How Virtual Animal Anatomy facilitated a successful transition to online instruction and supported student learning during the coronavirus pandemic.

Anatomy faculty with cadaver-based laboratory courses were presented with a significant challenge in March 2020 to create equivalent learning experiences without cadaveric access. The undergraduate domestic animal anatomy course at the Colorado State University was halfway into a 16-week semester when COVID-19 lockdown orders and the transition to remote instruction began. The new course curriculum was critically evaluated using student surveys and course outcome data. Most students (92.5%) agreed that the transition to online learning was a success; however, students who valued face-to-face lectures prior to March were less likely to perceive the transition as a success. Qualitative and quantitative analyses of survey results suggest that the resources perceived as most helpful for the transition to online learning were not the same as those that helped facilitate animal anatomy learning. Most students (92.5%) agreed that the Virtual Animal Anatomy (VAA) helped them learn anatomy, and 82.2% indicated that the VAA was a valuable resource following the transition to online learning. Additional resources associated with transition success included course instructors, weekly quizzes, written descriptions of anatomical structures and open laboratory sessions. In contrast, those resources associated with facilitating learning included guided quizzes and asynchronous lecture recordings. These findings suggest that the VAA can support online anatomy learning when used in conjunction with other best practices for online teaching.

Enhancing Anatomical Instruction: Impact of a Virtual Canine Anatomy Program on Student Outcomes.

Innovative reforms in medical education will require instructional tools to support these changes and to give students more flexibility in where and how they learn. At Colorado State University, the software program Virtual Canine Anatomy (VCA) was developed to assist student learning both inside and outside the anatomical laboratory. The program includes interactive anatomical photographs of dissected canine cadavers, dissection instructions with accompanying videos and diagrams, radiographs, and three-dimensional models. There is a need to evaluate the effectiveness of instructional tools like VCA so that decisions on pedagogical delivery can be evidence-based. To measure the impact of VCA on student outcomes in a dissection laboratory, this study compared student attitudes, quiz scores, dissection quality and accuracy, and instructor reliance between students with and without access to VCA. Students with VCA needed less time with teaching assistants (P < 0.01), asked teaching assistants fewer questions (P = 0.04), felt that the dissection was easier (P = 0.02), and were in stronger agreement that they had access to adequate resources (P = 0.02). No differences were found in the dissection quality or accuracy, quiz scores, or attitudes regarding overall enjoyment of the activity between the two groups. This study shows that VCA increases student independence and can be used to enhance anatomical instruction.

Origin and distribution of the lumbosacral plexus anatomy in van cats / Origen y distribución de la anatomía del plexo lumbosacro en gatos van

SUMMARY: The innervation of the pelvic limbs of the Van cat is investigated in this research. The origins of the nerves, the innervated muscles and nerve diameters were shown in a table. Five cat cadavers were used in the study. The pudendal nerve originated from the S1-S2 spinal nerves. The femoral nerve consisted of the ventral branches of the 5th and 6th lumbar nerves in 4 cats The ischiatic nerve was composed of the 6th and 7th lumbar (L6-L7) and S1 spinal nerves in all cadavers. The ischiatic nerve was the thickest branch of sacral plexus (the average diameter on the right side was 3.31 ± 0.27 mm and the average diameter on the left side was 3.28 ± 0.29 mm). The lumbosacral plexus was formed by the ventral branches of the L4-S3 spinal nerves. N.genitofemoralis consisted of only the ventral branches of L4 in all cadavers. N. femoralis did not give rise to a branch to the m. iliopsoas. N.plantaris lateralis was found to give a branch to the 3th finger. The quadriceps femoris muscles did not take any branches from either the ischiadicus nerve or the pudendal nerve. The obturator nerve did not receive any branches from the L4 spinal nerves. There was no branch to the skin from the caudal gluteal nerve. The thinnest nerve was the pudendal nerve. Due to the scarcity of studies on the lumbosacral plexus of cats, it is thought that this study will complete a gap in the field of veterinary anatomy.

RESUMEN: En esta investigación se estudió la inervación de los miembros pélvicos del gato Van. Los orígenes de los nervios, los músculos inervados y los diámetros de los nervios son mostrados en una tabla. En el estudio se utilizaron cinco cadáveres de gatos. En cuatro gatosel nervio pudendo se originaba a partir de los nervios espinales S1-S2. El nervio femoral consistió en los ramos ventrales de los nervios lumbares quinto y sexto. El nervio isquiático estaba compuesto por los nervios espinales sexto y séptimo lumbar (L6-L7) y S1 en todos los cadáveres. El nervio isquiático era el ramo más grueso del plexo sacro (el diámetro medio del lado derecho medía de 3,31 ± 0,27 mm y el diámetro medio izquierdo 3,28 ± 0,29 mm). El plexo lumbosacro estaba formado por los ramos ventrales de los nervios espinales L4-S3. N. genitofemoralis constaba solo de las ramas ventrales de L4 en todos los cadáveres. N. femoralis no dio lugar a un ramo a la m. iliopsoas. Los músculos del cuádriceps femoral no tomaron ningún ramo ni del nervio isquiático ni del nervio pudendo. El nervio obturador no recibió ramos de los nervios espinales L4. No existían ramos a la piel desde el nervio glúteo caudal. El nervio más delgado fue el nervio pudendo. Debido a la escasez de estudios sobre el plexo lumbosacro de los gatos, este estudio completará un vacío en el campo de la anatomía veterinaria.

Associations of Early Treatments for Low-Back Pain with Military Readiness Outcomes.

BACKGROUND: Chronic low-back pain (LBP) is a frequent cause of work absence and disability, and is frequently associated with long-term use of opioids. OBJECTIVE: To describe military readiness-related outcomes at follow-up in soldiers with LBP grouped by the type of early treatment received for their LBP. Treatment groups were based on receipt of opioid or tramadol prescription and receipt of nonpharmacologic treatment modalities (NPT). Design, Subjects, Measures: A retrospective longitudinal analysis of U.S. soldiers with new LBP episodes persisting more than 90 days between October 2012 and September 2014. Early treatment groups were constructed based on utilization of services within 30 days of the first LBP claim. Outcomes were measured 91-365 days after the first LBP claim. Outcomes were constructed to measure five indicators of limitations of military readiness: military duty limitations, pain-related hospitalization, emergency room visit for LBP, pain score of moderate/severe, and prescription for opioid/tramadol. RESULTS: Among soldiers with no opioid receipt in the prior 90 days, there were 30,612 new episodes of LBP, which persisted more than 90 days. Multivariable logistic regression models found that compared to the reference group (no NPT, no opioids/tramadol receipt), soldiers who received early NPT-only had lower likelihoods for military duty limitations, pain-related hospitalization, and opioid/tramadol prescription at follow-up, while soldiers' that started with opioid receipt (at alone or follow-up in conjunction with NPT) exhibited higher likelihoods on many of these negative outcomes. CONCLUSION: This observational study of soldiers with a new episode of LBP and no opioid receipt in the prior 90 days suggests that early receipt of NPT may be associated with small, significant gains in ability to function as a soldier and reduced reliance on opioid/tramadol medication. While further research is warranted, increased access to NPT at the beginning of LBP episodes should be considered.

Factors associated with psychiatric evacuation among service members deployed to Operation Enduring Freedom and Operation Iraqi Freedom, January 2004 to September 2010.

OBJECTIVES: To calculate the annual rate of psychiatric evacuation of U.S. Service members out of Iraq and Afghanistan and identify risk factors for evacuation. METHODS: Descriptive and regression analyses were performed using deployment records for Service members evacuated from January 2004 through September 2010 with a psychiatric diagnosis, and a 20% random sample of all other deployers (N = 364,047). RESULTS: A total of 5,887 deployers psychiatrically evacuated, 3,951 (67%) of which evacuated on first deployment. The rate increased from 72.9 per 100,000 in 2004 to 196.9 per 100,000 in 2010. Evacuees were overrepresented in both combat and supporting duty assignments. In multivariate analysis, Army active duty had the highest odds of evacuation relative to Army National Guard (adjusted odds ratio [AOR] 0.852, 95% confidence interval [CI] 0.790-0.919), Army Reserve (AOR 0.825, 95% CI 0.740-0.919), and all other components. Accessions in 2005 had the highest risk (AOR 1.923, 95% CI 1.621-2.006) relative to pre-2001 accessions. CONCLUSIONS: Risk for psychiatric evacuation is highest among the Army Active Component. A strong link between multiple deployments or combat-related exposure and psychiatric evacuation is not apparent. Increased risk among post-2001 accessions suggests further review of changes in recruitment, training, and deployment policies and practices.

Impact of the 2009 influenza (H1N1) pandemic on the United States military health care system.

BACKGROUND: During public health emergencies, the Military Health System experiences challenges similar to those across the U.S. public and private health systems. This study explored how 1 such event, the 2009/2010 influenza (H1N1) pandemic, impacted health care utilization and associated costs in the Military Health System. METHODS: Data from the Military Data Repository were used to examine diagnoses, claims data, and dates of services with respect to military or civilian care during 2004-2009/2010 influenza seasons. Comparison analysis was conducted through two-tailed t-tests and regression models. RESULTS: There was a significant increase in inpatient and outpatient health care utilization during the 2009/2010 H1N1 pandemic year, most markedly for emergency department visits. The 2009/2010 H1N1 pandemic cost the Department of Defense $100 million compared to influenza-related health care costs incurred in previous influenza seasons. Highest health care utilization costs were found in children less than age 5. The greatest cost burden was attributed to immunizations for active duty personnel delivered at military facilities. CONCLUSION: Annual trend analysis of costs and health care utilization would be helpful to plan and resource emerging influenza pandemics and to identify subgroups at greatest risk for contracting influenza.

Results from a mailed promotion of medication reviews among Department of Defense beneficiaries receiving 10 or more chronic medications.

BACKGROUND: Like many payers, the Department of Defense (DoD) has limited ability to work directly with prescribers to ensure appropriate medication use. Many older beneficiaries are prescribed multiple maintenance medications, placing them at higher risk for adverse drug interactions, contraindicated medication use, and other polypharmacy-related problems. Medication reviews may mitigate these risks, but the optimal venue for medication therapy management is unclear. OBJECTIVES: To (a) determine if beneficiaries will respond to a mailed request from the DoD to pursue a medication review; (b) identify medication review location and outcomes from the patient perspective; and (c) assess the statistical significance of changes in the number of prescription medications overall and for key categories, including maintenance medications and contraindicated medications, relative to a propensity-matched comparison group. METHODS: A total of 4,000 TRICARE beneficiaries aged 55 years or older, residing in North Carolina, who obtained 10 or more maintenance medications (defined by a unique combination of drug, strength, and dosage form) during the 90-day baseline period from May 3, 2008, to July 31, 2008, were mailed letters requesting their participation in the study. Consenting subjects received a personalized medication list to review with their physicians or pharmacists and a survey form to complete after the review. Survey results were compared by location of medication review (i.e., physician's office, pharmacy, or both). Changes from the 90-day baseline to 90-day post-intervention period were calculated for prescription utilization measures (total drug count, maintenance drug count, count of Beers list medications, and count of contraindicated drug combinations) for the subsample of subjects who completed the survey (n = 373) and for subjects who received the initial consent letter (n = 3,856) versus a propensity-matched comparison sample drawn from neighboring states. Variables included in the propensity score were gender, age group, military rank, catchment status indicating proximity to military pharmacies, enrollment status, number of pharmacy settings used, and each of 30 binary disease indicators. RESULTS: A total of 1,469 subjects responded to the consent letter (response rate = 38.1%); 606 subjects consented to participate (consent rate = 15.7%); and 373 subjects returned a completed survey (completion rate = 9.7%). Among those who completed the survey, 190 (50.9%) received reviews in a physician's office; 103 (27.6%) received reviews in a pharmacy; 60 (16.1%) received reviews in both locations; and 20 (5.4%) reported a different location or no location. 61 survey respondents (16.4%) indicated that they were told to stop a medication, and 77 (20.6%) reported a dosage change. Medication changes occurred significantly more frequently for reviews performed at a physician's office compared with other review locations. Therapeutic classes most frequently stopped or adjusted for dosage were antidiabetics, diuretics, antilipidemics, renin-angiotensin aldosterone system inhibitors, anticoagulants, nonsteroidal anti-inflammatory drugs, and beta-adrenergic blocking agents. 85% of respondents reported that the medication review was worth doing. In the assessments of changes in prescription utilization from the baseline to post-intervention periods, no significant by-group differences were noted among those who completed the study relative to their matched comparison subjects. In the comparison of subjects who received the initial consent letter with their matched counterparts, small but statistically significant differences were observed for several prescription utilization measures, including changes in use of high-risk Beers list medications (P = 0.033); use of electrolytic, caloric, and water balance medications (P = 0.038); and use of hypertension medications (P = 0.028). The magnitude of the decrease observed among comparison subjects, however, exceeded that observed among the case subjects. CONCLUSIONS: Response was poor to a mailing that promoted a beneficiary- initiated medication review. The absence of significant changes following the medication review suggests several possibilities: a mailed intervention is ineffective in promoting medication review; medication regimens for study subjects are already optimized to the extent obtainable through a routine medication review; or the study sample size was too small to detect relevant changes. Most drug regimen changes were dosage adjustments for current medications or substitutions within the same therapeutic class. The extent to which comprehensive assessment of a patient's medication regimen, including nonprescription and herbal agents, was performed is unclear. More intensive interventions may be required to ensure that medication regimens are being actively managed among those who use a large number of prescription medications.

Historical evolution of medical quality assurance in the Department of Defense.

The Department of Defense (DoD) Military Health System (MHS) embodies decades of health care practice that has evolved in scope and complexity to meet the demands for quality care to which its beneficiaries are entitled. War, Base Realignment and Closure (BRAC), and other dynamic forces require the ongoing review and revision of health care policy and practice in military hospitals as well as the expanded network of civilian providers who care for our nation's soldiers, sailors, airmen, and marines and their families. The result has been an incrementally constructed quality assurance (QA) program with emphasis on organizational structures, programs, and systems, and the use of robust data sources and standard measures to analyze and improve processes, manage disease, assess patient perceptions of care, and ensure that a uniform health care benefit and high quality health care is accessible to all MHS beneficiaries.

Use of oseltamivir after influenza infection is associated with reduced incidence of recurrent adverse cardiovascular outcomes among military health system beneficiaries with prior cardiovascular diseases.

BACKGROUND: Influenza infection has been associated with increased risk of adverse cardiac and cerebral vascular outcomes. Oseltamivir, a treatment for influenza, has been shown to decrease the severity of an influenza episode, but few data exist regarding its potentially protective effect against recurrent vascular outcomes among influenza patients with a history of vascular disease. METHODS AND RESULTS: Electronic healthcare service and pharmacy records for 37,482 TRICARE beneficiaries, aged 18 and older, with a coded history of cardiovascular (CV) disease and a subsequent diagnosis of influenza from October 1, 2003, through September 30, 2007, were examined. Subjects were grouped according to whether they had filled a prescription for oseltamivir within 2 days of their influenza diagnosis. The incidence of recurrent CV events within 30 days after the influenza diagnosis among oseltavmivir-treated and untreated subjects was 8.5% and 21.2%, respectively (P<0.005). Subject age was a persistent and significant contributor to the likelihood of recurrent CV outcomes. After controlling for the differences in demographics among treated and untreated cohorts using a propensity-scored logistic regression model, a statistically significant protective effect was associated with oseltamivir treatment (odds ratio, 0.417; 95% CI, 0.349 to 0.498). CONCLUSIONS: Our findings suggests that oseltamivir treatment for influenza is associated with significant decrease in the risk of recurrent CV events in subjects with a history of CV disease. These findings merit confirmation in further prospective and controlled studies. Meanwhile, in patients with CV disease, strict adherence with current practice guidelines for prevention and treatment of influenza is recommended.

Increase in lipid-lowering treatment rates among TRICARE beneficiaries: a population-based study.

PURPOSE: To evaluate the use of lipid-lowering treatment (LLT) among patients at risk for cardiovascular disease (CVD) in the US Military Health System (MHS). METHODS: The study examined healthcare service and prescription records among beneficiaries > or =18 years for calendar years 2002, 2004, and 2006. Patients were categorized based on cardiovascular (CV) risk, with exposure to LLT defined as one or more prescriptions for lipid-lowering medication. Logistic regression models estimated odds of treatment in 2004 and 2006 relative to 2002 after adjustment for age, gender, and CV risk. RESULTS: The yearly unadjusted population prevalence of LLT increased from 9.3% in 2002 to 14.7% in 2006. Among subjects with the highest CV risk, established coronary artery disease (CAD) or peripheral vascular disease (PVD), those receiving LLT increased from 55% in 2002 to 65% in 2006 (adjusted OR = 1.50, 95% CI 1.48, 1.52, p < 0.00). Treatment rates among diabetic patients with no coded CAD or PVD showed the largest relative increase from 47% in 2002 to 66% in 2006 (adjusted OR = 2.30, 95% CI 2.26, 2.332, p < 0.00). LLT growth was lowest among those with only 1 coded CV risk factor (adjusted OR = 1.32, 95% CI 1.31, 1.34, p < 0.00). CONCLUSIONS: The MHS experienced a significant increase in LLT among patients at greatest risk for cardiovascular disease. However, treatment may still be underutilized as approximately one-third of high-risk patients did not receive lipid-lowering medication.

The association between oseltamivir use and adverse neuropsychiatric outcomes among TRICARE beneficiaries, ages 1 through 21 years diagnosed with influenza.

UNLABELLED: Recent reports out of Japan have linked therapeutic use of the oral neuraminidase inhibitor oseltamivir with adverse neuropsychiatric outcomes in adolescents. OBJECTIVE: To assess if protective measures should be taken to mitigate potential adverse outcomes among United States Department of Defense (DoD) pediatric beneficiaries who are prescribed oseltamivir therapeutically. STUDY GROUP: DoD healthcare beneficiaries, ages 1 through 21 years, who received a diagnosis of influenza from 1 October 2006 through 30 September 2007. METHODS: A retrospective cohort study using electronic healthcare service and pharmacy fill. Cross tabulations and propensity-adjusted logistic regression analyses were performed to compare the frequency of adverse neuropsychiatric outcomes among those treated therapeutically with oseltamivir with those that were not. RESULTS: The prevalences of neuropsychiatric diagnoses following the influenza diagnosis overall and among the treated and untreated groups were 3.5%, 3.0%, and 3.8%, respectively (p < .05). A statistically significant protective effect was associated with oseltamivir treatment (prevalence odds ratio (POR) = 0.82 (95% CI, 0.69, 0.96)) in a propensity-adjusted regression model. The model significantly associated increasing patient age with the likelihood of an adverse neuropsychiatric outcome, but the associations with patient gender and parental rank, a proxy used for socioeconomic status, were not statistically Significant. CONCLUSIONS: Our retrospective study found no evidence that oseltamivir treatment for influenza increased the risk of adverse neuropsychiatric outcomes among the study population. An additional study focusing on prospective medical surveillance of influenza patients is warranted.

Formulary management in the Department of Defense.

BACKGROUND: The U.S. Department of Defense (DoD) health care benefit (TRICARE) provides 9.2 million active-duty and retired uniformed services personnel and their family members with access to a comprehensive pharmacy benefit with low out-of-pocket costs. DoD's Uniform Formulary is available worldwide at DoD's 3 pharmacy points of service (military pharmacies, contracted mail order, and community [network and non-network] pharmacies). Community pharmacies, military pharmacies, and mail order accounted for 64%, 23%, and 13%, respectively, of DoD's $6.5 billion total drug expenditures during fiscal year (FY) 2007 (October 1, 2006, through September 30, 2007). OBJECTIVE: To describe the DoD formulary management process and estimate cost savings associated with implementation of DoD's 3-tier formulary. SUMMARY: DoD implemented its 3-tier Uniform Formulary in 2005. This implementation required the development of a transparent formulary management process that (a) assesses medications for formulary status based on an evidence-based clinical evaluation and assessment of relative cost-effectiveness using pharmacoeconomic and budget impact modeling, (b) allows open and equitable price competition among pharmaceutical manufacturers based on formulary status, and (c) provides a public forum for beneficiaries and beneficiary organizations to comment on formulary changes. Through April 16, 2008, Uniform Formulary decisions had been implemented in 32 drug classes representing 53% of FY 2007 total drug expenditures. The 32 classes containing 343 drugs were reviewed at 12 quarterly meetings of the DoD Pharmacy and Therapeutics (P&T) Committee and the Beneficiary Advisory Panel, resulting in the classification of 85 drugs (24.8%) in tier 3, 92 drugs (26.8%) in tier 2, and 166 drugs (48.4%) in tier 1. Implementation of the 3-tier formulary was associated with an estimated $926 million in cost avoidance in FY 2007, primarily due to price reductions at military pharmacies and mail order, tier 3 copayments at community pharmacies and mail order, and change in product mix and pharmacy type (point of service). An additional $60 million in rebates were obtained in FY 2007 through the Voluntary Agreements for TRICARE Retail Pharmacy Refunds (UF VARR) program for prescriptions filled at community pharmacies; the UF VARR program first became available for drug classes reviewed in August 2006. The total of $986 million in cost avoidance and rebates represents an approximate 13% reduction, compared with what DoD otherwise would have paid in FY 2007 ($7.5 billion, compared with actual drug expenditures of $6.5 billion). CONCLUSION: As in most private-sector health plans, the DoD formulary management process (a) includes rigorous decision making that is informed by clinical literature evaluations and pharmacoeconomic analyses, (b) results in drug formulary changes that require considerable effort in communication with providers and beneficiaries, and (c) produces drug cost savings derived from increased price competition among drug manufacturers. Unlike private sector health plans, the DoD uses more disclosure of the results of evaluation of the evidence, solicits provider opinions before P&T committee deliberation, and provides the opportunity for beneficiaries to have input before implementation of formulary changes.

Proton-pump inhibitor utilization associated with the change to nonpreferred formulary status for esomeprazole in the TRICARE formulary.

UNLABELLED: inhibitor (PPI) esomeprazole in the third copayment tier on the TRICARE formulary on July 17, 2005. The change to nonpreferred formulary status for esomeprazole included a $13 copayment increase (from $9.00 to $22.00) for either a 30-day supply purchased from a community pharmacy or a 90-day supply purchased from the mail-order pharmacy and a $0 copayment if obtained from a military pharmacy but with a prior authorization (PA) requirement. The change to nonpreferred formulary status was designed to encourage the use of PPIs other than esomeprazole and to increase the use of the mail-order pharmacy for esomeprazole purchases. OBJECTIVE: To quantify changes in (a) the TRICARE beneficiary utilization of esomeprazole relative to other PPIs and (b) the pharmacy settings used for filling esomeprazole prescriptions following implementation of a copayment increase and nonpreferred formulary status for esomeprazole. METHODS: A census of outpatient pharmacy fill records for prescription acid-reducing medications (PPIs, histamine-2 blockers, misoprostol, and sucralfate) obtained by beneficiaries aged 18 years or older from January 1, 2005, through December 31, 2006, was examined. Interrupted time series regression analyses without a control group were used to compare the utilization of esomeprazole relative to other PPIs, as well as the pharmacy setting used to obtain esomeprazole, in the months before and after the formulary change. The rates of continued esomeprazole use, switching to other prescription PPIs (lansoprazole, omeprazole, pantoprazole, and rabeprazole), switching to non-PPI prescription acid-reducing drugs, and discontinued prescription acid-reducing medication use among existing esomeprazole users (i.e., beneficiaries who obtained esomeprazole as the last PPI fill before the formulary change) were calculated overall and for each pharmacy setting used prior to the formulary change. RESULTS: Over the 24-month study period from January 1, 2005, through December 31, 2006, the total numbers of PPI fills and PPI users increased by 8.5% and 9.0%, respectively, and the number of esomeprazole users decreased by 4.6%. Of esomeprazole users, the percentages of individuals obtaining esomeprazole from military pharmacies and community pharmacies, respectively, decreased from 1.7% to 1.1% and from 89.7% to 81.7%, while the percentage of individuals obtaining esomeprazole from the mail-order pharmacy increased from 8.8% to 17.6%. Time series analysis yielded a positive, statistically significant growth in esomeprazole fills (beta1=0.114; P=0.012) during the 6-month pre-intervention period (January through June 2005) and a significant reduction in August 2005 (beta2=-5.0%; P<0.001), the month immediately following the formulary change. During the 17-month post-intervention period (August 2005 through December 2006), no statistically significant change in trend for esomeprazole fills (beta3=-0.0265; P=0.534) was observed, although a small increase in the raw number of esomeprazole fills was noted. Among the 117,801 existing esomeprazole users, 86,386 (73.3%) continued using esomeprazole, 17,676 (15.0%) switched to other prescription PPIs, 679 (0.6%) used only non- PPI prescription therapy, and 13,060 (11.1%) discontinued all prescription acid-reducing pharmacotherapy after the formulary change. Significantly higher PPI switching and acid-reducing therapy discontinuation rates were observed among men aged 18-44 years and in TRICARE enrollees relative to women, those over 45 years of age, and those who used other health insurance (P<0.001). Individuals who used military pharmacies, where a PA requirement was implemented, were more likely to change pharmacy settings to obtain esomeprazole (43.8%) than were users of community pharmacies (11.9%) or the mail-order pharmacy (22.8%). Mail-order pharmacy users were less likely to discontinue acid-reducing pharmacotherapy (4.9%) than were community (11.9%) or military (12.9%) pharmacy users (P<0.05). CONCLUSIONS: After adjustment for serial correlation, the formulary change was associated with a migration of approximately 5% of all PPI fills and 25% of esomeprazole fills to the preferred PPIs in the first post-intervention month. Over the 17-month post-intervention period, the trend toward increased esomeprazole use was slowed and use of the mail-order pharmacy for esomeprazole fills nearly doubled. Our observed PPI switch rate of 15.0% resembled the rate observed for another insured population that experienced a similar formulary restructuring, but was substantially lower than the rates reported for more sizeable formulary changes. Thus, the present study's copayment differentials for third-tier medications ($19 compared with tier 1 and $13 compared with tier 2 copayments) may be less than the threshold amount required to optimize switching to preferred PPIs.

Factors associated with choice of pharmacy setting among DoD health care beneficiaries aged 65 years or older.

BACKGROUND: Department of Defense (DoD) health care planners want to stimulate a voluntary migration of prescription fills from military and community pharmacies to its mail-order pharmacy, a lower-cost dispensing option for the department. Beneficiary cost share for a 90-day supply of generic/ brand medication is $0/$0 at military (DoD) pharmacies, $3/$9 at the DoD mail-order pharmacy, and $9/$27 at network community pharmacies. OBJECTIVE: To examine the pharmacy use patterns among the beneficiary population age 65 years or older, traditionally the heaviest users of the TRICARE DOD prescription drug benefit, to identify factors that are associated with beneficiary use of pharmacy setting(s). METHODS: Outpatient prescription fill records were examined for TRICARE beneficiaries age 65 years or older (N = 300,084) residing in North Carolina, Texas, and California for dates of service from December 1, 2004 through February 28, 2005. Binary logistic regression models were run for each type (military, community, and mail order) and number of pharmacy settings used by beneficiary gender, age group, catchment area status (located either within or outside a 40-mile radius of each military pharmacy), state, and number of medications obtained (defined as count of unique combinations of strength, and route of administration). The mean number of medications per beneficiary and cost per medication were tabulated for each type and number of settings used. RESULTS: In the 3-month period from December 1, 2004 through February 28, 2005, beneficiary use of military, community, and mail-order pharmacies was 45.4%, 67.6%, and 22.1%, respectively. About 67% of the study population used 1 setting exclusively and 2.4% used all 3 settings. Noncatchment residents were significantly less likely (adjusted odds ratio [AOR]= 0.080; 95% confidence interval [CI], 0.078-0.082) to use a military pharmacy exclusively and significantly more likely to use a community pharmacy (AOR = 4.64; 95% CI, 4.55-4.73) or the mail-order pharmacy (AOR = 3.92; 95% CI, 3.80-4.05) exclusively than were catchment residents. Beneficiaries taking 10 or more medications were more likely (AOR = 8.43; 95% CI, 8.21-8.65) to use multiple settings than were those who obtained 3 or fewer medications. Single-setting users obtained a median of 4 (interquartile range [IQ]) 2-7) medications with a median copayment of $7.00 (IQ $0-$13.19) per medication. Those who used all 3 settings obtained a median of 9 (IQ 7-12) medications with a median copayment of $4.33 (IQ $3.00-$6.00) per medication. Among beneficiaries who obtained 6 or more unique medications during the 90-day study period, approximately 25% used the mail-order pharmacy to obtain 1 or more prescription fills. CONCLUSION: A significant portion of the study population did not use the mail-order pharmacy despite the financial incentive to use mail-order rather than community pharmacies. Relatively small financial incentives alone may be inadequate for promoting a switch to the mail-order option among those beneficiaries not already using it in a pharmacy benefit plan with low copayments. Larger monetary and other incentives may be necessary to achieve the desired transfer of prescriptions fills to the mail-order pharmacy and the associated reduction in military pharmacy workload.

Examination of multiple medication use among TRICARE beneficiaries aged 65 years and older.

BACKGROUND: The simultaneous use of multiple prescription medications has been associated with an increased risk of adverse drug events and other drug-related complications, especially in the elderly. OBJECTIVE: To quantify the prevalence of use of multiple medications among a sample of Department of Defense (DoD) health care beneficiaries, aged 65 years and older, who used their TRICARE (military health care services) benefit to obtain prescription medication. METHODS: Outpatient pharmacy fill records were analyzed for a 10% random sample of 1.27 million TRICARE beneficiaries aged 65 years and older who obtained 1 or more prescription medications in the 90-day period from December 1, 2004, through February 28, 2005. The First DataBank generic code number was used to identify drugs and to calculate the mean number of medications obtained and the mean, frequency, and type of American Hospital Formulary System drug therapy categories. Statistical significance for gender and age subgroups was tested via independent t tests. RESULTS: There were 1,268,162 users of the TRICARE pharmacy benefit in the 90-day study period from December 1, 2004, through February 28, 2005, approximately 72.7% of 1,744,072 eligible beneficiaries. The 10% sample of these users (n=126,682) accounted for 1,091,699 pharmacy fill records for 761,043 unique medications, or an average of 6.01 [SD 4.01] unique medications per user, distributed across an average of 3.80 [2.08] therapeutic categories; 8.8% of users received 1 medication, 50.0% received 5 or more medications from an average of 3 therapeutic categories, and 2.8% obtained 16 or more medications from an average of 8 therapeutic categories. Multiple drug use was more prevalent among women relative to men, with an average of 6.28 [4.12] medications from 4.03 [2.11] therapeutic categories for women versus an average of 5.69 [3.85] medications from an average of 3.80 [2.08] therapeutic categories for men (P <0.001). The prevalence of multiple drug use peaked among beneficiaries aged 80 to 84 years. Cardiovascular drugs, central nervous system agents, and hormones and synthetic substitutes were the 3 most common therapeutic categories used by 77%, 48%, and 42% of beneficiaries, respectively. CONCLUSION: This baseline analysis documented the common use of multiple medications among TRICARE beneficiaries. The DoD faces a challenge similar to that of Medicare Part D drug plans to cost-effectively monitor and optimize pharmacotherapy for its older beneficiaries.

Developing and implementing an assessment method to evaluate a virtual canine anatomy program.

A computer-based anatomy program, Virtual Canine Anatomy: The Head, was incorporated into a first-year veterinary dissection laboratory two years ago to address challenges inherent in the traditional pedagogical approach. The program uses specimen photographs, QuickTime Virtual Reality, and interactive features to help students study the dissection, osteology, and radiology of the canine head. Photographs of each phase of dissection are displayed in the program, along with dissection instructions. Students can click on anatomical structures in each photograph to highlight the selected structure and display a complete description of it. Related structures and views are accessible through hyperlinks. This study was designed to measure student and faculty attitudes toward the instructional software, to gauge its effect on student achievement, and to propose evaluation methodology and instrumentation for similar projects. Observations, interviews, focus groups, surveys, and test results were used for this assessment. Results suggest positive student and faculty attitudes toward the program. Students felt the program met their needs, increased their confidence and efficiency, and was easy to use. Both students and instructors felt the program was beneficial during dissection. There was no significant change in student achievement on course tests. Future research will measure the program's effect on student-instructor interactions.

Clinical case mix adjustment of cesarean delivery rates in U.S. military hospitals, 2002.

OBJECTIVE: To assess whether significant variations in observed cesarean rates in U.S. military hospitals may be attributed to differences in clinical case mix. METHODS: Hospital discharge records for births in U.S. military hospitals in 2002 were grouped into mutually exclusive clinical strata to calculate predicted cesarean rates for subgroups defined by maternal race, health plan, hospital location, delivery volume, teaching status, and neonatal intensive care unit (NICU) status. The 95% confidence interval (CI) around each standardized ratio (SR) of the observed-to-predicted cesarean rate was used to assess statistical significance. RESULTS: Observed cesarean rates were significantly higher than predicted rates for small hospitals (23.1% and 20.4%, respectively, SR 1.13, 95% CI 1.08-1.19), teaching hospitals (23.7% and 22.5%, respectively, SR 1.05, 95% CI 1.02-1.08), black women (25.1% and 22.8%, respectively, SR 1.10, 95% CI 1.05-1.14), and other minorities (22.7%, and 21.6%, respectively, SR 1.05, 95% CI 1.01-1.09). No significant differences between observed and predicted cesarean rates were found across hospital locations or NICU status. Significant differences found for non-managed care beneficiaries were attributed to teaching status of the hospitals in which they delivered. CONCLUSION: Clinical case mix does not adequately account for the relatively high rates of cesarean delivery observed for small hospitals and teaching hospitals and among black women in the study population. Further study is recommended to identify additional clinical and nonclinical factors that should be considered when comparing performance across institutions, health plans, or individual providers.

Effect of September 11th terrorist attacks on the self-reported health status of Department of Defense health care beneficiaries.

This study examined the changes in the self-reported health status of Department of Defense health care beneficiaries associated with the September 11th terrorist attacks. Responses to a single-item, general health measure from pre- and post-September 11 quarterly survey events for the calendar year 2001 were analyzed to compare the unfavorable health response rates before and after the attacks. Increases in rates of unfavorable health status following the terrorist attacks were reported by the total population and 39 of 44 subgroups examined. Statistically significant increases in unfavorable health were reported by active duty personnel and dependents of active duty personnel; beneficiaries under the age of 44 years; beneficiaries affiliated with the Army and Marines; and beneficiaries in the Mid-Atlantic, Mid-West/Central, and Pacific Rim regions. These findings suggest that stress associated with the likelihood of being deployed or having a family member deployed following the terrorist attacks significantly contributed to the increase in unfavorable health response reported on the post-September 11 survey.

Effect of managed care enrollment on primary and repeat cesarean rates among U.S. Department of Defense health care beneficiaries in military and civilian hospitals worldwide, 1999-2002.

BACKGROUND: In response to rising cesarean rates, it is reasonable for health care organizations to look to a managed care model as a means of controlling further rate increases. However, little conclusive evidence exists to support this solution. We undertook a study of the Department of Defense health care beneficiary population to assess the impact of enrollment in TRICARE Prime, the Department's managed care health plan, on cesarean delivery rates. METHODS: Pooled hospital discharge records from 1999-2002 for live, singleton births were analyzed to calculate primary and repeat cesarean rates for TRICARE Prime and non-Prime beneficiaries in the military and civilian hospitals that comprise the Department of Defense health care network. Stepwise logistic regression was used to calculate adjusted odds ratios for clinical indicators for each combination of health plan and hospital setting using the chi2 difference(p <0.05)to eliminate nonsignificant variables from the model. Total primary and repeat cesarean rates were compared with primary and repeat cesarean rates for women with no reported clinical complications to account for differences in case mix across subgroups. Statistical significance of the differences calculated for subgroups was assessed using chi2. RESULTS: Primary cesarean rates were significantly lower for TRICARE Prime enrollees relative to non-Prime beneficiaries for all race subgroups and three of five age subgroups in military hospitals and four of five age subgroups in civilian hospitals. No significant differences in repeat cesarean rates were observed between Prime and non-Prime beneficiaries within any race or age subgroup. Breech presentation followed by dystocia, fetal distress, and other complications were significant predictors for primary cesarean. Previous cesarean delivery was the leading predictor for repeat cesarean delivery. Primary and repeat cesarean rates observed for military hospitals were consistently lower than rates observed for civilian hospitals within each health plan type and age group. CONCLUSIONS: Enrollment in the managed care health plan was significantly associated with lower risk of primary cesarean delivery relative to membership in other health plans offered to Department of Defense health care beneficiaries. Repeat cesarean rates in this population varied independently of health plan type. Primary cesarean delivery was generally associated with clinical complications, whereas previous cesarean delivery was the strongest indicator for a repeat cesarean delivery. A clear explanation of reduced cesarean rates for Prime enrollees remains elusive, but it is likely that factors beyond individual practitioner decision-making were at work.

Effect of preexisting chronic disease on primary cesarean delivery rates by race for births in U.S. military hospitals, 1999-2002.

BACKGROUND: A previous study of the United States Department of Defense healthcare beneficiaries reported elevated cesarean delivery rates for black and Asian women relative to white women that were independent of maternal socioeconomic status. This finding suggests that other maternal factors may explain the elevated rates. The purpose of this study was to examine the prevalence of specific chronic diseases identified as risk factors for complications during pregnancy, labor, and delivery, and to explore the strength of each disease to predict a cesarean outcome. METHODS: United States military hospital discharge records from 1999 to 2002 for singleton births to women without a previous cesarean were used to calculate primary cesarean and chronic disease rates for diabetes, hypertension, cardiovascular disease, renal disease, anemia, asthma, sexually transmitted diseases, and substance abuse. Stepwise logistic regression was used to calculate adjusted odds ratios for dichotomized race and chronic disease indicators for five maternal age groups using the chi2 difference (p < 0.05) to identify significant variables for inclusion in the model. Primary cesarean delivery rates were then adjusted for the presence of chronic diseases that were significantly associated with a cesarean outcome. RESULTS: Diabetes, genital herpes, and hypertension were significant predictors of cesarean use among all maternal age groups. Cardiovascular disease, renal disease, asthma, and anemia were predictors in some age groups. The remaining disease conditions were not significant predictors for cesarean delivery. Adjustment of cesarean rates for these chronic diseases did not significantly alter the differences in primary cesarean rates for black and Asian mothers relative to white mothers. CONCLUSIONS: The presence of certain chronic conditions before pregnancy may increase the likelihood that a woman will deliver by cesarean section. Adjustment of cesarean rates for the presence of these chronic diseases, however, does not account for the difference in cesarean rates observed for white and minority mothers in the study population. The potential for underreporting of chronic diseases complicates a true assessment of the impact of chronic disease on cesarean delivery rate variations between white and minority women.