United States Military Health System Research Articles

High-Quality Hospital Status on Health Care Costs for Pediatric Congenital Heart Disease Care for U.S. Military Beneficiaries.

Congenital heart disease (CHD) is the most common and resource demanding birth defect managed in the United States, with approximately 40,000 children undergoing CHD surgery year. Researchers have compared high-volume to low-volume hospitals and found significant hospital-level variation in major complications, health resource utilization, and health care costs after CHD surgery. Using nationwide representative claim data from the United States Military Health System from 2016 to 2020, TRICARE beneficiaries diagnosed with CHD were tabulated based on ICD-10 codes (International Classification of Diseases, 10th revision). We examined the relationships between total costs and total hospitalizations costs post 1-year CHD diagnosis and presence or absence of High-Quality Hospital (HQH) designation. We applied both the naive generalized linear model (GLM) to control for the observed patient and hospital characteristics and the 2-stage least squares (2SLS) model to account for the unobserved confounding factors. This study was approved by University of Maryland, College Park Institutional Review Board (IRB) (Approval Number: 1576246-2). A relationship between HQH designation and total CHD related costs was not seen across 2SLS model specifications (marginal effect; -$41,579; 95% CI, -$83,429 to $271). For patients diagnosed with a moderate-complex or single ventricle CHD, the association of HQH status was a statistically significant reduction in total costs (marginal effect; -$84,395; 95% CI, -$140,560 to -$28,229) and hospitalization costs (marginal effect; -$73,958; 95% CI, -$121,878 to -$26,039). It is very imperative for clinicians and patient support advocates to urge policymakers to deliberate the establishment of a quality designation authority for CHD management. These efforts will not only help to identify and standardize quality care metrics but to improve long-term health, effectiveness, and equity in the management of CHD. Furthermore, these efforts can be used to navigate patients to proven HQH, thereby improving care and reducing associated treatment costs for CHD patients.

Survival Among Patients With Multiple Myeloma in the United States Military Health System Compared to the Surveillance, Epidemiology, and End Results (SEER) Program

BackgroundAccess to health care is an important factor affecting survival of patients with multiple myeloma (MM) in the U.S. general population. The U.S. Military Health System (MHS) provides universal health care to beneficiaries and has been associated with improved survival across multiple malignancies. In this study, we compared survival of MHS beneficiaries with MM with MM patients from the U.S. general population. Materials and methodsThe Department of Defense's Automated Central Tumor Registry (ACTUR) and the Surveillance, Epidemiology and End Results (SEER) databases were used to extract data for MM patients from MHS and the U.S. general population, respectively. Patients had histologically confirmed MM between 1987 and 2013 and were followed through 2015 for overall survival. Two SEER patients were matched to each ACTUR patient by age group, sex, race, and diagnosis year group. Five and 10-year survival was compared between ACTUR and SEER patients to estimate hazard ratios (HRs) and 95% confidence intervals (95% CI) with adjustment for potential confounders. ResultsMedian survival of the ACTUR patients was 47.1 months (95% CI: 43.9-50.4) compared to 33.0 months (95% CI, 32.0-35.0) of the SEER patients. Five and 10-year death rates were significantly lower for ACTUR patients than the SEER patients with an adjusted HR of 0.74 (95% CI, 0.68-0.81) and 0.79 (95% CI, 0.74-0.85), respectively. The survival advantage of ACTUR patients was preserved when stratified by age, sex, race, and diagnosis year. ConclusionMHS beneficiaries with MM had improved overall survival compared to MM patients from the U.S. general population.

Poster 130: Incidence and Treatment Characteristics of Coracoclavicular Ligament Injuries with Associated Lateral Clavicle Fractures in a Military Population

Objectives: To identify the demographics and characteristics of lateral clavicle fractures treated with coracoclavicular ligament repair or reconstruction, as well as to the subsequent postoperative complications. Methods: The United States Military Health System Data Repository was queried for patients with a Current Procedural Terminology (CPT) code for coracoclavicular ligament reconstruction between October 2013 and March 2020. Radiographs were evaluated for the presence of a lateral clavicle fracture at the time of initial injury and classified based on the modified Neer classification. The electronic health records to include operative reports and clinical notes were then reviewed for patient demographics, operative technique, and clinical course. Results: A total of 965 patients underwent coracoclavicular ligament repair or reconstruction between October 2013 and March 2020. Forty patients (4.6%) were identified with concomitant lateral clavicle fractures. The mean age of 29.575 years (SD 10.1) of which 85% male and 80% were active duty. Based on the Neer classification, there were three type I, 18 type IIB, 12 type III, and seven type V. Twenty-two of these injuries were addressed acutely (55%), while 18 were managed chronically (45%). Open reduction internal fixation of the distal clavicle was performed in 16 of the 40 patients (40%). An equivalent distribution of concomitant coracoclavicular ligament repair versus reconstruction was performed amongst the forty total patients. Postoperatively, two patients went on to nonunion and seven patients had loss of coracoclavicular reduction. Five patients returned to the operating room for removal of symptomatic hardware (3), revision (1), and irrigation and debridement (1). At the conclusion of their fracture care, five (12.5%) of patients necessitated medical separation from the military. Conclusions: A small subset of coracoclavicular reconstructions performed in the military occur for a concomitant lateral clavicle fracture. The majority of military patients who underwent coracoclavicular ligament repair or reconstruction in the setting of a lateral clavicle regained full, pain-free range of motion. Although malunion and nonunion are known complications of this injury pattern, only two patients went on to develop these complications. However, postoperative complications were common, occurring in 25% of patients. At the conclusion of their fracture care, five (12.5%) of patients necessitated medical separation from the military.

Surgical intervention and long-term renal outcomes of congenital ureteropelvic junction obstruction in a young adult cohort.

To evaluate the impact of surgical intervention on long-term renal outcomes for adult patients with congenital ureteropelvic junction obstruction (UPJO). We queried service members diagnosed with UPJO from the United States Military Health System electronic health records from 2005 to 2020. We assessed demographic, laboratory, radiology, surgical intervention, and outcome data. We evaluated the impact of surgical intervention on renal function based on the estimated glomerular filtration rate (eGFR), hypertension (HTN, defined as any prescription for blood pressure [BP] medication and/or average of two BP readings ≥ 130/80mmHg more than 2weeks apart), and changes in renal excretory function on radionuclide scans. We identified 108 individuals diagnosed with congenital UPJO; mean follow-up of 7years. Mean age at diagnosis was 25years; 95% male; 69% White, 15% Black. At diagnosis, median BP was 130/78mmHg and mean eGFR 93ml/min/1.73m2. Subsequently, 85% had pyeloplasty and 23% had stent placement. There were no significant differences in mean eGFR pre- and post-intervention (94 vs. 93ml/min/1.73m2, respectively; p = 0.15) and prevalence of defined HTN (59% vs. 61%, respectively; p = 0.20). Surgical intervention for right-sided UPJO significantly reduced the proportion of patients with delayed cortical excretion (54% pre vs. 35% post, p = 0.01) and T½ emptying time (35min vs. 19min, p = 0.009). Similar trends occurred with left-sided UPJO but were not significant. Surgical intervention was not associated with significant differences in the long-term outcomes of kidney function and HTN prevalence in our young adult cohort. However, renal excretory function improved on radionuclide scans.

The Association of High-Quality Hospital Use on Health Care Outcomes for Pediatric Congenital Heart Defects in a Universal Health Care System.

Congenital heart disease (CHD) has an incidence of 0.8% to 1.2% worldwide, making it the most common birth defect. Researchers have compared high-volume to low-volume hospitals and found significant hospital-level variation in major complications, health resource utilization, and mortality after CHD surgery. In addition, researchers found critical CHD patients at low-volume/non-teaching facilities to be associated with higher odds of inpatient mortality when compared to CHD patients at high-volume/teaching hospitals (odds ratio 1.76). We examined the effects of high-quality hospital (HQH) use on health care outcomes and health care costs in pediatric CHD care using an instrumental variable (IV) approach. Using nationwide representative claim data from the United States Military Health System from 2016 to 2020, TRICARE beneficiaries with a diagnosis of CHD were tabulated based on relevant ICD-10 (International Classification of Diseases, 10th revision) codes. We examined the relationships between annual readmissions, annual emergency room (ER) use, and mortality and HQH use. We applied both the naive linear probability model (LPM), controlling for the observed patient and hospital characteristics, and the two-stage least squares (2SLS) model, accounting for the unobserved confounding factors. The differential distance between the patient and the closest HQH at the index date and the patient and nearest non-HQH was used as the IV. This protocol was approved by the Institutional Review Board at the University of Maryland, College Park (Approval Number: 1576246-2). The naive LPM indicated that HQH use was associated with a higher probability of annual readmissions (marginal effect, 18%; 95% CI, 0.12 to 0.23). The naive LPM indicated that HQH use was associated with a higher probability of mortality (marginal effect, 2.2%; 95% CI, 0.01 to 0.03). Using the differential distance of closest HQH and non-HQH, we identified a significant association between HQH use and annual ER use (marginal effect, -14%; 95% CI, -0.24 to -0.03). After controlling for patient-level and facility-level covariates and adjusting for endogeneity, (1) HQH use did not increase the probability of more than one admission post 1-year CHD diagnosis, (2) HQH use lowered the probability of annual ER use post 1-year CHD diagnosis, and (3) HQH use did not increase the probability of mortality post 1-year CHD diagnosis. Patients who may have benefited from utilizing HQH for CHD care did not, alluding to potential barriers to access, such as health insurance restrictions or lack of patient awareness. Although we used hospital quality rating for congenital cardiac surgery as reported by the Society of Thoracic Surgeons, the contributing data span a 4-year period and may not reflect real-time changes in center performance. Since this study focused on inpatient care within the first-year post-initial CHD diagnosis, it may not reflect the full range of health system utilization. It is necessary for clinicians and patient advocacy groups to collaborate with policymakers to promote the development of an overarching HQH designation authority for CHD care. Such establishment will facilitate access to HQH for military beneficiary populations suffering from CHD.

Filling the Gaps in the Pandemic Response: Impact of COVID-19 on Telehealth in the Military Health System.

Introduction: As a result of the COVID-19 pandemic, telehealth use became widespread, allowing for continued health care while minimizing COVID-19 transmission risk for patients and providers. This rapid scale-up highlighted shortcomings of the current telehealth infrastructure in many health systems. We aimed to identify and address gaps in the United States Military Health System (MHS) response to the COVID-19 pandemic related to the implementation and utilization of telehealth. Methods: We conducted semistructured key informant interviews of MHS stakeholders, including policymakers, program managers, and health care providers. We recruited respondents using purposive and snowball sampling until we reached thematic saturation. Interviews were conducted virtually from December 2022 to March 2023 and coded by deductive thematic analysis using NVivo. Results: We interviewed 28 key informants. Several themes emerged from the interviews and were categorized into four defined areas of obstacles to the effective utilization of telehealth: administrative, technical, organizational, and quality issues. While respondents had positive perceptions of telehealth, issues such as billing, licensure portability, network connectivity and technology, and ability to monitor health outcomes represent major barriers in the current system, preventing the potential for further expansion. Conclusions: While the shift to telehealth during the COVID-19 pandemic demonstrated robust potential within the MHS, it highlighted shortcomings that impair the utility and expansion of telehealth on a level comparable to that of other large health systems. Future focus should be directed toward generating and implementing actionable recommendations that target these identified challenges in the MHS.

The Comparative Effectiveness andProvider-induced Demand Collaboration Project: A Pioneering Military-Civilian Academic Partnership to Build Health Services Research Capacity forthe Military Health System.

Like civilian health systems, the United States Military Health System (MHS) confronts challenges in achieving the aims of reducing cost, and improving quality, access, and safety, but historically has lacked coordinated health services research (HSR) capabilities that enabled knowledge translation and iterative learning from its wealth of data. A military-civilian academic partnership called the Comparative Effectiveness and Provider-Induced Demand Collaboration (EPIC), formed in 2011, demonstrated early proof-of-concept in using the MHS claims database for research focused on drivers of variation in health care. This existing partnership was reorganized in 2015 and its topics expanded to meet the need for HSR in support of emerging priorities and to develop current and HSR capacity within the MHS. A Donabedian framework of structure, process, and outcomes was applied to support the project, through a core of principal investigators, researchers, analysts, and administrators. Within this framework, new researchers and student trainees learn foundations of HSR while performing secondary analysis of claims data from the MHS Data Repository (MDR) focusing on Health and Readiness, Pediatrics, Policy, Surgery, Trauma, and Women's Health. Since 2015, the project has trained 25 faculty, staff, and providers; 51 students and residents; 21 research fellows across multiple disciplines; and as of 2022, produced 107 peer-reviewed publications and 130 conference presentations, across all five themes and six cores. Research results have been incorporated into Federal and professional policy guidelines. Major research areas include opioid usage and prescribing, value-based care, and racial disparities. EPIC researchers provide direct support to MHS leaders and enabling expertise to clinical providers. EPIC, through its Donabedian framework and utilization of the MHS Data Repository as a research tool, generates actionable findings and builds capacity for continued HSR across the MHS. Eight years after its reorganization in 2015, EPIC continues to provide a platform for capacity building and knowledge translation.

Associations of health care staff burnout with negative health and organizational outcomes in the U.S. military health system

RationaleBurnout is a personal and occupational phenomenon that has been associated with negative physical and psychological outcomes in medical staff. Additionally, there are implications for healthcare organizations, as those staff who are burned out are more likely to have lower productivity or leave the organization. As with the Covid-19 pandemic, future national emergencies and potentially large-scale conflicts will require similar and likely even larger scale responses from the U.S. Military Health System, thus it is important to understand burnout in this population so that the readiness of the staff and the military can remain at a high level. ObjectiveThis assessment was designed to examine levels of burnout among United States Military Health System (MHS) staff working at Army installations and the factors that influence the development of burnout. MethodsAnonymous data was collected from 13,558 active-duty U.S. Soldiers and civilian MHS employees. Burnout was measured using the Copenhagen Burnout Inventory and the Mini-Z. ResultsResults showed nearly half of staff who responded (48%) reported being burned out, an increase since last measured in 2019 (31%). Factors related to increased burnout included concerns about work/life balance and workload, low job satisfaction and feeling disconnected from others. Burnout was associated with increases in adverse physical and behavioral health (BH) outcomes. ConclusionsResults indicate that burnout is a common problem across MHS Army staff and is related to significant adverse health consequences for the individual and reduced retention of staff for the organization. These findings highlight the need to address burnout through policies that standardize health care delivery policies and practices, providing support to leadership to promote a healthy workplace, and individual support to those who experience burnout.

Trends in Telehealth Care During the COVID-19 Pandemic for the Military Health System.

The COVID-19 pandemic generated a major shift from in-person to telehealth care in efforts to reduce the spread of infection. This study assesses the effects of COVID-19 on the provision of telehealth in the United States Military Health System (MHS), a universally-insured, nationally representative population of beneficiaries who may receive direct care (DC) at military facilities or in the private-sector care (PSC). Under a cross-sectional study design, we queried the MHS Data Repository for all telehealth services in the MHS from January 2019 to December 2021, using common procedure terminology code telehealth modifiers GT, GQ, and 95. Analyses were stratified by clinical, provider, and facility characteristics, and comparisons were made between telehealth rates before and during the COVID-19 period using a percent change. Telehealth usage increased by 20-fold in 2020 versus 2019, whereas provider types shifted from predominantly physicians to advanced practice nurses and physician assistants. Patterns of task shifting were different between DC and PSC. Tele-mental health visits showed a 118% change in DC and -20% change in PSC, suggesting recapture of care to military facilities. Decreases in DC telehealth visits for metabolic, endocrine, and musculoskeletal disorders were not compensated by increases in PSC, suggesting care deferred, delivered by another modality, or sought outside the MHS. The increase in telehealth usage and behavioral health is in line with other published studies, whereas the shift in provider types aligns with MHS goals focused on increasing access through telehealth. More research is needed to answer questions of care deferral, which are relevant to national health care discussions.

Post-lumbar surgery prescription variation and opioid-related outcomes in a large US healthcare system: an observational study

BACKGROUND CONTEXTSpinal decompression and fusion procedures are one of the most common procedures performed in the United States (US) and remain associated with high postsurgical opioid burden. Despite guidelines emphasizing nonopioid pharmacotherapy strategies for postsurgical pain management, prescribing practices are likely variable and guideline-incongruent. PURPOSEThe purpose of this study was to characterize patient-, care-, and system-level factors associated with opioid, nonopioid pain medication, and benzodiazepine prescribing variation in the US Military Health System (MHS). STUDY DESIGN/SETTINGRetrospective study analyzing medical records from the US MHS Data Repository. PATIENT SAMPLEAdult patients (N=6,625) undergoing lumbar decompression and spinal fusion procedures from 2016 to 2021 in the MHS enrolled in TRICARE at least a year prior to their procedure and had at least one encounter beyond the 90-day postprocedure period, without recent trauma, malignancy, cauda equina syndrome, and co-occurring procedures. OUTCOME MEASURESPatient-, care-, and system-level factors influencing outcomes of discharge morphine equivalent dose (MED), 30-day opioid refill, and persistent opioid use (POU). POU was defined as dispensing of opioid prescriptions monthly for the first 3 months after surgery and then at least once between 90 and 180 days after surgery. METHODS(Generalized) linear mixed models evaluated multilevel factors associated with discharge MED, opioid refill, and POU. RESULTSThe median discharge MED was 375 mg (IQR 225, 580) and days’ supply was 7 days (IQR 4, 10); 36% received an opioid refill and 5%, overall, met criteria for POU. Discharge MED was associated with fusion procedures (+151–198 mg), multilevel procedures (+26 mg), policy release (-184 mg), opioid naïvty (-31 mg), race (Black -21 mg, another race and ethnicity -47 mg), benzodiazepine receipt (+100 mg), opioid-only medications (+86 mg), gabapentinoid receipt (-20 mg), and nonopioid pain medications receipt (-60 mg). Longer symptom duration, fusion procedures, beneficiary category, mental healthcare, nicotine dependence, benzodiazepine receipt, and opioid naivety were associated with both opioid refill and POU. Multilevel procedures, elevated comorbidity score, policy period, antidepressant receipt, and gabapentinoid receipt, and presurgical physical therapy were also associated with opioid refill. POU increased with increasing discharge MED. CONCLUSIONSSignificant variation in discharge prescribing practices require systems-level, evidence-based intervention.

Naloxone Prescribing Associated With Reduced Emergency Department Visits in the Military Health System.

The aim was to determine the association between the receipt of naloxone and emergency department (ED) visits within 60 days after the receipt of an opioid. A retrospective cohort of individuals 18 years of age or above, enrolled in TRICARE, and were dispensed an opioid at any time from January 1, 2019, through September 30, 2020 was identified within the United States Military Health System. Individuals receiving naloxone within 5 days of the opioid dispensing date were propensity score matched with individuals receiving opioids only. A logistic regression was used to estimate the odds of an ED visit in the 60-day follow-up period after the index opioid dispense event among those co-dispensed naloxone and those receiving opioids only. Of the 2,136,717 individuals who received an opioid prescription during the study period, 800,071 (10.1%) met study inclusion criteria. Overall, 5096 (0.24%) of individuals who received an opioid prescription were co-dispensed naloxone. Following propensity score matching, those who received naloxone had a significantly lower odds of ED utilization in the 60 days after receiving an opioid prescription (odds ratio: 0.74, 95% CI: 0.68-0.80, P<0.001). This study highlights the importance of expanding access to naloxone in order to reduce ED utilization. Future research is needed to examine additional outcomes related to naloxone receipt and develop programs that make naloxone prescribing a routine practice.

Patient Compliance With Surveillance of Thyroid Nodules Classified as Atypia of Undetermined Significance.

To determine whether thyroid nodule surveillance compliance is influenced by patient demographics or plan type. Retrospective case series from 2010 to 2018. United States Military Health System. There were 481 patients with a thyroid nodule fine-needle aspiration classified as atypia of undetermined significance for whom treatment and follow-up information were available. Demographic information and surveillance plan type were extracted from the medical record and statistical analysis was performed to determine whether these characteristics influenced compliance rates. A total of 289 nodules were surveilled and 192 diagnostic lobectomies were performed. An initial surveillance plan was documented in 93% (268/289) and 86% (231/268) complied. The most common plans were repeat biopsy in 78% (210/268) or ultrasound in 20% (53/268). A second plan was documented in 88% (204/231) of those who complied with the first. The most common second plans were ultrasound in 87% (178/204) or repeat biopsy in 8% (17/204). Compliance with the second plan was 64% (130/204), significantly lower than with the first (OR 3.6, 95% CI: [2.3, 5.6], P < .0001). Only 45% (130/289) were surveilled twice. Age and gender did not significantly affect compliance rates. Compliance with primary care ultrasound surveillance was 40% (21/52), significantly lower than with a specialist (77% [137/179]; OR 4.8, 95% CI: [2.5, 9.3, P < .0001). Compliance with surveillance of thyroid nodules classified as atypia of undetermined significance was poor in this military cohort. Ultrasound surveillance by a specialist may be more reliable than with primary care.

Poster 147: Operative Treatment of Acromioclavicular Injuries in the Military: Trends and Complications

Objectives:To identify the demographics and characteristics of operative acromioclavicular joint separations, as well as characterize reconstruction techniques and associated complications.Methods:The United States Military Health System Data Repository was queried for patients with a Current Procedural Terminology (CPT) code for coracoclavicular ligament reconstruction between October 2013 and March 2020. Patient demographics, radiology and operative reports, and clinical notes were reviewed to characterize reconstruction techniques and associated postoperative complications.Results:A total of 956 coracoclavicular ligament reconstructions (896 primary repairs or reconstructions, 60 revision reconstructions) were performed between October 2013 and March 2020. The 896 primary coracoclavicular ligament reconstructions were indicated for a range of acromioclavicular joint separation severities: three grade two separations, 392 grade three separations, 48 grade four separations, and 386 grade 5 separations; the remaining 67 patients did not have a definitive injury grade defined by the treating surgeon. Of the primary procedures, 356 were performed acutely within 6 weeks of injury, while 538 were performed greater than 6 weeks after injury. Two hundred and twenty eight primary procedures were categorized as repairs, while 652 were categorized as reconstructions utilizing a graft. Following these procedures, there were 104 major complications requiring return to the operating room, including 48 symptomatic failures requiring revision, 18 fractures of the clavicle or coracoid, 25 deep surgical site infections and 9 cases of symptomatic hardware requiring removal of hardware, and 4 cases of adhesive capsulitis requiring manipulation under anesthesia. There were 160 minor postoperative complications, including 5 non-operative fractures of the clavicle or coracoid, 16 superficial surgical site infections, 7 cases of non-operative adhesive capsulitis, 57 cases of neuropathy, 1 deep venous thrombosis, and 74 cases of persistent acromioclavicular joint pain. There were no significant differences in complication rates between injury grade, acute versus chronic treatment, repair versus reconstruction, or suspensory versus non-suspensory technique. The rate of major complications was 1.8 per 100 person-years and the rate of minor complications was 2.77 per 100 person-years. The overall complication rate was 4.57 per 100 person-years. At the conclusion of the acromioclavicular joint separation care, 60 service members necessitated medical separation from the military.Conclusions:Coracoclavicular ligament reconstruction is a relatively common and safe procedure in a physically active population. The rate of major complication was 1.8 per 100 person-years, while the overall complication rate in our series was 4.57 complications per 100 person-years. Complications are rare, however, when they occur, they frequently require one or more secondary surgeries to treat.

All MCIDs Are Wrong, But Some May be Useful.

To demonstrate how to apply a baseline-adjusted receiver operator characteristic curve (AROC) analysis for minimum clinically important differences (MCIDs) in an empirical data set and discuss new insights relating to MCIDs. Retrospective study. This study includes data from 999 active-duty military service patients enrolled in the United States Military Health System's Military Orthopedics Tracking Injuries and Outcomes Network. Anchored MCIDs were calculated using the standard receiver operator characteristic analysis and the AROC analysis for the Patient-Reported Outcome Measure Information System (PROMIS) Pain Interference and Defense and Veterans Pain Rating Scale (DVPRS). Point estimates where confidence intervals (CIs) crossed the 0.5 identity line on the area-under-the-curve (AUC) analysis were considered statistically invalid. MCID estimates where CIs crossed 0 were considered theoretically invalid. In applying an AROC analysis, the region of AUC and MCID validity for the PROMIS Pain Interference score exists when the baseline score is greater than 61.0 but less than 72.3. For DVPRS, the region of MCID validity is when the baseline score is greater than 5.9 but less than 7.9. Baseline values influence not only the MCID but also the accuracy of the MCID. MCIDs are statistically and theoretically valid for only a discrete range of baseline scores. Our findings suggest that the MCID may be too flawed a construct to accurately benchmark treatment outcomes. J Orthop Sports Phys Ther 2022;52(6):401-407. doi:10.2519/jospt.2022.11193.

An Essential Guide to Chiropractic in the United States Military Health System and Veterans Health Administration

ObjectiveThe purpose of this article is to provide an essential overview of chiropractic services in United States military and veterans’ health care systems. MethodsWe reviewed literature, legislation, and policies from 1936 through September 2021 pertaining to chiropractic services in the United States military and veterans’ health systems. Using these sources and our combined experience in these systems, we identified fundamental themes in the delivery of chiropractic care in the health care systems of the Department of Defense (providing health care for active duty service members) and the Department of Veterans Affairs (providing health care for veterans) in main topic areas. ResultsWe identified 7 main topic areas relevant to the 2 systems: populations served by chiropractors; health care systems; integration; utilization and supply of chiropractic care; vetting of chiropractors; roles and evaluation of chiropractors; and oversight and leadership. Key information about chiropractic care in these systems was synthesized into the main topic areas. Benefits of high-quality within-system chiropractic care to active-duty service members and veterans are presented. The assets that within-system chiropractors bring to the Department of Defense and Department of Veterans Affairs health care systems are discussed for each main topic area. ConclusionThis article contains an essential overview of chiropractic services in the Department of Defense and the Department of Veterans Affairs. It offers clarity regarding the integration of chiropractic services into these health care systems and includes a 1-page brief of talking points that may help better inform ongoing discussions of chiropractic services in these 2 different but intertwined environments.

Delayed Rehabilitation Is Associated With Recurrence and Higher Medical Care Use After Ankle Sprain Injuries in the United States Military Health System.

To investigate the influence of time taken to begin musculoskeletal rehabilitation on injury recurrence and ankle-related medical care use at 1 year after ankle sprain. Retrospective cohort study of all beneficiaries of the US Military Health System seeking care for an ankle sprain over a 4-year period. Individuals were classified according to whether they did or did not receive physical rehabilitation. For those who received rehabilitation (n = 6150), linear relationships (with appropriate covariate controls) were analyzed with generalized linear models and generalized additive models to measure the effects of rehabilitation timing on injury recurrence and injury-related medical care use (costs and visits) at 1 year after injury. The nonlinear effect of rehabilitation timing on the probability of recurrence was assessed. Approximately 1 in 4 people received rehabilitation. The probability of ankle sprain recurrence increased for each day that rehabilitation was not provided during the first week. The probability of ankle sprain recurrence plateaued until about 2 months after initial injury, then increased again, with 2 times greater odds of recurrence compared to those who received physical rehabilitation within the first month. When rehabilitation care was delayed, recurrence (odds ratio [OR] = 1.28), number of foot/ankle-related visits (OR = 1.22), and foot/ankle-related costs increased (OR = 1.13; up to $1400 per episode). The earlier musculoskeletal rehabilitation care started after an ankle sprain, the lower the likelihood of recurrence and the downstream ankle-related medical costs incurred. J Orthop Sports Phys Ther 2021;51(12):619-627. doi:10.2519/jospt.2021.10730.

Rates of prescription orders for United States active duty service members diagnosed with alcohol use disorder

Background: Alcohol-use disorders (AUD) pose a significant challenge for the United States (US) military. The US Department of Defense has strongly recommended several medications for use in the treatment of patients with diagnosed AUD. This study assessed the prescription of medications for active duty service members (ADSMs) diagnosed with AUD in the US Military Health System (MHS). Methods: Rates of prescription orders were retrospectively examined from 2010 to 2017 among ADSMs with an incident diagnosis of moderate-to-severe AUD. The rate of prescription orders was defined as the proportion of ADSMs with an ICD-9 or ICD-10 diagnosis code of alcohol dependence who received an order for acamprosate, disulfiram, naltrexone, and/or topiramate at a military treatment facility in the year following their incident diagnosis. Results: ADSMs receiving an order for at least one medication in the year following their incident AUD diagnosis increased from 8.8% in 2010 to 16.2% in 2017 (RR = 1.84, 95% CI, 1.76, 1.93). Oral naltrexone was ordered most frequently among this patient population, while injectable naltrexone, a medication option meant to ease and improve adherence, was ordered for a smaller proportion of patients. Conclusions: Most ADSMs who might benefit from prescriptions for AUD are not receiving them as part of their treatment despite strong clinical evidence and Department of Defense policy support for their use among this cohort.

CORR Insights®: Institutional Experience and Orthoplastic Collaboration Associated with Improved Flap-based Limb Salvage Outcomes.

CORR Insights®: Institutional Experience and Orthoplastic Collaboration Associated with Improved Flap-based Limb Salvage Outcomes.

Chiropractic in the United States Military Health System: A 25th-Anniversary Celebration of the Early Years

ObjectiveThe purpose of this report is to record noteworthy events that occurred during the early years of chiropractic in the United States Military Health System (MHS). MethodsWe used mixed methods to create this historical account, including documents, artifacts, research papers, and reports from personal experiences. ResultsChiropractic care was first included in the MHS in 1995, after years of legislative activity. The initial program was a 3-year study of the feasibility and advisability of integrating chiropractic in the MHS. This period was called the Chiropractic Health Care Demonstration Project; 20 pioneering chiropractors began their MHS journeys at 10 military bases in fiscal year 1995. The Demonstration Project was extended for 2 more years to gather research data, and 3 additional military facilities were added during those years to accomplish that purpose. The Demonstration Project concluded in 1999. In 2000, Congress approved the development of permanent chiropractic services and benefits for members of the uniformed services. These new clinics opened in 2002. ConclusionThis is the first article to chronicle the history of chiropractic in the MHS, and highlights some of the important events in the early years of chiropractors working within the MHS. Because of the efforts of the early MHS chiropractors to pave the way for a permanent chiropractic benefit for the deserving members of the United States uniformed services, chiropractic care is now offered at more than 60 United States military facilities.

Examining Racial Disparities in Diabetes Readmissions in the United States Military Health System.

Diabetes is one of the most common chronic conditions in the United States and has a cost burden over $120 billion per year. Readmissions following hospitalization for diabetes are common, particularly in minority patients, who experience greater rates of complications and lower quality healthcare compared to white patients. This study examines disparities in diabetes-related readmissions in the Military Health System, a universally insured, population of 9.5 million beneficiaries, who may receive care from military (direct care) or civilian (purchased care) facilities. The study identified a population of 7,605 adult diabetic patients admitted to the hospital in 2014. Diagnostic codes were used to identify hospital readmissions, and logistic regression was used to analyze associations among race, beneficiary status, patient or sponsor's rank, and readmissions at 30, 60, and 90 days. A total of 239 direct care patients and 545 purchased care patients were included in our analyses. After adjusting for age and sex, we found no significant difference in readmission rates for black versus white patients; however, we found a statistically significant increase in the likelihood for readmission of Native American/Alaskan Native patients compared to white patients, which persisted in direct care at 60 days (adjusted odds ratio [AOR] 11.51, 95% CI 1.11-119.41) and 90 days (AOR 18.42, 95% CI 1.78-190.73), and in purchased care at 90 days (AOR 4.54, 95% CI 1.31-15.74). Our findings suggest that universal access to healthcare alleviates disparities for black patients, while Native America/Alaskan Native populations may still be at risk of disparities associated with readmissions among diabetic patients in both the closed direct care system and the civilian fee for service purchased care system.