Missing in action: A bibliometric analysis of military research in the medical literature since 1950.

BACKGROUND: Top-tier general and specialty scientific journals serve as a bellwether for national research priorities. We hypothesize that military-relevant publications are underrepresented in the scientific literature and that such publications decrease significantly during peacetime. METHODS: We identified high impact journals in the fields of Medicine, Surgery and Critical Care and developed Boolean searches for military-focused topics using National Library of Medicine Subject Headings terms. A PubMed search from 1950 to 2020 returned the number of research publications in relevant journals and the rate of military-focused publications by year. Rates of military publications were compared between peacetime and wartime. Publication rate trends were modeled with a quadratic function controlling for the start of active conflict and total casualty numbers. Baseline proportions of military physicians relative to the civilian sector served to estimate expected publication rates. Comparisons were performed using Pearson's Chi Square and Mann-Whitney U test, with p < 0.05 considered a significant difference. RESULTS: From 1950 to 2020, a total of 716,340 manuscripts were published in the journals queried. Of these, military-relevant manuscripts totaled 4,052 (0.57%). We found a significant difference in the rate of publication during times of peace and times of war (0.40% vs. 0.69%, p < 0.001). Subgroup analysis found significantly reduced rates of publication in medical and critical care journals during peacetime. For each conflict, the percentage of military-focused publications peaked during periods of war but then receded below baseline levels within a median of 2.5 years (interquartile range 1.5-3.8 years) during peacetime. The proportion of military-focused publications never reached the current proportion of military physicians in the workforce. CONCLUSION: There is marked reduction in rates of publication for military-focused articles in high impact journals during peacetime. Military-focused articles are underrepresented in high-impact journals. Investigators of military-relevant topics and editors of high-impact journals should seek to close this gap.

Access to Mental Health and Substance Use Treatment in Comprehensive Primary Care Plus.

Importance: To meet increasing demand for mental health and substance use services, the Centers for Medicare & Medicaid Services launched the 5-year Comprehensive Primary Care Plus (CPC+) demonstration in 2017, requiring primary care practices to integrate behavioral health services. Objective: To examine the association of CPC+ with access to mental health and substance use treatment before and during the COVID-19 pandemic. Design, Setting, and Participants: Using difference-in-differences analyses, this retrospective cohort study compared adults attributed to CPC+ and non-CPC+ practices, from January 1, 2018, to June 30, 2022. The study included adults aged 19 to 64 years who had depression, anxiety, or opioid use disorder (OUD) and were enrolled with a private health insurer in Pennsylvania. Data were analyzed from January to June 2023. Exposure: Receipt of care at a practice participating in CPC+. Main Outcomes and Measures: Total cost of care and the number of primary care visits for evaluation and management, community mental health center visits, psychiatric hospitalizations, substance use treatment visits (residential and nonresidential), and prescriptions filled for antidepressants, anxiolytics, buprenorphine, naltrexone, or methadone. Results: The 188 770 individuals in the sample included 102 733 adults (mean [SD] age, 49.5 [5.6] years; 57 531 women [56.4%]) attributed to 152 CPC+ practices and 86 037 adults (mean [SD] age, 51.6 [6.6] years; 47 321 women [54.9%]) attributed to 317 non-CPC+ practices. Among patients diagnosed with OUD, compared with patients attributed to non-CPC+ practices, attribution to a CPC+ practice was associated with filling more prescriptions for buprenorphine (0.117 [95% CI, 0.037 to 0.196] prescriptions per patient per quarter) and anxiolytics (0.162 [95% CI, 0.005 to 0.319] prescriptions per patient per quarter). Among patients diagnosed with depression or anxiety, attribution to a CPC+ practice was associated with more prescriptions for buprenorphine (0.024 [95% CI, 0.006 to 0.041] prescriptions per patient per quarter). Conclusions and Relevance: Findings of this cohort study suggest that individuals with an OUD who received care at a CPC+ practice filled more buprenorphine and anxiolytics prescriptions compared with patients who received care at a non-CPC+ practice. As the Centers for Medicare & Medicaid Innovation invests in advanced primary care demonstrations, it is critical to understand whether these models are associated with indicators of high-quality primary care.

Limited Access to Aortic Valve Procedures in Socioeconomically Disadvantaged Areas.

BACKGROUND: To explore how differences in local socioeconomic deprivation impact access to aortic valve procedures and the treatment of aortic valve disease, in comparison to other open and minimally invasive surgical procedures. METHODS AND RESULTS: Procedure volume data were obtained from the Healthcare Cost and Utilization Project from 18 states from 2016 to 2019 and merged with area deprivation index data, an index of zip code-level socioeconomic distress. We estimate the relationship between local deprivation ranking and differences in volumes of aortic valve replacement, which include transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR), versus coronary artery bypass graft surgery and laparoscopic colectomy (LC). All regressions control for state and year fixed effects and an array of zip code-level characteristics. TAVR procedures have increased over time across all zip codes. The rate of increase is negatively correlated with deprivation ranking, regardless of the higher share of hospitalizations per population in high deprivation areas. Distributional analysis further supports these findings, showing that lower area deprivation index areas account for a disproportionately large share of SAVR, TAVR, and LC procedures in our sample relative to their share of all hospitalizations in our sample. By comparison, the cumulative distribution of coronary artery bypass graft procedures was nearly identical to that of total hospitalizations, suggesting that this procedure is equitably distributed. Regressions show high area deprivation index areas have lower prevalence of SAVR (ß=-15.1%, [95% CI, -26.8 to -3.5]), TAVR (ß=-9.1%, [95% CI, -18.0 to -0.2]), and LC (ß=-19.9%, [95% CI, -35.4 to -4.4]), with no statistical difference in the prevalence of coronary artery bypass graft (ß=-2.5%, [95% CI, -12.7 to 7.6]), a widespread and commonly performed procedure. In the population aged ≥80 years, results show high area deprivation index areas have a lower prevalence of TAVR (ß=-11.9%, [95% CI, -18.7 to -5.2]) but not SAVR (ß=-0.8%, [95% CI, 8.1 to 6.3]), LC (ß=-3.5%, [95% CI, -13.4 to -6.4]), or coronary artery bypass graft (ß=5.2%, [95% CI, -1.1 to 1.1]). CONCLUSIONS: People living in high deprivation areas have less access to life-saving technologies, such as SAVR, and even moreso to device-intensive minimally invasive procedures such as TAVR and LC.

The Relationship Between Scope of Practice Laws for Task Delegation and Nurse Turnover in Home Health.

OBJECTIVE: Nurse turnover can compromise the quality and continuity of home health care. Scope of practice laws, which determine the tasks nurses are allowed to perform and delegate, are an important element of autonomy and vary across states. In this study, we used human resource records from a multistate home health organization to examine the relationship between nurse turnover and whether nurses can delegate tasks to unlicensed aides. DESIGN: A retrospective, cross-sectional analysis. SETTING AND PARTICIPANTS: The study sample included 1820 licensed practical nurses and 3309 registered nurses, who spanned 30 states. The study period was 2016 through 2018. METHODS: We used weighted least squares to study the relationship between nurse turnover for registered and licensed practical nurses and task delegation across state-years. We measured task delegation continuously (0-16 tasks) and as a binary variable (14 or more tasks, which indicated the state was in the top half of the distribution). RESULTS: Across state-years, the turnover rate was 30.8% for licensed practical nurses and 36.8% for registered nurses. Although there was no significant relationship between task delegation and turnover among registered nurses, we found that states in which nurses could delegate the most tasks had lower turnover rates among licensed practical nurses. CONCLUSION AND IMPLICATIONS: The ability to delegate tasks to unlicensed aides was correlated with lower turnover rates among licensed practical nurses, but not among registered nurses. This suggests that the ability to delegate tasks is more likely to affect the workload of licensed practical nurses. This also points to a potential and unexplored element of expanding the scope of practice for nurses: reduced turnover. Given the added work-related hazards associated with home health care, including working in isolation, a lack of social recognition, and inadequate reimbursement, states should consider whether changes in their policy environment could benefit nurses working in home health.

Telemedicine catches on: changes in the utilization of telemedicine services during the COVID-19 pandemic.

OBJECTIVES: To determine the degree of telemedicine expansion overall and across patient subpopulations and diagnoses. We hypothesized that telemedicine visits would increase substantially due to the need for continuity of care despite the disruptive effects of COVID-19. STUDY DESIGN: A retrospective study of health insurance claims for telemedicine visits from January 1, 2018, through March 10, 2020 (prepandemic period), and March 11, 2020, through October 31, 2020 (pandemic period). METHODS: We analyzed claims from 1,589,777 telemedicine visits that were submitted to Independence Blue Cross (Independence) from telemedicine-only providers and providers who traditionally deliver care in person. The primary exposure was the combination of individual behavior changes, state stay-at-home orders, and the Independence expansion of billing policies for telemedicine. The comparison population consisted of telemedicine visits in the prepandemic period. RESULTS: Telemedicine increased rapidly from a mean (SD) of 773 (155) weekly visits in prepandemic 2020 to 45,632 (19,937) weekly visits in the pandemic period. During the pandemic period, a greater proportion of telemedicine users were older, had Medicare Advantage insurance plans, had existing chronic conditions, or resided in predominantly non-Hispanic Black or African American Census tracts compared with during the prepandemic period. A significant increase in telemedicine claims containing a mental health-related diagnosis was observed. CONCLUSIONS: Telemedicine expanded rapidly during the COVID-19 pandemic across a broad range of clinical conditions and demographics. Although levels declined later in 2020, telemedicine utilization remained markedly higher than 2019 and 2018 levels. Trends suggest that telemedicine will likely play a key role in postpandemic care delivery.

The Role of Schedule Volatility in Home Health Nursing Turnover.

Despite considerable research on nursing turnover, few studies have considered turnover among nurses working in home health care. Using novel administrative data from one of the largest home health care organizations in the United States, this study examined turnover among home health nurses, focusing on the role of schedule volatility. We estimated separation rates among full-time and part-time registered nurses and licensed practical nurses and used daily visit logs to estimate schedule volatility, which was defined as the coefficient of variation of the number of daily visits in the prior four weeks. Between 2016 and 2019, the average annual separation rate of home health nurses was over 30%, with most separations occurring voluntarily. Schedule volatility and turnover were positively associated for full-time nurses, but not for part-time nurses. These results suggest that reducing schedule volatility for full-time nurses could mitigate nursing turnover in home health care.

Medical Device Firm Payments To Physicians Exceed What Drug Companies Pay Physicians, Target Surgical Specialists.

Many physicians receive payments from medical device companies that make products physicians can use or recommend. Such payments are controversial because of concerns that they might influence physicians to treat patients with devices made by the firms that make those payments, even if those devices are not optimal for patients. This issue has been studied extensively in the drug industry. Medical devices entail a greater degree of physician-industry interaction regarding treatment, training, and innovation than pharmaceuticals, and they have been less studied because of data limitations. We summarize and compare device and drug firm payment rates and magnitudes reported in Open Payments data by payment type, physician specialty, and Medicare billing amount. Relative to drug firm payments, device firm payments as a percentage of industry revenue were seven times as large; device firm payments were also more often related to product development and training and were more strongly correlated with physicians' Medicare billing amounts. Using Food and Drug Administration product approval data, we further document that top-paying firms dominate high-revenue device categories. Our results suggest that optimal policy regarding physician-industry relationships for medical devices may be very different from that for pharmaceuticals. Estimating the causal relationships between payments and device use, pricing, and innovation to inform policy makers will be possible only with greater data transparency, such as including device identifiers in medical claims.

Disruptions in preventive care: Mammograms during the COVID-19 pandemic.

OBJECTIVE: To measure the extent to which the provision of mammograms was impacted by the COVID-19 pandemic and surrounding guidelines. DATA SOURCES: De-identified summary data derived from medical claims and eligibility files were provided by Independence Blue Cross for women receiving mammograms. STUDY DESIGN: We used a difference-in-differences approach to characterize the change in mammograms performed over time and a queueing formula to estimate the time to clear the queue of missed mammograms. DATA COLLECTION: We used data from the first 30 weeks of each year from 2018 to 2020. PRINCIPAL FINDINGS: Over the 20 weeks following March 11, 2020, the volume of screening mammograms and diagnostic mammograms fell by 58% and 38% of expected levels, on average. Lowest volumes were observed in week 15 (April 8 to 14), when screening and diagnostic mammograms fell by 99% and 74%, respectively. Volumes began to rebound in week 19 (May), with diagnostic mammograms reaching levels to similar to previous years' and screening mammograms remaining 14% below expectations. We estimate it will take a minimum of 22 weeks to clear the queue of missed mammograms in our study sample. CONCLUSIONS: The provision of mammograms has been significantly disrupted due to the COVID-19 pandemic.