seraph-100® Microbind® Affinity Blood Filter is a commercially available extracorporeal pathogen absorbent device with the ability to bind pathogens and cytokines present within the blood. Our study aimed to evaluate the efficacy of the Seraph-100® for patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and septic shock. A retrospective review was performed to evaluate the use of the Seraph-100® blood filter at a Single Center tertiary-care facility at Brooke Army Medical Center from 2020 to 2021. Nine patients (11 treatments) were completed with the Seraph-100® blood filter in patients with SARS-CoV-2 infection and septic shock. The Seraph-100® blood filter was used in combination with continuous renal replacement therapy and slow low-efficiency dialysis or directly in parallel with the extracorporeal membrane oxygenation circuit. Within this cohort, there was a statistically significant improvement in the following clinical parameters comparing values to before and after treatment with the Seraph-100® blood filter: Mean arterial pressure (mmHg) (64.2 ± 2.36 vs. 76.2 ± 2.68; P < .001), heart rate (beats per minute) (128 ± 6.6 vs. 100.3 ± 6.07; P < .001), administered fraction of oxygen (%) (74.4 ± 10.58 vs. 60.3 ± 10.35; P < .001), serum lactate (mmol/L) (6.14 ± 1.25 vs. 2.8 ± 1.14; P = .0095), and pH (7.29 ± 0.03 vs. 7.39 ± 0.04; P = .0203). There were statistically significant improvements in vasopressor requirements: norepinephrine (mcg/min) (36.3 ± 4.74 vs. 8.3 ± 3.92; P < .001), vasopressin (units/min) (0.04 ± 0.004 vs. 0.02 ± 0.003; P < .001), dobutamine (mcg/kg/min) (2.3 ± 1.00 vs. 0.2 ± 0.75; P = .006) and angiotensin II (ng/kg/min) (34.5 ± 6.4 vs. 3.3 ± 5.26; P < .001). The use of the Seraph-100® blood filter was associated with statistically and clinically significant improvements in hemodynamic parameters and decreased vasopressor requirements in patients with septic shock and SARS-CoV-2 infection.

Changes in Outpatient Healthcare Utilization and Costs Following Mild Traumatic Brain Injury Among Service Members in the Military Health System by Preexisting Behavioral Health Condition Status.

To evaluate changes in healthcare utilization and cost following an index mild traumatic brain injury (mTBI) diagnosis among service members (SMs). We hypothesized that differences in utilization and cost will be observed by preexisting behavioral health (BH) diagnosis status. Direct care outpatient healthcare facilities within the Military Health System. A total of 21 984 active-duty SMs diagnosed with an index mTBI diagnosis between 2017 and 2018. This retrospective study analyzed changes in healthcare utilization and cost in military treatment facilities among SMs with an index mTBI diagnosis. Encounter records 1 year before and after mTBI were assessed; preexisting BH conditions were identified in the year before mTBI. Ordinary least squares regressions evaluated difference in the average change of total outpatient encounters and costs among SMs with and with no preexisting BH conditions (eg, posttraumatic stress disorder, adjustment disorder). Additional regressions explored changes in utilization and cost within clinic types (eg, mental health, physical rehabilitation). There was a 39.5% increase in overall healthcare utilization during the following year, representing a 34.8% increase in total expenditures. Those with preexisting BH conditions exhibited smaller changes in overall utilization (β, -4.9; [95% confidence interval (CI), -6.1 to -3.8]) and cost (β, $-1873; [95% CI, $-2722 to $-1024]), compared with those with no BH condition. The greatest differences were observed in primary care clinics, in which those with prior BH conditions exhibited an average decreased change of 3.2 encounters (95% CI, -3.5 to -3) and reduced cost of $544 (95% CI, $-599 to $-490) compared with those with no prior BH conditions. Despite being higher utilizers of healthcare services both pre- and post-mTBI diagnosis, those with preexisting BH conditions exhibited smaller changes in overall cost and utilization. This highlights the importance of considering prior utilization and cost when evaluating the impact of mTBI and other injury events on the Military Health System.

TRICARE Extended Care Health Option Program: Prevalence of pediatric ECHO enrollees and healthcare service utilization in the Military Health System

BackgroundThe Extended Care Health Option (ECHO) Program is a TRICARE program aimed at reducing the disabling effects of chronic medical conditions for beneficiaries of the Department of Defense (DoD) healthcare program. However, little is known about military-connected children enrolled in the program. Objective/HypothesisThe aim of this study was to examine the demographic makeup of pediatric ECHO beneficiaries and their healthcare claims data. This is the first study to evaluate healthcare utilization of this subset of military dependents. MethodsA cross-sectional study was performed evaluating ECHO enrolled pediatric beneficiaries and their health service utilization during 2017–2019. TRICARE claims and military treatment facility (MTF) encounter data were utilized to evaluate health service utilization and identify the most frequently reported ICD-10-CM and CPT codes associated with care for this population. ResultsOf the 2,001,619 dependents aged 0–26 years who received medical care in the Military Health System (MHS) during 2017–2019, 21,588 individuals (1.1%) were enrolled in ECHO. The majority of encounters (65.4%) were provided in the MTFs. Inpatient visits, therapeutic services, and in-home nursing care were the top utilized private sector care services. Outpatient visits encompassed 94.8% of healthcare encounters, and neurodevelopmental disorders were the top principal diagnoses among ECHO beneficiaries. ConclusionsWith the increasing prevalence of children with medical complexity and developmental delay, the pediatric TRICARE beneficiaries eligible for ECHO will likely continue to rise. Improving services and supports for military children with special healthcare needs is needed to maximize their developmental trajectory.