Outcomes for Arthroplasties in Military Health: A Retrospective Analysis of Direct Versus Purchased Care.

INTRODUCTION: The Department of Defense is reforming the military health system where surgeries are increasingly referred from military treatment facilities (MTFs) with direct care to higher-volume civilian hospitals under purchased care. This shift may have implications on the quality and cost of care for TRICARE beneficiaries. This study examined the impact of care source and surgical volume on perioperative outcomes and cost of total hip arthroplasties (THAs) and total knee arthroplasties (TKAs). MATERIALS AND METHODS: We examined TRICARE claims for patients who underwent THA or TKA between 2006 and 2019. The 30-day readmissions, complications, and costs between direct and purchased care were evaluated using the logistic regression model for surgical outcomes and generalized linear models for cost. RESULTS: We included 71,785 TKA and THA procedures. 11,013 (15.3%) were performed in direct care. They had higher odds of readmissions (odds ratio, OR 1.29 [95% CI, 1.12-1.50]; P < 0.001) but fewer complications (OR 0.83 [95% CI, 0.75-0.93]; P = 0.002). Within direct care, lower-volume facilities had more complications (OR 1.27 [95% CI, 1.01-1.61]; P = 0.05). Costs for index surgeries were significantly higher at MTFs $26,022 (95% CI, $23,393-$28,948) vs. $20,207 ($19,339-$21,113). Simulating transfer of care to very high-volume MTFs, estimated cost savings were $4,370/patient and $20,229,819 (95% CI, $17,406,971-$25,713,571) in total. CONCLUSIONS: This study found that MTFs are associated with lower odds of complications, higher odds of readmission, and higher costs for THA and TKA compared to purchased care facilities. These findings mean that care in the direct setting is adequate and consolidating care at higher-volume MTFs may reduce health care costs.

Does Veteran Status Mitigate Racial Disparities in Prostate Cancer Screening? Analysis of Prostate Specific Antigen Screening Patterns in the 2018 Behavioral Risk Factor Surveillance System Data.

PURPOSE: We examined the effect of veteran status on prostate specific antigen (PSA) screening and whether health coverage available to veterans mitigates racial disparities in PSA screening. MATERIALS AND METHODS: We conducted a cross-sectional analysis of non-Hispanic White (NHW) and non-Hispanic Black (NHB) men aged between 55 and 69 years who responded to the PSA screening survey in the 2018 Behavioral Risk Factor Surveillance System data. Complex weighted logistic regression models were used to evaluate predictors of PSA screening. RESULTS: Screening prevalence was 43% in veterans (95% CI 42%-45%) versus 40% in nonveterans (95% CI 39%-40%, p <0.001). Among nonveterans, the prevalence of PSA screening was significantly lower in NHB (34%, 95% CI 31%-37%) versus NHW men (40%, 95% CI 39%-41%, p <0.001). Among veterans, NHB men had a significantly higher screening prevalence (48%, 95% CI 43%-54%) versus NHW men (42%, 95% CI 41%-44%, p=0.04). In adjusted analysis, veteran status (OR 1.11, 95% CI 1.01-1.21, p=0.02) and NHB race (OR 1.29, 95% CI 1.12-1.48, p <0.001) were significantly associated with receipt of PSA screening. Given that we found an interaction between veteran status and race (pint=0.03), a marginal analysis was performed. Compared to NHB nonveterans, NHB veterans had higher odds of undergoing PSA screening (OR 1.46, 95% CI 1.11-1.91, p=0.01). However, this association was not demonstrated when comparing NHW veterans versus nonveterans (OR 1.06, CI 0.97-1.16, p=0.22). CONCLUSIONS: Veteran status and NHB race were found to be independent predictors of PSA screening. The interaction between veteran status and race suggests that access to health coverage available to veterans may mitigate racial differences in prostate cancer screening behaviors. Further studies are needed to translate such findings into the civilian health care system.

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.

Trends in Surgical Volume in the Military Health System-A Potential Threat to Mission Readiness.

INTRODUCTION: The Military Health System (MHS) is tasked with a dual mission both to provide medical services for covered patients and to ensure that its active duty medical personnel maintain readiness for deployment. Knowledge, skills, and attitudes (KSA) is a metric evaluating the transferrable skills incorporated into a given surgery or medical procedure that are most relevant for surgeons deployed to a theatre of war. Procedures carrying a high KSA value are those utilizing skills with high relevance for maintaining deployment readiness. Given ongoing concerns regarding surgical volumes at MTFs and the potential adverse impact on military surgeon mission readiness were high-value surgeries to be lost to the civilian sector, we evaluated trends in the setting of high-value surgeries for beneficiaries within the MHS. METHODS: We retrospectively analyzed inpatient admissions data from MTFs and TRICARE claims data from civilian hospitals, 2005-2019, to identify TRICARE-covered patients covered under "purchased care" (referred to civilian facilities) or receiving "direct care" (undergoing treatment at MTFs) and undergoing seven high-value/high-KSA surgeries: colectomy, pancreatectomy, hepatectomy, open carotid endarterectomy, abdominal aortic aneurysm (AAA) repair, esophagectomy, and coronary artery bypass grafting (CABG). Overall and procedure-specific counts were captured, MTFs were categorized into quartiles by volume, and independence between trends was tested with a Cochran-Armitage test, hypothesizing that the proportion of cases referred for purchased care was increasing. RESULTS: We captured 292,411 cases, including 7,653 pancreatectomies, 4,177 hepatectomies, 3,815 esophagectomies, 112,684 colectomies, 92,161 CABGs, 26,893 AAA repairs, and 45,028 carotid endarterectomies. The majority of cases included were referred for purchased care (90.3%), with the proportion of cases referred increasing over the study period (P < .01). By procedure, all cases except AAA repairs were increasingly referred for treatment over the study period (all P < .01, except esophagectomy P = .04). On examining volume, we found that even the highest-volume-quartile MTFs performed a median of less than one esophagectomy, hepatectomy, or pancreatectomy per month. The only included procedure performed once a month or more at the majority of MTFs was CABG. CONCLUSION: On examining volume and referral trends for high-value surgeries within the MHS, we found low surgical volumes at the vast majority of included MTFs and an increasing proportion of cases referred to civilian hospitals over the last 15 years. Our findings illustrate missed opportunities for maintaining the mission readiness of military surgical personnel. Prioritizing the recapture of lost surgical volume may improve the surgical teams' mission readiness.