Racial Disparities in Highly Effective Contraceptive Use Among U.S. Active Duty Servicewomen, Fiscal Years 2016-2019.

Background: Previous studies have found that unintended pregnancy rates are higher among racial minorities and active duty servicewomen (ADSW), correlating with lower rates of effective contraceptive use. The Military Health System (MHS) provides universal health care benefit coverage for all ADSW, including access to all highly effective contraceptive (HEC) methods. This study investigated the association between race and HEC use among ADSW. Materials and Methods: We conducted a cross-sectional study using fiscal year 2016-2019 data from the MHS Data Repository for all ADSW ages 18-45 years. Statistical analyses included descriptive statistics and logistic regression models, adjusted and unadjusted, determining the odds of HEC use, overall and by method. Results: Of the 729,722 ADSW included in the study, 59.7% used at least one HEC during the study period. The highest proportions of users were aged 20-24 years, White, single, Junior Enlisted, and serving in the Army. Lower odds of HEC use were demonstrated in Black (odds ratio [OR] = 0.94, 95% confidence interval [CI] = 0.92-0.95), American Indian/Alaska Native (OR = 0.85, 95% CI = 0.82-0.89), Asian/Pacific Islander (OR = 0.81, 95% CI = 0.80-0.83), and Other (OR = 0.97, 95% CI = 0.94-0.99) ADSW compared with White ADSW. Conclusions: Universal coverage of this optional preventive service did not guarantee its use. The MHS can serve as a model for monitoring racial disparities in HEC use.

Reductions in sustained prescription opioid use within the US between 2017 and 2021.

Over the last decade, various efforts have been made to curtail the opioid crisis. The impact of these efforts, since the onset of the COVID-19 pandemic, has not been well characterized. We sought to develop national estimates of the prevalence of sustained prescription opioid use for a time period spanning the COVID-19 pandemic (2017-2021). We used TRICARE claims data (fiscal year 2017-2021) to identify patients who were prescription opioid non-users prior to receipt of a new opioid medication. We evaluated eligible patients for subsequent sustained prescription opioid use. The prevalence of sustained prescription opioid use during 2020-2021 was compared to 2017-2019. We performed multivariable logistic regression analyses to adjust for confounding. We performed secondary analyses that accounted for interactions between the time period and age, as well as a proxy for socioeconomic status. We determined there was a 68% reduction in the odds of sustained prescription opioid use (OR 0.32; 95% CI 0.27, 0.38; p < 0.001) in 2020-2021 as compared to 2017-2019. Significant reductions were identified across all US census divisions and all patient age groups. In both time periods, the plurality of encounters associated with initial receipt of an opioid that culminated in sustained prescription opioid use were associated with non-specific primary diagnoses. We found significant reductions in sustained prescription opioid use in 2020-2021 as compared to 2017-2019. The persistence of prescribing behaviors that result in issue of opioids for poorly characterized conditions remains an area of concern.

Changes in Surgical Volume in Military Medical Treatment Facilities and Military Surgeon Clinical Combat Readiness During the COVID-19 Pandemic.

Mini-abstract In this retrospective study, we evaluated changes in measures of surgeon clinical combat readiness within the military health system during the COVID-19 pandemic. We found a 36% reduction in surgical knowledge and skills as compared to pre-COVID. Sizable reductions were encountered for surgery for colectomy (-50%) and aneurysm repair (-61%).

Validation of the Stopping Opioids After Surgery (SOS) Score for the Sustained Use of Prescription Opioids Following Orthopaedic Surgery.

BACKGROUND: The Stopping Opioids after Surgery (SOS) score was developed to identify patients at risk for sustained opioid use following surgery. The SOS score has not been specifically validated for patients in a general orthopaedic context. Our primary objective was to validate the SOS score within this context. METHODS: In this retrospective cohort study, we considered a broad array of representative orthopaedic procedures performed between January 1, 2018, and March 31, 2022. These procedures included rotator cuff repair, lumbar discectomy, lumbar fusion, total knee and total hip arthroplasty, open reduction and internal fixation (ORIF) of ankle fracture, ORIF of distal radial fracture, and anterior cruciate ligament reconstruction. The performance of the SOS score was evaluated by calculating the c-statistic, receiver operating characteristic curve, and the observed rates of sustained prescription opioid use (defined as uninterrupted prescriptions of opioids for ≥90 days) following surgery. For our sensitivity analysis, we compared these metrics among various time epochs related to the COVID-19 pandemic. RESULTS: A total of 26,114 patients were included, of whom 51.6% were female and 78.1% were White. The median age was 63 years. The observed prevalence of sustained opioid use was 1.3% (95% confidence interval [CI], 1.2% to 1.5%) in the low-risk group (SOS score of <30), 7.4% (95% CI, 6.9% to 8.0%) in the medium-risk group (SOS score of 30 to 60), and 20.8% (95% CI, 17.7% to 24.2%) in the high-risk group (SOS score of >60). The performance of the SOS score in the overall group was strong, with a c-statistic of 0.82. The performance of the SOS score showed no evidence of worsening over time. The c-statistic was 0.79 before the COVID-19 pandemic and ranged from 0.77 to 0.80 throughout the waves of the pandemic. CONCLUSIONS: We validated the use of the SOS score for sustained prescription opioid use following a diverse array of orthopaedic procedures across subspecialties. This tool is easy to implement for the purpose of prospectively identifying patients in musculoskeletal service lines who are at higher risk for sustained opioid use, thereby enabling the future implementation of upstream interventions and modifications to avert opioid abuse and to combat the opioid epidemic. LEVEL OF EVIDENCE: Diagnostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Digoxin and Standard-of-Care Therapy for Heart Failure Patients with COVID-19: Analysis of Data from the US Military Health System (MHS) Data Repository.

BACKGROUND: Cardiac glycosides such as digoxin, digitoxin and ouabain are still used around the world to treat patients with chronic heart failure with reduced ejection fraction (HFrEF) and/or atrial fibrillation (AF). However, in the US, only digoxin is licensed for treating these illnesses, and the use of digoxin for this group of patients is increasingly being replaced in the US by a new standard of care with groups of more expensive drugs. However, ouabain and digitoxin, and less potently digoxin, have also recently been reported to inhibit SARS-CoV-2 virus penetration into human lung cells, thus blocking COVID-19 infection. COVID-19 is known to be a more aggressive disease in patients with cardiac comorbidities, including heart failure. OBJECTIVE: We therefore considered the possibility that digoxin might provide at least a measure of relief from COVID-19 in digoxin-treated heart failure patients. To this end, we hypothesized that treatment with digoxin rather than standard of care might equivalently protect heart failure patients with regard to diagnosis of COVID-19, hospitalization and death. METHODS: To test this hypothesis, we conducted a cross-sectional study by using the US Military Health System (MHS) Data Repository to identify all MHS TRICARE Prime and Plus beneficiaries aged 18-64 years with a heart failure (HF) diagnosis during the period April 2020 to August 2021. In the MHS, all patients receive equal, optimal care without regard to rank or ethnicity. Analyses included descriptive statistics on patient demographics and clinical characteristics, and logistic regressions to determine likelihood of digoxin use. RESULTS: We identified 14,044 beneficiaries with heart failure in the MHS during the study period. Of these, 496 were treated with digoxin. However, we found that both digoxin-treated and standard-of-care groups were equivalently protected from COVID-19. We also noted that younger active duty service members and their dependents with HF were less likely to receive digoxin compared with older, retired beneficiaries with more comorbidities. CONCLUSION: The hypothesis of equivalent protection by digoxin treatment of HF patients in terms of susceptibility to COVID-19 infection appears to be supported by the data.

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

BACKGROUND: The 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/HYPOTHESIS: The 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. METHODS: A 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. RESULTS: Of 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. CONCLUSIONS: With 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.

A Longitudinal Study of Prevalence Ratios for Musculoskeletal Back Injury Among U.S. Navy and Marine Corps Personnel, 2009-2015.

INTRODUCTION: Medical readiness to deploy is an increasingly important issue within the military. Musculoskeletal back pain is one of the most common medical problems that affects service members. This study demonstrates the associations between risk factors and the prevalence of musculoskeletal back pain among active duty sailors and Marines within the Department of the Navy (DoN). MATERIALS AND METHODS: Utilizing the Military Health System Data Repository, we conducted a retrospective cross-sectional review of administrative healthcare claim data for all active duty DoN personnel with at least one medical encounter during fiscal years 2009-2015. For each fiscal year, we identified all claims with an ICD-9 code for back pain and calculated prevalence. We compared those with and without back pain across all variables (age, gender, rank, race, body mass index, tobacco use, occupation, and branch of service) using chi-square analysis. Unadjusted and adjusted log-binomial regressions were used to calculate prevalence ratios and examine associated risk factors for back pain. RESULTS: The number of active duty subjects per fiscal year ranged from 424,460 to 437,053. The prevalence of back pain showed an upward trend, ranging from 9.99% in 2009 to 12.09% in 2015. Personnel aged 35 years and older had the strongest adjusted prevalence ration (APR) for back pain (APR 2.59; 95% CI, 2.53-2.66). There were also strong associations with obese body mass index (APR 1.76; 95% CI, 1.66-1.86), overweight body mass index (APR 1.29; 95% CI, 1.27-1.32), and tobacco use (APR 1.39; 95% CI, 1.36-1.42). Females were more likely to have back pain than males (APR 1.43; 95% CI, 1.40-1.47) and Marines more likely than sailors (APR 1.39; 95% CI, 1.36-1.42). The occupation with the highest prevalence ratio was healthcare (APR 1.34; 95% CI, 1.29-1.40) when compared to the reference group of combat specialists. CONCLUSIONS: There was an increasing prevalence of back pain across the DoN from 2009 to 2015. Different occupational categories demonstrate different prevalence of back pain. Surprisingly, combat occupations and aviators were among the groups with the lowest prevalence. Lifestyle factors such as excess body weight and use of tobacco products are clearly associated with increased prevalence. These results could inform military leaders with regard to setting policies that could increase medical readiness.

Long-term Mental Health Trajectories of Injured Military Servicemembers: Comparing Combat to Noncombat Related Injuries.

OBJECTIVE: We sought to quantify the impact of injury characteristics and setting on the development of mental health conditions, comparing combat to noncombat injury mechanisms. BACKGROUND: Due to advances in combat casualty care, military service-members are surviving traumatic injuries at substantial rates. The nature and setting of traumatic injury may influence the development of subsequent mental health disorders more than clinical injury characteristics. METHODS: TRICARE claims data was used to identify servicemembers injured in combat between 2007 and 2011. Controls were servicemembers injured in a noncombat setting matched by age, sex, and injury severity. The rate of development, and time to diagnosis [in days (d)], of 3 common mental health conditions (post-traumatic stress disorder, depression, and anxiety) among combat-injured servicemembers were compared to controls. Risk factors for developing a new mental health condition after traumatic injury were evaluated using multivariable logistic regression that controlled for confounders. RESULTS: There were 3979 combat-injured servicemember and 3979 matched controls. The majority of combat injured servicemembers (n = 2524, 63%) were diagnosed with a new mental health condition during the course of follow-up, compared to 36% (n = 1415) of controls ( P < 0.001). In the adjusted model, those with combat-related injury were significantly more likely to be diagnosed with a new mental health condition [odds ratio (OR): 3.18, [95% confidence interval (CI): 2.88-3.50]]. Junior (OR: 3.33, 95%CI: 2.66-4.17) and senior enlisted (OR: 2.56, 95%CI: 2.07-3.17) servicemem-bers were also at significantly greater risk. CONCLUSIONS: We found significantly higher rates of new mental health conditions among servicemembers injured in combat compared to service-members sustaining injuries in noncombat settings. This indicates that injury mechanism and environment are important drivers of mental health sequelae after trauma.

The Hidden Costs of War: Healthcare Utilization Among Individuals Sustaining Combat-related Trauma (2007-2018).

OBJECTIVE: We sought to evaluate long-term healthcare requirements of American military servicemembers with combat-related injuries. SUMMARY OF BACKGROUND DATA: US military conflicts since 2001 have produced the most combat casualties since Vietnam. Long-term consequences on healthcare utilization and associated costs remain unknown. METHODS: We identified servicemembers who were treated for combat-related injuries between 2007 and 2011. Controls consisted of active-duty servicemembers injured in the civilian sector, without any history of combat-related trauma, matched (1:1) on year of injury, biologic sex injury severity, and age at time of injury. Surveillance was performed through 2018. Total annual healthcare expenditures were evaluated overall and then as expenditures in the first year after injury and for subsequent years. Negative binomial regression was used to identify the adjusted influence of combat injury on healthcare costs. RESULTS: The combat-injured cohort consisted of 3981 individuals and we identified 3979 controls. Total healthcare utilization during the follow-up period resulted in median costs of $142,214 (IQR $61,428, $323,060) per combat-injured servicemember as compared to $50,741 (IQR $26,669, $104,134) among controls. Median expenditures, adjusted for duration of follow-up, for the combat-injured were $45,211 (IQR $18,698, $105,437). In adjusted analysis, overall costs were 30% higher (1.30; 95% confidence interval: 1.23, 1.37) for combat-injured personnel. CONCLUSION: This investigation represents the longest continuous observation of healthcare utilization among individuals after combat injury and the first to assess costs. Expenditures were 30% higher for individuals injured as a result of combat-related trauma when compared to those injured in the civilian sector.

Changes in Elective and Urgent Surgery Among TRICARE Beneficiaries During the COVID-19 Pandemic.

BACKGROUND: COVID-19 is known to have altered the capacity to perform surgical procedures in numerous health care settings. The impact of this change within the direct and private-sector settings of the Military Health System has not been effectively explored, particularly as it pertains to disparities in surgical access and shifting of services between sectors. We sought to characterize how the COVID-19 pandemic influenced access to care for surgical procedures within the direct and private-sector settings of the Military Health System. METHODS: We retrospectively evaluated claims for patients receiving urgent and elective surgical procedures in March-September 2017, 2019, and 2020. The pre-COVID period consisted of 2017 and 2019 and was compared to 2020. We adjusted for sociodemographic characteristics, medical comorbidities, and region of care using multivariable Poisson regression. Subanalyses considered the impact of race and sponsor rank as a proxy for socioeconomic status. RESULTS: During the period of the COVID-19 pandemic, there was no significant difference in the adjusted rate of urgent surgical procedures in direct (risk ratio, 1.00; 95% CI, 0.97-1.03) or private-sector (risk ratio, 0.99; 95% CI, 0.97-1.02) care. This was also true for elective surgeries in both settings. No significant disparities were identified in any of the racial subgroups or proxies for socioeconomic status we considered in direct or private-sector care. CONCLUSIONS: We found a similar performance of elective and urgent surgeries in both the private sector and direct care during the first 6 months of the COVID-19 pandemic. Importantly, no racial disparities were identified in either care setting.

Antibiotic Prescribing Patterns and Guideline Concordance for Uncomplicated Urinary Tract Infections Among Adult Women in the US Military Health System.

Importance: Urinary tract infections (UTIs) are one of the most commonly diagnosed infections, and prior studies have reported discordance in antibiotic treatment with the Infectious Diseases Society of America (IDSA) guidelines. Objective: To assess IDSA guideline concordance rates for women with uncomplicated UTIs treated with antibiotics, and compare concordance rates between different specialty field. Design, Setting, and Participants: Retrospective cross-sectional study of health care claims data from the US Military Health System Data Repository, which contains comprehensive health care encounter and claims data for all military beneficiaries. Participants were adult women between the ages of 18 to 50 years with uncomplicated UTIs from October 1, 2017, to September 30, 2019. Data extraction and analysis were performed in 2022. Patients with diagnosis of UTI in the preceding 6 months, current pregnancy, history of pyelonephritis, history of diabetes, history of organ transplant, history of human immunodeficiency virus, immunosuppression, renal insufficiency, urinary tract abnormalities, or history of urologic procedures were excluded. Exposures: Antibiotic treatment for uncomplicated UTIs. Only antibiotics received within 1 day after the diagnosis were analyzed. The IDSA recommends the following antibiotics as first-line therapy: nitrofurantoin, trimethoprim-sulfamethoxazole, fosfomycin, pivmecillinam. Main Outcomes and Measures: The IDSA guideline concordance rates were calculated as the number of patients receiving first-line antibiotic therapy divided by the total number of cases for uncomplicated UTIs. Results: A total of 46 793 adult women (67.3% [31 475 of 46 793] aged 18-34 years; 38.2% [31 475 of 46 793] of White race) were diagnosed with uncomplicated UTIs with 91.0% receiving guideline-concordant antibiotic treatment. In comparison with obstetrics and gynecology, IDSA guideline-concordant treatment was more likely in internal medicine (adjusted odds ratio [aOR], 2.87; 95% CI, 2.73-3.03), family medicine (aOR, 1.81; 95% CI, 1.76-1.87), surgery (aOR, 1.51; 95% CI, 1.36-1.67), and emergency medicine (aOR, 1.36; 95% CI, 1.32-1.39) and less likely in urology (aOR, 0.40; 95% CI, 0.38-0.43). Compared with direct military care, private sector care had lower concordance rates (aOR, 0.63; 95% CI, 0.62-0.64). Conclusions and Relevance: In this cross-sectional study of antibiotic treatments for uncomplicated UTIs in a universally insured population, the IDSA guideline-concordance rate was high at 91.0% with higher rates in direct military care compared with private sector care. There were higher rates in general medical specialties, surgery, and emergency medicine and lower rates in urology and obstetrics and gynecology. These results further enhance the literature on current antibiotic prescribing practices for uncomplicated UTIs in adult women.

Health-Care Utilization and Expenditures Associated with Long-Term Treatment After Combat and Non-Combat-Related Orthopaedic Trauma.

BACKGROUND: The long-term consequences of musculoskeletal trauma can be profound and can extend beyond the post-injury period. The surveillance of long-term expenditures among individuals who sustain orthopaedic trauma has been limited in prior work. We sought to compare the health-care requirements of active-duty individuals who sustained orthopaedic injuries in combat and non-combat (United States) environments using TRICARE claims data. METHODS: We identified service members who sustained combat or non-combat musculoskeletal injuries between 2007 and 2011. Combat-injured personnel were matched to those in the non-combat-injured cohort on a 1:1 basis using biologic sex, year of the injury, Injury Severity Score (ISS), and age at the index hospitalization. Health-care utilization was surveyed through 2018. The total health-care expenditures over the post-injury period were the primary outcome. These were assessed as a total overall cost and then as costs adjusted per year of follow-up. We used negative binomial regression to identify the independent association between risk factors and health-care expenditures. RESULTS: We identified 2,119 individuals who sustained combat-related orthopaedic trauma and 2,119 individuals who sustained non-combat injuries. The most common mechanism of injury within the combat-injured cohort was blast-related trauma (59%), and 418 individuals (20%) sustained an amputation. The total costs were $156,886 for the combat-injured group compared with $55,873 for the non-combat-injured group (p < 0.001). Combat-related orthopaedic injuries were associated with a 43% increase in health-care expenditures (incidence rate ratio, 1.43 [95% confidence interval, 1.19 to 1.73]). Severe ISS at presentation, ≥2 comorbidities, and amputations were also significantly associated with health-care utilization, as was junior enlisted rank, our proxy for socioeconomic status. CONCLUSIONS: Health-care requirements and associated costs are substantial among service members sustaining combat and non-combat orthopaedic trauma. Given the sociodemographic characteristics of our cohort, we believe that these results are translatable to civilians who sustain similar types of musculoskeletal trauma.

Geospatial Analysis of Access to Emergency Cesarean Delivery for Military and Civilian Populations in the US.

Importance: Many women in the US, particularly those living in rural areas, have limited access to obstetric care. Military-civilian partnership could improve access to obstetric care and benefit military personnel, their civilian dependents, and the civilian population as a whole. Objective: To identify medical facilities within military and civilian geographic areas that present opportunities for military-civilian partnership in obstetric care and to assess whether civilian use of military medical treatment facilities (MTFs) could improve access to emergency cesarean delivery care in the US. Design, Setting, and Participants: This geospatial epidemiological population-based cross-sectional study was conducted from November 2020 to March 2021. ArcGIS Pro software, version 2.7 (Esri), was used to assess population coverage for TRICARE (military insurance) beneficiaries and civilian populations and to estimate 30-minute travel time to 2392 total military and civilian medical facilities that were capable of providing emergency cesarean delivery care in the continental US. Data on health insurance coverage for TRICARE beneficiaries and their civilian dependents per county were obtained from the American Community Survey tables available through ArcGIS Pro software. Demographic characteristics of the general population were obtained from the 2020 key demographic indicators published by Esri. Race and ethnicity were not examined because the data used for this study were aggregated and did not include further categorization by race or ethnicity. Main Outcomes and Measures: Population coverage rates (measured in percentages) within 30-minute catchment areas, defined as areas that were within a 30-minute travel time to a medical facility capable of providing emergency cesarean delivery care. Results: A total of 29 MTFs and 2363 civilian hospitals capable of providing emergency cesarean delivery were identified across the contiguous US. Overall, an estimated 167 759 762 women (3 640 000 TRICARE beneficiaries and 164 119 762 civilians) were included in these service areas. The analysis identified 17 of 29 MTFs (58.6%) capable of providing emergency cesarean delivery care that were located within 30-minute catchment areas. Of those, 3 MTFs were the only facilities capable of providing emergency cesarean delivery care within a 30-minute travel time in those regions, and 14 additional MTFs had catchment areas partially overlapping with civilian hospitals that also covered areas without alternative access to emergency cesarean delivery. Expanded use of these 14 MTFs could enhance access to emergency cesarean delivery care not otherwise covered by current civilian hospitals. Conclusions and Relevance: In this study, 58.6% of MTFs capable of providing emergency cesarean delivery care were located in areas with the potential to improve access to obstetric care within a 30-minute travel time. Maintenance of MTFs in these important access regions could be prioritized in the context of restructuring MTFs. This prioritization has the potential to improve access to emergency cesarean delivery care for underserved civilian populations in the US, particularly among those living in rural areas.

Racial and Socioeconomic Disparities in CKD in the Context of Universal Health Care Provided by the Military Health System.

RATIONALE & OBJECTIVE: Health-impeding social determinants of health-including reduced access to care-contribute to racial and socioeconomic disparities in chronic kidney disease (CKD). The Military Health System (MHS) provides an opportunity to assess a large, diverse population for CKD disparities in the context of universal health care. STUDY DESIGN: Cross-sectional study. SETTING & PARTICIPANTS: MHS beneficiaries aged 18 to 64 years receiving care between October 1, 2015, and September 30, 2018. PREDICTORS: Race, sponsor's rank (a proxy for socioeconomic status and social class), median household income by sponsor's zip code, and marital status. OUTCOME: CKD prevalence, defined by International Classification of Diseases, Tenth Revision codes and/or a validated, laboratory value-based electronic phenotype. ANALYTICAL APPROACH: Multivariable logistic regression compared CKD prevalence by predictors, controlling separately for confounders (age, sex, active-duty status, sponsor's service branch, and depression) and mediators (hypertension, diabetes, HIV, and body mass index). RESULTS: Of 3,330,893 beneficiaries, 105,504 (3.2%) had CKD. In confounder-adjusted models, the CKD prevalence was higher in Black versus White beneficiaries (OR, 1.67; 95% CI, 1.64-1.70), but lower in single versus married beneficiaries (OR, 0.77; 95% CI, 0.76-0.79). The prevalence of CKD was increased among those with a lower military rank and among those with a lower median household income in a nearly dose-response fashion (P < 0.0001). Associations were attenuated when further adjusting for suspected mediators. LIMITATIONS: The cross-sectional design prevents causal inferences. We may have underestimated the CKD prevalence, given a lack of data for laboratory tests conducted outside the MHS and the use of a specific CKD definition. The transient nature of the MHS population may limit the accuracy of zip code-level median household income data. CONCLUSIONS: Racial and socioeconomic CKD disparities exist in the MHS despite universal health care coverage. The existence of CKD disparities by rank and median household income suggests that social risks may contribute to both racial and socioeconomic disparities despite access to universal health care coverage.

Long-Term Healthcare Expenditures Following Combat-Related Traumatic Brain Injury.

BACKGROUND: Traumatic brain injury (TBI) is one of the most common injuries resulting from U.S. Military engagements since 2001. Long-term consequences in terms of healthcare utilization are unknown. We sought to evaluate healthcare expenditures among U.S. military service members with TBI, as compared to a matched cohort of uninjured individuals. METHODS: We identified service members who were treated for an isolated combat-related TBI between 2007 and 2011. Controls consisted of hospitalized active duty service members, without any history of combat-related injury, matched by age, biologic sex, year of hospitalization, and duration of follow-up. Median total healthcare expenditures over the entire surveillance period represented our primary outcome. Expenditures in the first year (365 days) following injury (hospitalization for controls) and for subsequent years (366th day to last healthcare encounter) were considered secondarily. Negative binomial regression was used to identify the adjusted influence of TBI. RESULTS: The TBI cohort consisted of 634 individuals, and there were 1,268 controls. Healthcare expenditures among those with moderate/severe TBI (median $154,335; interquartile range [IQR] $88,088-$360,977) were significantly higher as compared to individuals with mild TBI (median $113,951; IQR $66,663-$210,014) and controls (median $43,077; IQR $24,403-$83,590; P < .001). Most expenditures were incurred during the first year following injury. CONCLUSION: This investigation represents the first continuous observation of healthcare utilization among individuals with combat-related TBI. Our findings speak to continued consumption of health care well beyond the immediate postinjury period, resulting in total expenditures approximately six to seven times higher than those of service members hospitalized for noncombat-related reasons.

Volume as an Indicator for Outcomes for Severe Maternal Morbidity in the Military Health System.

BACKGROUND: Maternal obstetric morbidity is a growing concern in the USA, where rates of maternal morbidity exceed Europe and most developed countries. Prior studies have found that obstetric case volume affects maternal morbidity, with low-volume facilities having higher rates of morbidity. However, these studies were done in civilian healthcare systems that are different from the Military Health System (MHS). This study evaluates whether obstetric case volume impacts severe maternal morbidity (SMM) in military hospitals located in the continental United States. METHODS: This cross-sectional study included all military treatment facilities (MTFs) (n = 35) that performed obstetric deliveries (n = 102,959) from October 2015 to September 2018. Data were collected from the MHS Data Repository and identified all deliveries for the study time period. Severe maternal morbidity was defined by the Centers for Disease Control. The 30-day readmission rates were also included in analysis. Military treatment facilities were separated into volume quartiles for analysis. Univariate logistic regressions were performed to determine the impact of MTF delivery volume on the probability of SMM and 30-day maternal readmissions. RESULTS: The results for all regression models indicate that the MTF delivery volume had no significant impact on the probability of SMM. With regard to 30-day maternal readmissions, using the upper middle quartile as the comparison group due to the largest number of deliveries, MTFs in the lower middle quartile and in the highest quartile had a statistically significant higher likelihood of 30-day maternal readmissions. CONCLUSION: This study shows no difference in SMM rates in the MHS based on obstetric case volume. This is consistent with previous studies showing differences in MHS patient outcomes compared to civilian healthcare systems. The MHS is unique in that it provides families with universal healthcare coverage and access and provides care for approximately 40,000 deliveries annually. There may be unique lessons on volume and outcomes in the MHS that can be shared with healthcare planners and decision makers to improve care in the civilian setting.

Minority Adolescent Mental Health Diagnosis Differences in a National Sample.

INTRODUCTION: Mental health disparities and differences have been identified amongst all age groups, including adolescents. However, there is a lack of research regarding adolescents within the Military Health System (MHS). The MHS is a universal health care system for military personnel and their dependents. Research has indicated that the MHS removes many of the barriers that contribute to health disparities. Additional investigations with this population would greatly contribute to our understanding of disparities and health services delivery without the barrier of access to care. MATERIALS AND METHODS: This study analyzed the diagnostic trends of anxiety, depression, and impulse control disorders and differences within a national sample of adolescents of active-duty military parents. The study utilized 2006 to 2014 data in the MHS Data Repository for adolescents ages 13-18. The study identified 183,409 adolescents with at least one diagnosis. Multivariable logistic regressions were conducted to assess the differences and risks for anxiety, depression, and impulse control disorders in the identified sample. RESULTS: When compared to White Americans, minority patients had a higher likelihood of being diagnosed with an impulse control disorder (odds ratio [OR] = 1.43; confidence interval [CI] 1.39-1.48) and a decreased likelihood of being diagnosed with a depressive disorder (OR = 0.98; CI 0.95-1.00) or anxiety disorder (OR = 0.80; CI 0.78-0.83). Further analyses examining the subgroups of minorities revealed that, when compared to White Americans, African American adolescents have a much higher likelihood of receiving a diagnosis of an impulse control disorder (OR = 1.66; CI 1.61-1.72) and a lower likelihood of receiving a diagnosis of a depressive disorder (OR = 0.93; CI 0.90-0.96) and an anxiety disorder (OR = 0.75; CI 0.72-0.77). CONCLUSION: This study provides strong support for the existence of race-based differences in adolescent mental health diagnoses. Adolescents of military families are a special population with unique experiences and stressors and would benefit from future research focusing on qualitative investigations into additional factors mental health clinicians consider when making diagnoses, as well as further exploration into understanding how best to address this special population's mental health needs.

Postpartum Opioid Use among Military Health System Beneficiaries.

OBJECTIVE: The aim of the study is to evaluate the prevalence and factors associated with opioid prescriptions to postpartum patients among TRICARE beneficiaries receiving care in the civilian health care system versus a military health care facility. STUDY DESIGN: We evaluated postpartum opioid prescriptions filled at discharge among patients insured by TRICARE Prime/Prime Plus using the Military Health System Data Repository between fiscal years 2010 to 2015. We included women aged 15 to 49 years old and excluded abortive pregnancy outcomes and incomplete datasets. The primary outcome investigated mode of delivery and demographics for those filling an opioid prescription. Secondary outcomes compared prevalence of filled opioid prescription at discharge for postpartum patients within civilian care and military care. RESULTS: Of a total of 508,258 postpartum beneficiaries, those in civilian health care were more likely to fill a discharge opioid prescription compared with those in military health care (OR 3.9, 95% CI 3.8-3.99). Cesarean deliveries occurred less frequently in military care (26%) compared with civilian care (30%), and forceps deliveries occurred more frequently in military care (1.38%) compared with civilian care (0.75%). Women identified as Asian race were least likely to fill an opioid prescription postpartum (OR 0.79, 95% CI 0.75-0.83). Women aged 15 to 19 years had a lower odds of filling an opioid prescription (OR 0.83, 95% CI 0.80-0.86). Women associated with a senior officer rank were less likely to fill an opioid prescription postpartum (OR 0.83, 95% CI 0.73-0.91), while those associated with warrant officer rank were more likely to fill an opioid prescription (OR 1.14, 95% CI 1.06-1.23). CONCLUSION: Our data indicates that women who received care in civilian facilities were more likely to fill an opioid prescription at discharge when compared with military facilities. Factors such as race and age were associated with opioid prescription at discharge. This study highlights areas for improvement for potential further studies. KEY POINTS: · Opioid prescription patterns for postpartum women may vary across the country.. · Our study indicates postpartum patients in civilian care are more likely to fill opioids postpartum.. · This study highlights a population which may have an improved opioid prescribing pattern..

CKD Prevalence in the Military Health System: Coded Versus Uncoded CKD.

RATIONALE & OBJECTIVE: Chronic kidney disease (CKD) is common but often goes unrecorded. STUDY DESIGN: Cross-sectional. SETTING & PARTICIPANTS: Military Health System (MHS) beneficiaries aged 18 to 64 years who received care during fiscal years 2016 to 2018. PREDICTORS: Age, sex, active duty status, race, diabetes, hypertension, and numbers of kidney test results. OUTCOMES: We defined CKD by International Classification of Diseases, Tenth Revision (ICD-10) code and/or a positive result on a validated electronic phenotype that uses estimated glomerular filtration rate and measures of proteinuria with evidence of chronicity. We defined coded CKD by the presence of an ICD-10 code. We defined uncoded CKD by a positive e-phenotype result without an ICD-10 code. ANALYTICAL APPROACH: We compared coded and uncoded populations using 2-tailed t tests (continuous variables) and Pearson χ2 test for independence (categorical variables). RESULTS: The MHS population included 3,330,893 beneficiaries. Prevalence of CKD was 3.2%, based on ICD code and/or positive e-phenotype result. Of those identified with CKD, 63% were uncoded. Compared with beneficiaries with coded CKD, those with uncoded CKD were younger (aged 45 ± 13 vs 52 ± 11 years), more often women (54.4% vs 37.6%) and active duty (20.2% vs 12.5%), and less often of Black race (18.5% vs 31.5%) or with diabetes (23.5% vs 43.5%) or hypertension (46.6% vs 77.1%; P < 0.001). Beneficiaries with coded (vs uncoded) CKD had greater numbers of kidney test results (P < 0.001). LIMITATIONS: Use of cross-sectional administrative data prevents inferences about causality. The CKD e-phenotype may fail to capture CKD in individuals without laboratory data and may underestimate CKD. CONCLUSIONS: The prevalence of CKD in the MHS is ~3.2%. Beneficiaries with well-known CKD risk factors, such as older age, male sex, Black race, diabetes, and hypertension, were more likely to be coded, suggesting that clinicians may be missing CKD in groups traditionally considered lower risk, potentially resulting in suboptimal care.

Long-term prescription opioid use among US military service members injured in combat.

INTRODUCTION: During the Global War on Terrorism, many US Military service members sustained injuries with potentially long-lasting functional limitations and chronic pain. We sought to understand the patterns of prescription opioid use among service members injured in combat. METHODS: We queried the Military Health System Data Repository to identify service members injured in combat between 2007 and 2011. Sociodemographics, injury characteristics, treatment information, and costs of care were abstracted for all eligible patients. We surveyed for prescription opioid utilization subsequent to hospital discharge and through 2018. Negative binomial regression was used to identify factors associated with cumulative prescription opioid use. RESULTS: We identified 3,981 service members with combat-related injuries presenting during the study period. The median age was 24 years (interquartile range [IQR], 22-29 years), 98.5% were male, and the median follow-up was 3.3 years. During the study period, 98% (n = 3,910) of patients were prescribed opioids at least once and were prescribed opioids for a median of 29 days (IQR, 9-85 days) per patient-year of follow-up. While nearly all patients (96%; n = 3,157) discontinued use within 6 months, 91% (n = 2,882) were prescribed opioids again after initially discontinuing opioids. Following regression analysis, patients with preinjury opioid exposure, more severe injuries, blast injuries, and enlisted rank had higher cumulative opioid use. Patients who discontinued opioids within 6 months had an unadjusted median total health care cost of US $97,800 (IQR, US $42,364-237,135) compared with US $230,524 (IQR, US $134,387-370,102) among those who did not discontinue opioids within 6 months (p < 0.001). CONCLUSION: Nearly all service members injured in combat were prescribed opioids during treatment, and the vast majority experienced multiple episodes of prescription opioid use. Only 4% of the population met the criteria for sustained prescription opioid use at 6 months following discharge. Early discontinuation may not translate to long-term opioid cessation in this population. LEVEL OF EVIDENCE: Epidemiology study, level III.