Musculoskeletal complaints and its economic impact in an Iranian army hospital.

AIM: Musculoskeletal conditions constitute a remarkable portion of disability cases in the military. This study evaluated the distribution and types of musculoskeletal problems and estimated the direct and indirect costs due to these complaints in an Iranian military hospital. METHODS: All medical records of patients with musculoskeletal complaints that were referred to the medical committee of a military hospital, including rheumatology, orthopedics, and neuro-surgical specialists, from 2014 to 2016, were reviewed. Details of each complaint and the final opinion of the medical committees were recorded. The cost of each diagnostic step was calculated based on the recorded data. The treatment costs were estimated for each complaint by calculating the average cost of treatment plans suggested by two specialists, a physical medicine and a rheumatologist. The estimated cost for each part is calculated based on the army insurance low. Indirect costs due to absences, inability to work, and disability were assessed and added to the above-mentioned direct costs. Statistical analysis was performed using SPSS version 21. RESULTS: 2,116 medical records of the committee were reviewed. 1252 (59.16%) cases were soldiers (who had to spend two years of mandatory duty in the army), and 864 (40.83%) cases were non-soldiers. The three most common complaints were fractures (301 cases, 14.22%), low back pain due to lumbar disc bulges and herniations (303 cases, 14.31%), and genu varus/genu valgus (257 cases, 12.14%). The most affected sites were the lower limbs and vertebral column. According to an official document in these subjects' records, 4120 person-days absent from work were estimated annually, and nearly $1,172,149 of annual economic impact was calculated. CONCLUSION: Musculoskeletal problems are common in the army, and establishing preventive strategies for these conditions is essential. The conservative and medical approach and the proper education for correct movement and the situation should be mentioned for the reduction of disability and its economic burden on the army's staff.

Cost Savings of Frequent, Concise Skills Competency Training in the Emergency Department.

Nurse educators are confronted with ensuring skills competency and staff compliance to support the provision of safe and quality care. The ED setting presents additional challenges when conducting skills competency training. One military hospital's emergency department implemented a method of frequent, concise skills training sessions to overcome barriers unique to the ED setting; the same method was then implemented at a second military organization owing to the effectiveness of the training approach to increase staff compliance. This article outlines the methods for the implementation of frequent, concise skills training sessions, and it displays the cost savings and increased compliance experienced by the 2 health care organizations after the implementation of this frequent, concise skills training method.

Military Hospital Spending on Environmental Services and Inpatient Satisfaction Ratings.

EXECUTIVE SUMMARY: To assess the impact of military hospital expenditures on environmental services (EVS) on inpatient satisfaction, the authors collected Defense Health Agency TRICARE Inpatient Satisfaction Survey data from fiscal years 2011 through 2013, military hospital EVS spending and workload data, facility construction/renovation data, and military health system inpatient administrative claims data. Multivariate logistic regression for panel data was performed independently for medical/surgical and obstetric product lines and each satisfaction question. A statistically significant positive relationship was found between hospital EVS spending and patient satisfaction, with the highest expenditure levels generally exhibiting a greater association with satisfaction. Statistically significant increases in satisfaction with cleanliness were associated with higher levels of hospital expenditures on EVS.

[Organisational aspects of medical support for civilians employed in the Armed Forces in the military-medical institutions of the Ministry of Defence, deployed in Moscow].

Organisational aspects of medical support for civilians employed in the Armed Forces in the military-medical institutions of the Ministry of Defence, deployed in Moscow. To ensure social protection of the civilian personnel of the Armed Forces is one of the main tasks of the Ministry of Defence of the Russian Federation. In Moscow formed a territorial system of medical support of citizens who have the right for medical care in military medical institutions of the Ministry of Defence of the Russian Federation. Russian legislation does not provide the right for medical assistance provision to the civilian personnel of the Armed Forces in military medical institutions at the expense of funds allocated from the federal budget for the maintenance of the Ministry of Defence of the Russian Federation. The function of the physician in providing primary medical care performs primary care physician. Providing medical assistance to the civilian personnel of the Armed Forces of the Russian Federation in military medical institutions on the basis of their attachment to the clinics onlv the Russian Defence Ministrv. or in the direction of the clinics of Moscow.

[Marketing in the system of military-medical facilities].

Military medical facilities of the Ministry of Defence of the Russian, have received the right to provide additional services and have been involved in the sphere of market relations. The strong influence of market relations - an objective reality that must be used for the development of military medical institutions and improving quality of care.Effective commercial activity can improve capabilities of the military medical institutions. This requires constant study of market mechanisms to implement and develop their competitive advantage. The paper substantiates the need for the participation of military medical institutions in the provision of health services to the public on the terms of compensation incurred by financial institutions costs (paid medical services, medical assistance program of compulsory and voluntary health insurance). Taking into account the specifics of military medical institutions set out basic principles and recommendations have been implementing marketing approach in their management, the practical application of which will not only increase efficiency, but also create conditions to improve the financial and economic indicators. This knowledge will help the mechanism of functioning health care market and the rules of interaction of market counterparties.

Finally "deliberate by design": milestones in the delivery of health care for U.S. military family members.

The development of medical care for U.S. military families and retirees was serendipitous, a fortunate accident. The formal development of military family medical care required the evolution of three factors: the emergence of a standing army, frontiers to guard, and a peace to defend. These factors were first realized in the late 19th Century, and beginning at that point in U.S. history, seven key years highlight major milestones in the history of military family member medical care. At the same time, these years exemplify changing ideas of disease and of health care and how the physical design of clinics and hospitals reflects and impacts these ideas. The Fort Belvoir Community Hospital, which opens in 2011, exemplifies the Nation's best example of green hospital construction, patient and family centered care, and evidence-based design in a Culture of Excellence that demonstrates that military family medical care is finally "deliberate by design."

The cost of providing health care to injured soldiers in war.

BACKGROUND: As the Global War on Terror progresses, the total health cost for treating wounded soldiers continues to rise. Although some reports have estimated the total cost of soldiers' health care, no study has attempted to rigorously quantify this amount. We sought to quantify the cost of providing health care to soldiers injured while on duty in a conflict area. METHODS: Retrospective study of all Canadian Forces (CF) soldiers injured in Afghanistan from February 7, 2006, to February 6, 2007. CF trauma registry was used to identify all injured Canadian soldiers and hospitalized at the military field hospital in Kandahar. Financial reports from the Canadian Forces Health Services were used to quantify the cost of providing care to these soldiers in Kandahar at Landstuhl Regional Medical Center and during evacuation back to Canada. Insurance claims paid (as of October 15, 2007) to a third-party insurer by the CF were used to quantify the charges and costs of health care in Canada. All dollar figures are in Canadian dollars. RESULTS: During the 1-year period, the CF spent more than $24.3 million to provide health care to 1,245 patients at its field hospital in Kandahar. One hundred twenty-seven of these patients were injured Canadian soldiers who required admission to the field hospital. A total of 93 soldiers required evacuation to Landstuhl Regional Medical Center, and of these, 75 required further care at the Canadian civilian hospitals. The CF spent approximately $2.5 million to provide trauma care in Kandahar to its 127 injured soldiers. Caring for 93 wounded soldiers at Landstuhl Regional medical center cost approximately $2.0 million. Air evacuation costs of 75 wounded soldiers back to Canada cost $3.9 million. The CF were charged approximately $2.4 million for further care in Canada for 75 severely wounded soldiers. The estimated actual cost of this care in Canada was $1.4 million. CONCLUSIONS: Estimating the financial cost to properly care for soldiers wounded on overseas duty in the conflict areas is critical for future planning and forecasting. We estimated on average, it costs approximately $20,000 to care for a wounded soldier at a field hospital who is subsequently returned to duty, $42,000 for the case of a wounded soldier treated at an out-of-theater regional referral hospital and subsequently returned to duty, and $113,000 to care for a wounded soldier who is repatriated and finally treated in Canada. Most of the costs are from establishing and staffing field hospitals in the conflict area and from evacuation costs.

Evaluation of Operative Waste in a Military Medical Center: Analysis of Operating Room Cost and Waste during Surgical Cases.

Operating rooms (ORs) contribute to at least 40 per cent of hospital costs. There is an existing cost waste in ORs for surgical devices that are opened without being used. There is a paucity of data evaluating the hospital cost of opened but unused OR supplies. The goal of this observational study is to examine the cost of opened but unused OR supplies for general surgery cases. We performed a quality improvement project of OR cost waste by observing 30 cases. Surgical cases of a senior surgeon who had been at the institution for more than five years were evaluated for items opened appropriately and whether the items are used. The cases evaluated ranged from open hernia repairs to robotic-assisted hernia repairs. We found that the cost of instruments opened but not used was $4528.18. Of the cases evaluated, we found that a range of 0 per cent to 27 per cent of total items were wasted, an average of 8.3 per cent. We found that for the open inguinal hernia case, there was minimal waste. The highest waste was among complex cases such as the robotic-assisted inguinal hernia with an average waste and cost of 15.8 per cent and $379. We found that on average for less complex cases such as open inguinal hernia repairs, $1.44 was potentially wasted per case, whereas for more complex cases up to $379 was wasted per case. We identified the outdated preference cards, lack of instrument knowledge, circulating nurse, and surgical technician distractions as reasons for contributing to waste.

Health seeking behavior as a predictor of healthcare utilization in a population of patients with spinal pain.

BACKGROUND: The global burden of low back pain is growing rapidly, accompanied by increasing rates of associated healthcare utilization. Health seeking behavior (HSB) has been suggested as a mediator of healthcare utilization. The aims of this study were to: 1) develop a proxy HSB measure based on healthcare consumption patterns prior to initial consultation for spinal pain, and 2) examine associations between the proxy HSB measure and future healthcare utilization in a population of patients with spine disorders. METHODS: A cohort of 1,691 patients seeking care for spinal pain at a single military hospital were included. Cluster analyses were performed for the identification of a proxy HSB measure. Logistic regression was used to identify the predictive capacity of HSB on eight different general and spine-related high healthcare utilization (upper 25%) outcomes variables. RESULTS: The strongest proxy measure of HSB was prior primary care provider visits. In unadjusted models, HSB predicted healthcare utilization across all eight general and spine-related outcome variables. After adjusting for covariates, HSB still predicted general and spine-related healthcare utilization for most variables including total medical visits (OR = 2.48, 95%CI 1.09,3.11), total medical costs (OR = 2.72, 95%CI 2.16,3.41), and low back pain-specific costs (OR = 1.31, 95%CI 1.00,1.70). CONCLUSION: Health seeking behavior prior to initial consultation for spine pain was related to healthcare utilization after consultation for spine pain. HSB may be an important variable to consider when developing an individualized care plan and considering the prognosis of a patient.

Cost drivers and resource allocation in military health care systems.

This study illustrates the feasibility of incorporating technical efficiency considerations in the funding of military hospitals and identifies the primary drivers for hospital costs. Secondary data collected for 24 U.S.-based Army hospitals and medical centers for the years 2001 to 2003 are the basis for this analysis. Technical efficiency was measured by using data envelopment analysis; subsequently, efficiency estimates were included in logarithmic-linear cost models that specified cost as a function of volume, complexity, efficiency, time, and facility type. These logarithmic-linear models were compared against stochastic frontier analysis models. A parsimonious, three-variable, logarithmic-linear model composed of volume, complexity, and efficiency variables exhibited a strong linear relationship with observed costs (R(2) = 0.98). This model also proved reliable in forecasting (R(2) = 0.96). Based on our analysis, as much as $120 million might be reallocated to improve the United States-based Army hospital performance evaluated in this study.

Does money really matter? The effects of fiscal margin on quality of care in military treatment facilities.

This study was prompted by an escalating interest in the quality of healthcare provided within the United States. The authors hypothesized that one determinant of quality is the adequacy of financial resources available to the healthcare organization. The authors addressed their question by using data from two Defense Department sources: the 2003 Health Care Survey of Defense Department Beneficiaries (HCSDB) and 1999-2003 data from the Department of Defense Medical Expense Performance Reporting System (MEPRS). The authors used a measure of military treatment facility fiscal margin to predict seven Consumer Assessment of Health Plan Satisfaction (CAHPS) quality dimensions. Regression analysis and multilevel modeling are the primary statistical methods. Results indicate a significant and positive association between organizational financial strength and quality outcomes. This finding indicates that organizations with more financial flexibility may be more adept at meeting or exceeding patient care expectations.

[Analyses of the competitive ability of military clinical-prophylactic institutions and the quality factor of medical care].

As a result of research it is proved, that the most significant factors of competitiveness are quality of rendered medical services. All can be estimated the necessary parties of quality on the basis of medical standards. The technique of an estimation of quality of out-patient medical aid consists in comparison of the standard of groups of parameters of quality (diagnostics, treatment, results), considering their factors of weightiness) with real data of concrete patients.

What Patients Really Want: Optimizing the Military Preoperative Evaluation Clinic.

The idea of the preoperative anesthesia clinic as a means of examining and treating the patient so that he will arrive in the operating theater as strong and healthy as possible is well established in practice and literature.However, problems in clinic design and execution often result in high patient waiting times, decreased patient and staff satisfaction, decreased patient capacity, and high clinic costs. Although the details of clinic design, outcomes, and satisfaction have been extensively evaluated at civilian hospitals, we have not found corresponding literature addressing these issues specifically within military preoperative evaluation clinics. We find that changing to an appointment-based (versus walk-in) system and eliminating data collection step redundancies will likely result in lower wait times, higher satisfaction, lower per patient costs, and a more streamlined and resource-efficient structure.

Service Block Time Allocation in the US Army Medical Command.

Service block time allocation is a critical requirement for the optimization of patient throughput and access to care in the Surgical Services Service Line of the US Army Medical Command. The procedure complexity, volume, and diversity across 25 facilities create significant variation in service block time. This variation requires the involvement of both the informatics and leadership teams for block time allocation to be effective. This article describes our use of the Army's Surgery Scheduling System, which includes service block time as an embedded function, to develop a standardized process that helps ensure service block time is optimized. We also present guidelines for block time allocation and offer case studies that demonstrate the application of these guidelines.

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

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

The occupational burden of mental disorders in theU.S. military: psychiatric hospitalizations, involuntary separations, and disability.

OBJECTIVE: A recent study showed that among U.S. military personnel, mental disorders were the leading medical correlate of separation from military service. The reasons for this association have not been determined. The purpose of this study was to characterize the risk and reasons for service separation for soldiers hospitalized with mental disorders compared with those hospitalized for other illnesses. METHOD: Population-based electronic health care data were linked with data on separations and disability. The authors constructed a cohort of 13,971 U.S. Army soldiers first hospitalized in 1998 and followed them for up to 2 years following this first hospitalization. RESULTS: The rate of service separation 6 months after first hospitalization was 45% among personnel whose primary hospital discharge diagnosis was a mental disorder, 27% among those with a secondary mental disorder discharge diagnosis, and 11% among those hospitalized for all other medical conditions. Separation from military service due to medical disability, misconduct and other legal problems, unauthorized work absences, behavior related to personality disorders, and alcohol rehabilitation failure was significantly more common following hospitalization for a mental disorder than for other medical conditions. Mental disorders were also significantly associated with medical separations in which there was evidence that the condition existed prior to service. CONCLUSIONS: In the military, the occupational impact of mental disorders compared with other medical conditions appears to be mediated not only by greater disease chronicity and severity but also by a variety of behavioral problems including misconduct, legal problems, unauthorized absences, and alcohol/drug-related problems. The study also points to the difficulties inherent in screening for mental disorders prior to entry into military service.

[The main approaches to economical analysis of military treatment-and-prophylactic institutions' activities].

In conditions of market economy the improvement of quality and competitiveness of services rendered in order to obtain the maximal economical results (profit) from their realization is one of the strategic tasks of any military treatment-and-prophylactic institution. That's why the main purpose of economical analysis of military institutions' treatment-and-economic activities is the search of inner reserves and choice of directions for best investments.