Health-Care Utilization and Expenditures Associated with Long-Term Treatment After Combat and Non-Combat-Related Orthopaedic Trauma

Lower Extremity Musculoskeletal Injuries in United States Active Duty Service Members: Prevalence/Incidence, Health Care Utilization, and Cost Analysis Spanning Fiscal Years 2016-2021

INTRODUCTION

Lower Extremity musculoskeletal injuries (LE MSKIs) represent a significant portion of overuse injuries in active duty service members (ADSMs). However, variations in study methods and research gaps related to LE MSKIs have prevented Department of Defense (DoD) leaders from assessing the burden of these conditions. The purpose of this study was to report the incidence, prevalence, and types of LE MSKIs sustained by ADSMs across four branches of service and describe associated health care utilization and private sector costs.

MATERIALS AND METHODS

This was a retrospective, longitudinal population study, including ADSMs from the Air Force, Army, Marine Corps, and Navy. Prevalence and incidence rates for LE MSKIs, associated health care utilization, and costs were obtained by querying electronic health records (EHR) from military treatment facilities (MTFs), private sector care (PC) claims, and theater medical data from the Military Health System Data Repository (MDR) from October 1, 2015 to September 30, 2021 (FY16-21). Utilization associated with LE MSKIs in both the direct care (DC) and PC settings was classified into mutually exclusive outpatient encounter categories and acute inpatient stays. PC costs related to LE MSKIs were captured for each year.

RESULTS

In FY21, LE MSKIs occurred in 25.3% of ADSMs (n = 378,615). A higher proportion of females sustained an LE MSKI (33.3%), compared to males (23.7%). From FY16-21, the Army had the highest annual prevalence of LE MSKIs (30.9-35.5%), followed by the Air Force (23.8-31.0%), Marine Corps (23.4-27.0%), and Navy (17.2-19.8%). Incidence rate patterns were similar, with the Army sustaining LE MSKIs at 320 to 377 injuries per 1,000 person-years, followed by the Air Force (241-318), Marines (255-288), and Navy (173-203). Overuse/non-specific MSKIs of the knee were the most common injury type and body region affected, respectively. There were 10,675,543 DC and 1,875,307 PC outpatient encounters from FY16-21 with a primary or secondary diagnosis of LE MSKI. The Air Force was most reliant on PC, with 21.5 to 36.8% of LE MSKI-related encounters occurring outside MTFs during FY16-21. Over $99 million was paid by TRICARE on LE MSKI in FY21 alone with Same Day Surgeries accounting for almost half ($48 million) of this total.

CONCLUSIONS

Among U.S. ADSMs, LE MSKIs remain highly prevalent and costly. We observed disparities across the Services in the prevalence and incidence of LE MSKIs, and their respective reliance on the private sector for management of these conditions. Findings from this work may support military leaders and MSKI researchers who seek to reduce the impact of LE MSKIs on the readiness and overall health of the U.S. Military.

Musculoskeletal Injuries in Female U.S. Active Duty Service Members: Prevalence/Incidence, Health Care Utilization, and Cost Analysis Spanning Fiscal Years 2016-2021

INTRODUCTION

Musculoskeletal injuries (MSKIs) are highly prevalent and costly conditions among active duty service members (ADSMs), and female service members sustain these injuries at a higher rate than men. However, lack of women-specific research regarding MSKIs in the U.S. military has limited Department of Defense (DoD) leadership from assessing and addressing the burden of these conditions. The purposes of this study were to report the incidence, prevalence, and types of MSKIs sustained by female ADSMs across the four services in direct care (DC) and private sector care (PC) settings from fiscal years (FYs) 2016 through 2021 and to quantify and describe the health care utilization and private sector costs associated with MSKIs in women over the same period.

MATERIALS AND METHODS

This retrospective, longitudinal population study included ADSMs from the Air Force, Army, Marine Corps, and Navy. Prevalence and incidence rates for Head/Neck, Upper Extremity (UE), Spine, and Lower Extremity (LE) MSKIs in female ADSMs, associated health care utilization, and private sector costs were derived by querying electronic health records from military treatment facilities, PC claims, and theater medical data from the Military Health System Data Repository from October 1, 2015 to September 30, 2021 (FY16-21). Health care utilization associated with MSKIs among female ADSMs for each body region in DC and PC settings was classified into mutually exclusive outpatient encounter categories and acute inpatient stays. PC MSKI-associated costs in service women were captured for each year and categorized by service, body region, and setting.

RESULTS

In FY21, 10.8% (n = 27,976) of female ADSMs sustained Head/Neck MSKI, 16.3% (n = 42,294) UE MSKI, 23.6% (n = 61,048) Spine MSKI, and 33.3% (n = 86,235) LE MSKI. Across the study period, female ADSMs had a 25%-29% higher risk of any MSKI (risk ratio (RR) 1.25-1.29) relative to men. Female soldiers had the highest annual prevalence of MSKIs (62.1%-66.4%), while female Marines had the highest risk of MSKI relative to men (RR 1.40-1.47) for all four major body regions. From FY16 to FY21, the body region with the highest risk of MSKI relative to men was Head/Neck (RR 1.61-1.63), while the region with the lowest relative risk was UE (RR 1.05-1.10). LE MSKIs represented the most common and costly type of injury in female ADSMs, with 406,997 outpatient DC and 87,374 PC encounters in FY21. Total PC costs of LE MSKI for female ADSMs were $30,643,535 in FY21 alone.

CONCLUSIONS

This is the first population-level assessment of MSKI prevalence, incidence rates, health care utilization, and PC costs over a 6-year period for service women in the military health system (MHS). Female ADSMs sustain MSKIs at a higher rate than their male counterparts. Given the critical role of service women in the military, MHS leaders, researchers, and public health officials should continue to explore the underlying causes of these disparities in MSKI rates between the sexes, by expanding research efforts to all services and military settings.

Effects of Gynecomastia Surgery on Readiness and Return to Duty in an Active Duty Military Population

INTRODUCTION

Simple mastectomies are routinely performed in the military health care system as gynecomastia can cause significant pain and discomfort when wearing body armor. Postoperative recovery negatively impacts personnel readiness. In this study, we sought to study time to return to duty in active duty service members who undergo surgery for gynecomastia.

METHODS AND MATERIALS

We conducted a single-center retrospective review of active duty patients undergoing a surgical operation for gynecomastia from July 2020-June 2022. A total of 96 patients were included. Our primary outcome of interest was time from surgery to return to duty. A multivariate analysis was performed to assess for factors independently associated with surgical complications including patient demographics and operative techniques.

RESULTS

The median number of days to return to duty after surgery was 28 days (IQR 13-37). The median loss of duty days because of gynecomastia without surgery was 19 days (IQR 10-21), which was different on the Mann-Whitney U test. Surgical complications were observed in 19 patients (19.7%) with the most common complications being seroma (11), hematoma (4), nipple-areolar complex necrosis (2), and infection (2). Patients with a complication have significantly more time to return to duty (28 vs. 49 days, P < .001). Risk factors associated with an increased risk of complication include ranks E1-E4, behavioral health diagnosis, "open" vs. "combined" technique with liposuction, length of operation greater than 58 minutes, and excised breast mass greater than 17.9 g.

CONCLUSIONS

Gynecomastia surgery is associated with a detriment to personnel readiness. Surgery should be reserved for patients with severe symptoms that prevent the performance of daily duties. Furthermore, factors associated with an increased risk for complications include ranks E1-E5, behavioral health diagnosis, length of operation >58 minutes, and excised breast mass >17.9 g. The operating surgeon should be mindful of these factors.

Does psychological distress predict risk of orthopaedic surgery and postoperative opioid prescribing in patients with hip pain? A retrospective study

BACKGROUND

Clinicians and public health professionals have allocated resources to curb opioid over-prescription and address psychological needs among patients with musculoskeletal pain. However, associations between psychological distress, risk of surgery, and opioid prescribing among those with hip pathologies remain unclear.

METHODS

Using a retrospective cohort study design, we identified patients that were evaluated for hip pain from January 13, 2020 to October 27, 2021. Patients' surgical histories and postoperative opioid prescriptions were extracted via chart review. Risk of hip surgery within one year of evaluation was analyzed using multivariable logistic regression. Multivariable linear regression was employed to predict average morphine milligram equivalents (MME) per day of opioid prescriptions within the first 30 days after surgery. Candidate predictors included age, gender, race, ethnicity, employment, insurance type, hip function and quality of life on the International Hip Outcome Tool (iHOT-12), and psychological distress phenotype using the OSPRO Yellow Flag (OSPRO-YF) Assessment Tool.

RESULTS

Of the 672 patients, n = 350 (52.1%) underwent orthopaedic surgery for hip pain. In multivariable analysis, younger patients, those with TRICARE/other government insurance, and those with a high psychological distress phenotype had higher odds of surgery. After adding iHOT-12 scores, younger patients and lower iHOT-12 scores were associated with higher odds of surgery, while Black/African American patients had lower odds of surgery. In multivariable analysis of average MME, patients with periacetabular osteotomy (PAO) received opioid prescriptions with significantly higher average MME than those with other procedures, and surgery type was the only significant predictor. Post-hoc analysis excluding PAO found higher average MME for patients undergoing hip arthroscopy (compared to arthroplasty or other non-PAO procedures) and significantly lower average MME for patients with public insurance (Medicare/Medicaid) compared to those with private insurance. Among those only undergoing arthroscopy, older age and having public insurance were associated with opioid prescriptions with lower average MME. Neither iHOT-12 scores nor OSPRO-YF phenotype assignment were significant predictors of postoperative mean MME.

CONCLUSIONS

Psychological distress characteristics are modifiable targets for rehabilitation programs, but their use as prognostic factors for risk of orthopaedic surgery and opioid prescribing in patients with hip pain appears limited when considered alongside other commonly collected clinical information such as age, insurance, type of surgery pursued, and iHOT-12 scores.

Healthcare Utilization Following Hemipelvectomy or Hip Disarticulation in the Military Health System

INTRODUCTION

Amputations at the hip and pelvic level are often performed secondary to high-energy trauma or pelvic neoplasms and are frequently associated with a prolonged postoperative rehabilitation course that involves a multitude of health care providers. The purpose of this study was to examine the health care utilization of patients with hip- and pelvic-level amputations that received care in the U.S. Military Health System.

MATERIALS AND METHODS

We performed a retrospective review of all patients who underwent a hip- or pelvic-level amputation in the Military Health System between 2001 and 2017. We compiled and reviewed all inpatient and outpatient encounters during three time points: (1) 3 months pre-amputation to 1 day pre-amputation, (2) the day of amputation through 12 months post-amputation, and (3) 13-24 months post-amputation. Health care utilization was defined as the average number of encounter days/admissions for each patient. Concomitant diagnoses following amputation including post-traumatic stress disorder, traumatic brain injury, anxiety, depression, and chronic pain were also recorded.

RESULTS

A total of 106 individuals with hip- and pelvic-level amputations were analyzed (69 unilateral hip disarticulation, 6 bilateral hip disarticulations, 27 unilateral hemipelvectomy, 2 bilateral hemipelvectomies, and 2 patients with a hemipelvectomy and contralateral hip disarticulation). Combat trauma contributed to 61.3% (n = 65) of all amputations. During the time period of 3 months pre-amputation, patients had an average of 3.8 encounter days. Following amputation, health care utilization increased in both the year following amputation and the time period of 13-24 months post-amputation, averaging 170.8 and 77.4 encounter days, respectively. Patients with trauma-related amputations averaged more total encounter days compared to patients with disease-related amputations in the time period of 12 months following amputation (203.8 vs.106.7, P < .001) and the time period of 13-24 months post-amputation (92.0 vs. 49.0, P = .005). PTSD (P = .02) and traumatic brain injuries (P < .001) were more common following combat-related amputations.

CONCLUSIONS

This study highlights the increased health care resource demand following hip- and pelvic-level amputations in a military population, particularly for those patients who sustained combat-related trauma. Additionally, patients with combat-related amputations had significantly higher rates of concomitant PTSD and traumatic brain injury. Understanding the extensive needs of this unique patient population helps inform providers and policymakers on the requirements for providing high-quality care to combat casualties.

Combined computational analysis and cytology show limited depth osteogenic effect on bone defects in negative pressure wound therapy

Background: The treatment of bone defects remains a clinical challenge. The effect of negative pressure wound therapy (NPWT) on osteogenesis in bone defects has been recognized; however, bone marrow fluid dynamics under negative pressure (NP) remain unknown. In this study, we aimed to examine the marrow fluid mechanics within trabeculae by computational fluid dynamics (CFD), and to verify osteogenic gene expression, osteogenic differentiation to investigate the osteogenic depth under NP. Methods: The human femoral head is scanned using micro-CT to segment the volume of interest (VOI) trabeculae. The VOI trabeculae CFD model simulating the bone marrow cavity is developed by combining the Hypermesh and ANSYS software. The effect of trabecular anisotropy is investigated, and bone regeneration effects are simulated under NP scales of -80, -120, -160, and -200 mmHg. The working distance (WD) is proposed to describe the suction depth of the NP. Finally, gene sequence analysis, cytological experiments including bone mesenchymal stem cells (BMSCs) proliferation and osteogenic differentiation are conducted after the BMSCs are cultured under the same NP scale. Results: The pressure, shear stress on trabeculae, and marrow fluid velocity decrease exponentially with an increase in WD. The hydromechanics of fluid at any WD inside the marrow cavity can be theoretically quantified. The NP scale significantly affects the fluid properties, especially those fluid close to the NP source; however, the effect of the NP scale become marginal as WD deepens. Anisotropy of trabecular structure coupled with the anisotropic hydrodynamic behavior of bone marrow; An NP of -120 mmHg demonstrates the majority of bone formation-related genes, as well as the most effective proliferation and osteogenic differentiation of BMSCs compared to the other NP scales. Conclusion: An NP of -120 mmHg may have the optimal activated ability to promote osteogenesis, but the effective WD may be limited to a certain depth. These findings help improve the understanding of fluid mechanisms behind NPWT in treating bone defects.