An evaluation of the delivery of clinical preventive services in the Joint Task Force National Capital Region Medical.

The Walter Reed Army Institute of Research General Preventive Medicine Residency conducted a performance improvement study to evaluate clinical preventive services (CPSs) in the National Capital Region. This study focused on enhancing medical care through quality management of both the process and measurement of service delivery, thereby improving the overall quality of a service by examining its constituent parts. Screening mammography and pneumococcal immunization were the CPSs selected for evaluation, and 9 of 40 military treatment facilities (MTFs) were visited. Mammography completion ranged from 64% to 81%. The process of providing mammography to eligible enrollees varied greatly among MTFs, and the majority did not utilize all identified steps deemed critical for mammography completion. Pneumococcal immunization ranged from 0% to 21%. There was a positive correlation between CPS completion, the number of eligible enrollees, and the use of critical steps. Recommendations include using critical steps to evaluate and improve MTFs' CPS processes.

America's "undiscovered" laboratory for health services research.

Debate over reforming the nation's healthcare system has stimulated a need for health services research (HSR) models that are nationally applicable. Toward this end, the authors identify the Military Health System (MHS) as America's "undiscovered" laboratory for HSR. Although many may confuse the MHS with the Department of Veterans Affairs (VA), the 2 systems vary dramatically with respect to their beneficiary populations, access to care, and other important attributes. In this article, the authors describe key characteristics of the MHS including its large beneficiary base, its direct care operating environment, its dedicated medical school and graduate education programs, and its fully operational integrated health information system. Although a few health systems (eg, Kaiser Permanente, Partners Healthcare, and Department of Veterans Affairs) possess some characteristics, no other has all of these components in place. This article sets the stage for contemporary HSR studies with broad applicability to current issues in American healthcare that could be performed within the MHS. Inclusion of the MHS environment in HSR studies of health services delivery modalities, adoption of health information technology, access to care, relationship of medical education to effective safe care delivery, health disparities, child health, and behavioral health would provide strong underpinnings for proposed changes in American healthcare delivery. Finally, the article highlights current regulatory barriers to research within the MHS whereas suggesting steps to minimize their impact in conducting HSR.

A study of cancer in the military beneficiary population.

This study's objective was to describe: (1) patterns of cancer prevalence and type, (2) patient demographics, and (3) the sources, and cost, of medical care in the military beneficiary population using the Military Health System administrative databases. Calendar year 2002 patient enrollment, inpatient and outpatient encounter, and cost data from the 50 United States were analyzed to determine beneficiary cancer prevalence, demographics, source of care, cost of care, and cancer type. A total of 355,442 military beneficiaries were identified to have a cancer diagnosis (excluding nonmelanoma skin cancers) in 2002. More than two-thirds of these beneficiaries were over the age of 65, 55% were male, and 44% lived in three geographic areas of the country. Cancer of the prostate, breast, lung, and colon were most common. Almost 90% received their care outside of military medical treatment facilities and the overall cost of their care for 2002 was over $1 billion.

Late urinary tract infection after renal transplantation in the United States.

BACKGROUND: Although urinary tract infection (UTI) occurring late after renal transplantation has been considered "benign," this has not been confirmed in a national population of renal transplant recipients. METHODS: We conducted a retrospective cohort study of 28,942 Medicare primary renal transplant recipients in the United States Renal Data System (USRDS) database from January 1, 1996, through July 31, 2000, assessing Medicare claims for UTI occurring later than 6 months after transplantation based on International Classification of Diseases, 9th Revision (ICD-9), codes and using Cox regression to calculate adjusted hazard ratios (AHRs) for time to death and graft loss (censored for death), respectively. RESULTS: The cumulative incidence of UTI during the first 6 months after renal transplantation was 17% (equivalent for both men and women), and at 3 years was 60% for women and 47% for men (P < 0.001 in Cox regression analysis). Late UTI was significantly associated with an increased risk of subsequent death in Cox regression analysis (P < 0.001; AHR, 2.93; 95% confidence interval [CI], 2.22, 3.85); and AHR for graft loss was 1.85 (95% CI, 1.29, 2.64). The association of UTI with death persisted after adjusting for cardiac and other infectious complications, and regardless of whether UTI was assessed as a composite of outpatient/inpatient claims, primary hospitalized UTI, or solely outpatient UTI. CONCLUSION: Whether due to a direct effect or as a marker for serious underlying illness, UTI occurring late after renal transplantation, as coded by clinicians in the United States, does not portend a benign outcome.

A qualitative study of post-settlement influences on State tobacco control funding.

State settlements with the tobacco industry increased the availability of funds that might be used for improving health outcomes and increased scrutiny of tobacco control funding overall. This research identified potential explanatory factors for state tobacco control funding and developed a conceptual framework to guide further exploration. Key informant interviews with 14 tobacco policy professionals were conducted to augment the information available in the scientific literature on funding influences. Interviews yielded a comprehensive list of 26 factors that were returned to key informants for ratings of importance using a modified Delphi process. Results indicate that the top funding influences are budgetary constraints, lobbying, advocacy, tobacco economy, legislative priorities, public opinion, and leadership by the governor or state legislators. A conceptual diagram is presented of all factors clustered into three categories. Further research is planned to quantify these factors and assess their explanatory value

A systematic process to prioritize prevention activities sustaining progress toward the reduction of military injuries.

BACKGROUND: To sustain progress toward injury reduction and other health promotion goals, public health organizations need a systematic approach based on data and an evaluation of existing scientific evidence on prevention. This paper describes a process and criteria developed to systematically and objectively define prevention program and policy priorities. METHODS: Military medical surveillance data were obtained and summarized, and a working group of epidemiology and injury experts was formed. After reviewing the available data, the working group used predefined criteria to score leading military unintentional injury causes on five main criteria that assessed factors contributing to program and policy success: (1) importance of the problem, (2) effectiveness of existing prevention strategies, (3) feasibility of establishing programs and policies, (4) timeliness of implementation and results, and (5) potential for evaluation. Injury problems were ranked by total median score. RESULTS: Causes with the highest total median scores were physical training (34 points), military parachuting (32 points), privately-owned vehicle crashes (31 points), sports (29 points), falls (27 points), and military vehicle crashes (27 points). CONCLUSIONS: Using a data-driven, criteria-based process, three injury causes (physical training, military parachuting, and privately owned-vehicle crashes) with the greatest potential for successful program and policy implementation were identified. Such information is useful for public health practitioners and policymakers who must prioritize among health problems that are competing for limited resources. The process and criteria could be adapted to systematically assess and prioritize health issues affecting other communities.

Faculty performance evaluation in accredited U.S. public health graduate schools and programs: a national study.

PURPOSE: To provide baseline data on evaluation of faculty performance in U.S. schools and programs of public health. METHOD: The authors administered an anonymous Internet-based questionnaire using PHP Surveyor. The invited sample consisted of individuals listed in the Council on Education for Public Health (CEPH) Directory of Accredited Schools and Programs of Public Health. The authors explored performance measures in teaching, research, and service, and assessed how faculty performance measures are used. RESULTS: A total of 64 individuals (60.4%) responded to the survey, with 26 (40.6%) reporting accreditation/reaccreditation by CEPH within the preceding 24 months. Although all schools and programs employ faculty performance evaluations, a significant difference exists between schools and programs in the use of results for merit pay increases and mentoring purposes. Thirty-one (48.4%) of the organizations published minimum performance expectations. Fifty-nine (92.2%) of the respondents counted number of publications, but only 22 (34.4%) formally evaluated their quality. Sixty-two (96.9%) evaluated teaching through student course evaluations, and only 29 (45.3%) engaged in peer assessment. Although aggregate results of teaching evaluation are available to faculty and administrators, this information is often unavailable to students and the public. Most schools and programs documented faculty service activities qualitatively but neither assessed it quantitatively nor evaluated its impact. CONCLUSIONS: This study provides insight into how schools and programs of public health evaluate faculty performance. Results suggest that although schools and programs do evaluate faculty performance on a basic level, many do not devote substantial attention to this process.