QUiC Clinics in the Central Texas Market: Value-Based Primary Care in Military Medicine.

INTRODUCTION: For the past 16 years, Military Health System primary care providers have been incentivized to pursue work in a fee-for-service (FFS) model. The system values documentation of productivity to earn as many relative value units as possible. The result is densely packed clinic schedules that often lack the space or flexibility to accommodate patients when sick. Leakage ensues. Furthermore, prevention and patient experience are not directly incentivized. METHODS: The Central Texas Market's Accountable Care Organization reformed incentives in its #5 FFS-designed community-based medical homes to value outcomes over productivity. The resulting quality, urgent, internet, and phone care (QUiC) clinics are value-based and, therefore, better structured to achieve the Quad aim (better care, better health/readiness, and low cost). Forsaking deeply ingrained FFS practices, QUiC clinics funnel all routine (information-sharing) appointments into efficient internet or phone appointments. With the time freed by managing common needs in short bursts, QUiC clinics see sick patients with no notice (urgent care). They also focus on prevention and patient experience. We measured the effectiveness of the QUiC clinics in the value-based metrics of (1) patient experience, (2) Healthcare Effectiveness Data and Information Set measures of quality and prevention. (3) access-to-care, (4) leakage, and (5) enrollment. RESULTS: Over a 19 month period, the five community-based medical homes improved significantly in all areas. Specifically, measures of patient satisfaction improved from the mid-80s percent satisfied to the mid-90s percent satisfied. Healthcare Effectiveness Data and Information Set measures increased from average compared to national benchmarks (<50th percentile to 75th percentile) to the 90th percentile in four of five measures of quality and the 75th percentile in the remaining measure. Access to care for routine appointments decreased from 15.4 days to the third next available appointment to 2.8 days. Leakage decreased from 12.2% to 9.6%. These successes were attained without cost or significant reductions in patient enrollments. In changing workflows, the market became the #1 user of virtual video visits in the DOD. CONCLUSIONS: This performance improvement project proved the concept that a military market can vastly improve value-based primary care outcomes at no cost and within multiple community-based clinics.

Pivoting to the QUAD AIM-Lessons Learned From the Central Texas Market.

INTRODUCTION: Since 2009, the Military Health System (MHS) has represented its mission as that of attaining the Quadruple Aim (QUAD AIM): increased readiness, better health, better care, and low per capita costs. The journey to reach the four goals is challenging and ongoing. Leaders in the MHS's Central Texas Market (CTM) sought to understand and overcome the root-cause obstacles that interfered with achieving the QUAD AIM. This process required a self-critical and thoroughly objective review of the behavioral economics of the system. We hypothesized that two corporate behaviors fed upon each other to create a vicious downward spiral. First, as a socialized (salary-based) system, the enterprise has a built-in incentive that covertly competes with the attainment of the QUAD AIM. Because additional work does not result in any material gain for its workers, the system regulates to a comfortable flow. Second, centralized leaders defer important management controls to tactical teammates due to their special medical expertise. This corporate behavior makes overcoming the first one challenging-keeping realization of the QUAD AIM elusive. METHODS: Beginning in July of 2019, CTM leaders strove to replace the two identified corporate behaviors with more productive ones. First, in place of regulating to comfort, we directed teammates to focus wholly on achieving the QUAD AIM. Second, we exerted leadership from the top down to attain the QUAD AIM's four goals. Because the vicious cycle manifested itself differently in the realms of primary, inpatient, and specialty care, we adapted the application of our virtuous behaviors to match the problem set in each realm. In primary care, we replaced fee-for-service incentives with value-based ones. In inpatient care, we eliminated hidden incentives that resulted in inappropriate and unnecessary transfers. In specialty care, we consolidated the management of referrals, templating, and scheduling-taking central control of system productivity. The interventions in each realm required the introduction of new workflows, policies, and dashboards to ensure change. RESULTS: Over a 2-year period, the CTM made a quantum to leap toward attaining the QUAD AIM. In our community based primary care homes, we significantly improved our operations as quantified by the value-based metrics of patient satisfaction, Healthcare Effectiveness Data and Information Set (HEDIS) quality metrics, access to care, and leakage. In the inpatient realm, we decreased monthly transfers by 73% (110 s to 30 s) resulting in higher bed censuses and multiple downstream positive impacts. In specialty care, we demonstrated our ability to return our specialty service lines quickly to high levels of production in the coronavirus disease-2019 crisis. Each of these interventions demonstrated large-scale movement toward the QUAD AIM. CONCLUSIONS: The CTM's actions demonstrate that the QUAD AIM can be attained in military medicine. Doing so requires the recognition of two destructive corporate behaviors. Through decades of hardening, these corporate behaviors have been imprinted upon the MHS, making them practically invisible as guiding currents in economic behavior. Counteracting them with persistent regulation to the QUAD AIM facilitated by proactive top-down leadership offers a solution.

Finding Opportunities for Health-Care System Advancement in the COVID-19 Crisis.

The coronavirus disease 2019 (COVID-19) pandemic forced American medical systems to adapt to high patient loads of respiratory disease. Its disruption of normal routines also brought opportunities for broader reform. The purpose of this article is to describe how the Carl R. Darnall Army Medical Center (CRDAMC), a medium-sized Army hospital, capitalized on opportunities to advance its strategic aims during the pandemic. Specifically, the hospital sequentially adopted virtual video visits, surged on preventative screenings, and made-over its image to appeal to patients seeking urgent care. These campaigns supported COVID-19 efforts and larger strategic goals simultaneously, and they will endure for years to come. Predictably, CRDAMC encountered obstacles in the course of its transformation. These obstacles and their follow-on lessons are provided to assist future medical leaders seeking quantum change in the opportunities made available by health crises.

Emergency Department Adaptations to COVID-19.

BACKGROUND: The COVID-19 pandemic creates unique challenges for healthcare systems. While mass casualty protocols and plans exist for trauma-induced large-scale resource utilization events, contagious infectious disease mass casualty events do not have such rigorous procedures established. COVID-19 forces Emergency Departments (EDs) to simultaneously treat seriously ill patients and evaluate large influxes of 'worried well'-while maintaining both staff and patient safety. METHODS: The objectives of this project are to create an avenue to evaluate large surges of patients while minimizing hospital-acquired infections. After identifying areas for improvement and anticipating potential failures, we devised eight healthcare delivery innovations to address those areas and meet our objectives: (1) Parallel ED Lanes (2) Universal Respiratory Precautions (3) Respiratory Drive Through (RDT) (4) Medical Company (5) Provider Triage (6) ED Quarterback Patient Liaison (EDQB) (7) Virtual Registration (8) Virtual Ward. RESULTS: To date, no staff members have contracted COVID-19 within the ED footprint. Our RDT has seen 16,994 patients and the medical company 1,109. Provider triage has redirected 465 patients, while our EDQB has interacted with 532 and redirected 93 patients for same-day appointments with their Primary Care Manager (PCM). CONCLUSION: The system of care establish at our Military Treatment Facility (MTF) has been effective in maximizing staff and patient safety, while providing a new patient-centered healthcare delivery apparatus.

Ultrasound Versus Landmarks for Great Toe Arthrocentesis.

BACKGROUND: Several studies have demonstrated ultrasound (US) is superior to traditional landmark (LM)-based techniques for large and medium joint aspiration; however, no studies of sufficient size have evaluated these interventions in the smaller toe joints. The purpose of this study was to determine if US provides an advantage over LM for successful first-pass aspiration of first metatarsophalangeal joint (1st MTPJ) effusions. METHODS: A cross-over, cadaveric trial evaluating the interventions of US and LM. Eighteen emergency medicine residents performed four US and four LM aspirations each of 1st MTPJ effusions simulated in fresh-frozen cadavers. The initial intervention utilized was randomized. The primary outcome measured was aspiration success or failure. A secondary outcome measured was time in seconds taken to complete a successful aspiration. RESULTS: A total of 144 1st MTPJ aspirations were attempted-72 by US and 72 by LM. US was the initial intervention used in 9 of 18 (50%) participants. Fifty-seven of 72 (79.2%) US attempts were successful, while 53 of 72 (73.6%) LM attempts were successful (95% confidence interval 69.5%, 83.3%; p = 0.56). Successful US aspirations took 43.7 seconds (±31.0), whereas successful LM aspirations averaged 34.0 seconds (±24.3). The mean difference in time to successful aspiration was 9.7 seconds (95% confidence interval 20.3, -0.9; p = 0.07). There was no statistically significant difference in success and time between US and LM. CONCLUSION: In this study, US did not prove superior to LM for first-pass aspiration of 1st MTPJ effusions.

Posttraumatic lingual artery pseudoaneurysm treated with ultrasound-guided percutaneous thrombin injection.

Pseudoaneurysms of the lingual artery are extremely rare and are commonly iatrogenic in nature or less frequently a result of blunt or penetrating trauma. Traditionally, these vascular abnormalities have been repaired with open or endovascular techniques. Although ultrasound-guided percutaneous thrombin injection has become a standard treatment for superficial pseudoaneurysms, there are no reports of this being used in the treatment of lingual artery pseudoaneurysms. We report the case of a 26-year-old man who suffered a penetrating head and neck injury after an improvised explosive device blast in Iraq who presented with persistent oropharyngeal swelling. Color-flow Doppler ultrasonography revealed the classic yin/yang sign of a pseudoaneurysm, and a computed tomography scan was obtained that revealed a right lingual artery pseudoaneurysm. With the lack of endovascular capabilities and the excessive risk of open surgery, thrombin was injected directly into the pseudoaneurysm under ultrasound guidance. A computed tomography scan and Doppler ultrasonography revealed complete resolution of the aneurysm. This article presents the first reported case in the English literature of a lingual artery aneurysm after penetrating trauma managed successfully with ultrasound-guided percutaneous thrombin injection.

Traumatic noncombat-related hand injuries in U.S. troops in the combat zone.

BACKGROUND: The epidemiology of traumatic, nonbattle, Combat Zone hand injuries has not been well explored. METHODS: This was a retrospective chart review of Emergency Department visits occurring at the Ibn Sina Hospital in Baghdad Iraq. RESULTS: During the 24-month period from May 2007 to June 2009, 7,520 patients were seen at the Ibn Sina Hospital Emergency Department. Three hundred thirty-one cases met the inclusion criteria. Seventy-four cases were found to have required near-term evacuation from area of operation. CONCLUSIONS: Traumatic, nonbattle hand injuries are common and appear to be a significant problem in the Combat Zone. Injuries occurring because of the closure of vehicle doors, hatches, and turrets make up a large portion of these injuries and represent an optimal area of intervention for possible injury mitigation.

Ultrasound diagnosis of a patellar tendon rupture.

Many forward units are being deployed with portable ultrasound capability. We describe a case of a patient with a complete patellar tendon rupture that was diagnosed in the deployed environment using a portable ultrasound. Military physicians can benefit from sonographic evaluation of patients with musculoskeletal injuries in a deployed setting. The information they gain can assist them in giving better care to their patients and in making decisions on patient evacuation.