Is the current referral trend a threat to the Military Health System? Perioperative outcomes and costs after colorectal surgery in the Military Health System versus civilian facilities.

BACKGROUND: TRICARE military beneficiaries are increasingly referred for major surgeries to civilian hospitals under "purchased care." This loss of volume may have a negative impact on the readiness of surgeons working in the "direct-care" setting at military treatment facilities and has important implications under the volume-quality paradigm. The objective of this study is to assess the impact of care source (direct versus purchased) and surgical volume on perioperative outcomes and costs of colorectal surgeries. METHODS: We examined TRICARE claims and medical records for 18- to 64-year-old patients undergoing major colorectal surgery from 2006 to 2015. We used a retrospective, weighted estimating equations analysis to assess differences in 30-day outcomes (mortality, readmissions, and major or minor complications) and costs (index and total including 30-day postsurgery) for colorectal surgery patients between purchased and direct care. RESULTS: We included 20,317 patients, with 24.8% undergoing direct-care surgery. Mean length of stay was 7.6 vs 7.7 days for direct and purchased care, respectively (P = .24). Adjusted 30-day odds between care settings revealed that although hospital readmissions (odds ratio 1.40) were significantly higher in direct care, overall complications (odds ratio 1.05) were similar between the 2 settings. However, mean total costs between direct and purchased care differed ($55,833 vs $30,513, respectively). Within direct care, mean total costs ($50,341; 95% confidence interval $41,509-$59,173) were lower at very high-volume facilities compared to other facilities ($54,869; 95% confidence interval $47,822-$61,916). CONCLUSION: Direct care was associated with higher odds of readmissions, similar overall complications, and higher costs. Contrary to common assumptions regarding volume and quality, higher volume in the direct-care setting was not associated with fewer complications.

Factors Associated With Progression to Surgical Intervention for Lumbar Disc Herniation in the Military Health System.

STUDY DESIGN: Retrospective cohort. OBJECTIVE: To determine surgery-free survival of patients receiving conservative management of lumbar disc herniation (LDH) in the military healthcare system (MHS) and risk factors for surgical intervention. SUMMARY OF BACKGROUND DATA: Radiculopathy from LDH is a major cause of morbidity and cost. METHODS: The Military Data Repository was queried for all patients diagnosed with LDH from FY2011-2018; the earliest such diagnosis in a military treatment facility (MTF) was kept for each patient as the initial diagnosis. Follow-up time to surgical intervention was defined as the time from diagnosis to first encounter for lumbar microdiscectomy or lumbar decompression in either a MTF or in the civilian sector. The Military Data Repository was also queried for history of tobacco use at any time during MHS care, age at the time of diagnosis, sex, MHS beneficiary category, and diagnosing facility characteristics. Multivariable Cox proportional hazards models were used to evaluate the associations of patient and diagnosing facility characteristics with time to surgical intervention. RESULTS: A total of 84,985 MHS beneficiaries including 62,771 active duty service members were diagnosed with LDH in a MTF during the 8-year study period. A total of 10,532 (12.4%) MHS beneficiaries, including 7650 (10.9%) active duty, failed conservative management onto surgical intervention with lumbar microdiscectomy or lumbar decompression. Median follow-up time of the cohort was 5.2 (interquartile range 2.6, 7.5) years. Among all healthcare beneficiaries, several patient-level (younger age, male sex, and history of tobacco use) and facility-level characteristics (hospital vs. clinic and surgical care vs. primary care clinic) were independently associated with higher risk of surgical intervention. CONCLUSION: LDH compromises military readiness and negatively impacts healthcare costs. MHS beneficiaries with LDH have a good prognosis with approximately 88% of patients successfully completing conservative management. However, strategies to improve outcomes of conservative management in LDH should address risks associated with both patient and facility characteristics.Level of Evidence: 4.

A Military Health System For The Twenty-First Century.

The Military Health System is one of the largest integrated health care systems in the United States. It is composed of a "direct care" system of military treatment facilities managed in a federated manner by the Army, Navy, Air Force, and Defense Health Agency and a "purchased care" component that consists of a network of health care providers managed through TRICARE. The system is undergoing significant reform and transformation. In 2017 Congress directed the Department of Defense (DoD) to consolidate all DoD military treatment facilities of the Army, Navy, and Air Force under the Defense Health Agency, while at the same time DoD civilian leaders put additional pressure on the system to accelerate reform efforts across the enterprise. Similar to other health systems, the Military Health System is under pressure to achieve greater efficiencies and reduce costs. This article portrays the drivers for consolidation of the three medical departments-those of the Army, Navy, and Air Force-under one agency and reflects on the impacts of this transformation in light of the DoD's unique mission.

Which US States Pose the Greatest Threats to Military Readiness and Public Health? Public Health Policy Implications for a Cross-sectional Investigation of Cardiorespiratory Fitness, Body Mass Index, and Injuries Among US Army Recruits.

OBJECTIVE: Many states in the southern region of the United States are recognized for higher rates of obesity, physical inactivity, and chronic disease. These states are therefore recognized for their disproportionate public health burden. The purpose of this study was to investigate state-level distributions of cardiorespiratory fitness, body mass index (BMI), and injuries among US Army recruits in order to determine whether or not certain states may also pose disproportionate threats to military readiness and national security. METHODS: Sex-specific state-level values for injuries and fitness among 165 584 Army recruits were determined. Next, the relationship between median cardiorespiratory fitness and injury incidence at the state level was examined using Spearman correlations. Finally, multivariable Poisson regression models stratified by sex examined state-level associations between fitness and injury incidence, while controlling for BMI, and other covariates. MAIN OUTCOME MEASURES: Cardiorespiratory fitness and training-related injury incidence. RESULTS: A cluster of 10 states from the south and southeastern regions (Alabama, Arkansas, Florida, Georgia, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, and Texas) produced male or female recruits who were significantly less fit and/or more likely to become injured than recruits from other US states. Compared with the "most fit states," the incidence of injuries increased by 22% (95% CI, 17-28; P < .001) and 28% (95% CI, 19-36; P < .001) in male and female recruits from the "least fit states," respectively. CONCLUSIONS: The impact of policies, systems, and environments on physical activity behavior, and subsequently fitness and health, has been clearly established. Advocacy efforts aimed at active living policies, systems, and environmental changes to improve population health often fail. However, advocating for active living policies to improve national security may prove more promising, particularly with legislators. Results from this study demonstrate how certain states, previously identified for their disproportionate public health burden, are also disproportionately burdensome for military readiness and national security.