The Comparative Effectiveness and Provider-induced Demand Collaboration Project: A Pioneering Military-Civilian Academic Partnership to Build Health Services Research Capacity for the Military Health System.

INTRODUCTION: Like civilian health systems, the United States Military Health System (MHS) confronts challenges in achieving the aims of reducing cost, and improving quality, access, and safety, but historically has lacked coordinated health services research (HSR) capabilities that enabled knowledge translation and iterative learning from its wealth of data. A military-civilian academic partnership called the Comparative Effectiveness and Provider-Induced Demand Collaboration (EPIC), formed in 2011, demonstrated early proof-of-concept in using the MHS claims database for research focused on drivers of variation in health care. This existing partnership was reorganized in 2015 and its topics expanded to meet the need for HSR in support of emerging priorities and to develop current and HSR capacity within the MHS. MATERIALS AND METHODS: A Donabedian framework of structure, process, and outcomes was applied to support the project, through a core of principal investigators, researchers, analysts, and administrators. Within this framework, new researchers and student trainees learn foundations of HSR while performing secondary analysis of claims data from the MHS Data Repository (MDR) focusing on Health and Readiness, Pediatrics, Policy, Surgery, Trauma, and Women's Health. RESULTS: Since 2015, the project has trained 25 faculty, staff, and providers; 51 students and residents; 21 research fellows across multiple disciplines; and as of 2022, produced 107 peer-reviewed publications and 130 conference presentations, across all five themes and six cores. Research results have been incorporated into Federal and professional policy guidelines. Major research areas include opioid usage and prescribing, value-based care, and racial disparities. EPIC researchers provide direct support to MHS leaders and enabling expertise to clinical providers. CONCLUSIONS: EPIC, through its Donabedian framework and utilization of the MHS Data Repository as a research tool, generates actionable findings and builds capacity for continued HSR across the MHS. Eight years after its reorganization in 2015, EPIC continues to provide a platform for capacity building and knowledge translation.

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.

Super-Utilization of the Emergency Department in a Universally Insured Population.

INTRODUCTION: Super-utilizers (patients with 4 or more emergency department [ED] visits a year) account for 10% to 26% of all ED visits and are responsible for a growing proportion of healthcare expenditures. Patients recognize the ED as a reliable provider of acute care, as well as a timely resource for diagnosis and treatment. The value of ED care is indisputable in critical and emergent conditions, but in the case of non-urgent conditions, ED utilization may represent an inefficiency in the healthcare system. We sought to identify patient and clinical characteristics associated with ED super-utilization in a universally insured population. MATERIAL AND METHODS: We performed a retrospective cohort study using TRICARE claims data from the Military Health System Data Repository (2011-2015). We reviewed the claims data of all adult patients (aged 18-64 years) who had at least one encounter at the ED for any cause. Multivariable logistic regression was used to determine independent factors associated with ED super-utilization. RESULTS: Factors associated with increased odds of ED super-utilization included Charlson Score ≥2 (adjusted odds ratio [aOR] 1.98, 95% confidence interval [CI]: 1.90-2.06), being eligible for Medicare (aOR 1.95, 95% CI: 1.90-2.01), and female sex (aOR 1.35, 95% CI: 1.33-1.37). Active duty service members (aOR 0.69, 95% CI 0.68-0.72) and beneficiaries with higher sponsor-rank (Officers: aOR 0.50, 95% CI: 0.55-0.57; Senior enlisted: aOR 0.82, 95% CI: 0.81-0.83) had lower odds of ED super-utilization. The most common primary diagnoses for ED visits among super-utilizers were abdominal pain, headache and migraine, chest pain, urinary tract infection, nausea and vomiting, and low back pain. CONCLUSIONS: Risk of ED super-utilization appears to increase with age and diminished health status. Patient demographic and clinical characteristics of ED super-utilization identified in this study can be used to formulate healthcare policies addressing gaps in primary care in diagnoses associated with ED super-utilization and develop interventions to address modifiable risk factors of ED utilization.

Racial Differences in Extremity Soft Tissue Sarcoma Treatment in a Universally Insured Population.

BACKGROUND: In prior reports from population-based databases, black patients with extremity soft tissue sarcoma (ESTS) have lower reported rates of limb-sparing surgery and adjuvant treatment. The objective of this study was to compare the multimodality treatment of ESTS between black and white patients within a universally insured and equal-access health care system. METHODS: Claims data from TRICARE, the US Department of Defense insurance plan that provides health care coverage for 9 million active-duty personnel, retirees, and dependents, were queried for patients younger than 65 y with ESTS who underwent limb-sparing surgery or amputation between 2006 and 2014 and identified as black or white race. Multivariable logistic regression analysis was used to evaluate the impact of race on the utilization of surgery, chemotherapy, and radiation. RESULTS: Of the 719 patients included for analysis, 605 patients (84%) were white and 114 (16%) were black. Compared with whites, blacks had the same likelihood of receiving limb-sparing surgery (odds ratio [OR], 0.861; 95% confidence interval [95% CI], 0.284-2.611; P = 0.79), neoadjuvant radiation (OR, 1.177; 95% CI, 0.204-1.319; P = 0.34), and neoadjuvant (OR, 0.852; 95% CI, 0.554-1.311; P = 0.47) and adjuvant (OR, 1.211; 95% CI, 0.911-1.611; P = 0.19) chemotherapy; blacks more likely to receive adjuvant radiation (OR, 1.917; 95% CI, 1.162-3.162; P = 0.011). CONCLUSIONS: In a universally insured population, racial differences in the rates of limb-sparing surgery for ESTS are significantly mitigated compared with prior reports. Biologic or disease factors that could not be accounted for in this study may contribute to the increased use of adjuvant radiation among black patients.

The Optimal Length of Stay Associated With the Lowest Readmission Risk Following Surgery.

BACKGROUND: Index length of stay (LOS) and readmissions are viewed as important quality measures. However, these metrics represent competing demands as an inordinate reduction in LOS may lead to unplanned readmissions. We sought to assess the optimal LOS associated with the lowest 90-d readmission rate following discharge after common surgical procedures. MATERIALS AND METHODS: This was a retrospective study relying on Tricare claims. We identified all eligible adult patients (18-64 y) receiving a series of common surgical procedures between 2006 and 2014. We used a generalized additive model with spline regression to determine the optimal LOS associated with the lowest 90-d risk of readmission. RESULTS: Ninety-day readmission rates varied from 6.03% to 34.69%. Most procedures exhibited a logit linear relationship, with the lowest risk of readmission evident on postoperative day-1 and increasing thereafter. Among the more invasive procedures (e.g., esophagectomy and radical cystectomy), a U-shaped relationship was realized, indicating that expedited discharge would increase the potential for readmission as would any extended hospital LOS. For these procedures, the ideal index LOS appeared to be 6-7 d for radical cystectomy and 12-13 d for esophagectomy. CONCLUSIONS: Our results support the practice of discharging patients as soon as clinically feasible after hip and knee arthroplasty, lumbar spine surgery, hernia repair, appendectomy, nephrectomy, and colectomy. Among esophagectomy or radical cystectomy, there is a well-defined optimal index admission period and discharge outside this window appears to be detrimental. Our results suggest that invasive procedures appear to possess a unique "signature" when it comes to optimal LOS.

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.

The Use of Prostate Specific Antigen Screening in Purchased versus Direct Care Settings: Data from the TRICARE® Military Database.

PURPOSE: Fee for service reimbursement incentives may affect care. We compared the odds of prostate specific antigen screening among former and active duty United States military service members based on receipt of primary care from integrated military health facilities vs community providers reimbursed via fee for service. MATERIALS AND METHODS: We retrospectively studied the records of all active duty and retired male service members 40 to 64 years old who were covered by the TRICARE® military health benefit in 2010. Beneficiaries may receive primary care at military run facilities via the direct care system or with private physicians via the purchased care system. We compared rates of prostate specific antigen screening between propensity score weighted cohorts of 219,290 men who received primary care in the direct care system and 177,748 who received it in the purchased care system. RESULTS: The screening rate was 35% in the direct care system vs 26% in the purchased care system. After propensity score weighting the former men were significantly more likely to undergo prostate specific antigen screening than men who received primary care in the purchased care system (adjusted OR 1.76, 95% CI 1.729-1.781). Age older than 52 years, rank and black race were associated with increased odds of prostate specific antigen screening in each cohort. CONCLUSIONS: These results suggest that salaried primary care providers employed at integrated military facilities are more likely to order prostate specific antigen screening compared to those reimbursed in a fee for service fashion by military insurance. Growing understanding of how fee for service incentives impact prostate specific antigen screening by primary care providers may enable advocates and policy makers to leverage reimbursement systems as a tool to change prostate cancer screening.

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.

Race-based differences in duration of stay among universally insured coronary artery bypass graft patients in military versus civilian hospitals.

BACKGROUND: Duration of stay for coronary artery bypass graft operation outcomes differs for black versus white patients, with differences often attributed to insurance. We examined black versus white differences in duration of stay among TRICARE-covered patients undergoing coronary artery bypass graft. METHODS: Patients aged 18-64 years with TRICARE who underwent isolated coronary artery bypass graft (ICD-9CM 36.10-36.20) between 2006-2010 and who identified as black or white race were identified. Negative binomial regression, stratified by sex and military versus civilian facility, examined the duration of stay controlling for patient- and hospital-level factors. RESULTS: Of 3,496 eligible patients, 2,904 underwent coronary artery bypass graft at 682 civilian and 592 at 11 military hospitals. Patients (mean age 56.2 years) were predominantly white (88.9%), male (88.7%), married (88.2%), and retired (87%). Black patients demonstrated longer duration of stay (8.6 vs 7.5 days, P > .001), and overall duration of stay was longer at military facilities (8.1 vs 7.5 days, P = .013). Among the men, mean duration of stay was 14% longer for black patients at civilian hospitals (95% confidence interval 1.07-1.22) with no race-based differences at military facilities. CONCLUSION: Among coronary artery bypass graft patients with TRICARE coverage, black, male patients demonstrated greater duration of stay at civilian facilities. Further work should examine care at military hospitals to elucidate factors that drive the apparent mitigation of race-related variability in duration of stay.

Association Between Race and Postoperative Outcomes in a Universally Insured Population Versus Patients in the State of California.

OBJECTIVE: To compare disparities in postoperative outcomes for African Americans after surgical intervention in the universally insured military system, versus the civilian setting in California. BACKGROUND: Health reform proponents cite the reduction of disparities for African Americans and minorities as an expected benefit. The impact of universal health insurance on reducing surgical disparities for African Americans has not previously been examined. METHODS: We used Department of Defense health insurance (Tricare) data (2006-2010) to measure outcomes for African Americans as compared with Whites after 12 major surgical procedures across multiple specialties. The experience of African Americans in the Tricare system was compared with a similar cohort undergoing surgery in the state of California using the State Inpatient Database (2007-2011). RESULTS: No significant difference in postoperative complications [odds ratio (OR) 0.91; 95% confidence interval (CI) 0.81, 1.03] or mortality (OR 0.98; 95% CI 0.43, 2.25) were encountered between African Americans and Whites receiving surgery at hospitals administered by the Department of Defense. African Americans in California who were uninsured or on Medicaid had significantly increased odds of mortality (OR 4.76; 95% CI 2.82, 8.05), complications (OR 1.67; 95% CI 1.34, 2.08), failure to rescue (OR 2.72; 95% CI 1.25, 5.94), and readmission (OR 1.78; 95% CI 1.45, 2.19). CONCLUSIONS: In the equal access military healthcare system, African Americans have outcomes similar to Whites. Disparities were evident in California, especially among those without private insurance. These facts point toward the potential benefits of a federally administered system in which all patients are treated uniformly.

Racial disparities in emergency general surgery: Do differences in outcomes persist among universally insured military patients?

BACKGROUND: Racial disparities in surgical care are well described. As many minority patients are also uninsured, increasing access to care is thought to be a viable solution to mitigate inequities. The objectives of this study were to determine whether racial disparities in 30-/90-/180- day outcomes exist within a universally insured population of military-/civilian-dependent emergency general surgery (EGS) patients and ascertain whether differences in outcomes differentially persist in care received at military versus civilian hospitals and among sponsors who are enlisted service members versus officers. It also considered longer-term outcomes of EGS care. METHODS: Five years (2006-2010) of TRICARE data, which provides insurance to active/reserve/retired members of the US Armed Services and dependents, were queried for adults (≥18 years) with primary EGS conditions, defined by the AAST. Risk-adjusted survival analyses assessed race-associated differences in mortality, major acute care surgery-related morbidity, and readmission at 30/90/180 days. Models accounted for clustering within hospitals and possible biases associated with missing race using reweighted estimating equations. Subanalyses considered restricted effects among operative interventions, EGS diagnostic categories, and effect modification related to rank and military- versus civilian-hospital care. RESULTS: A total of 101,011 patients were included: 73.5% white, 14.5% black, 4.4% Asian, and 7.7% other. Risk-adjusted survival analyses reported a lack of worse mortality and readmission outcomes among minority patients at 30, 90, and 180 days. Major morbidity was higher among black versus white patients (hazard ratio [95% confidence interval): 30 days, 1.23 [1.13-1.35]; 90 days, 1.18 [1.09-1.28]; and 180 days, 1.15 [1.07-1.24], a finding seemingly driven by appendiceal disorders (hazard ratio, 1.69-1.70). No other diagnostic categories were significant. Variations in military- versus civilian-managed care and in outcomes for families of enlisted service members versus officers altered associations, to some extent, between outcomes and race. CONCLUSIONS: While an imperfect proxy of interventions is directly applicable to the broader United States, the contrast between military observations and reported racial disparities among civilian EGS patients merits consideration. Apparent mitigation of disparities among military-/civilian-dependent patients provides an example for which we as a nation and collective of providers all need to strive. The data will help to inform policy within the Department of Defense and development of disparities interventions nationwide, attesting to important differences potentially related to insurance, access to care, and military culture and values. LEVEL OF EVIDENCE: Prognostic and epidemiologic study, level III.