Military Medicine's Value to US Health Care and Public Health: Bringing Battlefield Lessons Home.

Importance: Military medicine in the US was established to treat wounded and ill service members and to protect the health and well-being of our military forces at home and abroad. To accomplish these tasks, it has developed the capacity to rapidly adapt to the changing nature of war and emerging health threats; throughout our nation's history, innovations developed by military health professionals have been quickly adopted by civilian medicine and public health for the benefit of patients in the US and around the world. Observations: From the historical record and published studies, we cite notable examples of how military medicine has advanced civilian health care and public health. We also describe how military medicine research and development differs from that done in the civilian world. During the conflicts in Afghanistan and Iraq, military medicine's focused approach to performance improvement and requirements-driven research cut the case fatality rate from severe battlefield wounds in half, to the lowest level in the history of warfare. Conclusions and Relevance: Although innovations developed by military medicine regularly inform and improve civilian health care and public health, the architects of these advances and the methods they use are often overlooked. Enhanced communication and cooperation between our nation's military and civilian health systems would promote reciprocal learning, accelerate collaborative research, and strengthen our nation's capacity to meet a growing array of health and geopolitical threats.

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.

A Primer on the Military Health System's Approach to Medical Research and Development.

The Military Health System (MHS) has a medical research program aimed at a wide range of health-, disease-, and injury-related topic areas that works with civilian academic institutions and the biomedical industry to accomplish its goals. There are many opportunities for civilian academic institutions and the biomedical industry to engage with this program, but its unique features are important to understand to optimize the chances for successful partnerships. Unlike the National Institutes of Health, which uses an "investigator-initiated" approach, the Department of Defense (DoD) aligns its funding with specific needs, also referred to as requirements; thus, DoD research is often described as "requirements-driven" research. At the highest level, requirements are aligned with the National Security Strategy and National Defense Strategy, though requirements documents list specific areas in medicine with unmet needs. Military labs and the Uniformed Services University of the Health Sciences, which can also receive DoD appropriations to conduct medical research, serve as hubs that interface with civilian academic institutions and the biomedical industry and organize and track the overall progress of DoD investments. As a mechanism to propel findings from "bench to bedside," the military budgets funds for the various phases of research and development for a given topic area. Research programs are most effective when they are integrated into the MHS learning health system, which allows MHS clinical communities to inform and track research investments and evaluate the utility of research products in real clinical practice settings. This Perspective provides introductory information and a basic framework for those interested in performing DoD-funded medical research or collaborating with researchers in military labs. It is hoped that as academic institutions and the biomedical industry look to increase efficiency in medical research, they will find ways to engage with DoD research opportunities and consider elements of the military's approach useful.

Post-Mortem Evaluation of Potentially Survivable Hemorrhagic Death in a Civilian Population.

BACKGROUND: Although the survivability of military extremity hemorrhage is well documented, equivalent civilian data are limited. We analyzed statewide autopsy records in Maryland to determine the number of hemorrhagic deaths that might have been potentially survivable with prompt hemorrhage control. Similar analyses of battlefield deaths led to life-saving changes in military medical practice. STUDY DESIGN: This is a retrospective study of decedent records. The objective is to estimate the number of hemorrhagic deaths that might have been prevented by prompt placement of an extremity tourniquet. Maryland autopsy records from 2002 to 2016 were selected using the following search terms: amputation, arm/arms, avulsion, exsanguination, extremity/extremities, leg/legs. The records were analyzed by applying a checklist of previously developed military criteria to characterize deaths as potentially survivable or nonsurvivable with prompt use of a tourniquet. Suicides and decedents less than 18 years old were excluded. The study did not use information about living participants. Two expert reviewers independently evaluated and scored the death records. Deaths were classified as either potentially survivable or nonsurvivable. A third reviewer broke any ties. RESULTS: There were 288 full autopsy records included in the final analysis. Of the eligible decedents reviewed during the 14-year period, 124 of 288 had potentially survivable wounds; 164 had nonsurvivable wounds. CONCLUSIONS: Over the 14-year study interval, 124 Maryland decedents-an average of 9 per year-might have been saved with prompt placement of a tourniquet. If extrapolated, approximately 480 people in the US might be saved per year. These results provide evidence to support educating and equipping the public to provide bleeding control.

Brief, Web-based Education Improves Lay Rescuer Application of a Tourniquet to Control Life-threatening Bleeding.

OBJECTIVE: The objective was to determine whether brief, Web-based instruction several weeks prior to tourniquet application improves layperson success compared to utilizing just-in-time (JiT) instructions alone. BACKGROUND: Stop the Bleed is a campaign to educate laypeople to stop life-threatening hemorrhage. It is based on U.S. military experience with lifesaving tourniquet use. While previous research shows simple JiT instructions boost laypeople's success with tourniquet application, the optimal approach to educate the public is not yet known. METHODS: This is a prospective, nonblinded, randomized study. Layperson participants from the Washington, DC, area were randomized into: 1) an experimental group that received preexposure education using a website and 2) a control group that did not receive preexposure education. Both groups received JiT instructions. The primary outcome was the proportion of subjects that successfully applied a tourniquet to a simulated amputation. Secondary outcomes included mean time to application, mean placement position, ability to distinguish bleeding requiring a tourniquet from bleeding requiring direct pressure only, and self-reported comfort and willingness to apply a tourniquet. RESULTS: Participants in the preexposure group applied tourniquets successfully 75% of the time compared to 50% success for participants with JiT alone (p < 0.05, risk ratio = 1.48, 95% confidence interval = 1.21-1.82). Participants place tourniquets in a timely fashion, are willing to use them, and can recognize wounds requiring tourniquets. CONCLUSIONS: Brief, Web-based training, combined with JiT education, may help as many as 75% of laypeople properly apply a tourniquet. These findings suggest that this approach may help teach the public to Stop the Bleed.

Borrow or Serve? An Economic Analysis of Options for Financing a Medical School Education.

PURPOSE: To understand the long-term economic implications of key pathways for financing a medical school education. METHOD: The authors calculated the net present value (NPV) of cash flow over a 30-year career for a 2013 matriculant associated with (1) self-financing, (2) federally guaranteed loans, (3) the Public Service Loan Forgiveness program, (4) the National Health Service Corps, (5) the Armed Forces Health Professions Scholarship Program, and (6) matriculation at the Uniformed Services University of the Health Sciences. They calculated the NPV for students pursuing one of four specialties in two cities with divergent tax policies. Borrowers were assumed to have a median level of debt ($180,000), and conservative projections of inflation, discount rates, and income growth were employed. Sensitivity analyses examined different discount and income growth rates, alternative repayment strategies, and various lengths of public-sector service by scholarship recipients. RESULTS: For those wealthy enough to pay cash or fortunate enough to secure a no-strings scholarship, self-financing produced the highest NPV in almost every scenario. Borrowers start practice $300,000 to $400,000 behind their peers who secure a national service scholarship, but those who enter a highly paid specialty, such as orthopedic surgery, overtake their national service counterparts 4 to 11 years after residency. Those in lower-paid specialties take much longer. Borrowers who enter primary care never close the gap. CONCLUSIONS: Over time, the value of a medical degree offsets the high up-front cost. Debt avoidance confers substantial economic benefits, particularly for students interested in primary care.

Impact of Risk Adjustment for Socioeconomic Status on Risk-adjusted Surgical Readmission Rates.

OBJECTIVE: To assess whether differences in readmission rates between safety-net hospitals (SNH) and non-SNHs are due to differences in hospital quality, and to compare the results of hospital profiling with and without SES adjustment. BACKGROUND: In response to concerns that quality measures unfairly penalizes SNH, NQF recently recommended that performance measures adjust for socioeconomic status (SES) when SES is a risk factor for poor patient outcomes. METHODS: Multivariate regression was used to examine the association between SNH status and 30-day readmission after major surgery. The results of hospital profiling with and without SES adjustment were compared using the CMS Hospital Compare and the Hospital Readmissions Reduction Program (HRRP) methodologies. RESULTS: Adjusting for patient risk and SES, patients admitted to SNHs were not more likely to be readmitted compared with patients in in non-SNHs (AOR 1.08; 95% CI:0.95-1.23; P = 0.23). The results of hospital profiling based on Hospital Compare were nearly identical with and without SES adjustment (ICC 0.99, κ 0.96). Using the HRRP threshold approach, 61% of SNHs were assigned to the penalty group versus 50% of non-SNHs. After adjusting for SES, 51% of SNHs were assigned to the penalty group. CONCLUSIONS: Differences in surgery readmissions between SNHs and non-SNHs are due to differences in the patient case mix of low-SES patients, and not due to differences in quality. Adjusting readmission measures for SES leads to changes in hospital ranking using the HRRP threshold approach, but not using the CMS Hospital Compare methodology. CMS should consider either adjusting for the effects of SES when calculating readmission thresholds for HRRP, or replace it with the approach used in Hospital Compare.