Effect of an equal-access military health system on racial disparities in colorectal cancer screening.

BACKGROUND: Racial disparities in colorectal cancer (CRC) screening are frequently attributed to variations in insurance status. The objective of this study was to ascertain whether universal insurance would lead to more equitable utilization of CRC screening for black patients in comparison with white patients. METHODS: Claims data from TRICARE (insurance coverage for active, reserve, and retired members of the US Armed Services and their dependents) for 2007-2010 were queried for adults aged 50 years in 2007, and they were followed forward in time for 4 years (ages, 50-53 years) to identify their first lower endoscopy and/or fecal occult blood test (FOBT). Variations in CRC screening were compared with descriptive statistics and multivariate logistic regression. RESULTS: Among the 24,944 patients studied, 69.2% were white, 20.3% were black, 4.9% were Asian, and 5.6% were other. Overall, 54.0% received any screening: 83.7% received endoscopy, and 16.3% received FOBT alone. Compared with whites, black patients had higher screening rates (56.5%) and had 20% higher risk-adjusted odds of being screened (95% confidence interval [CI], 1.11-1.29). Asian patients had a likelihood of screening similar to that of white patients (odds ratio [OR], 1.06; 95% CI, 0.92-1.23). Females (OR, 1.20; 95% CI, 1.10-1.33), active-duty personnel (OR, 1.15; 95% CI, 1.06-1.25), and officers (OR, 1.28; 95% CI, 1.18-1.37) were also more likely to be screened. CONCLUSION: Within an equal-access, universal health care system, black patients had higher rates of CRC screening in comparison with prior reports and even in comparison with white patients within the population. These findings highlight the need to understand and develop meaningful approaches for promoting more equitable access to preventative care. Moreover, equal-access, universal health insurance for both the military and civilian populations can be presumed to improve access for underserved minorities.

Provider-Induced Demand in the Treatment of Carotid Artery Stenosis: Variation in Treatment Decisions Between Private Sector Fee-for-Service vs Salary-Based Military Physicians.

Importance: Although many factors influence the management of carotid artery stenosis, it is not well understood whether a preference toward procedural management exists when procedural volume and physician compensation are linked in the fee-for-service environment. Objective: To explore evidence for provider-induced demand in the management of carotid artery stenosis. Design, Setting, and Participants: The Department of Defense Military Health System Data Repository was queried for individuals diagnosed with carotid artery stenosis between October 1, 2006, and September 30, 2010. A hierarchical multivariable model evaluated the association of the treatment system (fee-for-service physicians in the private sector vs salary-based military physicians) with the odds of procedural intervention (carotid endarterectomy or carotid artery stenting) compared with medical management. Subanalysis was performed by symptom status at the time of presentation. The association of treatment system and of management strategy with clinical outcomes, including stroke and death, was also evaluated. Data analysis was conducted from August 15, 2015, to August 2, 2016. Main Outcomes and Measures: The odds of procedural intervention based on treatment system was the primary outcome used to indicate the presence and effect of provider-induced demand. Results: Of 10 579 individuals with a diagnosis of carotid artery stenosis (4615 women and 5964 men; mean [SD] age, 65.6 [11.4] years), 1307 (12.4%) underwent at least 1 procedure. After adjusting for demographic and clinical factors, the odds of undergoing procedural management were significantly higher for patients in the fee-for-service system compared with those in the salary-based setting (odds ratio, 1.629; 95% CI, 1.285-2.063; P < .001). This finding remained true when patients were stratified by symptom status at presentation (symptomatic: odds ratio, 2.074; 95% CI, 1.302-3.303; P = .002; and asymptomatic: odds ratio, 1.534; 95% CI, 1.186-1.984; P = .001). Conclusions and Relevance: Individuals treated in a fee-for-service system were significantly more likely to undergo procedural management for carotid stenosis compared with those in the salary-based setting. These findings remained consistent for individuals with and without symptomatic disease.

First employment characteristics for the 2011 pediatric surgery fellowship graduates.

PURPOSE: Information regarding initial employment of graduating pediatric surgery fellows is limited. More complete data could yield benchmarks of initial career environment. METHODS: An anonymous survey was distributed in 2011 to 41 pediatric surgery graduates from all ACGME training programs interrogating details of initial positions and demographics. RESULTS: Thirty-seven of 41 (90%) fellows responded. Male to female ratio was equal. Graduates carried a median debt of $220,000 (range: $0-$850,000). The majority of fellows were married with children. 70% were university/hospital employees, and 68% were unaware of a business plan. Median starting compensation was $354,500 (range: $140,000-$506,000). Starting salary was greatest for >90% clinical obligation appointments (median $427,500 vs. $310,000; p=0.002), independent of geographic location. Compensation had no relationship to private practice vs. hospital/university/military position, coastal vs. inland location, and practice sites number. Median clinical time was 75% and research time 10%. 49% identified a formal mentor. Graduates covered 1-5 different offices (median 1) and 1-5 surgery sites (median 2). 60% were satisfied with their compensation. CONCLUSION: Recent pediatric surgery graduates are engaged mainly in clinical care. Research is not incentivized. Compensation is driven by clinical obligations. Graduates have limited knowledge of the business plan supporting their compensation, nature of malpractice coverage, and commitments to resources including research. Graduates have important fiscal and parenting obligations.

Medical costs of war in 2035: long-term care challenges for veterans of Iraq and Afghanistan.

War-related medical costs for U.S. veterans of Iraq and Afghanistan may be enormous because of differences between these wars and previous conflicts: (1) Many veterans survive injuries that would have killed them in past wars, and (2) improvised explosive device attacks have caused "polytraumatic" injuries (multiple amputations; brain injury; severe facial trauma or blindness) that require decades of costly rehabilitation. In 2035, today's veterans will be middle-aged, with health issues like those seen in aging Vietnam veterans, complicated by comorbidities of posttraumatic stress disorder, traumatic brain injury, and polytrauma. This article cites emerging knowledge about best practices that have demonstrated cost-effectiveness in mitigating the medical costs of war. We propose that clinicians employ early interventions (trauma care, physical therapy, early post-traumatic stress disorder diagnosis) and preventive health programs (smoking cessation, alcohol-abuse counseling, weight control, stress reduction) to treat primary medical conditions now so that we can avoid treating costly secondary and tertiary complications in 2035. (We should help an amputee reduce his cholesterol and maintain his weight at age 30, rather than treating his heart disease or diabetes at age 50.) Appropriate early interventions for primary illness should preserve veterans' functional status, ensure quality clinical care, and reduce the potentially enormous cost burden of their future health care.

[Vacuum-assisted closure of head and neck wounds]. / Vakuumversiegelungstherapie im Kopf-Hals-Bereich.

OBJECTIVE: Since the early 1990s, vacuum-assisted closure (VAC) therapy has been used to treat acute and chronic wounds in almost all disciplines of surgery in Germany. Taking this into consideration, the use of vacuum therapy in the area of head and neck surgery was examined. METHODS: A literature review using MEDLINE (with PubMed) and EMBASE as well as a Cochrane search was performed on 15 December 2010. Search terms included "vacuum therapy", "vacuum-assisted closure", "V.A.C.", "VAC", "(topical) negative pressure (wound therapy)". RESULTS: There were 1,502 peer-reviewed articles about "vacuum therapy" concerning all medical fields in literature. There were a total of 37 publications from the discipline of head and neck surgery (538 patients). Although benefits for the patients are consistently reported, these results are usually presented only in case reports or case series (evidence level IV and V). Positive results are mainly observed for the treatment of lifting defects in reconstructive surgery and for the treatment of acute and chronic soft tissue defects of the neck. Only little experience exists in the vacuum therapy of war wounds in the head and neck region. CONCLUSION: Due to its advantages (i.e., hygienic temporary wound care with support of the continuous decontamination, wound drainage, promotion of granulation tissue formation, and effective wound conditioning), VAC is an integral and indispensable part of modern wound treatment. Analogous to this general experience, a benefit must also be assumed for head and neck wounds. High-quality and reliable studies on the use of VAC must be performed to verify this observation and the future reimbursement of in- and outpatient wound VAC treatment.

TRICARE; coverage of National Cancer Institute (NCI) sponsored Phase I studies. Final rule.

This final rule adds coverage of National Cancer Institute (NCI) sponsored Phase I studies for certain beneficiaries. The NCI sponsored clinical treatment trials are conducted in a series of steps called phases. Phase I trials are the first studies conducted in people. They evaluate how a new drug should be given (by mouth, injected into the blood, or injected into the muscle), how often, and what dose is safe.

Management of unilateral cervical radiculopathy in the military: the cost effectiveness of posterior cervical foraminotomy compared with anterior cervical discectomy and fusion.

OBJECT: To review the cost effectiveness for the management of a unilateral cervical radiculopathy with either posterior cervical foraminotomy (PCF) or anterior cervical discectomy and fusion (ACDF) in military personnel, with a particular focus on time required to return to active-duty service. METHODS: Following internal review board approval, the authors conducted a retrospective review of 38 cases in which patients underwent surgical management of unilateral cervical radiculopathy. Nineteen patients who underwent PCF were matched for age, treatment level, and surgeon to 19 patients who had undergone ACDF. Successful outcome was determined by return to full, unrestricted active-duty military service. The difference in time of return to active duty was compared between the groups. In addition, a cost analysis consisting of direct and indirect costs was used to compare the PCF group to the ACDF group. RESULTS: A total of 21 levels were operated on in each group. There were 17 men and 2 women in the PCF group, whereas all 19 patients in the ACDF group were men. The average age at the time of surgery was 41.5 years (range 27-56 years) and 39.3 years (range 24-52 years) for the PCF and ACDF groups, respectively. There was no statistically significant difference in operating room time, estimated blood loss, or postoperative narcotic refills. Complications included 2 cases of transient recurrent laryngeal nerve palsy in the ACDF group. The average time to return to unrestricted full duty was 4.8 weeks (range 1-8 weeks) in the PCF group and 19.6 weeks (range 12-32 weeks) in the ACDF group, a difference of 14.8 weeks (p < 0.001). The direct costs of each surgery were $3570 for the PCF and $10,078 for the ACDF, a difference of $6508. Based on the 14.8-week difference in time to return to active duty, the indirect cost was calculated to range from $13,586 to $24,045 greater in the ACDF group. Total cost (indirect plus direct) ranged from $20,094 to $30,553 greater in the ACDF group. CONCLUSIONS: In the management of unilateral posterior cervical radiculopathy for military active-duty personnel, PCF offers a benefit relative to ACDF in immediate short-term direct and long-term indirect costs. The indirect cost of a service member away from full, unrestricted active duty 14.8 weeks longer in the ACDF group was the main contributor to this difference.

Economic implications of reduced binge drinking among the military health system's TRICARE Prime plan beneficiaries.

This study examines the economic burden of alcohol misuse to the Department of Defense (DoD) and the benefits of reduced binge drinking among beneficiaries in the DoD's TRICARE Prime plan. Data analyzed include administrative records for approximately 3 million beneficiaries age 18 to 64, DoD's Survey of Health Related Behaviors Among Military Personnel, and the National Survey on Drug Use and Health. Alcohol misuse among Prime beneficiaries cost the DoD an estimated $1.2 billion in 2006--$425 million in higher medical costs and $745 million in reduced readiness and misconduct charges. Potential annual gross benefits to the DoD of reduced binge drinking are simulated for three scenarios: (1) implementing a comprehensive alcohol screening with referral to brief intervention or treatment by primary care ($87 million/$129 million in short/long-term benefits); (2) increasing the price of alcoholic beverages on military installations by 20% ($75 million/$115 million); and (3) implementing a Web-based education program ($81 million/$123 million).

[Toward strengthening the health politics in Africa: the military health system and its contribution to health policy in Senegal]. / Pour le renforcement des politiques de santé en Afrique: le cas de la contribution de l'armée à l'effort en matière de santé au Sénégal.

Since the following days of independences, the Senegalese army mission has mainly consisted in defending the national territory integrity and in ensuring the protection of the populations and their goods. In the public health system, thanks to the quality of its human resources the army intervenes specifically at every level of the health care structure. The mission assigned to the Senegalese army health unit is therefore multidimensional. In 2001, the operational budget of the army health services is estimated at 177 millions CFA F (265500 euros), its medical consumption at 212 millions CFA F (323 000 Euros) and its health expenditure at 385 millions CFA F (585 000 euros). The army supports the government health policies in different ways: on the one hand, availability of the ministry of health staff, on the other hand, the direct involvement in health care and the implementation of the national and international health programmes.

Socioeconomic issues of United States military neurosurgery.

Although the practice of neurosurgery in the United States (US) Armed Forces is in many ways similar to the civilian practice of neurosurgery, there are many differences as well. The unique challenges, duties, and opportunities US military neurosurgeons are given, both in peacetime and in times of conflict, are discussed, as are pathways for entering into service. The advantages of military service for neurosurgeons include sponsored training, decreased direct exposure to tort actions, little involvement with third-party payers, significant opportunities for travel, and military specific experiences. The most appealing aspect of military practice is serving fellow members of the US Armed Forces. Disadvantages include the extreme gap between the military and civilian pay scales, lack of support personnel, and in some areas low surgery-related case volume. The greatest concern faced by the military neurosurgical community is the failure to retain experienced neurosurgeons after their obligated service time has been completed, for which several possible solutions are described. It is hoped that future changes will make the practice of military neurosurgery attractive enough so that it will be seen as a career in itself and not an obligation to endure before starting practice in the "real world."

The cost-saving potential of prevaccination antibody tests when implementing a mass immunization program.

A seroprevalence study of hepatitis A virus (HAV), hepatitis B virus (HBV), and varicella-zoster virus (VZV) was carried out among Saudi Arabian National Guard soldiers with the objective of determining the cost-saving potential of prevaccination antibody tests when implementing an immunization program for the soldiers. A systematic sampling of 450 blood samples from 1,350 soldiers who donated blood at our hospital was carried out. Antibody tests were performed using the enzyme-linked immunosorbent assay method. The seropositivity rates for antibodies to HAV, HBV, and VZV were 97.5, 17.8, and 88.5%, respectively. Comparing the cost of prevaccine screening with that of universal vaccination, it was estimated that savings of 76 and 32% could be effected for HAV and VZV. Conversely, screening for HBV before immunization could increase the cost of vaccinating against the disease by 49%. A seroprevalence study could be a useful cost-saving approach to a mass immunization program against endemic, natural immunity-conferring diseases.

Access and late-stage diagnosis of breast cancer in the military health system.

The results reported in this paper are from a larger study examining the relationship between access and stage at diagnosis of breast cancer in African-American and white women. This paper focuses on the results describing the extent to which potential and realized access predict stage at diagnosis within an equal economic access health care system. Data in this descriptive-comparative study were collected through secondary analysis using the tumor registry records of 62 African-American and 573 white women diagnosed with breast cancer in the military health system between January 1, 1988, and December 31, 1997. Logistic regression analysis revealed that late-stage breast cancer was more likely to be diagnosed in African-American women from low socioeconomic strata with incidental breast self-examination-discovered cancers. The most significant predictors of late-stage diagnosis were means of discovery and the length of time between discovery and diagnosis.

The cost-effectiveness of varicella screening and vaccination in U.S. Army recruits.

Varicella outbreaks in the U.S. Army disrupt training, reduce readiness, and represent substantial costs. Vaccination of susceptible individuals may be cost-effective. We conducted a cost-effectiveness analysis comparing screening of all incoming recruits and vaccination of susceptible individuals at either initial entry training (IET) or medical entrance processing station (MEPS), universal vaccination at IET, and no intervention. Primary health outcomes included the number of varicella cases prevented during the 8-week initial training period. The varicella hospitalization rate was 21.6 per 10,000 per year. In 100,000 recruits, 36 cases of varicella are expected at a cost of $181,000 in the absence of an intervention. Screening at IET would prevent 4 cases but would cost an additional $3,255,000 more than no intervention. Screening at MEPS would prevent 3 cases and save $521,000 per case prevented during the IET but would cost $2,734,000 more than no intervention. Universal vaccination would prevent 2 cases but would cost $15,858,000 more than MEPS screening and $18,592,000 more than no intervention. These results are robust. Cost per case of varicella prevented ranged from $390,000 to $7.9 million. Scarce prevention resources could be more cost-effectively allocated to other prevention programs.