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Objective The aim of the study is to evaluate the prevalence and factors associated with opioid prescriptions to postpartum patients among TRICARE beneficiaries receiving care in the civilian health care system versus a military health care facility. Study Design We evaluated postpartum opioid prescriptions filled at discharge among patients insured by TRICARE Prime/Prime Plus using the Military Health System Data Repository between fiscal years 2010 to 2015. We included women aged 15 to 49 years old and excluded abortive pregnancy outcomes and incomplete datasets. The primary outcome investigated mode of delivery and demographics for those filling an opioid prescription. Secondary outcomes compared prevalence of filled opioid prescription at discharge for postpartum patients within civilian care and military care. Results Of a total of 508,258 postpartum beneficiaries, those in civilian health care were more likely to fill a discharge opioid prescription compared with those in military health care (OR 3.9, 95% CI 3.8–3.99). Cesarean deliveries occurred less frequently in military care (26%) compared with civilian care (30%), and forceps deliveries occurred more frequently in military care (1.38%) compared with civilian care (0.75%). Women identified as Asian race were least likely to fill an opioid prescription postpartum (OR 0.79, 95% CI 0.75–0.83). Women aged 15 to 19 years had a lower odds of filling an opioid prescription (OR 0.83, 95% CI 0.80–0.86). Women associated with a senior officer rank were less likely to fill an opioid prescription postpartum (OR 0.83, 95% CI 0.73–0.91), while those associated with warrant officer rank were more likely to fill an opioid prescription (OR 1.14, 95% CI 1.06–1.23). Conclusion Our data indicates that women who received care in civilian facilities were more likely to fill an opioid prescription at discharge when compared with military facilities. Factors such as race and age were associated with opioid prescription at discharge. This study highlights areas for improvement for potential further studies. Key Points Opioid prescription patterns for postpartum women may vary across the country. Our study indicates postpartum patients in civilian care are more likely to fill opioids postpartum. This study highlights a population which may have an improved opioid prescribing pattern. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: Performance-based budgeting (PBB) is a variation of pay for performance that has been used in government hospitals but could be applicable to any integrated system. It works by increasing or decreasing funding based on preestablished performance thresholds, which incentivizes organizations to improve performance. In late 2006, the U.S. Army implemented a PBB program that tied hospital-level funding decisions to performance on key cost and quality-related metrics. Purpose: The aim of this study was to estimate the impact of PBB on quality improvement in U.S. Army health care facilities. Approach: This study used a retrospective difference-in-differences analysis of data from two Defense Health Agency data repositories. The merged data set encompassed administrative, demographic, and performance information about 428 military health care facilities. Facility-level performance data on quality indicators were compared between 187 Army PBB facilities and a comparison group of 241 non-PBB Navy and Air Force facilities before and after program implementation. Results: The Army's PBB programs had a positive impact on quality performance. Relative to comparison facilities, facilities that participated in PBB programs increased performance for over half of the indicators under investigation. Furthermore, performance was either sustained or continued to improve over 5 years for five of the six performance indicators examined long term. Conclusion: Study findings indicate that PBB may be an effective policy mechanism for improving facility-level performance on quality indicators. Practice Implications: This study adds to the extant literature on pay for performance by examining the specific case of PBB. It demonstrates that quality performance can be influenced internally through centralized budgeting processes. Though specific to military hospitals, the findings might have applicability to other public and private sector hospitals who wish to incentivize performance internally in their organizational subunits through centralized budgeting processes. [ABSTRACT FROM AUTHOR]

Rationale, Aims and Objectives: Emergency department (ED) clinicians account for approximately 13% of all opioid prescriptions to opioid‐naïve patients and variability in the rates of prescribing have been noted among individual clinicians and different EDs. This study elucidates the amount of variability within a unified health system (the U.S. Military Health System [MHS]) with the expectation that understanding the sources of variability will enable health system leaders to improve the quality of decision making. Methods: The design was a retrospective cohort study examining variation in opioid prescribing within EDs of the US MHS. Participants were Army soldiers who returned from a deployment and received care between October 2009 and September 2016. The exposure was ED encounters at a military treatment facility. Key measures were the proportion of ED encounters with an opioid prescription fill; total opioid dose of the fill (morphine milligram equivalent, MME); and total opioid days‐supply of the fill. Results: The mean proportion of ED encounters with an opioid fill across providers was 19.7% (SD 8.8%), median proportion was 18.6%, and the distribution was close to symmetric with the 75th percentile provider prescribing opioids in 24.6% of their ED encounters and the 25th percentile provider prescribing in 13.4% of their encounters. The provider‐level mean opioid dose per encounter was 113.1 MME (SD 56.0) with the 75th percentile (130.1) 50% higher than the 25th percentile (87.4). The mean opioid supply per encounter was 6.8 days (SD 3.9) with more than a twofold ratio between the 75th percentile (8.3) and the 25th (4.1). Using a series of multilevel regression models to examine opioid fills associated with ED encounters and their dose levels, the variation among providers within facilities was much larger in magnitude than the variation among facilities. Conclusion: Among ED encounters of Army soldiers at military treatment facilities, there was substantial variation among providers in prescribing opioid prescriptions that were not explained by patient case‐mix. These results suggest that programmes and protocols to address less than optimal prescribing in the ED should be initiated to improve the quality of care. [ABSTRACT FROM AUTHOR]

Background: The Centers for Disease Control and Prevention (CDC) cite an increase of 200% in severe maternal morbidity (SMM) in the United States from 1993 to 2014. This study aims to identify the incidence of SMM in the Military Health System (MHS), along with factors that may be correlated with the risk of SMM and 30-day readmissions among universally insured, ethnically diverse women who delivered in military treatment facilities (MTFs). Methods: Using the MHS Data Repository, we conducted a cross-sectional study on all women 15 to 54 years of age who delivered at a MTF during fiscal years 2016 to 2018. Using the CDC's list of 21 indicators and corresponding International Classification of Diseases diagnostic and procedure codes, 10th revision (ICD-10) for SMM, hospitalizations with SMM were identified within our selected group at the time of the delivery, as well as the prevalence of overall 30-day maternal readmissions. Multivariable logistic regressions were conducted to determine the likelihood of SMM and 30-day readmissions, with patient demographics at each delivery as predictor variables. Results: Of the total deliveries, 2.58% had maternal readmissions within 30 days and 0.59% had SMM identified. Women 35–39 years of age and ages 40+ had significantly higher odds of SMM during delivery when compared with women 25–29 years of age. Black women were 1.39 times more likely than White women to be diagnosed with SMM during their delivery admission. Black women also had significantly greater odds of a 30-day postpartum readmission when compared with White women. Conclusions: The low rate of SMM in this population, compared with national data, is a significant finding. The overall 30-day readmission rate in this population is also lower than what has been reported in prior studies. In this study population, women 30–34 are also at higher risk for readmission, which is an area for further study to assess for potential risk factors and underlying causes that may be impacting the higher rates in this age group. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

The purpose of this study is to identify the socioeconomic and demographic characteristics of women cared for by Certified Nurse-Midwives (CNMs) versus physicians in the Military Health System (MHS) and compare birth outcomes between provider types. The MHS is one of America's largest and most complex health care systems. Using the Military Health System Data Repository, this retrospective study examined TRICARE beneficiaries who gave birth during 2012–2014. Analysis included frequency of patients by perinatal services, descriptive statistics, and logistic regression analysis by provider type. To account for differences in patient and pregnancy risk, odds ratios were calculated for both high-risk and general risk population. There were 136,848 births from 2012 to 2014, and 30.8% were delivered by CNMs. Low-risk women whose births were attended by CNMs had lower odds of a cesarean birth, induction /augmentation of labor, complications of birth, postpartum hemorrhage, endometritis, and preterm birth and higher odds of a vaginal birth, vaginal birth after cesarean, and breastfeeding than women whose births were attended by physicians. These results have implications for the composition of the women's health workforce. In the MHS, where CNMs work to the fullest scope of their authority, CNMs attended almost 4 times more births than our national average. An example to other U.S. systems and high-income countries, this study adds to the growing body of evidence demonstrating that when CNMs practice to the fullest extent of their education, they provide quality health outcomes to more women. [ABSTRACT FROM AUTHOR]

Burnout is a personal and occupational phenomenon that has been associated with negative physical and psychological outcomes in medical staff. Additionally, there are implications for healthcare organizations, as those staff who are burned out are more likely to have lower productivity or leave the organization. As with the Covid-19 pandemic, future national emergencies and potentially large-scale conflicts will require similar and likely even larger scale responses from the U.S. Military Health System, thus it is important to understand burnout in this population so that the readiness of the staff and the military can remain at a high level. This assessment was designed to examine levels of burnout among United States Military Health System (MHS) staff working at Army installations and the factors that influence the development of burnout. Anonymous data was collected from 13,558 active-duty U.S. Soldiers and civilian MHS employees. Burnout was measured using the Copenhagen Burnout Inventory and the Mini-Z. Results showed nearly half of staff who responded (48%) reported being burned out, an increase since last measured in 2019 (31%). Factors related to increased burnout included concerns about work/life balance and workload, low job satisfaction and feeling disconnected from others. Burnout was associated with increases in adverse physical and behavioral health (BH) outcomes. Results indicate that burnout is a common problem across MHS Army staff and is related to significant adverse health consequences for the individual and reduced retention of staff for the organization. These findings highlight the need to address burnout through policies that standardize health care delivery policies and practices, providing support to leadership to promote a healthy workplace, and individual support to those who experience burnout. • Rates of burnout in U.S. military healthcare staff rose significantly since 2019. • Burnout in U.S. military healthcare staff was associated with poor health outcomes. • Burnout may reduce retention of staff in the U.S. Military Health System. [ABSTRACT FROM AUTHOR]

This retrospective cohort study examined the Uniformed Services University of the Health Sciences Registered Nurse Anesthesia program to identify reasons for high attrition rates. Relevant data were examined for 180 students enrolled in classes from 2005 through 2011. During that period, 40 students were dismissed or disenrolled, with the highest attrition rate (35%) occurring in the class of 2010. Evidence from this investigation indicates students who completed the program were younger, earned higher grade point averages while completing their undergraduate bachelor of science in nursing, and achieved higher analytic and total Graduate Record Examination scores than did students who withdrew or were dismissed. Gender differences were noted, as a greater proportion of women completed the program compared with men. Personal, family, and other issues frequently overlapped, with academic performance problems leading to attrition. Based on these findings, a number of important changes were made in the admission process to the USUHS RNA program and in the nonaca-demic mentoring and assistance offered to students. [ABSTRACT FROM AUTHOR]