Avoidable Hospitalizations in the Military Health System, Fiscal Years 2018-2019.

INTRODUCTION: Ongoing health reforms in the Military Health System (MHS) are expected to shift locations of ambulatory care for up to 1.9 million beneficiaries. We sought to model the impact of this policy by determining potentially avoidable hospitalizations in the MHS based on different primary care settings. MATERIALS AND METHODS: We used the MHS Data Repository to conduct a retrospective cross-sectional study of TRICARE Prime and Prime Plus beneficiaries aged 18 to 64 years during fiscal years 2018-2019. Crude and adjusted risk ratios for each Agency for Healthcare Research and Quality prevention quality indicator based on primary care setting were calcualated to determine the total probability of admission for any of the Agency for Healthcare Research and Quality prevention indicators. RESULTS: We identified a total of 260,690 hospital admissions by patients in the MHS with a designated primary care manager (PCM) from fiscal year 2018 to 2019. Of the total admissions, 11,067 (4.25%) were for Agency for Healthcare Research and Quality prevention quality indicators, 3.63% by direct care PCM at a military treatment facility, and 0.61% by a civilian private sector PCM. Risk of admission was lower for private sector PCMs for urinary tract infection, hypertension, perforated appendix, and angina without the procedure. We did not observe a statistically significant adjusted odds ratio of admission in patients managed by private sector PCMs (1.04 adjusted odds ratio; 95% CI, 0.97-1.11). CONCLUSIONS: Our findings indicate no difference in the likelihood of avoidable hospitalizations for beneficiaries with a private sector PCM when looking at all conditions together. Patients with a private sector PCM are protected against hospitalization for several conditions. Our findings indicate no adverse impact on avoidable hospitalizations for beneficiaries transitioned to private sector care from direct care.

Assessing mid-career female physician burnout in the military health system: finding joy in practice after the COVID-19 pandemic.

BACKGROUND: Rates of physician burnout increased during the COVID-19 pandemic and are expected to continue to rise. Mid-career physicians, female physicians, and military physicians have all been identified as potentially vulnerable populations to experience burnout. We examine factors associated with physician burnout among this intersectional group through a qualitative key informant interview study. METHODS: We developed a semi-structured interview guide using the Institute for Healthcare Improvement's Improving Joy in Work Framework and recruited military, mid-career female physicians who worked in the Military Health System(MHS) during the COVID-19 pandemic, (March 2020 -December 2021). Notes were collated and deductive thematic analysis was conducted. RESULTS: We interviewed a total of 22 mid-career female physician participants. Participants were between 30 and 44 years of age and 7 were mothers during the pandemic. Most were White and served in the Army. All participants discussed the importance of building rapport and having a good relationship with coworkers. All participants also described their discontentment with the new MHS GENESIS electronic health record system. An emerging theme was military pride as most participants were proud to serve in and support the military population. Additionally, participants discussed the negative impact from not feeling supported and not feeling heard by leadership. CONCLUSIONS: Much like providers in other health systems during the pandemic, MHS physicians experienced burnout. This study allowed us to gather key insights to improve policies for active duty service mid-career female military physicians. Provider inclusion, autonomy, and work culture play critical roles in future systems improvement and workforce retention.

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.

Diphenhydramine-involved Fatal and Nonfatal Drug Overdoses in Tennessee, 2019-2022.

BACKGROUND: Diphenhydramine (DPH), known as the brand name Benadryl, is an over-the-counter medication associated with accidental ingestion leading to nonfatal overdoses. Additionally, DPH has been used in tandem with illicit substances leading to fatal drug overdoses. OBJECTIVE: In response to DPH being seized with illicit drugs as an adulterant, as well as its growing intentional misuse, we sought to explore its recent involvement in fatal and nonfatal drug overdoses in the state of Tennessee. METHODS: We conducted a statewide cross-sectional study to determine the characteristics of DPH-involved fatal and nonfatal overdoses in Tennessee during 2019-2022 using data from the State Unintentional Drug Overdose Reporting System, the Electronic Surveillance System for the Early Notification of Community-based Epidemics, and the National Forensic Laboratory Information System Public Data Query System. Frequencies were generated to compare demographic characteristics, circumstances, and toxicology between fatal and nonfatal DPH-involved overdoses. RESULTS: We identified 143 suspected nonfatal DPH and 409 fatal DPH-involved overdoses in Tennessee from 2019 to 2022. Nonfatal overdoses remained consistent while fatal overdoses peaked in 2021. Most nonfatal overdoses were under 18 (63.4%), while most fatal overdoses were between 18 and 64 years of age (95.7%). For fatal overdoses, fentanyl was the most prevalent substance on toxicology followed by prescription opioids. CONCLUSION: Nonfatal overdoses remained consistent while fatal overdoses peaked in 2021 in Tennessee. Use of DPH among other illicit substances lends to evidence suggesting its use as an adulterant. Monitoring of DPH-involved fatal and nonfatal overdoses is critical to inform harm reduction initiatives.

A qualitative assessment of Ukraine's trauma system during the Russian conflict: experiences of volunteer healthcare providers.

BACKGROUND: The Russian Federation's invasion of Ukraine is characterized by indiscriminate attacks on civilian infrastructure, including hospitals and clinics that have devastated the Ukrainian health system putting trauma care at risk. International healthcare providers responded to the need for help with the increasing numbers of trauma patients. We aimed to describe their experiences during the conflict to explore the gaps in systems and care for trauma patients to refine the Global Trauma System Evaluation Tool (G-TSET) tool. METHODS: We conducted qualitative key informant interviews of healthcare providers and business and logistics experts who volunteered since February 2022. Respondents were recruited using purposive snow-ball sampling. Semi-structured, in-depth interviews were conducted virtually from January-March 2023 using a modified version of the G-TSET as an interview guide. Interviews were transcribed verbatim and deductive thematic content analysis was conducted using NVivo. FINDINGS: We interviewed a total of 26 returned volunteers. Ukraine's trauma system is outdated for both administrative and trauma response practices. Communication between levels of the patient evacuation process was a recurrent concern which relied on handwritten notes. Patient care was impacted by limited equipment resources, such as ventilators, and improper infection control procedures. Prehospital care was described as highly variable in terms of quality, while others witnessed limited or no prehospital care. The inability to adequately move patients to higher levels of care affected the quality of care. Infection control was a key issue at the hospital level where handwashing was not common. Structured guidelines for trauma response were lacking and lead to a lack of standardization of care and for trauma. Although training was desired, patient loads from the conflict prohibited the ability to participate. Rehabilitation care was stated to be limited. CONCLUSION: Standardizing the trauma care system to include guidelines, better training, improved prehospital care and transportation, and supply of equipment will address the most critical gaps in the trauma system. Rehabilitation services will be necessary as the conflict continues into its second year.

Exploring trends in benzodiazepine-positive fatal drug overdoses in Tennessee, 2019-2021.

BACKGROUND: Benzodiazepine-positive overdoses increased between 2019 and 2021 in Tennessee. We sought to determine the changes in the number and characteristics of prescription and illicit benzodiazepine-positive fatal drug overdoses during this period. MATERIALS AND METHODS: A statewide study was conducted to determine changes in the number and characteristics of benzodiazepine-positive drug overdose decedents using 2019-2021 data from the Tennessee State Unintentional Drug Overdose Reporting System. The analyses were limited to Tennessee residents aged ≥ 18 years. A benzodiazepine-positive overdose was defined as any benzodiazepine on toxicology, regardless of the presence of other substances. Frequencies were generated to compare demographics, circumstances, prescription history, and toxicology between 2019 and 2021 for illicit and prescription benzodiazepine-positive fatal overdoses. RESULTS: Between 2019 and 2021, 1666 benzodiazepine-positive unintentional or undetermined fatal drug overdoses out of 5916 total overdoses that occurred among adult Tennessee residents with available toxicological information. Prescription benzodiazepines were identified in 80.7% of deaths, whereas illicit benzodiazepines were identified in 12.0% of deaths. Many decedents had an anxiety disorder (45.5%), while over half of all decedents had a history of substance use disorder (52.3%). Most benzodiazepine-positive overdoses involved fentanyl (71.3%). CONCLUSIONS: This analysis can inform local and regional public health workers to implement focused prevention and intervention efforts for people with co-occurring mental health conditions and substance use disorders to curb overdose epidemics among persons using benzodiazepines in Tennessee. Public health campaigns should focus on educating people on appropriate prescription medication use and the dangers of obtaining substances illicitly. Given the high proportion of opioids in this population, further education also is needed on the dangers of polysubstance drug use. The differences between prescription and illicit benzodiazepine-positive fatal overdoses indicate the need to develop substance-specific prevention and treatment strategies.

The burden of vestibular disorders among military health system (MHS) beneficiaries, fiscal years 2018-2019.

INTRODUCTION: Vestibular disorders affect an estimated 33 million adults and 3.5 million children and adolescents in the United States. Previous research relying on self-reported symptoms versus actual diagnosis has limited the ability to provide prevalence estimates for specific vestibular disorders at the population level. This study seeks to describe the burden of vestibular disorders among children and working-age adult beneficiaries in the Military Health System (MHS). MATERIALS AND METHODS: Using the MHS Data Repository (MDR), we conducted a cross-sectional study of all TRICARE Prime and Plus MHS beneficiaries aged 0 to 64 years from fiscal years (FY) 2018 to 2019. Study analyses included descriptive statistics of patient demographics and assessing the prevalence of vestibular disorders in pediatric and working-age adult beneficiaries. RESULTS: Of the 5,541,932 TRICARE Prime/Prime Plus MHS beneficiaries, 52,878 (0.95%) had a diagnosis of vestibular disorder during fiscal years 2018 to 2019, of which 1,359 were pediatric and adolescents (aged 0 to 17 years) and 51,519 were working-age adults (18 to 64 years). Vertigo was the most common diagnosis in both age-group populations (11.46 per 1,000 working-age adults; 0.52 per 1,000 children and adolescents), with benign vertigo being the most prevalent of the three diagnoses and occurring at a seven times higher rate in adults versus pediatric and adolescents. CONCLUSIONS: This study demonstrates the effectiveness of using medical claims data to estimate prevalence compared to self-reported survey data and supports prevalence estimates of vestibular disease in <1% of children overall, but indicate much higher prevalence for adolescents.

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.

Phentermine involvement in fatal drug overdoses in Tennessee, 2019-2022.

INTRODUCTION: Phentermine, one of the most-commonly prescribed pharmaceuticals for weight-loss in the United States (US), has appeared on toxicology and listed as a cause of death in fatal drug overdoses in the state of Tennessee. This study aims to evaluate phentermine's involvement in fatal drug overdoses in the state of Tennessee. METHODS: We used Tennessee State Unintentional Drug Overdose Reporting System (SUDORS) data and controlled substances monitoring program data (CSMD) to evaluate demographics, prescription history and co-occurring substances on toxicology in phentermine-positive cases compared with all other SUDORS cases from January 1, 2019 to June 30, 2022. A subset of these cases which listed phentermine as a cause of death was also assessed. RESULTS: We identified 51 phentermine-positive cases, with a subset of 20 that listed phentermine as a cause of death. When compared to all SUDORS cases, a higher proportion of cases that listed phentermine as a cause of death were White race, females, and aged 35-44. Additionally, in all phentermine-positive cases, 41% (21) of decedents had not had a phentermine prescription dating back to 2012 and 20% (Lee et al., 1998) did not have one within the last 30 days. While there was a slight decline each year in the number of phentermine-positive cases, the number of cases that listed phentermine as a cause of death remained relatively consistent, with 95% (19) of cases having different prescriptions and/or illicit drugs listed as a cause of death along with phentermine. CONCLUSION: Phentermine was listed as a cause of death in 20 fatal drug overdoses in TN. Our findings suggest there may be differences in the characteristics of these decedents when compared to all SUDORS decedents, including distribution of age, gender, and race. We also found a large presence of other prescription and illicit drugs in toxicology and cause of death along with phentermine, as well as evidence of use of the drug without a prescription. Given the lack of currently available data about non-prescribed phentermine use and its involvement in fatal drug overdoses elsewhere, a need exists to both expand surveillance capabilities and broaden research to better inform policies governing this drug in the US and internationally.

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.

Xylazine-Involved Fatal and Nonfatal Drug Overdoses in Tennessee From 2019 to 2022.

This cross-sectional study examines the characteristics of overdoses and the potential association between drug seizures and fatal overdoses.

Designing a knowledge translation tool for women's health research in the U.S. Military Health System.

BACKGROUND: Current United States Department of Defense (DoD) estimates indicate that women comprise 17% of the total active duty component. Despite this, the specific health needs of service women have often been neglected. The Center for Health Services Research (CHSR) at the Uniformed Services University (USU) has been working to create a portfolio of rapid research synthesis briefs on topics including, but not limited to reproductive health, infertility, pregnancy loss, and contraceptive use among active duty service women. The goal of these briefs is to condense and translate the existing research literature for a non-academic audience. The aim of this study is to evaluate the utility of the research briefs to inform decision making around service women's health issues and impart an overall understanding of the current literature surrounding these topics to a non-academic audience. METHODS: Adopting a previously tested knowledge translation evaluation tool, we conducted a series of key informant interviews in July-August 2022 with decision makers in the Military Health System and the US DoD to elicit feedback regarding the overall utility of the research brief, as well as its ability to meet standards of usefulness, usability, desirability, credibility, and value. RESULTS: We interviewed a total of 17 participants of a diverse range of healthcare occupations and educational backgrounds, but all currently were working within the Department of Defense in support of the Military Health System. User feedback on the research brief was thematically evaluated based on the predetermined themes of usefulness, desirability, credibility, value, and two emergent themes-findability and language. CONCLUSIONS: This study allowed us to gather key insights from decision makers to better tailor future iterations of our research brief toward rapidly disseminating information for improving the healthcare and policy of active duty service women. The key themes ascertained from this study may help others when adapting their own knowledge translation tools.

Opioid prescribing and use in the Military Health System: a framework synthesis, FY2016-FY2021.

BACKGROUND: Opioid misuse is a nationwide issue and is of particular concern with regard to military readiness. The 2017 National Defense Authorization Act charges the Military Health System with greater oversight of opioid use and mitigation of misuse. METHODS: We synthesized published articles using secondary analysis of TRICARE claims data, a nationally representative database of 9.6 million beneficiaries. We screened 106 articles for inclusion and identified 17 studies for data abstraction. Framework analysis was conducted, which assessed prescribing practices, patient use, and optimum length of opioid prescriptions after surgery, trauma, and common procedures, as well as factors leading to sustained prescription opioid use. RESULTS: Across the studies, sustained prescription opioid use after surgery was low overall, with <1% of opioid-naïve patients still receiving opioids more than 1 year after spinal surgery or trauma. In opioid-exposed patients who had undergone spine surgery, sustained use was slightly lower than 10%. Higher rates of sustained use were associated with more severe trauma and depression, as well as with prior use and initial opioid prescriptions for low back pain or other undefined conditions. Black patients were more likely to discontinue opioid use than were White patients. CONCLUSIONS: Prescribing practices are well correlated with degree of injury or intensity of intervention. Sustained prescription opioid use beyond 1 year is rare and is associated with diagnoses for which opioids are not the standard of care. More efficient coding, increased attention to clinical practice guidelines, and use of tools to predict risk of sustained prescription opioid use are recommended.

Using Natural Language Processing to Predict Fatal Drug Overdose From Autopsy Narrative Text: Algorithm Development and Validation Study.

BACKGROUND: Fatal drug overdose surveillance informs prevention but is often delayed because of autopsy report processing and death certificate coding. Autopsy reports contain narrative text describing scene evidence and medical history (similar to preliminary death scene investigation reports) and may serve as early data sources for identifying fatal drug overdoses. To facilitate timely fatal overdose reporting, natural language processing was applied to narrative texts from autopsies. OBJECTIVE: This study aimed to develop a natural language processing-based model that predicts the likelihood that an autopsy report narrative describes an accidental or undetermined fatal drug overdose. METHODS: Autopsy reports of all manners of death (2019-2021) were obtained from the Tennessee Office of the State Chief Medical Examiner. The text was extracted from autopsy reports (PDFs) using optical character recognition. Three common narrative text sections were identified, concatenated, and preprocessed (bag-of-words) using term frequency-inverse document frequency scoring. Logistic regression, support vector machine (SVM), random forest, and gradient boosted tree classifiers were developed and validated. Models were trained and calibrated using autopsies from 2019 to 2020 and tested using those from 2021. Model discrimination was evaluated using the area under the receiver operating characteristic, precision, recall, F1-score, and F2-score (prioritizes recall over precision). Calibration was performed using logistic regression (Platt scaling) and evaluated using the Spiegelhalter z test. Shapley additive explanations values were generated for models compatible with this method. In a post hoc subgroup analysis of the random forest classifier, model discrimination was evaluated by forensic center, race, age, sex, and education level. RESULTS: A total of 17,342 autopsies (n=5934, 34.22% cases) were used for model development and validation. The training set included 10,215 autopsies (n=3342, 32.72% cases), the calibration set included 538 autopsies (n=183, 34.01% cases), and the test set included 6589 autopsies (n=2409, 36.56% cases). The vocabulary set contained 4002 terms. All models showed excellent performance (area under the receiver operating characteristic ≥0.95, precision ≥0.94, recall ≥0.92, F1-score ≥0.94, and F2-score ≥0.92). The SVM and random forest classifiers achieved the highest F2-scores (0.948 and 0.947, respectively). The logistic regression and random forest were calibrated (P=.95 and P=.85, respectively), whereas the SVM and gradient boosted tree classifiers were miscalibrated (P=.03 and P<.001, respectively). "Fentanyl" and "accident" had the highest Shapley additive explanations values. Post hoc subgroup analyses revealed lower F2-scores for autopsies from forensic centers D and E. Lower F2-score were observed for the American Indian, Asian, ≤14 years, and ≥65 years subgroups, but larger sample sizes are needed to validate these findings. CONCLUSIONS: The random forest classifier may be suitable for identifying potential accidental and undetermined fatal overdose autopsies. Further validation studies should be conducted to ensure early detection of accidental and undetermined fatal drug overdoses across all subgroups.

Prevalence of hepatitis C virus among fatal drug overdoses in Tennessee: an analysis using 2019-2020 Tennessee State Unintentional Drug Overdose Reporting System Data.

PURPOSE: Given the nature of the co-occurring epidemics of hepatitis C virus (HCV) and fatal stimulant overdose, we sought to assess the prevalence of HCV among opioid and stimulant-positive overdoses. METHODS: We conducted a cross-sectional study to examine the prevalence of HCV among fatal drug overdoses in Tennessee using 2019-2020 data from the State Unintentional Drug Overdose Reporting System. We defined history of HCV using surveillance data and autopsy reports. Descriptive statistics were calculated for circumstances of overdose deaths for different categories of opioid and stimulant positivity on toxicology. RESULTS: Between 2019 and 2020, 3570 unintentional or undetermined drug overdose deaths occurred in Tennessee with an available autopsy. History of HCV was found in 24.6% of deaths. When assessing different involvement between stimulants and opioids, the highest prevalence of HCV was found for deaths where methamphetamine and opioids were present in toxicology (35.4%). Scene evidence of injection drug use occurred more frequently among decedents with a history of HCV (P < .0001). CONCLUSIONS: This analysis while descriptive highlights the importance of linking datasets to enhance infectious disease and drug overdose surveillance. Partnership between communicable disease and drug overdose surveillance teams should continue to identify relationships between disease and drug overdose and strengthen the evidence to tailor crucial treatment and prevention activities.

Free the Bun: Prevalence of Alopecia Among Active Duty Service Women, Fiscal Years 2010-2019.

INTRODUCTION: Active duty service women (ADSW) constitute 16% of the force. The prevalence of alopecia, a dermatologic condition characterized by hair loss, is understudied in regard to hairstyle regulations across the U.S. military services. Alopecia has several causes; one of which is due to tension on the scalp secondary to tight hairstyles. In the U.S., alopecia has a lifetime prevalence of 1.7-2.1%; no previous studies which evaluated this condition in service women were found. MATERIALS AND METHODS: We used the Military Health System Data Repository to perform a retrospective study to assess the prevalence of alopecia in ADSW from fiscal years (FYs) 2010 to 2019. Statistical analyses included descriptive statistics on patient demographics and trend analysis on the prevalence of alopecia over the 10-year study period. RESULTS: A total of 498,219 ADSW were identified over the 10-year study period, of which 2.40% had a diagnosis of alopecia. Overall, the prevalence of alopecia decreases over the 10-year period, with two observed periods of slight increase (FY 2013 to 2014 and FY 2018 to 2019) when comparing prevalence year-to-year. Of those diagnosed, the majority were young, Black, with a senior enlisted rank, and in the U.S. Army. CONCLUSION: The prevalence of alopecia in ADSW is slightly higher than that in civilian populations and is most likely underreported. It is more commonly diagnosed in Black women than would be expected based on ratios of this population in military service. Policy changes to ensure that traction alopecia is a qualifying medical condition for Veterans Affairs disability compensation, mechanisms are in place for more specific coding in the electronic medical record, and treatment options to be covered by TRICARE are recommended. All U.S. military services should consider updating and evaluating regulations to improve the health and quality of life of ADSW.

Non-Operative Shoulder Dysfunction in the United States Military.

INTRODUCTION: Recent epidemiological evidence shows that shoulder and upper-arm complaints impose a substantial burden on the armed forces of the United States and create significant challenges for all components of the physical fitness domain of total force fitness. Clinicians, epidemiologists, and health-services researchers interested in shoulder and upper-arm injuries and their functional limitations rarely have objective, validated criteria for rigorously evaluating diagnostic practices, prescribed treatments, or the outcomes of alternative approaches. We sought to establish and quantify patient volume, types of care, and costs within the Military Health System (MHS) in assessing and managing active duty members with nonoperative shoulder and upper-arm dysfunction. MATERIALS AND METHODS: We performed a retrospective cohort study using data from the MHS Data Repository and MHS MART (M2) from fiscal year 2014 to identify active duty individuals with a diagnosis of shoulder and upper-arm injury or impairment defined by one of the International Classification of Disease Ninth Edition diagnosis codes that were selected to reflect nonoperative conditions such as fractures or infections. Statistical analyses include descriptive statistics on patient demographics and clinical visits, such as the range and frequency of diagnoses, number and types of appointments, and clinical procedure information following the diagnosis. We also examined treatment costs related to shoulder dysfunction and calculated the total cost to include medications, radiological, procedural, and laboratory test costs for all shoulder dysfunction visits in 2014 and the average cost for each visit. We further examined the category of each medication prescribed. RESULTS: A total of 55,643 individuals met study criteria and accrued 193,455 shoulder-dysfunction-related clinical visits in fiscal year 2014. This cohort represents approximately 4.8% of the 1,155,183 active duty service members assigned to the United States and its territories during FY 2014. Most patients were male (85.32%), younger (85.25% were under 40 years old), and Caucasian/White (71.12%). The most common diagnosis code was 719.41 (pain in joint, shoulder region; 42.48%). The majority of the patients 42,750 (76.8%) had four or fewer medical visits during the study period and 12,893 (23.2%) had more than four visits. A total of 4,733 patients (8.5%) underwent arthrocentesis aspiration or injection. The total cost for all visits was $65,066,767.89. The average and median cost for each visit were $336.34 (standard deviation was $1,493.87) and $163.11 (range was from 0 to $84,183.88), respectively. Three out of four patients (75.3%) underwent radiological examinations, and 74.2% of these individuals had more than one radiological examination. Medications were prescribed to 50,610 (91.0%) patients with the three most common being IBUPROFEN (12.21%), NAPROXEN (8.51%), and OXYCODONE-ACETAMINOPHEN (5.04%), respectively. CONCLUSIONS: Nearly 1 in 20 active duty military service members presented for nonoperative care of shoulder and/or upper-arm dysfunction during FY2014. Further examinations of the etiology and potential impact of shoulder/upper-arm dysfunction on force readiness are clearly warranted, as are additional studies directed at identifying best practices for preventing injury-related dysfunction and determining best practices for the treatment of shoulder dysfunction to optimize service member fitness and force readiness.

Identifying prescribing differences of direct oral anticoagulants for atrial fibrillation within the Military Health System.

Background: Direct oral anticoagulants (DOACs) are a first-line anticoagulant therapy for eligible patients with atrial fibrillation. Prescribing differences in the Military Health System have not yet been assessed. Methods: We conducted a retrospective cross-sectional study using administrative claims data from the Military Health System Data Repository from fiscal years 2018-2019. We identified TRICARE Prime and Prime Plus patients between the ages of 18 and 64 with a diagnosis of atrial fibrillation and a CHA2DS2-VASc score of ≥2. Descriptive statistics and odds of receiving DOACs by gender, age, race, and socioeconomic status were calculated. Results: A total of 5289 TRICARE Prime and Prime Plus patients within the Military Health System who carried a diagnosis of atrial fibrillation and a CHA2DS2-VASc ≥2 were identified. Of all patients, 2373 (40.71 %) were prescribed a DOAC whereas 287 (4.92 %) were prescribed warfarin within 90 days of diagnosis of atrial fibrillation. Black patients were significantly less likely to be prescribed a DOAC compared to White patients (adjusted odds ratio [aOR], 0.82; 95 % CI 0.68-0.99), as were females compared to males (aOR, 0.64; 95 % CI 0.52-0.79). Senior officers were significantly more likely to be prescribed a DOAC compared to senior enlisted service members (aOR, 0.64; 95 % CI 0.52-0.79). Conclusions: Our study shows that differences exist within the Military Health System in the prescription of DOACs for atrial fibrillation by race, gender, and socio-economic status. These differences cannot be explained by differences in access to insurance or cost of medications.