The Impact of the COVID-19 Pandemic on the Military Health System's Care of Military Sexual Assault.

BACKGROUND: Sexual assault remains a high priority challenge for leaders in the U.S. military. The COVID-19 pandemic further complicated the issue by disrupting work and lifestyles, potentially affecting reporting and care-seeking by victims. To date, there are no studies addressing the impact of changes in access to health services and reporting of sexual assault by active duty service members to inform medical and public health interventions in a post-COVID-19 era and during future public health emergencies. METHODS: Using the Military Health System Data Repository (MDR), we identified a retrospective open cohort of active duty servicemembers receiving care in the Military Health System (MHS) from fiscal years 2018 to 2021. Through the use of ICD-10 diagnostic codes, all corresponding sexual assault care was identified for the cohort before (October 1, 2017-February 28, 2020; pre-pandemic period) and after (March 1, 2020-September 30, 2021; pandemic period) the institution of COVID-19 pandemic protective measures. Pre-pandemic and pandemic period rates of sexual assault associated encounters per 10,000 total health encounters were calculated by geographic location and compared using Wilcoxon's sign rank test. Multivariate log binomial regression models were performed to estimate associated risk of sexual assault among active duty servicemembers and compared across both periods. RESULTS: The study identified 47,067,073 encounters for servicemembers in the pre-pandemic period, of which 7,813 (0.016%) were associated with sexual assault. During the pandemic period, 4,377 (0.015%) of 28,926,480 encounters were associated with sexual assault, indicating a 44% reduction in total encounters and a 9% reduction in the proportion of encounters associated with sexual assault. Eighteen installations within the MHS had statistically significant increases in rates of encounters. Most sexual assault encounters occurred in the 20-24 year age, Female, White, Junior Enlisted, Army, and Unmarried categories. During both time-frames, younger age and being female were associated with an increased risk of sexual assault encounters. Race, service branch, and marital status were also associated with the risk of encounters. CONCLUSION: Contrary to reports indicating a modest increase in the number of sexual assaults reported within the DoD, we found a reduction in the frequency of healthcare encounters associated with sexual assault during the pandemic which may be related to reduced access to care. Men comprised approximately 22% of sexual assault encounters delivered through the MHS although the racial distribution of encounters approximates the estimates of the DoD-published demographic statistics. This study illustrates that COVID-19 measures appear to have reduced access to care for sexual assault within the MHS but did not demonstrably alter the demographics of servicemembers seeking care. These findings suggest that the MHS may require contingency plans for future disruptions to care and public health emergencies.

Caring for Service Members Who Have Been Sexually Assaulted: The Military Health System.

INTRODUCTION: Reports of sexual assault (SA) in the U.S. Military have increased in recent years. Given the deleterious effects of military SA, there remains a need for large-scale studies to assess SA-related health care utilization among active duty service members (ADSMs). The present study, therefore, utilized Military Health System (MHS) data to determine the prevalence of SA-related care, sociodemographic characteristics of ADSMs receiving said care, and the type of provider seen during the initial SA-related health encounter. MATERIALS AND METHODS: Utilizing the MHS Data Repository and Defense Enrollment Eligibility Reporting System, all ADSMs from the Air Force, Army, Navy, and Marine Corps during fiscal years (FY) 2016-2018 were identified. Those with an International Classification of Diseases diagnostic code related to SA during the study period were isolated. Descriptive statistics and multivariable logistic regression analyses were conducted. The study was exempt from human subjects review. RESULTS: A total of 1,728,433 ADSMs during FY 2016-2018 were identified, of whom 4,113 (0.24%) had an SA-related health encounter. Rates of SA-related health care encounters decreased each FY. Women (odds ratio [OR] = 12.02, P < .0001), those in the Army (reference group), and enlisted personnel (OR = 2.65, P < .0001) were most likely to receive SA-related health care, whereas ADSMs aged 18-25 years had lower odds (OR = 0.70, P < .0001). In addition, higher odds of SA-related care were observed among those identifying as American Indian/Alaskan Native (OR = 1.37, P = .02) and "Other" race (e.g., multiracial) (OR = 4.60, P < .0001). Initial SA-related health encounters were most likely to occur with behavioral health providers (41.4%). CONCLUSIONS: The current study is the first large-scale examination of health care usage by ADSMs in the MHS who have experienced SA. Results indicated that rates of SA-related care decreased throughout the study period, despite the increasing rates of SA documented by the DoD. Inconsistent with previous research and DoD reports indicating that younger ADSMs are at the highest risk for SA, our study observed lower rates of SA-related care among those aged 18-25 years; additional research is warranted to determine if there are barriers preventing younger ADSMs from seeking SA-related health care. Behavioral health providers were most frequently seen for the initial SA-related encounter, suggesting that they may be in a unique position to provide care and/or relevant referrals to ADSMs who have experienced SA. The present study provides key insights about the prevalence of SA-related care within the MHS, not yet reported in previous literature, which could help inform MHS screening practices. The strengths of the study are the inclusion of the entire active duty population without the need for research recruitment given the utilization of de-identified TRICARE claims data. The study is limited by its use of health care claims data, general SA International Classification of Diseases codes as a proxy indicator for military SA, and lack of data on ethnicity. Future research utilizing MHS data should examine mental health outcomes following the documentation of SA and disruptions in SA-related care due to SARS-CoV-2.

In defense of Direct Care: Limiting access to military hospitals could worsen quality and safety.

OBJECTIVE: Ongoing health care reforms within the US Military Health System (MHS) are expected to shift >1.9 million MHS beneficiaries from military treatment facilities (MTFs) into local civilian hospitals over the next 1-2 years. The objective of this study was to examine how such health care reforms are likely to affect the quality of MHS care. DATA SOURCES: Adult MHS beneficiaries, aged 18-64 years, treated in MTFs (under a program known as Direct Care) were compared against (1) MHS beneficiaries treated in locally available civilian hospitals (under a program known as Purchased Care) and (2) similarly-aged adult civilian patients across the United States. MHS beneficiaries in Direct and Purchased Care were identified from fiscal-year 2016-2018 MHS inpatient claims. National inpatients were identified in the 2017 Nationwide Readmissions Database. STUDY DESIGN: Retrospective cohort. DATA COLLECTION: Differences in quality were compared using two sets of quality metrics endorsed by the US Agency for Healthcare Research and Quality (AHRQ): Inpatient Quality Indicators, 19 quality metrics that look at differences in in-hospital mortality, and Patient Safety Indicators, 18 quality metrics that look at differences in in-hospital morbidity and adverse events. Among MHS beneficiaries (Direct and Purchased Care), we further simulated what changes in quality indicators might look like under various proposed scenarios of reduced access to Direct Care. PRINCIPAL FINDINGS: A total of 502,252 MHS admissions from 37 MTFs and surrounding civilian hospitals were included (326,076 Direct Care, 179,176 Purchased Care). Nationwide, 9.34 million adult admissions from 2453 hospitals were included. On average, MHS beneficiaries treated in MTFs experienced better inpatient quality and improved patient safety compared with MHS beneficiaries treated in locally available civilian hospitals (e.g., summary observed-to-expected ratio for medical mortality: 0.98 vs. 1.03, p < 0.001) and adult patients across the United States (0.98 vs. 1.02, p < 0.001). Simulations of proposed changes resulted in consistently worse outcomes for MHS patients, whether reducing MTF access by 10%, 20%, or 50% nationwide; limiting MTF access to active-duty beneficiaries; or closing MTFs with the worst performance on patient safety (p < 0.001 for overall quality indicators for each). CONCLUSIONS: Reducing access to MTFs could result in significant harm to MHS patients. The results underscore the importance of health-policy planning based on evidence-based evaluation and the need to consider the consequential downstream effects caused by changes in access to care.

Early Pediatric Fractures in a Universally Insured Population within the United States.

BACKGROUND: Musculoskeletal injury, including fracture, is one of the most common causes of morbidity in pediatric patients. The purpose of this epidemiologic study is to determine the prevalence and risk factors for fracture in a large cohort of pediatric patients under the age of 5. RESULTS: Of the 233,869 patients included in the study, 13,698 fractures were identified in 10,889 patients. The highest annual incidence was in the 4 year old age group with a rate of 24.2 fractures per 1000 children. The annual incidence within all age groups was 11.7 fractures per 1000 children. The two most common fractures were forearm and humerus fractures. Fracture incidence was increased in male children, patients who live outside the US, and in Caucasian patients. An increase in rate of fracture was also identified in children of officers when compared with children of enlisted service members. There were 35 abuse related fractures in our cohort, with 19 of them occurring in children less than 1 year old. Only three children in our cohort had Osteogenesis Imperfecta. CONCLUSION: Fractures are common injuries in young children with an incidence over the first 5 years of life of 5.86%. Multiple risk factors were also identified including age, race, geographic location and socioeconomic status. The results of this study are an important contribution to epidemiologic and public health literature and serve to characterize the incidence of and risk factors for sustaining an early childhood fracture.

New ACC/AHA Blood Pressure Guidelines and the Operational Readiness of Naval Aviators and Aircrew.

INTRODUCTION: Hypertension, also known as high blood pressure, is the "silent killer" and may lead to more severe conditions if left unmanaged. Hypertension in service members of the U.S. military has the potential to negatively impact readiness. The aim of this study was to assess the potential impact to readiness of active duty Naval aviators and aircrew under the new 2017 ACC/AHA blood pressure guidelines.METHODS: This cross-sectional study used the Military Health System Data Repository for 2015. The population included all active duty Naval aviators and aircrew. The absolute number and proportion of those with hypertension were compared based on previous Joint National Committee 7 and 2017 ACC/AHA guidelines. Impact to readiness was calculated based on lost work days and the number of individuals with hypertension that fit the criteria to be medically grounded according to the U.S Naval Aeromedical Reference and Waiver Guide.RESULTS: Hypertension diagnoses will increase by 2904 individuals (599%) in the 23,492 Naval aviators and aircrew included in the population. Impact to readiness will result in an estimate of 510 lost work days.CONCLUSION: The 2017 ACC/AHA hypertension guidelines will lead to a dramatic increase in hypertension diagnoses in this population. Depending on the U.S. Navy disposition on hypertension, the impact can be minor or substantial, but the early opportunity for care made available with the 2017 ACC/AHA guidelines may provide long-term benefits of a healthy fighting force worth the immediate impact to readiness.Johnson MC, Banaag AL, Condie KJ, Servies TE, Pérez Koehlmoos TL. New ACC/AHA blood pressure guidelines and the operational readiness of Naval aviators and aircrew. Aerosp Med Hum Perform. 2019; 90(4):409-414.

Prenatal use of medications for gastroesophageal reflux disease and early childhood fracture risk.

BACKGROUND: Gastroesophageal reflux disease is a common condition in pregnancy and is often managed with medications. Specific medications have been linked to osteoporosis and fragility fracture in older adults. This study assessed whether maternal use of antireflux medications is associated with early childhood fracture. METHODS: TRICARE beneficiaries during pregnancy were retrospectively identified using the Military Health System Data Repository and pharmacy data. Mother and infant data were linked; children with continuous enrollment for the first 5 years of life were included. Differences in the children's fracture risk were analyzed through multivariate analysis, adjusting for region, rank, and military branch of service. RESULTS: A total of 378 150 patients comprised the final cohort with 3.3% (n = 12 479) prescribed antireflux medications during pregnancy. A significant decrease in fracture rate was found among children of women who were prescribed antireflux medications during pregnancy compared with those who were not (0.8% vs 1.2%, RR = 0.70, 95% CI 0.58-0.85). There was no difference in fracture risk between histamine type 2 receptor antagonists and proton pump inhibitors. A significantly increased fracture incidence was seen in pregnancies with multiple gestations (RR = 1.38, 95% CI 1.04-1.85). There was no identified difference in fracture risk for women with gestational diabetes, preeclampsia, preterm or low birthweight, chronic hypertension, induction, or breech presentation when compared to women without these conditions. CONCLUSIONS: We found no increase in early childhood fracture risk with maternal antireflux medication use. This suggests that prenatal exposure to antireflux medications does not affect fetal bones to a clinically significant extent.

What Factors Affect Voluntary Uptake of Community-Based Health Insurance Schemes in Low- and Middle-Income Countries? A Systematic Review and Meta-Analysis.

INTRODUCTION: This research article reports on factors influencing initial voluntary uptake of community-based health insurance (CBHI) schemes in low- and middle-income countries (LMIC), and renewal decisions. METHODS: Following PRISMA protocol, we conducted a comprehensive search of academic and gray literature, including academic databases in social science, economics and medical sciences (e.g., Econlit, Global health, Medline, Proquest) and other electronic resources (e.g., Eldis and Google scholar). Search strategies were developed using the thesaurus or index terms (e.g., MeSH) specific to the databases, combined with free text terms related to CBHI or health insurance. Searches were conducted from May 2013 to November 2013 in English, French, German, and Spanish. From the initial search yield of 15,770 hits, 54 relevant studies were retained for analysis of factors influencing enrolment and renewal decisions. The quantitative synthesis (informed by meta-analysis) and the qualitative analysis (informed by thematic synthesis) were compared to gain insight for an overall synthesis of findings/statements. RESULTS: Meta-analysis suggests that enrolments in CBHI were positively associated with household income, education and age of the household head (HHH), household size, female-headed household, married HHH and chronic illness episodes in the household. The thematic synthesis suggests the following factors as enablers for enrolment: (a) knowledge and understanding of insurance and CBHI, (b) quality of healthcare, (c) trust in scheme management. Factors found to be barriers to enrolment include: (a) inappropriate benefits package, (b) cultural beliefs, (c) affordability, (d) distance to healthcare facility, (e) lack of adequate legal and policy frameworks to support CBHI, and (f) stringent rules of some CBHI schemes. HHH education, household size and trust in the scheme management were positively associated with member renewal decisions. Other motivators were: (a) knowledge and understanding of insurance and CBHI, (b) healthcare quality, (c) trust in scheme management, and (d) receipt of an insurance payout the previous year. The barriers to renewal decisions were: (a) stringent rules of some CBHI schemes, (b) inadequate legal and policy frameworks to support CBHI and (c) inappropriate benefits package. CONCLUSION AND POLICY IMPLICATIONS: The demand-side factors positively affecting enrolment in CBHI include education, age, female household heads, and the socioeconomic status of households. Moreover, when individuals understand how their CBHI functions they are more likely to enroll and when people have a positive claims experience, they are more likely to renew. A higher prevalence of chronic conditions or the perception that healthcare is of good quality and nearby act as factors enhancing enrolment. The perception that services are distant or deficient leads to lower enrolments. The second insight is that trust in the scheme enables enrolment. Thirdly, clarity about the legal or policy framework acts as a factor influencing enrolments. This is significant, as it points to hitherto unpublished evidence that governments can effectively broaden their outreach to grassroots groups that are excluded from social protection by formulating supportive regulatory and policy provisions even if they cannot fund such schemes in full, by leveraging people's willingness to exercise voluntary and contributory enrolment in a community-based health insurance.

Diagnosis of chronic conditions with modifiable lifestyle risk factors in selected urban and rural areas of Bangladesh and sociodemographic variability therein.

BACKGROUND: Bangladesh suffers from a lack of healthcare providers. The growing chronic disease epidemic's demand for healthcare resources will further strain Bangladesh's limited healthcare workforce. Little is known about how Bangladeshis with chronic disease seek care. This study describes chronic disease patients' care seeking behavior by analyzing which providers diagnose these diseases. METHODS: During 2 month periods in 2009, a cross-sectional survey collected descriptive data on chronic disease diagnoses among 3 surveillance populations within the International Center for Diarrheal Disease Research, Bangladesh (ICDDR, B) network. The maximum number of respondents (over age 25) who reported having ever been diagnosed with a chronic disease determined the sample size. Using SAS software (version 8.0) multivariate regression analyses were preformed on related sociodemographic factors. RESULTS: Of the 32,665 survey respondents, 8,591 self reported having a chronic disease. Chronically ill respondents were 63.4% rural residents. Hypertension was the most prevalent disease in rural (12.4%) and urban (16.1%) areas. In rural areas chronic disease diagnoses were made by MBBS doctors (59.7%) and Informal Allopathic Providers (IAPs) (34.9%). In urban areas chronic disease diagnoses were made by MBBS doctors (88.0%) and IAP (7.9%). Our analysis identified several groups that depended heavily on IAP for coverage, particularly rural, poor and women. CONCLUSION: IAPs play important roles in chronic disease care, particularly in rural areas. Input and cooperation from IAPs are needed to minimize rural health disparities. More research on IAP knowledge and practices regarding chronic disease is needed to properly utilize this potential healthcare resource.