Cardiothoracic Surgical Volume Within the Military Health System: Fiscal Years 2007 to 2017.

BACKGROUND: Cardiothoracic surgical services have been provided at 7 military treatment facilities over the past decade. Accurate case volume data for adult cardiac and general thoracic surgical service lines in the Military Health System is unknown. METHODS: We queried the Military Health System Data Repository for adult cardiac and general thoracic cases performed at military treatment facilities in the Military Health System and surrounding purchased care markets for fiscal years 2007 to 2017. Cases were filtered and classified into major cardiac and major general thoracic categories. Five military treatment facility markets had sufficient cardiac case data to perform cost analysis. RESULTS: Institutional major cardiac case volume was low across the Military Health System with less than 100 cardiopulmonary bypass cases per year (range, 17-151 cases per year) performed most years at each military treatment facility. Similarly, general thoracic surgical case volume was universally low, with less than 30 anatomic lung resections (range, 0-26) and fewer than 5 esophageal resections (range, 0-4) performed at each military treatment facility annually. Cost analysis revealed that provision of cardiac surgical services is significantly more expensive at most military treatment facilities compared with their surrounding purchased care markets. CONCLUSIONS: Adult cardiac and general thoracic surgical volume within the Military Health System is low across all institutions and inadequate to provide clinical readiness for active-duty surgeons. Recapture of major cases from the purchased care market is unlikely and would not significantly increase military treatment facility or individual surgeon case volume.

Return on Investment Analysis of Health Experts onLine at Portsmouth: A 2-Year Review of the Navy's Newest Teleconsultation System.

BACKGROUND: Health Experts onLine at Portsmouth (HELP) is a web-based teleconsultation system launched in June 2014 to facilitate communication between specialists at Naval Medical Center Portsmouth and providers assigned to both the fleet forces and primary care clinics across the eastern United States, Europe, and the Middle East. Specialist consultations through the HELP system purport to improve access to care for patients who otherwise might be referred to the civilian network or medically evacuated (MEDEVACed) to Naval Medical Center Portsmouth for specialized care. If HELP-facilitated communications help avoid civilian referrals or MEDEVACs, the associated costs of that care should be reduced. METHODS: We evaluated cost savings associated with prevented MEDEVACs by analyzing both tangible savings (prevented costs of flights, per diems, and consults) and intangible savings (reduced lost productivity time). We compared these savings to the costs of maintaining and utilizing the HELP system: startup costs, administrative costs, and provider time costs. We used patient and provider data from the HELP database to evaluate clinical consult cases. Before this analysis, a panel of 3 physicians associated with HELP reviewed each consult to determine whether a case qualified as a prevented MEDEVAC. Data from the Military Health System (MHS) Management and Analysis Reporting Tool and the MHS Data Repository were used to estimate costs associated with provider time, patient time, and direct care medical encounters. FINDINGS: The HELP program delivered measurable, positive returns on investment (ROIs) between June 2014 and December 2015. In that time frame, 559 consult cases occurred in the HELP system. Of the 559 total consult cases, 50 consults prevented MEDEVACs. Incorporating only tangible savings, HELP produced an 80% ROI on the basis of prevented medical evacuations; the addition of intangible savings such as reduced lost productivity increased the ROI to 250%. The dollar values of these savings were $693,461 and $1,337,628, respectively. IMPACT: The HELP program produces considerable savings (both tangible and intangible) to the Military Healthcare System for small costs. It does this both by increasing access to care at previously inaccessibly remote medical treatment facilities and by consequently decreasing the forward provider's reliance on medical evacuation in questionable cases. This positive ROI was potentially underestimated as this analysis did not account for recapture of care that would otherwise have been sent to the civilian market. On the basis of this analysis, a low bandwidth, asynchronous, and internet accessible teleconsultation system is both a feasible and effective means of projecting quality care forward into the deployed setting. Future implementation of similar initiatives throughout the MHS can be expected, and will likely draw from the lessons learned during the successful implementation and execution of the HELP system.

Use of the Fitbit to Measure Adherence to a Physical Activity Intervention Among Overweight or Obese, Postmenopausal Women: Self-Monitoring Trajectory During 16 Weeks.

BACKGROUND: Direct-to-consumer trackers and devices have potential to enhance theory-based physical activity interventions by offering a simple and pleasant way to help participants self-monitor their behavior. A secondary benefit of these devices is the opportunity for investigators to objectively track adherence to physical activity goals across weeks or even months, rather than relying on self-report or a small number of accelerometry wear periods. The use of consumer trackers for continuous monitoring of adherence has considerable potential to enhance physical activity research, but few studies have been published in this rapidly developing area. OBJECTIVE: The objective of the study was to assess the trajectory of physical activity adherence across a 16-week self-monitoring intervention, as measured by the Fitbit tracker. METHODS: Participants were 25 overweight or obese, postmenopausal women enrolled in the intervention arm of a randomized controlled physical activity intervention trial. Each participant received a 16-week technology-based intervention that used the Fitbit physical activity tracker and website. The overall study goal was 150 minutes/week of moderate to vigorous intensity physical activity (MVPA) and 10,000 steps/day; however, goals were set individually for each participant and updated at Week 4 based on progress. Adherence data were collected by the Fitbit and aggregated by Fitabase. Participants also wore an ActiGraph GT3X+ accelerometer for 7 days prior to the intervention and again during Week 16. RESULTS: The median participant logged 10 hours or more/day of Fitbit wear on 95% of the 112 intervention days, with no significant decline in wear over the study period. Participants averaged 7540 (SD 2373) steps/day and 82 minutes/week (SD 43) of accumulated "fairly active" and "very active" minutes during the intervention. At Week 4, 80% (20/25) of women chose to maintain/increase their individual MVPA goal and 72% (18/25) of participants chose to maintain/increase their step goal. Physical activity levels were relatively stable after peaking at 3 weeks, with only small declines of 8% for steps (P=.06) and 14% for MVPA (P=.05) by 16 weeks. CONCLUSIONS: These data indicate that a sophisticated, direct-to-consumer activity tracker encouraged high levels of self-monitoring that were sustained over 16 weeks. Further study is needed to determine how to motivate additional gains in physical activity and evaluate the long-term utility of the Fitbit tracker as part of a strategy for chronic disease prevention. TRIAL REGISTRATION: Clinicaltrials.gov NCT01837147; http://clinicaltrials.gov/ct2/show/NCT01837147 (Archived by WebCite at http://www.webcitation.org/6d0VeQpvB).

Randomized Trial of a Fitbit-Based Physical Activity Intervention for Women.

INTRODUCTION: Direct-to-consumer mHealth devices are a potential asset to behavioral research but rarely tested as intervention tools. This trial examined the accelerometer-based Fitbit tracker and website as a low-touch physical activity intervention. The purpose of this study is to evaluate, within an RCT, the feasibility and preliminary efficacy of integrating the Fitbit tracker and website into a physical activity intervention for postmenopausal women. METHODS: Fifty-one inactive, postmenopausal women with BMI ≥25.0 were randomized to a 16-week web-based self-monitoring intervention (n=25) or comparison group (n=26). The Web-Based Tracking Group received a Fitbit, instructional session, and follow-up call at 4 weeks. The comparison group received a standard pedometer. All were asked to perform 150 minutes/week of moderate to vigorous physical activity (MVPA). Physical activity outcomes were measured by the ActiGraph GT3X+ accelerometer. RESULTS: Data were collected and analyzed in 2013-2014. Participants were aged 60 (SD=7) years with BMI of 29.2 (3.5) kg/m(2). Relative to baseline, the Web-Based Tracking Group increased MVPA by 62 (108) minutes/week (p<0.01); 10-minute MVPA bouts by 38 (83) minutes/week (p=0.008); and steps by 789 (1,979) (p=0.01), compared to non-significant increases in the Pedometer Group (between-group p=0.11, 0.28, and 0.30, respectively). The Web-Based Tracking Group wore the tracker on 95% of intervention days; 96% reported liking the website and 100% liked the tracker. CONCLUSIONS: The Fitbit was well accepted in this sample of women and associated with increased physical activity at 16 weeks. Leveraging direct-to-consumer mHealth technologies aligned with behavior change theories can strengthen physical activity interventions.