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ObjectivesTo examine racial disparities in prenatal care (PNC) utilization and infant small for gestational age (SGA) among active duty US military women, a population with equal access to health care and known socioeconomic status.MethodsDepartment of Defense Birth and Infant Health Research program data identified active duty women with singleton live births from January 2003 through August 2015. Administrative claims data were used to define PNC utilization and infant SGA, and log-binomial regression models estimated associations with race/ethnicity. To examine whether associations between maternal race/ethnicity and infant SGA were subject to effect measure modification, respective analyses were stratified by demographic and health characteristics.ResultsOverall, 12.2% of non-Hispanic White women initiated PNC after the first trimester, compared with 14.8% of American Indian/Alaska Native, 15.1% of Asian/Pacific Islander, 14.2% of non-Hispanic Black, and 13.0% of Hispanic women. Infant SGA prevalence was 2.4% and 1.6% among non-Hispanic Black and White women, respectively (aRR 1.52, 95% CI 1.40–1.64). This disparity persisted across stratified analyses, particularly among non-Hispanic Black versus White women with a preeclampsia or hypertension diagnosis in pregnancy (RR 1.96, 95% CI 1.67–2.29) and those aged 35 + years at infant birth (RR 2.04, 95% CI 1.56–2.67).Conclusions for PracticeIn multiple assessments of PNC utilization and infant SGA, non-Hispanic Black military women had consistently worse outcomes than their non-Hispanic White counterparts. This suggests that equal access to health care does not eliminate racial disparities in outcomes or utilization; additional research is needed to elucidate the underlying etiology of these disparities.

Background Large healthcare databases, with their ability to collect many variables from daily medical practice, greatly enable health services research. These longitudinal databases provide large cohorts and longitudinal time frames, allowing for highly pragmatic assessment of healthcare delivery. The purpose of this paper is to discuss the methodology related to the use of the United States Military Health System Data Repository (MDR) for longitudinal assessment of musculoskeletal clinical outcomes, as well as address challenges of using this data for outcomes research. Methods The Military Health System manages care for approximately 10 million beneficiaries worldwide. Multiple data sources pour into the MDR from multiple levels of care (inpatient, outpatient, military or civilian facility, combat theater, etc.) at the individual patient level. To provide meaningful and descriptive coding for longitudinal analysis, specific coding for timing and type of care, procedures, medications, and provider type must be performed. Assumptions often made in clinical trials do not apply to these cohorts, requiring additional steps in data preparation to reduce risk of bias. The MDR has a robust system in place to validate the quality and accuracy of its data, reducing risk of analytic error. Details for making this data suitable for analysis of longitudinal orthopaedic outcomes are provided. Results Although some limitations exist, proper preparation and understanding of the data can limit bias, and allow for robust and meaningful analyses. There is the potential for strong precision, as well as the ability to collect a wide range of variables in very large groups of patients otherwise not captured in traditional clinical trials. This approach contributes to the improved understanding of the accessibility, quality, and cost of care for those with orthopaedic conditions. Conclusion The MDR provides a robust pool of longitudinal healthcare data at the person-level. The benefits of using the MDR database appear to outweigh the limitations.

Heart failure (HF) affects more than 5.1 million Americans and is projected to increase. Understanding the relationship between hospitalization and mortality can help to guide clinical management. The aim of the study is to evaluate the impact of repeat HF hospitalizations on all-cause mortality and to determine risk variables related to patient mortality. Using administrative data from the Military Health System, a cohort of patients with an index admission for HF between 2007 and 2011 was identified. HF hospitalizations were defined as any hospital claim with an International Classification of Diseases, Ninth Revision diagnosis of 428.xx in the primary diagnosis field over the 7-year study period (2007-2013). Patients were subsequently categorized based on total number of HF hospitalizations. A multivariate Cox regression model, adjusting for age, sex, and comorbidities, was used to estimate hazard ratios. Kaplan-Meier survival curves were constructed based on the frequency of HF hospitalizations. Of the 51,286 patients admitted for HF, 54.7% were male with a mean (SD) age of 76.3 (10.8) years, and 29,714 died during 135,211 person-years of follow-up. Mean survival time was 2.6, 1.8, 1.5, and 1.3 years after the first, second, third, and fourth hospitalization, respectively. The mortality rate of patients at 30 days and 1 year postindex HF hospitalization was 7.4% and 27.3%, respectively. A history of dementia and chronic kidney disease without dialysis decreased overall survival. Repeat HF hospitalizations remain a strong predictor of mortality for existing patients with HF. As a result, clinicians and patients can individualize the optimal treatment strategy and resources on the basis of the suspected prognosis.

PurposeBreast tumors from young women under the age of 40 account for approximately 7% of cases and have a poor prognosis independent of established prognostic factors. We evaluated the patient population served by the Military Health System, where a disproportionate number of breast cancer cases in young women are seen and treated in a single universal coverage healthcare system.MethodsThe Military Health System Repository and the DoD Central Registration databases were used to identify female breast cancer patients diagnosed or treated at military treatment facilities from 1998 to 2007.Results10,066 women were diagnosed with invasive breast cancer at DoD facilities from 1998 to 2007, of which 11.3% (1139), 23.4% (2355) and 65.2% (6572) were < 40, 40–49 and > 50 years old (yo), respectively, at diagnosis. 53% in the < 40 yo cohort were white, 25% were African American (AA) and 8% were Hispanic, with 14% undisclosed. Breast cancer in women diagnosed < 40 yo was more high grade (p < 0.0001), Stage II (p < 0.0001) and ER negative (p < 0.0001). There was a higher rate of bilateral mastectomies among the women < 40 compared to those 40–49 and > 50 (18.4% vs. 9.1% and 5.0%, respectively). Independent of disease stage, chemotherapy was given more frequently to < 40 yo (90.43%) and 40–49 yo (81.44%) than ≥ 50 yo (53.71%). The 10-year overall survival of younger women was similar to the ≥ 50 yo cohort. Outcomes in the African American and Hispanic subpopulations were comparable to the overall cohort.ConclusionYounger women had a similar overall survival rate to older women despite receiving more aggressive treatment.

Civilian suicide rates vary by occupation in ways related to occupational stress exposure. Comparable military research finds suicide rates elevated in combat arms occupations. However, no research has evaluated variation in this pattern by deployment history, the indicator of occupation stress widely considered responsible for the recent rise in the military suicide rate. The joint associations of Army occupation and deployment history in predicting suicides were analysed in an administrative dataset for the 729 337 male enlisted Regular Army soldiers in the US Army between 2004 and 2009. There were 496 suicides over the study period (22.4/100 000 person-years). Only two occupational categories, both in combat arms, had significantly elevated suicide rates: infantrymen (37.2/100 000 person-years) and combat engineers (38.2/100 000 person-years). However, the suicide rates in these two categories were significantly lower when currently deployed (30.6/100 000 person-years) than never deployed or previously deployed (41.2-39.1/100 000 person-years), whereas the suicide rate of other soldiers was significantly higher when currently deployed and previously deployed (20.2-22.4/100 000 person-years) than never deployed (14.5/100 000 person-years), resulting in the adjusted suicide rate of infantrymen and combat engineers being most elevated when never deployed [odds ratio (OR) 2.9, 95% confidence interval (CI) 2.1-4.1], less so when previously deployed (OR 1.6, 95% CI 1.1-2.1), and not at all when currently deployed (OR 1.2, 95% CI 0.8-1.8). Adjustment for a differential 'healthy warrior effect' cannot explain this variation in the relative suicide rates of never-deployed infantrymen and combat engineers by deployment status. Efforts are needed to elucidate the causal mechanisms underlying this interaction to guide preventive interventions for soldiers at high suicide risk.

The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) has found that the proportional elevation in the US Army enlisted soldier suicide rate during deployment (compared with the never-deployed or previously deployed) is significantly higher among women than men, raising the possibility of gender differences in the adverse psychological effects of deployment. Person-month survival models based on a consolidated administrative database for active duty enlisted Regular Army soldiers in 2004-2009 (n = 975,057) were used to characterize the gender × deployment interaction predicting suicide. Four explanatory hypotheses were explored involving the proportion of females in each soldier's occupation, the proportion of same-gender soldiers in each soldier's unit, whether the soldier reported sexual assault victimization in the previous 12 months, and the soldier's pre-deployment history of treated mental/behavioral disorders. The suicide rate of currently deployed women (14.0/100,000 person-years) was 3.1-3.5 times the rates of other (i.e. never-deployed/previously deployed) women. The suicide rate of currently deployed men (22.6/100,000 person-years) was 0.9-1.2 times the rates of other men. The adjusted (for time trends, sociodemographics, and Army career variables) female:male odds ratio comparing the suicide rates of currently deployed v. other women v. men was 2.8 (95% confidence interval 1.1-6.8), became 2.4 after excluding soldiers with Direct Combat Arms occupations, and remained elevated (in the range 1.9-2.8) after adjusting for the hypothesized explanatory variables. These results are valuable in excluding otherwise plausible hypotheses for the elevated suicide rate of deployed women and point to the importance of expanding future research on the psychological challenges of deployment for women.

Use of treatment for breast cancer is dependent on the patient's cancer characteristics and willingness to undergo treatment and provider treatment recommendations. Receipt of breast cancer treatment varies by insurance status and type. It is not clear whether different benefit types and care sources differ in breast cancer treatment and outcomes among Department of Defense beneficiaries. The objectives of this study are to assess whether receipt of breast cancer treatment varied by benefit type (TRICARE Prime vs non-Prime) or care source (direct care, purchased care, and both) and to examine whether survival and recurrence differed by benefit type and/or care source among female Department of Defense beneficiaries with the disease. Study subjects were women aged 40-64 yr, diagnosed with malignant breast cancer between 2003 and 2007. Multivariable logistic regression analyses were conducted to assess the likelihood of receiving treatment by benefit type or care source. Multivariable Cox proportional hazard models were used to investigate differences in survival and recurrence by benefit type or care source. A total of 2,668 women were included in this study. Those with Prime were more likely to have chemotherapy, radiation, hormone therapy, breast-conserving surgery, surveillance mammography, and recurrence than women with non-Prime. Survival was high, with 94.86% of those with Prime and 92.58% with non-Prime alive at the end of the study period. Women aged 50-59 yr with non-Prime benefit type had better survival than women with Prime of the same age. No survival differences were seen by care source. In regard to recurrence, women aged 60-64 yr with TRICARE Prime were more likely to have recurrent breast cancer than women with non-Prime. Additionally, women aged 50-59 yr who used purchased care were less likely to have a recurrence than women who used direct care only. To our knowledge, this is the first study to examine breast cancer treatment and survival by care source and benefit type in the Military Health System. In this equal access health care system, no differences in treatment, except mastectomy, by benefit type, were observed. There were no overall differences in survival, although patients with non-Prime tended to have better survival in the age group of 50-59 yr. In regard to care source, women who utilized mostly purchased care or utilized both direct and purchased care were more likely to receive certain types of treatment, such as chemotherapy and radiation, as compared with women who used direct care only. However, survival did not differ between different care sources. Future research is warranted to further investigate variations in breast cancer treatment and its survival gains by benefit type and care source among Department of Defense beneficiaries.

It is widely recognized that military populations regularly use a wide variety of dietary supplements (DS) ranging from those marketed for better health and joint health to weight-loss and performance-enhancing supplements.1 Based on the 2015 Department of Defense (DoD) Survey of Health-Related Behaviors, 32.0% of service members report using at least one DS daily, and 13.0% of males report using body-building supplements each day. Women use body-building supplements less frequently (5.4% daily) but are more likely to use weightloss supplements daily (8.6%) than men (6.3%). Military personnel typically take more DS than other populations and gravitate toward products marketed to enhance physical performance, to include stimulants, protein and amino acid supplements, and combination products.1,2 If all DS were safe, this topic would not be an issue, but not all are. DoD now relies on Operation Supplement Safety (available at OPSS.org) as the \"go-to\" resource for DS education and related content.

As we transition to an interwar period, combat-related injuries are at their lowest levels in over a decade, yet we must continue to maintain our surgical skills and train new surgeons. During the recent wars, the importance of the treatment and care for amputations and complex extremity injuries became apparent. This study compares the number of these procedures performed during the treatment of civilian and military orthopaedic trauma patients at a Department of Defense Level I trauma center over the past 9 years. The need to evaluate this unique system is further highlighted by the recent recommendation from the National Academies of Sciences, Engineering, and Medicine's to combine civilian and military trauma systems. Data derived through a retrospective review of electronic health records were charted and evaluated for statistically unique periods. There were significant fluctuations in the number of procedures performed within the military cohort, with peaks centered around 2007 and 2011-2012, whereas the number of civilian cases remained relatively steady. On average, the civilian cohort also produced a more consistent and greater number of tibia fractures than the military cohort. For the past 3 years, the civilian cohort has produced 22 more tibia fractures per quarter than the military cohort. Furthermore, although type III open tibia fractures were the most common classification within the military cohort, the civilian cohort provided comparable numbers of type III open fractures despite only being the second most common fracture classification in the civilian cohort. In fact, the civilian volume outpaced the military cohort the past 3 years in this metric. More importantly, the military cohort produced 6 type III fractures in 2013, and 3 in 2014, whereas the civilian cohort produced 14 and 25, respectively, during those years. Fluctuations in the military cohort's data mirrors surges in operational activity, whereas the civilian cohort demonstrates a higher and more predictable number of tibia fractures; with reliability and numbers being important factors in training new surgeons and maintaining surgical skills. Although this study focused on specific orthopaedic trauma cases deemed essential to combat casualty care, it highlights the universal reality facing U.S. Military Medicine: as combat trauma continues to decline, military medicine as a whole will have to look elsewhere for critical trauma experience. This study confirmed military case volumes fluctuate with operational demands and evaluated one method of supplementing the declining combat trauma volumes with a local civilian trauma mission. This indicates not only the need for a system that is able to quickly adapt to the increased patient load, but also depicts how little reliability there is within the system in terms of perpetuating physician experience when the civilian trauma mission is not considered.

Tobacco use is a major concern to the Military Health System of the Department of Defense (DoD). The 2011 DoD Health Related Behavior Survey reported that 24.5% of active duty personnel are current smokers, which is higher than the national estimate of 20.6% for the civilian population. Overall, it is estimated that tobacco use costs the DoD $1.6 billion a year through related medical care, increased hospitalization, and lost days of work, among others. This study evaluated future health outcomes of Tricare Prime beneficiaries aged 18-64 yr (N = 3.2 million, including active duty and retired military members and their dependents) and the potential economic impact of initiatives that DoD may take to further its effort to transform the military into a tobacco-free environment. Our analysis simulated the future smoking status, risk of developing 25 smoking-related diseases, and associated medical costs for each individual using a Markov Chain Monte Carlo microsimulation model. Data sources included Tricare administrative data, national data such as Centers for Disease Control and Prevention mortality data and National Cancer Institute's cancer registry data, as well as relative risks of diseases obtained from a literature review. We found that the prevalence of active smoking among the Tricare Prime population will decrease from about 24% in 2015 to 18% in 2020 under a status quo scenario. However, if a comprehensive tobacco control initiative that includes a 5% price increase, a tighter clean air policy, and an intensified media campaign were to be implemented between 2016 and 2020, the prevalence of smoking could further decrease to 16%. The near 2 percentage points reduction in smoking prevalence represents an additional 81,240 quitters and translates to a total lifetime medical cost savings (in 2016 present value) of $968 million, with 39% ($382 million) attributable to Tricare savings. A comprehensive tobacco control policy within the DoD could significantly decrease the prevalence and lifetime medical cost of tobacco use. If the smoking prevalence among Prime beneficiaries could reach the Healthy People 2020 goal of 12%, through additional measures, the lifetime savings could mount to $2.08 billion. To achieve future savings, DoD needs to pay close attention to program design and implementation issues of any additional tobacco control initiatives.