US Military Health Research Articles

Outcomes of Triceps Rupture in the US Military: Minimum 2-Year Follow-up.

The objective of this study was to examine the subjective and objective midterm functional clinical outcomes of surgically repaired triceps injuries in a moderate- to high-demand population. The US Military Health System was queried to identify all surgically treated triceps tendon ruptures between 2008 and 2013. Primary endpoints included rates of rerupture, perioperative complications, or significant persistent elbow dysfunction; Disability of the Arm, Shoulder and Hand (DASH) score, Mayo Elbow score, and ability to do push-ups were also extracted. Thirty-seven patients underwent triceps tendon repair with a mean follow-up of 49.8 ± 17.3 months (range: 26.8-80.2). The most common mechanisms of injury were military duties (27%), sporting activity (24%), or fall-related (21.6%), with most injuries occurring during an eccentric movement (54%). While 45% experienced occasional elbow pain postoperatively, only 1 patient (2.7%) had a rerupture. Despite this, at 2 years, 31 patients (84%) were able to return to full military duty. While 6 patients were discharged from military service, only 1 underwent medical separation while 5 retired for reasons unrelated to their triceps tendon rupture. Patient-reported outcomes were available for 14 patients at final follow-up. The average DASH and Mayo Elbow scores were 4.7 (SD ± 4.7, range: 0-15.9) and 85.4 (SD ± 11.7, range: 60-100), respectively. The cohort could perform mean 54.2 (range: 9-90) push-ups. In additional, 12 of 14 (85.7%) were satisfied with their elbow function. The active duty cohort experienced excellent postoperative results with a high rate of return to military duty, despite nearly half of the patients recognizing some degree of activity-related, elbow pain.

Sleep medicine is coming of age in military medicine : Report from the Military Health System Research Symposium (2017) in Kissimmee, Florida.

In August 2017, the US Military Health System held its sixth annual Research Symposium for medical researchers from the US Army, Navy, Air Force, and Public Health Service. The symposium provides a collaborative environment for academia, industry, and military researchers who address advancement in areas of Combat Casualty Care, Military Operational Medicine, Clinical and Rehabilitative Medicine, and Military Infectious Diseases. This year, Sleep Medicine received substantial attention with presentations scattered throughout the program, poster presentations as well as a scheduled breakout session with podium presentations. A brief description of the breakout session follows.

Epidemiology and Outcomes of Clostridium difficile Infection in Hospitalized Patients within the US Military Health Care System

Background Clostridium difficile infection (CDI) has become an emerging epidemic in the healthcare community. Our study aims to characterize the epidemiology and measure the attributable cost, length of stay, and in-hospital mortality of CDI among hospitalized patients in the US military health system (MHS).MethodsWe performed a retrospective cohort study of patients with CDI using MHS database billing records. Cases included all active duty patients, their dependents, or retirees admitted to a US military treatment facility for ≥2 days from October 2008 to September 2015 with a stool sample positive for Clostridium difficile via enzyme immunoassay, tissue cytotoxin assay, toxigenic culture, or polymerase chain reaction (PCR). Patient case-mix adjusted outcomes including in-hospital mortality, length of stay, and hospitalization cost were evaluated by high-dimensional propensity score adjusted logistic regression.ResultsAmong 1,156,672 admissions within the MHS from 2008–2015, we identified 1,640 (0.14%) patients with CDI and found a significant increase in the trend of CDI over the 7-year study period (P < 0.001). Median age (IQR) was 63 (41–76) in the CDI hospitalized group and 26 (6–46) in the non-CDI hospitalized group. Male gender was a risk factor for CDI (unadjusted odds ratio, 1.94; 95% confidence interval 1.76–2.14) and the majority of patients (84.5%) were associated with large-size medical centers. Patients hospitalized with CDI had significantly higher hospitalization cost (attributable difference [AD] $51,959, P < 0.001), prolonged hospital stay (AD 11.8 days, P < 0.001), and in-hospital mortality (case-mix adjusted odds ratio 3.28; 95% confidence interval 2.69–4.00).ConclusionCDI in hospitalized patients within the MHS is associated with advanced age, large medical centers, and an increased length of stay, hospital cost, and in-hospital mortality. We identified a significantly increased burden of hospitalization among patients admitted with CDI, highlighting the importance of infection control and antimicrobial stewardship initiatives aimed at decreasing the spread of this pathogen.Disclosures All authors: No reported disclosures.

CDC Screening Recommendation for Baby Boomers and Hepatitis C Virus Testing in the US Military Health System.

Chronic hepatitis C virus (HCV) is the most common blood-borne infection in the United States, with an estimated 2.7 to 3.9 million cases as of 2014. In August 2012, the Centers for Disease Control and Prevention (CDC) recommended 1-time HCV testing of all baby boomers. The objectives of this study were to (1) determine the proportion of people screened for HCV in the US Department of Defense Military Health System before and after the CDC screening recommendation for baby boomers and (2) assess whether certain patient or system factors were associated with screening for HCV before and after August 2012. We used a dataset containing 5% of beneficiaries randomly selected from the Military Health System Data Repository medical claims database for the period July 2011 through September 2013. Of 108 223 people eligible for HCV screening during the first period (July 2011 through July 2012), 1812 (1.7%) were screened. Of 109 768 people eligible during the second period (September 2012 through September 2013), 2599 (2.4%) were screened. HCV screening receipt was related to benefit type (Prime before August 2012: adjusted odds ratio [aOR] = 2.16; 95% confidence interval [CI], 1.89-2.46; Prime after August 2012: aOR = 1.93; 95% CI, 1.73-2.16) and care source (direct care before August 2012: aOR = 1.80; 95% CI, 1.57-2.07; direct care after August 2012: aOR = 2.45; 95% CI, 2.18-2.75); male sex (aOR = 1.17; 95% CI, 1.06-1.29) and black race (aOR = 1.20; 95% CI, 1.05-1.37) were associated with HCV testing only before August 2012. Interventions should be implemented to increase awareness and knowledge of the current national HCV testing recommendation among baby boomers to seek out testing and health care providers to perform screening.

Pre-End-Stage Renal Disease Care and Early Survival among Incident Dialysis Patients in the US Military Health System

Background: Previous reports showed an increased early mortality after chronic dialysis initiation among the end-stage renal disease (ESRD) population. We hypothesized that ESRD patients in the Military Health System (MHS) would have greater access to pre-ESRD care and hence better survival rates during this early high-risk period. Methods: In this retrospective cohort study, using the US Renal Data System database, we identified 1,256,640 patients initiated on chronic dialysis from January 2, 2004 through December 31, 2014, from which a bootstrap sample of 3,984 non-MHS incident dialysis patients were compared with 996 MHS patients. We assessed care by a nephrologist and dietitian, erythropoietin administration, and vascular access use at dialysis initiation as well as all-cause mortality as outcome variables. Results: MHS patients were significantly more likely to have had pre-ESRD nephrology care (adjusted OR [aOR] 2.9; 95% CI 2.3-3.7) and arteriovenous fistula used at dialysis initiation (aOR 2.2; 95% CI 1.7-2.7). Crude mortality rates peaked between the 4th and the 8th week for both cohorts but were reduced among MHS patients. The baseline adjusted Cox model showed significantly lower death rates among MHS vs. non-MHS patients at 6, 9, and 12 months. This survival advantage among MHS patients was attenuated after further adjustment for pre-ESRD nephrology care and dialysis vascular access. Conclusions: MHS patients had improved survival within the first 12 months compared to the general ESRD population, which may be explained in part by differences in pre-ESRD nephrology care and vascular access types.

Metformin use and survival after non-small cell lung cancer: A cohort study in the US Military health system.

Research suggests that metformin may be associated with improved survival in cancer patients with type II diabetes. This study assessed whether metformin use after non-small cell lung cancer (NSCLC) diagnosis is associated with overall survival among type II diabetic patients with NSCLC in the U.S. military health system (MHS). The study included 636 diabetic patients with histologically confirmed NSCLC diagnosed between 2002 and 2007, identified from the linked database from the Department of Defense's Central Cancer Registry (CCR) and the Military Health System Data Repository (MDR). Time-dependent multivariate Cox proportional hazards models were used to assess the association between metformin use and overall survival during follow-up. Among the 636 patients, 411 died during the follow-up. The median follow-up time was 14.6 months. Increased post-diagnosis cumulative use (per 1 year of use) conferred a significant reduction in mortality (adjusted hazard ratio (HR) = 0.76; 95% CI = 0.65-0.88). Further analysis by duration of use revealed that compared to non-users, the lowest risk reduction occurred among patients with the longest duration of use (i.e. use for more than 2 years) (HR = 0.19; 95% CI = 0.09-0.40). Finally, the reduced mortality was particularly observed only among patients who also used metformin before lung cancer diagnosis and among patients at early stage of diagnosis. Prolonged duration of metformin use in the study population was associated with improved survival, especially among early stage patients. Future research with a larger number of patients is warranted.

Enhancing mHealth Technology in the Patient-Centered Medical Home Environment to Activate Patients With Type 2 Diabetes: A Multisite Feasibility Study Protocol.

BackgroundThe potential of mHealth technologies in the care of patients with diabetes and other chronic conditions has captured the attention of clinicians and researchers. Efforts to date have incorporated a variety of tools and techniques, including Web-based portals, short message service (SMS) text messaging, remote collection of biometric data, electronic coaching, electronic-based health education, secure email communication between visits, and electronic collection of lifestyle and quality-of-life surveys. Each of these tools, used alone or in combination, have demonstrated varying degrees of effectiveness. Some of the more promising results have been demonstrated using regular collection of biometric devices, SMS text messaging, secure email communication with clinical teams, and regular reporting of quality-of-life variables. In this study, we seek to incorporate several of the most promising mHealth capabilities in a patient-centered medical home (PCMH) workflow.ObjectiveWe aim to address underlying technology needs and gaps related to the use of mHealth technology and the activation of patients living with type 2 diabetes. Stated differently, we enable supporting technologies while seeking to influence patient activation and self-care activities.MethodsThis is a multisite phased study, conducted within the US Military Health System, that includes a user-centered design phase and a PCMH-based feasibility trial. In phase 1, we will assess both patient and provider preferences regarding the enhancement of the enabling technology capabilities for type 2 diabetes chronic care management. Phase 2 research will be a single-blinded 12-month feasibility study that incorporates randomization principles. Phase 2 research will seek to improve patient activation and self-care activities through the use of the Mobile Health Care Environment with tailored behavioral messaging. The primary outcome measure is the Patient Activation Measure scores. Secondary outcome measures are Summary of Diabetes Self-care Activities Measure scores, clinical measures, comorbid conditions, health services resource consumption, and technology system usage statistics.ResultsWe have completed phase 1 data collection. Formal analysis of phase 1 data has not been completed. We have obtained institutional review board approval and began phase 1 research in late fall 2016.ConclusionsThe study hypotheses suggest that patients can, and will, improve their activation in chronic care management. Improved activation should translate into improved diabetes self-care. Expected benefits of this research to the scientific community and health care services include improved understanding of how to leverage mHealth technology to activate patients living with type 2 diabetes in self-management behaviors. The research will shed light on implementation strategies in integrating mHealth into the clinical workflow of the PCMH setting.Trial RegistrationClinicalTrials.gov NCT02949037. https://clinicaltrials.gov/ct2/show/NCT02949037. (Archived by WebCite at http://www.webcitation.org/6oRyDzqei)

Abstract TMP79: Does Race or Socioeconomic Class Matter in Socialized Medicine? A Retrospective Analysis of Stroke cost and outcomes in US Military Health Care System

Introduction: The racial disparity of stroke outcomes is well documented in the US Civilian Healthcare system. In contrast, the Military Healthcare system is a single payer system (Every member has the same health benefits). Does this affect outcomes? Hypothesis: We hypothesize there will be no difference in Healthcare outcomes within the Military Healthcare system when the effects of race and rank (socioeconomic surrogate) are considered. Methods: Data was collected from the Defense Health Agency Military Mart (M2) database from fiscal year 2010 to 2016 (All admissions to military care facilities). The M2 database stores data including rank and race. Adult patients with a primary diagnosis of stroke at discharge (International Classification of Diseases, 9th Revision codes 434.91, 434.11 or 10 th Revision code I63.9) were reviewed. Race and Rank were compared for Duration of hospitalization, total Cost of the hospitalization and Outcome (disposition status) using Multivariate Analysis. Results: A total of 3,910 patients discharged from Military hospitals were identified. The racial composition of this sample was: White 50.1%, Black 17.3%, Asian 7.2%, Other 2.9%, and Unknown/Not Reported 22.5%. There was no correlation between race and Duration of hospitalization, total Cost of the hospitalization or Outcome. Military Rank was identified with 2,134 (54.6%) of the 3,910 patients in the study. The Rank identified study population was: Senior Enlisted 71.4%, Senior Officers 18.2%, Junior Enlisted 4.9%, Junior Officers 2.9% and Warrant Officers 2.5%. There was no correlation between Rank and Duration of hospitalization or total Cost of the hospitalization. There was a statistically significant trend to better Outcome for higher rank then lower (p&lt;0.05). Conclusions: Racial disparities evident in the Civilian Healthcare system do not appear to transfer to the Military Healthcare system. Rank (as a socioeconomic surrogate) did have a trend toward better Outcomes with higher rank.

Abstract WP196: Can being Married Save the Healthcare System Money? A Retrospective Analysis of Stroke Admission in US Military Health Care System

Introduction: The role of gender and age is well documented with disparities noted in Duration of hospitalization, total Cost of hospitalization and Outcome in stroke patients. The military healthcare system database was reviewed to determine if marital status was risk factor for any of these three criteria. Hypothesis: We hypothesize that being unmarried would be correlated with an increase in Duration of hospitalization and total Cost of the hospitalization. Methods: Data was collected from the Defense Health Agency Military Mart (M2) database from fiscal year 2010 to 2016. The M2 database stores data including age, gender and marital status. Adult patients with a primary diagnosis of stroke at discharge (International Classification of Diseases, 9th Revision codes 434.91, 434.11 or 10 th Revision code I63.9) were reviewed. Age, Gender and Marital Status were compared for Duration of hospitalization, total Cost of hospitalization and Outcome using Multivariable Analysis. Results: A total of 3,910 patients discharged from Military hospitals were identified. The Marital status of this sample was: Married 67.1%, Widowed 12.4%, Single 4.7%, Legally Separated 0.5%, and Unknown/Not Reported 4.7%. There was a significant correlation between Marital Status and Duration of hospitalization (average of 1.2 fewer hospital days/patient, P-value &lt;0.01) and total Cost of hospitalization ($1,088 less/patient even after controlling for the shorter hospital stay (P-value &lt;0.05). There was no significant correlation for Marital Status with Outcome. There was a significant correlation between age and increased Duration of hospitalization and worse Outcome. There was no correlation of age with total Cost of hospitalization when we controlled for duration of hospitalizing. There was no correlation for gender with for Duration of hospitalization or total Cost of hospitalization. There was a small, statistically significant correlation of female gender and worse Outcomes (p-value &lt; 0.02). Conclusions: Unmarried status is an independent risk factor for increased Duration of hospitalization and total Cost of hospitalization. Older age is a risk factor for increased Duration of hospitalization and worse Outcome. Female gender is a risk factor for worse Outcomes.

Traumatic Brain Injury Incidence, Clinical Overview, and Policies in the US Military Health System Since 2000.

Exposure to explosive armaments during Operation Iraqi Freedom and Operation Enduring Freedom contributed to approximately 14% of the 352 612 traumatic brain injury (TBI) diagnoses in the US military between 2000 and 2016. The US Department of Defense issued guidelines in 2009 to (1) standardize TBI diagnostic criteria; (2) classify TBI according to mechanism and severity; (3) categorize TBI symptoms as somatic, psychological, or cognitive; and (4) systematize types of care given during the acute and rehabilitation stages of TBI treatment. Polytrauma and associated psychological and neurologic conditions may create barriers to optimal rehabilitation from TBI. Given the completion of recent combat operations and the transition of TBI patients into long-term care within the US Department of Veterans Affairs system, a review of the literature concerning TBI is timely. Long-term follow-up care for patients who have sustained TBI will remain a critical issue for the US military.

Epidemiology, Associated Conditions, and Outcomes of Hospital Associated Vancomycin-Resistant Enterococcus Infections in the US Military Health Care System

BackgroundBetter strategies to combat vancomycin-resistant Enterococcus (VRE) infections are needed. Our study aims to characterize the epidemiology and associated conditions, and to measure the attributable cost, length of stay, and in-hospital mortality of VRE infections among hospitalized patients in the US military health system (MHS).MethodsWe performed a retrospective cohort study of patients with VRE infections using MHS database billing records. Cases included all patients admitted to a military treatment facility for ≥2 days from October 2008 to September 2015 with a clinical culture growing Enterococcus faecalis, Enterococcus faecium or Enterococcus species (unidentified), reported as resistant to vancomycin. Comorbid conditions and procedures associated with VRE infection were identified by multivariable logistic regression. Patient case-mix adjusted outcomes including in-hospital mortality, length of stay, and hospitalization cost were evaluated by high-dimensional propensity score adjusted logistic regression.ResultsDuring the 7-year study period and among 1,161,335 hospitalized patients within the MHS, we identified 577 (0.050%) patients with VRE infection. A majority of VRE infections were urinary tract infections (57.7%), followed by bloodstream (24.7%), other site/device-related (12.9%), respiratory (2.9%), and wound infections (1.8%). Risk factors for VRE infection included invasive gastrointestinal and urologic procedures, tracheostomy, as well as recent exposure to glycopeptides and extended-spectrum penicillins. Patients hospitalized with VRE infection had significantly higher hospitalization cost (attributable difference [AD] $117,322, P < 0.001), prolonged hospital stay (AD 20.45 days, P < 0.001, and in-hospital mortality (case-mix adjusted odds ratio 5.77; 95% confidence interval 4.59–7.25).ConclusionVRE infection in hospitalized patients is associated with an increased length of stay, hospital cost, and in-hospital mortality. Active surveillance and infection control efforts should target those identified as high-risk for VRE infection. Antimicrobial stewardship programs should focus on limiting exposure to vancomycin and extended-spectrum penicillins.Disclosures All authors: No reported disclosures.

Clinical Characteristics, Risk Factors, and Outcomes of Carbapenem-Resistant Enterobacteriaceae Infection among Patients Hospitalized in the US Military Health System

Clinical Characteristics, Risk Factors, and Outcomes of Carbapenem-Resistant Enterobacteriaceae Infection among Patients Hospitalized in the US Military Health System

Changing Susceptibility of Staphylococcus aureus in a US Pediatric Population.

Staphylococcus aureus is a major cause of infection in both adult and pediatric populations. After several decades of increasing prevalence, the proportion of S aureus infections due to methicillin-resistant S aureus has been reported to be in decline in adults. Data for similar changes in pediatric populations are limited. Evaluation of S aureus susceptibility data for pediatric patients receiving care in the US Military Health System was performed. Microbiology and demographic data were collected for years 2005 through 2014. Trends in antibiotic susceptibility results were evaluated. Clinical and demographic characteristics were explored to assess for association with antibiotic susceptibilities. In this study, 41 745 S aureus isolates from 39 207 pediatric patients were included. An overall increase in susceptibility of isolates to oxacillin was noted over this 10-year period; with over 60% of isolates oxacillin-susceptible in 2014. S aureus susceptibility to clindamycin declined over the study period; notably methicillin-susceptible S aureus susceptibility to clindamycin declined from 90% to 83% (P < .0001). Differences in oxacillin susceptibility between US regions decreased over time. Similar to recent trends seen in adults, the proportion of pediatric S aureus infections secondary to methicillin-resistant S aureus appear to be decreasing, as is variability in US geographical resistance rates. Increasing clindamycin resistance among methicillin-susceptible S aureus should raise caution in the use of empirical clindamycin in presumed S aureus infection. Clinicians should be aware of regional susceptibility patterns when choosing empirical regimens.

Association of prematurity with the development of infantile hypertrophic pyloric stenosis

Infantile hypertrophic pyloric stenosis (IHPS) has several known risk factors. The association between prematurity and IHPS and the timeline of presentation are poorly defined. Our aim was to evaluate the associations between IHPS and prematurity. We performed a retrospective cohort study of 1,074,236 children born between June 2001 and April 2012 in the US Military Health System. IHPS cases and gestational ages (GA) were identified using billing codes. Additional risk factors for IHPS were controlled for in a multivariable logistic regression model. The incidence of IHPS was 2.99 per 1,000 in preterm infants and 2.25 per 1,000 in full term (relative risk (RR) = 1.33, 95% confidence interval (CI) 1.16-1.54). The adjusted odds ratio for prematurity was 1.26 (95% CI 1.08-1.46). The median (interquartile range (IQR)) chronological age at presentation was 40 d (30-56) in preterm infants vs. 33 d (26-45) in full term (P < 0.001). Median postmenstrual age at presentation was 42 wk in preterm infants (40-42) vs. 45 wk (44-46) in full term (P < 0.001). Prematurity is associated with IHPS. Premature infants develop IHPS at a later chronological age, but earlier postmenstrual age, than term infants. Providers should have an increased concern for IHPS development in premature infants.

P-024 YI The Incidence of Crohn’s Disease and Rate of Early Surgery in the U.S. Military Health Care System

Surgery is often required to treat complications of Crohn's Disease (CD) such as medically refractory inflammation, fistulas or strictures. Surgical intervention, especially early in the disease course, may be decreasing with the advent of more effective medical therapy for CD as gastroenterologists rely more readily on immunosuppressive strategies before referring for surgery. The US Military Health System (MHS) has a diverse population of patients with equal access, and the direct care military treatment facilities (MTF) utilize the same electronic medical record (EMR) nationwide. The aim of this study was to calculate the incidence of CD in a nationwide military population and to further characterize the CD population, while also assessing outcomes such as surgery, hospitalization and emergency room visits during the first 2 years of disease. Using the EMR and healthcare claims databases under the MHS Data Repository (MDR), the total number of new diagnoses of CD were examined from 2009 to 2012. The data collected were derived from a nationwide network of military treatment facilities and included a total study population of 3.2 million. For each new diagnosis of CD, demographic variables, basic laboratory data, other chronic comorbidities, and serious associated diseases or complications were analyzed. Outcomes such as ER visits, admissions, surgeries and deaths were also recorded up to 2 years from the time of diagnosis. Seven hundred and three new diagnoses of Crohn’s disease were identified. The average annual incidence of CD was 7.3 per 100,000 patients per year. Fifty-two percent of patients were male. Fifty-three percent of patients were under the age of 35. Within two years of diagnosis, 9% patients underwent surgery for CD with an average annual rate of 1 surgery for every 11 new diagnoses per year. Within two years of diagnosis, 38% of patients were admitted to the hospital (71% of these admissions were directly related to CD). Seven percent of patients were admitted to the ICU and 64% were seen in the ER. Two percent required total parenteral nutrition. No patients died. Three percent of patients were diagnosed with Clostridium difficile colitis. Two percent of patients had a pulmonary embolism or deep vein thrombosis. Our study shows a similar incidence rate of CD compared to an earlier large population study in the US (7.3/100,000 compared to 7.9/100,000), which suggests a stable incidence over time. The early surgery rate in our study is lower than that found in other published studies. This may correlate with a trend of decreasing reliance on surgery in the era of biologic medications. Our hospitalization rate is slightly higher than that reported in an earlier study in Olmsted County (32% at 1 year), but lower than that reported in an earlier study from Denmark (83% at 1 year) which indicates that treatments are more effective, but the disease still portends significant morbidity and utility of healthcare resources. Further research may help further elucidate the effects that the biologic agents have had in improving outcomes and reducing surgery in non-referral centers.

US Military Primary Care: Problems, Solutions, And Implications For Civilian Medicine

The US Military Health System (MHS), which is responsible for providing care to active and retired members of the military and their dependents, faces challenges in delivering cost-effective, high-quality primary care while maintaining a provider workforce capable of meeting both peacetime and wartime needs. The MHS has implemented workforce management strategies to address these challenges, including "medical home" teams for primary care and other strategies that expand the roles of nonphysician providers such as physician assistants, nurse practitioners, and medical technicians. Because these workforce strategies have been implemented relatively recently, there is limited evidence of their effectiveness. If they prove successful, they could serve as a model for the civilian sector. However, because the MHS model features a broad mix of provider types, changes to civilian scope-of-practice regulations for nonphysician providers would be necessary before the civilian provider mix could replicate that of the MHS.

STRESS AND WAR: THE LIMITS OF NEUROPSYCHIATRY

Professor Neil Greenberg is an academic psychiatrist based at King's College London UK and is a consultant occupational and forensic psychiatrist. Neil served in the United Kingdom Armed Forces for...

Epidemiology of Staphylococcus aureus Blood and Skin and Soft Tissue Infections in the US Military Health System, 2005-2010

Rates of hospital-onset methicillin-resistant Staphylococcus aureus (MRSA) infections are reported as decreasing, but recent rates of community-onset S. aureus infections are less known. To characterize the overall and annual incidence rates of community-onset and hospital-onset S. aureus bacteremia and skin and soft tissue infections (SSTIs) in a national health care system and to evaluate trends in the incidence rates of S. aureus bacteremia and SSTIs and the proportion due to MRSA. Observational study of all Department of Defense TRICARE beneficiaries from January 2005 through December 2010. Medical record databases were used to identify and classify all annual first-positive S. aureus blood and wound or abscess cultures as methicillin-susceptible S. aureus or MRSA, and as community-onset or hospital-onset infections (isolates collected >3 days after hospital admission). Unadjusted incidence rates per 100,000 person-years of observation, the proportion of infections that was due to MRSA, and annual trends for 2005 through 2010 (examined using the Spearman rank correlation test or the Mantel-Haenszel χ2 test for linear trend). During 56 million person-years (nonactive duty: 47 million person-years; active duty: 9 million person-years), there were 2643 blood and 80,281 wound or abscess annual first-positive S. aureus cultures. Annual incidence rates varied from 3.6 to 6.0 per 100,000 person-years for S. aureus bacteremia and 122.7 to 168.9 per 100,000 person-years for S. aureus SSTIs. The annual incidence rates for community-onset MRSA bacteremia decreased from 1.7 per 100,000 person-years (95% CI, 1.5-2.0 per 100,000 person-years) in 2005 to 1.2 per 100,000 person-years (95% CI, 0.9-1.4 per 100,000 person-years) in 2010 (P = .005 for trend). The annual incidence rates for hospital-onset MRSA bacteremia also decreased from 0.7 per 100,000 person-years (95% CI, 0.6-0.9 per 100,000 person-years) in 2005 to 0.4 per 100,000 person-years (95% CI, 0.3-0.5 per 100,000 person-years) in 2010 (P = .005 for trend). Concurrently, the proportion of community-onset SSTI due to MRSA peaked at 62% in 2006 before decreasing annually to 52% in 2010 (P < .001 for trend). In the Department of Defense population consisting of men and women of all ages from across the United States, the rates of both community-onset and hospital-onset MRSA bacteremia decreased in parallel, while the proportion of community-onset SSTIs due to MRSA has more recently declined.

Adolescent Caesarean Delivery in the US Military Health Care System

Objectives Determine cesarean delivery (CD) rates and associated demographics among military dependent teenagers. Methods United States military health care claims records of live births from 2003-2006 to 13- through 19-year-old dependent children were analyzed using logistic regression. Results The CD rate rose from 17% in 2003 to 20% in 2006. Rates were significantly higher for ages 18 and 19, for African American sponsors' children, and those who gave birth in a civilian facility. Rates did not differ significantly by sponsor's military rank. Conclusions Teenagers in the military health care system have increasing rates of CD. Independent demographic risk factors for teenage CD include age > 17 years, sponsor's race African American, and delivery at a civilian facility.

A retrospective analysis of extended-interval dosing and the impact on bisphosphonate compliance in the US Military Health System

This study evaluated whether patients treated with bisphosphonates in the US Military Health System were more compliant with treatment given monthly versus weekly. While medication compliance did improve with treatment given monthly, overall compliance with bisphosphonates was still suboptimal suggesting the need for further strategies to improve compliance with treatment for osteoporosis. The study objective was to evaluate the relationship between bisphosphonate dosing interval and medication compliance among new users initiating oral bisphosphonates. We conducted a retrospective observational cohort study of administrative claims data in the US Military Health System to examine medication compliance among 22,363 new users of oral bisphosphonates starting weekly (68%) or monthly (32%) therapy. Medication compliance during the first year of treatment was measured using two methods: (1) medication possession ratio (MPR) with compliance defined as ≥80% of days covered and (2) time to first gap of more than 30 days following initiation. Logistic regression and a proportional hazards model were used to detect differences in medication compliance between cohorts. After the first year of therapy, 57% of subjects were not compliant with bisphosphonates (MPR <80%), while 84% experienced a gap in treatment of more than 30 days. After adjustment for study covariates, the odds of a patient being compliant with treatment was 21% higher among monthly users compared to weekly users (OR 1.207, 95% confidence interval (CI) 1.119-1.257). Similarly, the risk of experiencing a 30-day gap in treatment was 6% lower among monthly users compared to weekly users (HR 0.934, 95% CI 0.905-0.964). Patients receiving oral bisphosphonates on a monthly basis showed higher rates of medication compliance compared to weekly dosing in our study. However, compliance with bisphosphonates among all new users was suboptimal, suggesting the need for improved strategies to enhance compliance with oral bisphosphonates in the US Military Health System.