Decision and economic evaluation of abortion availability in the United States military.

BACKGROUND: Active-duty service women rely on the civilian sector for most abortion care due to limits on federal funding for abortion. Abortion is now banned in many states with large military presences. The Department of Defense has implemented policies to assist active-duty service women in accessing abortion, but there is debate to reverse this support. OBJECTIVE: Our goal was to compare the cost-effectiveness and incidence of adverse maternal and neonatal outcomes of a hypothetical cohort of active-duty service women living in abortion-restricted states comparing restricted abortion access (abortion not available cohort) to abortion available with Department of Defense travel support (abortion available cohort). STUDY DESIGN: We developed a decision tree model to compare abortion not available and abortion available cohorts for active-duty service women living in abortion-restricted states. Our cohorts were subdivided into normal pregnancies and those with a major fetal anomaly. Cost estimates, probabilities, and disability weights of various health conditions associated with abortion and pregnancy were obtained and derived from the literature. Effectiveness was expressed in disability-adjusted life years and the willingness to pay threshold was set to $100,000 per disability-adjusted life year gained or averted. We completed probabilistic sensitivity analyses with 10,000 simulations to test the robustness of our results. Secondary outcomes included numbers of stillbirths, neonatal deaths, neonatal intensive care unit admissions, maternal deaths, severe maternal morbidities, and first and second trimester abortions. RESULTS: The abortion not available cohort had a higher annual cost to the military ($299.1 million, 95% CI 239.2 - 386.6, vs. $226.0 million, 95% CI 181.9 - 288.5) and was associated with 203 more disability-adjusted life years compared to the abortion available cohort. The incremental cost effectiveness ratio was dominant for abortion available. Abortion not available resulted in an annual additional 7 stillbirths, 1 neonatal death, 112 neonatal intensive care unit admissions, 0.016 maternal deaths, 24 severe maternal morbidities, 27 less second trimester abortions, and 602 less first trimester abortions. Probabilistic sensitivity analysis revealed that the chance of the abortion available cohort being the more cost-effective strategy was greater than 95%. CONCLUSION: Limiting active-duty service women's access to abortion care increases costs to the military, even with costs of travel support, and increases adverse maternal and neonatal outcomes. This analysis provides important information for policymakers about economic and health burdens associated with barriers to abortion care in the military.

Supporting the nation in crisis: the military health system's role in enhancing public health capacity through public-private partnerships.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic caused significant global disruptions to the healthcare system, which was forced to make rapid changes in healthcare delivery. The pandemic necessitated closer collaboration between the US civilian healthcare sector and the military health system (MHS), resulting in new and strengthened partnerships that can ultimately benefit public health and healthcare for the nation. In this study, we sought to understand the full range of partnerships in which the MHS engaged with the civilian sector during the COVID-19 pandemic and to elicit lessons for the future. METHODS: We conducted key informant interviews with MHS policymakers and advisers, program managers and providers who were affiliated with the MHS from March 2020 through December 2022. Key themes were derived using thematic analysis and open coding methods. RESULTS: We conducted 28 interviews between December 2022 and March 2023. During the pandemic, the MHS collaborated with federal and local healthcare authorities and private sector entities through endeavours such as Operation Warp Speed. Lessons and recommendations for future pandemics were also identified, including investment in biosurveillance systems and integration of behavioural and social sciences. CONCLUSIONS: The MHS rapidly established and fostered key partnerships with the public and private sectors during the COVID-19 pandemic. The pandemic experience showed that while the MHS is a useful resource for the nation, it also benefits from partnering with a variety of organizations, agencies and private companies. Continuing to develop these partnerships will be crucial for coordinated, effective responses to future pandemics.

Absolute and relative morbidity burdens attributable to various illnesses and injuries among non-service member beneficiaries of the Military Health System, 2023.

The Military Health System (MHS) is a global, integrated health delivery system tasked with ensuring the medical readiness of the U.S. Armed Forces while fulfilling the individual health care needs of eligible military personnel and their dependents. The MHS network comprises military hospitals and clinics that ensure the medical readiness of the force, which are complemented by programs that enable beneficiary care in the private sector through the TRICARE insurance program. Mental health disorders accounted for the largest proportions of the morbidity and health care burdens that affected the pediatric and younger adult beneficiary age groups of nonservice member beneficiaries of the Military Health System in 2023. Among adults aged 45-64 years and adults aged 65 years and older, musculoskeletal diseases accounted for the most morbidity and health care burdens. With almost all health care for Medicare-eligible beneficiaries aged 65 years and older at private sector medical facilities, over 91% of health care encounters among non-service member beneficiaries (TRICARE-eligible and Medicare-eligible) occurred at non-military medical facilities.

Fetal alcohol spectrum disorders prevention and clinical guidelines research - workshop report.

It is estimated that up to 1 in 20 people in the United States may have a fetal alcohol spectrum disorder (FASD), or the array of physical, cognitive, emotional, and social disorders caused by exposure to alcohol during prenatal development (May et al., JAMA 319:474-82, 2018). While this condition is present in a broad range of individuals and families, it has not previously been examined in the military community, where cultural factors including an increased prevalence of alcohol misuse may pose a unique set of challenges (Health.mil, Alcohol misuse, 2024).The Uniformed Services University of the Health Sciences (USUHS), in conjunction with FASD United, hosted the second annual Workshop on Fetal Alcohol Spectrum Disorders Prevention and Clinical Guidelines Research on 20 September 2023 in Washington, DC. Organized as part of a four-year, federally-funded health services research initiative on FASD in the U.S. Department of Defense (DoD) Military Health System (MHS), the workshop provided a forum for exploring the initiative's focus and progress; examining current knowledge and practice in the research and clinical spheres; and identifying potential strategies to further improve prevention, screening, diagnosis, interventions, and family support. Building off of the 2022 workshop that covered the state of the science surrounding prenatal alcohol exposure and FASD, the 2023 focused primarily on FASD and efforts aimed at identification and management (Koehlmoos et al., BMC Proc 17 Suppl 12:19, 2023). One hundred and thirty attendees from academia, healthcare, federal agencies, and patient advocacy organizations gathered to share research findings; learn from lived experiences; and discuss initiatives to advance research, screening, and services for at-risk pregnant women as well as families and caregivers supporting individuals with FASD.

Impact of Race-Free Glomerular Filtration Rate Estimations on CKD Prevalence in the US Military Health System: A Retrospective Cohort Study.

Rationale & Objective: The 2021 CKD-EPI removes Black race as a factor in calculating the estimated glomerular filtration rate (eGFR). We assessed its effect on CKD prevalence in the demographically-diverse US Military Health System. Study Design: A retrospective calculation of the eGFR from serum creatinine measured over 2016-2019 using both the 2009 and 2021 CKD-EPI equations. Setting & Population: Multicenter health care network with data from 1,502,607 adults in the complete case analysis and from 1,970,433 adults in an imputed race analysis. Predictors: Serum creatinine, age, sex, and race. Outcome: CKD stages 3-5, defined as the last eGFR persistently < 60 mL/min/1.73m2 for ≥90 days. Analytical Approach: The t test and Kruskal-Wallis test were used for continuous variables and Χ2 for categorical data. Results: The population in the complete case analysis had a median age of 40 years and was 18.8% Black race and 35.4% female. With the 2021 equation, the number of Black adults with CKD stages 3-5 increased by 58.1% from 4,147 to 6,556, a change in the crude prevalence from 1.47% to 2.32%. The number of non-Black adults with CKD stages 3-5 decreased by 30.4% from 27,596 to 19,213, a crude prevalence change from 2.26% to 1.58%. Similar results were seen with race imputation. Cumulatively, among adults with CKD stages 3-5 by at least one equation, 45.8% of Black adults were reclassified to more advanced stages of CKD and 44.0% of non-Black adults were reclassified to less severe stages across eGFR thresholds that could change clinical management. Limitations: Potential underestimation of CKD in individuals with only 1 measurement. Conclusions: Adoption of the 2021 CKD-EPI equation in the Military Health System reclassifies many Black adults into new CKD stages 3-5 or into more advanced CKD stages, with the opposite effect on non-Black adults. This may have an effect on CKD treatment and outcomes in ways that are yet unknown.

Until recently, kidney function level was calculated from equations that adjusted the result if the individual was of Black race. Because this may contribute to racial disparities in kidney disease care, a new equation was developed in 2021 that excludes race as a factor. We assessed the possible effects of this equation using data from adults in the US Military Health System from 2016 to 2019. With the new equation, the number of Black adults classified with kidney disease increased while that of non-Black adults decreased. There were similar trends seen in the more severe levels of kidney disease, which could affect decisions in clinical care. These results emphasize the potential positive and negative outcomes to be monitored with the new equation.

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

PURPOSE: To evaluate the impact of surgical intervention on long-term renal outcomes for adult patients with congenital ureteropelvic junction obstruction (UPJO). METHODS: 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 ≥ 130/80 mmHg more than 2 weeks apart), and changes in renal excretory function on radionuclide scans. RESULTS: We identified 108 individuals diagnosed with congenital UPJO; mean follow-up of 7 years. Mean age at diagnosis was 25 years; 95% male; 69% White, 15% Black. At diagnosis, median BP was 130/78 mmHg and mean eGFR 93 ml/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. 93 ml/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 (35 min vs. 19 min, p = 0.009). Similar trends occurred with left-sided UPJO but were not significant. CONCLUSION: 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.

Sexual and reproductive health in military settings: A qualitative study.

Mission readiness is critical to the operational success of the United States (US) military and includes having a healthy and fit fighting force. Service members and their dependents have access to a wide range of sexual and reproductive health services with no out-of-pocket costs. Despite this access, negative outcomes such as sexually transmitted infections (STIs) and unintended pregnancy persist. Semi-structured, in-depth interviews were conducted with service members and stakeholders (e.g. medical providers). Interviews explored the individual, interpersonal, organizational, and institutional factors that inform sexual norms, behaviors, and healthcare experiences in the US military. Interview transcripts were coded manually; data were summarized for themes related to unique aspects of military culture and healthcare affecting sexual and reproductive health. Twenty-five (25) service members and 15 stakeholders completed interviews. Four themes emerged: 1) despite free access, both general and military-specific barriers to sexual and reproductive healthcare persist; 2) general and military-specific cultural norms apply to sexual behavior and care seeking; 3) sexual and reproductive health-related norms can be perceived as confusing and contradictory within the military; and 4) resources addressing sexual assault are ubiquitous in military settings, but resources addressing prevention of STIs and unintended pregnancy are limited. Both general and military-specific norms, behavior, and healthcare experiences need to be considered in clinical care, public health campaigns, and other efforts to promote sexual and reproductive health in military settings.

Ivermectin prescription fill rates among U.S. Military members during the coronavirus disease 2019 (COVID-19) pandemic.

This report describes ivermectin prescription fill rates among U.S. active component service members (ACSM) over time during the early phases of the COVID-19 pandemic. Information about the unsubstantiated benefits of ivermectin for coronavirus 2019 (COVID-19) prevention and treatment was widely available online early in the COVID-19 pandemic. Ivermectin prescription fill rates increased among ACSM during periods of Alpha and Delta coronavirus variant predominance, but not during the predominance of the Omicron variant. At the peak of the fill rate curve, in August 2021, rates were higher among men compared to women, older compared to younger age groups, senior officers compared to junior officers, senior enlisted compared to junior enlisted service members, and those with a bachelor's or advanced degree compared to those without a bachelor's degree. Ivermectin prescriptions were more likely to have been filled at a retail pharmacy than at a military hospital or clinic. During the COVID-19 pandemic fill rates for ivermectin prescriptions among ACSM increased, including those without a qualifying diagnosis. Rates peaked in August 2021 but subsequently declined. The decrease in ivermectin fill rates was coincident with vigorous efforts to correct previous misinformation and implement pre-authorization requirements for prescriptions. Research on the impact of unproven online claims about clinical and public health interventions has potential to curtail future unnecessary and potentially harmful treatments.

Weight loss medication prescription prevalence in the active component, 2018-2023.

The U.S. military has witnessed rising obesity among active component service members. The Department of Defense authorized coverage of weight loss medications in 2018, but no study has evaluated prescription prevalence within the active component. This descriptive retrospective cohort study analyzed data from active component U.S. military service members from January 2018 through June 2023. The study used data from the Defense Medical Surveillance System to determine prescription period prevalence of weight loss medication. Data on demographics, body mass index, and history of diabetes were considered. The study revealed a 100-fold increase in the prescription period prevalence of weight loss agents in the active component from their initial authorization date. Demographics associated with higher prescription period prevalence were non-Hispanic Black race and ethnicity, female sex, and older age. Service members in the health care occupations and the Navy had higher prevalence compared to other service branches and occupations. The findings indicate a significant rise in the period prevalence of weight loss prescriptions over time. Further research is recommended to assess the effectiveness, safety, and use in austere military environments.

Association between body composition standards and eating disorder medical claims among active-duty service women.

INTRODUCTION: Eating disorders are a worldwide public health concern with the United States having a particularly high prevalence. Eating disorders are of particular concern to the Department of Defense and Military Health System (MHS) because body composition standards are in place for active-duty service members. METHODS: We conducted a cross-sectional study of active-duty service women (ADSW) ages 18 and older in the U.S. Army, Air Force, Navy, and Marine Corps during fiscal years (FY) 2018-2019. Utilizing claims data from the MHS Data Repository (MDR), we identified ADSW with a Body Mass Index (BMI) measure during the study period and compared their BMI to Service-specific requirements and diagnosis of an eating disorder. RESULTS: We identified a total of 161,209 ADSW from the MDR in FYs 2018-2019 with a recorded BMI, of whom 61,711 (38.3%) had a BMI exceeding the maximum BMI Service-specific standards during the study period and 0.5% had an eating disorder diagnosis. Increased risk of an eating disorder was found in ADSW with an Underweight BMI. Further, we found that there was no association of disordered eating diagnoses among ADSW who were near the maximum height/weight standard set by their Service. CONCLUSION: There appears to be no association between body composition standards of the Services and eating disorder diagnoses in ADSW. We were not able to investigate unhealthy habits around diet or exercise directly related to body composition standards.

Eating disorders are a worldwide public health concern with the United States having a particularly high prevalence. Active duty service women serving in the United States armed forces may be at an increased risk due to strict Service specific weight requirements. This study suggests that the height and weight standards do not increase the risk for eating disorder diagnoses in active duty service women. However, we were not able to investigate unhealthy habits around diet or exercise directly related to body composition standards near the time of measurement or assessment.

The response of the Military Health System (MHS) to the COVID-19 pandemic: a summary of findings from MHS reviews.

INTRODUCTION: The coronavirus disease 2019 (COVID-19) pandemic caused major disruptions to the US Military Health System (MHS). In this study, we evaluated the MHS response to the pandemic to understand the impact of the pandemic response in a large, national, integrated healthcare system providing care for ~ 9 million beneficiaries. METHODS: We performed a narrative literature review of 16 internal Department of Defense (DoD) reports, including reviews mandated by the US Congress in response to the pandemic. We categorized the findings using the Doctrine, Organization, Training, Materiel, Leadership, Personnel, Facilities, and Policy (DOTMLPF-P) framework developed by the DoD to assess system efficiency and effectiveness. RESULTS: The majority of the findings were in the policy, organization, and personnel categories. Key findings showed that the MHS structure to address surge situations was beneficial during the pandemic response, and the rapid growth of telehealth created the potential impact for improved access to routine and specialized care. However, organizational transition contributed to miscommunication and uneven implementation of policies; disruptions affected clinical training, upskilling, and the supply chain; and staffing shortages contributed to burnout among healthcare workers. CONCLUSION: Given its highly integrated, vertical structure, the MHS was in a better position than many civilian healthcare networks to respond efficiently to the pandemic. However, similar to the US civilian sector, the MHS also experienced delays in care, staffing and materiel challenges, and a rapid switch to telehealth. Lessons regarding the importance of communication and preparation for future public health emergency responses are relevant to civilian healthcare systems responding to COVID-19 and other similar public health crises.

Validation of ICD-9-CM codes for major genitourinary birth defects in Military Health System administrative data, 2006-2014.

BACKGROUND: The Department of Defense Birth and Infant Health Research program is dedicated to birth defects research and surveillance among military families. Here, we assess and refine the validity of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for selected genitourinary birth defects in the Military Health System (MHS). We additionally outline methods for the calculation of positive predictive value (PPV) and negative predictive value (NPV), sensitivity, and specificity using a stratified sampling design. METHODS: Among military infants born from 2006 through 2014, a random sample of ICD-9-CM screen-positive cases (for six genitourinary birth defects) and screen-negative cases were selected for chart review. PPV, NPV, sensitivity, and specificity were calculated for individual defects and any included defect (i.e., overall); measures were weighted by the inverse probability of being sampled. RESULTS: Of 461,557 infants, 686 were sampled for chart review. Bladder exstrophy was accurately reported (PPV: >90%), while the accuracy of renal dysplasia, renal agenesis/hypoplasia, and hypospadias was moderate (PPVs: 66%-68%) and congenital hydronephrosis was low (PPV: 20%). Specificity and NPVs always exceeded 98%. The overall PPV was 50%; however, excluding congenital hydronephrosis screen-positive cases and requiring at least two inpatient or outpatient diagnostic codes resulted in a PPV of 85%. CONCLUSIONS: The validity of major genitourinary birth defect codes varied in MHS administrative data. The accuracy of an overall defect measure improved by omitting congenital hydronephrosis and requiring at least two diagnostic codes. Although PPV is generally useful for research, additional calculation of NPV, sensitivity, and specificity better informs the identification of appropriate selection criteria across surveillance and research settings.

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.

Frequency of Medical Claims for Diastasis Recti Abdominis Among U.S. Active Duty Service Women, 2016 to 2019.

Background: Diastasis recti abdominis (DRA) is a condition in pregnant and postpartum women. Proposed risk factors include age, sex, multiparity, cesarean delivery, diabetes, gestational weight gain, and high birth weight. This study aims to estimate the prevalence of DRA using medical claims data among U.S. active duty service women (ADSW) and determine associated risk factors. Materials and Methods: We conducted a cross-sectional study of ADSW aged 18 years and older in the U.S. Army, Air Force, Navy, and Marine Corps during fiscal years (FYs) 2016 to 2019. Utilizing claims data, we identified ADSW with a diagnosis of DRA during the study period. Risk factors, including age, race, socioeconomic status, branch of service, military occupation, delivery type, and parity, were evaluated through descriptive statistics, chi-square tests, and logistic regression analysis. Results: A total of 340,748 ADSW were identified during FYs 2016 to 2019, of whom 2,768 (0.81%) had a medical claim for DRA. Of those with deliveries during the study period, 1.41% were multiparous and 84.53% had a cesarean delivery. Increased risk of DRA was found in ages 30 to 39 years, Black women, ranks representing a higher socioeconomic status, and women with overweight and obese body mass indices. Conclusions: Although the prevalence of DRA, defined as a medical claim for DRA, in the study population is low, subpopulations may be disproportionately affected by the condition. Further research could potentially detail the impact of DRA on the functional impairment and operational readiness of ADSW in the U.S. military and any possible means of prevention.

A cohort study of BMI changes among U.S. Army soldiers during the COVID-19 Pandemic.

BACKGROUND: The increasing number of individuals with obesity is a healthcare concern in the United States (U.S.) population; the men and women who serve in the Army are no exception, with 17.3% of soldiers categorized with a body mass index (BMI) of Obesity in 2017. The COVID-19 pandemic profoundly disrupted life around the globe. During the pandemic, restrictions to soldier movement and activity were put in place to limit COVID-19 transmission. We strive to assess what effects these changes may have had on the BMIs of soldiers. METHODS: We conducted a retrospective cohort study of active duty U.S. Army soldiers using data from the Military Health System Data Repository. BMI was calculated and categorized before (February 2019 - January 2020) and during the pandemic (September 2020 - June 2021). Women who were pregnant or delivered during and one year prior to the study periods were excluded. Statistical analyses included paired t-tests evaluating mean BMI, percent change, and the Stuart-Maxwell test for marginal homogeneity. RESULTS: 191,894 soldiers were included in the cohort. During the pandemic, 50.5% of soldiers in the cohort were classified as Overweight and 23.2% were classified as Obesity. T-test and Stuart-Maxwell test indicated significant differences and changes in BMI categories between the pre-pandemic and pandemic periods, particularly the Obesity category, which experienced a 5% growth and 27% change. Significant absolute changes were observed during the pandemic; 26.7% of soldiers classified as Healthy weight in the pre-pandemic period shifted to Overweight in the pandemic period and 15.6% shifted from Overweight in the pre-pandemic period to Obesity in the pandemic period. Absolute increases were observed across every demographic category in soldiers with obesity; the categories that saw the highest increases were female, ages 20-24, White, and Junior Enlisted soldiers. CONCLUSIONS: Higher rates of obesity may result in decreased health of the force. The specific needs of younger and Junior Enlisted soldiers need to be further addressed, with focus on special intervention programs by the U.S. Army.

Widening the scope of intensive treatment for PTSD in the military health system.

Recent trends have exacerbated existing problems accessing mental health care for military service members. To address these problems, lawmakers and military leaders have been busy introducing new legislation and changing policies in order to improve access. While these initiatives are critical for long-term change, military service members need solutions that can help them now. Although it may not be a panacea, intensive outpatient treatments may be part of the solution for the MHS, especially when considering posttraumatic stress disorder (PTSD). This commentary begins by describing the history of intensive treatments in the military health system, which has been largely offered as intensive outpatient treatments (IOPs). Next, it describes a decade of research on intensive treatments for PTSD, which has included a diverse array of IOP formats as well as stand-alone, massed treatments. Lastly, this commentary recommends that lawmakers and military leaders expand their notion of intensive outpatient treatments to include both programs and stand-alone, massed treatments. By doing so, the MHS could have more options for service members and commands as they search for workable treatment options.

Voice of the Customer: Factors Impacting Beneficiary Choice of Programs in TRICARE.

Little is known about how a consumer would choose a health plan if cost was not an option such as in the Military Health System. We sought to identify how to recruit TRICARE beneficiaries into new pilot programs challenged by low recruitment. We developed a semistructured interview guide by adapting a framework established by Klinkman to assess factors in choosing a health plan. Using social media platforms, we recruited TRICARE Prime and Select beneficiaries to participate in key informant interviews from October to December 2022. We conducted inductive thematic analysis to determine key areas of concern. We interviewed a total of 20 TRICARE Prime and Select beneficiaries. The majority were women, above age 40, had a master's degree, a sponsor in the US Army and of senior officer rank. Four overarching themes emerged: (I) patient choice; (II) access to care; (III) quality of care; and (IV) cost. This evaluation of TRICARE beneficiaries explores how to motivate high-quality value-based care in a traditionally fee for service system.

Prevalence of Heart Failure Stages in a Universal Health Care System: The Military Health System Experience.

BACKGROUND: Morbidity and mortality related to heart failure are increasing and disparities are widening. These alarming trends, often confounded by access to care, are poorly understood. This study evaluates the prevalence of all stages of heart failure by race and socioeconomic status in an environment with no access barrier to care. METHODS: We conducted a cross-sectional observational study of adult beneficiaries aged 18 to 64 years of the Military Health System (MHS), a model for universal health care for fiscal years 2018-2019. We calculated prevalence of preclinical (stages A/B) or clinical (stages C/D) heart failure stages as defined by professional guidelines. Results were analyzed by age, race, and socioeconomic status (using military rank as a proxy). RESULTS: Among 5,440,761 MHS beneficiaries aged 18 to 64 years, prevalence of preclinical and clinical heart failure was 18.1% and 2.5%, respectively. Persons with preclinical heart failure were middle aged, with similar proportions of men and women, while those with heart failure were older, mainly men. After multivariable adjustment, male sex (1.35 odds ratio [OR] [preclinical]; 1.95 OR [clinical]), Black race (1.64 OR [preclinical]; 1.88 OR [clinical]) and lower socioeconomic status were significantly associated with large increases in the prevalence of all stages of heart failure. CONCLUSION: All stages of heart failure are highly prevalent among MHS beneficiaries of working age and, in an environment with no access barrier to care, there are striking disparities by race and socioeconomic status. The high prevalence of preclinical heart failure, particularly notable among Black beneficiaries, delineates a critical time window for prevention.

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

RATIONALE: Burnout 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. OBJECTIVE: This 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. METHODS: Anonymous 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. RESULTS: Results 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. CONCLUSIONS: Results 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.

Does universal insurance influence disparities in high-quality hospital use for inpatient pediatric congenital heart defect care within the first year of diagnosis?

BACKGROUND: Healthcare disparities are an issue in the management of Congenital Heart Defects (CHD) in children. Although universal insurance may mitigate racial or socioeconomic status (SES) disparities in CHD care, prior studies have not examined these effects in the use of High-Quality Hospitals (HQH) for inpatient pediatric CHD care in the Military Healthcare System (MHS). To assess for racial and SES disparities in inpatient pediatric CHD care that may persist despite universal insurance coverage, we performed a cross-sectional study of the HQH use for children treated for CHD in the TRICARE system, a universal healthcare system for the U.S. Department of Defense. In the present work we evaluated for the presence of disparities, like those seen in the civilian U.S. healthcare system, among military ranks (SES surrogate) and races and ethnicities in HQH use for pediatric inpatient admissions for CHD care within a universal healthcare system (MHS). METHODS: We conducted a cross-sectional study using claims data from the U.S. MHS Data Repository from 2016 to 2020. We identified 11,748 beneficiaries aged 0 to 17 years who had an inpatient admission for CHD care from 2016 to 2020. The outcome variable was a dichotomous indicator for HQH utilization. In the sample, 42 hospitals were designated as HQH. Of the population, 82.9% did not use an HQH at any point for CHD care and 17.1% used an HQH at some point for CHD care. The primary predictor variables were race and sponsor rank. Military rank has been used as an indicator of SES status. Patient demographic information at the time of index admission post initial CHD diagnosis (age, gender, sponsor marital status, insurance type, sponsor service branch, proximity to HQH based on patient zip code centroid, and provider region) and clinical information (complexity of CHD, common comorbid conditions, genetic syndromes, and prematurity) were used as covariates in multivariable logistic regression analysis. RESULTS: After controlling for demographic and clinical factors including age, gender, sponsor marital status, insurance type, sponsor service branch, proximity to HQH based on patient zip code centroid, provider region, complexity of CHD, common comorbid conditions, genetic syndromes, and prematurity, we did not find disparities in HQH use for inpatient pediatric CHD care based upon military rank. After controlling for demographic and clinical factors, lower SES (Other rank) was less likely to use an HQH for inpatient pediatric CHD care; OR of 0.47 (95% CI of 0.31 to 0.73). CONCLUSIONS: We found that for inpatient pediatric CHD care in the universally insured TRICARE system, historically reported racial disparities in care were mitigated, suggesting that this population benefitted from expanded access to care. Despite universal coverage, SES disparities persisted in the civilian care setting, suggesting that universal insurance alone cannot sufficiently address differences in SES disparities in CHD care. Future studies are needed to address the pervasiveness of SES disparities and potential interventions to mitigate these disparities such as a more comprehensive patient travel program.