Graduate Medical Education in the Military Health System: Strategic Analysis and Options.

INTRODUCTION: At the request of then-Assistant Secretary of Defense for Health Affairs, Dr. Jonathan Woodson, Defense Health Horizons (DHH) examined options for shaping Graduate Medical Education (GME) in the Military Health System (MHS) in order to achieve the goals of a medically ready force and a ready medical force. MATERIALS AND METHODS: The DHH interviewed service GME directors, key designated institutional officials, and subject-matter experts on GME in the military and civilian health care systems. RESULTS: This report proposes numerous short- and long-term courses of action in three areas:1. Balancing the allocation of GME resources to suit the needs of active duty and garrisoned troops. We recommend developing a clear, tri-service mission and vision for GME in the MHS and expanding collaborations with outside institutions in order to prepare an optimal mix of physicians and ensure that trainees meet requirements for clinical experience.2. Improving the recruitment and tracking of GME students, as well as the management of accessions. We recommend several measures to improve the quality of incoming students, to track the performance of students and medical schools, and to foster a tri-service approach to accessions.3. Aligning MHS with the tenets of the Clinical Learning Environment Review to advance a culture of safety and to help the MHS become a high reliability organization (HRO). We recommend several actions to strengthen patient care and residency training and to develop a systematic approach to MHS management and leadership. CONCLUSION: Graduate Medical Education (GME) is vital to produce the future physician workforce and medical leadership of the MHS. It also provides the MHS with clinically skilled manpower. Graduate Medical Education (GME) research sows the seeds for future discoveries to improve combat casualty care and other priority objectives of the MHS. Although readiness is the MHS's top mission, GME is also vital to meeting the other three components of the quadruple aim (better health, better care, and lower costs). Properly managed and adequately resourced GME can accelerate the transformation of the MHS into an HRO. Based on our analysis, DHH believes that there are numerous opportunities for MHS leadership to strengthen GME so it is more integrated, jointly coordinated, efficient, and productive. All physicians emerging from military GME should understand and embrace team-based practice, patient safety, and a systems-oriented focus. This will ensure that those we prepare to be the military physicians of the future are prepared to meet the needs of the line, to protect the health and safety of deployed warfighters, and to provide expert and compassionate care to garrisoned service members, families, and military retirees.

Evaluating the Implementation of the Re-Engineering Systems of Primary Care Treatment in the Military (RESPECT-Mil).

A RAND team conducted an independent implementation evaluation of the Re-Engineering Systems of Primary Care Treatment in the Military (RESPECT-Mil) Program, a system of care designed to screen, assess, and treat posttraumatic stress disorder and depression among active duty service members in the Army's primary care settings. Evaluating the Implementation of the Re-Engineering Systems of Primary Care Treatment in the Military (RESPECT-Mil) presents the results from RAND's assessment of the implementation of RESPECT-Mil in military treatment facilities and makes recommendations to improve the delivery of mental health care in these settings. Analyses were based on existing program data used to monitor fidelity to RESPECT-Mil across the Army's primary care clinics, as well as discussions with key stakeholders. During the time of the evaluation, efforts were under way to implement the Patient Centered Medical Home, and uncertainties remained about the implications for the RESPECT-Mil program. Consideration of this transition was made in designing the evaluation and applying its findings more broadly to the implementation of collaborative care within military primary care settings.

The relationship between protective factors and outcomes for children exposed to violence.

To develop prevention and intervention programs for children exposed to violence, it is necessary to understand what factors might help alleviate the negative effects of violence exposure. In this study, we sought to test whether relationships exist between certain protective factors and subsequent adjustment and to examine whether violence re-exposure contributed to changes in outcomes over time. The analyses revealed that caregiver reports of both child self-control and the quality of the parent-child relationship were related to changes in child posttraumatic stress disorder (PTSD) symptoms and behavior problems. Furthermore, children experiencing more categories of violence re-exposure had increased behavior problems at follow-up compared to those without re-exposure. These findings advance our understanding of the relationship between these protective factors and outcomes for children exposed to violence and suggest that intervening to bolster these protective factors could improve outcomes.

How much does "how much" matter? Assessing the relationship between children's lifetime exposure to violence and trauma symptoms, behavior problems, and parenting stress.

The study explores whether and how lifetime violence exposure is related to a set of negative symptoms: child internalizing and externalizing behavior problems, child trauma symptoms, and parenting stress. Using a large sample of violence-exposed children recruited to participate in intervention research, the study employs different methods of measuring that exposure. These include total frequency of all lifetime exposure, total frequency of lifetime exposure by broad category (i.e., assault, maltreatment, sexual abuse, and witnessing violence), and polyvictimization defined as exposure to multiple violence categories. The results indicate that only polyvictimization, constructed as a dichotomous variable indicating two or more categories of lifetime exposure, emerged as a consistent predictor of negative symptoms. The total lifetime frequency of all violence exposure was not associated with negative symptoms, after controlling for the influence of polyvictimization. Likewise, in the presence of a dichotomous polyvictimization indicator the total lifetime frequency of exposure to a particular violence category was unrelated to symptoms overall, with the exception of trauma symptoms and experiences of sexual abuse. Taken together, these findings suggest that total lifetime exposure is not particularly important to negative symptoms, nor is any particular category of exposure after controlling for polyvictimization, with the single exception of sexual abuse and trauma symptoms. Instead, it is the mix of exposure experiences that predict negative impacts on children in this sample. Further research is needed to continue to explore and test these issues.

Feasibility of web-based self-triage by parents of children with influenza-like illness: a cautionary tale.

IMPORTANCE: Self-triage using web-based decision support could be a useful way to encourage appropriate care-seeking behavior and reduce health system surge in epidemics. However, the feasibility and safety of this strategy have not previously been evaluated. OBJECTIVE: To assess the usability and safety of Strategy for Off-site Rapid Triage (SORT) for Kids, a web-based decision support tool designed to translate clinical guidance developed by the Centers for Disease Control and Prevention to help parents and adult caregivers determine if a child with influenza-like illness requires immediate care in an emergency department (ED). DESIGN: Prospective pilot validation study conducted between February 8 and April 30, 2012. Staff who abstracted medical records and made follow-up calls were blinded to the SORT algorithm's assessment of the child's level of risk. SETTING: Two pediatric emergency departments in the National Capital Region. PARTICIPANTS: Convenience sample of 294 parents and adult caregivers who were at least 18 years of age; able to read and speak English; and the parent or legal guardian of a child 18 years or younger presenting to 1 of 2 EDs with signs and symptoms meeting Centers for Disease Control and Prevention criteria for influenza-like illness. INTERVENTION: Completion of the SORT for Kids survey. MAIN OUTCOME MEASURES: Caregiver ratings of the website's usability and the sensitivity of the underlying algorithm for identifying children who required immediate ED management of influenza-like illness, defined as receipt of 1 or more of 5 essential clinical services. RESULTS: Ninety percent of participants reported that the website was "very easy" to understand and use. Ratings did not differ by respondent race, ethnicity, or educational attainment. Of the 15 patients whose initial ED visit met explicit criteria for clinical necessity, the Centers for Disease Control and Prevention algorithm classified 14 as high risk, resulting in an overall sensitivity of 93.3% (exact 95% CI, 68.1%-99.8%). Specificity of the algorithm was poor. CONCLUSIONS AND RELEVANCE: This pilot study suggests that web-based decision support to help parents and adult caregivers self-triage children with influenza-like illness is feasible. However, prospective refinement of the clinical algorithm is needed to improve its specificity without compromising patient safety.

Monitoring Cancer Outcomes Across the Continuum: Data Synthesis and Analysis for the District of Columbia.

This article synthesizes and analyzes available data regarding cancer-related outcomes among District of Columbia residents, highlighting key findings and data gaps across the continuum of cancer prevention, treatment, and outcomes and noting variability across subgroups of District residents. Data sources used in this report include the Behavioral Risk Factor Surveillance System, the National Cancer Database, the Centers for Disease Control and Prevention and National Cancer Institute Wide-Ranging Online Data for Epidemiologic Research database, and the American Community Survey. The findings reveal disparities in cancer-related outcomes between black and white District residents across the continuum. First, black District residents are more likely than white residents to be uninsured. Lack of insurance is associated with lower rates of routine cancer screening among asymptomatic patients and may delay care for patients experiencing early symptoms of cancer. In addition, the rate of smoking is significantly higher, and the rate of exercise is significantly lower, among black District residents than among white residents, placing black residents at higher risk of the most common cancers. Limitations in general access to health care, in primary and secondary prevention, and in access to cancer-related treatment all likely contribute to dramatically higher cancer incidence and mortality among black residents of the District than among white residents.

Military Caregivers: Cornerstones of Support for Our Nation's Wounded, Ill, and Injured Veterans.

Military caregivers are an essential part of our nation's ability to care for returning wounded warriors. Far too often, their own needs are neglected. The RAND Corporation and the Elizabeth Dole Foundation collaborated on a first, exploratory phase of a larger research effort regarding this demographic and its needs. The research explores what is known about the number and characteristics of military caregivers, describes the roles and functions they perform, and highlights the effect of caregiving on their own well-being. Most existing literature on family caregivers is heavily focused on an older population caring for persons with chronic conditions or dementia. By comparison, research on military caregivers is scant, and there are notable differences that make this population unique: Military caregivers are spouses with young children, parents with full- and part-time jobs, and sometimes even young children helping shoulder some of the burden. Government services available to this population are in their infancy; community service organizations offer diverse services but they are generally uncoordinated. This article lays the groundwork to inform policy and program development relative to the unique needs of military caregivers.

An examination of measures related to children's exposure to violence for use by both practitioners and researchers.

Millions of children each year are exposed to violence in their homes, schools, and communities as both witnesses and victims. As a result, evidence-based programs for children and adolescents who have been exposed to traumatic events (CEV-EBPs) have been widely disseminated but rarely evaluated in their real-world applications. One crucial aspect of conducting such evaluations is finding appropriate measures that can be of use both to the practitioner and to the researcher. This review aims to provide guidance to the field by first identifying any gaps in the availability of psychometrically tested measures for certain outcome domains and age ranges and then recommending the measures that are most appropriate for use by both researchers and practitioners. Interviews with content experts in the measurement of trauma symptoms and parent-child relationships were conducted to identify the key outcome domains for measurement that are critical to the evaluation of CEV-EBPs and the criteria for dual-use measures, defined as measures that are useful to both researchers and practitioners. A database of 46 relevant measures was created by compiling measures from existing repositories and conducting a focused literature review. Our review of these measures found that existing repositories had few measures of depression, a major gap that should be addressed. Further, there were few measures for young children ages 0-3 years (n = 15) and only a handful of measures (n = 9) had both a child and parent version of the measure. Overall, although the different repositories that currently exist are helpful, researchers and practitioners would benefit from having a single reputable source (e.g., a centralized repository or item bank) to access when searching for measures to use in evaluating CEV-EBPs. Such a tool would hold promising to narrow the current gap between research and practice in the field of children's exposure to violence.

National Evaluation of Safe Start Promising Approaches.

Safe Start Promising Approaches (SSPA) is the second phase of a community-based initiative focused on developing and fielding interventions to prevent and reduce the impact of children's exposure to violence (CEV). This article shares the results of SSPA, which was intended to implement and evaluate promising and evidence-based programs in community settings. Fifteen program sites across the country were selected to implement a range of interventions for helping children and families cope with the effects of CEV. The settings, populations served, intervention types, types of violence addressed, community partners, and program goals differed across the 15 sites.