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Vargas SE, Thornton K, Norris C, Gist G, Clark MF, Ramirez L, Guillen M, Guthrie KM, Landoll RR. Sexual and reproductive health in military settings: A qualitative study. Mil Psychol 2024:1-10. [PMID: 38436987 DOI: 10.1080/08995605.2024.2324644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 02/22/2024] [Indexed: 03/05/2024]
Abstract
Mission readiness is critical to the operational success of the United States (US) military and includes having a healthy and fit fighting force. Service members and their dependents have access to a wide range of sexual and reproductive health services with no out-of-pocket costs. Despite this access, negative outcomes such as sexually transmitted infections (STIs) and unintended pregnancy persist. Semi-structured, in-depth interviews were conducted with service members and stakeholders (e.g. medical providers). Interviews explored the individual, interpersonal, organizational, and institutional factors that inform sexual norms, behaviors, and healthcare experiences in the US military. Interview transcripts were coded manually; data were summarized for themes related to unique aspects of military culture and healthcare affecting sexual and reproductive health. Twenty-five (25) service members and 15 stakeholders completed interviews. Four themes emerged: 1) despite free access, both general and military-specific barriers to sexual and reproductive healthcare persist; 2) general and military-specific cultural norms apply to sexual behavior and care seeking; 3) sexual and reproductive health-related norms can be perceived as confusing and contradictory within the military; and 4) resources addressing sexual assault are ubiquitous in military settings, but resources addressing prevention of STIs and unintended pregnancy are limited. Both general and military-specific norms, behavior, and healthcare experiences need to be considered in clinical care, public health campaigns, and other efforts to promote sexual and reproductive health in military settings.
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Affiliation(s)
- Sara E Vargas
- Center for Behavioral and Preventive Medicine, The Miriam Hospital, Providence, Rhode Island
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Kade Thornton
- Department of Medical & Clinical Psychology, Uniformed Services University of the Health Sciences School of Medicine, Bethesda, Maryland
| | - Colby Norris
- Department of Family Medicine, Uniformed Services University of the Health Sciences School of Medicine, Bethesda, Maryland
| | - Galen Gist
- Department of Family Medicine, Uniformed Services University of the Health Sciences School of Medicine, Bethesda, Maryland
| | - Madison F Clark
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland
| | - Leslie Ramirez
- Center for Behavioral and Preventive Medicine, The Miriam Hospital, Providence, Rhode Island
| | - Melissa Guillen
- Center for Behavioral and Preventive Medicine, The Miriam Hospital, Providence, Rhode Island
| | - Kate M Guthrie
- Center for Behavioral and Preventive Medicine, The Miriam Hospital, Providence, Rhode Island
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Providence, Rhode Island
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, Rhode Island
| | - Ryan R Landoll
- Department of Family Medicine, Uniformed Services University of the Health Sciences School of Medicine, Bethesda, Maryland
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Romano CJ, Magallon SM, Hall C, Bukowinski AT, Gumbs GR, Conlin AMS. Validation of ICD-9-CM codes for major genitourinary birth defects in Military Health System administrative data, 2006-2014. Birth Defects Res 2024; 116:e2265. [PMID: 37933714 DOI: 10.1002/bdr2.2265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 09/28/2023] [Accepted: 10/17/2023] [Indexed: 11/08/2023]
Abstract
BACKGROUND The Department of Defense Birth and Infant Health Research program is dedicated to birth defects research and surveillance among military families. Here, we assess and refine the validity of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for selected genitourinary birth defects in the Military Health System (MHS). We additionally outline methods for the calculation of positive predictive value (PPV) and negative predictive value (NPV), sensitivity, and specificity using a stratified sampling design. METHODS Among military infants born from 2006 through 2014, a random sample of ICD-9-CM screen-positive cases (for six genitourinary birth defects) and screen-negative cases were selected for chart review. PPV, NPV, sensitivity, and specificity were calculated for individual defects and any included defect (i.e., overall); measures were weighted by the inverse probability of being sampled. RESULTS Of 461,557 infants, 686 were sampled for chart review. Bladder exstrophy was accurately reported (PPV: >90%), while the accuracy of renal dysplasia, renal agenesis/hypoplasia, and hypospadias was moderate (PPVs: 66%-68%) and congenital hydronephrosis was low (PPV: 20%). Specificity and NPVs always exceeded 98%. The overall PPV was 50%; however, excluding congenital hydronephrosis screen-positive cases and requiring at least two inpatient or outpatient diagnostic codes resulted in a PPV of 85%. CONCLUSIONS The validity of major genitourinary birth defect codes varied in MHS administrative data. The accuracy of an overall defect measure improved by omitting congenital hydronephrosis and requiring at least two diagnostic codes. Although PPV is generally useful for research, additional calculation of NPV, sensitivity, and specificity better informs the identification of appropriate selection criteria across surveillance and research settings.
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Affiliation(s)
- Celeste J Romano
- Deployment Health Research Department, Naval Health Research Center, San Diego, California, USA
- Leidos, Inc., San Diego, California, USA
| | - Sandra M Magallon
- Deployment Health Research Department, Naval Health Research Center, San Diego, California, USA
- Leidos, Inc., San Diego, California, USA
| | - Clinton Hall
- Deployment Health Research Department, Naval Health Research Center, San Diego, California, USA
- Leidos, Inc., San Diego, California, USA
| | - Anna T Bukowinski
- Deployment Health Research Department, Naval Health Research Center, San Diego, California, USA
- Leidos, Inc., San Diego, California, USA
| | - Gia R Gumbs
- Deployment Health Research Department, Naval Health Research Center, San Diego, California, USA
- Leidos, Inc., San Diego, California, USA
| | - Ava Marie S Conlin
- Deployment Health Research Department, Naval Health Research Center, San Diego, California, USA
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Mani V, Pomer A, Madsen C, Coles CL, Schoenfeld AJ, Weissman JS, Koehlmoos TP. Filling the Gaps in the Pandemic Response: Impact of COVID-19 on Telehealth in the Military Health System. Telemed J E Health 2023. [PMID: 38126844 DOI: 10.1089/tmj.2023.0478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023] Open
Abstract
Introduction: As a result of the COVID-19 pandemic, telehealth use became widespread, allowing for continued health care while minimizing COVID-19 transmission risk for patients and providers. This rapid scale-up highlighted shortcomings of the current telehealth infrastructure in many health systems. We aimed to identify and address gaps in the United States Military Health System (MHS) response to the COVID-19 pandemic related to the implementation and utilization of telehealth. Methods: We conducted semistructured key informant interviews of MHS stakeholders, including policymakers, program managers, and health care providers. We recruited respondents using purposive and snowball sampling until we reached thematic saturation. Interviews were conducted virtually from December 2022 to March 2023 and coded by deductive thematic analysis using NVivo. Results: We interviewed 28 key informants. Several themes emerged from the interviews and were categorized into four defined areas of obstacles to the effective utilization of telehealth: administrative, technical, organizational, and quality issues. While respondents had positive perceptions of telehealth, issues such as billing, licensure portability, network connectivity and technology, and ability to monitor health outcomes represent major barriers in the current system, preventing the potential for further expansion. Conclusions: While the shift to telehealth during the COVID-19 pandemic demonstrated robust potential within the MHS, it highlighted shortcomings that impair the utility and expansion of telehealth on a level comparable to that of other large health systems. Future focus should be directed toward generating and implementing actionable recommendations that target these identified challenges in the MHS.
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Affiliation(s)
- Vivitha Mani
- Center for Health Services Research, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
| | - Alysa Pomer
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA Massachusetts, USA
| | - Cathaleen Madsen
- Center for Health Services Research, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
| | - Christian L Coles
- Center for Health Services Research, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
| | - Andrew J Schoenfeld
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA Massachusetts, USA
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA Massachusetts, USA
| | - Joel S Weissman
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA Massachusetts, USA
- Department of Health Policy and Management, Harvard Medical School, Boston, Massachusetts, USA
| | - Tracey Pèrez Koehlmoos
- Center for Health Services Research, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
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Murphy JW. Widening the scope of intensive treatment for PTSD in the military health system. Mil Psychol 2023:1-6. [PMID: 37624943 DOI: 10.1080/08995605.2023.2249798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 08/08/2023] [Indexed: 08/27/2023]
Abstract
Recent trends have exacerbated existing problems accessing mental health care for military service members. To address these problems, lawmakers and military leaders have been busy introducing new legislation and changing policies in order to improve access. While these initiatives are critical for long-term change, military service members need solutions that can help them now. Although it may not be a panacea, intensive outpatient treatments may be part of the solution for the MHS, especially when considering posttraumatic stress disorder (PTSD). This commentary begins by describing the history of intensive treatments in the military health system, which has been largely offered as intensive outpatient treatments (IOPs). Next, it describes a decade of research on intensive treatments for PTSD, which has included a diverse array of IOP formats as well as stand-alone, massed treatments. Lastly, this commentary recommends that lawmakers and military leaders expand their notion of intensive outpatient treatments to include both programs and stand-alone, massed treatments. By doing so, the MHS could have more options for service members and commands as they search for workable treatment options.
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Affiliation(s)
- Jonathan W Murphy
- Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, Illinois
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Korona-Bailey J, Janvrin ML, Juman L, Koehlmoos TP. Voice of the Customer: Factors Impacting Beneficiary Choice of Programs in TRICARE. J Patient Exp 2023; 10:23743735231184762. [PMID: 37528954 PMCID: PMC10388615 DOI: 10.1177/23743735231184762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2023] Open
Abstract
Little is known about how a consumer would choose a health plan if cost was not an option such as in the Military Health System. We sought to identify how to recruit TRICARE beneficiaries into new pilot programs challenged by low recruitment. We developed a semistructured interview guide by adapting a framework established by Klinkman to assess factors in choosing a health plan. Using social media platforms, we recruited TRICARE Prime and Select beneficiaries to participate in key informant interviews from October to December 2022. We conducted inductive thematic analysis to determine key areas of concern. We interviewed a total of 20 TRICARE Prime and Select beneficiaries. The majority were women, above age 40, had a master's degree, a sponsor in the US Army and of senior officer rank. Four overarching themes emerged: (I) patient choice; (II) access to care; (III) quality of care; and (IV) cost. This evaluation of TRICARE beneficiaries explores how to motivate high-quality value-based care in a traditionally fee for service system.
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Affiliation(s)
- Jessica Korona-Bailey
- Center for Health Services Research, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Miranda Lynn Janvrin
- Center for Health Services Research, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Luke Juman
- Center for Health Services Research, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Tracey Perez Koehlmoos
- Center for Health Services Research, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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Grob PC, Tindal RR, Lundeberg KR, Hamilton JL, Gonzalez-Brown VM, Keyser EA. Increased maternal morbidity and mortality among Asian American and Pacific Islander women in the military health system. AJOG Glob Rep 2023; 3:100212. [PMID: 37205300 PMCID: PMC10185736 DOI: 10.1016/j.xagr.2023.100212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/21/2023] Open
Abstract
BACKGROUND Rates of maternal morbidity and mortality experienced by women in the United States have been shown to vary significantly by race, most commonly attributed to differences in access to healthcare and socioeconomic status. Recent data showed that Asian Pacific Islanders have the highest rate of maternal morbidity despite having a higher socioeconomic status. In the military, women of all races are granted equal access to healthcare, irrespective of socioeconomic class. We hypothesized that within the military, there would be no racial disparities in maternal outcomes because of universal healthcare. OBJECTIVE This study aimed to evaluate if universal access to healthcare, as seen in the military healthcare system, leads to similar rates of maternal morbidity regardless of racial or ethnic background. STUDY DESIGN This was a retrospective cohort study of data from the National Perinatal Information Center reports obtained from participating military treatment facilities from April 2019 to March 2020 and included 34,025 deliveries. We compared racial differences in the incidence of each of the following 3 outcomes: postpartum hemorrhage, severe maternal morbidity among women with postpartum hemorrhage including transfusion, and severe maternal morbidity among women with postpartum hemorrhage excluding transfusion. RESULTS A total of 41 military treatment facilities (a list of participating military treatment facilities are provided in the Appendix) provided data that were included. There was an increased rate of postpartum hemorrhage (relative risk, 1.73; 95% confidence interval, 1.45-2.07), severe maternal morbidity including transfusion (relative risk, 1.22; 95% confidence interval, 0.93-1.61), and severe maternal morbidity excluding transfusion (relative risk, 1.97; 95% confidence interval, 1.02-3.8) among Asian Pacific Islander women when compared with Black or White women. CONCLUSION Even with equal access to healthcare in the military, Asian Pacific Islander women experience statistically significant increased rates of postpartum hemorrhage and severe maternal morbidity excluding transfusion when compared with Black or White women. The increased rates of severe maternal morbidity including transfusion were not statistically significant.
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Affiliation(s)
- Patrizia C. Grob
- Rocky Vista University College of Osteopathic Medicine, Parker, CO (Dr Grob)
- Corresponding author: Patrizia C. Grob, DO.
| | - Rachel R. Tindal
- University of Alabama Heersink School of Medicine, Birmingham, AL (Dr Tindal)
| | - Kathleen R. Lundeberg
- College of Osteopathic Medicine, Pacific Northwest University of Health Sciences, Yakima, WA (Dr Lundeberg)
| | - Jameaka L. Hamilton
- Department of Gynecologic Surgery & Obstetrics, Mike O'Callaghan Military Medical Center, Nellis Air Force Base, Las Vegas, NV (Dr Hamilton)
| | - Veronica M. Gonzalez-Brown
- Department of Gynecologic Surgery & Obstetrics, San Antonio Uniformed Services Health Education Consortium, Brooke Army Medical Center, Fort Sam Houston, TX (Drs Gonzalez-Brown and Keyser)
| | - Erin A. Keyser
- Department of Gynecologic Surgery & Obstetrics, San Antonio Uniformed Services Health Education Consortium, Brooke Army Medical Center, Fort Sam Houston, TX (Drs Gonzalez-Brown and Keyser)
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Mavragani A, Schwab SD, Wilkes M, Yourk D, Zahradka N, Pugmire J, Wolfberg A, Merritt A, Boster J, Loudermilk K, Hipp SJ, Morris MJ. Financial and Clinical Impact of Virtual Care During the COVID-19 Pandemic: Difference-in-Differences Analysis. J Med Internet Res 2023; 25:e44121. [PMID: 36630301 PMCID: PMC9879318 DOI: 10.2196/44121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 01/03/2023] [Accepted: 01/11/2023] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Virtual care (VC) and remote patient monitoring programs were deployed widely during the COVID-19 pandemic. Deployments were heterogeneous and evolved as the pandemic progressed, complicating subsequent attempts to quantify their impact. The unique arrangement of the US Military Health System (MHS) enabled direct comparison between facilities that did and did not implement a standardized VC program. The VC program enrolled patients symptomatic for COVID-19 or at risk for severe disease. Patients' vital signs were continuously monitored at home with a wearable device (Current Health). A central team monitored vital signs and conducted daily or twice-daily reviews (the nurse-to-patient ratio was 1:30). OBJECTIVE Our goal was to describe the operational model of a VC program for COVID-19, evaluate its financial impact, and detail its clinical outcomes. METHODS This was a retrospective difference-in-differences (DiD) evaluation that compared 8 military treatment facilities (MTFs) with and 39 MTFs without a VC program. Tricare Prime beneficiaries diagnosed with COVID-19 (Medicare Severity Diagnosis Related Group 177 or International Classification of Diseases-10 codes U07.1/07.2) who were eligible for care within the MHS and aged 21 years and or older between December 2020 and December 2021 were included. Primary outcomes were length of stay and associated cost savings; secondary outcomes were escalation to physical care from home, 30-day readmissions after VC discharge, adherence to the wearable, and alarms per patient-day. RESULTS A total of 1838 patients with COVID-19 were admitted to an MTF with a VC program of 3988 admitted to the MHS. Of these patients, 237 (13%) were enrolled in the VC program. The DiD analysis indicated that centers with the program had a 12% lower length of stay averaged across all COVID-19 patients, saving US $2047 per patient. The total cost of equipping, establishing, and staffing the VC program was estimated at US $3816 per day. Total net savings were estimated at US $2.3 million in the first year of the program across the MHS. The wearables were activated by 231 patients (97.5%) and were monitored through the Current Health platform for a total of 3474 (median 7.9, range 3.2-16.5) days. Wearable adherence was 85% (IQR 63%-94%). Patients triggered a median of 1.6 (IQR 0.7-5.2) vital sign alarms per patient per day; 203 (85.7%) were monitored at home and then directly discharged from VC; 27 (11.4%) were escalated to a physical hospital bed as part of their initial admission. There were no increases in 30-day readmissions or emergency department visits. CONCLUSIONS Monitored patients were adherent to the wearable device and triggered a manageable number of alarms/day for the monitoring-team-to-patient ratio. Despite only enrolling 13% of COVID-19 patients at centers where it was available, the program offered substantial savings averaged across all patients in those centers without adversely affecting clinical outcomes.
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Affiliation(s)
| | - Stephen D Schwab
- Brooke Army Medical Center, Joint Base San Antonio-Fort Sam Houston, TX, United States.,Department of Economics, Baylor University, Waco, TX, United States
| | - Matt Wilkes
- Current Health Ltd, Edinburgh, United Kingdom
| | | | | | | | | | - Amanda Merritt
- Brooke Army Medical Center, Joint Base San Antonio-Fort Sam Houston, TX, United States
| | - Joshua Boster
- Brooke Army Medical Center, Joint Base San Antonio-Fort Sam Houston, TX, United States
| | - Kevin Loudermilk
- Brooke Army Medical Center, Joint Base San Antonio-Fort Sam Houston, TX, United States
| | - Sean J Hipp
- Brooke Army Medical Center, Joint Base San Antonio-Fort Sam Houston, TX, United States
| | - Michael J Morris
- Brooke Army Medical Center, Joint Base San Antonio-Fort Sam Houston, TX, United States
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Adams RS, Hoover P, Forster JE, Caban J, Brenner LA. Traumatic Brain Injury Classification Variability During the Afghanistan/Iraq Conflicts: Surveillance, Clinical, Research, and Policy Implications. J Head Trauma Rehabil 2022; 37:361-370. [PMID: 36075868 PMCID: PMC9643596 DOI: 10.1097/htr.0000000000000775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Challenges associated with case ascertainment of traumatic brain injuries (TBIs) sustained during the Afghanistan/Iraq military operations have been widespread. This study was designed to examine how the prevalence and severity of TBI among military members who served during the conflicts were impacted when a more precise classification of TBI diagnosis codes was compared with the Department of Defense Standard Surveillance Case-Definition (DoD-Case-Definition). SETTING Identification of TBI diagnoses in the Department of Defense's Military Health System from October 7, 2001, until December 31, 2019. PARTICIPANTS Military members with a TBI diagnosis on an encounter record during the study window. DESIGN Descriptive observational study to evaluate the prevalence and severity of TBI with regard to each code set (ie, the DoD-Case-Definition and the more precise set of TBI diagnosis codes). The frequencies of index TBI severity were compared over time and further evaluated against policy changes. MAIN MEASURES The more precise TBI diagnosis code set excludes the following: (1) DoD-only extender codes, which are not used in other healthcare settings; and (2) nonprecise TBI codes, which include injuries that do not necessarily meet TBI diagnostic criteria. RESULTS When comparing the 2 TBI classifications, the DoD-Case-Definition captured a higher prevalence of TBIs; 38.5% were classified by the DoD-Case-Definition only (>164 000 military members). 73% of those identified by the DoD-Case-Definition only were diagnosed with nonprecise TBI codes only, with questionable specificity as to whether a TBI occurred. CONCLUSION We encourage the field to reflect on decisions made pertaining to TBI case ascertainment during the height of the conflicts. Efforts focused on achieving consensus regarding TBI case ascertainment are recommended. Doing so will allow the field to be better prepared for future conflicts, and improve surveillance, screening, and diagnosis in noncombat settings, as well as our ability to understand the long-term effects of TBI.
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Affiliation(s)
- Rachel Sayko Adams
- Institute for Behavioral Health, The Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts, USA
- VHA Rocky Mountain Mental Illness Research Education and Clinical Center, Aurora, Colorado, USA
| | - Peter Hoover
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD
| | - Jeri E. Forster
- VHA Rocky Mountain Mental Illness Research Education and Clinical Center, Aurora, Colorado, USA
- University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Jesus Caban
- National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, MD
| | - Lisa A. Brenner
- VHA Rocky Mountain Mental Illness Research Education and Clinical Center, Aurora, Colorado, USA
- University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
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Romano CJ, Hall C, Bukowinski AT, Gumbs GR, Conlin AMS. Pregnancy-associated and pregnancy-related deaths in the United States military, 2003-2014. Am J Obstet Gynecol 2022:S0002-9378(22)00292-7. [PMID: 35460627 DOI: 10.1016/j.ajog.2022.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 04/01/2022] [Accepted: 04/02/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND The Centers for Disease Control and Prevention has reported a steady increase in the US pregnancy-related mortality ratio since national surveillance began in 1987, although trends are partially induced by concurrent improvements in the identification of pregnancy-related deaths. No previous work has evaluated pregnancy-associated and pregnancy-related deaths among active-duty service members, a population with comprehensive health coverage and stable employment. OBJECTIVE This study aimed to assess trends and variations in pregnancy-associated and pregnancy-related deaths in the US military. STUDY DESIGN Live births to active-duty service members were captured in Department of Defense Birth and Infant Health Research program data from 2003 to 2014. Pregnancy-associated deaths (deaths temporally related to pregnancy from any cause) were identified through 1 year after pregnancy end date using National Death Index Plus data from the Joint Department of Defense and Department of Veterans Affairs Suicide Data Repository. Pregnancy-associated deaths were classified as pregnancy-related (causally related to pregnancy) based on cause-of-death codes in the National Death Index Plus data, administrative medical encounter data, and medical record review. Pregnancy-related deaths were reported including and excluding deaths from suicide and unintentional overdose. Mortality ratios (deaths per 100,000 live births) were reported overall, triennially, and by selected characteristics; the relative contribution of each cause of death to all pregnancy-associated deaths was reported overall and by age, race and ethnicity, and marital status. Timing of death relative to pregnancy end date was assessed by cause of death. RESULTS A total of 179,252 live births occurred to active-duty service members from 2003 to 2014. Pregnancy-associated and pregnancy-related mortality ratios were 41.3 (95% confidence interval, 32.4-51.8) and 18.4 (95% confidence interval, 12.7-25.9), respectively. Excluding deaths from suicide and unintentional overdose, the pregnancy-related mortality ratio was 11.2 (95% confidence interval, 6.8-17.2). Deaths from suicide and unintentional overdose composed a larger proportion of pregnancy-related deaths over time and accounted for 17.6% of all pregnancy-associated deaths. Deaths from other pregnancy-related causes accounted for a greater share of deaths among older vs younger service members (≥30 years: 41.2%; 18-29 years: 22.8%) and non-Hispanic Black vs White service members (33.3% vs 24.1%). Pregnancy-related deaths, excluding suicide and unintentional overdose, were more likely to occur within 42 days of pregnancy end date; in contrast, deaths from suicide, overdose, assault, and undetermined intent were more likely to occur between 42 days and 1 year after pregnancy. CONCLUSION Pregnancy-associated and pregnancy-related deaths varied over time and by age and race and ethnicity. Suicide and overdose are major recent causes of pregnancy-related death among active-duty service members.
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Pfaff JA. The Present State of Military Physician Leadership: A Lacking Paradigm? J Spec Oper Med 2022; 22:101-103. [PMID: 36651928 DOI: 10.55460/2j8e-msxs] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/01/2022] [Indexed: 01/19/2023]
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Westcott SL, Less K, Speirs I, Reilly E, Litkenhaus M, Walrath B. Annual Cost of Civilian EMS: An Analysis of Navy Expenditures in Southern California. PREHOSP EMERG CARE 2021; 26:855-862. [PMID: 34669555 DOI: 10.1080/10903127.2021.1993390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Objective: Southern California Naval hospitals incur substantial costs through the use of civilian emergency medical services (EMS) as they lack an internal transportation team. This study aimed to quantify the volume and the associated charges for these transports in the Southern California area as these are currently unknown. Methods: This is a retrospective analysis of de-identified billing claims accessed through the Military Health System Management Analysis and Reporting Tool (M2) system. Data collected included the number and type of transports from Naval Hospitals in the Southern California area as well as the resulting charges. Data from Naval Medical Center San Diego (NMCSD) and Naval Hospital Camp Pendleton (NHCP) were collected over the 2018 and 2019 fiscal years. Results: There were 19,886 and 19,014 total ambulance transports in 2018 and 2019, respectively. Of these, about a quarter (8674/38900, 22.3%) were 9-1-1 calls from the patient's home resulting in an admission at a military treatment facility or network hospital. The majority were interfacility transports (20138/38900, 51.8%). These included transports from hospital discharge to home (3900/38900, 10.0%), transfers between hospitals (1648/38900, 4.2%), transfers from an office to a hospital (1818/38900, 4.7%), and transport for medical care (11682/38900, 30.0%). A large portion of these transports were for unclear transport needs (10088/38900, 25.9%). TRICARE paid $3,872,057 in 2018 and $4,004,996 in 2019 for a total of $7,877,053 spent on ambulance transport over the 2 years analyzed. Outside health insurance paid $10,217,016 over the same timeframe for these same claims. Conclusion: The interfacility transport costs incurred between NMCSD and NHCP are substantial, possibly leaving room for cost savings to be determined by further studies.
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Affiliation(s)
- Sally L Westcott
- Received July 23, 2021; Naval Medical Center San Diego, San Diego, California (SLW, KL, ER, ML, BW); Naval Health Clinic Oak Harbor, Oak Harbor, California (IS). Revision received October 4, 2021; accepted for publication October 11, 2021
| | - Kennen Less
- Received July 23, 2021; Naval Medical Center San Diego, San Diego, California (SLW, KL, ER, ML, BW); Naval Health Clinic Oak Harbor, Oak Harbor, California (IS). Revision received October 4, 2021; accepted for publication October 11, 2021
| | - Ian Speirs
- Received July 23, 2021; Naval Medical Center San Diego, San Diego, California (SLW, KL, ER, ML, BW); Naval Health Clinic Oak Harbor, Oak Harbor, California (IS). Revision received October 4, 2021; accepted for publication October 11, 2021
| | - Erin Reilly
- Received July 23, 2021; Naval Medical Center San Diego, San Diego, California (SLW, KL, ER, ML, BW); Naval Health Clinic Oak Harbor, Oak Harbor, California (IS). Revision received October 4, 2021; accepted for publication October 11, 2021
| | - Michele Litkenhaus
- Received July 23, 2021; Naval Medical Center San Diego, San Diego, California (SLW, KL, ER, ML, BW); Naval Health Clinic Oak Harbor, Oak Harbor, California (IS). Revision received October 4, 2021; accepted for publication October 11, 2021
| | - Benjamin Walrath
- Received July 23, 2021; Naval Medical Center San Diego, San Diego, California (SLW, KL, ER, ML, BW); Naval Health Clinic Oak Harbor, Oak Harbor, California (IS). Revision received October 4, 2021; accepted for publication October 11, 2021
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Lin J, McGlynn KA, Shriver CD, Zhu K. Comparison of Survival among Colon Cancer Patients in the U.S. Military Health System and Patients in the Surveillance, Epidemiology, and End Results (SEER) Program. Cancer Epidemiol Biomarkers Prev 2021; 30:1359-1365. [PMID: 34162655 PMCID: PMC8477343 DOI: 10.1158/1055-9965.epi-20-1267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 10/27/2020] [Accepted: 04/27/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Access to health care is associated with cancer survival. The U.S. military health system (MHS) provides universal health care to beneficiaries, reducing barriers to medical care access. However, it is unknown whether the universal care has translated into improved survival among patients with colon cancer. We compared survival of patients with colon cancer in the MHS to that in the U.S. general population and assessed whether stage at diagnosis differed between the two populations and thus could contribute to survival difference. METHODS The data were from Department of Defense's (DoD) Automated Central Tumor Registry (ACTUR) and the NCI's Surveillance, Epidemiology, and End Results (SEER) program, respectively. The ACTUR (N = 11,907) and SEER patients (N = 23,814) were matched to demographics and diagnosis year with a matching ratio of 1:2. Multivariable Cox regression model was used to estimate all-cause mortality for ACTUR compared with SEER. RESULTS ACTUR patients exhibited better survival than their SEER counterparts (HR, 0.82; 95% confidence interval, 0.79-0.87) overall and in most subgroups by age, in both men and women, and in whites and blacks. The better survival remained when the comparison was stratified by tumor stage. CONCLUSIONS Patients with colon cancer in a universal health care system had better survival than patients in the general population. IMPACT Universal care access is important to improve survival of patients with colon cancer.
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Affiliation(s)
- Jie Lin
- John P. Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland.
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Katherine A McGlynn
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland
| | - Craig D Shriver
- John P. Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Kangmin Zhu
- John P. Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland.
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
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13
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Alexander M, Lin J, Shriver CD, McGlynn KA, Zhu K. Tumour size and overall survival among surgically treated patients with non-metastatic colon cancer in the U.S. Military Health System. Colorectal Dis 2021; 23:192-199. [PMID: 32976668 PMCID: PMC8573790 DOI: 10.1111/codi.15381] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 08/13/2020] [Accepted: 09/15/2020] [Indexed: 12/29/2022]
Abstract
AIM Larger tumour size and lymph node involvement traditionally predict poorer survival in colon cancer patients. However, it has been recently suggested that very small tumours (<5 mm) may be a predictor of poor prognosis in colon cancer patients when lymph nodes are involved. This study investigated whether node-positive colon cancer patients with small tumours had worse survival compared to those with larger tumours in the Department of Defense's (DoD) Military Health System (MHS), a universal health care system. METHODS Surgically treated colon cancer patients were identified from the DoD's Automated Central Tumour Registry (ACTUR). These patients were diagnosed with Stage I-III colon cancer between 1989 and 2010, had one or more lymph nodes examined, did not receive pre-operative radiotherapy and were followed through 2013 to determine vital status. Multivariable Cox models were used to examine survival differences according to tumour size, and data were stratified by lymph node status and age. RESULTS There were no differences in overall survival according to tumour size in the study population. These findings remained similar in analyses stratified by lymph node status and age. CONCLUSION In a universal healthcare system, small tumour size is not associated with worse prognosis in node-positive colon cancer patients.
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Affiliation(s)
- Melannie Alexander
- John P. Murtha Cancer Center Research Program, Department of Surgery, Uniformed Service University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, MD,Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD
| | - Jie Lin
- John P. Murtha Cancer Center Research Program, Department of Surgery, Uniformed Service University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, MD,Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD,Departmentof Surgery, Uniformed Service University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, MD,Departmentof Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Craig D. Shriver
- John P. Murtha Cancer Center Research Program, Department of Surgery, Uniformed Service University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, MD,Departmentof Surgery, Uniformed Service University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, MD
| | - Katherine A. McGlynn
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD
| | - Kangmin Zhu
- John P. Murtha Cancer Center Research Program, Department of Surgery, Uniformed Service University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, MD,Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD,Departmentof Surgery, Uniformed Service University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, MD,Departmentof Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD
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14
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Fritz JM, Rhon DI, Teyhen DS, Kean J, Vanneman ME, Garland EL, Lee IE, Thorp RE, Greene TH. A Sequential Multiple-Assignment Randomized Trial (SMART) for Stepped Care Management of Low Back Pain in the Military Health System: A Trial Protocol. Pain Med 2020; 21:S73-S82. [PMID: 33313724 DOI: 10.1093/pm/pnaa338] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND The Defense Health Agency has prioritized system-level pain management initiatives within the Military Health System (MHS), with low back pain as one of the key focus areas. A stepped care model focused on nonpharmacologic treatment to promote self-management is recommended. Implementation of stepped care is complicated by lack of information on the most effective nonpharmacologic strategies and how to sequence and tailor the various available options. The Sequential Multiple-Assignment Randomization Trial for Low Back Pain (SMART LBP) is a multisite pragmatic trial using a SMART design to assess the effectiveness of nonpharmacologic treatments for chronic low back pain. DESIGN This SMART trial has two treatment phases. Participants from three military treatment facilities are randomized to 6 weeks of phase I treatment, receiving either physical therapy (PT) or Army Medicine's holistic Move2Health (M2H) program in a package specific to low back pain. Nonresponders to treatment in phase I are again randomized to phase II treatment of combined M2H + PT or mindfulness-based treatment using the Mindfulness-Oriented Recovery Enhancement (MORE) program. The primary outcome is the Patient-Reported Outcomes Measurement Information System pain interference computer-adapted test score. SUMMARY This trial is part of an initiative funded by the National Institutes of Health, Veterans Affairs, and the Department of Defense to establish a national infrastructure for effective system-level management of chronic pain with a focus on nonpharmacologic treatments. The results of this study will provide important information on nonpharmacologic care for chronic LBP in the MHS embedded within a stepped care framework.
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Affiliation(s)
| | - Daniel I Rhon
- Brooke Army Medical Center, San Antonio, Texas.,Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Deydre S Teyhen
- Walter Reed Army Institute of Research, Silvers Spring, Maryland
| | - Jacob Kean
- University of Utah, Salt Lake City, Utah
| | | | | | - Ian E Lee
- Defense Health Management Systems, Falls Church, Virginia
| | - Richard E Thorp
- Directorate of Program Analysis and Evaluation, Office of the Army Surgeon General, Joint Base San Antonio Fort Sam Houston, San Antonio, Texas, USA
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Abstract
This research brief describes the use of acupuncture as a mechanism for the development of crossagency knowledge translation and evidence-based practices in order to ensure the best possible care for the nation's veterans.
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Affiliation(s)
- Cathaleen Madsen
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD
| | - Tracey Koehlmoos
- Uniformed Services University of the Health Sciences, Bethesda, MD
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16
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Schweitzer TL, White EJ, Hudak RP. Lessons Learned: Military Screening for Posttraumatic Stress Disorder. US Army Med Dep J 2018:54-58. [PMID: 30623399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
The purpose of this study was to assist military communities of interest to more accurately identify service members who may have emotional and behavior disorders. Specifically, this study identifies service members' perceptions of the Department of Defense Post-Deployment Health Reassessment (PDHRA) screening instrument for posttraumatic stress disorder (PTSD). Findings were that responses to the PDHRA were related to how it was administered and the respondents' perceptions of how the PTSD diagnosis could affect the ability to obtain jobs and obtain promotions. Recommendations include implementing a screening environment free of distractions, involving family members, and assuring a confidential PTSD diagnosis.
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Abstract
Objectives: The Military Healthcare System (MHS) shows increasing interest in acupuncture as an alternative to opioids for pain control. However, specific factors associated with this procedure in the MHS are not well-described in literature. This study examines usage within the MHS to determine patterns among the diagnoses, provider types, and facilities associated with acupuncture. Materials and Methods: Acupuncture-treated patients were identified from TRICARE claims data in the MHS Data Repository as having at least one acupuncture treatment in fiscal year (FY) 2014. Bivariate analysis was performed to determine demographics, diagnoses, and number of visits, for both active-duty and nonactive-duty personnel. Descriptive statistics were used to show associated provider and facility types. Results: A total of 15,761 people received acupuncture in the MHS in FY 2014. Use of acupuncture was greater for Army service, white race, and senior enlisted rank overall, and for males ages 26-35 among active-duty and females ages 46-64 among nonactive-duty beneficiaries. A cumulative 76% of diagnoses were for musculoskeletal or nerve and system issues. Approximately 60% of patients received acupuncture from physicians, 16% from physical therapists or chiropractors, and 9.7% from physician extenders. Specific acupuncture techniques (traditional, auricular, etc.) could not be determined from the data set. Conclusions: The most common diagnoses associated with acupuncture are consistent with pain management. However, full analysis is hampered by inconsistent coding and lack of granularity regarding specific techniques. Given the popularity of acupuncture in the MHS, further research is necessary to explore the full scope of this intervention.
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Affiliation(s)
- Cathaleen Madsen
- Uniformed Services University of the Health Sciences, Bethesda, MD.,The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD
| | - Avni Patel
- Uniformed Services University of the Health Sciences, Bethesda, MD.,The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD
| | - Megan Vaughan
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD.,Defense and Veterans Center for Integrative Pain Management, Rockville, MD
| | - Tracey Koehlmoos
- Uniformed Services University of the Health Sciences, Bethesda, MD
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Larson MJ, Adams RS, Mohr BA, Harris AHS, Merrick EL, Funk W, Hofmann K, Wooten NR, Jeffery DD, Williams TV. Rationale and methods of the Substance Use and Psychological Injury Combat Study (SUPIC): a longitudinal study of Army service members returning from deployment in FY2008-2011. Subst Use Misuse 2013; 48:863-79. [PMID: 23869459 PMCID: PMC3793632 DOI: 10.3109/10826084.2013.794840] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The Substance Use and Psychological Injury Combat Study (SUPIC) will examine whether early detection and intervention for post-deployment problems among Army Active Duty and National Guard/Reservists returning from Iraq or Afghanistan are associated with improved long-term substance use and psychological outcomes. This paper describes the rationale and significance of SUPIC, and presents demographic and deployment characteristics of the study sample (N = 643,205), and self-reported alcohol use and health problems from the subsample with matched post-deployment health assessments (N = 487,600). This longitudinal study aims to provide new insight into the long-term post-deployment outcomes of Army members by combining service member data from the Military Health System and Veterans Health Administration.
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Affiliation(s)
- Mary Jo Larson
- Institute for Behavioral Health, The Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts 02454, USA.
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